South African Journal of Surgery - Volume 50, Issue 2, 2012
Volume 50, Issue 2, 2012
Author B. Van der MerweSource: South African Journal of Surgery 50, pp 26 –29 (2012)More Less
Objectives. To evaluate the effects of ionising radiation and radiation limits, and measure radiation doses received by surgeons in theatre.
Design. Thermoluminescent dosimeter measurements of accumulated dose to specific anatomical regions of a neurosurgeon, gastroenterologist and orthopaedic surgeon performing fluoroscopy on 39 patients undergoing treatment for back pain, 7 for endoscopic retrograde cholangiopancreatography procedures, and 48 for orthopaedic operations respectively.
Results. Radiation dose levels with the X-ray tube above the table during back pain procedures exceeded the occupational annual recommendation to the neurosurgeon's hands. The protocol regarding the orientation of the C-arm was changed. Convincing evidence of the importance and effectiveness of lead shielding was recorded.
Conclusions. Constant revision of protocols should apply the as-low-as-reasonably-achievable principle in every unique setting. The ideal is to position the image intensifier above the theatre table. The longest possible distance from the source will lower radiation risk. Full-body protection of 0.35 mm lead equivalence during fluoroscopy is mandatory.
Source: South African Journal of Surgery 50, pp 30 –32 (2012)More Less
This report looks at the group of patients who required a laparotomy for blunt torso trauma at a busy metropolitan trauma service in South Africa.
Methods. A prospective trauma registry is maintained by the surgical services of the Pietermaritzburg metropolitan complex. This registry is interrogated retrospectively. All patients who required admission for blunt torso trauma over the period September 2006 - September 2007 were included for review. Proformas documenting mechanism of injury, age, vital signs, blood gas, delay in presentation, length of hospital stay, intensive care unit stay and operative details were completed.
Results. A total of 926 patients were treated for blunt trauma by the Pietermaritzburg metropolitan services during the period under consideration. A cohort of 65 (8%) required a laparotomy for blunt trauma during this period. There were 17 females in this group. The mechanisms of injury were motor vehicle accident (MVA) (27), pedestrian vehicle accident (PVA) (21), assault (5), fall from a height (3), bicycle accident (6), quad bike accident (1) and tractor-related accident (2). The following isolated injuries were discovered at laparotomy: liver (9), spleen (5), diaphragm (1), duodenum (2), small bowel (8), mesentery (8), bladder (10), gallbladder (1), stomach (2), colon/rectum (2) and retrohepatic vena cava (1). The following combined injuries were discovered: liver and diaphragm (2), spleen and pancreas (1), spleen and liver (2), spleen, aorta and diaphragm (1), spleen and bladder (1) and small bowel and bladder (2). Eighteen patients in the series (26%) required relaparotomy. In 10 patients temporary abdominal containment was needed. The mortality rate was 26% (18 patients). There were 6 deaths from massive bleeding, all within 6 hours of operation, and 3 deaths from renal failure; the remaining 9 patients died of multiple organ failure. There were 8 negative laparotomies (7%). In the negative laparotomy group false-positive computed tomography (CT) scan findings were a problem in 3 cases, in 1 case hypotension and a fractured pelvis on admission prompted laparotomy, and in the other cases clinical findings prompted laparotomy. All patients who underwent negative laparotomy survived. There were 10 pelvic fractures, 5 lower limb fractures, 2 spinal injuries, 4 femur fractures and 2 upper limb fractures. CT scans were done in 25 patients. In 20 patients the systolic blood pressure on presentation was <90 mmHg and in 41 the pulse rate was >110 beats/min. In 16 patients there was a base excess of <-4 on presentation.
Conclusion. Laparotomy is needed in less than 10% of patients who sustain blunt abdominal trauma. Solid visceral injury requiring laparotomy presents with haemodynamic instability. Hollow visceral injury has a more insidious presentation and is associated with a delay in diagnosis. CT scan is the most widely used investigation in blunt abdominal trauma. It is both sensitive and specific for solid visceral injury, but its accuracy for the diagnosis of hollow visceral injury is less well defined. Clinical suspicion must be high, and hollow visceral injury needs to be actively excluded.
Repair of abdominal aortic aneurysms with aorto-uni-iliac stentgraft and femoro-femoral bypass : vascular surgerySource: South African Journal of Surgery 50, pp 33 –36 (2012)More Less
Objectives. Endovascular repair (EVAR) is accepted as effective treatment for abdominal aortic aneurysms (AAAs) and has become the standard of care in many instances. The standard bifurcated stentgraft (BFG) is often not possible in patients with unfavourable aneurysm morphology. The aorto-uni-iliac (AUI) graft configuration with femoro-femoral bypass (FFBP) is a promising alternative which may extend the scope of EVAR for AAAs. The aim of this study was to evaluate the feasibility, efficacy and durability of AUI with FFBP.
Design. The results of a single institution and a single surgeon were prospectively collected from January 2002 to August 2010. All patients were followed up at 1, 3, 6 and 12 months and then annually.
Results. There were 33 patients (27 males) with a mean age of 71.7 years (range 46 - 84). Open surgery posed an unacceptably high risk to all patients owing to advanced age and/or American Society of Anesthesiologists (ASA) classification 3/4. Ineligibility for BFG was due to unfavourable anatomy or a combination of factors in most cases (31 patients). Two patients had anastomotic aneurysms after previous open surgery.
