South African Journal of Surgery最新文献

Summary: We present a case of a female patient with solitary fibrous tumour (SFT) originating in the parapharyngeal space which was successfully resected using an open transoral approach. The patient presented with a worsening airway obstruction, obstructive sleep apnoea, and dysphagia for three years. Rhinolaryngoscopy revealed a right nasopharynx and oropharynx lateral pharyngeal wall submucosal mass. Histopathological analysis was consistent with an SFT. This uncommon site of a rare tumour often presents diagnostic challenges or leads to overt misdiagnosis. We interrogated the literature in respect of the diagnostic and therapeutic approaches for this rare condition.

Background: Minimally invasive surgery has transformed surgery. Video-assisted thoracoscopic surgery (VATS) has been used for a few specific acute indications, however there is a paucity of data describing the management of intrathoracic foreign body removal compared to open thoracotomy.

Methods: A retrospective observational chart review of patients requiring surgical management of retained intrathoracic FB during the period of January 2005 to December 2021 at Inkosi Albert Luthuli Central Hospital was undertaken. This was approved as a sub-study of BCA207-09 by the UZKN BREC.

Results: Forty-two patients were identified. Sixteen (38%) were paediatric patients and 26 (62%) adults, with average age of 24 years (6 months-69 years) and a male predominance (78.6%). VATS was used initially in 33 patients, successfully in 11 (26%) and 12 (28%) required conversion to thoracotomy, while in 15 (36%) a thoracotomy was the initial procedure. Four (10%) required other surgical options. Median hospital stay was 7 days. Fourteen patients required postoperative ICU admission, 50% being those post-aspiration injury. Mechanistically, 13 were FB aspiration (31%), 25 trauma (60%) and 4 iatrogenic (9%) causes. Aspiration occurred only in paediatric patients. Among the trauma patients, 23 were adult and 2 paediatric. These included 12 retained knife blades, 8 with bullets or bullet fragments in situ, 1 nail and 2 sewing needles. Of these, 8 were managed successfully with VATS (1 bullet and 7 knife blade extractions) and 12 required conversion to thoracotomy or sternotomy. Both paediatric patients with sewing needle FB required thoracotomy. Regarding the iatrogenic FB, two Malecot® drains were removed with VATS and one patient required bilateral thoracotomies for removal of intercostal drain caps.

Conclusion: Approximately 25% of all intrathoracic retained FB can be successfully removed by VATS, while many still require thoracotomy. Most patients will recover without sequelae.

Background: The surgical benefits of preoperative low- or very low-calorie diets (LCDs or VLCDs) in bariatric surgery patients have been widely studied. This study aimed to observe the changes in body composition and left hepatic lobe volume (LHLV) following a two-week dietitian-led calorie-restricted diet in non-bariatric laparoscopic surgery patients, where fatty liver often complicates the surgery.

Methods: The study included 47 patients scheduled for a hiatus hernia repair with an anti-reflux procedure. Participants underwent bioelectrical impedance measurements and abdominal ultrasounds to determine changes in LHLV at baseline and again pre-surgery after following a calorie-restricted diet (800-1000 kcal daily) for two weeks.

Results: Participants (median baseline body mass index [BMI]: 33.4 (30.9-36.0) kg/m2) experienced statistically significant (p < 0.05) decreases in body mass, BMI, waist circumference, body fat mass, body fat percentage, abdominal fat and muscle mass on the two-week calorie-restricted diet. A median LHLV reduction of 33% (IQR 12.8-49.6%, p < 0.05) was noted. The outcomes of the ultrasound were unknown to the surgeons at the time of the surgery, and they subjectively reported good surgical visibility of the oesophagogastric (EG) junction in 86.5% of cases.

Conclusion: The findings suggest that in obese patients, losing 2.2 kg of body fat and 2.5 cm in waist circumference on a two-week dietitian-led calorie-restricted diet may significantly reduce LHLV that could potentially improve surgical visibility. Further research should determine if these changes in body composition may be used as a proxy for liver sonar.

I read with interest the survey by Nel et al.¹ "Procedures most frequently performed by South African-trained general surgeons - implications for training and assessment". I am heartened to see the long overdue move towards workbased assessment (WBA) and procedural competency as key elements of the assessment of fitness to practise as a consultant surgeon. The survey of recently trained surgeons found that 49% of the respondents felt unprepared to undertake one or more of the 10 procedures they most frequently perform. Of these, the procedure they felt most untrained to perform was colonoscopy. Even more revealing is that those who had gone directly into private practice had a 100% expectation that they should be able to perform colonoscopy.

Background: Tube thoracostomy (TT) is the standard treatment for haemothorax, but 5-30% of cases may result in retained haemothorax. Video-assisted thoracoscopy surgery (VATS) is a recognised treatment for retained haemothorax, although its timing and feasibility can be challenging in resource-limited settings with restricted theatre access. The objective was to evaluate and describe our experience with VATS at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), South Africa.

