South African Journal of Surgery最新文献

Background: KwaZulu-Natal bears a significant trauma burden, with polytrauma patients often experiencing traumatic limb amputations. This study investigates traumatic limb amputations in the subgroup of severely injured polytrauma patients admitted to the trauma ICU in KwaZulu-Natal. This study aims to describe the management and outcomes of traumatic limb amputations in polytrauma patients at the trauma ICU.

Methods: This retrospective observational study utilised data from the trauma ICU registry (BCA207/09). Descriptive methods were employed to analyse demographics, injury mechanisms, timing of amputations, anatomical sites affected, injury complexes, injury severity scores, and patient outcomes.

Results: Twenty-three patients were included, with a mean age of 32 years. The most common injury mechanism was motor vehicle collision pedestrian (43%), 82% of included cases underwent early amputation. The left lower leg was the most frequently affected site (62%), with a median injury severity score (ISS) score of 25 (13-42) and median new injury severity score (NISS) of 34 (20-43). Most were ultimately above-knee amputations but started as below-knee amputations. Most patients were discharged to base (60.8%), while 22% died.

Conclusion: This study provides valuable insights into traumatic limb amputations in polytrauma patients, emphasising the need for comprehensive management strategies. The outcomes of traumatic limb amputations require optimised patient care and better rehabilitation services.

Background: Postoperative patients' risk for developing venous thromboembolism (VTE) can be predicted using the adapted Caprini risk assessment model which informs administration of postoperative VTE prophylaxis. The study aimed to assess the appropriateness of postoperative VTE prophylaxis of patients according to the adapted Caprini scores and investigate whether a patient's HIV status influenced postoperative VTE prophylaxis administration.

Methods: This cohort study included patients who had elective or urgent surgery at a tertiary hospital, Bloemfontein. Data from patient files were captured on datasheets that comprised the adapted Caprini risk assessment model. The type of prophylaxis received was noted. The appropriateness of the prophylaxis prescribed was compared with the patient's score.

Results: Details of 147 patients were included. Three of the 16 patients who did not qualify for prophylaxis, were on VTE prophylaxis on day-one post-surgery. Only 24 (18.3%) of the 131 patients who qualified for prophylaxis were on prophylaxis one day post-surgery. Of the prophylaxis prescribed, 88.5% was enoxaparin, and 11.5% "other", mainly aspirin. Twenty-three (17.6%) patients who qualified for prophylaxis were discharged on prophylaxis. Of the 147 patients, 24 patients were HIV positive, and eight of these patients received postoperative VTE prophylaxis.

Conclusion: The majority of postoperative patients at the various surgical departments of the hospital did not receive appropriate postoperative VTE prophylaxis compared to the adapted Caprini scores obtained from their medical information. A patient's HIV status alone did not influence the decision of administering postoperative VTE prophylaxis.

Background: Endocrine hypertension is believed to be underestimated worldwide especially in the developing countries. There is a scarcity of publications on endocrine hypertension in sub-Saharan Africa. The aim of this study was to reflect the profile of patients with endocrine hypertension of adrenal/paraganglioma origin at Chris Hani Baragwanath Academic Hospital (CHBAH). The objective was to determine the aetiology, the lead time to diagnosis of endocrine hypertension and to reflect on the surgical approach and outcome.

Methods: This descriptive observational study reviewed all surgical procedures performed at CHBAH from 1 January 2013 to 31 December 2020. Parameters analysed included the demographics, the aetiologies, the location of the disease, the surgical approach, the histopathology, the incidence of malignancy, the lead time and the 30-days outcome.

Results: Of the 44 patients analysed, there were 66% female and 34% male. The mean age was 38 years. The majority of the cases were due to catecholamine secreting tumours (65.9%). Overall, 43.1% of the procedures were completed laparoscopically. Altogether, the mean lead time ranged from 5 to 12 years. The incidence of malignancy and the 30-day mortality were 15.9% and 4.5% respectively. The index presentation of endocrine hypertension was due to complications in 9% of the cases.

Conclusion: Catecholamine producing tumours were the most common aetiology. Laparoscopy was successful in 43.1%. The lead time was long and there were more tumours on the left side. The mortality rate was 4.5%.

Summary: Retroperitoneal lymphangioma is exceptionally rare. We present a case of a 41-year-old asymptomatic patient with a large abdominal cystic mass detected on contrast-enhanced computed tomography (CT) scan, initially suspected to be pseudomyxoma peritonei. Laparoscopic exploration revealed a 30 x 30 cm multilocular cystic tumour originating from the retroperitoneum. The tumour was successfully resected laparoscopically, and pathological analysis confirmed a lymphangioma. The patient recovered well with no recurrence over five years. For uncertain tumour types, transabdominal laparoscopic exploration should be prioritised. For treating retroperitoneal lymphangiomas with the origin in the retroperitoneum and a main body in the abdominal cavity, the transabdominal laparoscopic approach is a less invasive and effective treatment option.

Background: Data on trauma burden and outcome varies amongst the nine South African Provinces. In Limpopo Province there is a paucity of data which this study aimed to quantify and characterise the severe trauma burden in the province.

Methods: A retrospective chart review for all patients with injury severity score (ISS) > 16 over a 6-year period (Jan 2015-Dec 2020) at two central hospitals in Limpopo province. Descriptive analysis was undertaken of the following variables: patient demographics, injury patterns and outcomes.

