Clarke Dl

Acute appendicitis in the developing world is a morbid disease

INTRODUCTION Acute appendicitis in the developing world has a markedly different disease profile to that in the developed world. METHODS A retrospective study was undertaken over a four-year period at a university hospital in South Africa to review the disease spectrum and the clinical outcome of acute appendicitis. RESULTS A total of 1,004 patients (54% male, median age: 18 years) with intraoperatively confirmed appendicitis were reviewed. Over half (56%) were from the urban district within the city of Pietermaritzburg and the remaining 44% were from the rural health district. The median duration of illness from onset to definitive care was 4 days. Sixty per cent of appendices were perforated and associated with intra-abdominal contamination. Forty per cent of patients required reoperation to control intra-abdominal sepsis. Ten per cent required admission to the intensive care unit. The median overall length of hospital stay was 5 days. The mortality rate was 1%. Rural patients had a longer median duration of illness (3 vs 5 days, p<0.001) as well as a more advanced disease profile associated with perforation and severe intra-abdominal sepsis (19% vs 71%, p<0.001). Female patients had a longer median duration of illness (3 vs 4 days, p<0.001), were more likely to present with severe intra-abdominal sepsis (31% vs 54%, p<0.001) and were more likely to require a laparotomy (50% vs 73%, p<0.001). The total cost of managing the entire cohort of 1,004 patients over the 4-year period was £2,060,972. CONCLUSIONS Acute appendicitis in South Africa is a serious disease associated with significant morbidity. Late presentation is common. Female and rural patients have the worst clinical outcomes, with significant cost to the health system.

Mechanical complications of central venous catheterisation in trauma patients.

INTRODUCTION Central venous catheterisation (CVC) is a commonly performed procedure in a wide variety of hospital settings and is associated with appreciable morbidity. There is a paucity of literature focusing on mechanical complications specifically in the trauma setting. The aim of our study was to determine the spectrum of mechanical complications in a high‐volume trauma centre in a developing world setting where ultrasound guidance was not available. METHODS A retrospective study was performed analysing data from a four‐year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. RESULTS A total of 178 mechanical complications (18%) occurred in 1,015 patients undergoing CVC: 117 pneumothoraces, 25 malpositions, 18 catheter dislodgements, 14 arterial cannulations, one air embolism, one chylothorax, one pleural cannulation and one retained guide‐wire. The internal jugular vein (IJV) approach was associated with a higher overall complication rate than the subclavian vein (SCV) approach (24% vs. 13%, p<0.001). Pneumothorax (73% vs. 57%, p<0.001) and arterial cannulation (15% vs. 0%, p<0.001) were more common with the IJV. Catheter dislodgement (21% vs. 0%, p<0.001) was more common with the SCV. Junior doctors performed 66% of the CVCs and this was associated with a significantly higher complication rate (20% vs. 12%, p<0.001). CONCLUSIONS CVC carries appreciable morbidity, with pneumothorax being the most frequent mechanical complication. The SCV was the most commonly used approach at our institution. The majority of CVCs were performed by junior doctors and this was associated with a considerable complication rate.

Hypotension of ⩽110 mmHg is Associated with Increased Mortality in South African Patients After Trauma:

