South African Journal of Surgery - Volume 51, Issue 2, 2013
Volume 51, Issue 2, 2013
Source: South African Journal of Surgery 51, pp 42 –43 (2013)More Less
Colorectal cancer (CRC) is the third most common cancer and cause of cancer-related death worldwide. The majority of individuals who develop CRC have sporadic disease, but up to 20% may have an inherited predisposition. The two most common forms of autosomal dominant inherited colorectal cancer disorders are hereditary non-polyposis colorectal cancer (HNPCC), or Lynch syndrome, and familial adenomatous polyposis (FAP). The interesting publication by Vergouwe et al. in the February issue of SAJS highlights the high incidence of inherited CRC in a low-incidence area in South Africa. The authors postulate that inherited CRCs may constitute a significant portion of the total disease burden of CRC in South Africa. To put the implications of this article in context, it is important to understand the advances in understanding of the genetics and their implication for early detection and treatment of patients and their families with these hereditary conditions. Lynch syndrome is the commoner of the two, accounting for 2 - 7% of inherited colorectal cancers, with FAP accounting for less than 1%.
An honour and a privilege
28th Biennial Congress of the Association of Surgeons of South Africa, East London, 14 March 2013 : ASSA presidential addressAuthor R.S. Du ToitSource: South African Journal of Surgery 51, pp 44 –45 (2013)More Less
Pre-operative diagnosis of thyroid cancer : clinical, radiological and pathological correlation : general surgerySource: South African Journal of Surgery 51, pp 46 –49 (2013)More Less
Aim. Ultrasonography and fine-needle aspiration biopsy (FNAB) are the mainstays of diagnosing thyroid cancer accurately and reducing the number of diagnostic lobectomies. No benchmark for diagnostic accuracy has been published in the South African context. This single-institution study addresses this deficit.
Methods. The oncology, pathology and surgical records of all patients diagnosed with thyroid carcinoma from 2004 to 2010 at Groote Schuur Hospital, Cape Town, South Africa, were reviewed and data were recorded on a standardised confidential proforma. The findings on pre-operative clinical assessment, ultrasound and FNAB were correlated with the histopathology results. Diagnostic accuracy for thyroid cancer was determined by correlating pre-operative investigations with the final diagnosis. Sensitivity of ultrasound and FNAB were calculated.
Results. A total of 109 patients, 79 female and 30 male, were identified. The majority (99, 90.8%) had well-differentiated thyroid cancers (56 papillary, 30 follicular, 10 mixed and 3 Hurtle cell carcinomas). There were 6 anaplastic and 4 medullary carcinomas. Of the 109 patients 38 had a definite pre-operative diagnosis, in 61 a malignant tumour was suspected, and 10 had surgery for benign disease. FNAB was inadequate in 11 cases and the findings indicated a benign lesion in 47, a suspicious lesion in 13 and a malignant lesion in 38 patients diagnosed with thyroid carcinoma. FNAB diagnosed all patients with medullary and anaplastic carcinoma but less than half of those with well-differentiated thyroid carcinoma. Ultrasound scans detected at least one suspicious feature in 44 patients. Micro-calcification was the most common sign.
Conclusion. The rate of pre-operative diagnosis of well-differentiated thyroid carcinomas in this unit is under 50%, well below international norms. Our standard practice needs to change to include ultrasound-guided FNAB and standardised reporting of high-resolution ultrasound and cytology, before reassessment of our diagnostic accuracy.
Source: South African Journal of Surgery 51, pp 50 –53 (2013)More Less
Background.Pseudomonas aeruginosa infection is a major cause of morbidity in burns patients. There is a paucity of publications dealing with this infection in the paediatric population. We describe the incidence, microbiology and impact of P. aeruginosa infection in a dedicated paediatric burns unit.
Methods. A retrospective review of patients with clinically significant P. aeruginosa infection between April 2007 and January 2010 in the burns unit at Red Cross War Memorial Children's Hospital in Cape Town, South Africa, was performed.
Results. During the 36-month study period, 2 632 patients were admitted. Of 2 791 bacteriology samples sent for microscopy, culture and sensitivity, 406 (14.5%) were positive for P. aeruginosa. Thirty-four patients had clinically significant P. aeruginosa wound infection, giving an incidence of 1.3%. Three patients had loss of Biobrane or allografts, and 23 cases of skin graft loss occurred in 18 patients. An average of 12 dressing days was needed to obtain negative swabs. All isolates were sensitive to chlorhexidine, whereas 92.5% were resistant to povidone-iodine. Piperacillin-tazobactam was the systemic antimicrobial to which there was most resistance (36.1%), and tobramycin had least resistance (3.3%).
