South African Journal of Surgery

The South African way of trauma surgery

D L Clarke — Fri, 24 Nov 2023 08:59:44 +0000

South Africa is a dynamic and boisterous country with a rich history. However, in the daily noise and bustle of our existence, we often fail to appreciate our history and overlook its significance and relevance. The military historians Evert Kleynhans and David Katz recently published a book describing twenty battles fought by South African forces over the last century.¹ In this book, they identify a unique South African way of warfare which has evolved in response to our unique historical and geographic situation. The merging of the Boer way of mobile “commando” warfare and the more formal British army approach to warfare by Jan Smuts and Louis Botha, created a unique military doctrine which emphasised mobility and encirclement rather than frontal attacks. It has taken historians such as Kleynhans and Katz to identify and elucidate this approach. The same applies to our rugby heritage, with Rassie Erasmus being perhaps the foremost proponent of a very effective and successful quintessentially South African approach to the game.²

More than 60 years of Organised Trauma Care: The Johannesburg Trauma Unit at Charlotte Maxeke Johannesburg Academic Hospital

M S Moeng, K D Boffard — Fri, 24 Nov 2023 09:05:04 +0000

The Johannesburg Hospital was opened in 1923 with a casualty department and wards. It was then known as Johannesburg General Hospital, commonly referred to as “The Gen” by many. In 1960, the Head of the department of Surgery, Prof. DJ Du Plessis, recognised the need to organise trauma care. He is quoted saying, “A large proportion of the patients arriving in the hospital appear to have suffered traumatic injury,” and thus noted the need to reserve a separate area for the care of these patients.

Tutankhamun – Africa’s first reported road traffic crash victim?

A B van As, R Brown — Mon, 06 Nov 2023 00:00:00 +0000

The most famous of all the Egyptian pharaohs was Tutankhamun, also known as King Tut, who died aged 18 in January 1343 BC. King Tut is famous because his tomb was left in almost perfect condition and contained wonderful treasures upon its discovery. The tomb permitted discovering the world of ancient Egypt. However, the cause of King Tut’s death remains wrapped in a mystery.

We critically review the circumstantial findings in the tomb together with the various international examinations that were performed on the corpse of King Tut over the last 100 years. They include post-mortems, radiographic examination, CT-scanning, and DNA testing, and propose a hypothesis as to the cause of his death.

Adverse events associated with the use of indwelling devices in surgical patients

H Wain, S Wall, D L Clarke — Thu, 20 Jul 2023 00:00:00 +0000

Background: Indwelling devices (IDs) are ubiquitous in modern healthcare and may often be associated with morbidity. This paper investigates adverse events related to IDs in surgical patients, which are generally placed into patients either to administer therapy, manage outputs or for specific therapeutic benefit.

Methods: A retrospective electronic database-based assessment of all adverse events relating to IDs was undertaken from December 2012 to August 2021. All events were categorised by device type, event type, and event severity.

Results: A total of 11 130 morbidities were captured over the study period. Of those, 2 195 entries pertained to an ID with 2 402 reported adverse events affecting 1 592 patients. Two-thirds occurred in males and injuries occurred in patients age ranging from eight days to 93 years, with an average age of 36 years. The most frequently implicated devices were surgical drains (including intercostal chest drains), accounting for 491 (20.44%) of adverse events. Central venous catheters (CVCs) and intravenous cannulae were involved in 374 (15.57%) and 332 (13.83%) events, respectively. Unplanned removal (346, 13.91%), output not measured (319, 12.82%), injury (314, 12.62%), and blockage (279, 11.21%) were the most common error types. The majority of adverse events were considered minor, however 27 (1.1%) patients experienced organ dysfunction as a result of an ID-related adverse event, and seven (0.3%) died.

Conclusion: Morbidity related to IDs in surgical patients is a relatively frequent occurrence. Standardisation of ID insertion and care, staff education, and improvements in communication have been identified as the most important strategies by which we can limit error-associated morbidity in patients with IDs.

The impact of the COVID-19 pandemic on presentation of surgical disease in paediatric patients at a tertiary centre in Cape Town, South Africa

C Kohler, B Banieghbal — Tue, 17 Oct 2023 00:00:00 +0000

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.

Factors influencing outcome in patients with perforated peptic ulcer disease at a South African tertiary hospital

J J Nanack, L Ferndale — Tue, 17 Oct 2023 00:00:00 +0000

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.

The incidence and management of complications following stenting of oesophageal malignancies

G Teyangesikayi, M F Scriba, S Viranna, E G Jonas, G Chinnery — Mon, 31 Jul 2023 00:00:00 +0000

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.

