South African Journal of Surgery最新文献

Summary: Small bowel volvulus (SBV) is a rare cause of bowel obstruction, specifically in adults, accounting for approximately 1% of bowel obstruction in the adult population in North America. It is more common in the neonatal and paediatric population, mostly due to congenital abnormalities such as malrotation, atresia and congenital bands. We present two cases of SBV managed at a level 2 provincial hospital within a 2-month period. In the first case no primary cause could be found and in the second case adhesions following midline laparotomy resulted in SBV.

Background: Short-stay thyroid surgery is still nascent in developing nations like Nigeria. With the increasing cost of healthcare, there is consistently the need to reduce healthcare delivery costs. Short-stay services in selected cases meet this goal, in addition to other benefits of short hospital stays. This study aimed to highlight the feasibility of the practice of short-stay thyroidectomy in a rural tertiary hospital in Nigeria.

Methods: The study is a retrospective review of all patients who had short-stay thyroidectomy in a rural tertiary hospital in Nigeria from January 2017 to December 2021.

Results: The study reviewed 73 patients admitted for thyroidectomy on a short-stay basis within the study period. There were 70 (95.9%) females and three (4.1%) males, giving a ratio of 23:1 and a mean age of 39.8 years. Sixty-eight (93.2%) patients had no complications, and the others had minor complications that did not otherwise prolong their hospitalisation. Seventy-one (97.3%) patients were discharged within 24 hours of surgery, while two (2.7%) were discharged within 48 hours. There were no readmissions, and no mortality was recorded.

Conclusion: Short-stay hospitalisation for thyroid surgery is feasible and a viable alternative to the conventional 72-hour postoperative hospital stay in our setting.

Background: Workplace-based assessment (WBA) is being introduced across postgraduate training in South Africa. This study was undertaken to inform the selection of the core procedures for WBA, by determining the most frequently performed procedures in general surgery practice. These findings may also assist academic centres undertaking curriculum review to determine whether or not they are training surgeons who are competent to meet the current local needs of society.

Methods: This study was a cross-sectional observational study using a self-administered survey. General surgeons who passed the final fellowship examinations of the College of Surgeons of South Africa between 2017-2022, working in fulltime specialist practice, were eligible for participation.

Results: The study included 111 surgeons of which the majority (53%) were working full time in government practice, 23% were in private practice and 24% were in a combination of both government and private practice. The 10 most frequently listed procedures were - hernia repair (95%), appendicectomy (91%), emergency laparotomy (88%), laparoscopic cholecystectomy (80%), gastroscopy (80%), colonoscopy (61%), colectomy (55%), lower limb amputation (48%), mastectomy (40%) and intestinal stoma formation (31%). Fifty-seven (51%) participants reported that they felt prepared to independently perform the full range of most frequently listed procedures. Of the 49% who reported feeling unprepared for one or more procedures on completion of training, the most frequently listed procedure was colonoscopy.

Conclusion: This study identified a list of procedures that may be considered as core procedural activities for WBA of South African general surgery trainees.

Background: Serum albumin levels decrease following major trauma, for various reasons. We postulated that the serum albumin nadir (SAN) level would correlate negatively with severity of physiological insult.

Methodology: This retrospective cohort study included all patients with abdominal trauma admitted to the Trauma Intensive Care Unit at Inkosi Albert Luthuli Central Hospital during 2017 and 2018.

Results: Of the 87 patients, 70 (80.5%) were male. Mean age was 32.48 years (SD 11.65; range 12-73). Blunt trauma comprised 54 patients (62.1%). Median SAN level was 23 g/L (IQR 20-27; range 10-38). Median SAN level was not different between patients with blunt versus penetrating trauma (p = 0.69), patients in whom inotropic support had been used/not used (p = 0.0502), and no different between patients on the various modes of feeding at the time of SAN (p = 0.14). However, median SAN level was lower for patients with hollow visceral injury (p = 0.004), for patients who had undergone laparotomy (p = 0.0006), for those who had received damage control surgery (p = 0.001), those who had received blood transfusions (p = 0.03), and patients who died compared to survivors (p = 0.02). Univariate regression analysis revealed negative coefficients for the following in relation to SAN level: blood transfusion (-2.77; p = 0.023), hollow viscus injury (-3.21; p = 0.008), laparotomy (-4.5; p < 0.001), damage control surgery (-3.60; p = 0.02), day of SAN (-0.39; p = 0.001), ICU length of stay (-0.12; p = 0.002), and death (-3.27; p = 0.03).

