Scielo RSS <![CDATA[South African Journal of Surgery]]> http://www.scielo.org.za/rss.php?pid=0038-236120170003&lang=pt vol. 55 num. 3 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Perspective</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>ASSA News</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300002&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Editorial</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300003&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Does gender impact on female doctors' experiences in the training and practice of surgery? A single centre study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300004&lng=pt&nrm=iso&tlng=pt BACKGROUND: Surgery has been identified as a male-dominated specialty in South Africa and abroad. This study explored how female registrars perceived the impact of gender on their training and practice of surgery. METHOD: A self-administered questionnaire was used to explore whether females perceived any benefits to training in a male-dominated specialty, their choice of mentors and the challenges that they encountered during surgical training. RESULTS: Thirty-two female registrars participated in the study. The respondents were mainly South African (91%) and enrolled in seven surgical specialties. Twenty-seven (84%) respondents were satisfied with their training and skills development. Twenty-four (75%) respondents had a mentor from the department. Seventeen (53%) respondents perceived having received differential treatment due to their gender and 25 (78.2%) thought that the gender of their mentor did not impact on the quality of the guidance received in surgery. Challenges included physical threats to female respondents from patients and disrespect, emotional threats and defaming statements from male registrars. Additional challenges included time-constraints for family and academic work, poor work-life balance and being treated differently due to their gender. Seventeen (53%) respondents would consider teaching in the Department of Surgery. CONCLUSION: Generally, females had positive perceptions of their training in Surgery. They expressed concern about finding and maintaining a work-life balance. The gender of their mentor did not impact on the quality of the training but 'bullying' from male peers and selected supervisors occurred. Respondents will continue to recommend the specialty as a satisfying career to young female students. <![CDATA[<b>What is the diagnostic yield of colonoscopy in patients with a referral diagnosis of constipation in South Africa?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300005&lng=pt&nrm=iso&tlng=pt BACKGROUND: Constipation is a common problem for referral to surgical and colorectal units. Its association with colorectal cancer is controversial. Some authors have found an increased incidence while others have not. The aim of this study is to investigate the incidence of colorectal cancer (CRC) and other significant colonoscopic pathologies in patients undergoing colonoscopy for constipation. METHODS: All colonoscopy reports for constipation were retrieved from our database from January 2011 to 30 June 2014. Data extracted included demographics, colonoscopic findings and adequacy of bowel preparation. Exclusion criteria included patients with other symptoms known to be associated with colonic neoplasia such as lower GIT bleeding, loss of weight, patients with associated anaemia, those with abnormalities on imaging, patients with personal or family history of colorectal cancers or colorectal polyps and patients with inflammatory bowel disease. The primary outcome was the presence of neoplasia at colonoscopy and the secondary outcomes were other colonoscopy findings. RESULTS: A total of 985 colonoscopies were performed from January 2011 to June 2014 of which 144 were done for a referral diagnosis of constipation. Eighty eight (61.1%) were female. Their mean age was 58.6 + 13.8 years (range 19-95 years). There were 61 (42.4%) African patients, 38 (26.4%) White, 33 (22.9%) Asians and 12 (8.3%) Coloured patients. Eighty seven (60.4%) patients had a normal colonoscopy, 20 (13.9%) diverticular disease, 14 (9.7%) polyps of which 6 (4.2%) were neoplastic, and 9 (6.3%) had colorectal cancer. CONCLUSIONS: Constipation is associated with CRC. The presence of constipation should be a criterion for colonoscopy regardless of age or any other associated clinical features. <![CDATA[<b>Predictors of emergency colectomy in patients admitted with acute severe ulcerative colitis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300006&lng=pt&nrm=iso&tlng=pt BACKGROUND: Acute Severe Ulcerative Colitis (ASUC) is a life-threatening condition which requires urgent and aggressive medical therapy to reduce mortality, morbidity and avoid surgery. To facilitate this process, it is