versão On-line ISSN 2078-5151
S. Afr. j. surg. vol.46 no.3 Cape Town Ago. 2008
A. D. RogersI; M. I. HamptonII; M. BuntingIII; A. K. AtherstoneIV
IM.B. CH.B; Department of Surgery, Frere Hospital, East London, E Cape
IIM.B. CH.B; Department of Surgery, Frere Hospital, East London, E Cape
IIIM.B. CH.B., F.C.S. (S.A.); Department of Surgery, Frere Hospital, East London, E Cape
IVM.B. CH.B., F.R.C.S. (GLAS.); Department of Surgery, Frere Hospital, East London, E Cape
OBJECTIVE: We sought to evaluate the surgical service in the central part of the Eastern Cape Province by reviewing the practice of appendicectomy at Frere Hospital. Specifically, it was our aim to compare the service to those patients who reside in and outside the East London metropolitan area and the outcomes of patients according to their operative finding.
PATIENTS AND MOTHODS: A retrospective study was performed on the medical records of all patients who underwent appendicectomy in a 26-month period. This entailed a thorough review of demographic factors, mode of presentation, operation factors and findings, and the postoperative course.
RESULTS: In the study period, 436 appendicectomies were performed, of which 81% were performed after hours, with a consultant surgeon present in only 6% of cases. Of the group, 51% had a perforated appendix at surgery, and 12% a normal appendix. There was a significantly increased risk of perforation at the extremes of age and in patients from outside East London (63% v. 35% in East London). Those with perforated appendices stayed an average of 7.3 days in hospital, compared with 5 days for those with earlier appendicitis. Of the perforated group, 21% developed a complication, with 86% of all complications occurring in this group. The hospital stays were longer in those perforated appendices that were drained (10.7 days v. 6.1 days), and the rate of complications higher in this subgroup. Four patients died (1%) - all in the perforated group.
DISCUSSION: The perforation rate in our setting is significantly higher than other published results. Patients with perforated appendices have longer hospital stays and are more likely to develop significant complications, including re-operation. Patients from outside East London, males and those at the extremes of age are more likely to have perforated appendices. This study lends little support to the advocates of drains, and recommends the use of non-absorbable sutures for skin closure. The majority of procedures are performed after hours by medical officers and registrars, but there is no evidence to suggest that this practice be altered, particularly in light of the high perforation rate. The main factor identified as contributing to the huge discrepancy between perforation rates (and hence morbidity) is delay in presentation to the operating surgeon for the region. Patient factors may contribute, but service factors are regarded as significant, including poor access to clinics and hospitals, transport and ambulance services, and the expertise of the referring medical staff. The need to improve the quality of patient care in the under-serviced rural areas of the Eastern Cape is highlighted.
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