Conclusion: Greater physiological insults lead to lower levels of SAN. Serum albumin nadir level may therefore have value as a prognostic indicator in the acute trauma setting.

Background: Predicting complete closure of large ventral hernias without component separation (CS) could have clinical value. The utility of multidetector computed tomography (MDCT)-based component separation index (CSI) was derived and evaluated for these hernias.

Methods: In 60 patients with a ventral hernia, a CSI was calculated based on their MDCT. In group I (first 30 patients), hernia repair was performed by an open approach and operative assessment determined the need for CS to effect complete closure. A CSI value above which defect closure needed CS was taken as the CSI reference point. In group II (second 30 patients), the hernia repair was done laparoscopically. Patients with a CSI at or below the reference point of group I underwent intraperitoneal onlay mesh (IPOM) after direct closure of the defect (IPOM-plus). The other patients had bilateral endoscopic component separation (ECS) before entry into the peritoneal cavity for an intended IPOM-plus.

Results: A CSI above 0.067 and 0.044 in open and laparoscopic approaches respectively required CS for complete defect closure. A CSI above 0.25 and 0.125 in open and laparoscopic approaches respectively, despite CS, predicted complete closure of defect was not possible.

Conclusion: CSI is a more comprehensive parameter for evaluation of ventral hernia than the conventional twodimensional parameters and can predict the need of component separation prior to complete closure of the defect in both laparoscopic and open approach.

Summary: Pneumatosis intestinalis (PI) is characterised by pathological gas infiltration into the submucosa and subserosa of the gastrointestinal tract, sometimes with an unclear pathogenesis. The clinical presentation of PI varies, with the diagnosis established via computed tomography (CT), where PI manifests as linear or bubbly gas patterns within the bowel wall. Management often necessitates surgical intervention to address potential life-threatening causes like mesenteric ischemia or bowel necrosis. This case report discusses a 69-year-old male who presented with abdominal pain and distension alongside worrisome radiological features indicative of extensive PI, who underwent an exploratory laparotomy that revealed no pathological findings and with an eventual uneventful recovery.

Background: The aim of this study was to present our experience with late presentation Bochdalek hernia (BH), focussing on clinical presentation diagnostic and therapeutic approaches, and their outcomes.

Methods: Patients with late presenting BH 1 month of age between 1983 and 2022 were studied. We retrospectively collected and analysed the following data: age, sex, side of herniation, presenting symptoms and signs, associated anomalies, radiographic findings, intraoperative findings, postoperative course, complications, and mortality.

Results: Of 175 diaphragmatic hernias 46 (26%) were late presenting BH. Fifty-seven per cent (26/46) were males. Laparotomy was performed in 85% (39/46) of the patients, and a laparoscopy or thoracoscopy was performed in 15% (7/46). The mean hospital stay was 7.6 days, and the mean surgery time was 131 minutes. When the two groups were compared, the duration of surgery and hospitalisation was significantly shorter in the minimally invasive surgery (MIS) group (p < 0.05).

Conclusion: The clinical characteristics of late presenting BH are variable, either acute or chronic. A laparoscopic or thoracoscopic approach in selected patients is feasible.

Summary: Schwannomas are benign tumours of peripheral nerves originating in the nerve sheaths. Only 1% are reported in the oral cavity. We report a 24-year-old female who presented with a 10-year history of a mass at the base of the tongue with associated odynodysphagia, referred otalgia and loss of weight. Oral examination revealed a large left sided base of tongue mass extending into the vallecula. An open transcervical suprahyoid resection was performed with a good outcome.

