South African Journal of Surgery最新文献

Background: Diagnostic accuracy in acute appendicitis (AA) may be improved by using inflammatory markers. This study assessed the reliability of inflammatory markers in diagnosing AA in our patient population.

Methods: A retrospective cross-sectional study was conducted at King Edward Hospital (KEH) from January 2020 to June 2021. Data was collected on all patients with AA who underwent appendicectomy. Variables of age, gender, comorbidities, HIV status Alvarado score histology, C-reactive protein (CRP), and white cell count (WCC) were reviewed. A p-value of < 0.05 is deemed as statistically significant.

Results: The study cohort was comprised of 150 patients - 58(39%) females and 92(61%) males. Thirty-two (21.3%) patients had a normal appendix, of whom 19 had a normal WCC. The majority of patients 80 (53.3%) had inflamed appendix, and 38 (25.3%) had ruptured appendix. The sensitivity and specificity of WCC and the CRP were 81% and 46% and 100% and 18.6% respectively. No patient with a ruptured appendix had normal CRP. The CRP correlated with the ruptured appendix with a median of 141.5 and, p-value of 0.01. The level of WCC and the presence of a ruptured appendix had a significant correlation with a p-value of 0.002, median of 15.2.

Conclusion: A combination of WCC and CRP tests improves the diagnostic accuracy. There is a correlation between CRP level and ruptured appendicitis. In our setting, AA is likely to present late once it has already ruptured. The reasons behind this late presentation need to be explored and addressed.

A 49-year-old male with no comorbidities presented with acute colicky lower abdominal pain for one day, alongside three months of intermittent abdominal pain, loose stools, and melena. A contrast-enhanced computed tomography scan revealed an intussusception. During exploratory laparotomy, an ileo-ileal intussusception with a 3 cm polypoid lesion 10 cm from the ileo-caecal junction was found. The intussusception was reduced, followed by ileal resection and anastomosis. Histopathology and immunohistochemistry (positive for STAT6, CD34, Vimentin, and SMA) confirmed a solitary fibrous tumour (SFT) of the ileum. The patient recovered well and was discharged eight days postoperatively. He is on annual follow-up.

Background: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic gallstone disease. The procedure has a steep learning curve and may result in significant postoperative morbidity and mortality. LC carries a morbidity of 1.6-5.3%, a mortality of 0.05-0.14% and readmission rates of 3.3% (0-11.7%). We aimed to evaluate the 30-day outcomes of LC across four metropole hospitals in the Western Cape (WC) including mortality, length of stay, readmissions and complications according to the Clavien-Dindo classification system.

Methods: A retrospective review of a prospective database was performed. Data were collected between September 2019 and July 2022. Relative clinical, operative findings and postoperative outcomes were analysed.

Results: There were 1 000 consecutive LCs included in this study. The mean postoperative length of stay was 1.92 days. Forty surgical complications were noted of which the most common were a bile leak (n = 14) and intra-abdominal collections (n = 11). Seven patients with bile leaks required reintervention. Four (0.4%) bile duct injuries (BDI) were reported in our series. Twenty-five percent of postoperative complications were graded as Clavien-Dindo IIIa and 28% were graded as Clavien-Dindo IIIb. The 30-day readmission rate was 3.8% (n = 38). Thirty-five patients were readmitted with surgical complications. There were three reported deaths (0.3%).

Conclusion: Laparoscopic cholecystectomy is considered the standard of treatment for gallstone disease but a small percentage may have serious complications. The outcomes reported in this series are similar to that of other reported studies.

Background: The value of the textbook outcome in pancreatic surgery (TOPS) score, a composite measure of surgical performance for quality assurance, was evaluated in a South African tertiary hospital cohort of pancreaticoduodenectomies (PD) performed for adenocarcinoma of the ampulla of Vater (AAV).

