South African Journal of Surgery - Volume 53, Issue 3_4, 2015
Volume 53, Issue 3_4, 2015
A case of selective non-operative management of penetrating gunshot wound injury of the liver and kidney in a pregnant patient : case reportSource: South African Journal of Surgery 53, pp 1 –3 (2015)More Less
This case report focuses on the application of selective non operative management (SNOM) of penetrating abdominal trauma in a complex patient who was also pregnant at the time of injury. It goes on to contextualize SNOM in terms of its historical evolution as a strategy in South Africa and its appropriate safe application in the pregnant patient.
Kidney transplant outcomes following the introduction of hand-assisted laparoscopic living donor nephrectomy : a comparison of recipient groups : transplantationSource: South African Journal of Surgery 53, pp 1 –4 (2015)More Less
Background: Laparoscopic donor nephrectomy has become the procedure of choice for living donor kidney transplantation in many centres. We report on our experience with hand-assisted laparoscopic donor nephrectomy (HALDN). We concentrated on graft function and postoperative surgical complications in the recipient population, and compared outcomes to a similar recipient group who had received kidneys procured by open living-donor nephrectomy (OLDN).
Method: Following the receipt of institutional approval, the files of all patients who received a kidney transplant between September 2008 and June 2011 were reviewed. One hundred patients with end-stage renal disease received kidney transplantations from living donors. OLDN was performed in 65 donors, and 35 underwent HALDN. Delayed graft function (DGF) and postoperative complications were recorded.
Results: Six adverse events were reported, during which five patients presented with DGF. One DGF was reported in the HALDN group, and four in the OLDN group. The morbidity in the HALDN group (1/35, 3%) was a graft rupture secondary to acute rejection which required exploration and transplant nephrectomy. Reoperation was required in five patients in the OLDN group (5/65, 8%). This amounted to overall morbidity of 6%, with no recipient mortalities.
Conclusion: As previously documented, HALDN is safe for the donor, and not inferior to OLDN. In this study, it was associated with neither an increased incidence of DGF, nor a higher complication rate in the transplant recipient, when compared to the cohort that received a kidney harvested using the OLDN technique.
Prostate Cancer at a regional hospital in South Africa : we are only seeing the tip of the iceberg : urologySource: South African Journal of Surgery 53, pp 1 –6 (2015)More Less
Objectives: The objectives were to document the presentation of prostate cancer in the Zulu population of KwaZulu-Natal in South Africa, to identify this as a high-risk population, and to determine the potential for under-diagnosis in this population.
Methods: All histopathology results confirming prostatic adenocarcinoma from biopsies preformed at Edendale hospital from 01/11/2012 to 30/04/2014 were collected. A total of 81 participants were enrolled, and a review of their outpatient records was performed. Patient presentation was analysed, younger patients were compared to older patients, and observed incidence was compared to expected incidence.
Results: The majority of patients (66%, 95% confidence interval [CI]:54-76%) presented with radiographic evidence of metastatic disease or PSA greater than 100 ng/ml. The median PSA level at presentation was 154 ng/ml (Interquartile range [IQR] = 39-448). Clinically staged T4 disease was present in 44% of patients and only 10% of patients presented with PSA detected disease. Poorly differentiated tumours (Gleason grades 8, 9 and 10) were found in 43% of patients. Only 81 out of a maximum potential of 625 incident prostate cancer cases were diagnosed.
Conclusions: Black South African men from a predominantly rural Zulu population present late and with advanced and aggressive disease. We are missing the opportunity for remission in most patients in this high risk population group. The establishment of a National Prostate Cancer Registry and further research into a prostate cancer screening programme may be beneficial to this community.
Source: South African Journal of Surgery 53, pp 1 –5 (2015)More Less
Background: Cervical spine injured patients often require prolonged ventilatory support due to intercostal paralysis and recurrent chest infections. This may necessitate tracheotomy. Concern exists around increased complications when anterior cervical spine surgery and tracheotomies are performed.
Objective: The primary aim of this study was to evaluate the effect of tracheostomy in anterior cervical surgery patients in term of complications. In addition, the aetiology of trauma and incidence of anterior surgery and ventilation in this patient group was assessed.
Methods: Patients undergoing anterior cervical surgery and requiring ventilation were identified from the unit's prospectively maintained database. These patients were further sub-divided into whether they had a tracheotomy or not. The aetiology of injury and incidence of complications were noted both from the database and a case note review.
