South African Journal of Surgery - Volume 54, Issue 2, 2016
Volume 54, Issue 2, 2016
No longer Hocus Pocus. The time has come for surgeons to embrace point of care ultrasound training : editorialSource: South African Journal of Surgery 54, pp 2 –3 (2016)More Less
Ultrasound provides non-invasive real time high-resolution multiplanar quality imaging, which avoids ionizing radiation and is cost-effective. Traditionally, radiologists and radiographers have provided ultrasound services from centralised radiology departments. The development of portable, more versatile, cheaper equipment that is user friendly has led to the increased use of bedside ultrasound by non-radiologists which has been coined point of care US (POCUS). Despite the many advantages of applying ultrasound in clinical practice, surgeons have been slow to incorporate formal ultrasound training and experience in the surgical curriculum. In the current and in the previous issue of the journal, the clinical use and application of ultrasound were reported. The therapeutic use of ultrasound for monitoring the response of hydrostatic reduction of intussusception attests to its safety and efficacy. Hydrostatic reductions were performed by a combined surgery radiology team in the radiology suite with safe reduction of 70 out of 78 intussusceptions. In this issue authors report how the utilization of a centralised vascular ultrasound service is overwhelmed by an "open" service for the diagnosis of deep venous thrombosis. This can be appropriately curtailed by a request form that limits the application of the technique to those most likely to benefit. The POCUS philosophy is embraced by a further article in this issue. In paediatric blunt abdominal trauma, a cohort of surgeons and medical students underwent training in Focused Abdominal Sonography in Trauma (FAST). Their newly acquired skill was applied asa screening tool for high velocity blunt trauma in children.FAST was highly specific and when combined with physical examination was highly sensitive in predicting intra-abdominal injury.
Are too many compression ultrasounds being performed for acute lower limb deep venous thrombosis in tertiary inpatients? : vascular surgerySource: South African Journal of Surgery 54, pp 4 –7 (2016)More Less
Background: Venous thromboembolism (VTE) is a complex and serious condition, with high morbidity and mortality, especially in hospitalised patients. Yet its diagnosis remains challenging because of its unspecific clinical presentation. The objective of this study was to apply an algorithmic combination approach to diagnosing VTE by the addition of a D-dimer assay and Wells' criteria for our hospital's internal referral forms requesting compression ultrasound (CUS), to determine the effect on the number of referrals for CUS and the incidence of deep vein thrombosis (DVT) diagnoses.
Method: Inpatients who had been referred to the hospital's vascular laboratory and who had undergone a CUS to exclude an acute lower limb DVT were retrospectively analysed between January 2009 and December 2013, and compared to prospectively collected data for the full year (2014) after the introduction of the new referral form. Comparisons included the mean annual number of referrals for CUS and the incidence of DVT diagnoses.
Results: The hospital incidence of diagnosed DVTs for 2009-2013 was 0.17%, compared to 0.16% for 2014 (p = 0.930). In contrast, the total number of referrals for CUS as a percentage of all hospital admissions dropped from 0.84% in 2009-2013 to 0.63% in 2014 (p = 0.009, odds ratio 0.76, 95% confidence interval: 0.62-0.93).
Conclusion: The implementation of Wells' criteria and D-dimer to the new request form for CUS significantly decreased referrals to the hospital's vascular laboratory without impacting on the number of DVT cases diagnosed. This is a positive change which simplifies care and reduces the expense of ultrasonography investigations.
Author A. MannellSource: South African Journal of Surgery 54, pp 10 –13 (2016)More Less
The proliferative marker, Ki-67, is a human nuclear antigen, and forms an integral part of cell division in both normal and malignant tissue. Since the hallmark of cancer is uncontrolled and relentless cell proliferation, the Ki-67 proliferative index is increasingly used to assess and manage breast cancer. The value of Ki-67 as a prognostic indicator, a guide to the selection of therapy, and a method of measuring response to ongoing treatment, is examined in this review.
Outcomes for cervicomediastinal vascular trauma managed by a vascular sub-specialist led vascular trauma service : vascular surgerySource: South African Journal of Surgery 54, pp 15 –20 (2016)More Less
Background: The management of cervicomediastinal vascular trauma is challenging. We report on our experience with the condition in a newly established vascular trauma service unit, and compare the outcomes to those reported in our parent vascular surgery department.
