South African Journal of Surgery最新文献

Background: Selective non-operative management (SNOM) is the current gold standard for the treatment of patients with penetrating neck trauma. The policy revolves around the liberal use of computed tomography angiography (CTA) in those patients who are haemodynamically stable, irrespective of the anatomical zone of injury, aiming at reducing the incidence of negative and non-therapeutic interventions and their potential complications.

Methods: A retrospective audit of results of patients who underwent immediate surgical exploration at the Chris Hani Baragwanath Academic Hospital in Soweto between January 2010 and December 2015 was performed.

Results: One-hundred and forty-five (145) patients, with a median age of 28 years (range 18-67 years), predominantly males (93.8%), underwent immediate exploration. Most injuries were caused by stab wounds (92.4%) and affected zone 2 (54.1%) on the left side of the neck (69.6%). The most common presentations were active haemorrhage (29.4%), shock (24.1%) and expanding haematoma (15.1%). A major vascular injury was found in 40%, and aero-digestive organ injury in 19.3%. The rate of negative-non-therapeutic exploration in this cohort was 4.1%. Complications were recorded in 7.6%, and the overall mortality was 9.6% secondary to early uncontrolled haemorrhage, sepsis and occlusive strokes.

Conclusions: The utilisation of SNOM with strict criteria for selection of patients who require immediate surgical exploration versus investigations with CTA results in a low rate of non-therapeutic interventions.

Background: Haemothorax occurs in approximately 60% of all thoracic and polytrauma cases and is responsible for 15-30% of all trauma mortalities. Penetrating injuries to the thorax are a common presentation in South African hospitals. This study aims to audit the traumatic haemothoraces and their outcomes in regional hospitals in Durban, KwaZulu-Natal, South Africa.

Methods: In this study, patient characteristics were grouped as either continuous or categorical variables. Continuous variables, such as age were summarised as means (with standard deviations) or medians (interquartile range [IQR]), as appropriate. Categorical variables such as sex were summarised as proportions. Fisher's exact test was used to compare proportions. All analyses were performed using the Statistical Package for Social Sciences.

Results: A total of 118 patients were included comprising 110 (93%) males and eight (7%) females, with an average age of 29.7 years. Stab-chest was the most frequent mechanism of injury (76; 64.4%), followed by gunshot wound (GSW)- chest (27; 22.9%) and isolated blunt chest trauma (9; 7.6%). Other mechanisms of injury were stab-neck (3; 2.5%), stab-shoulder (2; 1.7%) and blunt chest trauma in the context of polytrauma (1; 0.8%). The most frequent type of injury was penetrating (108; 91.5%), with only 10 (8.5%) cases of blunt injury. This study found that there was a statistically significant association between patient age groups and type of injury.

Conclusion: Haemothorax is a common sequela of chest trauma. Retained haemothorax (RH) results in worsened patient outcomes including increased hospital length of stay (LOS). This study points to the need for auditing of proper intercostal chest drain (ICD) positioning, which is crucial for the successful drainage of haemothorax.

Summary: A diaphragmatic defect that permits abdominal contents to herniate into the right side of the chest is rare. In adults with right-sided diaphragmatic hernias, few occur without a history of trauma, and even fewer are symptomatic. This case report illustrates such a case and the rare entity of an anterolaterally located hernia. Although uncommon and easily missed, consequences of diaphragmatic hernias can be disastrous. The importance of a combination of high clinical suspicion and the use of computed tomography (CT) to aid diagnosis, and the dangers of a surgical condition being incorrectly assessed and admitted to a non-surgical specialty are highlighted in this case.

Background: In low- to middle-income countries (LMICs) like South Africa, there is a need to understand the clinical practices surrounding diagnosis and surveillance of paediatric Hodgkin lymphoma (HL) to reduce the burden on health systems. Understanding the clinical utility of PET/CT scans may decrease repeated tissue biopsies during disease surveillance.

Methods: This is a retrospective cohort study of patients aged less than 18 years treated for HL at Chris Hani Baragwanath Academic Hospital from 1 January 2009 to 31 December 2018.

Results: Fifty-four patients were included in the study; male-to-female ratio was 5:1 with a mean age of 9 years. Seventy per cent of patients (n = 38) received a PET/CT and tissue biopsy during their initial diagnostic workup, whereas 20.4% (n = 11) of patients received a PET/CT and tissue biopsy during surveillance. Tissue biopsy and PET/CT showed slight agreement (κ = 0.14) in diagnosing relapsed disease during surveillance. The false negative rate for tissue biopsy during surveillance was 42.9%. Surveillance PET/CT showed a positive predictive value (PPV) of 66.7% and negative predictive value (NPV) of 100% when compared to tissue biopsy.

Conclusion: This study is the first cohort to explore the clinical utility of PET/CT scans and tissue biopsies in a lowresourced setting. Our findings showed slight agreement between the modalities in diagnosing relapsed disease during surveillance. A portion of this discordance can be attributed to false negative tissue biopsy results. While the sample is limited, our findings are consistent with the high NPV of PET/CT scans of > 95% as is reported in the literature.

Background: Damage control surgery (DCS) is a widely used approach in trauma. An open abdomen carries complications, increased morbidity and mortality. This study aims to quantify the mortality rate, determine contributory factors and factors influencing the decision to perform DCS and assess morbidity in patients undergoing open abdomen.

Methods: A retrospective review was conducted on 205 patients in Charlotte Maxeke Johannesburg Academic Hospital Trauma Unit. The mortality rate was evaluated over a 24-hour, 7-day and 28-day period. Data were collected by a data collection sheet from 1 January 2016 to 31 December 2018.

Results: Of the 205 patients, 193 were male and the median age was 34.34 years. Penetrating trauma was the most predominant mechanism of injury in 162 (79%), with gunshot injuries seen in the majority (130/162). The mortality rate was 55/205 (26.8%) for open abdomen patients, 19/55 (34.5%) within the first 24 hours, 22/55 (40%) in the 24-hours to 7-days period, and 14/55 (25.4%) in the 8-day to 28-day period. Statistically significant factors contributing to mortality were haemodynamic instability, hypothermia, coagulopathy, massive transfusion, vasopressors, and significant associated injuries. Morbidities were entero-atmospheric fistula (EAF) in 7.3% (Clavien-Dindo grade IIIa), surgical site infection in 45.3% (Clavien-Dindo grade I) and ventral hernia in 10.24% (Clavien-Dindo grade IIIb).

Conclusion: Most open abdomens were performed in males, with gunshot injuries being the most common mechanism. The majority of mortalities were within the 24-hours to 7-days period. The most common morbidity associated with an open abdomen was surgical site infection.