Scielo RSS <![CDATA[South African Journal of Surgery]]> vol. 53 num. 2 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Delays in breast cancer: Do they matter?</b>]]> <![CDATA[<b>Hernia surgery, South Africa 2015</b>]]> <![CDATA[<b>ASSA presidential report</b>]]> <![CDATA[<b>System delays in breast cancer</b>]]> BACKGROUND: Centralised multidisciplinary management of breast cancer occurs in KwaZulu-Natal, South Africa, and requires a diagnostic and staging pathway at the referring hospital. Delays in this pathway are unknown. This study, conducted at a referring hospital, R K Khan (RKK), quantifies and analyses these delays METHODS: A retrospective folder review included all patients with breast cancer diagnosed at RKK from January 2008 to January 2009. Data extraction included demographic data, time to diagnosis and initial staging using a standardised data sheet. Specific care steps were identified, namely delays to initial imaging with mammography, pathology confirmation, staging work-up and eventual referral to a centralised breast clinic RESULTS: A total of 45 patients were included (43 females and 2 males). The average age was 56 years. The mean individual care step delays were 18.3 days to initial imaging, 21.2 days to pathological confirmation, 9.2 days to initial staging and 22.7 days to review at the centralised breast clinic. The delays were sequential, with a mean total delay of 70.1 days or 10 weeks with an interquartile range of48 - 82 days CONCLUSION: This study confirmed significant delays in the care pathway, which are almost double the international recommendations of 6 weeks. Steps to reduce delays at all phases have been instituted with specific care step targets leading to the establishment of a breast cancer registry with an audit capability. We suggest targeting an 8-week period for the work-up and staging of every patient with breast cancer. The establishment of a breast cancer registry and regular audits thereof are essential in maintaining care standards and achieving best practice. <![CDATA[<b>Treatment outcomes of breast carcinoma in a resource-limited environment</b>]]> BACKGROUND: Carcinoma of the breast is the second most common malignancy among South African women, its incidence is rising and the mortality rate is significantly higher than in the developed world. Offering quality treatment in a resource-limited environment with poor patient socioeconomic circumstances is an ongoing challenge. Frail health, lack of support in the event of severe toxicity, and the lack of advanced pharmaceuticals, taxane regimens and biologicals limit treatment options for chemotherapy. METHODS: Records of 250 consecutive female patients newly diagnosed with breast cancer from January to October 2008, were retrieved and analysed. Staging at diagnosis, demographic data, histopathology, treatment given, compliance and outcomes were recorded retrospectively. RESULTS: Average follow-up time was 36.2 months, the mean age was 56 years, 205 patients underwent surgery, and 84.4% of patients were fully compliant with therapy. Stage I and stage IV overall survival was similar to developed world figures. Combined stage II/III survival was 64.7%, which is significantly lower than survival figures in the developed world (84.6%). A large proportion of patients (15.7%) with stage II and III breast cancer in our series did not receive chemotherapy. For stage III patients, not a single pathologically complete response was recorded; in stage II complete response rate was 10%. Adjuvant chemotherapy was administered to 41 out of 51 patients (80.3%) with node-negative tumours larger than 2 cm and only 3 out of 14 patients (21.4%) with 1 - 2 cm node-negative tumours. Adjuvant radiotherapy was administered to 83.8% node-positive stage II and 88% stage III patients. Hormonal therapy was administered to 90.7% of the oestrogen receptor positive tumours and 64% of these patients were still taking treatment at time of last follow-up. CONCLUSION: Combined stage II and III disease-related survival in this series was considerably lower than developed world figures. Adjuvant radiotherapy and hormonal therapy were well applied where indicated. The options of neoadjuvant and adjuvant chemotherapy were underutilised in this series - for a large proportion of these patients (10.7%) the reason remains unknown. Administrative error, patient comorbid conditions and patient refusal also contributed to the underutilisation of chemotherapy. Moreover, tumours showed poor response to chemotherapy regimens administered. The emphasis on the expansion of the services to women with breast cancer should concentrate on the extension of medical oncological services to improve outcomes. Biologicals as well as advanced chemotherapeutic options including taxane regimens should be made available. <![CDATA[<b>Sentinel lymph node biopsy: An audit of intraoperative assessment after introduction of a cytotechnology service</b>]]> OBJECTIVE: To audit results from intraoperative assessment of sentinel lymph node biopsy (SLNB) after the introduction of a cytotechnologist. STUDY DESIGN: Since 2010, a cytotechnologist has been involved in the intraoperative assessment of SLNB in our breast cancer patients. The data