Scielo RSS <![CDATA[South African Journal of Surgery]]> vol. 51 num. 4 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>The rise and fall of CA 19-9</b>]]> <![CDATA[<b>Endoscopic management of bile leaks after laparoscopic cholecystectomy</b>]]> BACKGROUND: A bile leak is an infrequent but potentially serious complication after biliary tract surgery. Endoscopic intervention is widely accepted as the treatment of choice. This study assessed the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy and biliary stenting in the management of postoperative bile leaks. METHODS: An ERCP database in a tertiary referral centre was reviewed retrospectively to identify all patients with bile leaks after laparoscopic cholecystectomy. Patient records and endoscopy reports were reviewed. RESULTS: One hundred and thirteen patients (92 women, 21 men; median age 47 years, range 22 - 82 years) with a bile leak were referred for initial endoscopic management at a median of 12 days (range 2 - 104 days) after surgery. Presenting features included intra-abdominal collections with pain in 58 cases (51.3%), abnormal liver function tests (LFTs) in 22 (19.5%), bile leak in 25 (22.1%), and sepsis in 8 (7.1%). Twenty-nine patients (25.7%) were found to have either major bile duct injuries without duct continuity, vascular injuries or other endoscopic findings requiring surgical or radiological intervention. Of 84 patients managed endoscopically, 44 had a cystic duct (CD) leak, 26 a CD leak and common bile duct (CBD) stones, and 14 a CBD injury amenable to endoscopic stenting. Of the 70 patients with CD leaks (group A), 24 underwent sphincterotomy only (including 8 stone extractions), 43 had a sphincterotomy with stent placement (including 18 stone extractions) and 1 had only a stent placed, while 2 patients with previous sphincterotomies required no further intervention. The average number of ERCPs in group A was 2.3 (range 1 - 7). Of the 14 patients with bile duct injuries treated endoscopically (group B), 7 had a class D, 5 an E5 and 2 a class B injury; 13 patients underwent sphincterotomy and stenting, and 1 had a sphincterotomy only. Group B required an average of 3.6 ERCPs (range 2 - 5). The 113 patients underwent a total of 269 ERCPs (mean 2.4, range 1 - 7). Seven patients had one or more complications related to the ERCP: 3 acute pancreatitis, 2 cholangitis, 2 sphincterotomy bleeds, 1 duodenal perforation and 1 impacted Dormia basket, the latter 2 requiring operative intervention. CONCLUSIONS: Three-quarters of bile leaks after laparoscopic cholecystectomy were due to CD leaks (with or without retained stones) or lesser bile duct injuries and were amenable to definitive endoscopic therapy. Nineteen patients (16.8%) had major injuries that required operative intervention. <![CDATA[<b>Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital</b>]]> BACKGROUND: Several authors have suggested that the traditional surgical morbidity and mortality meeting be developed as a tool to identify surgical errors and turn them into learning opportunities for staff. We report our experience with these meetings. METHODS: A structured template was developed for each morbidity and mortality meeting. We used a grid to analyse mortality and classify the death as: (i) death expected/death unexpected; and (ii) death unpreventable/death preventable. Individual cases were then analysed using a combination of error taxonomies. RESULTS: During the period June - December 2011, a total of 400 acute admissions (195 trauma and 205 non-trauma) were managed at Edendale Hospital, Pietermaritzburg, South Africa. During this period, 20 morbidity and mortality meetings were held, at which 30 patients were discussed. There were 10 deaths, of which 5 were unexpected and potentially avoidable. A total of 43 errors were recognised, all in the domain of the acute admissions ward. There were 33 assessment failures, 5 logistical failures, 5 resuscitation failures, 16 errors of execution and 27 errors of planning. Seven patients experienced a number of errors, of whom 5 died. CONCLUSION: Error theory successfully dissected out the contribution of error to adverse events in our institution. Translating this insight into effective strategies to reduce the incidence of error remains a challenge. Using the examples of error identified at the meetings as educational cases may help with initiatives that directly target human error in trauma care. <![CDATA[<b>Operable severe obstructive jaundice</b>: <b>How should we use pre-operative biliary drainage?</b>]]> Obstructive jaundice is a common surgical problem, and surgery in jaundiced patients is associated with a higher risk of postoperative complications than surgery in non-jaundiced patients. However, the efficacy of pre-operative biliary drainage (PBD) for patients with obstructive jaundice remains controversial. Many studies have been unable to confirm the benefit of PBD and have suggested that it should not be performed routinely. While we agree that routine PBD is not recommended for all jaundiced patients, we believe that it is useful for certain subgroups; however, there are no clear guidelines regarding its application in these subgroups. We suggest that further large and detailed randomised control studies should focus on formulating codes and standards of PBD for patients with operable conditions causing severe obstructive jaundice. <![CDATA[<b>Patterns of injury seen in road crash victims in a South African trauma centre</b>]]> BACKGROUND: Road traffic crashes (RTCs) account for a significant burden of disease in South Africa. This prospective study reviews basic demographic and outcome data of patients who sustained an RTC-related injury and analyses the common patterns of injury associated with specific mechanisms of injury. METHOD: We reviewed all patients seen at a single regional hospital (Edendale Hospital, Pietermaritzburg) with injuries sustained in RTCs over a 10-week period. State mortuary data were gathered on all RTC-related fatalities over the same period. RESULTS: Three hundred and five RTC patients were seen at the hospital over the 10-week period. The average transfer time to hospital was 9.2 hours (range 1 - 17 hours). One hundred patients were admitted and the rest were discharged home from the emergency department. Of the admitted cohort, 59 were motor vehicle occupants (MVC group) and 41 were pedestrians (PVC group). PVC patients commonly had lower limb, head, radio-ulnar