South African Journal of Surgery - Volume 52, Issue 1, 2014
Volume 52, Issue 1, 2014
Understanding the reasons for delay to definitive surgical care of patients with acute appendicitis in rural South Africa : general surgerySource: South African Journal of Surgery 52, pp 2 –5 (2014) http://dx.doi.org/10.7196/SAJS.1737More Less
Appendicitis in South Africa is associated with prolonged delays to definitive surgical care and significant morbidity due to intra-abdominal sepsis. This is a directly causal relationship, as delayed source control has repeatedly been shown to be the variable most closely associated with poor outcomes from intra-abdominal sepsis. Strategies and quality improvement interventions designed to reduce the morbidity associated with acute appendicitis must attempt to reduce delays to definitive care. However, there is a paucity of research on the reasons for these delays. If the treatment of appendicitis is thought of as a process of care, there are a number of distinct areas or domains within the process where delay can be experienced. There may be a significant delay between the onset of symptoms and the patient making contact with the healthcare system. Once the patient has made contact with the system, further delays can be experienced. These include delayed recognition of the need for surgical care and subsequent logistical delays in transferring the patient to the regional hospital. This audit quantifies the delay to definitive surgical care of acute appendicitis in our system and attempts to increase our understanding of where in the process of care the delay was experienced and the factors that contributed to delay in each area or domain. It is hoped that this information may allow for the development of targeted quality improvement programmes.
Source: South African Journal of Surgery 52, pp 5 –9 (2014) http://dx.doi.org/10.7196/SAJS.1970More Less
Background: The risk of malignancy in patients with multinodular goitre (MNG) is approximately 7.2%. The gold standard for diagnosis of thyroid cancer is fine-needle aspiration biopsy (FNAB). Unsuccessful, inconclusive or suspicious results mandate further investigations. The concern is that with a benign FNAB result there is no indication for surgery unless the patient has compression symptoms or cosmetic issues, but the risk of missed malignancy is nevertheless present.
Objective: To determine the prevalence and histological features of incidental cancers in patients who had thyroidectomy for MNG.
Method: Records of patients who underwent thyroidectomy between January 2005 and December 2010 at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, were retrospectively reviewed. Data retrieved included demographic characteristics of the patients, type of thyroidectomy, thyroid function test results, FNAB cytology and final histology results.
Result: A total of 166 thyroidectomies were performed on 162 patients, the majority (139) of whom were females. The mean age was 46 years (range 15 - 79 years). A total of 120 pre-operative FNABs were available for analysis, 78 of which were suggestive of benign nodular goitre; 70 benign FNAB results were histologically confirmed to be MNG after thyroidectomy. Incidental malignancy was found in four of 70 cases of MNG (5.7%); all were papillary carcinomas, predominantly (75.0%) the follicular variant.
Conclusion: The risk of missing cancer in patients with MNG was 5.7%. The commonest histological subtype of thyroid cancer found in MNG was papillary carcinoma.
Source: South African Journal of Surgery 52, pp 10 –12 (2014) http://dx.doi.org/10.7196/SAJS.1604More Less
Background: The rising incidence of HIV/AIDS has resulted in a resurgence of abdominal tuberculosis (TB) in HIV-positive patients in South Africa. These often debilitated patients frequently present with acute complications requiring surgery.
Methods: A prospective audit of all patients with abdominal TB undergoing emergency laparotomy was conducted. From January 2008 to June 2010, 49 patients had emergency laparotomy and specimens obtained from them were diagnostic of TB. Twenty-five were males and 24 females, with a median age of 32 years (range 2 - 62). Thirty-nine patients were HIV-positive (79.6%).
Results: Intra-operative findings were bowel perforations in 13 cases, small-bowel obstruction in seven, a frozen abdomen in ten, and enlarged lymph nodes and an ileocaecal mass in 19. Eleven patients (22.4%) underwent small-bowel resection and eight (16.3%) right hemicolectomy. Eighteen patients (36.7%) ended up with stomas, 14 (28.6%) had re-laparotomies, and 18 (36.7%) were admitted to the intensive care unit. Twenty-three patients (46.9%) required blood transfusion and 15 (30.6%) total parenteral nutrition. Three patients (6.1%) developed an enterocutaneous fistula and 19 (38.8%) died. Pre-operative illness severity indices of acidosis, anaemia and hypo-albuminaemia were significant predictors of death, but mode of presentation and surgical interventions were not.
Conclusion: Laparotomy as currently practised for the 'acute abdomen' in patients with suspected HIV and abdominal TB is associated with very high morbidity and mortality, which is related to pre-operative severity indices. More liberal use of imaging may define cases in which a more conservative approach could improve outcome.
Source: South African Journal of Surgery 52, pp 13 –17 (2014) http://dx.doi.org/10.7196/SAJS.1571More Less
Objectives: To study the use of limb perfusion scans in children with limb-threatening ischaemia and determine whether such scans are helpful in making clinical decisions.
Methods: This retrospective study compared the clinical, scan and surgical findings in children who had limb perfusion scans for critical limb ischaemia at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, from July 2001 to December 2010. Records were reviewed and the data analysed for aetiology, clinical findings, limb perfusion results, operative findings and outcome.
Results: There were complete clinical and scan records for 20/22 patients, aged 1 month to 12 years. The causes of limb ischaemia were meningococcal septicaemia (n=9), septic shock (n=6), hypovolaemic shock due to gastroenteritis (n=4), and electrical burns (n=1). The clinical, scan and surgical findings correlated in 40/48 imaged limbs. In one leg the findings did not correlate, but the perfusion scan results predicted the outcome. In the remaining seven cases the exact correlation was uncertain owing to technical difficulties or absent operative notes.