The technical success rate was 100%. One severe intraoperative complication occurred (perforated iliac artery). Two patients (ASA 4) died within 30 days (peri-operative mortality rate 6.1%). Seven patients (21.1%) developed postoperative wound complications. Eight patients died during follow-up of non-aneurysm-related conditions. Twenty-three patients are alive, with mean follow-up of 24.4 months and a survival rate of 69.7%. Two complications occurred during long-term follow-up, namely 1 case of graft sepsis and 1 of FFBP occlusion.
Conclusion. AUI with FFBP is a safe, effective and durable alternative in high-risk patients with AAAs where standard open repair is contraindicated and BFG repair is not possible owing to unfavourable aneurysm morphology.
Intussusception in children : experience with 105 patients in a department of paediatric surgery, Turkey : paediatric surgerySource: South African Journal of Surgery 50, pp 37 –39 (2012)More Less
Aim. The aim of this study was to present our experience in patients with intussusception (IN).
Materials and methods. One hundred and five cases of IN treated between 1991 and 2007 were analysed. Age, gender, symptoms, signs, diagnostic and treatment methods, types of IN including leading point, and postoperative complications were evaluated.
Results. The mean age of the patients was 2.5 years (range 1 month - 15 years). Fifty-nine per cent (62/105) were under 1 year of age, and of these 28% were receiving therapy for upper respiratory tract infection. The most common symptom was colicky abdominal pain. Rectal bleeding was present in all patients under 2 years of age. In 23 children (21.9%) leading points were detected. Thirty per cent of the patients were older than 4 years, and 76.6% of these had leading points. Ultrasonography demonstrated the invaginated segment in 93 patients. Hydrostatic reduction was attempted in 71.4% (75) of the patients and was successful in 48% (36), 70% of whom were under 1 year of age. Of the patients with unsuccessful hydrostatic reduction, 11 required intestinal resection and primary anastomosis and 35 manual reduction. Twenty-four patients were diagnosed by means of ultrasonography and were operated on immediately. Ten of these patients had signs of peritonitis on admission and were treated by resection-primary anastomosis.
Conclusion. In patients with IN under 2 years of age, hydrostatic or pneumatic reduction may be successful. Considering the high incidence of leading points in older children, one should not persist with reduction but should rather design a treatment plan accordingly, i.e. laparotomy with manual reduction or resection.
Association between low serum free testosterone and adverse prognostic factors in men diagnosed with prostate cancer in KwaZulu-Natal : urologySource: South African Journal of Surgery 50, pp 40 –42 (2012)More Less
Background. The association of serum free testosterone (FT) with prostate cancer is not fully understood. Studies on the results of the relationship between serum testosterone level and prostate cancer are conflicting. However, there is a reported association between lower serum testosterone levels and high-grade prostate cancer.
Objective. To investigate the relationship between serum FT and the clinico-pathological characteristics of prostate cancer in South African patients.
Materials and methods. The clinical data of 109 consecutive patients diagnosed with prostate cancer on biopsy were evaluated prospectively. The variables were age, ethnic group, prostate-specific antigen (PSA), digital rectal examination (DRE) findings, clinical tumour, nodes and metastases (TNM) stage, and Gleason score. Low serum FT was defined as <250 ng/dl. Statistical analysis was performed using Stata V10 software (p<0.05 considered significant).
Results. There was a statistically significant association between low serum FT and high serum PSA, high Gleason score and clinically advanced stage prostate cancer.
Conclusions. In this cohort of men with histologically diagnosed prostate cancer, low serum FT was associated with higher PSA, higher grade, and locally advanced or metastatic prostate cancer.
Source: South African Journal of Surgery 50, pp 43 –44 (2012)More Less
Intussusception is usually a disease of children aged between 6 months and 4 years, in which a part of a bowel telescopes into another part of the bowel. We report a case in a 60-year-old man who required resection and anastomosis. Although intussception is unusual in adults, awareness of the differences in symptoms and causes should be borne in mind when adults present with intestinal obstruction.
Source: South African Journal of Surgery 50, pp 45 –46 (2012)More Less
Gastrointestinal duplications are uncommon congenital lesions that can occur anywhere along the alimentary tract, and the symptoms of which generally develop during infancy or childhood. Completely isolated duplication cysts are an extremely rare variant of duplication, where no communication between the cyst and the adjacent bowel segment is present. We report the unique case of an adult who presented with right lower abdominal pain and systemic signs of inflammation caused by infection of a completely isolated ileal duplication cyst. Histological examination of the cyst additionally revealed a low-grade mucinous cystadenoma. We discuss the clinical presentations, diagnosis and treatment of this rare entity.
Source: South African Journal of Surgery 50, pp 47 –49 (2012)More Less
The pedicled buccal fat pad is a reliable flap for the repair of small oral defects. It is durable, easy to harvest, and should be considered in settings where access to free flaps is limited and in cases where previous flaps have failed. We discuss a case in which this flap was used successfully for closure of an oro-antral fistula. The indications, anatomy and techniques of successful harvest are discussed.
Source: South African Journal of Surgery 50, pp 50 –51 (2012)More Less
A patient with the 'whirl sign' on computed tomography is 25.3 times as likely as a patient without the sign to have small-bowel obstruction (SBO) necessitating surgery. The 'whirl sign' therefore has an important role in the assessment of patients with clinical and radiological signs of SBO.
Author Viroj WiwanitkitSource: South African Journal of Surgery 50 (2012)More Less
I read the recent article on the relationship between thyroglobulin and recurrence of thyroid cancer with great interest. Papageorgiou et al. concluded that 'Although low, a cutoff Tg level of 1.3 ng/ml represents a simple indication for further investigation in patients receiving thyroxine after completion of treatment for thyroid cancer, in the absence of measurement of anti-Tg auto-antibodies'.