South African Journal of Surgery - Volume 53, Issue 2, 2015
Volume 53, Issue 2, 2015
Author I. BuccimazzaSource: South African Journal of Surgery 53, pp 34 –36 (2015) http://dx.doi.org/10.7196/sajsnew.8415More Less
'...all women have the right to access to healthcare, but considerable challenges exist in implementing breast healthcare programmes when resources are limited.'
Breast cancer constitutes a significant burden of disease in South Africa. The latest available statistics of the National Cancer Registry published in 2009 reveal that breast cancer is the leading cause of cancer in South African women and accounts for 20.82% of all female cancers. The lifetime risk of developing breast cancer for all South African females is 1 in 33. The risk varies between the various racial groups and is 1:11 for white, 1:22 for coloured, 1:17 for Asian and 1:36 for black women.
Author Ravi OoditSource: South African Journal of Surgery 53 (2015) http://dx.doi.org/10.7196/sajsnew.8412More Less
Abdominal hernia repair is one of the most common operations in general surgery. Abdominal wall hernias include inguinal, incisional, ventral and femoral hernias. The repair rate ranges from 10 per 100 000 population in the UK to 28 per 100 000 in the US. More than one million hernia repairs are performed each year in the US. No published hernia repair rate is available for South Africa.
Author Bob BaigrieSource: South African Journal of Surgery 53, pp 38 –39 (2015) http://dx.doi.org/10.7196/sajsnew.8413More Less
This edition of the South African Journal of Surgery coincides with the biennial joint meeting of the Association of Surgeons of South Africa (ASSA) and the South African Gastroenterology Society meeting in Durban. This meeting includes the 12 integrated societies and three interest groups within the Federation of South African Surgeons (FoSAS). How did this all begin?
Source: South African Journal of Surgery 53, pp 40 –42 (2015) http://dx.doi.org/10.7196/sajsnew.7741More Less
Background. Centralised multidisciplinary management of breast cancer occurs in KwaZulu-Natal, South Africa, and requires a diagnostic and staging pathway at the referring hospital. Delays in this pathway are unknown. This study, conducted at a referring hospital, R K Khan (RKK), quantifies and analyses these delays.
Methods. A retrospective folder review included all patients with breast cancer diagnosed at RKK from January 2008 to January 2009. Data extraction included demographic data, time to diagnosis and initial staging using a standardised data sheet. Specific care steps were identified, namely delays to initial imaging with mammography, pathology confirmation, staging work-up and eventual referral to a centralised breast clinic.
Results. A total of 45 patients were included (43 females and 2 males). The average age was 56 years. The mean individual care step delays were 18.3 days to initial imaging, 21.2 days to pathological confirmation, 9.2 days to initial staging and 22.7 days to review at the centralised breast clinic. The delays were sequential, with a mean total delay of 70.1 days or 10 weeks with an interquartile range of 48 - 82 days.
Conclusion. This study confirmed significant delays in the care pathway, which are almost double the international recommendations of 6 weeks. Steps to reduce delays at all phases have been instituted with specific care step targets leading to the establishment of a breast cancer registry with an audit capability. We suggest targeting an 8-week period for the work-up and staging of every patient with breast cancer. The establishment of a breast cancer registry and regular audits thereof are essential in maintaining care standards and achieving best practice.
Source: South African Journal of Surgery 53, pp 43 –47 (2015) http://dx.doi.org/10.7196/sajsnew.7842More Less
Background. Carcinoma of the breast is the second most common malignancy among South African women, its incidence is rising and the mortality rate is significantly higher than in the developed world. Offering quality treatment in a resource-limited environment with poor patient socioeconomic circumstances is an ongoing challenge. Frail health, lack of support in the event of severe toxicity, and the lack of advanced pharmaceuticals, taxane regimens and biologicals limit treatment options for chemotherapy.
Methods. Records of 250 consecutive female patients newly diagnosed with breast cancer from January to October 2008, were retrieved and analysed. Staging at diagnosis, demographic data, histopathology, treatment given, compliance and outcomes were recorded retrospectively.
Results. Average follow-up time was 36.2 months, the mean age was 56 years, 205 patients underwent surgery, and 84.4% of patients were fully compliant with therapy. Stage I and stage IV overall survival was similar to developed world figures. Combined stage II/III survival was 64.7%, which is significantly lower than survival figures in the developed world (84.6%). A large proportion of patients (15.7%) with stage II and III breast cancer in our series did not receive chemotherapy. For stage III patients, not a single pathologically complete response was recorded; in stage II complete response rate was 10%. Adjuvant chemotherapy was administered to 41 out of 51 patients (80.3%) with node-negative tumours larger than 2 cm and only 3 out of 14 patients (21.4%) with 1 - 2 cm node-negative tumours. Adjuvant radiotherapy was administered to 83.8% node-positive stage II and 88% stage III patients. Hormonal therapy was administered to 90.7% of the oestrogen receptor positive tumours and 64% of these patients were still taking treatment at time of last follow-up.