essential to identify patients at high risk of poor outcomes and emergency colectomy. Numerous such risk factors have been described in Western literature, however there is no local data addressing this issue. As such it is unclear if these predictors are applicable in our setting. The aim of this study is thus to identify risk factors for emergency colectomy in patients admitted to Groote Schuur Hospital with ASUC. METHODS: A retrospective cohort study of 98 patients admitted with ASUC between January 2003 and January 2013 was performed. Clinical, demographic, laboratory and endoscopic factors on admission and 3 days thereafter were analysed as predictors of colectomy by univariate and multivariate analysis. RESULTS: Twenty-five percent of the cohort underwent emergency colectomy. On univariate analysis, factors predicting colectomy on admission were exposure to oral corticosteroids (p=0.01), megacolon (p=0.049) or mucosal islands (p=0.04) on abdominal X-ray, and a short duration from UC diagnosis until presentation with ASUC (p=0.04). The only variable that was significantly associated with colectomy on day 3 was serum albumin (p=0.01). This was also the only variable to remain significant on multivariate analysis (OR 0.79, 95% CI 0.65-0.97, p=0.01. CONCLUSION: ASUC is a medical emergency and predicting colectomy risk aids in therapeutic management. The only variable significantly associated with the need for surgery in our study was hypoalbuminaemia on day 3. Given the small study numbers a larger prospective study would be of value. <![CDATA[<b>Resection of benign liver tumours: an analysis of 62 consecutive cases treated in an academic referral centre</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300007&lng=pt&nrm=iso&tlng=pt BACKGROUND: Benign tumours of the liver are increasingly diagnosed and constitute a substantial proportion of all hepatic tumours evaluated and resected at tertiary referral centres. This study assessed the safety and outcome after resection of benign liver tumours at a major referral centre. METHODS: All patients with symptomatic benign liver tumours who underwent resection were identified from a prospective departmental database of a total of 474 liver resections (LRs). Demographic data, operative management and morbidity and mortality using the Accordion classification were analysed. RESULTS: Sixty-two patients (56 women, 6 men, median age 45 years, range 17-82) underwent resection of symptomatic haemangiomata n=23 (37.1%), focal nodular hyperplasia n=19 (30.6%), biliary cystadenoma n=16 (25.8%) and hepatic adenomas n=4 (6.5%). A major resection was required in 25 patients, 14 patients had 4 segments resected, 11 had 3 segments and 37 patients had 2 or fewer segments resected. Median operating time was 169 minutes (range 80-410). Median blood loss was 300 ml (range 50-4500 ml) and an intra-operative blood transfusion was required in 6 patients. Median length of post-operative hospital stay was 7 days (range 4-32). Complications occurred in 11 patients (Accordion grades 1 n=1, 2 n=4, 3 n=1, 4 n=4, 6 n=1). Four patients required re-operation (bleeding n=2, bile leak n=1, small bowel obstruction n=1). An elderly patient died in hospital on day 16 following a postoperative cerebrovascular accident. CONCLUSIONS: Clinically relevant symptomatic benign liver tumours comprise a substantial proportion of LRs. Our data suggest that resections can be performed safely with minimal blood loss and transfusion requirements. We advocate selective resection according to established indications. Despite the low postoperative mortality rate, the risk of postoperative complications emphasizes the need for careful selection of patients for resection. <![CDATA[<b>Defining predictors of mortality in pediatric trauma patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300008&lng=pt&nrm=iso&tlng=pt BACKGROUND: The aim of this study was to describe our cohort of pediatric trauma patients and to analyze their physiological data. The intention was to highlight the difficulty in using systolic blood pressure (SBP) readings in this population and to investigate the role of base excess (BE) in predicting clinical outcomes in pediatric trauma patients. METHODOLOGY: The Pietermaritzburg Metropolitan Trauma Service (PMTS) maintains a prospective digital trauma registry, and all pediatric trauma patients admitted to the service for the period January 2012 - July 2016 were included. RESULTS: Out of an original dataset of 1239 pediatric trauma patients admitted to the emergency departments of the PMTS, 26 elective patients and 216 patients with missing SBP were excluded to leave a sample size of 997 patients. The majority of the sample was male accounting for 669 patients (67.2 %) with 327 females (32.8%) and 1 (0.1%) missing data. The mean age (SD) was 7.7 years (3.9) and the