Results: Of the 1829 admissions over an 8.5 year period, 444 underwent anterior cervical surgery. Of the 112 that required ventilation, 72 underwent tracheotomy. Motor vehicle accidents, followed by falls, were the most frequent cause of injury. There was a bimodal incidence of tracheostomy insertion, the day of spine surgery and 6-8 days later. There was no difference in the general complication rate between the two groups. With regards to specific complications attributable to the surgical approach/tracheotomy, there was no statistically significant difference. The timing of the tracheotomy also had no effect on complication rate. Although the complications occurred mostly in the formal insertion group as opposed to the percutaneous insertion group, this was most likely due to selection bias.
Conclusion: Anterior cervical surgery and subsequent tracheostomy are safe despite the intuitive concerns. Timing does not affect the incidence of complications and there is no reason to delay the insertion of the tracheostomy. Ventilation in general is associated with increased complications rather than the tracheostomy tube per se.
Source: South African Journal of Surgery 53, pp 1 –3 (2015)More Less
Background: The parotid tissue can give rise to a large variety of benign and malignant neoplasms. The objective of this study was to describe the management and outcome of parotid gland tumours over a 15-year period.
Method: The records of consecutive patients treated by parotid gland excision from January 1995 to December 2008 were reviewed retrospectively. Data recorded were age, gender, history, physical findings, surgical procedure, fine-needle aspiration biopsy (FNAB), final pathological diagnosis and complications.
Results: The vast majority of patients (306) had benign neoplasms, and 14 patients had malignant neoplasms. Overall, pleomorphic adenoma contributed to 76% of the lesions, and Warthin's tumour to 17%. The sensitivity and specificity of FNAB was 79% and 100%, respectively. There were 15 cases of marginal mandibular transitory paresis and 12 cases of seroma. Marginal mandibular definitive paralysis was observed in three cases with malignant tumour.
Conclusion: Standardised parotidectomy is a safe operation, with a low complication rate.
Source: South African Journal of Surgery 53, pp 1 –3 (2015)More Less
Background: Burn injuries in South Africa result in significant morbidity and mortality, and specific vulnerable groups of patients are at increased risk of sustaining a burn injury. Epileptic patients are one such vulnerable group. The spectrum of burn injuries sustained by epileptic patients in a South African township and the pattern of injury, mechanism and outcome were reviewed in this study.
Method: A retrospective review of all epileptic patients admitted to the burn service of Edendale Hospital was undertaken for the period July 2011 to June 2013.
Results: One hundred and ninety-seven adult patients were admitted with burns over this period. There were 39 epileptic patients in this cohort, of whom 26 were female. The average age of the patients was 36 years (a range of 21-40 years). The majority of patients sustained a small total body surface area burn. The most common mechanism of burn was from a fire or flames, followed by hot water scalding. Coal or wood fires were the predominant energy source used for heating and cooking at home.
Conclusion: Epileptics comprise a significant proportion of patients who sustain a burn injury. Typically, they sustain burns during a seizure. These are mostly caused by open flames in the South African environment, and are deep. They tend to be confined to the upper torso, upper limbs and hands. Injury prevention programmes should target epileptics as a vulnerable group.
Validation of the mortality prediction equation for damage control surgery in an independent severe trauma population : general surgerySource: South African Journal of Surgery 53, pp 1 –3 (2015)More Less
Background: A prediction model was developed in Cape Town which utilised age, preoperative lowest pH and lowest core body temperature to derive an equation for the purpose of predicting mortality in damage control surgery. It was shown to reliably predict death despite damage control surgery. The equation derivation dataset and the validation set showed the equation to have 100% positive predictive value (PPV) for both datasets and 24% sensitivity. The aim of the study was to validate the prediction model in an independent dataset from a prospective trauma registry.
Method: Retrospective analysis of an ethics-approved prospectively collected database and electronic medical records was performed on trauma patients undergoing damage control surgery at the Inkosi Albert Luthuli Central Hospital, Durban, between 2007 and 2013. Age, lowest preoperative core body temperature and the pH of the patients were analysed using the previously derived equation. The output from the equation was then classified as a prediction of death, based on the obtained values, and then compared to the actual outcome of whether the patients survived or died.
Result: A total of 48 patient records were analysed in the study. Twenty-nine patients in the cohort died. The equation predicted mortality in only four cases, of whom three died and one survived (75% PPV and 10% sensitivity). The unexpected survivor reduced the PPV to 75%, compared to 100% PPV achieved in the original study.
Conclusion: The results of this study were inconsistent with those of the original study, and the 0.500 cut-off value used in the equation yielded PPV and sensitivity which were relatively non-clinically useful for the average patient in this cohort.