Conclusion. Combined stage II and III disease-related survival in this series was considerably lower than developed world figures. Adjuvant radiotherapy and hormonal therapy were well applied where indicated. The options of neoadjuvant and adjuvant chemotherapy were underutilised in this series - for a large proportion of these patients (10.7%) the reason remains unknown. Administrative error, patient comorbid conditions and patient refusal also contributed to the underutilisation of chemotherapy. Moreover, tumours showed poor response to chemotherapy regimens administered. The emphasis on the expansion of the services to women with breast cancer should concentrate on the extension of medical oncological services to improve outcomes. Biologicals as well as advanced chemotherapeutic options including taxane regimens should be made available.
Sentinel lymph node biopsy : an audit of intraoperative assessment after introduction of a cytotechnology service : general surgerySource: South African Journal of Surgery 53, pp 47 –49 (2015) http://dx.doi.org/10.7196/sajsnew.7850More Less
Objective. To audit results from intraoperative assessment of sentinel lymph node biopsy (SLNB) after the introduction of a cytotechnologist.
Study design. Since 2010, a cytotechnologist has been involved in the intraoperative assessment of SLNB in our breast cancer patients. The data from patients over the period 2006 - 2013 were used to compare outcomes before and after the introduction of a cytotechnology service. The database was divided into the periods 2006 - 2008 and 2010 - 2013 (2009 was the training period).
Results. A total of 335 intraoperative SLNB assessments were performed: 165 between 2006 and 2008 (group 1) and 170 between 2010 and2013 (group 2). In the study period (2010 - 2013), 2 (1%) metastatic deposits >2 mm were missed in patients with lobular carcinoma and 1 in a patient with ductal carcinoma. There was one (0.6%) false positive in a patient with a lobular carcinoma in each group. For patients with metastases >2 mm, group 1 had a sensitivity of 87% and a specificity of 99%. Group 2 had a sensitivity of 92% and a specificity of 99%.
Conclusion. A trained cytotechnologist performing imprint cytology on SLNB to determine metastatic breast cancer can deliver results comparable with those of a group of pathologists.
Source: South African Journal of Surgery 53, pp 50 –54 (2015) http://dx.doi.org/10.7196/sajsnew.7864More Less
Introduction. Seroma formation is one of the most frequently encountered complications following mastectomy. It may cause significant morbidity, including delayed wound healing, infection and frequent clinic attendance for seroma aspiration.
Objective. To evaluate the effect of surgical quilting after mastectomy in the prevention of postoperative seroma and to investigate which factors influence seroma formation.
Methods. This was a single-centre prospective cohort study over a 1-year period. All patients who had a mastectomy operation during this period were included in this study. Group 1 patients (quilting) had mastectomy flaps sutured to pectoral muscle using interrupted absorbable sutures. Seroma requiring aspiration, number of aspirations and volume aspirated were recorded postoperatively.
Results. During the study period, 168 patients were recruited, with 54 patients in group 1 (quilting) and 114 patients in group 2 (nonquilting). The proportion of patients who developed seroma requiring aspiration was 69% (n=79) in the non-quilting group and 29% (n=15) in the quilting group (p<0.001). Additionally, the total volume of seroma drained was 427 mL (standard error (SE)=69) in the nonquilting group and 63 mL (SE=21) in the quilting group (p=0.0008). The total number of seroma aspirations was 152 in the non-quilting group compared with 23 in the quilting group (p=0.0001). Seroma was more common in smokers (p=0.003) and was not decreased by the presence of drains.
Conclusion. Quilting of the mastectomy flaps significantly reduces seroma formation. Both total volume of seroma aspirated and number of aspirations are significantly reduced using this technique. We would therefore recommend quilting of mastectomy flaps to reduce the incidence of postoperative seromas and morbidity.
Comparison of the incidence of oesophageal cancer in two 6-year periods from selected hospitals in and around Gauteng Province, South Africa : general surgerySource: South African Journal of Surgery 53, pp 55 –58 (2015) http://dx.doi.org/10.7196/sajsnew.7857More Less
Introduction. Global trends suggest that the incidence of squamous cell carcinoma (SCC) has decreased but that the incidence of adenocarcinoma (AC) has increased. In South Africa, outdated data exist, thereby prompting this investigation.