median age (IQR) was 8 years (5 - 11). There were 58 children < 2 years of age, 177 between the age of 2 to < 5 years of age, 402 between 5 to < 10 years of age and 360 between 10 and < 15 years of age. The predominant mechanism of injury was blunt trauma (78.4% or 782/997). Penetrating trauma accounted for 11.0% of cases (110/997). The mean systolic BP (SD) across the whole cohort was 110.1 mm Hg (16.9) and the median systolic BP (IQR) was 110 mm Hg (100-119). Mortality rate remains low and then precipitously increases below a SBP of 93 mm Hg in children older than 2 and below 89 mm Hg in children younger than 2. This suggests that a SBP of 93 mm Hg or less in children older than 2 and 89 mm Hg or less in children under 2 years is clinically significant. Similarly, as BE decreased, the mortality risk also increased prominently. CONCLUSION: This study has used a previously described methodology based on large developed world trauma databases and confirms the current thinking that SBP is a late marker and thus not useful in the pediatric population and a better system/ approach is needed. The use of BE in conjunction with SBP may be a more useful means of identifying shock. <![CDATA[<b>Oesophageal squamous cell cancer in a South African tertiary hospital: a risk factor and presentation analysis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300009&lng=pt&nrm=iso&tlng=pt BACKGROUND: Squamous carcinoma of the oesophagus (SCO) is the most common form of oesophageal cancer in South Africa (SA). Risk factors include male gender, smoking, alcohol consumption and low socio-economic status (SES). This study assessed the risk factors for SCO in KwaZulu-Natal. METHODOLOGY: Information on patients managed at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South Africa, between 1 October 2013 and 31 December 2014 was retrieved from a prospective database of Oesophageal Cancer (OC). Data collected included demographics, risk factors, symptoms and clinical findings. RESULTS: One hundred and fifty-nine patients (159) with SCO were identified. The site of tumour location was in the middle 96 (60.4%), distal 42(26.4%) and proximal 17(10.6%) oesophagus. The male to female ratio was 1:1 with an age range of 22-93 years (mean 60.6; SD±12.1). Females were significantly older than males (p = 0.018). Eighty-eight per cent were Black African. Dysphagia was reported in 158 (99.4%) of patients and loss of weight in 149(95.5%). Thirty-six patients were HIV positive (age 52.8; SD±9.7) and significantly younger than those without HIV infection (age 61.2; SD±11.5). Most patients had low SES and poor dental health. Male patients were significantly more likely to use tobacco (p < 0.001; Odds Ratio (OR) 7.8) and consume alcohol (p < 0.001; OR 7.7) than females who were 2.5 times more likely to report a family history of cancer (p = 0.017; OR 2.6). CONCLUSION: An equal gender distribution was observed. Male patients with SCO reported the expected risk factors; however these were not observed amongst women. SES may contribute to the development of SCO. Poor dental health may be a surrogate marker for low SES and a possible risk factor for SCO. HIV positive individuals present a decade younger when compared with HIV negative patients. <![CDATA[<b>Pattern and distribution of peripheral arterial disease in diabetic patients with critical limb ischemia (rutherford clinical category 4-6)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300010&lng=pt&nrm=iso&tlng=pt BACKGROUND: This study investigated the pattern and distribution of peripheral arterial disease in diabetic patients with critical limb ischaemia (CLI) and to stratify the findings according to the patients' risk factor profile, gender and age group. METHODS: We conducted a one-year prospective descriptive study (January 2014 to December 2014) at Groote Schuur Hospital, University of Cape Town. The research protocol and the informed consent were approved by the Institutional Review Board, and all subjects included in this study gave an informed consent. We included all diabetic patients over the age of 18 years with critical limb ischemia who had pre and post-intervention vascular imaging. The calculated minimum sample size was 63 limbs. We hypothesize that the proportions of arterial segment patency categories and the arterial foot arch status varies according to gender, age group and risk factor combinations in diabetic patients. The Null hypothesis (N0) assumes that the proportions of arterial segment patency categories and arch status are the same in diabetic patients irrespective of gender, age group and risk factor combination. The equality of distribution was analysed using the One Sample Chi-square test. Three risk factor combination groups were analysed: Group 1 (diabetes mellitus, hypertension, dyslipidemia), Group 2 (diabetes