Conclusions. The incidence of clinically significant burn wound infection is low in our unit, yet the morbidity due to debridement and re-grafting is significant. We observed very high resistance to topical povidone-iodine. Resistance to systemic antimicrobials is lower than that reported from other burns units.
Initial experience with laparoscopic splenectomy for immune thrombocytopenic purpura : general surgerySource: South African Journal of Surgery 51, pp 54 –56 (2013)More Less
Background. Laparoscopic splenectomy has become the preferred method of splenectomy for refractory immune thrombocytopenic purpura (ITP). We present our experience with the introduction of laparoscopic splenectomy for ITP.
Methods. Over a 2-year period, retrospective and prospective data were collected on all patients undergoing laparoscopic splenectomy for ITP at our institution. We analysed demographic data, peri-operative courses, platelet count responses and complications.
Results. Twenty laparoscopic splenectomies were performed. There were 2 conversions to an open procedure. The average operating time was 100 minutes (range 30 - 170 minutes), and mean blood loss was 106 ml (range 50 - 200 ml). There were no deaths or major complications. The mean follow-up period was 7 months. Ninety-five per cent of patients had a complete or partial response to splenectomy.
Conclusion. Laparoscopic splenectomy can be introduced safely with an acceptable conversion rate, and is an effective treatment for ITP on short-term follow-up.
Palpable discrete breast masses in young women : two of the components of the modified triple test may be adequate : general surgerySource: South African Journal of Surgery 51, pp 58 –60 (2013)More Less
Background. Palpable breast masses in young women, though usually benign, are a common source of anxiety. Current practice is assessment using the modified triple test (MTT). This entails clinical breast examination (CBE), ultrasound scans and cytological examination of a fine-needle aspiration biopsy specimen (FNAC). It is unclear whether it is necessary to utilise all three components in most patients.
Objectives. We aimed to determine the diagnostic value of the MTT for the evaluation of palpable discrete breast masses in women under 35 years of age, and to assess the performance of its components when used individually or in combinations of two.
Design and setting. This was a cross-sectional study carried out between August 2010 and October 2010 in the breast and general surgical outpatient clinics at Kenyatta National Hospital, Nairobi, Kenya.
Patients and methods. Fifty-eight patients presenting during the study period with palpable discrete breast masses satisfying the inclusion criteria were recruited. All patients had a CBE, ultrasound scans and FNAC. A core biopsy was performed as a reference standard.
Main outcome measures. The test results of the MTT and its elements (CBE, ultrasonography and FNAC) were compared with the histological findings (the reference standard).
Results. The age range of the 58 patients was 18 - 34 years (mean 25.5 years, standard deviation 5.1 years). Forty-five patients (77.6%) had concordant MTT results (agreement in all the three components). Concordant MTTs had a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 100%. Sensitivity, specificity, PPV and NPV were 100%, 92.3%, 60% and 100%, respectively, for CBE; 100%, 94.2%, 66.7% and 100%, respectively, for ultrasonography; and 100%, 98.1%, 83.3% and 100%, respectively, for FNAC. The combinations CBE plus ultrasound and CBE plus FNAC had sensitivities, specificities, PPVs and NPVs of 100%.
Conclusion. Use of the MTT for diagnosis of palpable breast masses in young women (<35 years of age) yields high diagnostic accuracy. The combinations of CBE plus ultrasound and CBE plus FNAC have high PPVs and NPVs with almost similar concordance in this population, suggesting that they can be used for diagnosis and therefore could be modelled for use in patients choosing between conservative care and excision.
Source: South African Journal of Surgery 51, pp 62 –66 (2013)More Less
Objectives. The standard predictive factors of actuarial survival such as T and N stage become less important as patients live for more than 10 years after treatment of cancer. Reports of actual 10-year survivors of oesophageal squamous cell carcinoma (SCC) are rare, and demographic and clinicopathological factors associated with 10-year survival have not been well documented. In this research we evaluated factors predictive of actual, as opposed to actuarial, 10-year survival.