from patients over the period 2006 - 2013 were used to compare outcomes before and after the introduction of a cytotechnology service. The database was divided into the periods 2006 - 2008 and 2010 - 2013 (2009 was the training period. RESULTS: A total of 335 intraoperative SLNB assessments were performed: 165 between 2006 and 2008 (group 1) and 170 between 2010 and 2013 (group 2). In the study period (2010 - 2013), 2 (1%) metastatic deposits >2 mm were missed in patients with lobular carcinoma and 1 in a patient with ductal carcinoma. There was one (0.6%) false positive in a patient with a lobular carcinoma in each group. For patients with metastases >2 mm, group 1 had a sensitivity of 87% and a specificity of 99%. Group 2 had a sensitivity of 92% and a specificity of 99%. CONCLUSION: A trained cytotechnologist performing imprint cytology on SLNB to determine metastatic breast cancer can deliver results comparable with those of a group of pathologists. <![CDATA[<b>Quilting after mastectomy significantly reduces seroma formation</b>]]> INTRODUCTION: Seroma formation is one of the most frequently encountered complications following mastectomy. It may cause significant morbidity, including delayed wound healing, infection and frequent clinic attendance for seroma aspiration. OBJECTIVE: To evaluate the effect of surgical quilting after mastectomy in the prevention of postoperative seroma and to investigate which factors influence seroma formation. METHODS: This was a single-centre prospective cohort study over a 1-year period. All patients who had a mastectomy operation during this period were included in this study. Group 1 patients (quilting) had mastectomy flaps sutured to pectoral muscle using interrupted absorbable sutures. Seroma requiring aspiration, number of aspirations and volume aspirated were recorded postoperatively. RESULTS: During the study period, 168 patients were recruited, with 54 patients in group 1 (quilting) and 114 patients in group 2 (non-quilting). The proportion of patients who developed seroma requiring aspiration was 69% (n=79) in the non-quilting group and 29% (n=15) in the quilting group (p<0.001). Additionally, the total volume of seroma drained was 427 mL (standard error (SE)=69) in the non-quilting group and 63 mL (SE=21) in the quilting group (p=0.0008). The total number of seroma aspirations was 152 in the non-quilting group compared with 23 in the quilting group (p=0.0001). Seroma was more common in smokers (p=0.003) and was not decreased by the presence of drains. CONCLUSION: Quilting of the mastectomy flaps significantly reduces seroma formation. Both total volume of seroma aspirated and number of aspirations are significantly reduced using this technique. We would therefore recommend quilting of mastectomy flaps to reduce the incidence of postoperative seromas and morbidity. <![CDATA[<b>Comparison of the incidence of oesophageal cancer in two 6-year periods from selected hospitals in and around Gauteng Province, South Africa</b>]]> INTRODUCTION: Global trends suggest that the incidence of squamous cell carcinoma (SCC) has decreased but that the incidence of adenocarcinoma (AC) has increased. In South Africa, outdated data exist, thereby prompting this investigation. OBJECTIVES: To determine the incidence of oesophageal cancer in two 6-year periods in and around Gauteng Province. Further distinction was made based on gender, race and histological types. METHODS: A retrospective audit was conducted including histologically documented oesophageal cancer cases collected over a 12-year period from 2001 to 2012, which was divided into two 6-year periods. Incidence was calculated based on the 2013 Gauteng estimated population size. Statistical analysis was performed using the χ2 test. RESULTS: On the whole, there was a significant decrease in the incidence of SCC (p=0.0001). Significant decreases were seen in the African male and female groups (p=0.001 and p=0.0006, respectively). No significant difference was seen in the non-African male and female groups. A non-significant decrease was seen in the AC type with regards to gender and race. CONCLUSION: Reasons for the decline shown here are unknown as patient risk factors were not available. Furthermore, major healthcare centres were not included. These are points for future investigation. The incidence of oesophageal cancer has decreased since 2001, owing to the decrease in SCC in African males and females. Although the decreases in the AC type were not significantly different, they do not parallel global trends. <![CDATA[<b>Management of chronic exertional compartment syndrome</b>]]> BACKGROUND: Post-exercise pain is an uncommon symptom in young, healthy adults. Rest and avoidance of exercise are frequently ineffective and poorly accepted by young, active and otherwise healthy individuals. METHODS: A total of 123 patients with extremity muscle pain, swelling and paraesthesia during the last 10 years were evaluated from a prospective database with compartment pressures and selectively evaluated with Doppler ultrasound and angiography. RESULTS: Patients were young (average 28 years) with long duration of symptoms (average 3.5 years), affecting both upper limbs (3), and lower limbs (120), and 