South African Journal of Surgery - Volume 51, Issue 1, 2013
Volume 51, Issue 1, 2013
Source: South African Journal of Surgery 51, pp 2 –4 (2013)More Less
The modern era of safe liver resection is based on notable advances in non-invasive solid organ imaging, improved anaesthetic management, enhanced knowledge of segmental liver anatomy as described by Couinaud, better surgical technique, an appreciation of the functional reserve of the liver remnant, and the remarkable capacity of normal liver to regenerate. The evolution and development of the surgical techniques utilised during liver resection are largely an account of the efforts to minimise bleeding during hepatic parenchymal transection. Three decades ago, major liver resection was associated with mortality rates of up to 20%, and excessive bleeding was an important and common cause of operative mortality. Liver resection can now be accomplished with mortality rates of less than 3% in most specialised hepatopancreato-bilary (HPB) centres. While better patient selection and improved assessment of intrinsic liver reserve are important factors, reduced blood loss and the diminishing need for blood transfusion have been additional reasons for improved perioperative outcome. Other advances in operative technique, including improved delineation of the optimal transection plane with intra-operative ultrasound and the benefit of intermittent inflow occlusion, have also contributed to a reduction in blood loss during major liver resections.
Temporary vascular shunting in vascular trauma : a 10-year review from a civilian trauma centre : general surgerySource: South African Journal of Surgery 51, pp 6 –10 (2013)More Less
Background. Temporary intravascular shunts (TIVSs) can replace immediate definitive repair as a damage control procedure in vascular trauma. We evaluated their use in an urban trauma centre with a high incidence of penetrating trauma.
Method. A retrospective chart review of all patients treated with a TIVS in a single centre between January 2000 and December 2009.
Results. Thirty-five TIVSs were placed during the study period: 22 were part of a damage control procedure, 7 were inserted at a peripheral hospital without vascular surgical expertise prior to transfer, and 6 were used during fixation of a lower limb fracture with an associated vascular injury. There were 7 amputations and 5 deaths, 4 of the TIVSs thrombosed, and a further 3 dislodged or migrated. Twenty-five patients underwent definitive repair with an interposition graft, 1 primary anastomosis was achieved, and 1 extra-anatomical bypass was performed. Five patients with non-viable limbs had the vessel ligated.
Conclusions. A TIVS in the damage control setting is both life- and limb-saving. These shunts can be inserted safely in a facility without access to a surgeon with vascular surgery experience if there is uncontrollable bleeding or the delay to definitive vascular surgery is likely to be more than 6 hours. A definitive procedure should be performed within 24 hours.
A comparative study assessing a new tool for occluding parenchymal blood flow during liver resection for hepatocellular carcinoma : general surgerySource: South African Journal of Surgery 51, pp 12 –15 (2013)More Less
Background. The aim of this study was to compare the efficacy of a new tool (the hepatic section vascular blocker, HSVB) with hepatic pedicle clamping and hemihepatic vascular exclusion to control bleeding during liver resection for cancer.
Methods. Clinical data on 117 patients who underwent liver resection from 2004 to 2009 were analysed retrospectively. Forty-two patients had liver resection using the HSVB (group A), in 35 patients hemihepatic vascular exclusion was used (group B), and in 40 patients hepatic pedicle clamping with a Pringle manoeuvre was used (group C). Blood loss, operative time, postoperative hepatic function and complications were compared.
Results. Mean blood loss and operative time in group A were significantly less than in groups B (p=0.026 and p<0.001, respectively) and C (p<0.001 and p<0.001). There were significant differences between groups A and C in total bilirubin (TB) and alanine transaminase (ALT) levels on postoperative days 3 and 7, and group A had better hepatic function (TB p=0.014 and p=0.009; ALT p<0.001 and p<0.001). The rate of postoperative ascites was significantly higher in group C compared with group A (p<0.001). In group C, 2 patients had liver failure, 1 had a gastrointestinal haemorrhage and 1 died.
Conclusions. Using the HSVB during liver resection effectively controlled bleeding, saved operative time and preserved hepatic function. It proved to be a safe and feasible technique.
Source: South African Journal of Surgery 51, pp 16 –21 (2013)More Less
Background. In a previous study we identified 206 patients with colorectal adenocarcinoma in the Northern Cape province of South Africa, diagnosed between January 2002 and February 2009. The age-standardised incidence was 4.2/100 000 per year world standard population. This is 10% of the rate reported in First-World countries. In high-incidence areas, the rate of abnormal mismatch repair gene expression in colorectal cancers is 2 - 7%.
Objectives. The aim of this study was to determine the prevalence of hMLH1- and hMSH2-deficient colorectal cancer in the Northern Cape.
Methods. Formalin-fixed paraffin wax-embedded tissue blocks from 87 colorectal adenocarcinomas identified in the previous study were retrieved. Standard immunohistochemical staining methods were used to detect the expression of hMLH1 and hMSH2 (i.e. products of the hMLH1 and hMSH2 genes) in the tumours using heat-induced antigen retrieval and diaminobenzidene as a chromogen.
Results. In 8 blocks there was insufficient tumour tissue and in 1 case the immunohistochemical staining failed, probably owing to poor fixation, leaving 78 cases for analysis. In 11 cases hMLH1 was deficient and in 6 cases hMSH2 was deficient. Overall, 21.8% of cancers were deficient for hMLH1 or hMSH2.
Conclusion. Presuming that 80% of all hMLH1 deficiencies are due to hypermethylation of the gene, we found 10.5% of colorectal cancers in an area with a low incidence of colorectal cancer to be deficient in the product of the mismatch repair gene/s. This is approximately three times the reported rate in high-incidence areas.