mellitus, hypertension, dyslipidemia, ex-smoker) and Group 3 (diabetes mellitus, hypertension, dyslipidemia, smoker. RESULTS: Seventy-one patients were analysed (38 females and 33 males). We recorded the patency grades (ranging from normal to occlusion) of arteries in all 3 lower extremity arterial segments (aortoiliac; femoropopliteal and tibioperoneal segments). Altogether the patency grades of 820 lower extremity arteries were recorded. Diabetics, collectively, were found to have more severe occlusive disease in the tibioperoneal segment (P < .001). Group 3 patients however, had more severe occlusive disease in the femoropopliteal segment compared to the other subgroups (P < .001). Group 1 and Group 2 patients had more severe occlusive disease in the tibioperoneal segment (P < .001). Females were more likely to have complete foot arches (22/37; P = .004) while males tended to have more incomplete foot arches (17/32; P = .048). CONCLUSION: Diabetic patients collectively have severe tibioperoneal occlusive disease. However, Group 3 patients tend to have disproportionately more occlusive disease in the femoropopliteal segment (P < .001). Diabetic female patients with CLI are more likely to have a complete arterial foot arch than males (P = .004). <![CDATA[<b>A survey of selected key areas of management of South African neurosurgical patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300011&lng=pt&nrm=iso&tlng=pt BACKGROUND: Previous surveys of neurosurgical patient management, including a South African (SA) survey conducted in 2001, confirmed the existence of significant dissimilarities in management on national and international levels. This survey aimed to determine current SA neurosurgical patient management and to compare this with international trends. METHODS: Questionnaires in multiple choice question (MCQ) and free text entry format covering key areas of neurosurgical practice were emailed to SA neurosurgeons following ethics approval. All responses were captured anonymously. RESULTS: The response rate was 53%. Demographically only 5.7% respondents were younger than 40 years, 59.3% obtained a local college fellowship, 14.8% an international fellowship, 40.7% a MMed and 16.6% obtained more than one postgraduate qualification. Public sector specialists predominantly practised intracranial surgery (69%) while private specialists practised mainly spinal surgery (58%). Years in specialist practice were negatively associated with endoscopic surgery (p = 0.014) and decompressive craniectomies (p = 0.008) but not with other more recently introduced techniques including pedicle screws, neuro-navigation and cell-saver techniques. Age per se had no influence on practice. In subarachnoid haemorrhage (SAH) disease, 88% routinely administered nimodipine, 8% restricting its use to managing vasospasm. Endovascular coiling, more recently introduced for intracranial aneurysm management, was preferred to surgical clipping (54%); 69% preferred total intravenous to inhalational anaesthesia with propofol primarily replacing thiopentone for brain protection. 27% still utilised the sitting position. Only one incident of a postoperative visual defect was recorded with prone positioning. CONCLUSION: With the exception of endoscopic and decompressive craniectomy surgery, overall management in key areas surveyed was in line with international trends. <![CDATA[<b>"I see you" - Gender representation and unconscious bias in images of surgeons: the South African Journal of Surgery</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300012&lng=pt&nrm=iso&tlng=pt BACKGROUND: Previous surveys of neurosurgical patient management, including a South African (SA) survey conducted in 2001, confirmed the existence of significant dissimilarities in management on national and international levels. This survey aimed to determine current SA neurosurgical patient management and to compare this with international trends. METHODS: Questionnaires in multiple choice question (MCQ) and free text entry format covering key areas of neurosurgical practice were emailed to SA neurosurgeons following ethics approval. All responses were captured anonymously. RESULTS: The response rate was 53%. Demographically only 5.7% respondents were younger than 40 years, 59.3% obtained a local college fellowship, 14.8% an international fellowship, 40.7% a MMed and 16.6% obtained more than one postgraduate qualification. Public sector specialists predominantly practised intracranial surgery (69%) while private specialists practised mainly spinal surgery (58%). Years in specialist practice were negatively associated with endoscopic surgery (p = 0.014) and decompressive craniectomies (p = 0.008) but not with other more recently introduced techniques including pedicle screws, neuro-navigation and cell-saver techniques. Age per se had no influence on practice. In subarachnoid haemorrhage (SAH) disease, 88% routinely administered nimodipine, 8% restricting its use to managing vasospasm. Endovascular coiling, more recently introduced for intracranial aneurysm management, was preferred to surgical clipping (54%); 69% preferred total intravenous to inhalational anaesthesia with propofol primarily replacing thiopentone for brain protection. 