Scielo RSS <![CDATA[South African Journal of Surgery]]> http://www.scielo.org.za/rss.php?pid=0038-236120170001&lang=es vol. 55 num. 1 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Breast surgery in SA 2017: Quo vadis?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100001&lng=es&nrm=iso&tlng=es <![CDATA[<b>Breast ductal carcinoma in situ in an unscreened population: presentation, diagnosis and management at a single tertiary centre</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100002&lng=es&nrm=iso&tlng=es BACKGROUND: To determine the clinical presentation of patients presenting with isolated ductal carcinoma in situ at a single tertiary center in the Cape Town, South Africa. To review the diagnostic techniques most commonly used and the primary surgery performed for these patients. METHODS: We performed a retrospective folder review of patients diagnosed with DCIS over a period from Jan 2005 to Dec 2012, at the Combined Breast Cancer Clinic at Groote Schuur Hospital. Patients with a histological diagnosis of DCIS were identified from a prospectively collected patient database and the South African National Health Laboratory System (NHLS) histological reports and operative records. RESULTS: 42 patients with isolated DCIS were identified. This represents 1.1% (42/3636 ) of all breast malignancies managed in this period. The average age of presentation was 58 years. Most patients presented with a breast lump (23/42). The diagnosis was made on core biopsy in 14 patients while 8 patients required excision of the palpable lump to make the diagnosis. 23 patients underwent a primary mastectomy, 6 patients had a wide local excision 8( WLE) and 6 patients had radio-guided occult lesion localization (ROLL) with therapeutic intent. CONCLUSION: Though rare, the management of DCIS in this setting highlights the challenges of diagnosing and managing early breast malignancies in LMICs. <![CDATA[<b>Breast Cancer and HIV: a South African perspective and a critical review of the literature</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100003&lng=es&nrm=iso&tlng=es BACKGROUND: The diagnosis of breast cancer and concurrent HIV in South Africa is common. The limited current evidence on this subject suggests that the patients thus afflicted appear to be younger, have a more advanced stage of breast cancer, have a higher treatment related complications and poorer outcomes. This paper reviews the literature related to HIV and breast cancer, with a view to improving the standard and quality of care of HIV positive breast cancer patients. METHODS: Pubmed, EBSCOhost, Google scholar and Science Direct electronic databases were searched from 2001 and 2015. using the terms ('HIV' OR 'human immunodeficiency virus' OR 'AIDS' OR 'Acquired Immunodeficiency Syndrome') and 'breast cancer' or 'breast carcinoma' to identify all publications related to HIV and breast cancer. Titles and abstracts were evaluated for eligibility and appropriate full text articles obtained. The data extraction variables included the type of study, year of publication, study setting, participants, sample size, outcome measures and main findings. RESULTS: Only five studies fulfilled the criteria, in respect of the aforementioned maladies, with twenty or more participants in each study. Evidence suggested that breast cancers develop at a much younger age in the HIV positive patient compared to the HIV negative patients, with more aggressive appearing tumour biology. Overall, it appears that HIV positive patients experienced a higher cancer-specific mortality than HIV negative patients, and this is independent of the stage of the cancer or the cancer therapy received, further the relationship between the HIV syndrome and breast cancer is currently marginal and inconclusive, and hence requires further investigation. CONCLUSION: The prescription and administration of chemotherapy is a challenge, with potential complications impacting on the morbidity and mortality in HIV positive patients. Currently there are no reliable predictors of those at risk to complications from chemotherapy; however, being on ART appears to provide an acceptable safety profile. HIV positive patients are best managed in the context of a multi-disciplinary team in order to achieve favourable outcomes in the treatment of cancer. Well-designed prospective trials to assess the response to multimodal therapy, and the long-term outcomes of HIV positive patients with breast cancer are needed. <![CDATA[<b>The circumareolar approach to gynecomastia and transgender surgery: