South African Journal of Surgery最新文献

Summary: Retroperitoneal lymphangioma is exceptionally rare. We present a case of a 41-year-old asymptomatic patient with a large abdominal cystic mass detected on contrast-enhanced computed tomography (CT) scan, initially suspected to be pseudomyxoma peritonei. Laparoscopic exploration revealed a 30 x 30 cm multilocular cystic tumour originating from the retroperitoneum. The tumour was successfully resected laparoscopically, and pathological analysis confirmed a lymphangioma. The patient recovered well with no recurrence over five years. For uncertain tumour types, transabdominal laparoscopic exploration should be prioritised. For treating retroperitoneal lymphangiomas with the origin in the retroperitoneum and a main body in the abdominal cavity, the transabdominal laparoscopic approach is a less invasive and effective treatment option.

Background: Bowel trauma, encompassing injuries to the small and large intestine, represents a significant medical challenge due to its potential for morbidity and mortality. Management of bowel injuries remains surgical, but multiple factors influence the outcome in these patients. This study provides an in-depth analysis of the high-risk features of hollow visceral trauma in the ICU setting and the corresponding mortality rates, shedding light on the critical factors that influence outcomes in these cases.

Methods: Retrospective review of patients admitted to the trauma intensive care unit (ICU) at Inkosi Albert Luthuli Hospital from January 2017 until September 2022 were reviewed to identify risk features associated with morbidity and mortality. Statistical analysis was performed using Python 3.10.

Results: Ninety-four patients were reviewed, the majority (88.3%) were male and median age was 31.5 years. Mortality was 31.9%. The median length of stay in the ICU was 9.0 days (IQR 4-19 days, range 2-94 days). Small bowel injuries were more common than colonic injuries (75.3% vs 63.8%). Multiple colon injuries, renal injuries, extra hepatic biliary injuries and older age were associated with significant increase in mortality.

Conclusion: This study's findings underscore the multifaceted nature of bowel injury management in an ICU population. A comprehensive, multidisciplinary approach that considers injury severity, anatomical site, and patient-specific factors is crucial for achieving favourable outcomes in bowel trauma cases.

Background: This study aimed to assess the contribution of human error to adverse events over 10 years in a single surgical department in South Africa.

Methods: A retrospective database analysis was undertaken to identify all adverse events, which were further assessed to identify which were error-associated.

Results: A total of 14 237 adverse events occurred between December 2012 and January 2023, of which 7 504 (52.7%) were judged to be error-associated. An error rate of 14% per admission, or 2% per inpatient day was shown. Errors during delivery of care accounted for 76% of all errors and 40% of all adverse events. Of those, medication errors contributed 29%, those due to indwelling devices contributed 28%, and iatrogenic injuries 18%. Errors in assessment accounted for 14% of the total errors and 7% of all adverse events, with clinical assessment failure contributing 55.8% and missed injuries 19%. Mixed type errors contributed 10% of the total. Assessment by year demonstrated an upward trend from 2013 to 2016, followed by a downward trend from 2016 to 2022. Error-associated adverse events increased length of stay and mortality significantly.

Conclusion: Error contributes to more than half of adverse events and increased length of stay and mortality and is potentially avoidable. Errors may occur at any stage during an admission and highlights the need for multilevel interventions. The decrease in error noted is due to the cumulative effect of multiple endeavours, and not a single intervention.

Summary: A five-year-old male presented with small bowel obstruction and a worm bolus on a plain abdominal radiograph. Peritonism and acidosis prompted laparotomy after a short period of resuscitation. At surgery a worm bolus had caused a small bowel volvulus with a segment of necrosis that was successfully managed by detorsion and resection. This highlights that though ascaris lumbricoides, a common parasite in impoverished communities, has many mild manifestations the most life-threatening complication is volvulus. Hence when worm bolus is suspected vigilant observation to detect sepsis, acidosis and peritonism is essential to expedite surgery and prevent the morbidity of perforation.

Background: Colorectal cancer (CRC) is the fifth most common cancer in sub-Saharan Africa (SSA) and the third most common in South Africa (SA). CRC characteristics in SSA are not well described. The aim is to describe patient characteristics and anatomic location of colorectal adenocarcinoma (CRC-AC) in SA.

Methods: A retrospective analysis of the histology specimens of CRC in SA through utilisation of the South African National Cancer Registry from 2006 to 2011.

Results: Six thousand one hundred and forty-six patients with colorectal malignancies were identified of which 5 498 (89%) had CRC-AC. The median age at presentation was 60 (interquartile range, 49-70) years. One thousand three hundred and seventy-two (25%) were < 50 years and 2 870 (52%) were male. Right colonic tumours were found in 1 277 (26%), 1 214 (25%) were left colonic lesions, and 2 404 (49%) lesions were located in the rectum. Patients ≥ 50 years at presentation (OR = 1.29, 95% CI = 1.11-1.50, p < 0.001) were more likely to have left colonic and rectal adenocarcinoma. Patients < 50 years at presentation were more likely to be black (OR = 1.67, 95% CI = 1.39-2.02, p < 0.001) and have right-sided tumours (OR = 1.25, 95% CI = 1.06-1.46, p < 0.007).