Methods: This was a retrospective study over seven years (1 January 2017 - 31 December 2023). All adult trauma patients with retained haemothorax who underwent VATS were included. Data were collected from hospital databases, focusing on patient demographics, mechanism of injury, vital signs, radiological findings, indications for VATS, and clinical outcomes.

Results: A total of 71 patients underwent VATS, with 98.6% being male and an average age of 34 years. The procedure was performed for retained haemothorax in 97% (n = 69) of cases and empyema in two patients. Penetrating trauma was the most common cause, with 82% of patients suffering stab wounds and 18% gunshot wounds. The median time to surgery was 5 days, with a median operating time of 77 minutes. Conversion to thoracotomy occurred in 14% (n = 10) of cases. Intraoperative findings included clots (42%), retained blood (42%), and pus (2.8%). Postoperative complications occurred in 12.7% (n = 9), including pneumonia (2.8%), drain site infections (5.6%), and recurrence of haemothorax (4.2%). The median length of hospital stay after VATS was 6 days, with no in-hospital mortalities.

Conclusion: VATS is a safe and feasible option for managing penetrating chest trauma in resource-constrained environments, with low complication rates and low in-hospital mortality rates.

I would like to thank the president of the SRS and the committee for inviting me to present the annual DJ du Plessis lecture. It remains a great honour and is undoubtedly one of the highlights of a career in South African academic surgery. I have entitled my lecture "Reflections on surgical leadership". I would like to remind us all about DJ du Plessis. As time progresses the number of people in the audience who actually knew the man grows fewer and memories dim. Fortunately, there are many fine anecdotes and character sketches of Professor du Plessis which have been recorded in journals and history books. He took over a relatively new department at Wits, in 1958, which had just become embroiled in a rather unpleasant academic scandal.

Background: The proven advantages of minimal access surgery (MAS), such as laparoscopy, are globally recognised. However, its adoption is variable in all countries irrespective of income level. One of the commonly cited barriers is lack of training. This study assesses the uptake of laparoscopy following intensive MAS training in the general surgical program at Sefako Makgatho Health Sciences University (SMU).

Methods: Surveying general surgeons trained at SMU between 2012 and 2018, who had completed their training at SMU and worked elsewhere thereafter. Questionnaires, distributed post-consent, were analysed descriptively.

Results: Among 22 participants, a 100% response rate was achieved. Prior to training, 86.4% were unable to perform laparoscopic appendectomy; 81.8%, laparoscopic cholecystectomy; 94.5%, laparoscopic bowel repair; and 100%, laparoscopic diaphragmatic injury repair. Post-training, participants judged themselves proficient in all these procedures. Participants are currently performing 53% of cases laparoscopically vs 47% via an open technique, with 35% opting for open surgery despite laparoscopic feasibility. The main barriers to using laparoscopic techniques were medical aid denial (59.1%) and lack of equipment (50%).

Conclusion: Intensive MAS training led to widespread laparoscopic adoption among SMU-trained general surgeons in South Africa. Key obstacles to a laparoscopic approach were medical aid refusal in the private sector and equipment scarcity in the public sector.

Summary: Hydatid disease is a zoonotic parasitic infection caused by Echinococcus granulosus and is not uncommonly encountered in South Africa, especially in certain endemic areas. It generally affects the liver and lungs, with primary isolated peritoneal involvement being extremely rare. We report the case of a 14-year-old female with an isolated peritoneal hydatid cyst, initially thought to be a simple ovarian cyst, with no apparent hepatic or pulmonary involvement. This case highlights the potential consideration of hydatid disease in the differential of peritoneal cystic masses, even in the absence of hepatic or pulmonary involvement, especially in patients from endemic regions.

Summary: Obesity complicates clinical evaluations of acute abdominal conditions like appendicitis, with excess fat limiting the accuracy of physical examinations and delaying diagnosis. This report presents a case of a 49-year-old morbidly obese female with uncontrolled diabetes who developed acute peritonitis secondary to retrocaecal appendicitis, which presented as retroperitoneal necrotising fasciitis (NF). Diagnostic delays were attributed to atypical clinical signs and limitations of ultrasound in obese patients. A computed tomography (CT) scan eventually revealed extensive retroperitoneal fluid collections, confirming the diagnosis. Surgical intervention, including appendicectomy, drainage, and debridement, was complicated by septic shock, requiring intensive care. This case highlights the diagnostic complexity of NF in high-risk patients, emphasising the role of advanced imaging modalities and diagnostic scoring systems. Improved diagnostic strategies and early imaging are crucial for managing life-threatening conditions in obese populations.

Summary: Wilkie's syndrome, also known as superior mesenteric artery (SMA) syndrome, is a rare condition characterised by the compression of the third portion of the duodenum between the abdominal aorta and the overlying SMA. Due to its rarity, the exact number of documented case reports is limited. As of recent literature, approximately 500 cases have been reported worldwide with a reported incidence of 0.013-0.3%.