Scielo RSS <![CDATA[South African Journal of Surgery]]> http://www.scielo.org.za/rss.php?pid=0038-236120200004&lang=en vol. 58 num. 4 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Minimal access surgery training in South Africa - changing philosophy and enabling the future</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Global surgery: a South African action plan</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Embrace innovation and redefine South African surgery</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400003&lng=en&nrm=iso&tlng=en <![CDATA[<b>Surgical innovation: the health sector conundrum?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400004&lng=en&nrm=iso&tlng=en <![CDATA[<b>Current practice of inguinal hernia repair at University of Cape Town affiliated hospitals: implications for training</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400005&lng=en&nrm=iso&tlng=en BACKGROUND: Various inguinal hernia repair techniques exist, without one 'single best' option. Hernia society guidelines recommend laparoscopic repair as one of its mainstays, provided surgeons are adequately trained. The current practice for hernia repair in South Africa as well as the surgical registrar exposure to laparoscopic repair training is unknown. OBJECTIVES: To quantify the current practice of inguinal hernia surgery in hospitals affiliated to the University of Cape Town (UCT) and to assess trainee exposure to laparoscopic repair. METHODS: Adult patients who underwent inguinal hernia repair during the 12-month study period, at the four UCT affiliated hospitals were included. Collected data parameters included age, gender, primary or recurrent, uni- or bilateral hernia, primary surgeon consultant or non-consultant, operative time, and open or laparoscopic technique used. RESULTS: Three hundred and seventy-seven patients were included. Eighty-eight (23.2%) repairs were performed laparoscopically, of which five (5.7%) were converted to open. Non-consultants were present at 70/88 (79.5%) cases performed laparoscopically and were the primary surgeon at only 15 (17%). Laparoscopic repair was performed for 63.6% of bilateral versus 19.5% of unilateral hernias, 39.4% of recurrent hernias and 45% of hernias in females. Two of the four hospitals in this study performed 81.8% of all laparoscopic repairs CONCLUSION: Inguinal hernias in our setting are predominantly repaired by open surgery. The likelihood of laparoscopic repair varies significantly depending on which hospital the patient is referred to. Non-consultants have limited exposure to performing laparoscopic hernia repairs as the primary surgeon. <![CDATA[<b>Retrospective audit of laparoscopic inguinal hernia repair at a South African tertiary academic hospital</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400006&lng=en&nrm=iso&tlng=en BACKGROUND: Adoption of laparoscopic inguinal hernia repair (LIHR) in sub-Saharan Africa is poor. The aim of this study was to describe our experience of the feasibility and short-term efficacy of the LIHR service at a South African tertiary academic hospital. METHODS: A retrospective audit of all the adult, elective, laparoscopic inguinal hernia cases that were done between November 2011 and 31 October 2016. Data were collected regarding the patient demographics, index side of hernia, type of repair, conversion rate, peri- and postoperative complications, postoperative hernia recurrence, persistent groin pain for more than three months and procedure-related mortality. RESULTS: One hundred and eighty-six patients were evaluated. One hundred and twenty-six (68%) patients were followed up for a mean of 38 months (3.1 years; range 9-67 months). Sixty (32%) patients were lost to follow-up. Early hernia recurrence (onset in < 7 days) occurred in one case after a totally extra-peritoneal (TEP) repair had required conversion to a trans-abdominal pre-peritoneal (TAPP) repair. Late recurrence (onset in &gt; 7 days) occurred in seven TEP repair cases (5.6%). Four recurrences (57%) occurred within the first two years. Recurrences in the next three years showed a 59% reduction giving a recurrence rate of 2.9%. At follow-up, six TEP cases (4.8%) had persistent groin pain persisting for 3-6 months in two cases and for more than one year in four cases. Five cases had seroma, six scrotal haematoma and one port-site sepsis. No death occurred. CONCLUSION: LIHR could be safely offered in a South African tertiary academic centre with acceptable results that are comparable with the South African private sector setting. LIHR could be implemented in other surgical training centres within a resource-limited environment. <![CDATA[<b>Can computed tomographic angiography accurately exclude digestive tract injury after penetrating cervical trauma?