Thandinkosi E Madiba

Volvulus of the sigmoid colon.

Aims  The current status of sigmoid volvulus (SV) was reviewed to assess trends in management and to assess the literature.

Preoperative imaging of pancreatic cancer: a management-oriented approach.

Imaging of pancreatic cancer involves both diagnosis and staging of the tumor. Accurate diagnosis allows the clinician to be frank with the patient and eliminates anxiety and uncertainty associated with a pancreatic lesion of unknown etiology. Accurate staging should facilitate clinical decision making and limit surgery to those who would benefit from laparotomy. Imaging includes nonoperative techniques, such as abdominal ultrasonography, CT scan, MRI, and angiography and a variety of invasive techniques, such as laparoscopy and laparoscopic or intraoperative ultrasonography. Operative imaging complements nonoperative imaging but is outside the scope of this article. The algorithm for use of nonoperative imaging techniques needs to be clearly defined, because rapid technologic development has resulted in increasing costs and a degree of confusion among clinicians. Recent reviews have focused on diagnosis of early pancreatic cancer in high-risk patients using a combination of biochemical markers and imaging or technical aspects of current imaging techniques without attempting to integrate them into a flexible management algorithm that can be tailored to the individual patient. This article attempts to relate these investigations directly to individual patient management. So patient factors, such as the need to assess stage, and establish a tissue diagnosis in certain categories of patient, factor into the choice of appropriate investigations. The importance of the clinical examination cannot be understated. This has two objectives: to assess fitness for operation and to detect evidence of metastatic disease. If the patient is not fit enough to withstand abdominal surgery or has diffuse metastatic disease, surgery is contraindicated and more thorough investigation is not warranted. The presence of supraclavicular or umbilical nodes, peritoneal carcinomatosis on rectal examination, or ascites can provide evidence of diffuse malignant disease. It is a simple matter to confirm this with a lymph node biopsy or an ascitic tap. Clinically apparent disseminated disease is a contraindication to pancreatic resection because of its abysmal prognosis. But in the absence of signs, the clinician relies on imaging techniques to stage the disease.