Background: We aimed to present our experience with children with symptomatic omphalomesenteric duct (OMD) anomalies and evaluate the patients' characteristics, treatment, and outcomes.

Methods: Records of children who were operated for symptomatic OMD anomalies in Şanlıurfa Training and Research Hospital between October 2018 and November 2022 were retrospectively analysed.

Results: There were 35 patients with a median age of 31.7 (1 day-17 years) weeks, 29 (82.8%) males and six (17.2%) females. The presenting signs were gastrointestinal tract (GIT) obstruction in 17 (48.6%) patients, acute abdomen in 11 (31.4%), umbilical abnormalities in four (11.4%) and rectal bleeding in three (8.6%). All patients presenting with umbilical abnormalities were newborn. These were OMD fistula to skin (n = 1), OMD fistula to umbilical cord hernia sac (n = 1), OMD cyst in umbilical cord hernia (n = 1) and OMD band adherence to umbilical cord hernia sac (n = 1). Meckel's scan was positive in all three patients with rectal bleeding. Surgical findings in patients other than umbilical abnormalities were diverticulitis (with/without perforation) (n = 14), intussusception due to diverticulum (n = 9) and Meckel's band obstruction (n = 8). At surgery, an ileal resection was performed in 19 cases, wedge resection in 10 cases, resection with stapler in five cases and ileocolonic resection in one patient. On histopathological examination, ectopic gastric mucosa was detected in 11 specimens and both gastric and pancreatic tissue in two. There were only two cases of postoperative complications (incisional hernia, n = 1, postoperative colon perforation due to forced manual reduction of intussusception, n = 1) and all patients survived in good condition.

Conclusion: In the present study, GIT obstruction is the primary symptom in patients with symptomatic OMD anomalies, with umbilical anomalies exclusively found in newborns. Surgery is confirmed as the definitive treatment, with wedge resection and simple diverticulectomy being safe but sometimes insufficient. A significant portion of patients might need more complex segmental bowel resections due to severe complications. With ectopic tissue found in about one-third of cases, managing OMD anomalies presents distinct challenges.

Background: The primary goal of perioperative antibiotics is to reduce the rate of surgical site infections (SSI); however, in certain surgical procedures, the use of perioperative antibiotics has been shown to have no impact on the rate of SSI. Inappropriate use of antimicrobials increases cost, potential side effects and further promotes antibiotic resistance. This study aims to provide insight into the adherence of South African otorhinolaryngologists to available evidence-based international guidelines.

Methods: An electronic survey was sent to otorhinolaryngologists in South Africa.

Results: Ninety-two respondents indicated that they utilise the following resources to guide their decisions regarding perioperative antibiotic prescribing - anecdotal evidence 27% (25/92), practices of the surgeon's postgraduate training unit 28% (26/92), published international guidelines 28% (26/92), recommendation of their local hospital's microbiologists 14% (13/92). Respondents indicated they take the following factors into consideration to guide decisions regarding perioperative antimicrobial use - 48% (35/92) duration of surgery, 85% (78/92) degree of contamination of the surgical field, 8% (7/92) patient's age, 8% (7/92) degree of blood loss, 22% (20/92) HIV status of patient, and 22% (20/92) patient's access to hospital. Thirty-five per cent (32/92) of respondents indicated they audit their own rate of wound complications.

Conclusion: There is significant heterogeneity in the use of perioperative antibiotic prescribing practices and variable adherence to international consensus guidelines amongst ENT surgeons in South Africa. In light of the global increase in antibiotic resistance, this study highlights the need for increased awareness regarding the principles of antibiotic stewardship, pre-existing evidence-based guidelines and the need for a locally-generated South African otorhinolaryngology consensus guideline that promotes safe and rational use of perioperative antibiotic prophylaxis.