Scielo RSS <![CDATA[South African Journal of Surgery]]> http://www.scielo.org.za/rss.php?pid=0038-236120190001&lang= vol. 57 num. 1 lang. <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Breast cancer surgery: when less is more</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100001&lng=&nrm=iso&tlng= This brief review traces the evolution of breast cancer surgery from radical mastectomy (MTX) to breast conserving therapy (BCT) where wide local excision (WLE) of the cancer is combined with whole breast irradiation. The role of sentinel lymph node biopsy (SLNB) to assess the axilla as an alternative to more extensive axillary lymph node dissection (ALND) is examined. This review is a contemporary evaluation of these procedures (BCT, SLNB) and their impact on survival and in reduction of morbidity, and shows that local recurrence of breast cancer (BC) after BCT has been reduced to < 5% at 10-year follow-up when guidelines that excision margins should be free of microscopic cancer are followed and where patients receive whole breast irradiation together with systemic therapy after WLE. Over the past decade, studies of women with early BC entered on the SEER data base, the California Cancer Register and the Norwegian Cancer Registry have shown that overall survival (OS) and disease specific survival (DSS) are significantly better after BCT than following MTX. The improved survival after BCT compared to MTX cannot be attributed to radiation alone. The critical difference between these two procedures is the extent of dissection. Experimental studies using animal models have provided convincing evidences that the more extensive the tissue trauma, the greater the postoperative inflammatory cascade. This cascade of cytokines and growth factors impairs humoral immunity and enhances cancer cell survival and growth. The reduction in tissue trauma in patients undergoing BCT is a likely explanation for their improved survival. Compared to ALND, SLNB results in less lymphoedema, sensory loss and impaired shoulder function. For the clinically negative axilla, normal on palpation and imaging, SLNB is accurate in both the initial assessment and after neoadjuvant chemotherapy (NAC). <![CDATA[<b>Lymph node harvest in breast cancer patients with and without preoperative scintigraphy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100002&lng=&nrm=iso&tlng= BACKGROUND: Sentinel lymph node biopsy (SLNB) is the standard of care for women with node negative breast cancer. Tc99 nanocolloid is a popular tracer, facilitating preoperative lymphoscintigraphy to identify sentinel nodes. This study compares the number of sentinel lymph nodes identified at the time of surgery in women who had lymphoscintigraphy with those who did notMETHOD: All women with primary breast cancer undergoing a SLNB from 2003-2017 who were node negative and did not have neoadjuvant chemotherapy were retrospectively reviewed in this studyRESULTS: 576 women who had Tc99 preoperative injection were included in the study. Three hundred patients (Group 1) underwent lymphoscintigraphy preoperatively and 276 (Group 2) had no lymphoscintigraphy. The mean age at diagnosis for Groups 1 and 2 were 56 and 58 years, respectively. Both groups were also found to be similar in terms of histological subtype, tumour location, size, and HER2- and Estrogen receptor (ER) status. The surgery for the breast primary was similar in groups 1 and 2. While both groups had a median number of 2 nodes identified, the mean number of nodes identified for Group 2 (2.12) was 10% higher than for Group 1 (1.92) (p = 0.0026CONCLUSION: This is the largest series to show that a preoperative lymphoscintigram (scan) can safely be omitted when performing a SLNB. As newer tracers are being used (e.g. Iron Oxide), it is important to know that accuracy of SLNB is not compromised by omission of a scan <![CDATA[<b>The effect of beliefs about breast cancer on stage and delay to presentation: results from a prospective study in urban South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100003&lng=&nrm=iso&tlng= BACKGROUND: The disparity in breast cancer survival in Africa is often linked to poor education and awareness leading to late diagnosis and subsequent reduced survival. This study was designed to explore the relationship of attitudes and beliefs held regarding breast cancer to the stage and delay to diagnosis in South Africa. This study provies an epidemiological analysis of the spectrum of disease and outcomes of primary amputation for diabetic foot sepsis in a regional rural hospitalMETHODS: Women attending an open-access breast unit over 14 months with newly-diagnosed breast cancer answered a survey regarding their fears and beliefs of breast cancer care. Questions addressed demographic, socioeconomic and educational factors linked to delay, and documented time taken to care. Odds ratio with 95% confidence intervals were calculated to identify factors associated with advanced stage at presentation and delay greater than six monthsRESULTS: Of the 233 participants the median (IQR) age was 56 years (46-65). The most common stage at presentation was Stage 3 (55%), with 30.5% presenting with T4 tumour at