South African Journal of Surgery - Volume 46, Issue 3, 2008
Volume 46, Issue 3, 2008
Source: South African Journal of Surgery 46 (2008)More Less
New Health Act
Surgeons practice cost study
Operation Hernia, Ghana - Outreach into Africa
Distinguished Service Award
ASSA Clinical Excellence / Young Surgeons Award
ASSA-SAGES Conference 2007
Surgical checklist launched
Source: South African Journal of Surgery 46, pp 68 –72 (2008)More Less
Background. While disorders such as gastro-oesophageal reflux disease, gastrointestinal (GI) cancers and inflammatory bowel disease are prevalent among all racial groups in the Western Cape, there is little knowledge of local GI service provision. The state of equipment, facilities and staffing is largely unrecorded and to date unknown. The aim of this study was to audit the availability of GI facilities in the provincial sector, which provides care for the majority of people in the Western Cape.
Method. All hospitals in the Western Cape providing endoscopy were evaluated by means of a hands-on audit, to identify available organisational infrastructure. Data including staffing, details and utilisation of existing equipment, maintenance and disinfection techniques and delays in service provision were collected.
Results. Over a period of 12 months, 17 Western Cape hospitals were visited : 3 tertiary, 5 regional and 9 district-level institutions. There are currently 89 GI endoscopes in state service, with an average age of 6.1 years (range 1 - 23 years). While most institutions utilise video endoscopy, in many instances equipment is near the end of its economic life. A total of 26 434 endoscopic procedures were performed over a 12-month period. Overall at least 60% of all adult endoscopy was undertaken at tertiary institutions. The mean delay from consultation until gastroscopy or colonoscopy was 9.25 weeks (range 0.5 - 28 weeks) and 8 weeks (range 1 - 20 weeks), respectively. Only 1 tertiary and 1 regional hospital employed fully trained, registered nurses, and the majority of institutions did not conform to internationally accepted standards for the maintenance and disinfection of endoscopic equipment.
Conclusion. While endoscopy equipment is widely distributed throughout the province, it is evident from this study that services in the Western Cape fall short of international standards, with delays in endoscopic provision, lack of adequate equipment, inadequate scope maintenance and disinfection and a shortage of trained staff. As such, much of the population reliant on state facilities has poor access to GI health care. These deficiencies need to be addressed.
Source: South African Journal of Surgery 46, pp 74 –77 (2008)More Less
Objective. We sought to evaluate the surgical service in the central part of the Eastern Cape Province by reviewing the practice of appendicectomy at Frere Hospital. Specifically, it was our aim to compare the service to those patients who reside in and outside the East London metropolitan area and the outcomes of patients according to their operative finding.
Patients and methods. A retrospective study was performed on the medical records of all patients who underwent appendicectomy in a 26-month period. This entailed a thorough review of demographic factors, mode of presentation, operation factors and findings, and the postoperative course.
Results. In the study period, 436 appendicectomies were performed, of which 81% were performed after hours, with a consultant surgeon present in only 6% of cases. Of the group, 51% had a perforated appendix at surgery, and 12% a normal appendix. There was a significantly increased risk of perforation at the extremes of age and in patients from outside East London (63% v. 35% in East London). Those with perforated appendices stayed an average of 7.3 days in hospital, compared with 5 days for those with earlier appendicitis. Of the perforated group, 21% developed a complication, with 86% of all complications occurring in this group. The hospital stays were longer in those perforated appendices that were drained (10.7 days v. 6.1 days), and the rate of complications higher in this subgroup. Four patients died (1%) - all in the perforated group.
Discussion. The perforation rate in our setting is significantly higher than other published results. Patients with perforated appendices have longer hospital stays and are more likely to develop significant complications, including re-operation. Patients from outside East London, males and those at the extremes of age are more likely to have perforated appendices. This study lends little support to the advocates of drains, and recommends the use of non-absorbable sutures for skin closure. The majority of procedures are performed after hours by medical officers and registrars, but there is no evidence to suggest that this practice be altered, particularly in light of the high perforation rate. The main factor identified as contributing to the huge discrepancy between perforation rates (and hence morbidity) is delay in presentation to the operating surgeon for the region. Patient factors may contribute, but service factors are regarded as significant, including poor access to clinics and hospitals, transport and ambulance services, and the expertise of the referring medical staff. The need to improve the quality of patient care in the under-serviced rural areas of the Eastern Cape is highlighted.
Author I. ChamisaSource: South African Journal of Surgery 46, pp 79 –81 (2008)More Less
Introduction. The cancellation of surgery wastes theatre time and creates hardship for patients, who often plan their working and family lives around the proposed operation date.
Methods. A retrospective evaluation of cancellations of scheduled elective and urgent operations was done using theatre records from May 2006 to April 2007. The reasons for cancellation were examined.
Results. Of a total of 5 786 operations, 5.6% were cancelled or postponed. Lack of medical clearance and patient preparation (65.1%) was the most common reason for cancellation. Lack or failure of instruments and patient cancellation constituted 2.8% and 1.8% of the cancellations respectively.
Conclusion. Last-minute cancellation of surgery was a significant problem, and appreciation of the usual reasons for cancellations can improve theatre utilisation and avoid inconveniencing patients and their families.
