South African Journal of Surgery

Is oesophageal stenting for cancer the answer? A report from a secondary hospital in the developing world

INTRODUCTION: Oesophageal cancer causes much morbidity and mortality in South Africa. Social and economic constraints further impact on the management of these patients. Many prospective randomised trials of palliative treatment have been done in the developed world, not taking into account these socio-economic constraints. We present a study from Tshepong Hospital, a secondary hospital in South Africa, comparing stenting with radiation therapy in the palliative treatment of oesophageal cancer. PATIENTS AND METHODS: We retrospectively reviewed the data on 30 patients seen between February 2005 and January 2008. All presented with inoperable oesophageal cancer and were palliated with either stenting (N=18) or radiotherapy (N=12). We compared number of admissions, length of hospital stay and time from when first seen to intervention as primary outcomes. RESULTS: The number of admissions, length of hospital stay and days to procedure were significantly lower in the stent group. No major complications resulting from brachytherapy were reported. Complications in the stent group included chest pain, tumour overgrowth, stent migration and death. DISCUSSION: Studies have shown the superiority of brachytherapy over stenting with regard to long-term palliation and number of complications. In our setting, however, socioeconomic constraints result in a delay in treatment. Given the short survival expected in these patients, stenting may be a reasonable option to consider given the decreased time to final intervention and hospital stay in patients with a poor prognosis. Adopting a prognostic score can help in identifying these patients.

The evaluation of bedside teaching - an instrument for staff evaluation and student experience: A pilot study at a South African university

BACKGROUND: Bedside teaching is the core teaching strategy in the clinical study years of the medical undergraduate degree at the University of the Witwatersrand. The quality of this teaching strategy has not been formally evaluated by students as other teaching strategies have been. METHOD: A quantitative, descriptive study was undertaken in the final year of study of the graduate entry medical programme (GEMP). The sample comprised medical students who were completing their surgical block during September and November 2008. There were approximately 30 students in each of these 2 blocks. A bedside teaching evaluation questionnaire was developed, based on previously validated peer review questionnaires used in evaluating small group formal classroom-based lectures. The purpose of the study was to determine the reliability of the instrument for evaluating bedside teaching. RESULTS: A sample of 112 evaluations was obtained and the constructs and sub-constructs were subjected to an analysis using Cronbach's alpha. CONCLUSION: The overall Cronbach's alpha was 0.9627, demonstrating that the instrument is reliable and can be used to evaluate bedside teaching.

A review of burn care at an emerging centralised burns unit

BACKGROUND: The aim of the study was to investigate the demographics, aetiological factors, anatomical lesions, biological features, management protocol and outcomes of patients admitted with major burn injuries to the Nelson Mandela Academic Hospital (NMAH), which is one of only three tertiary hospitals in the Eastern Cape and is in the process of establishing a designated burns unit. METHODS All burns patients admitted to the burns ward from January 2006 to July 2008 were included in the study. All were treated using multidisciplinary team care, a high index of suspicion for inhalation injuries, followed by prompt treatment, accurate burn extent and depth assessment, fluid therapy, patient-controlled analgesia, strict aseptic wound care, and early enteral feeding. Data collected included gender, age, residential address, cause and extent and depth of burns, serum albumin, whether any skin graft was done, hospital stay, complications and mortality. RESULTS: The sample comprised 66 patients; 59 were children <14 years old, and 38 were <4 years. There were 34 males and 32 females; scalds and flame injuries accounted for 68% and 17% of cases respectively. The majority (85%) sustained burns ranging from 11% to 40% total body surface area (TBSA). The body areas injured were the left upper limb (60%), chest (58%), abdomen (49%) and right upper limb (48%). All sustained major burns, and skin grafts were performed on 39%. Complications included respiratory distress syndrome, fluid and electrolyte imbalances, protein energy malnutrition, infection and contracture deformities. The mean hospital stay was 3.7 days/% TBSA burn, and the overall mortality rate was 17%. CONCLUSION: Mortality was unacceptably high. The strain of aggressive management to reduce mortality and morbidity would be alleviated by measures such as community health education, raised socio-economic status, and safety legislation. Establishing a well-staffed and well-equipped burns unit would greatly improve patient care.

