South African Journal of Surgery最新文献

Background: Sentinel lymph node biopsy (SLNB) is performed for staging and prognostication of breast cancer (BC) in cases with a clinically and radiologically negative axilla. Using blue dye and a radioactive colloid injection is considered the gold standard for SLNB. This study aims to evaluate the SLNB outcomes before and after the introduction of Sentimag at an academic breast unit. Sentimag uses an injection of superparamagnetic iron oxide which is then detected in the sentinal lymph node using a magnetometer.

Methods: A retrospective cohort study was performed comparing SLNBs done from 1 January 2017 to 31 December 2018. During 2017, a nuclear medicine technique was used for all SLNBs, while the Sentimag system was used in 2018.

Results: There was no difference between the two groups comparing age, T-stage, size of tumour, and molecular status. The only statistically significant difference found was more higher-grade tumours in the group where a nuclear medicine technique was used in 2017 (p = 0.04). There was no difference in the type of surgery performed comparing mastectomy and breast-conserving surgery rates between the two groups. There was an 11% increase in the number of patients who had an SLNB done with the Sentimag technique (2018). In 2017, 42% (58/139) had an SLNB and in 2018, 53% (59/112) had an SLNB.

Conclusion: This result demonstrates the feasibility of the magnetic technique for SLNB in a resource-limited setting. This new method shows promise as a safe and effective technique for SLNB - it is a valuable alternative in the absence of nuclear medicine (N.Med) facilities.

Summary: This report details a patient who sustained a posterior stab to a lumbar artery. The diagnosis was challenging and could have been easily missed if a high index of suspicion were not maintained. In a trauma context, this injury is missed due to focus on other concomitant injuries. We discuss the merits of computed tomography angiography (CTA) to identify the arterial blush which led to onward referral for successful catheter-directed arterial embolotherapy.

Background: Mediastinal goitres are rare and may be diagnosed late since they are likely to manifest with non-specific cardiorespiratory symptoms especially when there is no visible cervical component. The imaging modality of choice is a contrast-enhanced computed tomography (CT) scan of the neck and chest after incidental finding of goitre on chest X-ray indicated for a condition unrelated to goitre.

Methods: This case series aims to highlight the peculiarity of mediastinal goitre in terms of clinical presentation, surgical approach, airway challenges at anaesthesia, specific complications and final histopathological report.

Results: Over a nine-year period, four cases of euthyroid mediastinal goitre underwent sternotomy. The mean age was 57.5 years (45-71) and all patients were female. Most patients presented with non-specific cardiorespiratory symptoms. The difficult airway set was used in all cases and there were two instances of damage to the recurrent laryngeal nerve (RLN). All histopathological reports were benign.

Conclusion: The presentation of the mediastinal goitres was atypical. Cervical incision and sternotomy were performed in all cases. There were two instances of RLN injury and no malignant histopathology. Despite the potential threat to the airway, all intubations were uneventful.

Summary: Fungal parotitis is rare and the sequela parotid abscess exceedingly so. We report our experience with Candida glabrata and Candida albicans parotid gland abscesses in critically ill HIV-positive patients and highlight the value of microbiological assessment to tailor management.

Background: The spectrum and outcome of colorectal cancer (CRC) presenting with obstruction is not well studied in low- to middle-income countries (LMIC) and could have implications for health policy. This study aimed to address this deficit in an LMIC setting.

Methods: A retrospective analysis was conducted of patients with large bowel obstruction, during the period 2000-2019 from the prospective Inkosi Albert Luthuli Central Hospital (IALCH) CRC registry data. Data analysed included the site of CRC, tumour differentiation, management of patients with obstructive CRC, resection margins post resection, oncological management and reasons for failure to receive oncological therapy. Patient follow-up and recurrence were recorded.

Results: Malignant obstruction from CRC occurred in 510 patients (20% of the CRC registry). Median age at presentation was 57 years (IQR 48-67). One hundred and seventy-six (34.5%) and 135 (26.5%) had stage III and IV disease respectively. Moderately differentiated cancer was seen in 335 (65.6%). Management was resection (370; 72.5%), diverting colostomy (123; 24.1%) and stent insertion (55; 10.8%). Twenty-one patients (5.7%) had positive resection margins. Recurrence occurred in 34 patients (6.7%), all of whom had initially undergone resection, giving a recurrence rate of 9.8% in those receiving surgery. Median disease-free interval for patients developing recurrence was 21 months (IQR 12-32).

Conclusion: One in five patients with CRC presented with obstruction. These patients were younger than in high incomecountry (HIC) series. Over 70% underwent resection. Stomas were used twice as frequently as stents to relieve the obstruction, a finding that is the reverse of that in HICs.

