South African Journal of Surgery

Obesity and surgery in general

Is conservative management of fibroadenomas feasible? 5-year results from the Durban Breast Unit

BACKGROUND: Fibroadenomas (FAs) usually present in young women and, despite being the commonest benign breast masses, are often excised. This study aimed to assess the results of a conservative management protocol in the setting of dedicated breast clinics to reassess the validity of this conservative approachMETHOD: A retrospective chart review of a prospectively maintained database of the index presentation of patients diagnosed with FAs on triple assessment at the breast clinics of Inkosi Albert Luthuli Central Hospital (IALCH) and Addington Hospital (ADH) was undertaken. Women under 35 years with FA less than 5 cm and agreeable to the 5-year conservative management strategy from 2008 to 2015 were included. Variables assessed over the 5-year study period included adherence to clinic visits and any change in size of the lesion(sRESULTS: Three hundred and six women were studied. The mean age of presentation was 21.5 years (IQR 12-34), and the mean FA size was 2.43 cm (IQR 0.5-4.8). 72.9% were of African ethnicity. 76.5% had a single FA, and in 16.3%, they were bilateral. 50.7% of patients were lost to follow-up, and 9.6% (n = 25) had spontaneous resolution of their FA. Conservative management of FAs was feasible in only 26.1% of patientsCONCLUSION: Conservative management of FAs over 5 years is not practical in our local setting due to the high patient attrition rate. In those who completed the 5-year observation period, only 1 in 10 patients had complete resolution of their FA

Intensive care unit hospitalisation costs associated with road traffic crashes at a central hospital in KwaZulu-Natal for the 2017/18 financial year

BACKGROUND: The financial and physical impacts of road traffic crashes are borne by the individual, the extended family, society, the health sector and the economy of the country. The main contributors to these costs are the loss of productivity and the accrual of ongoing healthcare costs over a long-term period. There is limited information available on the cost of admitting seriously injured patients post accidents to a central hospital intensive care unitMETHODS: Cost data was obtained from the electronic database for all patients admitted for more than 24 hours to the trauma intensive care unit at Inkosi Albert Luthuli Central Hospital. A mixed costing approach was used. Data was collected on surgical procedures, imaging, laboratory tests, trauma receiving fees, pharmaceuticals, goods and services and compensation of employeesRESULTS: The total cost of treating road traffic crash patients for the 2017/18 financial year equated to R21 140 475.49. The three main cost drivers comprised the compensation of employees (R12 135 848.41; 57.4%), goods and services (R5 083 182.12; 24%) and surgery costs (R1 429 321.00; 6.8%). The average cost per admission was R163 879.65, with the average cost per inpatient day equating to R12 727.56. Male patients admitted from motorcycle crashes had the highest cost per admission, followed by motor vehicle crashes and pedestrian vehicle crashesCONCLUSION: The cost and burden associated with road traffic crashes is reflective of national and international trends and will require a comprehensive strategy to reduce accidents as well as better management at the scene and at lower levels of care

Microsurgical testicular sperm extraction for testicular failure: the South African experience and first successful pregnancy

BACKGROUND: In men with non-obstructive azoospermia (NOA), biological fatherhood is only possibly by specialised microsurgical sperm retrieval techniques (micro-TESE), only recently introduced to South Africa. This study aimed to analyse the spectrum of causes of NOA and the outcomes of micro-TESE, including live births, following the use of this technique in South AfricaMETHODS: This was a retrospective review of all micro-TESE cases performed in South Africa by a single surgeon from 2014 to 2018. Data collected prospectively included: patient demographics, preoperative blood results, cause of azoospermia, intraoperative findings and postoperative complications. The primary outcome measured was surgical success of micro-TESE, which was defined as testicular sperm successfully retrieved and cryopreserved. Subsequent live births from assisted reproductive technology (ART) using the cryopreserved sperm were also documentedRESULTS: Twenty-six men with NOA underwent micro-TESE between May 2014 and April 2018. Mean preoperative total testosterone level was 12.0 nmol/l (IQR 5.2) and follicle-stimulating hormone level 23.5 IU/l (IQR 15.6). Genetic testing was performed as part of the preoperative work-up in only 10 of the 26 patients. A specific cause of NOA was identified in 9 of the 26 patients and included Klinefelter syndrome (1 patient), Y-chromosome AZFc microdeletion (1 patient), undescended testicles (5 patients) and chemotherapy (2 patients). The average testicular volume was 9.05 ml (IQR 5.6), and the mean duration of surgery 95.8 minutes (IQR 28.0). The overall sperm retrieval rate was 34.6%. A single pregnancy and subsequent live birth were recorded from a total of eight cycles of intracytoplasmic sperm injection (ICSI): four female partners had one ICSI cycle each and two females underwent two cycles each. Frozen and thawed sperm was used in seven of the ICSI cycles and fresh sperm in one cycleCONCLUSION: In this South African series, sperm retrieval rates of micro-TESE for non-obstructive azoospermia were comparable to those reported internationally. Preoperative genetic testing should be increased to optimise the selection of surgical candidates

Lessons from a pilot study of screening for upper tract urothelial cell carcinoma in Lynch syndrome