Conclusion: CRC-AC in SA presents at an earlier age than in HICs, such as the United States of America. The majority of CRC were left-sided and rectal; thus, screening with faecal immunochemical testing and flexible sigmoidoscopy should be considered. Further studies on the age-specific incidence and the genetics and epigenetics and socioeconomic determinants of CRC-AC in SA are needed.

Summary: Tailgut cyst is an exceedingly rare congenital anomaly originating from embryonic remnants of the tailgut. Owing to its asymptomatic nature in the early stages, it is prone to clinical misdiagnosis. We present a case of a 55-year-old female with initial symptoms manifesting as sacrococcygeal pain. Magnetic resonance imaging (MRI) revealed a multilocular cystic lesion, prompting preoperative suspicion of an enormous tailgut cyst. Following a comprehensive assessment, an open posterior approach with coccygectomy was chosen, proving to be a safe and effective surgical technique, particularly for large, low-lying tailgut cysts.

Background: COVID-19 was first identified in Wuhan, China, in December 2019, where it spread over a wide geographic area until it reached the status of a pandemic in 2020. We postulated that patients who were diagnosed with incidental COVID-19, and underwent surgery, did not have a worse outcome due to the COVID-19 virus compared to their counterparts who did not have the virus.

Methods: This retrospective study included surgical patients (COVID-19 incidentals and COVID-19 negatives) who were admitted to the surgical intensive care unit (SICU) at Tygerberg Academic Hospital between 1 May 2020 and 31 December 2021.

Results: The sample consisted of 578 patients. Forty-one (41) patients had incidental COVID-19 infection, and 537 patients were COVID-19 naïve. The mean age was 43.9 years (SD = 16.7 years; range = 13.0-82.0 years) and 181 (31.3%) were female. The rates of complications in patients with COVID-19 infection (7.3%) and those without (5.0%) were similar (p = 0.64). Grades of complications, as measured using the Clavien-Dindo classification were also similar between patients with and without COVID-19 infection (p = 0.19). The mortality rates of patients with COVID-19 infection (17.1%) and those without (13.6%) were similar (p = 0.53).

Conclusion: This study demonstrates that surgery among asymptomatic PCR-positive patients was not associated with increased mortality or morbidity in the SICU. This also adds a valuable contribution to the growing body of literature regarding COVID-19 infections. Further prospective and multicentred studies are required to provide more robust results.

Background: District hospitals in South Africa have limited surgical capacity and regional hospitals treat most essential surgical conditions. This study aimed to describe the pathway and time to regional hospital surgical care for persons with general surgery conditions (PSC) in South Africa.

Methods: This was a retrospective audit of all persons referred on the Vula Mobile App to the general surgery service at Worcester Regional Hospital (WRH) from 1 January 2019 to 31 December 2019. Outcomes were time to care and the proportion lost to follow-up. Reasons for the proportion lost to follow-up were not reported.

Results: There were 617 index PSC referrals to WRH from 23 health facilities. Of these, 472 (76.5%) were referred from district hospitals and 88 (14.3%) from health clinics. Overall, 171 (27.7%) PSC referrals were handled via online-consultation only, 249 (40.4%) were referred to the WRH outpatient clinic, and 197 (31.9%) for inpatient admission. 133 (53.4%) outpatient referrals were lost to follow-up. One hundred and seventy-nine (29.0%) PSC had an operation at WRH. The median number of days from referral to operation was 28 days (IQR:10-86) for those evaluated in the outpatient clinic and 10 days (IQR: 1-125) for those directly admitted as inpatients.

Conclusion: Most surgical referrals to this South African regional hospital came from district hospitals and were for outpatient conditions. The use of telemedicine allowed triage of one quarter of referrals without the need for face-to-face consultation. Median time to operation was less than a month for outpatients; however, there was a high loss to follow-up. Further studies are needed to understand why many PSC did not access outpatient care.

Summary: Endoscopy is widely used for diagnostic and therapeutic purposes in modern clinical practice. Two of the less common complications are barotrauma and benign pneumoperitoneum. In isolation, these two complications have been successfully managed conservatively. We report a case of concomitant insufflation-induced complication of barotrauma and benign pneumoperitoneum following endoscopy on a 74-year-old female who was admitted for lower gastrointestinal (GIT) bleeding. A non-therapeutic laparotomy was performed, and she had an uneventful postoperative course. Although conservative management has been documented, in confounding findings, there should be a low threshold for intervention.

Despite the title and content of my talk, I am optimistic for the future of healthcare research. I will return to that sense of optimism in my conclusion. But to cheer you up at the end of my talk I first must depress you. I have included one intentional lie in my talk. See if you can spot it.