South African Journal of Surgery最新文献

Background: Acute pancreatitis (AP) may be the presenting symptom in a small percentage of patients harbouring pancreatic or extra pancreatic tumours. This case series aims to describe the pathological spectrum of tumours detected in two AP cohorts from a high HIV-endemic region.

Methods: Prospectively collected databases of patients admitted with AP over two periods 2001 to 2010 and 2013 to 2015, were retrospectively evaluated to detect those with pancreatic and extra-pancreatic tumours. The diagnosis of AP was by standard criteria. HIV infection and CD4 counts were routinely tested for in the latter period and only tested on clinical grounds in the initial period. CT scan was performed when there was diagnostic doubt, predicted severe disease, and failure to improve clinically after one week. Demographic, clinical, investigative, and pathology details were collected and presented.

Results: HIV-positive patients admitted with AP were 106 (17%) of 628 in the first period and 90 (38%) of 238 of the second period. No tumours were diagnosed in the HIV-negative patients. Seven of the HIV-positive patients had tumours diagnosed at endoscopy, CT scan, and endoscopic retrograde cholangiography. Of the seven HIV-positive patients with tumours, two patients had a CD4 count above 200. There were four patients with lymphoma involving the pancreatic head, three having associated cholestasis, and three patients with Kaposi's Sarcoma. One Kaposi's sarcoma patient died three months after presentation. One patient with lymphoma died on day 14 and another two months after initial presentation, and the remaining four patients were referred to oncology.

Conclusion: Despite their rarity (< 4%), when HIV-positive patients with low CD4 count and cholestasis present with AP,tumours should be suspected and evaluated by cross sectional imaging and endoscopic ultrasound.

A 63-year-old female presented to the hospital with a history of alleged accidental fall onto a rusted iron rod. She was hypotensive but stable. Cooling of the rod while cutting the protruding part was performed as per basic trauma life support (BTLS) access. Following resuscitation, she was re-evaluated clinically and radiologically, and prepared for surgery. The iron rod trajectory was shown on computed tomography (CT) scan to be entering through the left popliteal fossa, then traversing the abdominal cavity with injury to the descending colon and the left dome of the diaphragm. At laparotomy the iron rod was removed under vision. The laceration to the left dome of the diaphragm was repaired. The perforation of the descending colon was identified and repaired. Colostomy was deferred as there was no peritoneal contamination. The penetrating thigh wound was debrided. Her recovery was uneventful. She was discharged on postoperative day 15. She came for follow-up as out-patient after 3 weeks and the thigh wound had healed. Impalement injuries are rare and often severe. Most impalement injuries require a multidisciplinary approach. Adequate early resuscitation, proper evaluation and early surgical management is ideal. Immediate stabilisation of the foreign body from the time of encounter is essential. Removal under anaesthesia is mandatory.

Background: Oesophageal stenting effectively palliates malignant dysphagia with reported high technical and clinical success rates approaching 90% and a low, though often problematic, complication frequency. This study aimed to benchmark success rates, the incidence and management of complications at a tertiary interventional endoscopy centre.

Methods: This single centre three-year (March 2018-March 2021) study reviewed demographics, tumour histology/ position, and early and late complications of palliative oesophageal stenting. A multivariate analysis of tumour position association with complications was performed.

Results: A total of 297 patients (73.4% squamous cell carcinoma) underwent 354 stent insertion attempts. Immediate technical insertion success rate was 97.5% with dysphagia improvement achieved in all successful insertions (100% clinical success rate). Three hundred and forty-six (98.6%) were fully covered stents, with 17 (4.8%) placed for tracheaoesophageal fistulae. Twenty-one (6.0%) immediate insertion-related complications occurred, including two oesophageal perforations, but no insertion-related mortalities. Late complications occurred in 73 (20.8%) with tumour overgrowth (10.1%) and stent migration (6.1%) being the most frequent. Of all 354 stents, 75.2% had no documented complications for the lifetime of that stent, while 68 complications required re-intervention, equating to a re-intervention rate of 19.4% per stent insertion. Stent migration was significantly higher in distal tumours (11.8% vs 1.8%, p < 0.001), while discomfort necessitating same-day stent removal was higher in proximal tumours starting at < 20 cm from the incisors (16.7% vs 0.5%, p < 0.001).

