South African Journal of Surgery - Volume 52, Issue 3, 2014
Volume 52, Issue 3, 2014
Author Martin D. SmithSource: South African Journal of Surgery 52 (2014) http://dx.doi.org/10.7196/SAJS.2391More Less
The article by De Beer et al. in this issue of SAJS is timeous within the context of changing paradigms in the training of surgeons globally. In South Africa (SA), the training of surgeons is the responsibility of the university departments of surgery. This function takes place on a training platform that is incorporated in the service platform, most commonly in the public sector. De Beer et al. examine a combination of activities on both platforms by analysing the views of SA surgeons on aspects of training, research and the practice of surgery in this country. The number of responders is small but statistically adequate. The study concentrates on perceptions that are of concern, but provides some insights into the way in which preparation for surgical practice is viewed.
Perspectives of South African general surgeons regarding their postgraduate training : general surgerySource: South African Journal of Surgery 52, pp 67 –71 (2014) http://dx.doi.org/10.7196/SAJS.1993More Less
Background. There is a perception among general surgeons that there are deficiencies in surgical training in South Africa (SA). Dependence on under-resourced state training institutions possibly plays a role. The opinions of qualified surgeons may make an invaluable contribution in this regard.
Objectives. To canvass the perceptions of SA general surgeons regarding certain aspects of their training.
Methods. An electronic postal survey was conducted. All general surgeons on the Association of Surgeons of South Africa database were requested to complete a structured questionnaire. Four Likert scale items were interrogated: knowledge acquisition, surgical skill, research, and practice management.
Results. Eighty-eight surgeons responded. Knowledge acquisition and surgical skills development were regarded positively, except for a perceived deficiency in availability of newer technologies. Exposure to surgical research was viewed as beneficial and useful. However, the mandatory research project during training was not perceived as useful for current careers. Training in practice management was perceived as severely deficient.
Conclusion. This survey highlights positive perceptions of general surgeons regarding the acquisition of knowledge and surgical skills during training in SA, but some negative views emerged regarding research, exposure to newer technology, and especially practice management training.
Serum lipase should be the laboratory test of choice for suspected acute pancreatitis : general surgerySource: South African Journal of Surgery 52, pp 72 –75 (2014) http://dx.doi.org/10.7196/SAJS.2003More Less
Background. Serum lipase and amylase are biochemical analyses used to establish the diagnosis of acute pancreatitis (AP). Despite lipase having been shown internationally to be a more sensitive and specific test, amylase remains a popular first-line test.
Objective. To provide a local basis for the recommendation of the best first-line laboratory test, an assessment of their performance in our local setting was undertaken.
Methods. From a prospective dataset on patients with acute abdominal pain and raised serum lipase and/or amylase values, the sensitivity and specificity of serum lipase, amylase and the two in combination was calculated for the diagnosis of AP, as defined by the Atlanta criteria.
Results. During the study period, 476 patients presented with acute upper or generalised abdominal pain and raised serum amylase and/or lipase values. The median age of the patients was 43 years (range 14 - 85), and 58% were men and 42% women. Of the patients, 322 (68%) presented with abdominal conditions other than AP, and 154 (32%) had AP. Ethanol abuse and gallstones accounted for 55% and 23% of cases of AP, respectively. Lipase displayed a sensitivity of 91% for AP, against 62% for amylase. Specificity was 92% for lipase and 93% for amylase. Dual testing with lipase and amylase had a sensitivity of 93%.
Conclusions. Lipase is a more sensitive test than amylase when utilising cut-off levels to diagnose AP. Lipase should replace amylase as the first-line laboratory investigation for suspected AP.
Source: South African Journal of Surgery 52, pp 75 –78 (2014) http://dx.doi.org/10.7196/SAJS.1954More Less
Background. In breast cancer, sentinel lymph node biopsy (SLNB) is widely used to assess the axilla when the nodes appear normal on palpation and ultrasonography. When the sentinel lymph nodes (SLNs) are negative, no further dissection is required. Surgical dissection or radiotherapy of the axilla is indicated for macrometastases, as well as adjuvant therapy for macrometastases and micrometastasic spread.
Aim. To determine the accuracy of scrape cytology (SC) for intraoperative examination of the SLNs.