Results: The review identified 355 patients whose mean age was 31 years (Range 0.25-74 years). Eighty four per cent were males. Forty nine per cent were unemployed. The most common mechanisms of injury were interpersonal violence 49 % and motor vehicle crashes (MVCs) 34.9%. Head (41%), torso (25%) and limbs (15.2%) were the body-regions most frequently involved. The median ISS was 16 with IQR (16-16) (0). The median length of stay was 7 days with IQR (5-15) (10). Of the ICU admissions 50% were MVCs and 56% due to head injury. Of the 50 deaths 50% were due to MVC and pedestrian vehicle crashes (PVCs), and head injuries were present in 54% of those who died.

Conclusion: Young males were the most predominantly affected. Assault and MVC were the most common mechanisms of injury. The unemployment rate also seems to be a key factor in trauma epidemiology in the province. Further study of the wider trauma burden is required.

Summary: A five-year-old male presented with small bowel obstruction and a worm bolus on a plain abdominal radiograph. Peritonism and acidosis prompted laparotomy after a short period of resuscitation. At surgery a worm bolus had caused a small bowel volvulus with a segment of necrosis that was successfully managed by detorsion and resection. This highlights that though ascaris lumbricoides, a common parasite in impoverished communities, has many mild manifestations the most life-threatening complication is volvulus. Hence when worm bolus is suspected vigilant observation to detect sepsis, acidosis and peritonism is essential to expedite surgery and prevent the morbidity of perforation.

Background: Bowel trauma, encompassing injuries to the small and large intestine, represents a significant medical challenge due to its potential for morbidity and mortality. Management of bowel injuries remains surgical, but multiple factors influence the outcome in these patients. This study provides an in-depth analysis of the high-risk features of hollow visceral trauma in the ICU setting and the corresponding mortality rates, shedding light on the critical factors that influence outcomes in these cases.

Methods: Retrospective review of patients admitted to the trauma intensive care unit (ICU) at Inkosi Albert Luthuli Hospital from January 2017 until September 2022 were reviewed to identify risk features associated with morbidity and mortality. Statistical analysis was performed using Python 3.10.

Results: Ninety-four patients were reviewed, the majority (88.3%) were male and median age was 31.5 years. Mortality was 31.9%. The median length of stay in the ICU was 9.0 days (IQR 4-19 days, range 2-94 days). Small bowel injuries were more common than colonic injuries (75.3% vs 63.8%). Multiple colon injuries, renal injuries, extra hepatic biliary injuries and older age were associated with significant increase in mortality.

Conclusion: This study's findings underscore the multifaceted nature of bowel injury management in an ICU population. A comprehensive, multidisciplinary approach that considers injury severity, anatomical site, and patient-specific factors is crucial for achieving favourable outcomes in bowel trauma cases.

Background: This study aimed to assess the contribution of human error to adverse events over 10 years in a single surgical department in South Africa.

Methods: A retrospective database analysis was undertaken to identify all adverse events, which were further assessed to identify which were error-associated.

Results: A total of 14 237 adverse events occurred between December 2012 and January 2023, of which 7 504 (52.7%) were judged to be error-associated. An error rate of 14% per admission, or 2% per inpatient day was shown. Errors during delivery of care accounted for 76% of all errors and 40% of all adverse events. Of those, medication errors contributed 29%, those due to indwelling devices contributed 28%, and iatrogenic injuries 18%. Errors in assessment accounted for 14% of the total errors and 7% of all adverse events, with clinical assessment failure contributing 55.8% and missed injuries 19%. Mixed type errors contributed 10% of the total. Assessment by year demonstrated an upward trend from 2013 to 2016, followed by a downward trend from 2016 to 2022. Error-associated adverse events increased length of stay and mortality significantly.

Conclusion: Error contributes to more than half of adverse events and increased length of stay and mortality and is potentially avoidable. Errors may occur at any stage during an admission and highlights the need for multilevel interventions. The decrease in error noted is due to the cumulative effect of multiple endeavours, and not a single intervention.

Background: Colorectal cancer (CRC) is the fifth most common cancer in sub-Saharan Africa (SSA) and the third most common in South Africa (SA). CRC characteristics in SSA are not well described. The aim is to describe patient characteristics and anatomic location of colorectal adenocarcinoma (CRC-AC) in SA.

Methods: A retrospective analysis of the histology specimens of CRC in SA through utilisation of the South African National Cancer Registry from 2006 to 2011.

Results: Six thousand one hundred and forty-six patients with colorectal malignancies were identified of which 5 498 (89%) had CRC-AC. The median age at presentation was 60 (interquartile range, 49-70) years. One thousand three hundred and seventy-two (25%) were < 50 years and 2 870 (52%) were male. Right colonic tumours were found in 1 277 (26%), 1 214 (25%) were left colonic lesions, and 2 404 (49%) lesions were located in the rectum. Patients ≥ 50 years at presentation (OR = 1.29, 95% CI = 1.11-1.50, p < 0.001) were more likely to have left colonic and rectal adenocarcinoma. Patients < 50 years at presentation were more likely to be black (OR = 1.67, 95% CI = 1.39-2.02, p < 0.001) and have right-sided tumours (OR = 1.25, 95% CI = 1.06-1.46, p < 0.007).

Conclusion: CRC-AC in SA presents at an earlier age than in HICs, such as the United States of America. The majority of CRC were left-sided and rectal; thus, screening with faecal immunochemical testing and flexible sigmoidoscopy should be considered. Further studies on the age-specific incidence and the genetics and epigenetics and socioeconomic determinants of CRC-AC in SA are needed.