South African Journal of Surgery - latest Issue
Volume 54, Issue 3, 2016
Source: South African Journal of Surgery 54, pp 2 –5 (2016)More Less
Laparoscopic cholecystectomy (LC) is the preferred and most widely used method for removal of the gallbladder in patients with symptomatic cholelithiasis. Modern laparoscopic equipment provides better illumination and definition with the most recent generation processors and cameras offering the possibility of 3D visualization. The minimal access approach results in smaller wounds, less postoperative pain, faster recovery, shorter hospital stay and ultimately a better cosmetic result. The major disadvantage of LC, however, is the biliary complications associated with the procedure, the most serious of which is a major bile duct injury (BDI). Although the technique was introduced more than two decades ago, the incidence of BDIs has not decreased and still occurs in 0.4% of operations, a figure twice as high as recorded during the era of open cholecystectomy. A recent Swedish population-based study reporting a BDI rate of 1.5% suggests that the rates in the literature may be an underestimation, or more alarmingly, that BDI rates are increasing.
Author R. OoditSource: South African Journal of Surgery 54 (2016)More Less
Ventral hernia repair is one of the most common general surgical procedures. An estimated 20 million patients with hernias are operated on worldwide every year. An incisional hernia will develop in 10-15% of patients with an abdominal incision. The risk increases to 23% in those who develop surgical site infection. Recurrence rates of up to 69% have been reported in high-risk patients.
Source: South African Journal of Surgery 54, pp 8 –12 (2016)More Less
Background : Laparoscopic cholecystectomy (LC) is a common surgical procedure performed for symptomatic gallstones. There is a trend towards early cholecystectomy for patients with acute cholecystitis who present timeously. Local inflammation has been identified as a risk factor for bile duct injuries. This study sought to assess the outcomes of LC in patients managed within a resource constrained environment where late presentation is common.
Methods : We performed a retrospective analysis of laparoscopic cholecystectomy performed from January 2010 to June 2011. The mode of presentation, co-morbidities, timing of cholecystectomy and complications were analysed.
Results : One hundred and sixty seven patients were evaluated. The median age was 43 years with range (17-78) years and 93% were female and 7% male. There were 44%, 23%, 20% and 13% who presented with biliary colic, acute pancreatitis, acute cholecystitis and obstructive jaundice respectively. Nine (5.4%) patients required conversion to an open cholecystectomy. Complications occurred in 16.2% and bile duct injuries and bile leaks in 1.2% and 1.8% respectively. One patient died.
Conclusions : Most patients had a delayed laparoscopic cholecystectomy. There was no difference in outcomes for the different presentations and the complications are similar to other reports.
Source: South African Journal of Surgery 54, pp 14 –17 (2016)More Less
Background : Hydatid liver disease management has evolved from traditional operative approaches to the increasing application of laparoscopic treatments. We aimed to prospectively assess the early outcomes of laparoscopic treatment at our institution.
Patients and methods : Forty-four patients with hydatid disease of liver were screened with ultrasonography and computed tomography of the abdomen to exclude Gharbi type V cysts. The distribution of cyst sizes was: 1-4 cm, 10; 5-10 cm, 24; 10-15 cm, 8; > 15 cm, 2 patients. The following laparoscopy therapies were performed: 30 patients had cystectomy alone, 14 patients had partial pericystectomy. Pericystectomy was performed using a hook and harmonic tissue sealers with the resection made through normal liver tissue.
Results : Three patients were converted to open surgery. Seven patients had biliary leakage through their cystic cavity drains. Five stopped spontaneously by the 7th postoperative day and 2 responded to ERCP sphincterotomy. There were no deaths and no recurrence of disease noted by 6 months.
Conclusion : In selected patients with hepatic hydatid disease, a laparoscopic treatment is feasible and safe with low conversion rate and short term recurrences.
Incidence and management of postoperative bile leaks : a prospective cohort analysis of 467 liver resections : general surgerySource: South African Journal of Surgery 54, pp 18 –23 (2016)More Less
Background : Bile leaks from the parenchymal transection margin are a major cause of morbidity following major liver resections. The aim of this study was to benchmark the incidence and identify the risk factors for postoperative bile leakage after hepatic resection.
Patients and methods : A prospective database of 467 consecutive liver resections performed by the University of Cape Town HPB surgical unit between January 1990 and January 2016 was analysed. The relationship of demographic, clinical and perioperative factors to the development of bile leakage was determined. Bile leak and postoperative complications severity were graded using the International Study Group of Liver Surgery and Accordion classifications.
Results : Overall morbidity was 24% (n = 112), with bile leaks occurring in 25 (5.4%) patients. Significantly more bile leaks occurred in patients who had major resections (≥ 3 segments) and longer total operative times (p < 0.05). There were 5 Grade A bile leaks which stopped spontaneously. Seventeen Grade B leaks required a combination of percutaneous drainage (n = 15), endoscopic biliary stenting (n = 8) and percutaneous transhepatic biliary drainage (n = 3). All 3 Grade C leaks required laparotomy for definitive drainage. Median hospital stay in the 442 patients without a bile leak was 8 days (IQR 1-98) compared with 12 days (IQR 6-30) for the 25 with bile leaks (p < 0.05) with no mortality. Major resections (≥ 3 segments) and total operative time (> 180mins) were significantly associated with bile leaks.