Selective Conservatism in Trauma Management: A South African Contribution

Trauma in South Africa has been termed the malignant epidemic [1]. This heritage was the result of a violent colonial legacy [2] which spawned the apartheid system of injustice and the struggle against it [3,4] The Apartheid regime created overcrowding, unemployment, social stagnation, and the disruption of normal family life. These were the catalysts for the incredible amount of criminal and interpersonal conflict in South Africa over the last 50 years. African townships such as Soweto in Johannesburg and Umlazi in Durban were crime-ridden ghettoes where the apartheid police were more interested in fueling the ‘‘black on black’’ violence rather than trying to curb it. Baragwanath (Chris HaniBaragwanath) and King Edward the VIII Hospital in Durban were the ‘‘trauma care epicenters’’ on the fringes of these huge urban conurbations. Both were designated black hospitals and both were underfunded and dilapidated. Even the architecture was similar, with prefabricated, poorly ventilated structures serving as wards and clinics in both institutions. Trauma volumes consisted of between 10 and 20 laparotomies on weekend nights at the height of political unrest. This led to vast individual experience in several areas of trauma typified by Demetriades experience with 70 penetrating cardiac injuries [5]. In this setting of limited resources and an overwhelming volume of trauma, selective conservatism as a surgical philosophy took root and has profoundly influenced the way the world manages trauma. We detail and illustrate the evolution of this approach and its continued application. Selective conservatism is not a new concept. By necessity in the pre-anaesthetic era it was practiced for centuries with few survivors [6]. It was called into question only in the late 19th century and early 20 century when the mass casualties of modern warfare and advances in surgical and anaesthetic techniques swung the pendulum to an operative approach. This dominated surgical practice until the 1960s 5 when Shaftan [7,8] reintroduced the concept and described the successful nonoperative management of penetrating abdominal wounds. Both well-funded and resource-poor centers, some dealing with high volumes of blunt and penetrating trauma, now advocate this policy [9–14]. What does selective conservatism mean? It has more facets than simply not operating on selected individuals. The primary elements are clinical observation and re-evaluation. The first decision point is whether to intervene or continue observation and investigation. This decision is tempered by the knowledge that an intervention, either diagnostic or therapeutic, may do more harm than good. Therefore, the question must be: Is an intervention truly necessary? If the answer is yes then we need to decide what intervention is appropriate and whether a simple option would suffice instead of a complex operation. We ask these questions on a daily basis and they remain the key elements of this approach. This has generated observational studies, retrospective audits, prospective audits, and comparative studies. We present some of these to illustrate and substantiate the value of this approach in different anatomical regions and how it has developed with emerging technology. Until the mid-1980s these studies were based almost exclusively on injuries inflicted by stab wounds. Since then there has been a significant change in the nature of penetrating trauma in South Africa as typified by the reports from clinical and forensic audits [15, 17–17]. From 1983 to 1992 [15] 2500 penetrating torso injuries were treated annually. Over that decade stab wounds declined by 30% but firearm wounds increased by 873% with a mortality rate of 1.6% for stabs and 12.5% for firearms. This has prompted us to review our approach to these problems to see if the principles of selective conservatism need to be modified when applied to firearm injuries. Penetrating Neck Trauma The high concentration and intimate relationship of vital structures in the neck meant that most surgeons felt that exploration was mandatory for any injury that penetrated the platysma muscle. The natural history and the results of a selective policy were documented at Baragwanath [18]. In 1980 [19] over a six-month period 108 patients admitted to King Edward the VIII were prospectively evaluated. Exploration was undertaken only for hard clinical or radiologic signs of vascular or aerodigestive injury. Only 26 were explored of whom two died. In the conservative group one died from an associated thoracic injury. This concept of nonoperative management was again analyzed in a cohort of Correspondence to: S. R. Thomson, ChM, FRCS (Ed and Eng), e-mail: Thomson@ukzn.ac.za World J. Surg. 29, 962–965 (2005) DOI: 10.1007/s00268-005-0131-9

Global and country underestimation of hepatocellular carcinoma (HCC) in 2012 and its implications

PURPOSE The problems of screening costs, as well as poor data, potentially lead to the underestimation of the incidence of hepatocellular carcinoma (HCC). In particular, this is problematic in developing countries with limited resources and poor data. The study develops a model to inform policy makers of the true incidence and potential extra cost of HCC in a developing country context. METHODS Using Globocan 2012 data, we employed an ecological correlation design at country level to associate HCC incidence data with relevant determinant data like HBV-HCV and other exposure factors. A Poisson regression model was used to estimate potentially missed incident cases of HCC by country and region based on the country risk factor covariate values. RESULTS The results indicated that HBV and HCV prevalence were significantly associated with HCC incidence (p<0.001) and potentially accounted for 94%% of incident HCC in 2012. We estimated a total of 120,772 potentially missed incident HCC cases in 2012. These cases are largely predicted for South Asia (>21,000), North Asia (>15,000), Western Africa (14,500) and Eastern Africa (12,500). CONCLUSIONS Developing countries, with poorer quality data and a high historical burden of hepatitis, were predicted to have the majority of missed HCC cases in 2012 based on our model. These countries are, therefore, less able to detect, budget for or manage HCC. The high cost of HCC treatment, as well as its economic implications, poses a challenge in resource poor settings.

Human Immunodeficiency Disease: How Should It Affect Surgical Decision Making?