modifications to provide correct nipple areolar complex position and shape</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100004&lng=es&nrm=iso&tlng=es BACKGROUND: In surgery for gynaecomastia, excision with minimal scarring and correct position of the nipple areolar complex (NAC) are key to a successful outcome. We report on a pilot study on the use of a circumareolar excision and the use of mathematical vector calculation to position the NAC and execute surgery and report on the outcomes. METHODS: From 2014 to 2015, the authors operated on 9 gynecomastia or transgender patients. Based on research performed by Gertrude Beer, Beckenstein and Shulman we designed a mathematical modification of the technique described by Persichetti to provide correct NAC positioning as well as aesthetically pleasing NAC shape. We utilised the technique in 6 patients, 4 males with gynecomastia and 2 transgender patients. Liposuction was performed as an adjunct as needed RESULTS: In 5 of the patients, the NAC did move in the direction of the desired vector. The NAC was on average within 0.4 cm of the desired nipple to mid-sternal position. The lateral movement averaged 0.6 cm. We found the modified circumareolar approach to deliver good aesthetic results with predictable NAC movement. Seroma formation was the most common complication. CONCLUSION: The mathematically modified circumareolar approach to transgender and gynecomastia surgery may provide better aesthetic outcomes. Several factors need to be considered in deciding how the oval shaped vector should be designed intraoperatively. The study was limited by small sample size and short follow-up. <![CDATA[<b>Surgical anatomy of reduction mammaplasty: a historical perspective and current concepts</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100005&lng=es&nrm=iso&tlng=es Reduction mammaplasty is the volumetric reduction in the bulk of the breast. Techniques have evolved from primarily reducing the breast bulk to reducing with emphasis on functional and aesthetic outcome. The deeper understanding of the surgical anatomy of the breast has guided this development. While Paulus Aegina (sixth century AD), Dieffenbach (1848) and Gaillard-Thomas (1882) set the pace in glandular reduction; Pousson (1897) and Dehner (1908) focused on breast ptosis. It took quite some time before the enigma of the vascularization to the nipple areolar complex could be solved. Progress over a decade saw Thorek's (1922) free nipple grafting replaced by the periareolar de-epithelialization introduced by Schwarzmann (1930); which subsequently gave way to the Gillies and Mclndoe (1939) skin-gland undermining technique. The era of breast remodeling while preserving the nipple areolar complex was soon ushered forward. This was driven by Arie (1957), Strombeck (1960) and Pitanguy (1961). The preservation of the subdermal plexus became crucial whilst retaining sensory supply to the breast as the pectoral fascia was spared. Skoog's (1963) nipple transposition without skin-gland undermining formed the basis for modern day reduction mammaplasty. Aesthetics was in mind throughout this period as different skin incisions were developed and advanced following Dieffenbach's small submammary incision in 1848. Surgical landmarks that ensured reproducible aesthetic outcomes were described by Penn (1955) and Wise (1956). Liposuction-assisted reduction was introduced by Teimourian in 1985 and is best utilised in patients with predominantly fatty breast tissue. <![CDATA[<b>An overview of risk factors for recurrent breast cancer</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100006&lng=es&nrm=iso&tlng=es The multidisciplinary management of Breast Cancer (BC) has evolved over the past 50 years: the patient is offered a choice of surgical procedures with or without radiation therapy, cytotoxics and treatments targeting the nuclei of the cancer cells. This has resulted in a reduction of disease recurrence and a significant increase in 5-year survival. But these good results deteriorate over time and almost 20% women with early stage, oestrogen-receptor (ER) positive BC will suffer recurrent cancer at 10 years. The aim of this review is the identification of risk factors for the recurrence of BC, to examine pathogenic pathways leading to BC and to report on modifications to lifestyle, surgical procedures and treatment regimes which can reduce the recurrence of BC. Patient factors associated with increased risk included the extremes of age, ethnicity, genetic inheritance obesity and alcohol ingestion. Human