27% still utilised the sitting position. Only one incident of a postoperative visual defect was recorded with prone positioning. CONCLUSION: With the exception of endoscopic and decompressive craniectomy surgery, overall management in key areas surveyed was in line with international trends. <![CDATA[<b>Yvonne Pyne-James 13 April 1934 - 10 April 2017</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300013&lng=pt&nrm=iso&tlng=pt BACKGROUND: Previous surveys of neurosurgical patient management, including a South African (SA) survey conducted in 2001, confirmed the existence of significant dissimilarities in management on national and international levels. This survey aimed to determine current SA neurosurgical patient management and to compare this with international trends. METHODS: Questionnaires in multiple choice question (MCQ) and free text entry format covering key areas of neurosurgical practice were emailed to SA neurosurgeons following ethics approval. All responses were captured anonymously. RESULTS: The response rate was 53%. Demographically only 5.7% respondents were younger than 40 years, 59.3% obtained a local college fellowship, 14.8% an international fellowship, 40.7% a MMed and 16.6% obtained more than one postgraduate qualification. Public sector specialists predominantly practised intracranial surgery (69%) while private specialists practised mainly spinal surgery (58%). Years in specialist practice were negatively associated with endoscopic surgery (p = 0.014) and decompressive craniectomies (p = 0.008) but not with other more recently introduced techniques including pedicle screws, neuro-navigation and cell-saver techniques. Age per se had no influence on practice. In subarachnoid haemorrhage (SAH) disease, 88% routinely administered nimodipine, 8% restricting its use to managing vasospasm. Endovascular coiling, more recently introduced for intracranial aneurysm management, was preferred to surgical clipping (54%); 69% preferred total intravenous to inhalational anaesthesia with propofol primarily replacing thiopentone for brain protection. 27% still utilised the sitting position. Only one incident of a postoperative visual defect was recorded with prone positioning. CONCLUSION: With the exception of endoscopic and decompressive craniectomy surgery, overall management in key areas surveyed was in line with international trends. <![CDATA[<b>ASSA SAGES Congress</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612017000300014&lng=pt&nrm=iso&tlng=pt BACKGROUND: Previous surveys of neurosurgical patient management, including a South African (SA) survey conducted in 2001, confirmed the existence of significant dissimilarities in management on national and international levels. This survey aimed to determine current SA neurosurgical patient management and to compare this with international trends. METHODS: Questionnaires in multiple choice question (MCQ) and free text entry format covering key areas of neurosurgical practice were emailed to SA neurosurgeons following ethics approval. All responses were captured anonymously. RESULTS: The response rate was 53%. Demographically only 5.7% respondents were younger than 40 years, 59.3% obtained a local college fellowship, 14.8% an international fellowship, 40.7% a MMed and 16.6% obtained more than one postgraduate qualification. Public sector specialists predominantly practised intracranial surgery (69%) while private specialists practised mainly spinal surgery (58%). Years in specialist practice were negatively associated with endoscopic surgery (p = 0.014) and decompressive craniectomies (p = 0.008) but not with other more recently introduced techniques including pedicle screws, neuro-navigation and cell-saver techniques. Age per se had no influence on practice. In subarachnoid haemorrhage (SAH) disease, 88% routinely administered nimodipine, 8% restricting its use to managing vasospasm. Endovascular coiling, more recently introduced for intracranial aneurysm management, was preferred to surgical clipping (54%); 69% preferred total intravenous to inhalational anaesthesia with propofol primarily replacing thiopentone for brain protection. 27% still utilised the sitting position. Only one incident of a postoperative visual defect was recorded with prone positioning. CONCLUSION: With the exception of endoscopic and decompressive craniectomy surgery, overall management in key areas surveyed was in line with international trends.