BACKGROUND: Lynch syndrome is a hereditary disorder, with a very high risk of developing colorectal carcinoma (CRC) and a predilection to develop other cancers, including upper tract urothelial carcinoma (UTUC). We aimed to assess the prevalence of UTUC in a Lynch syndrome cohort undergoing screening for CRC, to determine the need for a UTUC screening programmeMETHODS: Lynch syndrome patients were screened with urine dipstick for microscopic haematuria. Patients with confirmed microhaematuria were offered urine cytology, microscopy and culture, ultrasound (US) of their upper tracts and flexible cystoscopyRESULTS: Of the 89 patients screened, 86 had an MLH1 mutation and two had an MSH2 mutation. Eleven of the 12 patients who had microscopic haematuria were female. Ten patients had urinary tract infections. One patient had follicular cystitis and another had a simple renal cyst. No patients had hydronephrosis on ultrasound. All urine cytology specimens were negative for malignancyCONCLUSION: No cases of UTUC were detected in our cohort during this study. A more rational screening protocol in this group may be to screen patients for UTUC with known MSH2 mutations at an earlier age (over 35

The spectrum of orofacial clefts and treatment logistics at Universitas Academic Hospital, Bloemfontein, South Africa

BACKGROUND: Cleft lips and/or palates should be identified early and be operated on at specific ages according to international recommendations. In African countries, however, cleft lip and palate surgeries are often delayedMETHODS: A retrospective, descriptive study was done to determine the distribution, specific time delays, demographics and loss to follow-up of patients with cleft lip and/or palates treated at Universitas Academic Hospital over a 10-year period. Data was obtained from outpatient files from the Plastic and Reconstructive Surgery Department at Universitas Academic Hospital. Two hundred and three of 318 records (63.8%) had the defined variables documentedRESULTS: The median time from first presentation to specialist consultation was 1.9 months. The median ages for first presentation was 2.2 months and for specialist consultation 5.2 months. Patients mainly had isolated cleft palates (42.4%), followed by both cleft lip and palate (31%) and isolated cleft lips (24.6%). A quarter of patients (25.6%) were lost to follow-up. More than a third (36.5%) of patients were referred from the local Motheo district and 12.8% were referred from LesothoCONCLUSION: In our setting, patients with cleft lip and/or palate are generally diagnosed and referred late. These patients also have delayed access to specialist consultation. Often patients are only evaluated by specialists at ages whereby they should have already undergone their first surgeries. Too many patients are lost to follow-up

Risk factors for recurrence after pilonidal sinus surgery in children and adolescents

BACKGROUND: Acquired pilonidal sinus disease (PSD) is a condition involving hair bundles most commonly located in the midline of the sacrococcygeal region. The aim of this study is to investigate the risk factors for recurrence after the surgical treatment of PSD in children and adolescentsMETHODS: This retrospective study was conducted with patients who underwent surgery for PDS at the Paediatric Surgery Clinic of Karaman State Hospital between July 2010 and December 2018. Age, gender, weight, and height of the patients were recorded. Whether or not there was a recurrence after the surgery as well as the factors affecting recurrence in the cases with recurrence were examinedRESULTS: A total of 86 PSD patients were included in the study. Of these, 36 (41.9%) were girls and 50 (58.1%) were boys. The mean follow-up period was 15.1 ± 8.4 months. Their mean age was 15.16 ± 1.29 years. Postoperative recurrence developed in 14 patients (16.3%). Postoperative recurrence was significantly higher in those who were overweight than in those of normal weight (p < 0.001) and in females when compared to males (p = 0.014). Gender and BMI were interrelated as risk factors. The effect of female gender on the likelihood of recurrence was threefold that of BMICONCLUSION: It was observed in this study that female gender and a high BMI significantly increased the risk of PSD recurrence after surgery

Magnetic resonance imaging features of dermatofibrosarcoma protuberans; what the surgeon should know: a case series

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing, spindle cell neoplasm with low to intermediate grade malignant potential, commonly found in young and middle-aged adults, more in males than females. DFSP mostly originates in the dermis; rarely, it may be located in the deeper tissues without dermal involvement. Typically, DFSP appears as a multinodular mass, which then spreads into the subcutaneous tissues and muscle; it rarely dedifferentiates to high-grade fibrosarcoma, and more rarely, it may metastasise. We describe magnetic resonance imaging (MRI) features in three female patients with histologically proven DFSP and review the literature.

Laparoscopic repair of a delayed traumatic bladder injury

Isolated bladder injuries from falls are not common; we report a laparoscopic bladder repair in a patient with delayed presentation. There are about 20 case reports of laparoscopic repair of traumatic bladder reported in the literature, but none with such a delayed presentation.¹ We describe the technique of laparoscopic bladder repair. The delay in the presentation might have facilitated laparoscopic repair as it might have excluded bowel injuries.

Two sides of one coin: pan-gastrointestinal Kaposi sarcoma presenting with small bowel intussusception and severe gastrointestinal haemorrhage

We report a case of multi-focal pan-gastrointestinal Kaposi sarcoma in an HIV positive patient, presenting with two life-threatening complications of the disease, intestinal obstruction and upper gastrointestinal haemorrhage. The patient responded well to combined surgical and oncological treatment. The reported complications of the disease are regarded as relatively rare events, and this report aims to highlight the need for more intensive screening for Kaposi sarcoma in immune-compromised individuals.

Duodenojejunal intussusception due to an inflammatory fibroid polyp: a mimic of acute pancreatitis

This report describes an extremely unusual cause of acute pancreatitis. It highlights the value of cross-sectional imaging, in the absence of alcohol and gallstone aetiology, to establish a diagnosis and direct management. Computed tomography (CT) revealed a duodenal jejunal intussusception. A benign inflammatory fibroid tumour, acting as a lead point, was surgically resected and the patient made an unremarkable recovery without further episodes of acute pancreatitis.

Impact of the body mass index on the duration of laparoscopic cholecystectomy in a black African population