Immunodeficiency Virus (HIV) was not identified as a cause of BC. Treatment-related factors included microscopically positive excision margins, delay in initiation of adjuvant chemoradiation and lack of compliance with endocrine therapy. Reclassifying BC according to molecular subgroups more accurately identifies patients at risk for recurrence and aids in the appropriate selection of therapy targeted to the primary and lymphatic metastases. <![CDATA[<b>Crossbow injury to the neck</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100007&lng=es&nrm=iso&tlng=es Crossbow injuries are uncommon among penetrating trauma. The tendency for a crossbow bolt to remain in situ appears to limit catastrophic haemorrhage despite the involvement of major vessels.¹ Here we report our experience with an injury to the left internal jugular vein by a crossbow bolt. The injury was successfully treated by emergency neck exploration. Crossbow injuries are uncommon among penetrating trauma. The tendency for a crossbow bolt to remain in situ appears to limit catastrophic haemorrhage despite the involvement of major vessels.¹ Here we report our experience with an injury to the left internal jugular vein by a crossbow bolt. The injury was successfully treated by emergency neck exploration. <![CDATA[<b>Primary fusobacterium osteomyelitis and pyomyositis of the thigh in an immunocompetent young adult</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100008&lng=es&nrm=iso&tlng=es An unusual case of an immunocompetent young adult with osteomyelitis and pyomyositis of his right thigh is presented. Despite the absence of typical clinical signs, a high index of suspicion and 16S RNA PCR led to an early diagnosis of Fusobacterium infection and subsequent successful multidisciplinary treatment <![CDATA[<b>Parathyroid adenoma with concurrent toxic thyroid adenoma: a rare combination</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100009&lng=es&nrm=iso&tlng=es BACKGROUND: Hypercalcemia in association with hyperthyroidism is a well-recognized phenomenon. Primary hyperparathyroidism due to parathyroid adenoma in association with thyroid adenoma is extremely rare. These cases can present a diagnostic and therapeutic challenge to the treating physician as the patient may present with symptoms of either disease. CASE SUMMARY: A 47-year-old female patient presented with non-specific complaints including fatigue and muscle cramps. Diagnostic workup revealed significantly elevated plasma calcium levels in association with hyperthyroidism. There was a considerable delay in measuring the parathyroid hormone levels which were significantly elevated. Nuclear medicine studies revealed features consistent with a parathyroid adenoma and a concurrent thyroid adenoma. The patient was rendered euthyroid and subsequently taken to theatre for a thyroid lobectomy and removal of the associated parathyroid adenoma. One year later the patient remains normocalcemic, euthyroid and clinically well. CONCLUSION: Toxic thyroid adenoma with concurrent parathyroid adenoma and primary hyperparathyroidism is rare. The possibility of primary hyperparathyroidism should be considered where hypercalcemia persists on correcting the hyperthyroidism. Removal of both adenomas will result in cure of the patient. <![CDATA[<b>The First World War: what can it teach us about medical education?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100010&lng=es&nrm=iso&tlng=es BACKGROUND: Hypercalcemia in association with hyperthyroidism is a well-recognized phenomenon. Primary hyperparathyroidism due to parathyroid adenoma in association with thyroid adenoma is extremely rare. These cases can present a diagnostic and therapeutic challenge to the treating physician as the patient may present with symptoms of either disease. CASE SUMMARY: A 47-year-old female patient presented with non-specific complaints including fatigue and muscle cramps. Diagnostic workup revealed significantly elevated plasma calcium levels in association with hyperthyroidism. There was a considerable delay in measuring the parathyroid hormone levels which were significantly elevated. Nuclear medicine studies revealed features consistent with a parathyroid adenoma and a concurrent thyroid adenoma. The patient was rendered euthyroid and subsequently taken to theatre for a thyroid lobectomy and removal of the associated parathyroid adenoma. One year later the patient remains normocalcemic, euthyroid and clinically well. CONCLUSION: Toxic thyroid adenoma with concurrent parathyroid adenoma and primary