South African Journal of Surgery最新文献

Summary: A 23-year-old female presented with spinal cord compression and worsening motor weakness due to an extradural cyst in the thoracic spine on MRI thought to be due to a benign, non-infective spinal arachnoid cyst. Surgical excision surprisingly revealed a histological diagnosis of a spinal hydatid cyst. This case highlights that hydatid cyst disease, though a rare spinal pathology, should be considered as a differential diagnosis using serology and history of transmission risk as part of the preoperative workup. This would allow the implementation of intraoperative precautions to minimise risk of recurrence. Despite no preoperative diagnosis in this case, surgical excision and adjunctive pharmacotherapy led to marked short term neurological improvement. Long-term follow-up with clinical assessment, imaging, serological testing, is vital to detect recurrence early and optimise long-term outcomes. If serological testing is positive preoperatively it will assist with follow-up screening for recurrence.

Background: Trauma cost studies have been limited in low-to middle-income countries (LMICs). The aim of the study was to calculate economic costs resulting from major trauma in those with brain injuries.

Methods: This is a retrospective study of patients who sustained a traumatic brain injury (TBI) and injury severity score (ISS) > 16 treated at Pietersburg Hospital in a 2-year period (January 2019 to December 2020). Theatre registers were used as starting point for data collection. Additional data was obtained from ICU and the neurosurgical ward. Data analysis utilised dual methods with both micro-costing and grossing models.

Results: The review identified 83 patients. The most common mechanism of injury was assault with a blunt object (54.2%), followed by motor vehicle collisions (MVC) (16.9%). The mean length of stay for ICU admissions was 14 days, while ward admissions were 9.2 days. The most common diagnosis on CT scan was epidural haematoma with or without skull fracture (51.8%), followed by isolated skull fracture (21.8%). The average cost per admission was R572 925.00 for ICU patients and R244 503.00 for the ward stay.

Conclusion: The most common cause of TBI was assault. The cost of treating a patient with TBI was higher than in most studies and exceeded R50 000 per patient per day.

Summary: We present a rare case of isolated gallbladder tuberculosis (GBTB) confirmed on histological diagnosis after a laparoscopic cholecystectomy for suspected chronic cholecystitis. GBTB remains an extremely rare form of extrapulmonary tuberculosis (EPTB) and is furthermore unlikely to be seen in isolation from miliary or other abdominal tuberculosis (TB). It accounts for less than 1% of all TB cases, with even rarer presentations in the absence of other TB infection within the body. Diagnosis is hence often overlooked if clinical suspicion is not present, or histopathology is not considered.

Summary: Acute appendicitis is one of the most commonly encountered surgical emergencies. It usually presents with typical symptoms; however, diagnostic doubt may be encountered in atypical presentations. Rarely, complicated appendicitis may manifest as necrotising fasciitis (NF), further complicating the diagnosis and management. This case illustrates an atypical presentation where the diagnosis of appendicitis was initially missed. This report explores the pathophysiology, diagnostic challenges, and management principles when appendicitis presents as NF.

Background: The COVID-19 pandemic prompted the transition of all teaching and learning of final-year General Surgery students to an online platform.

Methods: A document review was conducted to determine the essential aspects of the teaching and learning programme that needed to be retained, and proposed modifications and implementation of an online surgical module. We followed the "READ" approach to analyse the documents, and the steps included readying the materials, extracting and analysing the data, and distilling the findings.

Results: Thirty-three curriculum and policy documents were reviewed, including General Surgery module templates, assessment policies, and institutional and external stakeholder guidance on the transition to remote learning and implementation plans. The main online instructional methods comprised video-based instruction on core surgical topics, including lectures, case-based discussion, pre-recorded clinical and procedural skills videos delivered via the Moodle Learning Management System (LMS) and an assessment of knowledge and skills (weekly quizzes on Moodle). The assessment format for the clinical component also changed from a clinical case examination and oral viva voce examination pre-COVID-19 to a written, structured clinical case scenario examination.

