Scielo RSS <![CDATA[South African Journal of Surgery]]> vol. 60 num. 1 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>The negative appendicectomy rate at Charlotte Maxeke Johannesburg Academic Hospital - a 10-year review</b>]]> BACKGROUND: The negative appendicectomy rate (NAR) is defined as the proportion of surgically removed appendices that are pathologically normal. The acceptable NAR has been a debated issue. Previously, a higher rate was accepted, whilst newer thinking favours a lower rate. Diagnosing appendicitis is often a clinical challenge and may require cross-sectional imaging to assist in the diagnosisMETHODS: A retrospective review was conducted at the Charlotte Maxeke Johannesburg Academic Hospital. Appendix histopathological reports were retrieved for patients older than 18 years over a 10-year period. Reports of ultrasound (US) and/or computed tomography (CT) scans were analysed in the last 18 monthsRESULTS: One thousand two hundred and seventeen appendicectomy specimens were included. The overall NAR was 19%. This demonstrated a significant downward trend over the period (p < 0.003). Per gender, the female NAR showed a significant decline (p = 0.002) while the male decline was not significant (p = 0.517). Reproductive-age females were found to have significantly higher NAR as compared to other age groups. The overall perforation rate was 17% which demonstrated a significant increase over the study period (p = 0.012). In the last 18 months, 240 appendicectomies were performed. One hundred and eleven patients underwent imaging (46%), of which 78 underwent ultrasound (70%), 14 CT (13%) and 19 US and CT (17%CONCLUSION: The overall NAR declined significantly over the period. Females under the age of 45 were found to have significantly higher NARs. Further prospective studies are needed to determine the benefit and feasibility of preoperative CT in resource-limited settings, particularly in reproductive-age females to reduce the NAR <![CDATA[<b>Outcomes for open and laparoscopic appendicectomy for complicated appendicitis in children</b>]]> BACKGROUND: The study aimed to compare the outcomes of paediatric laparoscopic appendectomy (LA) with open appendectomy (OA) for complicated appendicitis (CA). All trainees could perform OA without supervisionMETHODS: This is a single-centre, retrospective, non-randomised review of children 4-12 years of age, who had either an OA or LA for CA. The data was collected from August 2012 to June 2016. Nineteen surgical trainees were initially supervised by a consultant until deemed able to perform LA safely. The on-call surgeon decided on operative approach. Intra- and postoperative complications were analysed. Primary endpoint was comparison of infection rates between groups, simultaneous differences between the two procedures performed by surgical trainees and consultants were evaluatedRESULTS: One hundred and fifty-five patients had appendicectomy for CA during the study period. Fourteen patients with incomplete information were excluded. Ninety had OAs and 51 LAs. Both groups were well matched demographically. Postoperative infective complications occurred in 13/51 (25.5%) of the LAs, and in 23/90 (25.6%) of the OA (p = 0.159). Fourteen trainees performed 27 LAs without consultant supervision by the conclusion of the study. The mean duration of LA surgery for surgical trainees was 110.35 minutes (IQR 22.5) and for consultants 93.87 minutes (IQR 35, p = 0.497CONCLUSION: There is no difference in intra- and postoperative complications between LA and OA for CA. Duration of surgery between surgical trainees and consultants were comparable. This indicates that surgical trainees acquire LA skill over a short period of time and that LA as a laparoscopic teaching procedure merits consideration <![CDATA[<b>The influence of HIV status on the duration of chemoradiotherapy for anal squamous cell carcinoma</b>]]> BACKGROUND: The HIV epidemic has changed the demographic of patients with anal squamous cell carcinoma. The influence of HIV status on the ability to complete standard chemoradiotherapy was studiedMETHODS: A retrospective analytic observational study was conducted of all patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital radiation oncology department with anal squamous cell carcinoma from January 2014 to December 2016. Standard chemoradiotherapy was offered to all patients. Stage of anal squamous cell carcinoma, HIV status and cluster of differentiation 4 (CD4) levels were measured and compared in groups. We considered a maximum of 42 days as complete therapy without delayRESULTS: Ninety-two patients with anal squamous cell carcinoma were identified, of whom 67 were seen with the intention to treat and had known HIV status, of whom 59 received chemoradiotherapy. Eighty-eight per cent were people living with HIV (PLWH). PLWH were younger (p < 0.001) and less likely to receive full-dose chemotherapy (63%, p = 0.41). No patients presented in stage 1. More than 60% presented in stage 3. Fifty-six per cent of PLWH and 57% of HIVnegative patients were able to complete the 50 Gy radiation in 42 days (p = 1.0). CD4 above 200 did not impact therapy (p = 0.71CONCLUSION: HIV status of anal squamous cell carcinoma has minimal impact on the duration of chemoradiotherapy <![CDATA[<b>Microsatellite instability in north Indian colorectal cancer patients and its clinicopathological