Scielo RSS <![CDATA[South African Journal of Surgery]]> vol. 56 num. 4 lang. <![CDATA[SciELO Logo]]> <![CDATA[<b>Absence of effect of post-discharge socioeconomic circumstances on the outcome of dysvascular lower limb amputees: a prospective cohort study</b>]]> BACKGROUND: Significant mortality and morbidity occur after major lower limb amputation for diabetes-related foot complications and peripheral arterial disease. Risk factors for atherosclerosis and medical comorbidities are common in amputation for diabetes-related foot complications and are major determinants of outcome. Conversely, the effect of post-hospitalisation circumstances on outcome has not been systematically studied. We hypothesised that poor socioeconomic circumstances after discharge would have an adverse effect on the outcome of major amputation in a developing country. OBJECTIVES: To determine the association of the status of post discharge socioeconomic circumstances on the outcome of dysvascular amputation. METHODS: This was a prospective cohort study. Patients scheduled for major dysvascular lower limb amputation were recruited. Data were collected regarding the socioeconomic circumstances to which patients would be discharged, such as housing, income and personal care. Patients were followed up at our hospital, at clinics and later telephonically for three years. Mortality and wound morbidity were documented. Association of differences in status of socioeconomic factors and outcomes was analysed statistically. RESULTS: Ninety nine patients were enrolled. Eight patients died in hospital and 91 were discharged. The socioeconomic circumstances of discharged patients were relatively favourable, the majority living in brick houses (92%) with running water (87%). Most patients had a regular income (86%), more than half had state/government grants. The availability of co-habitants, care givers and accessible medical facilities was also favourable. None of the different socioeconomic status levels demonstrated an effect on morbidity or mortality, all associations having a p-value greater than 0.05 (Chi-squared Fisher's exact and Spearman's rank correlation tests. CONCLUSION: No association between socioeconomic status factors and post-discharge outcome of amputees was demonstrated. This is probably because the dysvascular amputees in this study cohort were living in relatively favourable circumstances. <![CDATA[<b>The effect of neoadjuvant chemotherapy on pathological response and the hormone receptor profile in locally advanced breast carcinomas</b>]]> BACKGROUND: The impact of neoadjuvant chemotherapy (NACT) on tumour biomarkers and the histopathological response to treatment in breast cancer specimens remains controversial. Chemotherapy and hormonal therapy decisions for breast cancer management are influenced by the expression of tumour biomarkers: estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth receptor 2 (HER2). On the other hand, pathological response is an indicator of chemotherapy effectiveness. The study of the effect of NACT in breast cancer is an important issue. OBJECTIVES: To assess the changes to biological markers ER, PR, and HER2, and the pathological response in locally advanced breast cancer patients after neoadjuvant chemotherapy. METHODS: 100 patients with locally advanced breast cancer were assessed with core needle biopsy for biological markers (ER, PR, HER2) and pathological grading. Subsequently they were treated with six cycles of taxane based NACT followed by surgical resection. Biological markers and the pathological response (assessed by the Miller Payne grading system) were re-evaluated to assess changes. RESULTS: The patient mean age was 45.62 ± 7.12 years. Most patients (56%) were postmenopausal. Clinical disease stage ranged between any T N2, T3 N1-2, T4 N0-2. Post NACT, pathological complete response rate was 14%, ER positivity decreased from 80 (80%) to 78 (78%) (p = 0.67). PR positive dropped from 66 to 62% (p = 0.002), and HER2 receptor positivity was increased from 22% to 28% (p-value 0.000). CONCLUSION: It was observed that biological markers (ER, PR, HER2) and the histopathological response of breast cancer may change after NACT. This change may affect treatment decisions. <![CDATA[<b>Outcome of liver resection for small bowel neuroendocrine tumour metastases</b>]]> BACKGROUND: Small bowel