Introduction: This study used data from a prospectively maintained trauma database to assess the level of systolic blood pressure at which mortality rates for trauma begin to increase and to compare systolic blood pressure with base deficit as a predictor of outcome. Methodology: The Pietermaritzburg Metropolitan Trauma Service maintains a prospective digital trauma registry. All trauma patients admitted to the service for the period January 2012–January 2015 were included. Analysis was performed on systolic blood pressure relative to a number of selected markers of outcome and a variety of physiological parameters. Results: Out of an original data set of 2974 trauma patients, a total of 169 elective patients, 799 patients with isolated traumatic brain injury, and 27 patients with incomplete data were excluded to leave a sample size of 2148 patients. Of these, 1830 (85.2%) were males and 318 (14.8%) were females. The mean age (standard deviation) was 31.8 (12.0) years. The median age (interquartile range) was 29 (23–37) years. There were 89 deaths in this cohort (4.1%). The median systolic blood pressure (interquartile range) was 123 (112–136) mmHg. The median base deficit was −1.4 (interquartile range: −4.5 to 1). The inflection curves below with fitted non-linear curve clearly show the upward change in mortality frequency around a systolic blood pressure of ⩽110 mmHg as well for a base deficit below −5. A cutoff of <110 for systolic blood pressure yields a high sensitivity and very high positive predictive value of 82% (95% confidence interval: 81–84) and 98% (95% confidence interval: 97–98), but low specificity (56%) and negative predictive value (12%), respectively. Similar optimal cutoff analysis for base deficit versus mortality suggests base deficit >4.8 as a good predictor area under the curve (0.82; 95% confidence interval: 0.75–0.88). This cutoff yields a high sensitivity of 80% (95% confidence interval: 78–82), moderate specificity of 75% (95% confidence interval: 62–85), very high positive predictive value of 98% (95% confidence interval: 97–99) but low negative predictive value of 17% (15–28). Conclusion: The data suggest that traumatic shock starts to become manifest at a systolic blood pressure of 110 mmHg and that a systolic blood pressure reading of 90 mmHg represents an advanced state of shock. Systolic blood pressure by itself is a poor predictor of mortality and outcome. Base deficit appears to be a far better predictor of mortality than systolic blood pressure. Future models to categorize shock will have to combine vital signs with biochemical markers of hypoperfusion.

The management of colonic trauma in the damage control era

INTRODUCTION The purpose of this study was to audit our current management of colonic trauma, and to review our experience of colonic trauma in patients who underwent initial damage control (DC) surgery. METHODS All patients treated for colonic trauma between January 2012 and December 2014 by the Pietermaritzburg Metropolitan Trauma Service were included in the study. Data reviewed included mechanism of injury, method of management (primary repair [PR], primary diversion [PD] or DC) and outcome (complications and mortality rate). RESULTS A total of 128 patients sustained a colonic injury during the study period. Ninety‐seven per cent of the injuries were due to penetrating trauma. Of these cases, 56% comprised stab wounds (SWs) and 44% were gunshot wounds (GSWs). Management was by PR in 99, PD in 20 and DC surgery in 9 cases. Among the 69 SW victims, 57 underwent PR, 9 had PD and 3 required a DC procedure. Of the 55 GSW cases, 40 were managed with PR, 9 with PD and 6 with DC surgery. In the PR group, there were 16 colonic complications (5 cases of breakdown and 11 of wound sepsis). Overall, nine patients (7%) died. CONCLUSIONS PR of colonic trauma is safe and should be used for the majority of such injuries. Persistent acidosis, however, should be considered a contraindication. In unstable patients with complex injuries, the optimal approach is to perform DC surgery. In this situation, formal diversion is contraindicated, and the injury should be controlled and dropped back into the abdomen at the primary operation. At the repeat operation, if the physiological insult has been reversed, then formal repair of the colonic injury is acceptable.

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience

INTRODUCTION The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited. METHODS We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa. RESULTS Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19). CONCLUSIONS The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.

The effect of systematic factors on the outcome of trauma laparotomy at a major trauma centre in South Africa

