South African Journal of Surgery最新文献

Background: Gastric outlet obstruction (GOO) due to peptic ulcer disease (PUD) has seen a global decline, with endoscopic management now considered first-line therapy. Modern surgeons have limited exposure to PUD GOO, with a lack of recent literature and contemporary guidelines to aid in surgical decision-making. This study aims to review a cohort of PUD GOO patients with specific focus on those needing surgical intervention.

Methods: All patients managed for PUD GOO at a single South African centre over a four-year period were included. Those requiring surgery were sub-analysed and multivariate analysis performed to identify factors associated with increased morbidity.

Results: A total of 84 PUD GOO patients were included. Forty-five were selected for endoscopic balloon dilatation (EBD), with only 21 (46.7%) successfully managed with EBD. Thirteen patients required only medical therapy, eight were selected for upfront surgery and 18 patients were managed with stenting. A total of 31 patients (36.9%) required surgery, with 33 separate operations performed (12 resections and 21 bypass operations). The surgical procedure performed was the only variable shown to be significantly associated with postoperative morbidity, with both pyloroplasty and partial gastrectomy having higher complication rates when compared to gastro-jejunal bypass (50.0% and 66.7% vs 5.6%, OR:17.0 and 8.5, p = 0.016 and p < 0.001 respectively).

Conclusion: In our setting obstructed PUD often requires surgical management. The choice of surgical procedure should be individualised. Due to the multifactorial complexity of these patients, they are best managed in multidisciplinary team settings with input from dieticians, endoscopists and surgeons.

Summary: This report describes a 13-year-old male patient admitted with superior mesenteric artery syndrome (SMAS) requiring urgent surgery for decompression due to worsening pain and elevated lactate levels. SMAS is a rare cause of upper gastrointestinal obstruction and in this case may have been due to a rapid growth spurt.

Background: Crush syndrome arises from community assault when perpetrators of crime within a community are beaten resulting in muscle damage of varying degrees. The insult to the muscles leads to the development of acute kidney injury which may lead to the need for renal replacement therapy, intensive care unit (ICU) admission for cardiovascular and respiratory support, or death. There are various known methods used to prognosticate patients with crush syndrome. The current literature only provides limited information about the role of urinary pH when it comes to risk stratifying patients with crush syndrome, thus the aim of the study is to reveal whether a urinary pH of 6 or less could potentially predict poor outcomes in those who present with this pathology.

Methods: This paper is a quantitative retrospective review of 107 patients who were diagnosed with myorenal syndrome at Ngwelezana Hospital between September 2021 and September 2023.

Results: Sixty out 107 patients developed an acute kidney injury and three patients died. All participants who died had a urine pH of < 6; however, patients who required dialysis or needed ICU admission had urine pH of 5 and 6 showing no correlation between urine pH and adverse outcomes.

Conclusion: Urine pH may not serve as a marker of complications related to acute kidney injury in patients with crush syndrome but may help to prognosticate patients to predict death.

Background: Breast cancer is a significant global health concern. Primary endocrine therapy (PET) and primary chemotherapy (PCT) are employed to manage hormone receptor positive breast cancers in the neoadjuvant setting. We hypothesise that PET is as effective as chemotherapy to treat axillary metastases.

Methods: All patients treated for breast cancer at Tygerberg Hospital Breast Unit during the period of 2016-2019 were included. Patients who did not receive PCT or PET were excluded, as were patients who did not undergo axillary lymph node dissection (ALND).

Results: The sample consisted of 176 patients. The median age was 49.2 years (IQR = 42.4-57.9 years; range = 25.1-84.6 years), and 174/176 (98.9%) were female. Of the 176 patients, 35/176 (19.9%) had luminal A cancers, while 141/176 (80.1%) had luminal B cancers. Among these patients, 150/176 (85.2%) underwent PCT while 26/176 (14.8%) received PET. The lymph node burdens found via ALND were similar for patients who underwent PCT (median = 25.0%; IQR = 0.0-50.0%) and PET (median = 16.8%; IQR = 0.0-89.0%; p = 0.66). The rates of patients with no nodal involvement were also similar for patients who underwent PCT (47/150 = 31.3%) and PET (9/26 = 34.6%; p = 0.74). Multivariate analysis showed that there were no significant confounding effects due to age, sex, HIV status, molecular subtype or AJCC stage.

Conclusion: Our study showed no statistically significant difference in the lymph node burden regardless of whether PET or PCT was given to patients with a hormone receptor positive breast cancer.

Summary: A visual record of standardised anatomical landmarks and specific pathology in gastrointestinal endoscopy is now considered by international endoscopy and gastroenterology societies as a mandatory component of the procedural report.^1-4 Photo and video documentation of gastrointestinal endoscopy procedures accurately monitor key performance indicators (KPAs) for trainees and consultants, which are essential to assess the attainment and maintenance of competency. In addition, visual documentation is an excellent adjunct for feedback during training, enables remote teaching and mentorship, is essential for multidisciplinary teams (MDTs) and the conducting of clinical audits, and may be invaluable for medicolegal purposes. The endoscopy equipment of all the major manufacturers in South Africa (Fuji Film, Olympus and Pentax) allows for image capturing directly from buttons on the control handle to a Universal Serial Bus (USB) flash drive. The flash drive can be used to transfer images, and in some instances video, to a reporting computer, but involves time-consuming manual transfers. Some systems have polaroid reproduction systems which are usually single-print photographs attached to reports and generally only document pathology. Commercial medical video hardware and software technology is costly. For example, one of the manufacturers has reporting software and hardware, at a cost of about ZAR 250 000 per stack, that allows direct video and image capture.⁵ S uch major costs highlight the major hurdle to routine photo or video documentation in under-resourced settings. We describe the development in the Groote Schuur Hospital Gastrointestinal Unit of a simple, low-cost method of stillimage and video capture that can be set up on current endoscopy equipment to provide routine still-image and video capture. This system makes use of inexpensive hardware and open access software. It has been implemented and is in routine use for oesophagogastroduodenoscopy, colonoscopy, and advanced interventional endoscopy.

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: 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.

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%.