South African Journal of Surgery - Volume 54, Issue 1, 2016
Volume 54, Issue 1, 2016
Source: South African Journal of Surgery 54, pp 2 –3 (2016)More Less
Stephen Eisenhammer was born in Middelburg in the Cape province in South Africa. His parents were of Viennese descent. He grew up on a farm in southern Rhodesia (now Zimbabwe), and studied medicine at the University of Cape Town and in Edinburgh in Scotland, where he graduated with a MBBCh in 1930. He was a house surgeon and surgical registrar at St Mark's Hospital for Diseases of the Rectum and Colon, London. He joined the London Emergency Medical War Services at the outbreak of war, and returned to South Africa in 1942. He then joined the South African Medical Corps and served in Madagascar.
Gastroschisis in a developing country : poor resuscitation is a more significant predictor of mortality than postnatal transfer time : paediatric surgerySource: South African Journal of Surgery 54, pp 4 –9 (2016)More Less
Background: The time from birth to the first paediatric surgical consultation of neonates with gastroschisis is a predictor of mortality in developing countries. This is contrary to findings in the developed world. We set out to document this relationship within our population.
Methods: Neonates with gastroschisis who were transferred to Steve Biko Academic Hospital within the study period were included. The association between mortality and demographic, clinical and biochemical variables was assessed. Significant variables after univariate analysis were subjected to multivariate regression.
Results: Sixty patients were included. The mortality rate was 65%. Mean transfer time and distance were 14.9 hours and 225km. Forty-eight per cent of the neonates were either clinically dehydrated or in hypovolaemic shock on arrival. It was shown through univariate analysis that female sex, appropriate weight for gestational age, hydration status, gestation, transfer time, serum urea, base deficit and serum bicarbonate (HCO3) were significant predictors of mortality. Only female sex, appropriate weight for gestational age and serum HC03 were shown to be significant using multivariate analysis.
Conclusion: Our high mortality rate was not due to lengthy transfer times. The poor clinical condition of the patients on arrival at our hospital, which relates to deficiencies in the neonatal transfer system, had a direct impact on the survival of neonates with gastroschisis.
An experience of ultrasound-guided hydrostatic reduction of intussusception at a tertiary care centre : paediatric surgerySource: South African Journal of Surgery 54, pp 10 –13 (2016)More Less
Background: Intussusception is an important and one of the most commonly encountered diagnoses of intestinal obstruction in the paediatric age group. Ultrasound-guided hydrostatic reduction is an effective, nonoperative treatment modality for this condition and is associated with a high success rate. In addition, it is simple and safe as the entire procedure is carried out with real-time ultrasound, without the hazard of radiation. The aim of this study was to evaluate the efficacy and safety of ultrasound-guided hydrostatic reduction in the management of intussusceptions in the paediatric age group.
Methods: A case study was carried out on 89 patients diagnosed with intussusception using high-resolution ultrasonography over a period of two years, spanning February 2012 to January 2014. Ultrasound-guided hydrostatic reduction was performed in 78 of these patients, and 11 patients were excluded owing to clinical contraindications. Follow-up ultrasound was performed after 24 hours to rule out recurrence.
Results: The disease was most prevalent in the age group 6-24 months. The ileocolic type was the most common. Mean duration (hours) was 17.02 ± 20.81 for time to presentation. Complete therapeutic reduction was achieved in 70 of the 78 cases, with a success rate of 90%. Two recurrences occurred in the following 24 hours, which were successfully reduced on the second attempt. Complications and mortality did not occur secondary to the procedure.
Conclusion: Our study found that ultrasound-guided hydrostatic reduction is a simple, safe and effective nonoperative treatment for intussusceptions in the paediatric age group, and should be the first line of management in appropriate patients.
A morphological and immunohistochemical evaluation of gastric carcinoma in the Western Cape province of South Africa : original articleSource: South African Journal of Surgery 54, pp 15 –21 (2016)More Less
Background: Gastric resections for carcinoma are common, but gastric carcinoma in South Africa, and particularly within the Western Cape province, has not been well documented.
Method: The objective of the study was to immunohistochemically evaluate HER2/neu overexpression, determine aberrations in β-catenin and epithelial-cadherin (E-cadherin) expression, and correlate these findings with gastric carcinoma subtypes.