Source: South African Journal of Surgery 53, pp 1 –8 (2015)More Less
Background: Acute appendicitis is one of the most common surgical emergencies in the West. A large body of research is investigating the risk factors for disease and perforation. As South Africa has a social environment, health system structure, and population demography unique from developed nations, the findings may not be generalisable to this setting. A systematic review has not been performed for appendicitis research in South Africa. The objective of this review was to systematically examine the literature on appendicitis in South Africa.
Method: Published articles discussing appendicitis in South Africa up to March 2014 were identified using MEDLINE and EBMReviews. Research themes were analysed in the literature. Perforation rates, mortality, negative appendicectomy rates and gender differences were analysed from audits of patients undergoing appendicectomy for acute appendicitis.
Results: Ten audits were included in the quantitative analysis. Some were excluded in the subgroup analyses. Negative appendicectomies occurred at a rate of 17% (580/3 354). Women were more likely to have a negative appendicectomy than men (28% vs. 9%, p < 0.01). The perforation rate for appendicectomy patients was 36% (970/2 688), and mortality rate was 1% (36/2 946). Research efforts focused on investigating differential incidence and outcomes between racial groups within the country.
Conclusion: Appendicitis trends in South Africa are consistent with those in developing regions. However, there is lack of research from the private sector. Further research is needed to investigate specific factors which delay care, outcomes and cost analyses for laparoscopic surgery, and the system strengthening of surgical services at district hospitals.
A prospective evaluation of the predictive value of serum amylase levels in the assessment of patients with blunt abdominal trauma : general surgerySource: South African Journal of Surgery 53, pp 1 –5 (2015)More Less
Introduction: Less than ten percent of patients who sustain blunt abdominal trauma will suffer a significant intra-abdominal injury. Identifying these patients is difficult and this study reviews the results of routine serum amylase levels in a series of patients with blunt abdominal trauma.
Methods: All patients admitted, by the primary author from November 2010 to November 2012, with a diagnosis of blunt abdominal trauma were included. All these patients had a serum amylase level measurement performed on admission.
Results: One hundred and three patients were selected, with an age range from 3 to 68 years. There were 33 females and 70 males. Imaging was obtained in 47 patients (38 CT scans and 9 ultrasounds). Nine (19%) of the patients who were imaged required a laparotomy due to the radiological findings, and 38 (81%) of this sub group underwent successful conservative management. Eighteen patients had a laparotomy on clinical grounds. Intra-abdominal injuries were identified in 38 patients on imaging and/or at laparotomy. In five patients laparotomy did not reveal any injuries. The remaining 38 patients were admitted for serial abdominal observation. They were all discharged home and their symptoms resolved. The serum amylase level ranged from 34 U/L to 3 156 U/L, with a mean of 227 U/L (standard deviation 456 U/L). The levels were raised in 60 patients (58%) of whom 19 (32%) had a significant intra-abdominal injury. The serum amylase level was normal in 43 patients (42%), of whom 19 (44%) had a significant intra-abdominal injury. There were eight pancreatic injuries in the group (pancreatitis (1), pancreatic contusion (3), laceration (1), and transection (3). The serum amylase level was normal in two and mildly elevated in one of the patients with contusions (91, 92 and 129 U/L respectively), mildly elevated in the patient with pancreatitis (121 U/L), and significantly raised in the others (340 U/L with the pancreatic laceration; 3 156, 472, and 1 497 U/L in those with a transected pancreas). Four patients had a serum amylase level of greater than 1 000 U/L. Two of these had pancreatic injuries (3 156 and 1 497 U/L) and had hospital stays of six and sixteen days respectively. In the other two (3 042 and 1 454 U/L) no intra-abdominal injury was found.
Conclusion: The routine use of serum amylase level in the investigation of patients with blunt abdominal trauma cannot be supported as a mildly raised serum amylase level is common following blunt abdominal trauma, is of uncertain clinical significance, and does not have any predictive value. A markedly raised serum amylase level is associated with major pancreatic injury but is in itself a non-specific finding.
The effect of opioids on field block for hernia repair : a study comparing pethidine with a placebo : general surgerySource: South African Journal of Surgery 53, pp 1 –4 (2015)More Less
Background: Intramuscular (IM) pethidine injection is used as pre-analgesia (pre-medication) in hernia repair under local anaesthesia in some district hospitals. We evaluated the relevance of this practice in a facility based study at one of the district hospitals in Ghana.