Methods: A review of all patients undergoing a PD for AAV at a single centre between January 1999 and December 2023 was performed. Demographic, operative, pathological and postoperative variables were recorded. Ten clinical and histological variables were used to construct a TOPS score. These included an R0 resection, no postoperative pancreatic fistula (POPF), no bile leak, no post-pancreatectomy haemorrhage, no delayed gastric emptying, no major postoperative complications (< Gr 3 Clavien-Dindo), no readmission to ICU, length of stay ≤ 10 days, no 30-day readmission or intervention and no 30-day mortality. A textbook outcome (TO) was defined as the fulfilment of all 10 variables. In patients in whom TO was not achieved, the reasons for failure were identified. In addition, the number of patients who had major complications and died were categorised as failure to rescue (FTR).

Results: A positive TOPS score was achieved in 27 of 79 (34.2%) patients undergoing a PD. Overall five-year survival after PD was 33.9%. TOPS conferred a significant 1-year survival benefit, 88.9% vs 66.7% (OR 4.12, 95% CI 1.08-15.67, p = 0.038). There was no significant difference in 5-year survival between TOPS and non-TOPS patients, 40.0% vs 32.4% (OR 1.39, 95% CI 0.48-3.99, p = 0.54). A POPF occurred in 31.6% patients, resulting in a significantly longer hospital admission, 17 vs 10 days (95% CI 2.66-11.34, p = 0.0019). Twenty-one (26.6%) patients developed a major complication, five of whom died (FTR = 6.3%).

Conclusion: This study confirmed the value of TOPS as a useful measurement to assess hospital quality metrics and short-term survival after PD for AAV. One quarter of patients developed a major complication with a 6.3% FTR.

Background: Prolonged obstructive jaundice (OJ), associated with resectable pancreatic pathology, has many deleterious effects that are potentially rectifiable by preoperative biliary drainage (POBD) at the cost of increased postoperative infective complications. The aim of this study is to assess the impact of POBD on intraoperative biliary cultures (IBCs) and surgical outcomes in patients undergoing pancreatic resection.

Methods: Data from patients at Groote Schuur Hospital, Cape Town, between October 2008 and May 2019 were analysed. Demographic, clinical, and outcome variables were evaluated, including perioperative morbidity, mortality, and 5-year survival.

Results: Among 128 patients, 69.5% underwent POBD. The overall perioperative mortality in this study was 8.8%. The POBD group had a significantly lower perioperative mortality rate compared to the non-drainage group (5.6% vs. 25.6%). POBD patients had a higher incidence of surgical site infections (55.1% vs. 23.1%), polymicrobial growth from IBCs and were more likely to culture resistant organisms. Five-year survival was similar in the two groups.

Conclusion: POBD was associated with a high incidence of resistant organisms on the IBCs, a high incidence of surgical site infections and a high correlation between cultures from the surgical site infection and the IBCs.

Summary: Cannabis legalisation continues to grow globally and its effects on the vascular system have been scrutinized.¹ Cannabis has become recognised as a contributor to cardiovascular, cerebrovascular and peripheral vascular disease.^2,3 This case report highlights the case of a young male patient presenting with atypical symptoms following cannabis use who developed gangrenous cholecystitis (GC) following vasospasm of his cystic artery. We believe that this is the first-ever case, shared with the anticipation of stimulating more research and prompting recognition of vascular events in this group of patients as our knowledge on the effects of cannabis continues to grow.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a useful, minimally invasive intervention in managing complicated hepatic cystic echinococcosis (HCE). This study aims to assess the use of ERCP in a South African HCE cohort with and without human immunodeficiency virus (HIV) co-infection.

Methods: An analysis was performed of patients with HCE who were assessed for surgery and underwent ERCP at a tertiary hospital in South Africa between 2011 and 2023. Demographics, clinical data, imaging characteristics, operative management, and postoperative complications were compared between HIV-negative (HIV-) and HIV-positive (HIV+) cohorts.

Results: Of the 91 patients assessed, 45 (mean age 34.6 years, 73.3% females, 23 HIV+) required ERCP. HIV status did not significantly affect cyst characteristics or surgical outcomes. HIV+ patients had a higher incidence of intraoperative bile leaks (p = 0.025). There were 18 patients who underwent preoperative ERCPs, mainly for biliary-cyst complications primarily causing obstructive jaundice. A total of 40 patients required postoperative ERCPs, mainly for bile leaks. There were no ERCP-related mortalities and only one case of pancreatitis. ERCP success rates were comparable in both cohorts, with an overall success rate of 86.7%.