BackgroundThe ever-increasing prevalence of human immunodeficiency virus (HIV) infection and the continued improvement in clinical management has increased the likelihood of surgery being performed on patients with this infection. The aim of the review was to assess current literature on the influence of HIV status on surgical decision-making.MethodsA literature review was performed using MEDLINE articles addressing “human immunodeficiency virus,” “HIV,” “acquired immunodeficiency syndrome,” “AIDS,” “HIV and surgery.” We also manually searched relevant surgical journals and completed the bibliographic compilation by collecting cross references from published papers.ResultsResults of surgery between noninfected and HIV-infected individuals and between HIV-infected and acquired immunodeficiency syndrome (AIDS) patients are variable in terms of morbidity, mortality, and hospital stay. The risk of major surgery is not unlike that for other immunocompromised or malnourished patients. The multiple co-morbidities associated with HIV infection and the availability of highly active antiretroviral therapy must be considered when assessing and optimizing the patient for surgery. The clinical stage of the patient’s disease should be evaluated with a focus on the overall organ system function. For patients with advanced HIV disease, palliative surgery offers relief of acute problems with improvement in the quality of life. When indicated, diagnostic surgery assists with further decision-making in the medical management of these patients and hence should not be withheld.ConclusionHIV infection should not be considered a significant independent factor for major surgical procedures. Appropriate surgery should be offered as in normal surgical patients without fear of an unfavorable outcome.

Abdominal Trauma in Durban, South Africa: Factors Influencing Outcome

Abdominal injury as a result of both blunt and penetrating trauma has an appreciable mortality rate from hemorrhage and sepsis. In this article, we present our experience with the management of abdominal trauma in Durban and investigate factors that influence outcome. We performed a prospective study of patients with abdominal trauma in one surgical ward at King Edward VIII Hospital in Durban over a period of 7 years, from 1998 through 2004. Demographic details, cause of injury, delay before surgery, clinical presentation, findings at surgery, management and outcome were documented. There were 488 patients with abdominal trauma with a mean age of 29.2 ± 10.7 years. There were 440 penetrating injuries (240 firearm wounds; 200 stab wounds) and 48 blunt injuries. The mean delay before surgery was 11.7 ± 16.4 hours, and 55 patients (11%) presented in shock. Four hundred and forty patients underwent laparotomy, and 48 were managed nonoperatively. The Injury Severity Score was 11.1 ± 6.7, and the New Injury Severity Score was 17.1 ± 11.1. One hundred and thirty-seven patients (28%) were admitted to the intensive care unit (ICU), with a mean ICU stay of 3.6 ± 5.5 days. One hundred and thirty-two patients developed complications (28%), and 52 (11%) died. Shock, acidosis, increased transfusion requirements, number of organs injured, and injury severity were all associated with higher mortality. Delay before surgery had no influence on outcome. Hospital stay was 9.2 ± 10.8 days. The majority of abdominal injuries in our environment are due to firearms. Physiological instability, mechanism of injury, severity of injury, and the number of organs injured influence outcome.

Sigmoid colon morphology in the population groups of Durban, South Africa, with special reference to sigmoid volvulus.

Sigmoid volvulus demonstrates geographical, racial, and gender variation. This autopsy study was undertaken to establish morphological differences of the sigmoid colon and its mesocolon in which the length and other characteristics were assessed. A total of 590 cadavers were examined (403 African, 91 Indian, and 96 White). Length and height of the sigmoid colon and mesocolon were significantly longer in Africans, and mesocolon root was significantly narrower in Africans. Mesocolic ratio for Africans, Indians, and Whites was 1.1 ± 0.8, 1.8 ± 0.7, and 1.9 ± 1.0, respectively. Africans had a significantly high incidence of redundant sigmoid colon with the long‐narrow type and suprapelvic position predominating (P = 0.003); the opposite applied to the classic type. There was no difference in sigmoid colon length, mesocolon height, and width between males and females in all population groups. Among Africans, the long‐narrow type was more common in males, and the classic and long‐broad types were more common in females. Splaying of teniae coli and thickening of the mesentery were more common in Africans. Tethering of the sigmoid colon to the posterior abdominal wall was less common in Africans compared with other population groups. In conclusion, the sigmoid colon was longer, and the sigmoid mesocolon root was narrower in Africans compared with the other population groups, and the sigmoid colon had a suprapelvic disposition among Africans. In Africans, the sigmoid colon was longer in males with a long‐narrow shape. These differences may explain geographical and racial differences in sigmoid volvulus. Clin. Anat. 24:441–453, 2011.