Does sentinel lymph node biopsy have a role in node-positive head and neck squamous carcinoma? : head and neck surgerySource: South African Journal of Surgery 51, pp 22 –25 (2013)More Less
Objectives/hypothesis. The objective of the study was to determine whether sentinel lymph node biopsy (SLNB) can be used to reduce clinical overstaging of cervical nodes in head and neck squamous cell carcinoma (SCC) in a developing world setting.
Study design. Sentinel and echelon lymph nodes were identified by means of a combination of lymphoscintigraphy, gamma probe and blue dye staining. They were analysed histologically and their pathological status was compared with the rest of the neck dissection specimen to determine diagnostic accuracy in patients with T1-4 N0-3 SCC of the oral cavity or oropharynx undergoing primary surgical resection and neck dissection.
Results. Thirty-three patients were included in the study, 13 in the node-negative (N0) and 20 in the node-positive (N+) group. In the clinically N0 group the sensitivity of SLNB was 100% and the negative predictive value (NPV) 100%. In the clinically N+ group the sensitivity was 71% and the NPV 60% for staging the nodal status of the neck.
Conclusion. The accuracy of SLNB in the clinically N+ neck is too low for SLNB to be a means of avoiding comprehensive neck dissection.
Level of evidence: 2B.
Paediatric blunt abdominal trauma - are we doing too many computed tomography scans? : paediatric surgerySource: South African Journal of Surgery 51, pp 26 –31 (2013)More Less
Background. Blunt abdominal trauma in childhood contributes significantly to both morbidity and mortality. Selective non-operative management of blunt abdominal trauma in children depends on both diagnostic and clinical factors. Computed tomography (CT) scanning is widely used to facilitate better management. Increased availability of CT may, however, result in its overuse in the management of blunt abdominal trauma in children, which carries significant radiation exposure risks.
Aim. To evaluate the use and value of CT scanning in the overall management and outcome of blunt abdominal trauma in children in the Tygerberg Academic Hospital trauma unit, Parow, Cape Town, South Africa, before and after improved access to CT as a result of installation of a new rapid CT scanner in the trauma management area (previously the scanner had been 4 floors away).
Methods. Patients aged 0 - 13 years who were referred with blunt abdominal trauma due to vehicle-related accidents before the introduction of the new CT scanner (group 1, n=66, November 2003 - March 2009) were compared with those seen in the 1-year period after the scanner was installed (group 2, n=37, April 2009 - April 2010). Details of clinical presentation, imaging results and their influence on management were retrospectively reviewed. A follow-up group was evaluated after stricter criteria for abdominal CT scanning (viz. prior evaluation by paediatric surgical personnel) were introduced (group 3, n=14, November 2011 - May 2012) to evaluate the impact of this clinical screening on the rate of negative scans.
Results. There were 66 patients in group 1 and 37 in group 2. An apparent increase in CT use with increased availability was accompanied by a marked increase in negative CT scans (38.9% compared with 6.2%; p<0.006). Despite a slightly higher prevalence of associated injuries in group 2, as well as a slightly longer length of hospital stay, there was a similar prevalence of intra-abdominal injuries detected in positive scans in the two groups. In addition, rates of small-bowel perforation in the two groups were similar. The rate of negative scans in group 3 was 46.2% (6/13), but all except one of these patients had a severe brain injury preventing adequate clinical evaluation of intra-abdominal injury.
Conclusion. CT scanning for blunt abdominal trauma in children is essential in the presence of appropriate clinical indications. Ease of access probably increases availability, but the rate of negative scans may increase. Management guidelines should be in place to direct CT scanning to cases in which clinical examination and/or other modalities indicate a likelihood of intra-abdominal injury. The principle of 'as low (radiation) dose as reasonably achievable' (ALARA) should be adhered to because of the increased radiation exposure risks in children.
Source: South African Journal of Surgery 51, pp 32 –33 (2013)More Less
Source: South African Journal of Surgery 51, pp 33 –34 (2013)More Less
An 18-year-old girl with no psychiatric history presented with abdominal pain. Four months previously she had given birth to a healthy baby. On palpation, a painful abdominal mass was identified in the epigastric region, and gastrotomy was performed. A J-shaped hair-wool ball and two large pieces of sheep's wool were removed. No history of trichotillomania was reported.
Rapid pre-operative diagnosis of ileal hernia through the foramen of Winslow with multi-detector computed tomography, enabling successful laparoscopic reduction : case reportSource: South African Journal of Surgery 51, pp 35 –37 (2013)More Less
Internal hernias through the foramen of Winslow are extremely rare. Prompt diagnosis and early surgical reduction are vital to prevent bowel gangrene and avoid resection. We report a case of ileal hernia through the foramen of Winslow in a 48-year-old woman. She presented to the emergency department with acute epigastric pain, and rapid and definitive pre-operative diagnosis of internal hernia of ileum through the foramen of Winslow without ischaemia was made by means of multi-detector computed tomography. Emergency laparoscopic bowel reduction was performed. The postoperative course was uneventful, and the patient recovered rapidly.
Source: South African Journal of Surgery 51, pp 38 –39 (2013)More Less
One of the most critical tenets of burn care is efficient triage of the victim of severe burns and transfer to a burns unit or centre where resuscitation and definitive care can be most effectively implemented. It is well established that a multidisciplinary team accustomed to managing such patients should undertake this care.
Author R.T. GrundmannSource: South African Journal of Surgery 51 (2013)More Less
This book describes the principles of care of the diabetic surgical patient with an emphasis on diabetic foot problems. It is the third updated edition since its first publication in 2002. The overwhelming majority of the contributors work in the USA, and experience at the Joslin-Beth Israel Deaconess Foot Center in particular is presented.