presentation. Most women believed cancer could be beaten (90.0%), and their families would support them (92.8%). They disagreed that cancer was a curse (93.8%), punishment (90.5%) or that alternative therapies or traditional healing would cure their cancer (75.3% and 85.5% respectively). On univariate analysis, age under 45 years and transport difficulties predicted advanced stage at presentation. No socio-economic factors or beliefs increased the risk of delay to presentationCONCLUSION: Participants' beliefs about their new breast cancer were most commonly appropriate, and showed a low level of fatalism, in contrast to other studies in Africa. Whilst raising awareness may be important, efforts to increase awareness alone may not directly prevent the likelihood of late or advanced diagnosis in this population <![CDATA[<b>Experiences of women in survivorship following mastectomy in the Cape Metropole</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100004&lng=&nrm=iso&tlng= BACKGROUND: In spite of significant improvements in the treatment of breast cancer, many women still undergo mastectomy. The effects of breast cancer surgery on the diverse population of South African women have not been well studied. Insight may be gained in how to aid recovery in survivorship by identifying the support needs of women following mastectomy. This study aimed to explore and describe the lived experiences of women in the Cape Metropole following mastectomy in survivorshipMETHODS: A qualitative study guided by descriptive phenomenology and grounded in the post positivist philosophy of Husserl. Seven women from the Cape Metropole were interviewed in English following ethical approval. The semi-structured interviews were thematically analysedRESULTS: Three general themes emerged: Psychological impact of breast cancer diagnosis and treatment, the impact of an altered body image and concern for family and reliance on them for support, with a theme specific to stigmatisation within the Xhosa cultureCONCLUSION: The need to shield family members from breast cancer diagnosis was contrasted by the need for family support. Cultural stigmata still prevail within the South African population <![CDATA[<b>Frailty: what the South African surgeon needs to know</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100005&lng=&nrm=iso&tlng= Frailty is a state characterised by diminished physiological reserve that leaves one vulnerable to external stressors such as surgery and delays recovery thereof. Frailty assessments are proving to be more valuable in predicting poor perioperative outcomes than other well-known perioperative risk assessment tools. Frailty and comorbidity are interlinked as increased number of comorbidities are associated with higher levels of frailty but are distinct entities as frailty can exist without multiple comorbidity. It is therefore important that screening tools that allow for quick identification of frail individuals become commonplace in the perioperative environment. Identification of these frail individuals should lead to vigilance in preventing perioperative complications and allow for interventions that will reduce morbidity and lead to better outcomes. <![CDATA[<b>Surgical infections at a regional hospital in Gauteng: reasons for delay to care and profile of pathology</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100006&lng=&nrm=iso&tlng= BACKGROUND: Present on arrival infection is a common indication for admission of surgical patients initially managed at primary care level. We aimed to describe the demographic and disease profile of patients presenting with infection requiring surgical management, describe determinants of patients' health-seeking behaviour, and identify barriers to careMETHODS: A prospective descriptive questionnaire-based study was conducted at Edenvale General Hospital between February 2014 and October 2016. Minors were excludedRESULTS: Eighty-nine patients participated. Abscesses (26%), diabetic foot (22%), and cellulitis (16%) were the commonest categories of infection necessitating admission. The majority of patients were South African (88%), Black African (82%), males (58%), without medical aid (99%), who were not formally employed (58%), were from poor households (74%), inhabited some form of formal housing (90%), were in charge of decisions regarding personal health (80%), and first sought help at the primary care level (71%). Delay to presentation was noted in 69% of patients, and delay to referral in 46%. Age, race, history of diabetes, and main source of monthly income were significant variables in delayed presentation (p<0.05), and age and level of care on first contact in delayed referral (p<0.05) in the study sample. The most common reason for delay to presentation (84%) and referral (61%) was patients' belief that their problem would resolve spontaneouslyCONCLUSIONS: Patients' socio-economic status, past medical history, demographics, level of first contact with the health care system, and perceptions of their own health contributed to delays in seeking and receiving care in the study sample. These delays may be addressed by interventions that target the availability, accessibility, acceptability