neuroendocrine tumours frequently metastasise to the liver. While liver resection improves survival and provides symptomatic relief, multifocal bilobar disease adds complexity to surgical management. OBJECTIVES: This study evaluated outcome in patients with small bowel neuroendocrine liver metastases who underwent liver resection at Groote Schuur Hospital and UCT Private Academic Hospital. METHODS: All patients with small bowel neuroendocrine liver metastases treated with resection from 1990-2015 were identified from a prospective departmental database. Demographic data, operative management, morbidity and mortality using the Accordion classification were analysed. Survival was assessed using the Kaplan-Meier method. RESULTS: Seventeen patients (9 women, 8 men, median age 55 years, range 31-76) underwent resection. Each patient had all identifiable liver metastases resected and/or ablated (median n = 3, range 1-20). Ten patients had major anatomical liver resections. Three patients had five segments resected, and seven had four resected. Nine patients (53%) had a concurrent bowel resection of the small bowel NET primary and a regional mesenteric lymphadenectomy. Median operating time was 255 min (range 150-720). Median blood-loss was 800 ml (range 200-10,000). Five patients required intraoperative blood transfusion. Hepatic vascular inflow control was used in ten patients (56.5 min median, range 20-150 min), which included hepatic inflow control n = 8, total hepatic exclusion n = 1, and selective hepatic exclusion n = 1. Median postoperative hospital stay was 9 days (range 2-28). Thirteen complications occurred in seven patients. Accordion grades were 1 n = 3, 2 n = 4, 3 n = 3, 4 n = 2, 6 n = 1. One patient required reoperation for bleeding and a bile leak. One patient died of a myocardial infarction 36 hours postoperatively. Sixteen patients (94%) had symptomatic improvement. Five-year overall survival was 91% (median follow-up 36 months, range 14-86 months. CONCLUSION: Our data show that liver resection can be safely performed for small bowel NET metastases with a good 5-year survival. However, a substantial number of patients require a major liver resection and these patients are best managed at a multidisciplinary referral centre <![CDATA[<b>Compliance efficacy and patient satisfaction with two litre polyethylene glycol ascorbic acid for colonoscopy preparation in a outreach rural setting</b>]]> BACKGROUND: Annual surveillance of Lynch Syndrome patients from the rural Northern Cape Province of South Africa is conducted with a mobile colonoscopic unit. Excellent preparation of the colon is essential to detect small right sided lesions. We wished to evaluate a two litre polyethylene glycol (PEG) electrolyte solution containing ascorbic acid and sodium ascorbate Moviprep® as preparation for colonoscopy in this cohort. METHODS: Six weeks prior to the colonoscopy surveillance week, a team travelled to the area to prepare the patients for colonoscopy. Patients were individually counselled on the importance of bowel cleansing and the use of Moviprep®. Prior to their colonoscopy, subjects completed a product acceptability questionnaire. At the procedure, the quality of bowel preparation was assessed by a single individual (DJdV) using the Harefield cleansing scale grades; grades A or B were defined as good preparation and grades C or D as poor preparation. RESULTS: Sixty four of the 71 subjects seen on the preparation trip completed the questionnaire and took their Moviprep®. The questionnaire responses showed that 53 (83%) had used other colon preparations previously and 57 (89%) would prefer Moviprep® for their next colonoscopy. Eighteen patients did not undergo colonoscopy due to time constraints. Forty-one of the 46 subjects (89%) who underwent colonoscopy had successful colonic preparation 7 of whom received an extra litre of Moviprep due to stool based nursing assessment prior to colonoscopy. Side effects of nausea and hunger were occasionally troublesome but did not affect compliance. CONCLUSION: When patients are pre-councelled, Moviprep® provides adequate colonic cleansing in 73% with the standard regimen and 89 % after additional prep in subjects undergoing surveillance colonoscopy in a rural setting. Moviprep was tolerated well and 88% of subjects would choose the same preparation for their next colonoscopy. <![CDATA[<b>Is direct consultant supervision of all trauma laparotomies necessary?