Acute pancreatitis : demographics, aetiological factors and outcomes in a regional hospital in South Africa : general surgerySource: South African Journal of Surgery 46, pp 83 –86 (2008)More Less
Introduction. The spectrum of aetiologies and outcomes of acute pancreatitis in South African settings is under-reported. We report our experience at a regional hospital and compare it with international norms.
Patients and methods. Data were prospectively collected on all admissions of patients with acute pancreatitis to a regional hospital during the period June 2001 - April 2006. The causes of the pancreatitis were noted and complications and mortality rate were determined.
Results. From June 2001 to April 2006 there were 322 admissions of 282 patients with acute pancreatitis. The median age was 37 years (range 13 - 73 years). There were 94 females and 188 males. Episodes of pancreatitis were associated with alcohol consumption in 62% of cases and with gallstones in 14%; 4% of cases were associated with both gallstones and alcohol consumption, 8% with dyslipidaemia and 5% with retroviral disease. In 15% of admissions local complications developed, and 9% of admissions ended in death of the patient. Of the 28 deaths, 71% occurred in the first 2 weeks.
Conclusions. As in other South African reports, alcohol was the main cause of pancreatitis. Outcomes in this series are similar to those in Western studies except that the majority of deaths occurred early, implying that improved supportive care may improve overall survival.
Source: South African Journal of Surgery 46 (2008)More Less
A 32-year-old man presented with a progressively enlarging, firm, non-tender abdominal mass, more prominent on the left. He was fit and had no significant past medical history. Routine blood tests were all normal (including liver functions, amylase and α-fetoprotein). A computed tomography (CT) scan showed a 10x13x11.5 cm well-defined, solid and cystic mass in the lesser sac, with no evidence of distant spread. At laparotomy, a distal pancreatectomy and splenectomy were performed with a satisfactory plane around the tumour allowing complete macroscopic excision. Histological results were consistent with a pure acinar cell carcinoma. After discussion at a multidisciplinary oncology clinic, he was placed on a trial of gemcitabine-based chemotherapy.
The clinical and pathological features of hereditary mixed polyposis syndrome : report on a South African family : case reportSource: South African Journal of Surgery 46, pp 90 –92 (2008)More Less
Background. Hereditary mixed polyposis syndrome is characterised by multiple large-bowel polyps of differing histological types including a mixture of atypical juvenile polyps, hyperplastic polyps and adenomas. Affected individuals are thought to have an increased risk of malignancy, possibly via the juvenile polyposis pathway.
Methods. A 51-year-old woman (with a history of a colectomy for polyps during childhood) presented with rectal bleeding. Endoscopy demonstrated small rectal polyps which were hyperplastic on histology. A family tree was drawn up and the three children of the proband underwent flexible sigmoidoscopy.
Results. Endoscopic surveillance of the three children revealed one who had a similar phenotype to the mother. This child underwent colectomy and ileorectal anastomosis. The pathological specimen revealed more than 70 polyps, with a combination of juvenile retention, hyperplastic, adenomatous and inflammatory polyps. A second child had multiple small hyperplastic polyps, and the third had a normal colon. Although the gene locus for the disorder has been mapped, neither the gene nor the disease-causing mutation has been defined.
Conclusion. A rare inherited polyposis syndrome has been identified in a South African family. Where clinical suspicion of a possible inherited condition exists, investigating at-risk first-degree relatives confirms the inherited nature of the disease. It is possible to use genetic haplotyping (i.e. with a range of markers in the area of the gene) to provide statistical risk to immediate relatives and therefore those at highest risk.
Source: South African Journal of Surgery 46 (2008)More Less
To the Editor : A 53-year-old man who had been on antiretroviral treatment for 8 months presented with dyspnoea, weight loss and night sweats. Investigations showed anaemia (haemoglobin concentration 8 g/dl), leucocytosis (white cell count 20x109/l) and dehydration, the erythrocyte sedimentation rate was 135 mm/h, and the CD4 count was 4 cells/µl. The chest radiograph was not suggestive of tuberculosis (TB), but showed a right pleural effusion; a drain was inserted and 1.5 litres of pus was drained. When the drain was removed, ingested food was seen to be draining through the site. Despite this, the patient was in a stable condition.
Urologic Robotic Surgery, Jeffrey A. Stock, Michael P. Esposito and Vincent J. Lanteri (Eds.)
Clinical Management of Renal Tumours, Ronald M. Bukowski and Andrew C. Resnick (Eds.) : book reviewsAuthor Stephen M. CornishSource: South African Journal of Surgery 46 (2008)More Less
This book is an ideal introduction to robotic surgery for the urologist. Robotic surgery is the way of the future for surgery in the 21st century. It allows great precision in surgical technique, as well as enabling the surgeon to reach areas not easily accessible with open surgery. Robotics will allow surgeons to operate on patients in remote areas, even outer space!
This is a well-written tome really intended for the urologist, oncologist and others with a direct interest in renal cancer. It assumes there is already familiarity with the subject matter. The book has been edited by two globally acknowledged experts. The 38 chapters are written by recognised specialists on that particular topic. Each article has been given a similar format and is laid out clearly and logically. Each chapter comes with a long list of references.