and affordability of health care services <![CDATA[<b>An overview of penetrating traumatic brain injuries at a major civilian trauma centre in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100007&lng=&nrm=iso&tlng= BACKGROUND: This study reviews our experience with penetrating Traumatic Brain Injury (TBI) in order to define and describe the injury pattern and the outcome. A secondary aim of this study was to review the use of the Motor Score (M Score) and the Simplified Motor Score (SMS) to assess and triage patients with penetrating TBIMETHODS: All patients with a TBI secondary to a penetrating mechanism were identified from the Hybrid Electronic Medical Registry at Pietermaritzburg Metropolitan Trauma Service (PMTS) from January 2012 to December 2014. Standard demographic data, need for neuro-surgical intervention, location of external wounds, CT findings and mortality where analysed. The Glasgow Coma Scale (GCS) M score and SMS score were specifically evaluated to determine the relationship between the individual motor component and patient outcomeRESULTS: Over the two-year period January 2012-December 2014, a total of 384 patients were admitted following a penetrating TBI. There were 350 males and 34 females and of this total 7 (1.82%) died. The mechanism of injury was axe (30), bottle (34), gunshot wound (GSW) (22) and stab wound (298). The average age for axe injuries was 27 and bottle injuries was 30. The average age for firearms and knives was 29 and 30 respectively Surgery was not required for 76.67% of patients. The need for surgery varied according to mechanism of injury. Axe injuries were treated non-operatively in 47.83%, bottle injuries in 87.50%, firearms 70% and knife injuries were treated non-operatively in 86.84% of cases. The overall survival rate for a penetrating head injury in this population is 98.16%. There were a total of 368 patients with a motor score of 6 of which one died. The survival rate was 99.7% and the mortality rate 0.3%. There were only 6 patients with a motor score of 5 and only 2 with a motor score of 4. The survival rate for both these groups was 100%. There was a total of 6 patients with a motor score of 1. There was a 100% mortality rate is this group.CONCLUSION: Penetrating TBI has a good prognosis. The vast majority of cases do not require neuro-surgical intervention. Poor motor score is associated with a poor outcome <![CDATA[<b>A review of the complications encountered in a quaternary trauma intensive care unit in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100008&lng=&nrm=iso&tlng= BACKGROUND: Due to the invasive nature required for support and multiple therapeutic interventions, critically ill patients are at high risk of complications unrelated to their underlying illness or injury. This audit aimed to describe the spectrum of complications in a trauma intensive care unit, to identify potential remedial interventions to improve quality of care and reduce morbidityMETHODS: Complications in the Trauma Intensive Care Unit at Inkosi Albert Luthuli Central Hospital are documented prospectively on a specific proforma. A 12-month audit was performed between 2012-2013. Complications were divided into septic and non-septic adverse events and the relationship to injury severity, time of onset and outcome were analysedRESULTS: Of 283 patients admitted during the study period, 77 (32.5%) suffered a total of 161 adverse events. Ninety-seven (60.2%) complications were sepsis-related and 64 (39.2%) were unrelated to sespis. Ventilator-associated pneumonia was the commonest septic event (38.1%) and extubation-related events the most frequent non-septic complication (45.3%). The number of complications ranged from one in the majority of patients (49.4%) to 6 (3.9%) in 3 patients. There was no significant difference in mortality between those with (24.7%) or without (17.4%) complications (p = 0.22) however, those with complications had a significantly longer length of ICU stay (p < 0.001CONCLUSION: Complications are common in the critically injured who necessitate admission to an intensive care unit. The vast majority arise from infective causes, especially ventilator-associated pneumonia. Adverse events related to the endotracheal tube are the commonest non-infective events. The identification of these adverse events should prompt interventions aimed at reducing the incidence <![CDATA[<b>Intra-abdominal injury identified by CTA in stable blunt polytrauma patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100009&lng=&nrm=iso&tlng= BACKGROUND: Patients with multiple injuries are a challenge to evaluate and to exclude abdominal injury, especially those who are intubated and sedated. Ultrasound is a screening tool and peritoneal lavage is unreliable. The aim of the study was to determine the incidence of intra-abdominal injury and describe the subsequent management after CT "panscan" in patients sustaining blunt trauma with injuries both above the thoracic and below the pelvic diaphragmMETHODS: In a retrospective analysis anonymised patient data were extracted from a prospective ethics approved database of patients admitted to the level I Trauma Unit at Inkosi Albert