Conclusion: This study describes a method for performing limb perfusion studies in children. Limb perfusion studies correlated well with surgical findings. These studies were useful in treatment decisions, parent and patient counselling and surgical planning. They supplemented clinical examination in assessment of the children.
The intramyocardial left anterior descending artery : prevalence and surgical considerations in coronary artery bypass grafting : vascular surgerySource: South African Journal of Surgery 52, pp 18 –21 (2014) http://dx.doi.org/10.7196/SAJS.1572More Less
Background: Major coronary arteries usually have a subepicardial course and only dip into the myocardium near or at their termination. However, occasionally a segment of the epicardial artery may have an intramural course, and it is often referred to as a myocardial bridge. The left anterior descending (LAD) artery is the most commonly bridged vessel. Its prevalence has been evaluated at both autopsy and angiography. However, in the literature reviewed it is apparent that there are no reports of the prevalence of the intramyocardial LAD (IMLAD) artery in coronary artery bypass graft (CABG) series.
Objectives: To document the prevalence of the IMLAD artery in a series of CABGs and to describe the surgical techniques used in these cases.
Methods: A retrospective analysis of 1 349 surgical reports of consecutive CABGs performed over a period of 23 years was conducted.
Results: An IMLAD artery was present in 293 patients (21.7%). The prevalence was 20.2% (51/253) in females and 22.1% (242/1 096) in males. The IMLAD arteries extended into the interventricular septum in 3.8% (11/293) of the patients.
Conclusion: An intramyocardial course of the LAD artery is relatively common in patients undergoing CABG and poses a challenge in bypass grafting. Techniques are described to address this anatomical variation when it is encountered at surgery.
Severity of upper-limb panga injuries and infection rates associated with early v. late tendon repair : traumaSource: South African Journal of Surgery 52, pp 22 –25 (2014) http://dx.doi.org/10.7196/SAJS.1716More Less
Background: Panga or machete attacks are a common cause of significant upper-limb trauma in South Africa. Pangas are a multipurpose household tool used predominantly for foraging and agricultural purposes and are highly contaminated. While some centres advocate immediate primary repair if no concern exists regarding the risk of infection, others delay definitive repair until satisfied there is no evidence of infection.
Objectives: To compare infection rates and tendon re-rupture following early primary repair (within 24 h), primary repair after 24 h, and delayed repair following initial debridement.
Methods: We conducted a multicentre, retrospective, observational study of 49 patients (mean age 28.9 years; range 17 - 69), who were followed up for a mean of 3.4 months (range 0 - 8). The injuries sustained included 32 flexor tendon injuries, 14 extensor tendon injuries, 9 fractures and 21 peripheral nerve injuries.
Results: Of the patients, 17 underwent early primary repair (within 24 h), 19 delayed primary repair, and 13 delayed repair following primary washout. Wounds were assessed postoperatively using the ASEPSIS wound scoring system and patients were clinically assessed for tendon re-rupture. No significant differences were found in the comparative infection rates for early primary repair (5.9%; 1/17), delayed primary repair (10.5%; 2/19) and delayed repair following primary washout (23.1%; 3/13; p=0.662).
Conclusion: Our results indicate indicate that panga injuries can be repaired safely at first presentation with no increased risk of infection or re-rupture.
Source: South African Journal of Surgery 52, pp 26 –28 (2014) http://dx.doi.org/10.7196/SAJS.1691More Less
Endometriosis, a relatively common condition, rarely involves the bowel; even more rarely does it present as a large-bowel stricture with intestinal obstruction. We report the case of a young woman who presented to an emergency department with intestinal obstruction secondary to an endometriotic stricture of the sigmoid colon, without evidence of disease elsewhere in the peritoneal cavity. Although large-bowel obstruction is usually caused by a malignant tumour, it can sometimes result from rare causes such as endometriosis. Symptoms of a cyclical nature may remind the clinician of this possibility.
Colonic perforation following endoscopic retrograde cholangiopancreatography-associated pancreatitis : case reportAuthor V.G. NaidooSource: South African Journal of Surgery 52, pp 29 –31 (2014) http://dx.doi.org/10.7196/SAJS.2012More Less
We highlight a potentially lethal complication of acute severe pancreatitis that may not be suspected in severely ill patients. A 41-year-old woman developed acute severe pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis. When her condition deteriorated dramatically after 2 weeks of intensive medical management, a computed tomography scan and water-soluble contrast enema examination revealed a large colonic perforation and associated collection in the right flank. Surgical management included an extended right hemicolectomy and a second laparotomy to attend to soiling at the surgical site. She survived and was discharged. Colonic perforation is a recognised complication of pancreatitis that carries a high mortality. It may result from a combination of ischaemia to the colon and a direct effect of noxious pancreatic enzymes. Almost all cases are only diagnosed at laparotomy. In view of the current trend of non-surgical management of pancreatitis and associated complications, colonic perforation should be considered in patients who deteriorate or fail to improve. To our knowledge this is the first case of a secure pre-operative diagnosis of colonic perforation due to to pancreatitis.
Author Cedric G. BremnerSource: South African Journal of Surgery 52 (2014)More Less
Hymie Gaylis passed away on 11 December 2013, a week before his 93rd birthday. Hymie graduated from the University of the Witwatersrand in 1945 and did his internship at Johannesburg Hospital under Professor I W Brebner and Dr E S Braun. He was a senior house officer in ENT and paediatrics in 1947 and a surgical registrar from 1948 to 1954 at the NEH and Baragwanath Hospital. From 1954 to 1957 he was a senior registrar to Professor Ian Aird at the Hammersmith Postgraduate Medical School in London.