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400007&lng=en&nrm=iso&tlng=en BACKGROUND: Multislice computed tomographic angiography (MCTA) has become the method of choice to screen for arterial injury in penetrating cervical trauma (PCT). There is, however, limited knowledge on its accuracy in terms of digestive tract injury (DTI). Currently, our unit liberally employs both computed tomographic angiography (CTA) and contrast swallow for platysma breaching penetrating neck injuries. This study aimed to determine the accuracy of specific computed tomography findings in the diagnosis of DTI after PCT. METHODS: This was a retrospective review of all consecutive patients with PCT who had undergone MCTA that presented at a single, tertiary, high-volume trauma centre from January 2013 until December 2015. Blinded radiological review of 140 MCTA investigations (33 in the injury group and 107 in the control group) was performed in order to calculate the diagnostic accuracy of trajectory, air, and conventional MCTA signs in the diagnosis of DTI after PCT. RESULTS: Over the study period, 906 patients presenting with PCT had undergone MCTA and a total of 33 patients (3.6%) had confirmed DTI on aggregate gold standard of diagnosis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MCTA for detecting DTI was 100%, 65.4%, 47.1%, and 100%, respectively. No injuries were missed on MCTA. CONCLUSION: Our findings suggest that DTI can be safely excluded by means of careful assessment of specific signs on CTA in patients presenting after PCT, obviating the need for further investigation. <![CDATA[<b>Predictors of the need for surgery in upper gastrointestinal bleeding in a resource constrained setting: the Pietermaritzburg experience</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400008&lng=en&nrm=iso&tlng=en BACKGROUND: This review from a tertiary centre in South Africa aims to describe the spectrum and outcome of upper gastrointestinal bleeding (UGIB) and identify risk factors for surgical management and death. METHODS: This was a retrospective review of a prospectively entered database of all adults presenting with UGIB between December 2012 and December 2016. Demographics, presenting physiology, risk assessment scores, outcomes of endoscopy endo-therapy and surgery were reviewed. Comparisons were made between patients who required operative therapy and those who did not, and between survivors and non-survivors. RESULTS: During the review period, 632 patients were admitted with suspected UGIB. Out of these, 406 (64%) had an identifiable potential source of bleeding and 226 (36%) had no identifiable potential source of UGIB. The latter were excluded from further analysis. Of the 406 patients with a potential source of haemorrhage, there were 249 males (61%) and 157 females (39%). Nine of these were expedited directly to the operating room and never underwent an endoscopy. Of the 397 (98%) who had upper endoscopy 107 (26%) had endotherapy. Forty-six patients (11%) required surgery. They had significantly higher shock index (SI), increased need for transfusion, higher international normalised ratio (INR) and higher serum lactate than the non-operative group. Nine patients went to the operating room without endoscopy. Of the 46 patients who required surgery, 37 underwent an attempt at endoscopic intervention. Transfusion and transfusion volume increased the probability of requiring a laparotomy (p = 0.015) and (0.003) respectively. The independent predictors of need for operation were a raised shock index or serum lactate and Forrest Ia and Ib ulcers. Thirty-nine patients died, giving a mortality rate of 9.6%; ten had a gastric ulcer and 16 had a duodenal ulcer. Survival was significantly higher in the non-operative group (93.1% versus 68.2%; p < 0.001). The odds ratio for mortality in the laparotomy group is 6.73, 95% CI (3.15-14.17). Receiver operator curve (ROC) analysis showed that the pre-endoscopic Rockall score (PER), total Rockall score (TR) and the SI were poor predictors of mortality. CONCLUSION: Patients with UGIB in our setting are younger than in high-income countries (HIC) and a larger number fail endoscopic therapy and require open surgery. The mortality in this subset is very high. Detailed analysis of failed endo-therapy has the potential to reduce mortality. <![CDATA[<b>Do upper GI bleed guidelines reach patient care: effect of a quality improvement initiative</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400009&lng=en&nrm=iso&tlng=en BACKGROUND: Adherence is variable in clinical practice to consensus guidelines on the management of upper gastrointestinal bleeding. We aimed to assess the effect of a quality improvement program (QIP) on guideline adherence. METHODS: A QIP was undertaken over a two-month period. Data were collected retrospectively, for the one-year pre QIP and prospectively for one-year post QIP. The QIP goals were adherence to criteria for the timing of oesophago-gastroduodenoscopy (OGD), achievement of dual endotherapy and blood transfusion triggers. RESULTS: Fifty-one patients were pre QIP and 58 post QIP. The two groups' baseline data were