Emergency abdominal surgery in Zaria, Nigeria

BACKGROUND: The causes of abdominal surgical emergencies in a particular setting may change because of alterations in demographic, socio-economic or geographical factors. We present the pattern, management and outcome of such emergencies in Zaria, Northern Nigeria. METHODS: This is a retrospective review of prospectively collected data conducted in a tertiary health centre between 2001 and 2005. Patients aged 14 years and over with abdominal surgical emergencies were consecutively entered into the study at the time of admission. The frequencies of different diagnoses, management and outcome were recorded. The indications for and outcome of operative treatment were compared with a similar study performed about two decades ago in our institution. RESULTS: There were 3 717 patients, accounting for 29.5% of all emergency surgical admissions. The mean age was 32.5 years. The most common diagnoses were appendicitis (996, 26.8%), nonspecific abdominal pain (871, 23.4%), intestinal obstruction (498, 13.4%) and abdominal trauma (245, 6.6%). In all, 1 788 patients (48.1%) had operations during their emergency admission compared with 37.0% in our previous study. Appendicectomy (903, 50.5%) was the most common operation. Operations for abdominal trauma and typhoid ileal perforation have increased, while operations for strangulated external hernia and perforated duodenal ulcer have decreased. Of the 169 (4.5%) patients who died, 107 (6.0%) died after an operation. Delayed presentation increased mortality. CONCLUSIONS: Operations for appendicitis, infectious diseases and trauma have increased while those for strangulated external hernia have decreased. The expense of surgery contributes to late presentation and delayed intervention, which impact negatively on treatment outcome.

The undergraduate paediatric surgery curriculum in Nigeria - how have we fared?

BACKGROUND: In the Nigerian setting the curriculum of each medical school is the sole responsibility of the senate of the respective university. This arrangement results in variability in learning objectives and in students' acquisition of skills to manage clinical problems. Educational objectives can be used to both standardise and evaluate curricula. This study aimed to: (i) identify main objectives of paediatric surgery at the undergraduate level; (ii) establish students' knowledge with regard to these objectives; (iii) evaluate the input of both specialists and non-specialists to these objectives; and (iv) examine the status of undergraduate paediatric surgery instruction in our medical schools. MATERIALS AND METHODS: This was a cross-sectional survey of students, teachers and undergraduate deans with regard to undergraduate paediatric surgery teaching. The cognitive and perceived level of knowledge about common paediatric surgical conditions of 4th- and 6th-year medical students in four randomly selected Nigerian universities was surveyed using educational objectives. The same objectives were used to survey 26 paediatric surgeons, 46 senior house officers and 46 general surgeons. Undergraduate paediatric surgery curricula, obtained from the offices of the deans of the four medical schools, were also reviewed. Data were analysed using descriptive methods and one-way analysis of variance (ANOVA). RESULTS: The 6th-year students' and house officers' perceived knowledge of the objectives was remarkably similar. Overall, students' familiarity scores increased from the 4th to the 6th year (p<0.05), but fell short of the expected proficiency levels in the 6th year. The general surgeons and paediatric surgeons expressed similar expectations. Thirty items on the objectives were considered to be essential (mean score >2.0) and 8 items to be non-essential (mean score <1.5) by paediatric surgeons, whereas the general surgeons regarded 27 items to be essential (mean score >2.0) and 11 to be non-essential (mean score <1.5). Data from the deans' offices varied, but indicated limited exposure to paediatric surgery in the undergraduate curriculum in 2 (50%) of the 4 institutions. CONCLUSION: The study clarified the relationship between the expected and perceived students' knowledge of these objectives, and identified areas requiring specific attention. These results, and perhaps similar ones in future, can be used towards establishing a unified, standardised undergraduate paediatric surgery curriculum.

Saw-toothed fish bone ingestion: A method for propulsion

We describe the case of an 11-year-old girl who presented with a lump in her neck. On exploration a 4 cm saw-toothed fish bone was extracted from the soft tissue of the anterior triangle of the neck. Ingested fish bones are a common presentation in accident and emergency departments, but there are only a small number of reports of migration through the pharynx into soft tissues. Rare complications can include oesophageal perforation, haematoma formation, retropharyngeal abscesses and recurrent infections. To the best of our knowledge this is the first reported case of migration of an ingested fish bone in Malawi.

Stump appendicitis - a cautionary tale of appendicitis after appendicectomy

The negative appendicectomy rate in Zaria, Nigeria