Objectives. To determine the incidence of oesophageal cancer in two 6-year periods in and around Gauteng Province. Further distinction was made based on gender, race and histological types.
Methods. A retrospective audit was conducted including histologically documented oesophageal cancer cases collected over a 12-year period from 2001 to 2012, which was divided into two 6-year periods. Incidence was calculated based on the 2013 Gauteng estimated population size. Statistical analysis was performed using the χ2 test.
Results. On the whole, there was a significant decrease in the incidence of SCC (p=0.0001). Significant decreases were seen in the African male and female groups (p=0.001 and p=0.0006, respectively). No significant difference was seen in the non-African male and female groups. A non-significant decrease was seen in the AC type with regards to gender and race.
Conclusion. Reasons for the decline shown here are unknown as patient risk factors were not available. Furthermore, major healthcare centres were not included. These are points for future investigation. The incidence of oesophageal cancer has decreased since 2001, owing to the decrease in SCC in African males and females. Although the decreases in the AC type were not significantly different, they do not parallel global trends.
Source: South African Journal of Surgery 53, pp 59 –61 (2015) http://dx.doi.org/10.7196/sajsnew.7855More Less
Background. Post-exercise pain is an uncommon symptom in young, healthy adults. Rest and avoidance of exercise are frequently ineffective and poorly accepted by young, active and otherwise healthy individuals.
Methods. A total of 123 patients with extremity muscle pain, swelling and paraesthesia during the last 10 years were evaluated from a prospective database with compartment pressures and selectively evaluated with Doppler ultrasound and angiography.
Results. Patients were young (average 28 years) with long duration of symptoms (average 3.5 years), affecting both upper limbs (3), and lower limbs (120), and 80% were bilateral. Eighty-six were male (70%). All of them were taking part either in active sports or exercise programmes, mostly athletics (49%). Common symptoms were isolated muscle pain in the anterolateral compartments in all patients, paraesthesia in 15% and swelling in 10%. Post-exercise mean compartment pressure was 61 mmHg (normal <30 mmHg).Modified open fasciotomies were performed by lateral and medial incisions in lower limbs and by a single incision in upper limbs.Minor complications occurred in 11% of patients. Full relief of symptoms occurred in 90%, 7% had some improvement of symptoms, and treatment failure occurred in 3% of patients.
Conclusion. Chronic exertional compartment syndrome is underdiagnosed and should be considered as a potential cause for post-exercise pain in young individuals, and should be treated surgically. Measurement of compartment pressure is important in order to confirm the diagnosis. Open fasciotomy is safe and effective and should be considered as the preferred surgical procedure.
Source: South African Journal of Surgery 53, pp 62 –64 (2015) http://dx.doi.org/10.7196/sajsnew.1781More Less
Background. Traditional open surgery for frontal sinus pathology and cerebrospinal fluid (CSF) leaks is complex and involves a craniotomy. Minimally invasive options offer an alternate solution. We describe and assess the outcome of a minimally invasive approach for lesions and defects involving the frontal sinus.
Methods. The technique introduces an endoscope via a small frontal sinusotomy accessed via a small medial brow incision. This allows excellent visualisation of the frontal sinus. Fine thin-shafted instruments traditionally used during tympanoplasty or pituitary surgery are passed through the sinusotomy together with an endoscope for dissection and tissue excision. This technique can be combined with conventional endonasal surgery.
Results. We describe the use of this technique in three patients: A fracture of the posterior table of the right frontal sinus with CSF leak, a right frontal sinus osteoma and a right frontal sinus mucocoele. Symptom resolution occurred in all patients and no short-term postoperative complications occurred.
Conclusion. This approach avoids the morbidity associated with a craniotomy and obviates the need for postoperative intensive care required for conventional osteoplastic flap surgery or extensive endonasal surgery required for the alternative minimally invasive endoscopic technique. Our initial success merits further assessment of the use of this technique.
Source: South African Journal of Surgery 53, pp 65 –66 (2015) http://dx.doi.org/10.7196/sajsnew.7743More Less
Background. Burn patients have high metabolic demands requiring aggressive nutritional supplementation. Multiple operations necessitate a period of starvation. This audit was undertaken to review the total duration of starvation experienced by burn patients in a regional hospital.
Methods. This study reviewed the nutritional intake/output data for 3 months of admitted patients using standard formulas to calculate the average energy deficit.
Results. Nine adult patients with an average burn of 21% total body surface area (TBSA) were included, with an average starvation period of 21 hours. There were 10 paediatric patients with an average burn of 18% TBSA and average starvation period of 18 hours. There was an average 12% deficit in weekly energy requirements.
