South African Journal of Surgery - Volume 49, Issue 4, 2011
Volume 49, Issue 4, 2011
Source: South African Journal of Surgery 49, pp 174 –177 (2011)More Less
The International Society for Burns Injuries (ISBI) has published guidelines for the management of multiple or mass burns casualties, and recommends that 'each country has or should have a disaster planning system that addresses its own particular needs.' The need for a national burns disaster plan integrated with national and provincial disaster planning was discussed at the South African Burns Society Congress in 2009, but there was no real involvement in the disaster planning prior to the 2010 World Cup; the country would have been poorly prepared had there been a burns disaster during the event. This article identifies some of the lessons learnt and strategies derived from major burns disasters and burns disaster planning from other regions. Members of the South African Burns Society are undertaking an audit of burns care in South Africa to investigate the feasibility of a national burns disaster plan. This audit (which is still under way) also aims to identify weaknesses of burns care in South Africa and implement improvements where necessary.
Source: South African Journal of Surgery 49, pp 178 –181 (2011)More Less
Objective. Assaults by burning occur infrequently and are related to the social circumstances and demographics of each population. We aimed to explore the mechanisms, complications, morbidity and mortality associated with assault burn injuries admitted to the Burns Intensive Care Unit of Merheim University Hospital in Cologne.
Methods. A retrospective data analysis of a consecutive series of 1 243 burn patients between 1989 and 2004. The cohort was divided into two groups: AG (assault group) and CG (control group). Analyses were controlled for clinical data, treatment and outcome of all patients involved.
Results. Forty-one patients with assault burn injuries were identified during the study period. Compared with the general burn population (CG), the AG had a significantly larger size of third-degree burns (p=0.047), a higher incidence of inhalation injury (p<0.001) and a longer intubation period (p=0.047). Patients in the AG were also more likely to undergo escharotomy (p=0.013) and to receive antibiotics on admission (p=0.016). The mortality rate was higher in the AG than in the CG (26.8% v. 19.9%), but this difference was not significant.
Conclusions. Burned patients who were victims of assault tend to have more severe injuries than the general burn population. These injuries are not only physical, and their management requires a multidisciplinary approach to improve outcome.
Author Robert P. MillsSource: South African Journal of Surgery 49, pp 182 –185 (2011)More Less
This study reports on the surgical anatomy and technique of perineal repair in a selected group of parous women with faecal incontinence and/or difficulty in evacuation. Anal sphincter muscle damage is usually attributed to childbirth, although most of these women present for the first time years later.
Consecutive patients with the above symptoms were examined clinically and then investigated with a perineal ultrasound scan. During the perineal operation for repair, further investigation by transillumination and measurements with calipers were done in 50 patients. All patients received routine postoperative care, and were followed up for at least 6 months.
From 1995 to 2009 a total of 117 patients, all female, underwent perineal repair by a single surgeon. The age range was 24 - 82 years. In the last 50 consecutive patients, transillumination was positive prior to repair in all, and negative after. The average thickness of the rectocele wall was 2.4 mm prior to repair and 4.8 mm after. In all patients, a rectocele was found in conjunction with the anal sphincter defect. The results of combined repair were satisfactory in 109 of 117 patients (93%).
Long-term outcomes after laparoscopic total mesorectal excision for advanced rectal cancer : general surgerySource: South African Journal of Surgery 49, pp 186 –189 (2011)More Less
Purpose. The aim of this study was to evaluate the long-term outcomes of laparoscopic total mesorectal excision in the treatment of advanced rectal cancer in a randomised population.
Methods. Between 2001 and 2005, 125 patients (70 males, 55 females, mean age 55.5 (standard deviation (SD) 11) years, range 25 - 81 years) with rectal cancer were evaluated and prospectively followed up in our hospital (mean follow-up 42 (SD 23 months, range 5 - 113 months). The 5-year overall survival rate, 5-year disease-free survival rate and recurrence rate were analysed.
Results. There were 54 cases of cancer defined as UICC stage II and 68 cases defined as stage III. Of these cases, 22 were localised to the upper rectum, 50 to the middle rectum and 53 to the lower rectum. The 5-year overall survival rates were 71.3% and 51% among the stage II and the stage III patients, respectively. The 5-year disease-free survival rates were 59.2% and 45.4% among the stage II and the stage III cancer patients, respectively. The overall recurrence rate was 16.8% (local recurrence rate 11.25%, distant recurrence rate 8%). Multivariate analysis showed that age and size were independent predictors of overall survival (p=0.006 and p<0.001 for stage II and stage III patients, respectively).