and clavicular injuries, while MVC patients commonly had neck and intraabdominal injuries. Thirty-seven patients had multiple injuries. The in-hospital mortality rate was 5.6%, but the overall mortality rate was 10.0%, as 15 patients died at the scene. CONCLUSIONS: Patterns of injury differ according to the mechanism of injury. Pedestrians impact against various parts of the vehicle and the ground and so sustain injuries to their arms and legs. Occupants of vehicles impact against the dashboard and steering wheel and are more likely to sustain torso injuries. The low number of severe injuries and multiple injuries and the relatively low inpatient mortality rate are a consequence of the triage effect of long delays in transfer. More severely injured patients are more likely to die at the scene. <![CDATA[<b>Intra-orbital knife blade foreign body</b>: <b>A case series</b>]]> OBJECTIVE: To describe cases of intra-orbital knife blade foreign body following stabs to the orbit, together with a novel technique for removal. METHODS: Retrospective case series of 3 patients. RESULTS: All 3 patients had knife blades embedded in the orbit as a result of assault. The blades assumed the same direction within the orbit with varying degrees of depth, one causing serious vascular injury. In 2 cases the globes were intact after foreign body removal, with good visual outcomes. The third patient required enucleation. Two of the 3 knife blades were removed using a 'double bone nibbler' technique. The third was embedded without a handle and required removal with minor manipulation of the globe. CONCLUSIONS: Thorough investigation for vascular injury must be done before any attempted surgical removal. Visual outcomes can be good after removal of a knife blade foreign body. The double bone nibbler technique is promising for the controlled removal of embedded blades that are rigidly fixed. <![CDATA[<b>Maxillofacial injury</b>: <b>A retrospective analysis of time lapse between injury and treatment in a South African academic maxillofacial and oral surgery unit</b>]]> BACKGROUND: The study was undertaken in an academic maxillofacial and oral surgical unit in a large quaternary hospital attached to the Medical School of the University of the Witwatersrand, Johannesburg, between 2002 and 2006. OBJECTIVE: To investigate the number of days in seven patient management intervals from facial fracture occurrence to discharge from hospital, to gain insight into reasons for treatment delays. RESULTS: Facial fractures were treated a mean of 20.4 days from occurrence. There was a mean of 10.3 days from fracture to hospital presentation, and an identical period from hospital presentation to treatment. Statistical analysis showed that delay times decreased from 2002 to 2006. CONCLUSION: More rapid referral to the maxillofacial and oral surgical unit is the most practical way to reduce delays further. <![CDATA[<b>Tubercular biliary stricture - a malignant masquerade</b>]]> Hilar cholangiocarcinoma is the most common cause of a stricture in the hilar region, and hilar stricture in the absence of any previous surgical intervention should be considered to indicate malignant disease until proven otherwise. We present a rare case of isolated hilar tubercular stricture, all the features of which were suggestive of malignancy. <![CDATA[<b>Use of a circular stapler for Billroth I anastomosis after distal gastrectomy</b>]]> Staplers are widely used in gastrointestinal surgery. We used a circular stapler to establish gastroduodenal anastomosis after distal gastrectomy in a recent case. After separating the stomach from the duodenum, we anastomosed the posterior wall of the stomach to the duodenum by introducing the circular stapler through the part of the stomach that was to be resected. Then we separated the distal part of the stomach with a linear stapler, and so completed the distal gastric resection. The advantages of this technique are that it is simple and safe. <![CDATA[<b>Gastric heterotopia causing jejunal ulceration and obstruction</b>]]> A young woman with persistent postprandial vomiting was found to have a high-grade proximal jejunal stricture. The stricture was surgically excised, and histopathological examination showed gastric heterotopia with localised ulceration and fibrosis. Symptomatic gastric heterotopia in the small bowel is rare, and to our knowledge this is the first report of jejunal gastric heterotopia resulting in ulceration with subsequent stricturing and obstruction. <![CDATA[<b>The ectopic posterior pituitary gland</b>]]> An ectopic posterior pituitary gland is a rare condition and may present with an empty pituitary fossa, hypoplasia or absence of the infundibular stalk and resultant short stature due to growth hormone deficiency. The location of the ectopic lobe can vary, but it is most commonly situated along the median eminence in the floor of the third ventricle. We report a case of an ectopic posterior pituitary gland, describe the causes and discuss the diagnostic imaging features. <![CDATA[<b><i>Salmonella</i></b><b> thyroiditis</b>: <b>A case report and review of the literature</b>]]> Thyroid abscesses are rare, and Staphylococcus aureus is the main causative organism. Abscesses caused by other organisms are even rarer. This report describes a case of Salmonella thyroiditis in an HIV-positive patient. Fine-needle aspiration cytology was performed and Salmonella sp. were cultured. The patient was successfully treated with antibiotics and incision and drainage. <![CDATA[<b>Astronomically high CA 19-9 in a patient with a benign lesion</b>]]> Thyroid abscesses are rare, and Staphylococcus aureus is the main causative organism. Abscesses caused by other organisms are even rarer. This report describes a case of Salmonella thyroiditis in an HIV-positive patient. Fine-needle aspiration cytology was performed and Salmonella sp. were cultured. The patient was successfully treated with antibiotics and incision and drainage. <![CDATA[<b><i>Pseudomonas aeruginosa</i></b><b> burn wound infection in a dedicated paediatric burns unit</b>]]> Thyroid abscesses are rare, and Staphylococcus aureus is the main causative organism. Abscesses caused by other organisms are even rarer. This report describes a case of Salmonella thyroiditis in an HIV-positive patient. Fine-needle aspiration cytology was performed and Salmonella sp. were cultured. The patient was successfully treated with antibiotics and incision and drainage.