South African Journal of Surgery - Volume 45, Issue 4, 2007
Volume 45, Issue 4, 2007
Author T.E. MadibaSource: South African Journal of Surgery 45, pp 115 –120 (2007)More Less
The D. J. du Plessis lecture of the Surgical Research Society of Southern Africa commemorates one of the most outstanding surgeons in South Africa. The title of this lecture is a subject that I have been deliberating on for some time. It poses a question that I have had to ask myself a number of times when inviting registrars and junior consultants to undertake research with me.
Source: South African Journal of Surgery 45, pp 122 –126 (2007)More Less
Purpose. Assessment of the effect of a short ischaemic time prior to liver transplantation on the liver graft.
Methods. White X Landrace pigs (N=10) were subjected to liver transplantation. Before being removed from the donor animal, the livers were randomised into two groups: group 1 - pre-procurement ischaemia (15 minutes' temporary arrest of portal venous and hepatic arterial inflow to the liver, followed by reperfusion of these vessels for a period of 15 minutes); group 2 - no prior inflow occlusion (control group). In group 1 a spleno-jugular bypass was established to prevent venous congestion, portal venous hypertension, intestinal oedema and bacterial translocation. The livers were perfused with Eurocollins solution (4oC), after which they were stored on ice for a period of 3 hours' cold ischaemic time. Hepatocellular injury was assessed according to liver cell function tests (aspartate aminotransferase, AST), biochemical indicators of reperfusion injury (malondialdehyde) and histopathology.
Results. There was a significant rise of AST in both groups 1 hour after transplantation (from 51+27 IU/l to 357+152 IU/l in group 1 and from 29+10 IU/l to 359+198 IU/l in group 2). AST levels were marginally lower in group 1 at 2 and 4 hours after transplantation. There was also a rise in malondialdehyde levels in both groups at 5, 20, 40 and 60 minutes after transplantation. Levels of malondialdehyde were lower in the primed group at 5, 20 and 40 minutes, while the levels at 60 minutes after transplantation were comparable. Histological changes, as measured by vacuolisation, neutrophil infiltration and hepatic cell necrosis, were less in livers transplanted after ischaemic preconditioning, although the difference was not significant.
Conclusions. Ischaemic preconditioning of the donor liver seems to decrease hepatocellular damage, reperfusion injury and histological changes in the liver after transplantation. Further studies with larger numbers are indicated.
Source: South African Journal of Surgery 45, pp 128 –132 (2007)More Less
Background. The modern management of abdominal stab wounds remains controversial and subject to continued reappraisal. In the present study we reviewed patients with abdominal stab wounds to examine and validate a policy of selective non-operative management with serial physical abdominal examination in a busy urban trauma centre with a high incidence of penetrating trauma.
Methods. Over a 12-month period (2005), the records of all patients with abdominal stab wounds were reviewed. Patients with abdominal stab wounds presenting with peritonitis, haemodynamic instability, organ evisceration and high spinal cord injury underwent emergency laparotomy. No local wound exploration, diagnostic peritoneal lavage or ultrasound was used. Haematuria in patients without an indication for emergency surgery was investigated with a contrasted computed tomography (CT) scan. Patients selected for non-operative management were admitted for serial clinical abdominal examination for 24 hours. Patients in whom abdominal findings were negative were given a test feed. If food was tolerated, they were discharged with an abdominal injury form.
Results. One hundred and eighty-six patients with abdominal stab wounds were admitted. There were 171 (91.9%) males, with a mean age of 29.5 years. Seventy-four patients (39.8%) underwent emergency laparotomy. There were 5 negative laparotomies (6.8%). The remaining 112 patients (60.2%) were assigned for abdominal observation. One hundred (89.3%) of these patients were successfully managed non-operatively. The remaining 12 patients underwent delayed laparotomy, which was negative in 2 cases (16.7%). Non-operative management was successful in 53.8% of patients overall. The overall sensitivity and specificity of serial abdominal examination was 87.3% and 93.5%, respectively.
Conclusion. Serial physical examination alone for asymptomatic or mildly symptomatic patients with abdominal stab wounds enables a significant reduction in unnecessary laparotomies.
Source: South African Journal of Surgery 45, pp 134 –135 (2007)More Less
Objective. To test the validity of the reported high incidence (50%) of malignancy in neoplasms of the submandibular salivary gland, and to compare it with that of the parotid gland.
Methods. This is a retrospective analysis of major salivary gland neoplasms in 127 patients who were treated between August 1988 and December 2004 (15½ years) at Kalafong Hospital, Pretoria.
Results. All but 1 of the patients were black. There were 100 benign and 27 malignant tumours. Thirty tumours were in the submandibular gland, including 3 malignant tumours, i.e. 10%. Of 97 parotid gland tumours, 24 (24.7%) were malignant.
Conclusion. The 10% incidence of malignancy in neoplasms of the submandibular gland in our series is much lower than the 50% reported in the literature. We postulate that race (black ethnicity) is probably a factor in this low incidence.