Conclusion: This document review provided a comprehensive understanding of the existing General Surgery curriculum at our institution and the events and policies that influenced the changes implemented due to the COVID-19 pandemic. It does not reflect the teaching and learning experiences of faculty and students; however, it provides a valuable point of departure for further studies to understand the teaching and learning experiences better.

Background: Pan computed tomography (CT) has become ubiquitous in the evaluation of patients with blunt polytrauma. The indications for Pan CT were previously evaluated in our unit and judicious use was demonstrated. Since CT has become increasingly readily available, we questioned whether "indication creep" has occurred in our unit. We aimed to determine, based on local imaging criteria, whether Pan CT is being over-utilised within our trauma service.

Methods: We performed a retrospective review of all pan scans conducted in our unit in Pietermaritzburg, South Africa, during a 5-year period, January 2017 to December 2021. Data was analysed to determine injuries identified on Pan CT and how these findings influenced patient management.

Results: Of 301 pan scans, 269 (89.4%) prompted an intervention, including brain scans (47.2%), cervical spine scans (9.3%), chest scans (22.7%) and abdominal scans (20.8%). The remaining 32 pan scans (10.6%) did not influence management. Many of these "clinically negative" scans were clinically important, ruling out injury in patients in whom clinical assessment was regarded as unreliable: 5 patients (1.7%) were hypoxic and had to be sedated, intubated and ventilated; 8 (2.7%) had a Glasgow Coma Score < 15; and 4 (1.3%) had major distracting injuries. This left only 15 pan scans (4.98%) that were not regarded as clinically helpful.

Conclusion: In comparison with the results from a previous report from our unit, "indication creep" has not occurred. We continue to have fewer than 5% of patients who may be considered for imaging modalities other than Pan CT.

Background: Pancreatic ductal adenocarcinoma (PDAC) has a 5-year survival rate of less than 10%. Treatment with curative intent surgery still poses high rates of overall postoperative morbidity (68.7%) and mortality (5.4%). It is therefore essential to identify preoperative factors influencing early postoperative outcomes to provide better insight for improved patient selection and care.

Methods: Sixty patients diagnosed with PDAC who had undergone surgical resection at Groote Schuur Hospital, Cape Town, between 2016 and 2023 were included. The patient cohort was divided into two groups, postoperative survival ≤ 90 days vs > 90 days. The groups were compared regarding demographic and preoperative assessment tools using ASA, ECOG and Codman scores, baseline clinical and imaging data, preoperative treatment and surgical related parameters.

Results: Significant differences were found in patients, with patients presenting with pancreatic duct dilation (p < 0.05), tumour location in the pancreatic head (p < 0.05), elevated gamma-glutamyl transferase (GGT) (p < 0.01) and carbohydrate antigen 19-9 (CA19-9) (p < 0.05). Using regression analysis, GGT serum levels > 500 U/L were correlated with mortality ≤ 90 days, while pancreatic duct dilatation and CA19-9 levels > 200 U/L were associated with survival > 90 days.

Conclusion: The results of this study present important insights regarding risk factors influencing postoperative mortality and offer a potential roadmap for optimising preoperative care and judicious patient selection before pancreatic surgery.

Background: The scope of emergency general surgical care services varies among health institutions and countries. The burden, profile, and outcomes of patients in many low- to middle-income countries is not adequately investigated.

Methods: Medical records of patients admitted to acute surgical care (ASC) team were reviewed for a year. Demographics, diagnosis, dates of admission and discharges, comorbidities, operative procedures and operative care providers, outcomes, and factors associated with outcomes were analysed.