Method: One hundred and twenty patients above 10 years of age with a mean age of approximately 49 years diagnosed as having inguinal hernias of different sizes were recruited into the study. Each group of 60 patients was randomly selected. A maximum of 50 ml 1% lignocaine plus 2 ml (100 mg) of pethidine was used in group A and 50 ml 1% lignocaine plus 2 ml of sterile water in group B. A score ranging from 0 to 3 was assigned at the end of each surgery depending on the degree of pain experienced.
Results: 33.3%, 33.3%, 21.7% and 11.7% of patients in group A scored 0, 1, 2, and 3 respectively in pain perception while 26.7%, 33.3%, 25% and 15.0% were the scores in group B. None of the patients in group B experienced an adverse effect to any of the agents used. 2% and 5% in group A experienced nausea and generalized pruritus respectively. Post-operation condition was satisfactory and all patients were discharged the same day.
Discussions and Conclusion: There was no significant difference in pain perception when IM pethidine is combined with local infiltration compared with local infiltration plus sterile water for herniorrhaphy. Good and adequate local infiltration is enough for the repair of simple hernias as the addition of pethidine does not give any significant analgesia but increases the chance of patient developing complications.
Author B.D. BebingtonSource: South African Journal of Surgery 53, pp 2 –4 (2015)More Less
The precise biochemical nature of malignant transformation remains elusive. This article reviews some of the current theories of oncogenesis and aims to synthesize these concepts into a possible schema for the origins of malignant transformation, using a cell-programmed origin for neoplastic progression. It is proposed that cell transformation in malignancy is initiated by injury but finds ultimate promulgation through cellular, self-determined, epigenetic events. Explanations for this arrangement are sought in evolutionary models and our knowledge of cell biology. The proposed mechanisms have not been experimentally validated, but will hopefully stimulate further research.
Author N. MorseSource: South African Journal of Surgery 53, pp 5 –7 (2015)More Less
The publication by Brendan Bebington entitled "Concepts in malignant transformation" was a thought provoking article. The article theorises that the process of aging, as a consequence of programmed cellular events, will result in death, which is essential for survival of the population. The theory then expands to suggest that eukaryotic cells have retained an epigenetic ability to enable demise of the organism via cell-determined origin for events like aging and malignant transformation. The author suggests that "cancer may be a de-suppression of an ancient epigenetic instruction" and "malignancy has become an evolutionary advantage, even though it may be disadvantageous to the individual".
Source: South African Journal of Surgery 53, pp 8 –10 (2015)More Less
Background: Surgical training has undergone major changes worldwide, especially with regard to work hour regulations. Very little is known regarding the situation in South Africa, and how it compares with other countries.
Method: We conducted a retrospective review of the hours worked by surgical residents in a major university hospital in South Africa.
Results: The attendance records of 12 surgical residents were reviewed during the three-month study period from January 2013 to March 2013. Ten were males. The mean age of the residents was 33 years. The mean total hours worked by each resident each month was 277 hours in January, 261 hours in February and 268 hours in March. The mean monthly total over the study period was 267 hours. This equates to approximately 70 hours per week.
Conclusion: The average surgical resident worked 70 hours per week in our unit. This was shorter than that in USA, but higher than that in Europe. There is likely to be a degree of heterogeneity between different training units, which needs to be explored further if a more accurate overall picture is to be provided.
International medical graduates in South Africa and the implications of addressing the current surgical workforce shortage : general surgerySource: South African Journal of Surgery 53, pp 11 –13 (2015)More Less
Background: The surgical workforce in South Africa is currently insufficient in being able to meet the burden of surgical disease in the country. International medical graduates (IMGs) help to alleviate the deficit, yet very little is known about these doctors and their career progression in our healthcare system.
Method: The demographic profile and career progression of IMGs who worked in our surgical department in a major university hospital in South Africa was reviewed over a four-year period.
Results: Twenty-eight IMGs were identified. There were 23 males (92%) and their mean age was 33 years. Seventy-one per cent (20/28) were on a fixed-term service contract, and returned to their respective country of origin. The option of renewing their service contracts was available to the 16 IMGs who left. Three explicitly indicated they would have stayed in South Africa if formal training was possible. Eight of the 28 IMGs (29%) extended their tenure, and remained in the service position as medical officers. All of the eight IMGs stayed with the intention of entering a formal surgical training programme.
Conclusion: IMGs represented a significant proportion of service provision in our unit. Over one third of IMGs stayed beyond their initial tenure, and of these, all stayed in order to gain entry into the formal surgical training programme. A significant proportion of those who left would have stayed if entry to the programme was feasible.