Conclusion: HIV co-infection did not significantly impact the clinical course or outcomes of cystic echinococcosis (CE) patients undergoing ERCP. Perioperative ERCP proved effective in managing biliary complications of HCE as well as postoperative complications, regardless of HIV status. This study underscores the importance of endoscopic interventions in the comprehensive management of CE.

Summary: We present a previously healthy 13-year-old male, who sustained a handlebar injury after falling from his bicycle. The computerised tomography (CT) scan indicated a probable pancreatic neoplasm associated with a retroperitoneal haematoma which was, following resection, confirmed histologically to be a solid pseudopapillary neoplasm of the pancreas. These are rare tumours of the pancreas, especially in young males. The rarity of this neoplasm and the mechanism that led to its presentation make this an interesting and unique case.

Background: Hepatic inflammatory myofibroblastic tumours (HIMTs) are rare and poorly described in the literature. Most publications are single patient case reports and lack detailed reporting on characteristics, management, and outcomes. This systematic review aimed to assess the demography, clinical presentation, typical imaging features, histopathology, treatment, and outcomes of patients presenting with HIMTs.

Methods: A systematic literature search was performed in MEDLINE (PubMed), EMBASE (Scopus), JSTOR, Cochrane CENTRAL (Cochrane Library), and the databases included in the Web of Science for studies published between 1940 and 2023 on HIMTs, including its reported synonyms. Case series or cohort studies that reported on the management and outcomes of at least four patients with histologically confirmed HIMTs were included in the analysis.

Results: After screening 4553 publications, 22 articles including a total of 440 patients with confirmed HIMTs were eligible for inclusion. The average age was 53.4 years (range 42.0-65.0) with a male to female ratio of 1.7:1. Abdominal pain, discomfort, fever, and loss of weight were the most common presenting symptoms. Surgical resection is the standard of care for HIMTs and is associated with low mortality of 3.4% and low disease recurrence.

Conclusion: HIMT is a disease more often affecting middle-aged males. The lesions are typically solitary with low recurrence after treatment. The relative roles of surgical versus medical treatment remain unclear. Differences in clinical presentation, histopathology, and treatment of HIMTs compared to inflammatory myofibroblastic tumour (IMT) at extrahepatic sites could challenge the current view of IMT as a single pathological entity.

Background: Surgical resection of distal cholangiocarcinoma (dCCA) offers the only chance for cure and long-term survival. The current literature provides limited data regarding the surgical management and long-term outcomes of dCCA. This study aims to describe the presentation, management, and outcomes of dCCA at a large academic referral centre in South Africa.

Methods: A retrospective study was performed of all patients who underwent curative-intended surgery for dCCA at Groote Schuur Hospital from 2000 to 2020.

Results: Over 21 years, 25 patients underwent pancreaticoduodenectomy (PD) for dCCA. Most patients were male (68%), and the mean age was 56.8 years. Of the patients, 22 (84%) underwent preoperative biliary drainage (PBD). There were 29 recorded complications in 25 patients; postoperative pancreatic fistula (POPF) and surgical site infection (SSI) each occurred in 24% of the cohort. The mean hospital stay was 17.2 days without perioperative mortality. With none lost to follow-up, the 1, 3, 5, 10, and 20-year survival rates were 84%, 24%, 16%, 12%, and 4%, respectively. Only T3 status was associated with significantly lower overall survival (OS). Age, albumin levels, PBD, margin status (R0 vs. R1), and nodal status (N0 vs. N1/N2) did not influence OS.

Conclusion: This is the first study detailing the management and outcomes of dCCA from sub-Saharan Africa (SSA). Despite the complete resection of dCCA, the prognosis is poor, and the long-term survival rate in our study is equivalent to that reported in the literature. T3 disease is an important prognostic factor and is associated with poor OS. Surprisingly, nodal disease and margin status did not affect OS in the cohort of patients.