Methods. SLNB was performed in 100 patients with early breast cancer in whom the axillary nodes appeared normal on clinical examination and ultrasonography. None of the patients with negative SLNs or SLNs with micrometastases only (N1mic, 0.2 - 2 mm) had further axillary dissection. Patients with SLNs containing macrometastases (N1, >2 mm) underwent axillary lymph node dissection. The results of intraoperative cytology were compared with the histopathological findings on examination of serial paraffin-embedded sections of the SLNs.
Results. Intraoperative SC identified SLN metastases in 20 patients: 17 had macrometastases and 3 micrometastases. Histopathological examination of the SLNs found macrometastases in 18 patients and micrometastases in 6. SC had a sensitivity of 94% and specificity of 100% for the detection of macrometastases. For micrometastatic spread, the sensitivity and specificity were 50% and 100%, respectively.
Conclusion. SC is a rapid, sensitive technique for detection of macrometastases in the SLNs of women with breast cancer. The overall accuracy in identification of any metastatic spread (N1mic, N1) to the SLNs was 85%, rising to 94% in SLNs with macrometastases.
Source: South African Journal of Surgery 52, pp 79 –81 (2014) http://dx.doi.org/10.7196/SAJS.1409More Less
Laryngotracheal stenosis develops when scar tissue forms in the trachea and, rarely, in the larynx itself. Symptoms depend on the degree of airway obstruction and can range from asymptomatic to upper airway obstruction severe enough to cause death. We report on 21 patients who underwent tracheal resection for severe stenosis. Resection remains a good option in this situation, and there is a minimal need for specialised postoperative care or intensive care unit admission in the majority of cases.
Clinical (non-histological) diagnosis of advanced prostate cancer : evaluation of treatment outcome after androgen deprivation therapy : urologySource: South African Journal of Surgery 52, pp 82 –85 (2014) http://dx.doi.org/10.7196/SAJS.1689More Less
Introduction. Transrectal biopsy in suspected adenocarcinoma of the prostate (ACP) may cause significant morbidity and even mortality. A strong association between serum prostate-specific antigen (PSA) and tumour burden exists. If biopsy can be avoided in advanced disease, much morbidity and cost may be saved.
Objective. To evaluate the reliability of using PSA and clinical features to establish a non-histological diagnosis of ACP.
Methods. Androgen deprivation therapy (ADT) was used in 825 (56.2%) of 1 467 men with ACP. The diagnosis of ACP was made histologically in 607 patients (73.6%) and clinically alone in 218 (26.4%), based on a serum PSA level of >60 ng/ml, and/or clinical evidence of a T3 - T4 tumour on digital rectal examination, and/or imaging evidence of metastases. We compared two randomly selected groups treated with bilateral orchidectomy (BO) based on a clinical-only (n=90) v. histological (n=96) diagnosis of ACP.
Results. There was no significant difference between the groups with regard to mean follow-up (26.1 v. 26.8 months), documented PSA relapse (70% v. 67.7%), and patients alive at last follow-up (91.1% v. 95.8%). ZAR1 068 200 (US$1 = ZAR8) was saved by treating men with advanced ACP on the basis of a clinical (non-histological) diagnosis only, and a total of ZAR24 321 000 was saved by using BO instead of luteinising hormone-releasing hormone agonists as ADT.
Conclusion. A reliable clinical (non-histological) diagnosis of advanced ACP can be made based on serum PSA and clinical features. This avoids the discomfort and potentially serious complications of biopsy and saves cost.
Successful selective angiographic embolisation of a gastroduodenal pseudoaneurysm following penetrating abdominal trauma : case reportSource: South African Journal of Surgery 52, pp 86 –87 (2014) http://dx.doi.org/10.7196/SAJS.2083More Less
Source: South African Journal of Surgery 52 (2014) http://dx.doi.org/10.7196/SAJS.2157More Less
A stranguled rectal prolapse is a rare cause of intestinal occlusion. It requires emergency surgery. A patient who underwent emergency perineal proctectomy, the Altemeier operation, combined with diverting loop sigmoid colostomy is described. The postoperative course was uneventful, with an excellent final result after colostomy closure. The successful treatment of this patient illustrates the value of the Altemeier procedure in the difficult and unusual scenario of bowel incarceration.