</b>]]> INTRODUCTION: This study examines the nature of trauma laparotomies performed primarily by trainees and those performed under the direct supervision of a consultant. MATERIALS AND METHODS: A retrospective review was undertaken at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. All patients who underwent a trauma laparotomy were included. Admission physiology, organ injury and outcome were assessed. Statistical comparison using STATA was performed. Chi-squared analysis was used for categorical variables and unpaired T-test for physiology. RESULTS: A total of 562 patients for trauma laparotomy were identified. Ninety percent (506/562) were male and the mean age was 30 years. The in hospital mortality was 7% (40/562). A consultant was present at 35% of cases (197/562). Consultant-lead operations were found to have a higher rate of mortality 16% vs 2% (32/197 vs 8/365: p < 0.001) and ICU 45% vs 25% (89/197 vs 91/365: p < 0.001) than trainee only. Significant differences in many parameters of admission physiology were identified. Consultant-lead procedures had a higher lactate (3.7 vs 2.9: p 0.0043), respiratory rate (RR) (22 vs 20: p 0.0005), heart rate (HR) (102 vs 96: p 0.0035) and a lower systolic blood pressure (SBP) (115 vs 122: p 0.0001) diastolic blood pressure (DBP) (69 vs 73: p 0.0350) pH (7.34 vs 7.36: p 0.0216) base excess (BE, mEq/L) (-4.1 vs -2.5: p 0.0036) and bicarbonate (HCO3, mEq/L) (21.3 vs 22.5: p 0.0043) than trainee only procedures. Consultants were more likely to be called in for a gunshot than a stab wound (p < 0.001). Of the solid organ injuries, consultants are more likely to be called in for cases with liver injury 23% vs 16% (45/197 vs 58/365: p 0.005) and pancreatic injury 15% vs 3% (30/197 vs 11/365: p < 0.001). CONCLUSION: Trainees can safely undertake a subset of trauma laparotomies. However, patients with deranged physiology and complex hepatobiliary injuries should be operated on directly by a consultant. <![CDATA[<b>A selective vacuum assisted mesh mediated fascial traction approach following temporary abdominal containment for trauma laparotomy is effective in achieving closure</b>]]> BACKGROUND: Definitive primary abdominal closure is often not possible nor desirable following trauma laparotomy. In such situations, temporary abdominal containment (TAC) is necessary. This audit reviews our experience with TAC and interrogates our use of the Vacuum Assisted Mesh Mediated Fascial Traction approach (VAMMFT) to achieve delayed closure of the Open Abdomen (OA). METHODS: We conducted a retrospective study over a 4-year period of trauma patients who underwent a trauma laparotomy and who required a TAC. RESULTS: Over the four-year period, 596 patients underwent a laparotomy for trauma. Of these trauma laparotomies, 463 (78%) underwent primary closure and 133 (22%) required a TAC. Of these 133 patients who required a TAC, 37 died, 41 underwent delayed primary fascial closure at repeat laparotomy and 55 were left with an OA. Of this cohort of 55 patients, 15 underwent a VAMMFT procedure. The VAMMFT procedure yielded a 60% closure rate, with failure to close being due to late mesh insertion and sepsis. CONCLUSION: Our initial results with VAMMFT are encouraging. The technique appears to be effective and safe. Ongoing audit will allow us to accrue more patients and to better refine our algorithms and strategies. <![CDATA[<b>Haemodynamically unstable pelvic trauma: initial validation of a dedicated protocol by a retrospective cohort study with historical controls</b>]]> BACKGROUND: We present our experience after the introduction of Advanced Trauma Life Support (ATLS)©, Trauma Team (TT) and Preperitoneal Pelvic Packing (PPP) protocols for the treatment of hemodynamically unstable pelvic blunt trauma. METHODS: This is a retrospective study with historical controls: before (Control Group, CG) and after (Study Group SG) the introduction of the protocol. A single physician managed the CG and angiography was the emergency manoeuvre. A team with ATLS guidelines and PPP as an emergency manoeuvre managed the SG. Data were collected retrospectively. Patients were divided into two groups: before and after the introduction of protocols. RESULTS: From January 2007 to October 2014, 36 patients were treated