comparable. Over 80% had their OGD within 24 hours (pre QIP 82.3%, post QIP 81.0%). The overall and high-risk groups (variceal and MBS > 10) had an insignificantly longer time to OGD (mean 19.2 and 17.8 hours respectively) in the post QIP cohort (mean 14.2 and 15.2 hours).The practice of dual endotherapy improved post QIP (p = 0.02) for non-variceal bleeding. The Hb g/dL (mean + SD) in stable patients who were transfused was significantly different pre QIP (6.3 + 2) and post QIP (5.7 + 1.69) (p = 0.04). Twelve patients (23.5%) were transfused for Hb above 7 g/dl pre QiP and six (10.3%) post QIP (p = 0.047). Thirty-day mortality rate was 9.8% (pre QIP) and 10.3% (post QIP). Univariate analysis showed that Grade III shock was the only significant factor in determining 30-day mortality. CONCLUSION: This QIP had no effect on time to OGD adherence which compares favorably to similar audits. Adherence to transfusion triggers and the ability to deliver dual endotherapy routinely were positive QIP outcomes. <![CDATA[<b>General and dietary oxalate restriction advice reduces urinary oxalate in the stone clinic setting</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400010&lng=en&nrm=iso&tlng=en BACKGROUND: Idiopathic hyperoxaluria is a risk factor for developing calcium oxalate nephrolithiasis. Dietary oxalate's effect on urinary oxalate is not well studied. The aim of this study is to assess the effect of advice focused on reducing dietary oxalate in a cohort of idiopathic hyperoxaluric patients. METHODS: Patients referred to the Groote Schuur Hospital Stone Clinic from 2015 to 2017 were considered eligible, if they were an idiopathic hyperoxaluric stone former, excreting > 40 mg/d of urinary oxalate on a pre-intervention 24-hour stone study urinalysis. Patients were asked to adhere to a diet sheet which included general stone prevention advice (low salt diet, increased fluid intake and moderate protein intake) and specific low oxalate diet advice. A post-intervention 24-hour urinalysis was performed at six weeks. RESULTS: Nineteen patients had hyperoxaluria (eight men and 11 women) with a mean age of 49 years (range 25-76 years). The mean BMI of the group was 28.4 kg/m² (17.4-50). All patients had mean number of 1.9 range prior stone episodes (range 1-6 stone episodes). Fourteen (14/19) patients completed the study. The mean pre-dietary advice urinary oxalate was 53.2 mg/24 hours (n = 14), SD while the post-intervention was 29.6 mg/24 hours SD (p = 0.0002). Only 3/14 patients who completed the assessment failed to normalise their urinary oxalate on the diet. CONCLUSION: In the stone clinic setting, general advice of low salt diet, increased water intake, moderate protein intake and specific oxalate restriction can significantly reduce oxalate excretion in hyperoxaluric stone formers. Sustained reduction of oxalate excretion and longitudinal clinical benefit are worthy of study in larger cohorts. <![CDATA[<b>Towards solving the riddle of nephrolithiasis: a South Africa perspective</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400011&lng=en&nrm=iso&tlng=en BACKGROUND: Idiopathic hyperoxaluria is a risk factor for developing calcium oxalate nephrolithiasis. Dietary oxalate's effect on urinary oxalate is not well studied. The aim of this study is to assess the effect of advice focused on reducing dietary oxalate in a cohort of idiopathic hyperoxaluric patients. METHODS: Patients referred to the Groote Schuur Hospital Stone Clinic from 2015 to 2017 were considered eligible, if they were an idiopathic hyperoxaluric stone former, excreting > 40 mg/d of urinary oxalate on a pre-intervention 24-hour stone study urinalysis. Patients were asked to adhere to a diet sheet which included general stone prevention advice (low salt diet, increased fluid intake and moderate protein intake) and specific low oxalate diet advice. A post-intervention 24-hour urinalysis was performed at six weeks. RESULTS: Nineteen patients had hyperoxaluria (eight men and 11 women) with a mean age of 49 years (range 25-76 years). The mean BMI of the group was 28.4 kg/m² (17.4-50). All patients had mean number of 1.9 range prior stone episodes (range 1-6 stone episodes). Fourteen (14/19) patients completed the study. The mean pre-dietary advice urinary oxalate was 53.2 mg/24 hours (n = 14), SD while the post-intervention was 29.6 mg/24 hours SD (p = 0.0002). Only 3/14 patients who completed the assessment failed to normalise their urinary oxalate on the diet. CONCLUSION: In the stone clinic setting, general advice of low salt diet, increased water intake, moderate protein intake and specific oxalate restriction can significantly reduce oxalate excretion in hyperoxaluric stone formers. Sustained reduction of oxalate excretion and longitudinal clinical benefit are worthy of study in larger cohorts. <![CDATA[<b>Alarm features as predictors of major findings in a rural South African upper endoscopic