correlation</b>]]> BACKGROUND: Colorectal cancer (CRC) is the third most deadly and fourth most commonly diagnosed cancer in the world. Microsatellite instability (MSI) has been found associated with CRC, especially in prognostication. The present study has been carried out to find the genetic instability as demonstrated by MSI and its clinicopathological correlation in north Indian patientsMETHODS: This prospective study was carried out on 103 CRC patients admitted for surgery between 2014 and 2018. MSI testing was done using 5-panel markers (BAT25, BAT26, D2S123, D5S346, and D17S250) by standard polymerase chain reaction (PCR) technique. The various clinicopathological factors were analysed to see their association with MSI status and also their effect on survival. Univariate analysis was performed by using the 2-tailed Student's t-test for continuous non-normally distributed variables, and categorical variables were compared using the chi-square test. Multivariate correlation analysis was performed by logistic regression test using SPSS version 16.0 (IBM Corporation, Armonk, NY, USA). Kaplan-Meier analysis was done to detect the patient's survival. A p-value < 0.05 was considered statistically significantRESULTS: The frequency of MSI in patient population that we studied was 41.7% (43/103). MSI tumours were significantly associated with family history (OR = 5.63, p = 0.022*, 95% CI = 1.1-28.6) and tumour-infiltrating lymphocytes (TILS) (OR = 2.60, p = 0.023*, 95% CI = 1.1-6.0). The patients surviving longer (< 5 years vs &gt; 5 years) were found significantly associated with MSI-high (MSI-H) (OR = 3.76, p = 0.029*, 95% CI = 1.2-4.5CONCLUSION: Family history of cancer and presence of TILS were significantly associated with the presence of MSI-H tumours; also, patients surviving more than 5 years had more MSI-H phenotype <![CDATA[<b>Immunohistochemical determination of mismatch repair gene product in colorectal carcinomas in a young indigenous African cohort</b>]]> BACKGROUND: Colorectal cancer (CRC) in the indigenous African population of South Africa is uncommon (age standardised incidence rates of 11.29 for males and 7.27/100 000 for females) and tends to occur at a young age. Lynch syndrome (LS), an inherited mismatch repair (MMR) gene abnormality, accounts for 3-4% of newly diagnosed CRCs in high incidence areas. There is some evidence that the contribution of an MMR abnormality to the overall CRC burden may be increased in low incidence areas. We aimed to determine the prevalence of MMR deficiency in an indigenous African populationMETHODS: A cohort of 66 self-declared indigenous African patients, less than 50 years of age at diagnosis with CRC was identified from clinical and pathological records. The original histopathology was reviewed to confirm the diagnosis and features suggestive of MMR abnormality determined (pushing edge, mucinous, lymphocytic infiltration, Crohn's like reaction). Where sufficient tissue was available, samples were sectioned and stained for the four MMR proteinsRESULTS: Histopathological examination confirmed adenocarcinoma in 31 individuals. At least one feature suggestive of MMR was identified in 22 of these specimens. Twenty-seven cases were stained for all four MMR proteins using standard immunohistochemistry (IHC). MMR deficiency was found in 37% (n = 10/27) of cases. Median age of diagnosis was 35 years in the MMR-proficient group and 44 years in the MMR-deficient group, p < 0.008. No other significant differences between the groups were notedCONCLUSION: MMR deficiency was common in colorectal carcinomas in the older patients in this cohort, but very young indigenous Africans CRCs do not appear to result from mismatch repair gene mutations <![CDATA[<b>Patient perceptions of surgical training in the private sector in South Africa - a single centre survey</b>]]> BACKGROUND: As the worldwide demand for specialist surgeons increases, and to complement surgical training provided through governmental institutions, private hospitals are increasingly hosting trainees. Wits Donald Gordon Medical Centre (WDGMC) is a private academic hospital in Johannesburg with a Colorectal Unit (CRU) that hosts several trainees. While published studies demonstrate that the involvement of trainees in surgery does not adversely impact outcomes, private patients' perceptions of the role of trainees in their care have not been as widely researchedMETHODS: This was a prospective, cross-sectional study using a self-administered questionnaire hosted on a REDCap database. Statistical analysis was performed using SPSS version 26RESULTS: One hundred and seventy-four patients participated in the study, and 74.1% of respondents felt that training of doctors should occur in private hospitals in South Africa. Of the sample, 83.3% would allow a supervised trainee to perform a part of their operation, provided they had been made aware of trainee participation in advance (78%). Sixty per cent of patients felt that interaction with a trainee enhanced their care, and 52.3% of patients suggested that seeing more than one doctor a day improved their experienceCONCLUSION: Our results suggest that privately funded patients support the surgical training of medical doctors in private academic training hospitals, and they are willing to be participants in the training process. Moreover, training programmes in this setting