Conclusion: Oesophageal stenting for malignant dysphagia is peri-procedurally safe and effective. Outcomes reported from this South African cohort compare favourably to high-volume international units.

Summary: Transverse colon volvulus is a rare diagnosis, with less than 100 cases reported up to 2019. The condition is complicated by the absence of characteristic radiological findings and is typically diagnosed intraoperatively. It is a surgical emergency as the condition can lead to bowel necrosis and is associated with a mortality rate of up to 33%. Bowel resection is the treatment of choice, and if a megacolon is present a subtotal colectomy is recommended. Due to the rarity of transverse colon volvulus, limited data is available on the long-term outcome of patients.

Background: Acute pancreatitis (AP) may be the presenting symptom in a small percentage of patients harbouring pancreatic or extra pancreatic tumours. This case series aims to describe the pathological spectrum of tumours detected in two AP cohorts from a high HIV-endemic region.

Methods: Prospectively collected databases of patients admitted with AP over two periods 2001 to 2010 and 2013 to 2015, were retrospectively evaluated to detect those with pancreatic and extra-pancreatic tumours. The diagnosis of AP was by standard criteria. HIV infection and CD4 counts were routinely tested for in the latter period and only tested on clinical grounds in the initial period. CT scan was performed when there was diagnostic doubt, predicted severe disease, and failure to improve clinically after one week. Demographic, clinical, investigative, and pathology details were collected and presented.

Results: HIV-positive patients admitted with AP were 106 (17%) of 628 in the first period and 90 (38%) of 238 of the second period. No tumours were diagnosed in the HIV-negative patients. Seven of the HIV-positive patients had tumours diagnosed at endoscopy, CT scan, and endoscopic retrograde cholangiography. Of the seven HIV-positive patients with tumours, two patients had a CD4 count above 200. There were four patients with lymphoma involving the pancreatic head, three having associated cholestasis, and three patients with Kaposi's Sarcoma. One Kaposi's sarcoma patient died three months after presentation. One patient with lymphoma died on day 14 and another two months after initial presentation, and the remaining four patients were referred to oncology.

Conclusion: Despite their rarity (< 4%), when HIV-positive patients with low CD4 count and cholestasis present with AP, tumours should be suspected and evaluated by cross sectional imaging and endoscopic ultrasound.

Background: This study aimed to compare factors contributing to a positive outcome of adult burn injury patients managed at two primary and one tertiary level Western Cape hospitals. These patients from the primary hospitals (PLHs) met the referral criteria for specialised care at the Tygerberg Hospital burns unit (TBU) but were not accepted or were accepted late.

Methods: A total of 1034 adult burn injury patients seen at two primary level ("A" and "B") hospitals and the TBU between 2016 and 2019 were retrospectively analysed. One hundred and eleven (111) primary level patients ("A" 71, "B" 40) met the criteria for referral to the TBU. The outcomes and factors contributing to positive outcome of these patients were compared with the 859 patients treated at the TBU during the same period.

Results: Patients treated at the TBU showed longer theatre waiting times, more operations, and higher complication and death rates than their primary level counterparts. The PLHs showed no factors significantly contributing to hospital discharge. At TBU, pregnancy status, younger age, hot water burns, lower abbreviated burns severity index (ABSI) score, and longer time to theatre were associated with hospital discharge. A shortage of beds was the main reason for denial of admission to the TBU.

Conclusion: The PLHs showed good outcomes in managing severe burn injuries, although no significant contributors to a positive outcome were identified. Patient- and facility-related factors contributed to positive outcomes at the TBU. Upgrading both the Western Cape's primary level capabilities and the TBU's accessibility and efficiency are necessary to improve burns services.

A 63-year-old female presented to the hospital with a history of alleged accidental fall onto a rusted iron rod. She was hypotensive but stable. Cooling of the rod while cutting the protruding part was performed as per basic trauma life support (BTLS) access. Following resuscitation, she was re-evaluated clinically and radiologically, and prepared for surgery. The iron rod trajectory was shown on computed tomography (CT) scan to be entering through the left popliteal fossa, then traversing the abdominal cavity with injury to the descending colon and the left dome of the diaphragm. At laparotomy the iron rod was removed under vision. The laceration to the left dome of the diaphragm was repaired. The perforation of the descending colon was identified and repaired. Colostomy was deferred as there was no peritoneal contamination. The penetrating thigh wound was debrided. Her recovery was uneventful. She was discharged on postoperative day 15. She came for follow-up as out-patient after 3 weeks and the thigh wound had healed. Impalement injuries are rare and often severe. Most impalement injuries require a multidisciplinary approach. Adequate early resuscitation, proper evaluation and early surgical management is ideal. Immediate stabilisation of the foreign body from the time of encounter is essential. Removal under anaesthesia is mandatory.