Technical success of endoscopic stenting for malignant gastric outlet obstruction

D Tait, M F Scriba, C Robinson, E G Jonas, G E Chinnery — Mon, 31 Jul 2023 00:00:00 +0000

Background: Palliation of irresectable malignant gastric outlet obstruction (GOO) using self-expanding metal stents (SEMS) is gaining popularity with high technical success rates. The aim of this study was to review and compare GOO stenting for malignancy with other series.

Methods: A retrospective review of all patients undergoing pyloroduodenal stenting for malignant GOO at Groote Schuur Hospital, 1 March 2018–31 August 2021, evaluating demographics, technical success, pathology, and stent-related complications was done.

Results: One hundred and fourteen patients, of which 38.6% were female, were included, with gastric malignancies (74.6%) being the most frequent underlying pathology. Median age was 64 years (IQR 53–70 years), with 48.2% having at least one comorbidity. The majority (96 patients; 85.7%) required only one stent. In total, 132 stent insertion attempts were undertaken. Three technical failures were experienced (one incorrect stent placement and two failed insertions), equating to a 97.4% technical success rate. Four immediate complications occurred (3.1%): two related to sedation, one incorrect stent placement and an oesophagogastric junction perforation with procedural death. Fifteen delayed complications occurred: 13 tumour in-growth blockages, one stent fracture and one case of poor radial stent expansion. Stent blockages occurred at a median of 107 days (IQR 80–275 days). Salvage stenting was 100% successful in 14 cases requiring re-stenting.

Conclusion: Technical insertion success rates of primary and salvage duodenal stenting for malignant GOO are on par with international high-volume units. The leading pathology locally is gastric adenocarcinoma, with palliative stenting remaining a feasible and accessible option.

Outcomes of complex burn injury patients managed at two primary and one tertiary level burns facilities in the Western Cape province of South Africa – a retrospective review

S W Carolissen, W Kleintjes, F Gool, S Gilbert — Wed, 25 Oct 2023 00:00:00 +0000

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.

HIV associated malignancies presenting as acute pancreatitis: a case series

F Madela, F Anderson, G B Nhlonzi, S R Thomson — Wed, 25 Oct 2023 00:00:00 +0000

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.

Small bowel metastasis from embryonal rhabdomyosarcoma of the extremity – a case report

P Joubert, M Mihalik — Tue, 17 Oct 2023 00:00:00 +0000

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.

Successful management of a thoracoabdominal impalement injury

A J Philip, D V Sneha, N Theckumparampil, S Jagdish — Wed, 25 Oct 2023 00:00:00 +0000

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.

Transverse colon volvulus – a case report and literature review

L Niksch, M Lockwood, P L van Rooyen, N A Niksch, L A Lorentz — Wed, 25 Oct 2023 00:00:00 +0000

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.

50th Surgical Research Society of Southern Africa Research Symposium Abstracts

Thu, 16 Nov 2023 00:00:00 +0000

50th Surgical Research Society of Southern Africa Research Symposium Abstracts

Professor JAL van Wyk 5 May 1936 – 5 May 2022

Elmin Steyn — Fri, 24 Nov 2023 09:29:12 +0000

It is with sadness yet with a wealth of fond memories that I report on the death of Professor Johannes Adriaan Louw van Wyk, a truly remarkable person. His unwavering commitment to excellence in every aspect of his life was what he expected from his registrars and everyone he worked with. Ahead of his time in many ways, he was also a liberal thinker, unafraid to offer the alternative view, a pioneer, and widely travelled, having forged friendships all over the world. Professor van Wyk was an expert on classical music (he collected and curated the complete works of the composers Schumann and Brahms on big reel tapes), a collector of art and historical books. He enjoyed cooking, was great fun at a party, and quick to laugh, especially at his own jokes. His long legs and arms, bounding with long strides up flights of stairs, earned him the nickname of Rabobie (Spiderman, a Xhosa TV cartoon character in the mid 1980s) from the students at the Medical University of South Africa (MEDUNSA) campus.

Dr Bhaskar Fulena Gujadhur 12/03/1982 – 28/09/2023

Fri, 24 Nov 2023 09:34:22 +0000

It is with sadness that we inform the surgical community of the passing of our colleague from Mauritius after a brave struggle with cancer. He was 41 years of age

CPD Questionnaire (V61N04)

Fri, 24 Nov 2023 09:45:42 +0000

CPD Questionnaire