Results: During the study period, 278 ASC admissions were made. The median age was 32 years. Males constituted 52.5%. The common admissions were acute appendicitis (57.2%), intestinal obstructions (15.5%), and soft-tissue infections (6.1%). Twenty-one point two per cent of the admissions had comorbidities and HIV infection was the commonest comorbidity. Seventy-one point nine per cent of the patients underwent operations. Appendicectomies (72.0%) were the commonest operations. Most of the operations (60.5%) were performed by residents. Complications occurred in 9.7% of the cases of which 6.5% were surgical site infection (SSI) and 2.2% resulted in mortality. Patients with complications had a significantly higher rate of mortality, p < 0.001. For all admissions and operated patients longer onset of illness was associated with longer hospital stays (p = 0.002 and 0.031) and mortality (p = 0.014 and 0.019) respectively. Patients operated by surgeons and residents together had a longer hospital stay than only by residents, p < 0.001. Similarly, when surgeons operated alone the hospital stay was longer than residents, p = 0.002.

Conclusion: The commonest ASC pathology was acute appendicitis. Longer onset of symptoms was associated with longer hospital stay and mortality. This study provides foundational data relevant to surgical education and unit organisation, including the development of clinical guidelines, resident supervision, and workforce planning.

Background: There is a paucity of epidemiological colorectal adenocarcinoma data in sub-Saharan Africa. This deficiency coupled with the rising trends of colorectal cancer (CRC) incidence and mortality necessitated the need for an epidemiological colorectal adenocarcinoma study to be conducted in the South African setting.

Methods: A retrospective analysis of demographic and histopathological data of colorectal adenocarcinoma patients diagnosed in the Western Cape public health sector was performed through the utilisation of the National Health Laboratory Services (NHLS) Academic Affairs and Research Management System (AARMS) database.

Results: A total of 612 patients were diagnosed with colorectal carcinoma in the Western Cape during the study period. 595/612 (97.2%) were diagnosed with adenocarcinoma, of these 284 (48%) of patients with primary rectal adenocarcinoma, 304 (51%) with primary colon adenocarcinoma and 7 (1%) with synchronous colorectal adenocarcinoma or a lesion involving both the colon and the rectum. Rectal adenocarcinoma most commonly occurred in 99/284 (34.9%), in the > 60-70 age group, while colon adenocarcinoma occurred most commonly in the > 50-60 age group, 78/304 (25.7%). The commonest stage of rectal adenocarcinoma patients was IIA 35/119 (29.4%), whereas stage IIIB was the commonest colon adenocarcinoma stage comprising 66/212 (31.3%) patients. Forty patients had mutations of mismatch repair genes, 7 of which had a positive BRAF mutation.

Conclusion: The study showed an even distribution of colorectal adenocarcinoma incidence between males and females, with the highest rates of diagnosis in patients aged more than 50 years. Patients with stage III and IV disease had a higher rate of serum CEA elevation as compared to stage I and II.

Background: Time from diagnosis to operative care is a quality indicator in breast cancer (BCA) care. The recommended time from diagnosis to definitive treatment in South Africa (SA) is 31 days. The primary objective of this study was to determine the time to operative care (TOC) for BCA patients attending a multidisciplinary breast clinic at a tertiary hospital in Cape Town, SA.

Methods: This was a retrospective review of women with BCA reviewed by the BCA multidisciplinary unit at Groote Schuur Hospital, SA, from 1 January 2018 to 31 December 2019.

Results: Of 563 women who underwent BCA operations, 370 (65.7%) had surgery as the primary treatment modality. The median TOC for those who had surgery first was 86 days (IQR: 63-109). Of the 370 who had surgery first, 20 (5.4%) were operated on within the recommended 31 days. TOC at the district hospital was 35.1 days shorter (p < 0.001), and at the regional hospital, it was 16.3 days (p = 0.008) shorter than at the tertiary hospital after controlling for age, district, and stage of cancer.

Conclusion: A low proportion of women with BCA had definitive surgery within the 31-day recommended waiting period. Decentralisation of operative care allowed faster access to surgery at district hospitals for women who did not need sentinel node biopsy or advanced anaesthesia care. Identifying additional resources needed to decrease TOC for BCA patients could improve access to timeous surgical care.