Results: Ninety-seven gastric adenocarcinoma resections were morphologically categorised as intestinal-, diffuse- or mixed-type adenocarcinomas, and immunohistochemically stained for β-catenin, E-cadherin (extracellular and cytoplasmic domains) and HER2/neu. The results of staining were compared between the subtypes for statistically significant differences. All 97 cases were confirmed as gastric adenocarcinomas, with 39 (40%) intestinal-type, 51 (53%) diffuse-type, and 7 (7%) mixed-type tumours identified. Patient ages ranged from 18-84 years. HER2/neu was overexpressed in 12 (12%) cases, with intestinal-type morphology (p = 0.017) reported in nine. Fourteen cases (14%) demonstrated abnormal β-catenin localisation. Aberrant E-cadherin (extracellular domain) localisation occurred in 36 (37%) cases. Diffuse-type morphology was associated with a significantly high proportion (p = ≤ 0.001). Aberrant E-cadherin (cytoplasmic domain) localisation occurred in 7 (7%) cases. A significantly high proportion (six of these cases) (p = 0.023) of these was diffuse-type morphology. Eleven (11%) adenocarcinomas occurred in patients aged ≤ 40 years, with intestinal morphology reported in nine of these 11. Aberrant E-cadherin (extracellular domain) localisation was noted in seven of the 11, a significantly high proportion when compared to that in the older patients (p = 0.025).
Conclusion: Distinct immunomorphological correlations are apparent in tumours demonstrating HER2/neu overexpression or abnormal E-cadherin localisation. Intestinal morphology, poor differentiation and E-cadherin abnormalities are frequently demonstrated in tumours occurring in younger individuals.
Molecular genetic features and risk assessment in a series of 30 patients who underwent an operation for gastrointestinal stromal tumours : original articleSource: South African Journal of Surgery 54, pp 23 –28 (2016)More Less
Background: The objective of the study was to investigate the relationship between molecular genetic features and the standard criteria of risk assessment in patients affected by gastrointestinal stromal tumours (GISTs).
Methods: A review was conducted of a series of 30 patients, with a mean age of 67 years, who underwent surgery for primary GISTs. R0 resection was accomplished in 27 patients. CD117, CD34 desmin, vimentin, S-100 and smooth muscle actin were immunohistochemically tested to achieve a diagnosis of GIST. The loss of wild-type KIT or platelet-derived growth factor receptor alpha (PDGFRα) genes was investigated by sequencing the tumour DNA.
Results: Tumour genes mutations were reported in 23 patients (77%), and wild-type in seven. Mutations on the KIT gene occurred in 18 patients, and mutations on the PDGFRα gene in five. The average sizes of the GIST were 8.7 cm, 5.4 cm and 5.9 cm for KIT gene-mutated, PDGFRα gene-mutated and wild-type tumours, respectively. KIT gene mutations were detected in 50% of gastric and in 70% of extragastric GISTs. Moreover, 70% of tumours with a mitotic rate ≥ 5 x 50 high-power fields (HPFs) underwent KIT gene mutations. Conversely, PDGFRα mutations were observed only in gastric GISTs with a mitotic rate ≤ 5 x 50 HPFs. By stratifying GISTs according to classes of risk, KIT mutation was shown in most of the high-risk tumours. PDGFRα mutations occurred exclusively in lower classes of risk.
Conclusion: Molecular analysis data might have a role as a prognostic variable in models of risk assessment for patients with GISTs.
Platelet indices and neutrophil to lymphocyte ratio in adults with acute appendicitis : original articleSource: South African Journal of Surgery 54, pp 29 –34 (2016)More Less
Background: A study was performed in adults with acute appendicitis and matched controls to assess the utility of the platelet indices and neutrophil to lymphocyte ratio, as a diagnostic adjunct.
Methods: Data were retrospectively collected from a complete blood count test of 155 adult patients (72 men and 83 women) with histologically proven acute appendicitis upon admission, and of 50 healthy adults (20 men and 30 women). The parameters for white blood cells and platelets were compared between the two groups, and for each gender separately.
Results: A higher white blood cell count, neutrophil count, neutrophil percentage, neutrophil to lymphocyte ratio and lower lymphocyte percentage was reported in patients with acute appendicitis than that in the healthy controls, with high areas under the curve (AUC), sensitivities, specificities, positive predictive values (PPVs) and moderate negative predictive values (NPVs). The lymphocyte count was lower in patients than it was in the healthy controls. The platletcrit was lower in the female patients than that in the female controls, whereas a difference was not detected in the male participants. Differences were not detected with regard to platelet count, mean platelet volume and platelet distribution width for both genders.