Methods. We retrospectively analysed 1 046 patients who had undergone oesophagectomy for oesophageal SCC. The demographic and clinicopathological characteristics of patients who were alive more than 10 years after oesophagectomy and those of patients who had died were compared.
Results. Univariate analysis showed that 18 factors differed significantly between the two groups. Based on logistic regression analysis, factors associated with 10-year survival were younger age, female gender, absence of dysphagia, a left transthoracic surgical approach, lower pathological T stage, and fewer metastatic lymph nodes.
Conclusion. The independent positive predictors of actual as opposed to actuarial 10-year survival are younger age, female gender, absence of dysphagia, lower pathological T stage, and fewer metastatic lymph nodes.
Source: South African Journal of Surgery 51, pp 68 –72 (2013)More Less
Introduction. Octogenarians constitute a rapidly growing segment of patients undergoing colorectal cancer resection, but their outcomes remain understudied and under-reported. Our aims were to analyse outcomes of octogenarian patients undergoing curative colorectal resections compared with a similar cohort 2 decades younger.
Methods. Data from a prospectively collected database of consecutive patients undergoing colorectal resection between 2004 and 2006 were analysed. Primary endpoints were 30-day mortality and morbidity. The secondary endpoint was long-term survival.
Results. Eighty-one consecutive patients aged >80 years and 61 patients aged 60 - 70 years undergoing elective and emergency resections were identified. In the octogenarian group, 75.3% of resections were elective compared with 78.0% in the younger cohort (p=0.9), with pelvic procedures accounting for 34.6% and 44.3%, respectively (p=0.34). The elderly had a significantly higher median CR-Possum (performance status) score than the younger cohort (18.0 v. 14.0; p=0.001). Permanent stoma rates were similar (22% for octogenarians v. 27% for younger patients; p=0.8), as was pathological stage (p=0.24). There was 1 death within 30 days after resection in each group. Median survival in the octogenarian cohort was 73 months compared with 74 months in the younger cohort, and 5-year survival rates were 53.1% and 66.0%, respectively (p=0.2, Mantel-Cox). CR-Possum score did not affect overall survival (p=0.711, Mantel-Cox), but a higher score correlated with more postoperative complications in both groups.
Conclusions. Octogenarians have poor performance status, but can undergo resection with acceptable mortality and morbidity. Overall survival in the two age groups studied was similar, with poor performance status being associated with higher postoperative complications but no long-term difference in survival.
Author G. Wenzel-SmithSource: South African Journal of Surgery 51, pp 73 –74 (2013)More Less
Bochdalek hernia (BH), a closing defect of the peripheral posterior aspect of the diaphragm, is the most common of the congenital diaphragmatic hernias and is usually diagnosed in neonates. Symptomatic presentation of a right-sided diaphragmatic hernia in an adult is unusual. Owing to their rarity and varied presentation, these hernias can pose a diagnostic challenge. A right-sided BH in a 40-year-old woman who presented with respiratory distress associated with abdominal pain and symptoms of small-bowel obstruction is reported. Midline laparotomy revealed necrotic small bowel and faecothorax of the pleural cavity. Diaphragmatic hernias should be included in the differential diagnosis of patients with acute or chronic gastrointestinal, or less frequently respiratory, symptoms.
Post-traumatic diaphragmatic hernias - importance of basic radiographic investigations : case reportAuthor E. MansoorSource: South African Journal of Surgery 51, pp 75 –76 (2013)More Less
This case presentation highlights important principles in the management of post-traumatic diaphragmatic hernia. A suggestive history should prompt early diagnosis even if the patient appears well. The chest radiograph, although not pathognomonic, is extremely useful in the detection of diaphragmatic hernia if accurately interpreted. Herniated bowel is at high risk of strangulation, especially in the presence of a 'ribbon sign'. Delayed operative intervention can prove fatal.
Source: South African Journal of Surgery 51, pp 77 –79 (2013)More Less
A 22-year-old man sustained a strangulation-type injury to the neck, with bilateral blunt carotid artery injuries detected on computed tomography (CT) angiography. His Glasgow Coma Score was 15/15, and he was managed conservatively with therapeutic lowmolecular-weight heparin and antiplatelet therapy. A repeat CT angiogram 6 weeks later showed complete resolution of an intimal flap, and he demonstrated no neurological deterioration. There are no definitive management guidelines regarding this type of injury, and our report emphasises the role of conservative anticoagulation therapy in the management of this rare condition.