Background: Perforated peptic ulcer (PPU) is associated with significant morbidity and mortality, particularly in low to middle income countries. This study aimed to scrutinise the clinical course of patients diagnosed with PPU and identify modifiable factors to improve outcomes.

Methods: A retrospective review of the hybrid electronic medical record (HEMR) database at Grey's Hospital was performed. All patients diagnosed with PPU between January 2013 and December 2020 were entered into the study. The variables collected include age, ethnicity, comorbid profile, Boey score, type of surgery performed and complications. These factors were analysed to determine the factors responsible for morbidity and mortality.

Results: One hundred and ninety four patients were diagnosed with PPU during the study period. Six patients were treated non-operatively, all of whom survived. In the surgically treated group, omental patch repair was performed in 159 (84.5%) patients, and primary closure in 26 (13.8%) patients. The leak rate was 32% in the cohort that underwent relaparotomy and the overall mortality was 14%. There was no significant relationship between the type of repair performed and outcome. All patients had a Boey score of 1 or more. The following factors were found to increase the probability of in-hospital mortality: age > 40 years (OR: 8.49, 95% CI 2.46-29.29 p < 0.01), female gender (OR: 2.509, CI 0.98-6.37, p = 0.048), need for relaparotomy (OR: 0.398, CI 0.17-0.91, p = 0.027) and Boey score > 1 (OR: 46.437, CI 6.13-350.28, p < 0.01). A Boey score > 1 was the only variable that increased the likelihood of finding a leaking repair at relaparotomy (p < 0.01).

Conclusion: The Boey score was a significant predictor of mortality and leak rate in our patients with PPU. Adding age as a variable may improve the ability to predict mortality in our setting, while the impact of gender and ethnicity needs further investigation.

Rhabdomyosarcoma is the most common soft tissue tumour in children and adolescents, but extremely rare in adults with comparatively worse outcomes. Metastatic disease is not uncommon, but intra-abdominal metastases are exceedingly rare. We report an unusual case of ileal metastases from an upper extremity rhabdomyosarcoma in a 17-year-old male who presented with abdominal pain during a routine follow-up visit. Laparotomy and ileocecectomy for a perforated ileal mass confirmed metastatic embryonal rhabdomyosarcoma with 1 out of 14 positive lymph node metastases. This case demonstrates that, although rare, intra-abdominal metastases should be considered when patients with a rhabdomyosarcoma present with abdominal complaints.

Background: Children are less susceptible to infection with SARS-CoV-2 and subsequent severe disease, yet especially vulnerable to the indirect effects of the pandemic. A constrained healthcare service, combined with the societal and behavioural changes observed during the pandemic, is likely to have altered the presentation of paediatric surgical disease. The objective was to investigate the impact of the COVID-19 pandemic on the volume of paediatric surgical admissions, the severity of disease and the type of surgical pathology treated at our centre.

Methods: A retrospective cohort study compared paediatric surgical admissions in an eleven-month period before COVID-19 to the same period during the pandemic. Comparisons in volume and diagnoses were based on the number of admissions. Predetermined criteria for severity of disease using triage scores, intraoperative findings and intensive care admissions were compared.

Results: A total of 1 810 admissions were recorded, 1061 in the pre-COVID group and 749 during COVID. Emergency admissions reduced by 9.2%, most notably due to a reduction in trauma, caustic ingestions and constipation. There was an increase in incarcerated inguinal hernias and helminth-related pathologies. Significantly more intussusceptions failed pneumatic reduction requiring surgical intervention with bowel resection. There was a two-fold increase in patients requiring emergency intensive care.

Conclusion: Paediatric surgical volumes at our centre decreased during the COVID-19 pandemic. There was evidence of more advanced disease on presentation of inguinal hernias and intussusception and a generalised increased demand for emergency ICU admission.