Conclusion: The neutrophil to lymphocyte ratio increases and lymphocyte percentage decreases in acute appendicitis, and can be used as an additional diagnostic marker. Plateletcrit, and therefore total platelet mass, is reduced in women with acute appendicitis, indicating the involvement of platelets in its pathophysiology. However, it is neither a reliable predictor or excluder of the disease.
Source: South African Journal of Surgery 54, pp 36 –42 (2016)More Less
Background: The aim of the study was to present the surgical management of injuries to the abdominal vena cava (AVC) and to identify clinical and physiological factors and management strategies which affect the outcome.
Methods: A retrospective review was conducted of AVC injuries in patients attending the trauma centre at Groote Schuur Hospital, Cape Town, from January 2003 to December 2011. Demographic data, mechanism and agent of injury, level of injury, physiological parameters, associated injuries, trauma scores, management strategy, morbidity and mortality, and length of hospital stay were taken from the trauma centre's operative databank at Groote Schuur Hospital.
Results: Thirty-five patients with AVC injuries were identified. There were 33 penetrating injuries (94%).Gunshot wounds accounted for 28 of them (85%). There were 19 (54%) infrarenal, 9 (26%) juxtarenal, 3 (7%) suprarenal and 4 (11%) retrohepatic AVC injuries. Most patients were treated with ligation (66%). There were 17 (49%) deaths. There were significant differences in the preoperative systolic blood pressure (p = 0.044), number of red cell units transfused (p = 0.001), serum lactate (p = 0.007), arterial pH (p = 0.002) and preoperative temperature (p = 0.000) between the survivors and non-survivors. There was also a significant difference in ligation versus repair between the two groups (p = ≤ 0.000). There was no difference in the injury severity, level of injury and the number of associated injuries between survivors and non-survivors.
Conclusion: AVC injuries are associated with high mortality. Patients presenting with clinical and physiological evidence of shock and who require "damage control" surgery are more likely to suffer a worse outcome, particularly when multiple physiological derangements are present. Patients who died often have severe associated injuries.
Positron emission tomography/computed tomography scanning for the diagnosis of occult sepsis in the critically injured : intensive careSource: South African Journal of Surgery 54, pp 43 –48 (2016)More Less
Background: Although the site of nosocomial sepsis in the critically ill ventilated patient is usually identifiable, it may remain occult, despite numerous investigations. The rapid results and precise anatomical location of the septic source using positron emission tomography (PET) scanning, in combination with computed tomography (CT), has promoted this modality as the diagnostic tool of choice for pyrexias of unknown origin.
Methods: The objective of this study was to report our experience using PET/CT scanning for the localisation of a septic focus in critically injured patients in whom no source could be identified using conventional investigations.
Results: Two patients with gunshot wounds and two who had sustained multiple fractures following motor vehicle collisions developed pyrexias of unknown origin during their stay in the trauma intensive care unit. Routine screening for a septic focus was unrewarding, and 18F-fluorodeoxyglucose PET/CT scanning was used to identify the possible source. PET/CT scanning identified the septic focus in all patients. Abscesses were drained successfully in those with penetrating trauma and in one with blunt polytrauma. Pulmonary tuberculosis, not apparent on initial radiology, was identified using PET/CT in one patient with blunt thoracic trauma.
Conclusion: PET/CT scanning appears to both confirm and localise the source of sepsis in a variety of pathologies in critically ill patients who develop pyrexias for which no source can be identified by conventional screening techniques.
Patterned bruising caused by an automobile tyre : an accurate guide to the mechanism of injury : scientific letterAuthor R. MohanSource: South African Journal of Surgery 54, pp 49 –50 (2016)More Less
Patterned bruises are frequently noted on trauma victims. Although these bruises do not require any specific treatment, they provide objective evidence of impact. They also provide valuable clues to determining the impacting object, the mechanism of injury and have medico-legal importance. We present a case to illustrate and discuss the clinical utility of patterned bruises.
Author Paul CookeSource: South African Journal of Surgery 54, pp 51 –52 (2016)More Less
The world lost a fine man and a renowned surgeon when Ray Dawson died in December 2015 at his home in Scotland. His professional and social vision reached far beyond conventional horizons, while his courage enabled him to overcome every hurdle in the way to serving his country and mankind in general with a dedication and sensitivity that came naturally to him.