Source: South African Journal of Surgery 53, pp 15 –17 (2015)More Less
Background: The large-scale migration of doctors, including surgeons, from South Africa, has had a major impact on healthcare resources in this country. Although previous studies have suggested that the University of Cape Town (UCT) is of the main institution contributing to this "brain drain", the extent of the problem has not been documented previously. The aim of this study was to investigate where UCT trained surgical registrars go after completing their training.
Method: General surgery registrars who trained at UCT and who wrote and passed the FCS final examination between 1992 and 2011 were included in the study. The data for this study were obtained from the examinations office of the Colleges of Medicine of South Africa. The number of registrars writing and passing the final examination, the number of registrars who went overseas, the number of registrars in private practice, and the number of registrars in subspecialist practice, were recorded.
Results: A total of 102 UCT-trained registrars wrote and passed the FCS final examination during the study period. Only 13% of the South African UCT-trained registrars left the country. Only 31% of the registrars who remained in South Africa went into private practice. A large proportion of the UCT-trained registrars (43%) elected to subspecialise.
Conclusion: "Brain drain" with respect to UCT-trained surgical registrars was not as extensive as anticipated.
Source: South African Journal of Surgery 53, pp 18 –20 (2015)More Less
Background: It remains controversial whether or not healthcare workers on upper gastrointestinal endoscopy teams are at risk of Helicobacter pylori infection. An association between occupational exposure and an increased risk of infection has been shown in a number of studies, while such a risk was not confirmed in others. None of these studies were conducted in Africa.
Method: We performed a cross-sectional study to determine the prevalence of H. pylori infection in endoscopy personnel versus that in a control group of other healthcare workers.
Results: Ninety-two participants were included in the study. Thirty-two (55%) in the control group tested positive for H. pylori. Twenty participants (59%) in the combined endoscopy groups (34 in total) tested seropositive for H. pylori. The seropositive rate was highest in those more frequently involved with endoscopies in the endoscopy groups. None of these differences were statistically significant.
Conclusion: An H. pylori infection rate, similar to the national prevalence rate, estimated to be 51-71%, was displayed in both the study and control groups. We were unable to confirm that endoscopy was a risk factor for endoscopy teams with regard to contracting H. pylori.
Source: South African Journal of Surgery 53, pp 37 –39 (2015)More Less
Background: The aim of this observational study was to audit the burden of trauma with which patients present at the three hospitals that comprise the Pietermaritzburg Metropolitan Complex, as well as their intensive care units (ICUs) and the government medico-legal mortuary.
Method: A retrospective audit was conducted by assessing emergency department, critical care unit admission record books and medico-legal mortuary report files over a period of two years as well as reviewing patient demographics and the mechanism of trauma in patients. Data were manually entered into a data spreadsheet for the period 1 January 2010 to 31 December 2011. Recorded data included basic demographic information, mechanism of injury and the facility. Details of the injury precipitating the ICU admission and the length of stay were included in the ICU data.
Results: During the period 10 644 patients presented to the Pietermaritzburg Metropolitan Trauma Service as a result of trauma-related injuries. Of the 10 644 trauma patients seen, there were 3 688 assault-related injuries (35%), 3 715 motor vehicle accident (MVA)-related injuries (35%), 516 gunshot wound (GSW)-related injuries (5%) and 2 725 stabbings (26%). The trauma burden consisted predominantly of blunt trauma (70%), followed by penetrating trauma (30%). The majority of trauma patients were male (77%). Of the 10 644 trauma patients seen, 510 (5%) needed admission to an ICU. The composition of the group requiring ICU was assault (8%), MVAs (48%), GSWs (14%) and stabbings (30%). A total of 1 105 (10%) trauma victims died, 471 of whom survived long enough to be admitted to a medical facility. The mortuary group consisted of 56% incidents of blunt trauma and 44% of penetrating trauma. There were 153 (14%) assault-related deaths, 462 (42%) MVA-related deaths, 181 (17%) GSW-related deaths and 309 (28%) stabbing-related deaths.
Conclusion: Although the rate of penetrating trauma remains high, it is being overtaken by blunt trauma. Almost half of this blunt trauma load is nonintentional. MVAs are expensive to treat, consume ICU resources and are associated with significant mortality. Injury-prevention strategies are a priority, and should address the high rate of MVAs and the high rate of interpersonal violence. The decline in GSW-related trauma is cause for cautious optimism.