Lymphoepithelial lesions of the parotid gland in the HIV era - a South African experience : general surgerySource: South African Journal of Surgery 45, pp 136 –140 (2007)More Less
Objective. Historically, lymphoepithelial lesions (LELs) have been a peripheral indication for surgery on the parotid gland, accounting for less than 1% of all parotidectomies undertaken. In the HIV era the profile of parotidectomy has changed, with LEL becoming a common indication for parotidectomy, prompting a review of our current experience.
Design. A retrospective study was undertaken between January 1998 and December 2005.
Setting. Surgical services at King Edward VIII Hospital, Durban.
Subjects. All patients presenting with parotidomegaly.
Results. One hundred and sixty-two patients with parotidomegaly were evaluated; 53 (32.7%) had LEL lesions. A total of 151 parotidectomies (including 42 parotidectomies undertaken for LEL lesions) were performed in 147 patients. Radiotherapy was offered to 11 patients with LEL lesions. Complications following parotidectomy for LEL included facial nerve palsy (N = 3), seroma formation (N = 5) and facial artery false aneurysm (N = 1). Three patients required re-parotidectomy for recurrent LEL parotidomegaly. In the patients who underwent radiotherapy, there was a satisfactory outcome; 2 patients who received 4 Gy radiation per sitting developed mild skin discolouration of the treated area.
Conclusion. Although surgical management of LEL parotidomegaly may provide a satisfactory result, this approach is technically challenging and is associated with complications and recurrences. For these reasons, the non-operative approach employing radiotherapy should be considered.
Meningococcal septicaemia complications involving skin and underlying deeper tissues - management considerations and outcome : paediatric surgerySource: South African Journal of Surgery 45, pp 142 –146 (2007)More Less
Objective. To describe surgical experience with purpura fulminans related to meningococcaemia in a single institution, and to suggest a management protocol.
Methods. A retrospective review was done of patients admitted to the intensive care unit at Red Cross War Memorial Children's Hospital in Cape Town with the clinical diagnosis of purpura fulminans.
Results. During a 28-year period (1977 - 2005) 112 children (average age 3.4 years) were treated for meningococcaemia with purpura fulminans. Overall mortality was 10.7%. Local treatment consisted of measures to improve circulation, infection control and healing of necrotic tissue. Demarcation of necrotic areas was evident at 5.5 days and the average area of skin necrosis was 14% total body surface area (range 2 - 85%). The lower limbs were predominantly affected. Purpura fulminans resolved in 35 children (31.2%) without skin necrosis. Skin grafting was required in 77 children (68.8%). Factors associated with a poor outcome for peripheral extremity salvage were progressive irreversible skin changes, early disappearance of distal pulses, tense cold swollen extremities and intense pain on passive movement of the affected extremity. Amputations were performed proximal to the area of necrosis, on average 27 days after injury.
Conclusions. Meningococcaemia is a disease with potentially devastating consequences. Early surgical consultation is essential. Skin- and soft-tissue-releasing incisions should be considered early to reduce the incidence of extremity necrosis. Small necrotic areas usually separate spontaneously with secondary healing or can be excised and sutured. Larger necrotic areas should be excised only after demarcation has been established, and can be covered with delayed skin grafting. Amputation should be conservative but may require revision.
Source: South African Journal of Surgery 45, pp 148 –150 (2007)More Less
Retrorectal cystic hamartomas are rare congenital lesions derived from the vestigial portion of the embryonic hindgut. These lesions present in a vague manner and so mimic the presentation of more common mass lesions in the pelvic region. They most frequently afflict middle-aged women, causing vague pelvic pains, discomfort with defaecation or sitting, and altered bowel function. Malignant transformation within these lesions is extremely rare.
We describe a case of adenocarcinoma within a retrorectal cystic hamartoma, initially manifesting in a 54-year-old woman and recurring over a 5-year period. A computed tomography (CT) scan and pathology reports are included in the study, and findings at operations are discussed. We also include a comprehensive review of the literature.
Source: South African Journal of Surgery 45 (2007)More Less
A 9-year-old boy presented to our department 8 days after attempting to insert a non-piercing magnetic ear stud on either side of his nose. He had been unable to remove them, and both magnetic parts of the ear studs were still present in his nose. Examination of the nose was difficult, as he was unco-operative and his nose was filled with mucus and crusts. X-rays of the nose revealed the two ear studs on either side of the nasal septum.
Principles and Practice of Surgery, O. J. Garden, A. W. Bradbury, J. L. R. Forsythe, R. W. Parks : book reviewAuthor G.J. OettleSource: South African Journal of Surgery 45 (2007)More Less
A good measure of a textbook's worth may be the number one sees under the arms of medical students. Judging by this unorthodox criterion previous editions of this book have amply succeeded, and I have no doubt the 5th will follow. It is a pleasure to see that Elsevier have taken the trouble to sew, rather than glue, even the cheaper, international edition, which will ensure a longer life in the rough and tumble of undergraduate use.
Source: South African Journal of Surgery 45 (2007)More Less
To the Editor: We wish to bring to your attention some statements made in a recent article by Van Lierop and Fagan.
In the summary they state that 'The spectrum of parotid disease in southern Africa has not previously been reported'. This is repeated in the first paragraph of the text.