at our Centre. We consider patients from January 2007 to August 2011 (19 patients, CG) and from September 2011 to October 2014 (17 patients, SG). Median age was 54 years (43-69) in the CG vs. 47 (40-63) in the SG (p = 0.43), median initial SBP 90 mmHg (85-103) in the CG 94 (69-103) in the SG, (p = 0.60), heart rate was 90 (80-110) in the CG and 110 (95-130) in the SG, (p = 0.09). Median Injury Severity Score was 33 (21-41) in the CG and 34 (26-41) in the SG (p = 0.29). Time from arrival in the Emergency Department to first therapeutic manoeuvre was 132 minutes (109-180) in the CG and 87 minutes (51-204) in the SG (p = 0.4). The difference in mortality was statistically significant: 64.7% (11/17) in the CG and 23.5% (4/17) in the SG (p = 0.02). CONCLUSIONS: The introduction of protocols changed our approach in hemodynamically unstable pelvic trauma, achieving a remarkable improvement in early mortality. <![CDATA[<b>#PlasticSurgery</b><b>: </b><b>an overview of the internet presence and utilisation of social media platforms by South African plastic surgeons</b>]]> BACKGROUND: Information about plastic surgery procedures is becoming more easily accessible everyday as the influence of social media expands rapidly. Plastic surgeons may use these platforms to advertise their practices and facilitate patient education. This study aimed to investigate the online presence of South African plastic surgeons with regard to personal practice websites and social media profiles. METHODS: Plastic surgeons listed on the Association of Plastic, Reconstructive and Aesthetic Surgeons of South Africa (APRASSA) website were searched for on the internet. Professional websites were examined for links to social media (Facebook, Instagram, Twitter). Personal profiles on Facebook, Twitter and Instagram were excluded. RESULTS: The total number of South African plastic surgeons listed on the APRASSA website totaled 148 at the time of collation. Three surgeons (2%) had direct links to their personal website on the APRASSA listing. Sixty-four plastic surgeons (42.7%) had websites directly related to their plastic surgery practice. Of those, only 15 provided links to any form of social media. Twelve surgeons had links to a Facebook page (18.75%) pertaining to their practice. Eleven had links to a Twitter profile (17.8%), and only one had links to an Instagram account (1.6%). CONCLUSION: The role of social media in the plastic surgery community appears to have significant implications for the future of the specialty. Adoption of these platforms is necessary to maintain interaction with patients and colleagues in the digital age. <![CDATA[<b>The first series of laparoscopic radical cystectomies done in South Africa</b>]]> BACKGROUND: Radical cystectomy (RC) with extended lymphadenectomy and urinary diversion remains the standard of care for muscle-invasive urothelial carcinoma. Laparoscopic radical cystectomies (LRC) have been performed at Groote Schuur Hospital (GSH) since 2009. We aimed to audit our data regarding complications and oncological outcome and compare it to data obtained from patients undergoing open radical cystectomy (ORC) by the same surgeon since 2007. METHODS: All adult patients who underwent open and laparoscopic RC from 2007 to 2013 have been included in the study. Data on demographics, operative time, intraoperative blood loss, postoperative complications, margin positivity, and lymph nodes was obtained retrospectively by means of folder review. RESULTS: Thirty (30) patients who underwent LRC and 32 who underwent ORC were included in the study. Participants undergoing ORC experienced shorter operative duration (301 minutes versus 382 minutes; p-value < 0.0001), increased blood loss (1376 ml versus 779ml; p-value = 0.0023) and transfusion requirement (2 units versus 0; p-value = 0.071) in contrast to LRC. Postoperative complications were more prevalent in the ORC arm compared to the LRC arm (61% versus 43%). Patients with a past medical history were at higher risk of experiencing postoperative complications (p-value = 0.04; Risk Ratio: 1.6). Margin positivity was comparable between the two arms. A higher number of nodes was sampled by the laparoscopic technique in this study (overall p-value = 0.07). CONCLUSION: Laparoscopic RC is associated with longer operative times, decreased blood loss, and equivalent oncological