80% were bilateral. Eighty-six were male (70%). All of them were taking part either in active sports or exercise programmes, mostly athletics (49%). Common symptoms were isolated muscle pain in the anterolateral compartments in all patients, paraesthesia in 15% and swelling in 10%. Post-exercise mean compartment pressure was 61 mmHg (normal <30 mmHg). Modified open fasciotomies were performed by lateral and medial incisions in lower limbs and by a single incision in upper limbs. Minor complications occurred in 11% of patients. Full relief of symptoms occurred in 90%, 7% had some improvement of symptoms, and treatment failure occurred in 3% of patients. CONCLUSION: Chronic exertional compartment syndrome is underdiagnosed and should be considered as a potential cause for post-exercise pain in young individuals, and should be treated surgically. Measurement of compartment pressure is important in order to confirm the diagnosis. Open fasciotomy is safe and effective and should be considered as the preferred surgical procedure. <![CDATA[<b>Minimally invasive approach for lesions involving the frontal sinus</b>]]> BACKGROUND: Traditional open surgery for frontal sinus pathology and cerebrospinal fluid (CSF) leaks is complex and involves a craniotomy. Minimally invasive options offer an alternate solution. We describe and assess the outcome of a minimally invasive approach for lesions and defects involving the frontal sinus. METHODS: The technique introduces an endoscope via a small frontal sinusotomy accessed via a small medial brow incision. This allows excellent visualisation of the frontal sinus. Fine thin-shafted instruments traditionally used during tympanoplasty or pituitary surgery are passed through the sinusotomy together with an endoscope for dissection and tissue excision. This technique can be combined with conventional endonasal surgery. RESULTS: We describe the use of this technique in three patients: A fracture of the posterior table of the right frontal sinus with CSF leak, a right frontal sinus osteoma and a right frontal sinus mucocoele. Symptom resolution occurred in all patients and no short-term postoperative complications occurred. CONCLUSION: This approach avoids the morbidity associated with a craniotomy and obviates the need for postoperative intensive care required for conventional osteoplastic flap surgery or extensive endonasal surgery required for the alternative minimally invasive endoscopic technique. Our initial success merits further assessment of the use of this technique. <![CDATA[<b>Perioperative fasting in burn patients: Are we doing it right?</b>]]> BACKGROUND: Burn patients have high metabolic demands requiring aggressive nutritional supplementation. Multiple operations necessitate a period of starvation. This audit was undertaken to review the total duration of starvation experienced by burn patients in a regional hospital. METHODS: This study reviewed the nutritional intake/output data for 3 months of admitted patients using standard formulas to calculate the average energy deficit. RESULTS: Nine adult patients with an average burn of 21% total body surface area (TBSA) were included, with an average starvation period of 21 hours. There were 10 paediatric patients with an average burn of 18% TBSA and average starvation period of 18 hours. There was an average 12% deficit in weekly energy requirements. CONCLUSION: Burn patients are starved for periods longer than necessary, which may have implications for recovery. Shortened fasting is preferable and safe. Perioperative starvation protocols specific for burn patients in this hospital need to be developed and enforced. <![CDATA[<b>Hypoxic brain injury and cortical blindness in a victim of a Mozambican spitting cobra bite</b>]]> Snakebite and the subsequent envenomation is a serious and potentially fatal illness, owing to the effects of the various toxins present in the venom. Cortical blindness following bites containing neurotoxin is a rare complication. We describe the clinical findings and imaging in a child who sustained significant brain injury following a bite from a Mozambican spitting cobra. We also discuss the venom composition, complications and appropriate management of such cases. <![CDATA[<b>The role of surgery in an imatinib-resistant GIST liver secondary</b>]]> This is a case report describing the management of an imatinib-resistant liver secondary as a result of an exon 13 mutation. The gastric primary was completely excised 3 years prior and proven to contain an exon 11 mutation. Resective liver surgery was undertaken after the patient developed imatinib resistance and he has been disease-free for 19 months. The application of surgery in the context of other treatment options is discussed. <![CDATA[<b>Peter Colin Jeffery 1943 - 2015</b>]]> This is a case report describing the management of an imatinib-resistant liver secondary as a result of an exon 13 mutation. The gastric primary was completely excised 3 years prior and proven to contain an exon 11 mutation. Resective liver surgery was undertaken after the patient developed imatinib resistance and he has been disease-free for 19 months. The application of surgery in the context of other treatment options is discussed.