Background: There is a paucity of data around corrosive ingestion in South Africa over the last three decades. As such, we set out to review our experience with adult corrosive ingestion in our tertiary gastrointestinal surgical service.

Methods: A retrospective, quantitative review was performed. The parameters analysed were demographics, substance ingestion, ingestion time to first presentation to a healthcare facility, clinical presentation, severity of injury based on endoscopic classification, computed tomography (CT) findings, management and outcomes. Patients presenting within 72 hours with alarm symptoms underwent flexible upper endoscopy and injury severity grading. In patients presenting after 72 hours, a water-soluble contrast study was obtained prior to upper endoscopy. Patients with signs of sepsis, surgical emphysema or physiological instability were referred for urgent CT to exclude oesophageal perforation and mediastinitis.

Results: Between January 2012 and January 2019, a total of 64 patients presented with a history of corrosive ingestion - 40 (31%) were males and 24 (19%) females. The average time from ingestion to presentation was 72 hours. In 78% of patients, the agents were intentionally ingested, whilst 22% claimed accidental ingestion. A quarter of the patients (21%) presented to the unit clinically unstable, requiring emergent cardiorespiratory support. Eight (12%) patients required urgent surgical intervention due to the extent of injury. Nine (14%) patients demised during the acute admission. Of this group, three patients had undergone surgical intervention, and six were managed conservatively. Eighty-five per cent of all patients survived their initial admission.

Conclusion: This paper has highlighted the problem of corrosive ingestion in our setting. It remains a complicated problem to manage associated with significant morbidity and mortality rates. The current trend in the assessment of these patients is increased use of CT scan to assess the extent of transmural necrosis. Our algorithms should change to reflect this contemporary approach.

Background: Trauma-induced coagulopathy (TIC) is a complex multifaceted process which contributes to higher mortality rates in severely injured trauma patients. Thromboelastography (TEG) is effective in detecting TIC which assists in instituting goal-directed therapy as part of damage control resuscitation.

Methods: This retrospective study included all adult patients over a 36-month period with penetrating abdominal trauma who required a laparotomy, blood products and admission for critical care. Analysis included demographics, admission data, 24-hour interventions, TEG parameters and 30-day outcomes.

Results: Eighty-four patients with a median age of 28 years were included. The majority (93%; 78/84) suffered from a gunshot injury, with 75% (63/84) receiving a damage control laparotomy. Forty-eight patients (57%) had a TEG. Injury severity score and total fluid and blood product administered in the first 24 hours were all significantly higher in patients who had a TEG (p < 0.05). TEG profiles were: 42% (20/48) normal, 42% (20/48) hypocoagulable, 12% (6/48) hypercoagulable and 4% (2/48) mixed parameters. Fibrinolysis profiles were: 48% (23/48) normal, 44% (21/48) fibrinolysis shutdown and 8% (4/48) hyperfibrinolysis. Mortality rate was 5% (4/84) at 24 hours and 26% (22/84) at 30 days, with no difference between the two groups. High-grade complication rates, days on a ventilator and intensive care unit length of stay were all significantly higher in patients who did not have a TEG.

Conclusion: TIC is common in severely injured penetrating trauma patients. The usage of a thromboelastogram did not impact on 24-hour or 30-day mortality but did result in a decreased intensive care stay and a decreased high-grade complication rate.

Background: In high-income countries (HICs) 17-20% of colorectal cancer (CRC) patients have metastatic CRC (mCRC) at the time of diagnosis, of which 10-25% are or become resectable, and a further 4-11% of patients will develop metachronous metastases. The study aimed to establish the prevalence and pattern of metastatic CRC to document treatment outcomes in KwaZulu-Natal (KZN), and to compare results to international norms.

Methods: The study population comprised patients with mCRC presenting between 2000 and 2019. Demographics, primary tumour site, spectrum of metastatic disease and resection rate were assessed.

Results: MCRC occurred in 33% of the CRC patient population. Eight hundred and thirty-six patients had metastatic disease, comprising Africans (325, 38.8%), Indians (312, 37.3%), Coloureds (37, 4.4%) and Whites (161, 19.2%). Six hundred and fifty-four patients (79%) had synchronous metastases and 182 patients had metachronous metastases (21%). Single organ metastases occurred in 596 patients (71.2%) (M1A) and multiple organ metastasis occurred in 240 patients (28.7%) (M1B). Metastases occurred in the liver (613), lung (240) and peritoneum (85). Fifty-two patients (6.2%) underwent resection of their metastases.

Conclusion: The prevalence of stage IV CRC in our setting is at the upper limit of international norms. mCRC occurred in 33%, with similar proportions in all races. Resection rate for metastases is low.