Luthuli Central Hospital for the period from April 2007 to March 2011. Blunt polytrauma patients, aged 2 years and older with injuries above the diaphragm and below the pelvic floor were included, provided they were investigated by a full-body trauma Computed Tomography contrast study. Descriptive statistics were employed for all variables of interest, with counts/frequencies and associated percentages being reportedRESULTS: Of 284 patients with injuries above the thoracic and below the pelvic diaphragm, 87 (30.6%) had intra-abdominal injury and 197 (69.4%) had no intra-abdominal injuries. Of those 87 patients, 54 (62.1%) were treated non-operatively and 33 (37.9%) were treated surgically with regard to their abdominal injuries. Twenty (22.9%) patients died, 4 due to intraabdominal injuries and 16 due to of extra-abdominal injuries. Nine (45%) of the twenty patients who died were treated operatively for intra-abdominal injuries and the remaining 11 (55%) were treated non-operativelyCONCLUSION: Around thirty percent of patients with injuries above the thoracic and below the pelvic diaphragm had concomitant intra-abdominal injuries. Of those with abdominal injury, just over half required laparotomy. For haemodynamically stable patients CT scanning identified those who require surgical intervention and those who may be managed non-operatively, therefore liberal CT-scanning is advisable for this patient group <![CDATA[<b>Lymph node transplant in Kenya: a case series of 20 patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100010&lng=&nrm=iso&tlng= BACKGROUND: Patients with multiple injuries are a challenge to evaluate and to exclude abdominal injury, especially those who are intubated and sedated. Ultrasound is a screening tool and peritoneal lavage is unreliable. The aim of the study was to determine the incidence of intra-abdominal injury and describe the subsequent management after CT "panscan" in patients sustaining blunt trauma with injuries both above the thoracic and below the pelvic diaphragmMETHODS: In a retrospective analysis anonymised patient data were extracted from a prospective ethics approved database of patients admitted to the level I Trauma Unit at Inkosi Albert Luthuli Central Hospital for the period from April 2007 to March 2011. Blunt polytrauma patients, aged 2 years and older with injuries above the diaphragm and below the pelvic floor were included, provided they were investigated by a full-body trauma Computed Tomography contrast study. Descriptive statistics were employed for all variables of interest, with counts/frequencies and associated percentages being reportedRESULTS: Of 284 patients with injuries above the thoracic and below the pelvic diaphragm, 87 (30.6%) had intra-abdominal injury and 197 (69.4%) had no intra-abdominal injuries. Of those 87 patients, 54 (62.1%) were treated non-operatively and 33 (37.9%) were treated surgically with regard to their abdominal injuries. Twenty (22.9%) patients died, 4 due to intraabdominal injuries and 16 due to of extra-abdominal injuries. Nine (45%) of the twenty patients who died were treated operatively for intra-abdominal injuries and the remaining 11 (55%) were treated non-operativelyCONCLUSION: Around thirty percent of patients with injuries above the thoracic and below the pelvic diaphragm had concomitant intra-abdominal injuries. Of those with abdominal injury, just over half required laparotomy. For haemodynamically stable patients CT scanning identified those who require surgical intervention and those who may be managed non-operatively, therefore liberal CT-scanning is advisable for this patient group <![CDATA[<b>Vascularised free lymph node transfer - a procedure for secondary lymphoedema management in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100011&lng=&nrm=iso&tlng= Lymphoedema is a condition in which impaired function of lymphatics results in poor lymphatic drainage and an accumulation of proteinaceous fluid in the interstitium. Lymphoedema has a broad clinical spectrum, and treatment options must be tailored to individual patients. Microsurgery is becoming popular as a surgical tool to manage refractory lymphoedema, and techniques include lymphaticovenous anastomosis(LVA) and vascularised lymph node transfer (VLNT). VLNT for treatment of lymphoedema has had promising outcomes thus far. We present a case report detailing the use of VLNT for treating post-surgical lymphoedema in the upper extremity. <![CDATA[<b>An approach to the transected umbilical vein catheter: a case series</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100012&lng=&nrm=iso&tlng= Transected umbilical vein catheters (UVC) are potentially fatal and associated with considerable morbidity. Timely identification and catheter retrieval are crucial. The successful surgical managment of three neonates referred to Inkosi Albert Luthuli Central Hospital with retained UVCs and a proposed algorithmic approach to manage these patients is described. <![CDATA[<b>Spontaneous extrahepatic biliary tree perforation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100013&lng=&nrm=iso&tlng= Spontaneous perforation of the common bile duct is an extremely uncommon cause