Conclusion : The incidence of bile leakage was 5.4% and occurred after major liver resections with longer operative times and resulted in significantly extended hospitalisation. Most were effectively treated nonoperatively by percutaneous drainage of the collection and/or endoscopic or percutaneous biliary drainage without mortality.
Severe post-pancreatoduodenectomy haemorrhage : an analytical review based on 118 consecutive pancreatoduodenectomy patients in a South African Academic Hospital : general surgerySource: South African Journal of Surgery 54, pp 23 –28 (2016)More Less
Background : Bleeding after a major pancreatic resection, although uncommon, has serious implications and substantial mortality rates.
Aim : To analyse our experience with severe post-pancreatoduodenectomy haemorrhage (PPH) over the last 7 years to establish the incidence, causes, intervention required and outcome.
Methods : All patients who underwent a pancreatoduodenectomy (PD) between January 2008 and December 2015 were identified from a prospectively maintained database. Data analysed included demographic information, operative details, anastomotic technique, histology, postoperative complications including pancreatic fistula and PPH, length of hospital stay, need for blood products and special investigations. Pancreatic fistula was classified according to the International Study Group of Pancreatic Surgery (ISGPS) classification. A modified ISGPS classification was used for PPH.
Results : One hundred and eighteen patients underwent PD during the study period of whom 6 (5.0%) died perioperatively. Twenty patients (16.9%) developed a pancreatic fistula and 11 patients (9.3%) had a severe PPH of whom one (9.1%) died. No patients had a severe bleed during the first 24 hours postoperatively. Four patients bled within the first 5 days and the remaining 7 after five days. Six patients bled from the gastroduodenal artery and were all preceded by a pancreatic fistula. Three of the 7 patients who bled late presented with extraluminal bleeding, 3 presented with intraluminal bleeding and 1 with a combination of both. Patients presenting in the first 5 days were all successfully managed either endoscopically or surgically. Five patients who presented beyond 5 days postoperatively were managed primarily with interventional angiography, either with coiling or deployment of a covered stent. Three patients who had radiological intervention developed a liver abscess or necrosis.
Conclusion : Severe PPH is associated with substantial morbidity. Clinical factors including the onset of the bleeding, presentation with either extra and/or intraluminal haemorrhage, and the presence of a pancreatic fistula give an indication of the likely aetiology of the bleeding. A management algorithm based on these factors is presented.
Comparing laparoscopic appendectomy to open appendectomy in managing generalised purulent peritonitis from complicated appendicitis : the uncharted path : general surgerySource: South African Journal of Surgery 54, pp 30 –34 (2016)More Less
Background : The objective of the study was to compare the outcomes of patients with generalised purulent peritonitis from complicated appendicitis diagnosed intraoperatively who were managed laparoscopically to those managed via the open approach in a single institution.
Methods : Data were collected from all cases admitted at Sebokeng Hospital, Johannesburg, over the past two years (2008 and 2009) with an intraoperative diagnosis of generalised purulent peritonitis from complicated appendicitis. Cases managed laparoscopically or by the open approach were analysed. The demographic findings, theatre duration, complications, days to the commencement of a full ward diet and the length of the hospital stay were the analysed parameters.
Results : One hundred and twenty appendectomies with generalised purulent peritonitis were performed during the study period. Of these, 58 patients underwent open appendectomy, and 62 patients had laparoscopic appendectomy. Both groups were comparable with regard to the demographics and preoperative findings. Theatre duration was significantly higher in the laparoscopic appendectomy group -116 minutes for a laparoscopic appendectomy compared to 87 minutes for an open appendectomy. The rate of intra-abdominal sepsis was also higher in the laparoscopic appendectomy group - 13% for a laparoscopic appendectomy, and 9% for an open appendectomy. A statistically significant decrease in the wound sepsis rate was shown in the laparoscopic appendectomy group. No statistical significant difference was demonstrated with regard to other postoperative complications, days to the commencement of a full ward diet and the length of hospital stay in both groups. More time (an average of 3.7 days) was spent in the intensive care unit and high care unit by those in the open appendectomy group, than those in the laparoscopic appendectomy group (an average of 2.0 days). However, age, duration of symptoms, clinical presentation and white blood cell count were influencing factors on the outcome measures in the open appendectomy group.
Conclusion : Generalised purulent peritonitis from complicated appendicitis can be managed successfully laparoscopically. Both approaches are feasible, safe and have comparable outcomes. The laparoscopic approach resulted in fewer postoperative wound sepsis complications.
Source: South African Journal of Surgery 54, pp 35 –42 (2016)More Less
Objective : Blood is a limited resource in middle-income countries such as South Africa. Transfusion is associated with complications and expense. We aimed to understand our transfusion practices in burn surgery as well as ascertain the opinion of a broader group of surgeons and anaesthetists regarding transfusion triggers in order to understand the rationale and bias that drives current transfusion practice in our setting.
