South African Journal of Surgery - Volume 47, Issue 3, 2009
Volume 47, Issue 3, 2009
Author J.E.J. KrigeSource: South African Journal of Surgery 47, pp 67 –70 (2009)More Less
Bleeding from oesophageal varices is the most serious complication of portal hypertension and accounts for most cirrhosis-related deaths. A quarter of high-risk cirrhotic patients with liver decompensation who present with a first major variceal bleed die as a consequence of the bleed. After control of the index bleed, there is a 70% chance of rebleeding with a similar mortality if further effective treatment is not given. Mortality is related to several factors, including failure of rapid control of initial bleeding, early rebleeding, presence and severity of underlying liver disease and functional hepatic reserve. Optimal emergency management requires an efficient and organised team to provide accurate initial assessment of the patient, effective resuscitation, rapid endoscopic diagnosis, successful intervention with control of bleeding, and prevention of early rebleeding as well as the anticipated complications of liver decompensation including spontaneous bacterial peritonitis, progressive liver and renal failure and hepatic encephalopathy. The modern management of acute, persistent variceal bleeding is therefore best accomplished by a skilled, knowledgeable and well-equipped team that can offer the full spectrum of treatment options.
Early rebleeding and death at 6 weeks in alcoholic cirrhotic patients with acute variceal bleeding treated with emergency endoscopic injection sclerotherapy : general surgerySource: South African Journal of Surgery 47, pp 72 –79 (2009)More Less
Background. This study evaluated the incidence of rebleeding and death at 6 weeks after a first episode of acute variceal haemorrhage (AVH) treated by emergency endoscopic sclerotherapy in a large cohort of alcoholic cirrhotic patients.
Methods. From January 1984 to December 2006, 310 alcoholic cirrhotic patients (242 men, 68 women; mean age 51.7 years) with AVH underwent 786 endoscopic variceal injection treatments (342 emergency, 444 elective) during 919 endoscopy sessions in the first 6 weeks after the first variceal bleed. Endoscopic control of initial bleeding, variceal rebleeding and survival at 6 weeks were recorded.
Results. Endoscopic intervention controlled AVH in 304 of 310 patients (98.1%). Seventy-five patients (24.2%) rebled, 38 (12.3%) within 5 days and 37 (11.9%) within 6 weeks. No patient scored as Child-Pugh A died. Seventy-seven (24.8%) Child-Pugh B and C patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days. Mortality increased exponentially as the Child-Pugh score increased, reaching 80% when the score exceeded 13.
Conclusion. Despite initial control of variceal haemorrhage, 1 in 4 patients (24.2%) rebled within 6 weeks. Survival at 6 weeks was 75.2% and was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients.
Author A. AhmedSource: South African Journal of Surgery 47, pp 80 –85 (2009)More Less
Background. The most appropriate management of penetrating neck injury (PNI) remains controversial. This study was conducted to determine the accuracy and safety of physical examination as the basis of selective observational management of PNI at our institution.
Methods. The study was conducted between 1991 and 2006. Patients whose injuries penetrated platysma were included. Following resuscitation, physical signs were utilised to select patients for exploration or observation. Investigations were based on physical signs which, with details of injured structures, treatments and outcomes, were recorded.
Results. There were 225 patients of whom 209 (93.0%) were men. Their mean age was 28 years. The majority (74.2%) of cases were stab wounds, and the balance (25.8%) were gunshot injuries. In 37.8% and 27.6% of patients, injuries were sustained during armed civilian conflicts and robberies, respectively. Patients with no signs of significant injuries (37.8%) were treated by observation. Overall, 52.4% underwent neck exploration; injuries requiring repair were found in 87.3% of these patients. Physical signs as a basis of detecting significant injury had a sensitivity of 97.2% and specificity of 87.4%. Overall mortality was 4.0%.
Conclusion. Physical examination can accurately select patients with PNI who can be safely managed by observation. Physical signs can also identify patients who require further diagnostic evaluations.
Source: South African Journal of Surgery 47, pp 86 –88 (2009)More Less
Aortocaval fistula (ACF) formation is a rare condition occurring in 0.2 - 1.3% of patients with degenerative aortic aneurysms. This paper describes the presentation and successful management of a patient with such an ACF. We wish to highlight the need to maintain a high index of suspicion for this condition in patients with abdominal aortic aneurysms (AAA), particularly if they present with haematuria or are in congestive cardiac failure.
Author J.B. YigaSource: South African Journal of Surgery 47 (2009)More Less
A 25-year-old HIV-negative man was admitted to the Burns Unit at Pelonomi Hospital, Bloemfontein. He had been involved in a domestic fire accident and had sustained 25% total body surface area burns, mostly fullthickness, involving the lower limbs. He had no inhalation injury and was otherwise in good health. On admission he was moderately oliguric.
Author David MuckartSource: South African Journal of Surgery 47, pp 90 –91 (2009)More Less
Of all professions, medicine must be the one possessed of the most numerous eponyms. Yet, from student to specialist alike, ignorance abounds of the great men and women of the past, and the discoveries, procedures and instruments to which they have given their names. In addition to books on the history of medicine, I am fortunate indeed to possess the sixth edition of Hamilton Bailey's Emergency Surgery printed in 1953. The magnificent use of the English language aside, the text is replete with hints, useful suggestions, and tips not based on the science, but the art, of medicine. Perhaps therein lies the root of historical indifference. We are science-driven, everything must be evidence-based, there is no room in the modern medical arena for gut feeling and instinct; a situation recently regarded as a regime of truth and an example of microfascism.