outcomes when compared to ORC. Laparoscopic RC is a feasible option in our setting. <![CDATA[<b>Deep brain stimulation in Parkinson's disease: analysis of the variation in final stimulating lead placement based on multi-tract electrode recordings</b>]]> BACKGROUND: Deep brain stimulation (DBS) of the subthalamic nucleus (SNT) is a treatment modality for Parkinson's Disease (PD). Either single central trajectory tract or multiple selected trajectory tracts based on microelectrode recordings (MER) are used for the placement of the final stimulating electrodes. This study aims to explore how many times trajectory tracts, other than the central tract are used for final lead placement. METHODS: Retrospective analysis of a randomly selected convenience sample of 24 subjects from patients who had DBS by a single neurosurgeon. After MRI and CT assessment, planning using a stereotactic frame for variable trajectory placement of temporary electrodes and MER that was the basis for site and tract selection for the final electrode placements used for DBS. RESULTS: Twenty four patients had 47 DBS electrodes placed: 1 unilateral and 23 bilateral. The central tract was used in 45 (95.75%) of these cases. The central trajectory tract accounted for 30 (63.83%), the anterior trajectory tract for 7 (14.89%), the medial tract for 5 (10.64%), the posterior for 4 (8.51%) and the lateral for 1 (2.13%) of final lead placements. CONCLUSION: The results of this study based on the predicted best stimulating sites following MER show that alternates to the central trajectory tract are required in 37% of site placements. A comparative study exploring clinical benefit is required to assess if variable electrode trajectory placement based on accurate physiological measurements is superior to single central trajectory placement. <![CDATA[<b>Surgical treatment of Dermatofibrosarcoma protuberans with a free anterolateral thigh (ALT) flap in an adolescent</b>]]> A 16-year-old male presented with a 2-year history of a 5 x 5 cm dermatofibrosarcoma protuberans (DFSP) on the medial aspect of his right lower leg. Wide local excision (WLE) with a 2cm margin was performed and a free anterolateral thigh (ALT) flap was used to reconstruct the defect. This technique satisfactorily reconstructed a large defect in an adolescent with minimal donor site morbidity, as the donor site was closed primarily, and a functionally and aesthetically acceptable outcome. There was no evidence of tumour recurrence at 6 months follow-up. <![CDATA[<b>A teenager with ductal carcinoma in situ arising in a fibroadenoma: a case report</b>]]> Breast cancer arising within fibroadenomas (BcaFad) is a very rare finding. BcaFad occurs mostly in women between the ages of 40 and 50. This report details the unique case of an 18-year-old woman with bcafad. We present an 18-year-old woman with a ductal carcinoma in situ (DCIS) arising within a fibroadenoma. This is the youngest reported case of BcaFad in the literature. Clinically, the mass presented characteristics of a benign breast lump. Microscopically, an atypical proliferation of luminal epithelial cells was classified as a low-grade DCIS. As a very rare presentation at an especially unusual age, this case challenges the current risk evaluation and management in young women diagnosed with fibroadenoma. <![CDATA[<b>Littre's hernia- a rare case of a strangulated Meckel's diverticulum</b>]]> Littre's hernia a reminder of the unusual contents of an inguinal hernia and the principles of management. <![CDATA[<b>Voice prosthesis related expanding tracheoesophageal puncture repair: microsurgical reconstruction to pedicled pectoralis major muscle flap</b>]]> Insertion of voice rehabilitation devices (VRD) via tracheoesophageal punctures (TEP) post laryngectomy is considered the standard of care. The management of periprosthetic leakage from the puncture site in a zone of previous neck dissection and or radiotherapy is problematic when it results in a tracheoesophageal fistula (TOF), as simple surgical closure and use of tissue for flaps carries a high risk of failure. We share our clinical experience in 3 of 42 patients who had a laryngectomy and VDR, who developed an expanding TEP with failure of free flaps in two, and the utility of a narrow pectoralis major myofascial flaps (PMMF) as a universally successful salvage or primary procedure.