of an abdominal emergency. Owing to the rarity of the condition it is seldom suspected or diagnosed preoperatively. We report a case of a 42-year-old female presenting with features of severe biliary pancreatitis who responded well to organ support. Five days post admission she was deemed fit for cholecystectomy to prevent further attacks of pancreatitis. Surgery revealed a common hepatic duct perforation treated with cholecystectomy, lavage and common hepatic duct drainage. This was followed by postoperative biliary stenting which led to complete resolution without further surgery. This conservative staged approach obviated the need for major biliary reconstruction and is a viable strategy when confronted with this rare complication without prior ductal imaging. <![CDATA[<b><i>Amanita phalloides </i>poisoning: one harvest, three outcomes</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100014&lng=&nrm=iso&tlng= The case study is to alert all health care workers and the public alike to the dangers of ingesting wild mushrooms. We describe an incidence of Amanita phalloides poisoning in Johannesburg, South Africa, where three different outcomes were experienced. A pregnant mother recovered with conservative management while her unborn foetus died, and her three-year-old daughter required an emergency liver transplant. We outline the clinical course, management options and principles of mushroom identification and toxicology to increase awareness of the presence of Amanita phalloides and its toxic relatives in South Africa. We highlight that early recognition, prompt treatment and referral to a transplant service is life-saving. <![CDATA[<b>Peptide Receptor Radionuclide Therapy of Neuroendocrine Tumors: how important is internal dosimetry?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100015&lng=&nrm=iso&tlng= The case study is to alert all health care workers and the public alike to the dangers of ingesting wild mushrooms. We describe an incidence of Amanita phalloides poisoning in Johannesburg, South Africa, where three different outcomes were experienced. A pregnant mother recovered with conservative management while her unborn foetus died, and her three-year-old daughter required an emergency liver transplant. We outline the clinical course, management options and principles of mushroom identification and toxicology to increase awareness of the presence of Amanita phalloides and its toxic relatives in South Africa. We highlight that early recognition, prompt treatment and referral to a transplant service is life-saving. <![CDATA[<b>Peptide Receptor Radionuclide Therapy of Neuroendocrine Tumors: how important is internal dosimetry?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100016&lng=&nrm=iso&tlng= The case study is to alert all health care workers and the public alike to the dangers of ingesting wild mushrooms. We describe an incidence of Amanita phalloides poisoning in Johannesburg, South Africa, where three different outcomes were experienced. A pregnant mother recovered with conservative management while her unborn foetus died, and her three-year-old daughter required an emergency liver transplant. We outline the clinical course, management options and principles of mushroom identification and toxicology to increase awareness of the presence of Amanita phalloides and its toxic relatives in South Africa. We highlight that early recognition, prompt treatment and referral to a transplant service is life-saving. <![CDATA[<b>Professor Victor John Ramsay Farrell</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100017&lng=&nrm=iso&tlng= The case study is to alert all health care workers and the public alike to the dangers of ingesting wild mushrooms. We describe an incidence of Amanita phalloides poisoning in Johannesburg, South Africa, where three different outcomes were experienced. A pregnant mother recovered with conservative management while her unborn foetus died, and her three-year-old daughter required an emergency liver transplant. We outline the clinical course, management options and principles of mushroom identification and toxicology to increase awareness of the presence of Amanita phalloides and its toxic relatives in South Africa. We highlight that early recognition, prompt treatment and referral to a transplant service is life-saving. <![CDATA[<b>Emeritus Professor Jacquez Charl "Kay" de Villiers</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100018&lng=&nrm=iso&tlng= The case study is to alert all health care workers and the public alike to the dangers of ingesting wild mushrooms. We describe an incidence of Amanita phalloides poisoning in Johannesburg, South Africa, where three different outcomes were experienced. A pregnant mother recovered with conservative management while her unborn foetus died, and her three-year-old daughter required an emergency liver transplant. We outline the clinical course, management options and principles of mushroom identification and toxicology to increase awareness of the presence of Amanita phalloides and its toxic relatives in South Africa. We highlight that early recognition, prompt treatment and referral to a transplant service is life-saving.