Method: The details of patients with cervicomediastinal vascular injuries from January 2012 to June 2014 were retrieved for analysis from a prospective database.
Results: Ninety-three patients were identified, 84 of whom were male (90%), with an average age of 29 years. Most were penetrating injuries (89%), and 87% of these were due to stab wounds. There were 107 vascular injuries, 88 cervical and 19 mediastinal. Of these, 87 were arterial and 20 venous injuries. The most common arterial injury involved the subclavian artery (24%), followed by the common carotid artery (22%). Management was multimodal, and included conservative (8%), stenting and embolisation (8%), referral to a higher centre (8%), vascular repair (64%) and ligation (12%). Nineteen per cent required median sternotomy or thoracotomy. Eight patients died post operatively (9%). Seven of them presented in extremis and died within 24 hours, and one died after a week from associated abdominal injuries. Postoperative complications were 9%. There was no incidence of a stroke or limb loss despite ligation of the arteries, including ligation of four internal carotids.
Conclusion: The development of endovascular techniques would allow for noninvasive management of a significant number of patients. Open surgery is still necessary, and associated with significant morbidity. Comparable results were reported in our newly established vascular trauma service unit to those obtained in our parent vascular surgery department in Durban.
Source: South African Journal of Surgery 54, pp 21 –27 (2016)More Less
Background: South Africa's crude death rate was recorded as the highest in the world in 2014. In 2013, 47 murders occurred daily nationwide, and it was confirmed that sharp force fatalities were frequent events. The aim of our study was to review the fatalities of persons admitted to the Pretoria Medico-Legal Laboratory over a two-year period. Understanding the magnitude of the problem, identifying the most commonly injured area and the mechanism of death in cases where the patient died in hospital could aid in the clinical management of some of these cases in order to reduce mortality.
Method: A retrospective descriptive case audit was conducted at the Pretoria Medico-Legal Laboratory from January 2012 through to December 2013.
Results: A total of 173 applicable cases were included. These comprised 5% of the annual case load. Most of the injured persons were male (84%) and aged 21-30 years (50%). Only 27 (16%) decedents were hospitalised and 12 (44%) survived for ≥ 1 day. The most predominantly injured area on the body was the thoracic area (65% of cases). Positive alcohol concentration in the blood was reported in 109 (66%) cases (a range of 0.01 g/100ml to 0.35 g/100ml). Exsanguination was the leading mechanism of death (85% of cases).
Conclusion: Compared with various international regions, an exceptionally higher percentage of these fatalities occur in Pretoria, South Africa. Most stab wounds penetrated the body's thoracic region, consequently perforating the heart and lungs, resulting in immediate death. The proportion of hospital fatalities of patients who sustained abdominal and extremity injuries, and who had already survived ≥ 1 day, was a worrying finding into which further research is required. It is surprising that these patients mostly succumbed to blood loss.
Role of focused assessment with sonography for trauma as a screening tool for blunt abdominal trauma in young children after high energy trauma : paediatric surgerySource: South African Journal of Surgery 54, pp 28 –34 (2016)More Less
Background: The objective of the study was to review the utility of focused assessement with sonography for trauma (FAST) as a screening tool for blunt abdominal trauma (BAT) in children involved in high energy trauma (HET), and to determine whether a FAST could replace computed tomography (CT) in clinical decision-making regarding paediatric BAT.
Method: Children presented at the Trauma Unit of the Red Cross War Memorial Children's Hospital, Cape Town, after HET, and underwent both a physical examination and a FAST. The presence of free fluid in the abdomen and pelvis was assessed using a FAST. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) for identifying intra-abdominal injury were calculated for the physical examination and the FAST, both individually and when combined.
Results: Seventy-five patients were included as per the criteria for HET as follows: pedestrian motor vehicle crashes (MVCs) (n = 46), assault (n = 14), fall from a height (n = 9), MVC passenger (n = 4) and other (n = 2). The ages of the patients ranged from 3 months to 13 years. The sensitivity of the physical examination was 0.80, specificity 0.83, PPV 0.42 and NPV 0.96. The sensitivity of the FAST was 0.50, specificity 1.00, PPV 1.00 and NPV 0.93. Sensitivity increased to 0.90 when the physical examination was combined with the FAST. Nonoperative management was used in 73 patients. Two underwent an operation.