hyperparathyroidism is rare. The possibility of primary hyperparathyroidism should be considered where hypercalcemia persists on correcting the hyperthyroidism. Removal of both adenomas will result in cure of the patient. <![CDATA[<b>Tattooing gone wrong</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100011&lng=es&nrm=iso&tlng=es BACKGROUND: Hypercalcemia in association with hyperthyroidism is a well-recognized phenomenon. Primary hyperparathyroidism due to parathyroid adenoma in association with thyroid adenoma is extremely rare. These cases can present a diagnostic and therapeutic challenge to the treating physician as the patient may present with symptoms of either disease. CASE SUMMARY: A 47-year-old female patient presented with non-specific complaints including fatigue and muscle cramps. Diagnostic workup revealed significantly elevated plasma calcium levels in association with hyperthyroidism. There was a considerable delay in measuring the parathyroid hormone levels which were significantly elevated. Nuclear medicine studies revealed features consistent with a parathyroid adenoma and a concurrent thyroid adenoma. The patient was rendered euthyroid and subsequently taken to theatre for a thyroid lobectomy and removal of the associated parathyroid adenoma. One year later the patient remains normocalcemic, euthyroid and clinically well. CONCLUSION: Toxic thyroid adenoma with concurrent parathyroid adenoma and primary hyperparathyroidism is rare. The possibility of primary hyperparathyroidism should be considered where hypercalcemia persists on correcting the hyperthyroidism. Removal of both adenomas will result in cure of the patient. <![CDATA[<b>Consequences of EMS delays</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100012&lng=es&nrm=iso&tlng=es BACKGROUND: Hypercalcemia in association with hyperthyroidism is a well-recognized phenomenon. Primary hyperparathyroidism due to parathyroid adenoma in association with thyroid adenoma is extremely rare. These cases can present a diagnostic and therapeutic challenge to the treating physician as the patient may present with symptoms of either disease. CASE SUMMARY: A 47-year-old female patient presented with non-specific complaints including fatigue and muscle cramps. Diagnostic workup revealed significantly elevated plasma calcium levels in association with hyperthyroidism. There was a considerable delay in measuring the parathyroid hormone levels which were significantly elevated. Nuclear medicine studies revealed features consistent with a parathyroid adenoma and a concurrent thyroid adenoma. The patient was rendered euthyroid and subsequently taken to theatre for a thyroid lobectomy and removal of the associated parathyroid adenoma. One year later the patient remains normocalcemic, euthyroid and clinically well. CONCLUSION: Toxic thyroid adenoma with concurrent parathyroid adenoma and primary hyperparathyroidism is rare. The possibility of primary hyperparathyroidism should be considered where hypercalcemia persists on correcting the hyperthyroidism. Removal of both adenomas will result in cure of the patient. <![CDATA[<b>Authors' response</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000100013&lng=es&nrm=iso&tlng=es BACKGROUND: Hypercalcemia in association with hyperthyroidism is a well-recognized phenomenon. Primary hyperparathyroidism due to parathyroid adenoma in association with thyroid adenoma is extremely rare. These cases can present a diagnostic and therapeutic challenge to the treating physician as the patient may present with symptoms of either disease. CASE SUMMARY: A 47-year-old female patient presented with non-specific complaints including fatigue and muscle cramps. Diagnostic workup revealed significantly elevated plasma calcium levels in association with hyperthyroidism. There was a considerable delay in measuring the parathyroid hormone levels which were significantly elevated. Nuclear medicine studies revealed features consistent with a parathyroid adenoma and a concurrent thyroid adenoma. The patient was rendered euthyroid and subsequently taken to theatre for a thyroid lobectomy and removal of the associated parathyroid adenoma. One year later the patient remains normocalcemic, euthyroid and clinically well. CONCLUSION: Toxic thyroid adenoma with concurrent parathyroid adenoma and primary hyperparathyroidism is rare. The possibility of primary hyperparathyroidism should be considered where hypercalcemia persists on correcting the hyperthyroidism. Removal of both adenomas will result in cure of the patient.