appear to enhance the patient experience. We are optimistic that these findings could be used to advocate for expanded training opportunities across the private sector in South Africa <![CDATA[<b>Surgical training during the COVID-19 pandemic - a single institution's trainee survey</b>]]> BACKGROUND: Few studies have assessed the impact of COVID-19 on surgical training in low- and middle-income countries. The aim of this study was to survey the effect of the COVID-19 pandemic on postgraduate surgical training, research and registrar wellbeing in South AfricaMETHODS: A cross-sectional study was conducted as an online survey from 5 October 2020 to 1 December 2020. The study population was registrars from all surgical disciplines at the Faculty of Medicine and Health Sciences of Stellenbosch University. The survey consisted of 26 multiple-choice and five open-ended qualitative questions on the impact of COVID-19 on physical and mental wellbeing, skills acquisition and postgraduate researchRESULTS: Of 98 surgical registrars, 35 (36%) responded. Twenty-three (65.7%) reported missed planned surgical rotations, 30 (85.7%) decreased surgical training time, and 22 (62.9%) reported a perceived decrease in training quality. Simulated skills training was only available to eight (22.9%) participants. Twenty-four (68.6%) experienced burnout and/or depression symptoms during the pandemic. Twenty-seven (77.1%) reported that postgraduate research was unaffected by the pandemicCONCLUSION: During the COVID-19 pandemic, surgical trainees at this institution reported a decrease in the quality of surgical training and skills acquisition and a negative impact on their mental wellbeingSupplement available online: <![CDATA[<b>A South Africa tertiary centre experience with redo mitral valve replacement</b>]]> BACKGROUND: Severe cardiac failure from mechanical mitral valve thrombosis due to poor warfarin control is a major cause of emergency redo mitral valve replacement (MVR) in South Africa. This study aimed to review the outcomes of redo MVR in patients presenting with mitral valve failure to a tertiary South African centreMETHODS: Retrospective chart review of patients undergoing redo MVR over a 10-year period (2005-2014). Patient demographics, aetiology of valve dysfunction, preoperative clinical assessment and outcomes were analysedRESULTS: Sixty-four patients had 80 mitral valve procedures. The M:F ratio was 1:2.8 and the median age was 18 (IQR 14-28.5) and 25 (iQR 18-40) at initial surgery and at redo surgery, respectively. Median interval between original and redo MVRs was 47.5 (IQR 7.5-124) months. Rheumatic valve disease was the original pathology in 58 patients (90.6%). Fifty-two patients underwent a single redo MVR and 12 patients had multiple redo MVRs. Fifty-eight (72.5%) were emergency redo procedures. Prosthetic valve thrombosis was present in 73.8%. Ten patients (15.6%) developed postoperative complications. The median hospital stay and ICU stay were 19 (IQR 12-27.5) days and 4 (IQR 3-7) days, respectively. Two patients died in the postoperative period (3.1%). The mean patient follow-up was 42 months. Three patients died during follow-upCONCLUSION: The majority of redo MVR procedures were undertaken as an emergency with valve thrombosis being the most common aetiology. The mortality rate was 3.1% and postoperative complication rate was 15.6% <![CDATA[<b>Brachial artery injuries - the impact of the anatomical site of injury on postoperative outcomes</b>]]> BACKGROUND: The start of the armed conflicts in Libyan society in 2011 led to a dramatic increase in the incidences of unusual types of brachial artery injuries, which were previously uncommon. In this study, the postoperative outcomes have been compared prospectively between patients who have had injuries at the proximal anatomical half of the brachial artery with those who suffered injuries at the distal anatomical halfMETHODS: A cohort study was undertaken to compare patients who had an injury at the proximal anatomical half of the brachial artery (considered as the first group) and patients who had an injury at the distal anatomical half of the brachial artery (considered as the second group). This was undertaken to analyse the influence of the anatomical site of injury on the postoperative outcomes in patients who underwent urgent surgical repair procedures at the hospital from February 2011 to December 2016RESULTS: Out of fifty-one patients, 31 (60.8%) patients had gunshot injuries, 12 (23.5%) had explosive injuries, four (7.8%) had stab wounds and four (7.8%) were victims of road traffic accidents. There were 13 (25.5%) patients in the first group and 38 (74.5%) patients in the second group. Three patients (5.9%) had postoperative arterial occlusion due to thrombosis, while two (3.9%) had postoperative graft occlusion due to thrombosis; the other two (3.9%) had compartment syndromeCONCLUSION: Based on the anatomical background, critical limb ischaemia and postoperative ischaemic complications, as well as delayed limb amputation, are more associated with the injuries to the proximal anatomical half of the brachial artery due to poor collateral circulation at this level <![CDATA[<b>Organ transplantation during the COVID-19 pandemic - impact on deceased organ donor referrals and consent rates in the Western Cape, South Africa</b>]]> BACKGROUND: The impact of the COVID-19 