Conclusion. Burn patients are starved for periods longer than necessary, which may have implications for recovery. Shortened fasting is preferable and safe. Perioperative starvation protocols specific for burn patients in this hospital need to be developed and enforced.
Hypoxic brain injury and cortical blindness in a victim of a Mozambican spitting cobra bite : case reportSource: South African Journal of Surgery 53, pp 67 –69 (2015) http://dx.doi.org/10.7196/sajsnew.7851More Less
Snakebite and the subsequent envenomation is a serious and potentially fatal illness, owing to the effects of the various toxins present in the venom. Cortical blindness following bites containing neurotoxin is a rare complication. We describe the clinical findings and imaging in a child who sustained significant brain injury following a bite from a Mozambican spitting cobra. We also discuss the venom composition, complications and appropriate management of such cases.
Source: South African Journal of Surgery 53, pp 70 –71 (2015) http://dx.doi.org/10.7196/sajsnew.7861More Less
This is a case report describing the management of an imatinib-resistant liver secondary as a result of an exon 13 mutation. The gastric primary was completely excised 3 years prior and proven to contain an exon 11 mutation. Resective liver surgery was undertaken after the patient developed imatinib resistance and he has been disease-free for 19 months. The application of surgery in the context of other treatment options is discussed.
Author Philip MatleySource: South African Journal of Surgery 53 (2015)More Less
Peter Jeffery died in Cape Town on 10 April 2015, having battled complications of cardiac surgery for nearly 6 months. Peter was always larger than life. He was a born leader with a drive to achieve and a remarkable ability to get people to work together. His contribution to surgery in South Africa, and in particular to the Association of Surgeons of South Africa (ASSA), was substantive.
Source: South African Journal of Surgery 53, pp 73 –80 (2015) http://dx.doi.org/10.7196/sajsnew.8420More Less
Background. Inguinal hernia repair is the most frequent general surgical procedure. These guidelines aim to improve and standardise practice. They apply to adult patients only. This is a summary of the key points in the document. The authors strongly recommend the guidelines be read thoroughly.
Clinical. The diagnosis is almost always a clinical one. Imaging is seldom required and should only be requested at specialist level.
Referral.Routine referral of men with uncomplicated, minimally symptomatic, reducible hernias. All hernias should be repaired wherever possible as most patients ultimately come to surgery. Urgent referral of all women and men with irreducible hernias is recommended and emergency referral is used for patients with obstruction or strangulation. Patients with hernia recurrences should be referred to a surgeon with an interest in hernia surgery.
Anticoagulation. It is recommended to continue aspirin, but stop clopidogrel 5 - 7 days before surgery. Warfarin should be stopped 5 days before, and bridging with low-molecular weight heparin (LMWH) should be done if the patient has a high thromboembolic risk.
Hair removal. Shaving should be avoided. If needed, clipping is recommended.
Antibiotic prophylaxis is not routinely recommended; however, it should be used in high-risk groups (recurrence, age >70, immunocompromised, obese, diabetes mellitus (DM), catheterised patients).
Anaesthesia. General anaesthetic (GA) is required for laparoscopic repair, although it is feasible to do a totally extraperitoneal (TEP) repair under spinal anaesthesia. Open repair could be performed under local anaesthesia in all patients with reducible unilateral hernias, especially ASA III/IV, the elderly and those with multiple comorbidities. Patients with morbid obesity, incarcerated hernias, and very anxious patients should have a GA. Spinal anaesthesia is not recommended. Day-case surgery should be offered to all patients, where feasible.
Surgery. Laparoscopic repair is the treatment of choice for all inguinal hernias including primary unilateral hernias. The contralateral side should always be inspected for an occult hernia, but repair should only be performed if a defect exists. Prophylactic repair is not advised. There are no data to recommend transabdominal preperitoneal (TAPP) over TEP repairs or vice versa. The Lichtenstein repair is the preferred technique for open repairs. The Shouldice repair may be considered if there is gangrenous bowel and resection is required. All groin hernias must be repaired with a mesh. A regular polypropylene or polyester mesh is adequate for all open and laparoscopic hernia repairs.
Special circumstances. If the initial operation was an open repair, then the operation for a recurrence should be laparoscopic, and vice versa. Strangulated hernias may be repaired with open or laparoscopic methods but the bowel should always be inspected. A femoral hernia should always be excluded in women with a groin hernia. Patients presenting with hernias in pregnancy should be managed conservatively, with a planned postpartum repair.
Complications. Include seroma (which is common but often insignificant clinically), haematoma (which should be managed conservatively unless causing tension of skin), urinary retention, ischaemic orchitis, infection, and chronic groin pain. In patients with mesh infection it is not always essential to remove the mesh.
Aftercare. Patients may return to work and driving after 1 week.