service</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400012&lng=en&nrm=iso&tlng=en BACKGROUND: Alarm features are commonly used to identify patients who require an endoscopy to rule out significant upper-gastrointestinal (GI) pathology. Validation of these features in a rural South African (SA) setting has implications for the provision of endoscopy services and was the aim of this study. METHODS: This was a retrospective chart review of 1 000 consecutive endoscopies performed at a rural SA regional/ referral hospital over three years. Demographic data, indication for endoscopy (upper GI bleed, dyspepsia, dysphagia, anaemia, weight loss, age) and major endoscopic findings (defined any tumour, ulcer, or stricture) were recorded. A multivariate logistic regression analysis was done to identify risk factors for major endoscopic findings. RESULTS: The median age of the study sample was 51.0 (range14.0-88.0) years. Males (306/1 000) accounted for 30.6% of the study population. The prevalence of alarm features in the study sample was as follows: upper GI bleed - 16.6%; dyspepsia - 58.4%; dysphagia - 10.3%; anaemia - 3.5%; weight loss - 0.3%. The following alarm features were statistically significant in detecting a major endoscopic finding: age &gt; 60 (OR: 2.67, CI: 1.82-3.96), male gender (OR: 1.52, CI: 1.03-2.24), dysphagia (OR: 12.16, CI: 4.33-34.19) and upper GI bleed (OR: 2.77, CI: 1.03-7.47), p < 0.05. CONCLUSION: Dysphagia, age &gt; 60, male gender, and upper GI bleed are identifiable risk factors for major endoscopic findings. Not all the alarm features for major endoscopic findings that are established elsewhere can be applied in our rural SA setting. <![CDATA[<b>Bowel preparation for colonoscopy: is diet restriction necessary?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400013&lng=en&nrm=iso&tlng=en BACKGROUND: Bowel preparation is essential for quality colonoscopy. Although most bowel preparation regimens recommend dietary restriction for 24 to 48 hours before the procedure, the evidence for this is poor. This study aimed to investigate whether dietary restriction during bowel preparation improves the quality of colonoscopy. METHODS: A prospective, randomised controlled pilot study in which the dietary restriction (DR) group (control) was instructed not to ingest high fibre foods for 48 hours prior to the use of a polyethylene glycol (PEG) bowel preparation. The non-dietary restriction (NDR) group were given no dietary instruction but received instructions for the use of the PEG-based preparation. On the day of colonoscopy, the quality of the bowel effluent was assessed, and additional preparation given as necessary. The primary endpoint was quality of bowel cleansing using the Harefield Cleansing Scale during colonoscopy. The secondary endpoints were the need for additional bowel preparation and the quantity of additional bowel preparation given prior to endoscopy. Data were analysed on an intention to treat basis. RESULTS: Twenty-three participants were randomised to the intervention group and thirty-four to the control group. Patient demographics were similar in both groups. Dietary restriction did not influence the success rate of bowel preparation: 97% successful bowel preparation in the DR group, vs 91% successful bowel preparation in the NDR group (p = 0.559). Additional bowel preparation requirement were similar in both groups: 35% in the DR group vs 39% in the NDR group (p = 0.768). Mean amount of additional bowel preparation required was similar: 560 ml in the DR group vs 460 ml in the NDR group (p = 0.633). CONCLUSION: The quality of bowel preparation was comparable in patients with and without dietary restrictions prior to colonoscopy. Non-restrictive diets prior to bowel preparation should be considered to increase compliance. The sample size of this pilot study prohibited definite statistical conclusions but demonstrated this to be a reasonable methodology for a larger study. <![CDATA[<b>A comparison of blunt and penetrating pancreatic trauma</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400014&lng=en&nrm=iso&tlng=en BACKGROUND: This project reviews our experience with managing pancreatic trauma from 2012 to 2018. METHODS: All patients over the age of 15 years with a pancreatic injury during the period December 2012-December 2018 were retrieved from the Hybrid Electronic Medical Registry at Grey's Hospital and reviewed. RESULTS: During the study period 161 patients sustained a pancreatic injury. The mechanism of trauma was penetrating in 86 patients (53%) and blunt in 75 (47%). The blunt mechanisms included MVA in 27, PVA in 15, falls in four and assaults in the remaining 29. There were 52 stab wounds and 34 gunshot wounds of the pancreas. A total of 26 patients (16%) were shocked on presentation with a systolic blood pressure of 90 mm Hg or less. The median injury severity score was 16. There were 90 patients with American Association for the Surgery of Trauma (AAST) grade I injury to the pancreas, 36 