South African Journal of Surgery - Volume 48, Issue 1, 2010
Volume 48, Issue 1, 2010
Source: South African Journal of Surgery 48, pp 4 –5 (2010)More Less
Damage control surgery (DCS) has been one of the major advances in trauma surgery over the past two decades and is now a well-established surgical strategy in the management of the severely injured and shocked patient. DCS refers to a conscious decision by the surgeon to minimise operative time in a seriously injured patient when the combined effects of the magnitude of the injury and the markedly altered physiological state of the patient preclude an immediate and safe definitive operative procedure.
Source: South African Journal of Surgery 48, pp 6 –9 (2010)More Less
Background. Damage control surgery (DCS) has become well established in the past decade as the surgical strategy to be employed in the unstable trauma patient. The aim of this study was to determine which factors played a predictive role in determining mortality in patients undergoing a damage control laparotomy.
Materials and methods. A retrospective review of all patients undergoing a laparotomy and DCS in a level 1 trauma centre over a 3-year period was performed. Twenty-nine potentially predictive variables for mortality were analysed.
Results. Of a total of 1 274 patients undergoing a laparotomy for trauma, 74 (6%) required a damage control procedure. The mean age was 28 years (range 14 - 53 years). The mechanism of injury was gunshot wounds in 57 cases (77%), blunt trauma in 14 (19%) and stabs in 3 (4%). Twenty patients died, giving an overall mortality rate of 27%. Factors significantly associated with increased mortality were increasing age (p=0.001), low base excess (p=0.002), pH (p<0.001), core temperature (p=0.002), and high blood transfusion requirement over 24 hours (p=0.002).
Conclusion. The overall survival of patients after damage control procedures for abdominal trauma was excellent (73%). The main factors that are useful in deciding when to initiate DCS are age, base excess, pH and the core temperature.
Source: South African Journal of Surgery 48, pp 10 –14 (2010)More Less
Background. Pancreaticoduodenal injuries are uncommon owing to the protected position of the pancreas and duodenum in the retroperitoneum. Management depends on the extent of injury. This study was undertaken to document outcome of pancreaticoduodenal injuries and to re-evaluate our approach.
Patients and methods. A prospective study of all patients treated for pancreaticoduodenal trauma in one surgical ward at King Edward VIII hospital over a 7-year period (1998 - 2004). Demographic data, clinical presentation, findings at laparotomy and outcome were documented. Prophylactic antibiotics were given at induction of anaesthesia.
Results. A total of 488 patients underwent laparotomy over this period, 43 (9%) of whom (all males) had pancreatic and duodenal injuries. Injury mechanisms were gunshot (30), stabbing (10) and blunt trauma (3). Their mean age was 30.1+9.6 years. Delay before laparotomy was 12.8+29.1 hours. Seven were admitted in shock. Mean Injury Severity Score (ISS) was 14+8.6. Management of 20 duodenal injuries was primary repair (14), repair and pyloric exclusion (3) and conservative (3). Management of 15 pancreatic injuries was drainage alone (13), conservative management of pseudocyst (1) and distal pancreatectomy (1). Management of 8 combined pancreaticoduodenal injuries was primary duodenal repair and pancreatic drainage (5) and repair with pyloric exclusion of duodenal injury and pancreatic drainage (3). Twenty-one patients (49%) developed complications, and 28 required ICU admission with a median ICU stay of 4 days. Ten patients died (23%). Mean hospital stay was 18.3+24.4 days.
Conclusions. The overall mortality was comparable with that in the world literature. We still recommend adequate exploration of the pancreas and duodenum and conservative operative management where possible.
Source: South African Journal of Surgery 48, pp 15 –19 (2010)More Less
Introduction. The management of splenic injuries has shifted from splenectomy to splenic preservation owing to the risk of overwhelming post-splenectomy infection (OPSI). This study aimed to identify the factors that determine splenectomy in patients with isolated splenic injuries, with a view to increasing the rate of splenic preservation.
Patients and methods. Files of 55 patients managed for isolated splenic injuries from blunt abdominal trauma between 1998 and 2007 were retrospectively analysed using a pro forma. Management options were classified into nonoperative, operative salvage and splenectomy.
Results. The majority of patients suffered splenic injury as a result of motor vehicle accident (MVA) trauma or falls. Splenectomy was undertaken in 33 (60%) patients, 12 (22%) had non-operative management, and operative salvage was achieved in 10 (18%) patients. Significant determinants of splenectomy were grade of splenic injury, hierarchy of the surgeon, and hierarchy of the assistant.
Discussion. MVA injury and falls accounted for the vast majority of blunt abdominal trauma in this study. The rate and magnitude of energy transferred versus splenic protective mechanisms at the time of blunt abdominal trauma seems to determine the grade of splenic injury. Interest in splenic salvage surgery, availability of technology that enables splenic salvage surgery, and the experience of the surgeon and assistant appear to determine the surgical management.
Conclusion. Legislation on vehicle safety and good parental control may reduce the severity of splenic injury in blunt abdominal trauma. When surgery is indicated, salvage surgery should be considered in intermediate isolated splenic injury to reduce the incidence of OPSI.
Bilateral versus posterior injection of botulinum toxin in the internal anal sphincter for the treatment of acute anal fissure : general surgeryAuthor Ibrahim OthmanSource: South African Journal of Surgery 48, pp 20 –22 (2010)More Less
Aim. Comparison of bilateral versus posterior injection of botulinum toxin into the internal anal sphincter for treatment of acute anal fissure.
Methods. Forty patients with acute anal fissure were randomly divided into two equal groups. Group 1 was treated by injecting 20 units of botulinum toxin into each side of the internal anal sphincter, and group 2 by injecting 25 units of botulinum toxin into the midline posteriorly.
Results. The mean time to pain relief was 8.45 (standard deviation (SD) 7.41) days in group 1 and 7.20 (SD 7.19) days in group 2. Healing took place in a mean of 5.20 (SD 1.85) weeks in group 1 and 5.40 (SD 2.01) weeks in group 2. Fissures failed to heal in 2 patients in group 1 and 3 in group 2, and recurred in 4 patients in group 1 and 3 in group 2.
Conclusion. Botulinum toxin injection is effective in treating acute anal fissure. A single posterior injection is easier and less painful than bilateral injection, and is as effective in pain relief.
Source: South African Journal of Surgery 48, pp 23 –38 (2010)More Less
Author Sarah AsburySource: South African Journal of Surgery 48 (2010)More Less
We all study medicine for a reason. Sometimes at three in the morning after the fifth incision and drainage or gunshot laparotomy it is not easy to remember why, but once there was a reason. For most of us the reasons we enjoy medicine and practise surgery have changed over the years, and are not something many surgeons muse over to any degree. It's a job, it's a good and interesting job, and for most of us it is a passion.