Conclusions. Our results suggest good long-term outcomes of laparoscopic surgery in the treatment of rectal cancer. However, this technique should be used with caution in older patients and patients with larger tumours.
Source: South African Journal of Surgery 49, pp 190 –193 (2011)More Less
Background. Inflammatory myofibroblastic tumours (IMFTs) are rare tumours characterised by nosologic, histogenetic and aetiopathogenetic controversy and variable clinicopathological features. We report our experience with intestinal-IMFTs (I-IMFTs) that have been reported mainly as single case reports to date.
Methods. Five patients with I-IMFTs, identified between 2005 and 2008, formed the study cohort. The clinicopathological features were obtained from departmental and hospital records.
Results. The median patient age was 13 years. While 4 patients presented with symptoms and signs of intestinal obstruction, one IMFT was an incidental finding at laparotomy for trauma. Three I-IMFTs were located in the small bowel and 2 in the colon. Complete resection with end-to-end anastomoses was performed. The gross morphology included 1 polypoid myxoid tumour that served as a lead point for an intussusception, 3 multinodular whorled masses and 1 firm circumferential, infiltrative tumour.Microscopically, all tumours had typical features of IMFT with variable expression of ALK-1, a low proliferation index and tumour-free resection margins. All patients had an uneventful recovery. One patient was lost to further follow-up. Four patients were well, without local recurrence or metastases at 6 months to 3 years.
Conclusions. Surgery with tumour-free resection margins is the gold standard of care of adult and paediatric I-IMFTs. Heightened recognition of I-IMFT, albeit rare, as a cause of intestinal obstruction, including intussusception, is necessary for preoperative suspicion of I-IMFT.
Source: South African Journal of Surgery 49, pp 194 –198 (2011)More Less
Introduction. Caring for trauma patients is a dynamic process, and it is often necessary to move the trauma patient around the hospital to different locations. This study attempted to document the quality of observations performed on acute trauma patients as they moved through the hospital during the first 24 hours of care.
Methodology. This study was a student elective and was undertaken at Grey's Hospital, Pietermaritzburg. A third-year medical student was assigned to follow acute trauma patients throughout the hospital during the first 24 hours after admission. This single independent observer recorded the frequency with which vital signs were recorded at each geographical location in the hospital for each patient. A scoring system was devised to classify the quality of the observations that each patient received in the different departments. The observer recorded all the geographical movements each patient made during the first 24 hours after admission.
Results. Fifteen patients were recruited into this study over a 4-week period. There were 14 adult males (average age 28 years, range 18 - 56 years) and a 7-year-old girl in the cohort. There were significant differences in the quality of the observations, depending on the geographical location in the hospital. These variations and differences were consistent in certain locations and highly variable in others. Observations in the intensive care unit (ICU) and operating theatre were uniformly excellent. In the radiology suite the level of observations was universally poor. In casualty and the wards there was great variability in the level of observation. A total of 45 distinct geographical visits were made by the study cohort. Each patient made an average of 3 (range 2 - 5) visits during their first 24 hours after admission. All patients attended casualty, and there were 11 patient visits to the ward, 10 to radiology, 4 to ICU and 5 to theatre.
Conclusion. Significant variations exist in the level of observations of vital signs between different geographical locations within the hospital. This is problematic, as acute trauma patients need to be moved around the hospital as part of their routine care. If observations are not done and acted upon, subtle clinical deterioration may be overlooked and overt deterioration may be heralded by a catastrophic event.
Source: South African Journal of Surgery 49, pp 199 –201 (2011)More Less
This brief literature review examines the causes of missed injury, the typical clinical pictures that are associated with missed injury and techniques and procedures to help avoid missing injury in the light of the recent literature, while highlighting the cost implications for clinicians.
Source: South African Journal of Surgery 49, pp 202 –203 (2011)More Less
A biliary cyst is a congenital dilatation of the extrahepatic and/or intrahepatic biliary tract. It occurs in approximately 1:100 000 - 1:150 000 live births, being most common in Japan and among females. Approximately 80% of these cysts are diagnosed before the age of 10, when they classically present with a triad of right upper quadrant pain, a mass and jaundice. In adults, this triad is unusual, and abdominal pain with tenderness is usually the only initial feature. Alonso-Lej and colleagues first proposed a classification system for bile duct cysts in 1959, which was later modified by Todani and colleagues in 1977 (Fig. 1).