AAST grade II, 27 AAST grade III, 7 AAST grade IV and a single AAST grade V Fifty-four patients (34%) were initially treated non-operatively of which three eventually required surgery. Of the patients who required surgery, 26 (16%) underwent a distal pancreatectomy. The remainder simply underwent pancreatic drainage. The overall mortality rate was 13% (21/161). The operative mortality was 11% (18/161). Thirteen patients (8%) with penetrating injuries and eight patients (5%) with blunt injuries died. Of the 21 patients who died, 14 had multiple injuries. Five patients died due to overwhelming sepsis. One patient died due to hypovolemic shock and another due to a traumatic brain injury. CONCLUSION: Our centre not infrequently deals with pancreatic trauma secondary to both blunt and penetrating trauma. We follow the general principles outlined in the literature. Despite this, pancreatic trauma is still associated with significant morbidity and mortality <![CDATA[<b>Evaluation of views and perceptions of junior doctors on urology training and exposure during internship in South Africa: are we losing future urologists?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400015&lng=en&nrm=iso&tlng=en BACKGROUND: In South Africa, urological and other subspecialty training and exposure vary across each university at undergraduate and internship level. Many students and junior doctors complete their degrees and medical internship with little or no exposure and training to enable them to manage common urological conditions at primary healthcare level with the adequate competency, proficiency and confidence. We aimed to evaluate the exposure and urological training ofjunior doctors during internship and to determine whether it had any impact on their attitudes toward urology as a speciality in which to pursue a career. METHODS: We used a descriptive cross-sectional survey design. We emailed a questionnaire to 200 community service doctors who completed internship during 2016-2018, working across Western Cape hospitals. The questionnaire aimed to assess their clinical exposure to urology, confidence in basic urological knowledge and clinical skills, and their attitudes toward urology as a postgraduate career choice. RESULTS: The response rate was 104/200 (52%), 75% (n = 78) of the respondents had completed their internship without rotating through the urology department, 53.8% (n = 56) felt that their knowledge of essential urology topics was 'average' and still required further teaching and guidance, and 43.3% (n = 45) were not confident of performing a circumcision. 11.5% (n = 12) respondents were interested in pursuing a career in urology. The duration of the rotation through urology during internship and pursuing a career in urology were significantly associated (p = 0.005). CONCLUSION: The study showed that urological exposure and training at internship level is below the standard it needs to be in order to produce proficient and competent doctors able to practise efficiently during community service. The study also highlighted that limited exposure has a negative impact on potential future urologists wanting to pursue a career in the field. Incorporation of necessary urology skills short courses into the internship programme might help mitigate some of these challenges. <![CDATA[<b>Beware the bolus size: understanding intrarenal pressure during ureteroscopic fluid administration</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612020000400016&lng=en&nrm=iso&tlng=en BACKGROUND: Flexible ureteroscopy (FURS) and laser lithotripsy for ureteric and renal calculi requires adequate irrigation for visualisation. This study aimed to evaluate how bolus administration of irrigant fluid impacts intrarenal pressure (IRP) during FURS. We also investigated how ureteral access sheaths (UAS) of varying sizes mitigate elevated IRP METHODS: Using a porcine cadaveric model, IRP was evaluated using an arterial invasive pressure measurement system. Given a fluid column height (driving force) of 80 cm H2O, and varying bolus administration (1, 2, 3, 5, 10 ml), IRP was studied with and without a UAS. An IRP of < 40 mmHg was considered the cut off for "safe" FURS. The flow (drainage capacity) of UAS was also evaluated. At varying fluid column heights, three sizes of UAS were used, 10/12 French size (Fr), 11/13 Fr and 12/14 Fr, all 36 cm long RESULTS: Bolus administration with a UAS of < 5 ml with a starting fluid column height of 80 cm H2O was "safe" (< 40 mmHg). In contrast, where no UAS was used, bolus sizes as small as 2 ml produced "unsafe" peak pressures. The flow through a 10/12 Fr UAS was poor but improved greatly with larger UAS diameters CONCLUSION: This study suggests that 10/12 Fr UAS may be inadequate to maintain drainage from the kidney at acceptable pressures. Bolus fluid administration produces "unsafe" (&gt; 40 mmHg) elevated IRP in the absence of a UAS. When a UAS is used, a fluid bolus of < 5 ml is likely "safe"