Methods : Firstly, we investigated the current blood practices at our regional burn service through an audit of perioperative notes for all patients receiving packed cell transfusions in a 24-month period. Secondly, we formulated a questionnaire asking for opinion on acceptable preoperative and postoperative haemoglobin targets for a list of elective, emergency and burn operations that was distributed at a number of meetings.
Results : Seventy-two patients received a total of 103 perioperative transfusions. The median preoperative haemoglobin was 9.8 g/dL in both children and adults and the median postoperative haemoglobin was 10.1 and 9.1 g/dL in children and adults respectively. The cohort was divided into two groups: the first surgery and the subsequent surgeries. In the adult group the mean time to first surgery post burn was 11.5 days with a median volume of 0.73 mls/kg/% operated surface area (range 0.16-1.54) of packed cells transfused per operation. In the paediatric group the mean time to first surgery post burn was 9 days (range 2-54) with a median volume of 1.1 mls/kg/% operated surface area (range 0.56-2.14) of packed cells transfused per operation. One hundred and fifty questionnaires were handed out and 103 (69%) were completed. The average proposed preoperative and postoperative haemoglobin was 9.3 g/dL and 8.4g/dL respectively. The majority of respondents (60% in elective surgery, 43% in emergency surgery and 60% in burn surgery) would like preoperative haemoglobin to be 10 g/dL and above.
Conclusion : Research suggests that a restrictive blood transfusion approach is being increasingly implemented as best practice. However, our surgical community does not seem to accept a restrictive strategy as part of blood management principles. A shift in this practice could result in clinical benefit by reducing complications and increasing cost saving in our resource constrained setting. We plan to protocolise earlier surgery and blood conservation strategies intraoperatively in addition to a restrictive strategy in our burn service.
Source: South African Journal of Surgery 54, pp 42 –43 (2016)More Less
A duplication cyst of the caecum is a very rare congenital malformation, representing 0.4% of all gastrointestinal duplications. We present a case of cystic duplication of the caecum in a 12-year-old child who presented with a right iliac fossa mass and peritonitis. An ischaemic, perforated caecal duplication cyst was found on emergency laparotomy, mandating a right hemicolectomy.
Source: South African Journal of Surgery 54, pp 44 –45 (2016)More Less
A 72-year-old woman presented with a slow growing mass on the left side of the abdomen, which was found to originate from the mesentery of the descending colon. Histopathology revealed a seromucinous cystadenocarcinoma of the mesentery, a rare clinical entity occurring most often in females. There are only 20 cases reported in the literature. It is postulated that these tumours develop as a result of serous or mucinous metaplasia of pre-existing coelomic mesothelium. Surgical excision remains the mainstay of successful management.
Intestinal volvulus after conservative management of incidental midgut malrotation discovered at laparoscopic appendectomy in a teenager : case reportSource: South African Journal of Surgery 54, pp 47 –50 (2016)More Less
Midgut malrotation (MMR) is the abnormal rotation of the foetal midgut around the axis of the superior mesenteric artery which in symptomatic neonates requires a Ladd's procedure. We present a rare case of midgut volvulus occurring in a teenager 3 days after observational management of incidentally discovered MMR during laparoscopic appendectomy. A Ladd's procedure was performed and the patient is well at one-year follow up. We suggest prophylactic Ladd's procedure remains the treatment of choice for MMR even when discovered incidentally.
Source: South African Journal of Surgery 54, pp 51 –52 (2016)More Less
Typical cases of acute appendicitis have excellent treatment outcomes, if managed appropriately. We discuss an unusual case of perforated retrocaecal appendicitis that presented as a right thigh abscess without prominent abdominal symptoms, which highlights the lethal nature of advanced appendicitis even when appropriate surgical therapy is instituted.
Self-Expanding Metal Stent (SEMS) insertion : fluoroscopy versus pure endoscopic technique - a cost comparison : letter to the editorSource: South African Journal of Surgery 54, pp 54 –55 (2016)More Less
Oesophageal cancer is a disease with significant morbidity and mortality, and in South Africa most patients present with advanced disease. Self-expanding metal stents (SEMS) are now widely used in the palliation of oesophageal cancer, and in most institutions SEMS are deployed under fluoroscopic guidance. In our institution, we use an exclusive endoscopic deployment technique which is comparable to the traditional fluoroscopic technique in terms of safety and efficacy. We undertook a study to compare the two techniques with respect to their time- and cost-effectiveness.
Source: South African Journal of Surgery 54 (2016)More Less
Surgery in Cape Town has lost one of its most loyal servants. Harold Spilg died peacefully on 19 June 2016 in Israel. Harold, as he was known to everyone, was born in Lithuania in 1929. His family moved to South Africa and settled in Port Elizabeth. He matriculated from Grey High School in 1946 and thereafter completed a Diploma in Pharmacy in 1954. He was awarded the PE Technical College Medal for the best Pharmacy student.