Conclusion: A FAST should be performed in combination with a physical examination on every paediatric patient involved in HET to detect BAT. When both are negative, nonoperative management can be implemented without fear of missing a clinically significant injury. FAST is a safe, effective and easily accessible alternative to CT, which avoids ionising radiation and aids in clinical decision-making.
Source: South African Journal of Surgery 54, pp 36 –42 (2016)More Less
Background: Mobile phone applications (Apps) have become a vital assistant to medical personnel in today's technologically advanced era. The utility of Apps with case logbook capabilities has not yet been explored.
Objectives: To assess and evaluate all currently available surgical and procedural case logbook Apps.
Methods: A comprehensive search was conducted in April 2015 on the Android Play Store, iTunes (Apple App Store, iOS), and BlackBerry World for surgical and/or procedural logbooks. The search terms 'surgical logbook', 'logbook', 'procedure logbook' and 'surgical log' were used. Apps which could not be utilized as a surgical/procedural logbook were excluded. Each App was individually assessed and rated using preset criteria, by the unit consultant, registrars, and medical officer.
Results: In total, 2 740 Apps were assessed. After applying our exclusion criteria, only 16 Apps were relevant, and 11 suitable for critical review. Data sizes ranged from 510Kb to 12.2Mb. Costing of the Apps ranged from ZAR 0.00 to ZAR 105.32. The overall study scores revealed the following top five rated Apps: Surgical Logbook by Surgilog; Surgeon Logbook Pro; Surgery Notebook, Surgical Logbook, and Universal Logbook.
Conclusion: The current mobile Apps available are efficient in replacing traditional case logbooks. The use of the 'Smart Logbook' may become common practice in the life of the modern-day surgeon.
Tumour reduction with a Cavitron Ultrasonic Surgical Aspirator® in the palliative care of anaplastic thyroid cancer : case reportSource: South African Journal of Surgery 54, pp 43 –44 (2016)More Less
A 54-year-old woman developed a fungating locally invasive anaplastic thyroid cancer with distant metastases, and was treated with aggressive tumour reduction, using a Cavitron® Ultrasonic Surgical Aspirator. This mode of treatment, applied for the first time in this context, proved to be effective, safe and improved her quality of life.
Source: South African Journal of Surgery 54, pp 45 –47 (2016)More Less
Solitary extramedullary plasmacytoma (SEP) is a neoplastic proliferation of a single clone of plasma cells that occur outside of the bone and bone marrow. It is rare, commonly occurring in the head and neck region, followed by the gastrointestinal tract. The aetiology, risk factors, natural history and consequent treatment are not well defined. We report an unusual case of SEP of the colon in an human immunodeficiency virus (HIV)-infected patient. The patient was managed with colonic resection and made an uneventful recovery. To our knowledge, this is the first reported case of extramedullary plasmacytoma of the colon and rectum in association with HIV infection.
Gallbladder duplication masquerading as a dilated common bile duct with choledocholithiasis : case reportSource: South African Journal of Surgery 54, pp 48 –50 (2016)More Less
A duplicate gall bladder was diagnosed at laparoscopy, having been erroneously diagnosed on ultrasonography as a dilated common bile duct with choledocholithiasis. Gallbladder duplication is a congenital abnormality with a rare incidence, occuring in approximately 1 in 4 000 births and 0.020% in al large autopsy series. This report highlights its existence to improve awareness and lessen the potential for biliary injury.
Source: South African Journal of Surgery 54, pp 51 –52 (2016)More Less
We report on the rare entity of transvaginal small bowel herniation following a transvaginal hysterectomy. The risk factors, presentation, initial management and various surgical approaches are discussed. It is a condition that requires prompt surgical intervention. This report serves to highlight awareness of the condition, and how knowledge of the various methods of addressing an ischaemic bowel and a ruptured vaginal vault can result in a favourable outcome.
Source: South African Journal of Surgery 54, pp 53 –54 (2016)More Less
Giant peritoneal loose bodies are very rare. Only a few cases have been reported in the literature. The mechanism of their formation is currently unknown. However, the hypothesis is that a detached appendix epiploicae becomes calcified overtime in the abdominal cavity. We present a case of a 73-year-old man who presented with urinary symptoms. Computed tomography (CT) of the abdomen and pelvis revealed a well circumscribed mass in the pelvis. A firm egg-shaped mass was excised laparoscopically. Histology confirmed a giant loose peritoneal body.
Source: South African Journal of Surgery 54, pp 55 –56 (2016)More Less