INTRODUCTION The aim of this study was to examine and interrogate outcomes in trauma laparotomy in a South African trauma centre to determine whether systematic factors were associated with any discrepancies in outcome. METHODS This was a retrospective review of a prospectively entered trauma registry undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. The service has developed a hybrid electronic medical record system (HEMR) where clinical data were captured in real time, which were incorporated this into a database. RESULTS During the period from December 2012 to July 2016, 562 patients underwent emergency laparotomy for trauma and the time and date of surgery was recorded in the HEMR. The mean age of all patients was 29.5 years. There were 256 operations during the weekend or over a public holiday, with a mortality of 8% (n = 21) compared with 306 during the week (mortality of 10%, n = 31). This difference was not statistically significant (P = 0.237). A total of 327 operations were performed at night (18:00 ‐ 08:00) and 235 operations were performed during the day (08:00‐18:00 Hours). This was a significant difference in mortality (10% (33) vs 7 % (16), P=0.013) These differences persisted if weekends and public holidays were separated out from normal working days. A total of 188 operations were performed on a week night, with a mortality of 11% (n = 20) and 121 operations were performed during a week day, with a mortality of 8% (n = 10). There were 139 operations on a weekend or public holiday night, with a mortality of 9% (n = 13). A total of 114 operations were performed on a weekend or public holiday day with a mortality of 7% (n = 8). A total of 208 procedures were performed with an consultant present. Of these, 32 patients (15%) died. A total of 368 procedures were performed without a consultant present and 8 (2%) died. CONCLUSIONS This study demonstrated a discrepancy in outcome for trauma laparotomy, depending on whether the operation was performed at night or during the day. The reasons for this are unclear, although the lack of consultant presence at night in comparison to during the day appears to be implicated.

The impact of mechanism on the management and outcome of penetrating colonic trauma

INTRODUCTION In light of continuing controversy surrounding the management of penetrating colonic injuries, we set out to compare the outcome of penetrating colonic trauma according to whether the mechanism of injury was a stab wound or a gunshot wound. METHODS Our trauma registry was interrogated for the 5‐year period from January 2012 to December 2016. All patients over the age of 18 years with penetrating trauma (stab or gunshot) and with intraoperatively proven colonic injury were reviewed. Details of the colonic and concurrent abdominal injuries were recorded, together with the operative management strategy. In‐hospital morbidities were divided into colon‐related and non‐colon related morbidities. The length of hospital stay and mortality were recorded. Direct comparison was made between patients with stab wounds and gunshot wounds to the colon. RESULTS During the 5‐year study period, 257 patients sustained a colonic injury secondary to penetrating trauma; 95% (244/257) were male and the mean age was 30 years. A total of 113 (44%) sustained a gunshot wound and the remaining 56% (144/257) sustained a stab wound. Some 88% (226/257) of all patients sustained a single colonic injury, while 12% (31/257) sustained more than one colonic injury. A total of 294 colonic injuries were found at laparotomy. Multiple colonic injuries were less commonly encountered in stab wounds (6%, 9/144 vs. 19%, 22/113, P < 0.001). Primary repair was more commonly performed for stab wounds compared with gunshot wounds (118/144 vs. 59/113, P < 0.001). Patients with gunshot wounds were more likely to need admission to intensive care, more likely to experience anastomotic failure, and had higher mortality. CONCLUSIONS It would appear that colonic stab wounds and colonic gunshot wounds are different in terms of severity of the injury and in terms of outcome. While primary repair is almost always applicable to the management of colonic stab wounds, the same cannot be said for colonic gunshot wounds. The management of colonic gunshot wounds should be examined separately from that of stab wounds.

Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score

INTRODUCTION Cerebral gunshot wounds are highly lethal and literature on the clinical scores for mortality prediction is limited. MATERIALS AND METHODS A retrospective study was undertaken over a 5‐year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. A simplified clinical prediction score was developed based on clinical and/or physiological variables readily available in the resuscitation room. RESULTS A total of 102 patients were included; 92% (94/102) were male and the mean age was 29 years; 22% (22/102) died during the admission. The presence of visible brain matter (odds ratio 12.4, P = 0.003) and motor score less than 5 (odds ratio 89.6, P < 0.001) allows the prediction success of 92% (sensitivity 73% and specificity 98%). The area under the receiver operating characteristic curve was 94% (95% confidence interval 88‐100%, P < 0.001). CONCLUSIONS The presence of visible brain matter, together with a motor score of less than 5, allows accurate identification of non‐survivors of cerebral gunshot wounds. Further study is required to validate this score.

Selective angioembolisation for splenic salvage following blunt abdominal trauma.

Isolated high-grade splenic injury following blunt abdominal trauma is an uncommon finding. The selected use of catheter-directed angiography and angioembolisation for splenic salvage has been successful in haemodynamically stable patients.