Source: South African Journal of Surgery 49, pp 204 –205 (2011)More Less
A 27-year-old woman, gravida 1, was seen at our surgical emergency department with abdominal pain at 25 weeks' gestation. She had pain, nausea and vomiting, a temperature of 37°C and a blood pressure of 100/70 mmHg. The cervix was closed, and an ultrasound scan showed a normal single fetus. A plain abdominal radiograph showed distension of the colon and a sigmoid volvulus. At emergency laparotomy, non-gangrenous sigmoid colon was resected with primary anastomosis. There were no complications, and 4 months later the patient delivered a healthy infant.
Early diagnosis of sigmoid volvulus in pregnancy and prompt intervention minimise maternal and fetal morbidity and mortality.
Author Daniel SurridgeSource: South African Journal of Surgery 49 (2011)More Less
The Handbook of Trauma was first published in 2004 and set out to give South African health care practitioners a manual relevant to this unique situation, in which we are all too often lost. As we better understand the disease of trauma and best practice for care of these patients has changed, a revised second edition has been released (2010). Once again, experts in the field have contributed to give the most relevant information available. New chapters have been added to make the book even more comprehensive.
Is transdermal nitroglycerin application effective in preventing and healing flap ischaemia after modified radical mastectomy? : letters to the editorSource: South African Journal of Surgery 49 (2011)More Less
We read the article by Kutun et al. on the use of transdermal nitroglycerin application in preventing and healing flap ischaemia after modified radical mastectomy with interest. Although we do not dispute the numerous attributes of nitroglycerin, we would like to voice some concerns and highlight certain relevant issues not discussed by the authors in this paper.
Bilharzia of the breast masquerading as a breast skin papilloma in a pregnant woman : letters to the editorSource: South African Journal of Surgery 49 (2011)More Less
A 21-year-old woman from Khayelitsha, Western Cape, presented with a 3 cm diameter papillomatous growth lateral to her left nipple with satellite lesions around the areola. She was 25 weeks pregnant and was concerned that the mass would interfere with breastfeeding. She was otherwise well. The papilloma was excised, and histological examination showed an exophytic papillary lesion with numerous viable Schistosoma haematobium ova (Fig 1.). There was a conspicuous surrounding mixed inflammatory reaction as well as extensive fibrosis, but no evidence of malignancy.
Source: South African Journal of Surgery 49 (2011)More Less
Tuberculosis (TB) is often the first manifestation of AIDS. Extrapulmonary disease can occur in up to 40% of these patients, particularly when immunosuppression is advanced. Abdominal TB can mimic common non-infectious abdominal syndromes. Several cases of digestive fistulas attributed to AIDS-associated TB have been described, most of them being oesophageal fistulas from mediastinal lymph nodes. More distal intestinal fistulas are extremely rare. We report what is probably the first case in which a biliary fistula was the first presentation of abdominal TB and AIDS.
Author Selim SozenSource: South African Journal of Surgery 49 (2011)More Less
Most surgeons follow the practice of leaving a drain following thyroid surgery, in the hope that this will obliterate the dead space and evacuate collected blood and serum. The main reason is to drain off a possible post-operative haemorrhage that may compress air passages and produce respiratory failure. Although haemorrhage after thyroid surgery is rare, it may be life-threatening and require immediate re-operation.
Author Del KahnSource: South African Journal of Surgery 49 (2011)More Less
The surgical fraternity was saddened by the death of Nathan Cirota, who passed away on 6 June 2011.
Nathan was born on 8 December 1944. He matriculated from Pretoria Boy's High School in 1962 and completed his M.B. Ch.B. at the University of Pretoria in 1970. He undertook postgraduate training in general surgery at the University of Stellenbosch and was awarded the M.Med. in General Surgery in 1982.
Author Harold SpilgSource: South African Journal of Surgery 49 (2011)More Less
Cyril Harold Wolpe was born in 1925 in Humansdorp in the Eastern Cape, and matriculated there in 1943. He entered the medical faculty at the University of Cape Town the following year and graduated M.B. Ch.B. in 1949. Thereafter he first worked as a relieving medical officer at Groote Schuur Hospital and then proceeded to the UK.
Source: South African Journal of Surgery 49, pp 211 –215 (2011)More Less