pandemic on transplantation is multifactorial. This study reports on its influence on deceased donation for transplantation in the Western CapeMETHODS: The volume of referrals and those who were consented for organ donation in the province in the pre-pandemic period of May 2017 to February 2020 were compared to those of the initial pandemic period (March through December 2020RESULTS: Prior to the pandemic, there were 201 deceased donor referrals in the Western Cape province - 152 (75.6%) and 49 (24.4%) in public and private sectors, respectively. The mean referral rates ranged between 59-69 referrals per year, translating into a monthly rate of 4.8 (range 2.8-5.8). During the first 10 months of the pandemic, there were 18 referrals -12 (66.7%) and six (33.3%) in the public and private sectors; a decrease of 63%, with a mean monthly referral rate of 1.8. The overall consent rate prior to the pandemic in the public and private sectors was 36.6% (38% and 27%, respectively) with an increase to 44.4% (37.5% and 62.5%) during the pandemicCONCLUSION: Despite a 10% increase in consent rate for deceased donation during the COVID-19 pandemic, there was a significant decrease in the number of potential donors referred. Strategies to improve organ donation and transplantation during and after the COVID-19 pandemic are required <![CDATA[<b>Double jeopardy avoided by thorough investigation</b>]]> Penetrating junctional torso trauma with multiple and complex injuries presents the clinician with many investigational and management decisions.1-3 This situation has been termed double jeopardy in the literature.4-6 The management of this multiple gunshot victim's injuries - massive haemothorax and severe liver and kidney injuries - describes how this pathway can be negotiated with a successful outcome.6 <![CDATA[<b>Profile of paediatric tuberculosis mastoiditis - a case series</b>]]> BACKGROUND: Tuberculosis (TB) otitis media is an uncommon site of extrapulmonary TB and can primarily present as a complicated TB mastoiditis (TBM). This complication is rare in children, even in TB endemic areas but necessitates early identification as delays can lead to severe morbidities. We describe the clinical characteristics as a case series to raise awareness of the condition, and highlight fundamentals related to diagnosis and managementMETHODS: A retrospective chart review of clinical and radiological information of five children with TBM seen at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa, over the last 5 years. Variables collected included symptomatology, duration of disease, investigations and managementRESULTS: All were under 5 years of age and presented with typical features of acute bacterial mastoiditis. Mean duration of symptoms was 12 days (range 3-30 days). Two children had known TB contacts. Two children had pulmonary involvement, one with miliary TB. CT of the temporal bone demonstrated extensive bony destruction of the petromastoid and demineralised ossicles in all cases. Three children had intracranial extension. Four children demonstrated hearing loss between 30 dB and 83 dB. Necrotising granulomatous inflammation was present in the mastoid specimens in all cases. Confirmatory diagnosis was made via GeneXpert polymerase chain reaction (PCR) (2), Ziehl-Nielson (ZN) stain (1) or a positive TB culture (2). Postoperatively, one patient had normal hearing, two patients had mild conductive hearing loss (CHL), one had mild-moderate CHL and one had profound hearing lossCONCLUSION: Delays in identification and management result in marked bony destruction and hearing loss. Radiological and surgical findings typical of TBM, therefore, require tissue sampling from the ear for urgent microscopic, PCR and histologic testing, allowing the avoidance of a mastoidectom. In a TB endemic setting, children with typical findings and necrotising granulomatous inflammation on histology should be considered for prompt commencement of anti-TB therapy while awaiting a definitive diagnosis <![CDATA[<b>The value of MRCP in children with biliary symptomatology - an essential adjunct for safe cholecystectomy</b>]]> Congenital abnormalities of the biliary system are a consideration in children with biliary symptomatology. The preoperative diagnosis rate is still not satisfactory, despite progresses made in imaging technology, with the potential of biliary tract injury if surgery is indicated. The double gallbladder is a rare developmental abnormality of the biliary tract with several anatomical variations. This abnormality was accurately delineated in a 7-year-old child by MRI/MRCP, allowing the ductal anatomy to be accurately identified and safe laparoscopic cholecystectomies to be performed. <![CDATA[<b>Professor Letlhogela Meshack Ntlhe MBChB (Natal) FCS (SA) - 1951-2022</b>]]> Congenital abnormalities of the biliary system are a consideration in children with biliary symptomatology. The preoperative diagnosis rate is still not satisfactory, despite progresses made in imaging technology, with the potential of biliary tract injury if surgery is indicated. The double gallbladder is a rare developmental abnormality of the biliary tract with several anatomical variations. This abnormality was accurately delineated in a 7-year-old child by MRI/MRCP, allowing the ductal anatomy to be accurately identified and safe laparoscopic cholecystectomies to be performed.