Current management of large bowel injuries and factors influencing outcome

BACKGROUND Colonic and intra-peritoneal rectal injuries may be managed by primary repair and extra-peritoneal rectal injuries by diverting colostomy. This study was undertaken to document our experience with this approach and to identify factors which might impact on outcome. PATIENTS AND METHODS Prospective study of all patients treated for colon and rectal injuries in one surgical ward at King Edward VIII hospital, Durban, over a 7-year period (1998-2004). Demographic data, clinical presentation, findings at laparotomy and outcome were documented. RESULTS Of 488 patients undergoing laparotomy, 177 (36%) had injuries to the colon and rectum with age 29.8+/-10.9 years. Injury mechanisms were firearms (118) stabs (54) and blunt trauma (5). Delay before laparotomy was 10+/-9.3 h. Complication and mortality rates were 36% and 17%, respectively. 68 patients (38%) required ICU management. Shock on admission and increased transfusion requirements were associated with a significantly increased mortality. Patients with delay < or = 12 h before laparotomy had a higher mortality rate than those with delay >12 h. The mortality rate increased with the number of associated injuries and it was higher the higher the Injury Severity Score (ISS); it was similar for stabs, firearms and blunt trauma. Hospital stay was 9.5+/-9.2 days. CONCLUSION We reaffirm that primary repair is appropriate for colonic and intra-peritoneal rectal injuries and that extra-peritoneal rectal injuries require diverting colostomy. Shock on admission, increased blood transfusion requirements, associated organ injury and severity of the injury were associated with high mortality.

Anatomical variations in the level of origin of the sigmoid colon from the descending colon and the attachment of the sigmoid mesocolon

The origin of the sigmoid colon is considered constant as is the V‐shaped attachment of the sigmoid mesocolon attachment. This study was undertaken to establish anatomical variations in the level of origin of the sigmoid colon (590 autopsies; 403 Africans, 91 Indians, and 96 Whites), and the shape of the attachment of the sigmoid mesocolon (211 autopsies, 127 Africans, 47 Indians, and 37 Whites) in different population groups. The low‐level origin was significantly less common among Africans compared with the other population groups (P = 0.003) and the high‐level origin was significantly more common in Africans (P = 0.003). A midlevel origin was similar in all three groups. The shape of the mesocolon attachment was either straight (94), inverted U‐shaped (79), or inverted V‐shaped (38). The straight shape was more common in Whites (Whites vs. African and Indian P = 0.003), and the U‐shape more common in Africans (African vs. Whites P = 0.042). The distribution of the V‐shape was similar. There are anatomical variations in the level of origin of the sigmoid colon from the descending colon as well as in the shape of the attachment of its mesocolon. These variations are population based. Clin. Anat. 23:179–185, 2010.

The South African Surgical Outcomes Study: A 7-day prospective observational cohort study

BACKGROUND Non-cardiac surgical morbidity and mortality is a major global public health burden. Sub-Saharan African perioperative outcome data are scarce. South Africa (SA) faces a unique public health challenge, engulfed as it is by four simultaneous epidemics: (i) poverty-related diseases; (ii) non-communicable diseases; (iii) HIV and related diseases; and (iv) injury and violence. Understanding the effects of these epidemics on perioperative outcomes may provide an important perspective on the surgical health of the country. OBJECTIVES To investigate the perioperative mortality and need for critical care admission in patients undergoing inpatient non-cardiac surgery in SA. METHODS A 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 public sector, government-funded hospitals in SA. RESULTS The study included 3 927/4 021 eligible patients (97.7%) recruited, with 45/50 hospitals (90.0%) submitting data that described all eligible patients. Crude in-hospital mortality was 123/3 927 (3.1%; 95% confidence interval (CI) 2.6 - 3.7). The rate of postoperative admission to critical care units was 255/3,927 (6.5%; 95% CI 5.7 - 7.3), with 43.5% of admissions being unplanned. Of the surgical procedures 2,120/3,915 (54.2%) were urgent or emergency ones, with a population-attributable risk for mortality of 25.5% (95% CI 5.1 - 55.8) and a risk of admission to critical care of 23.7% (95% CI 4.7 - 51.4). CONCLUSIONS Most patients in SAs public sector hospitals undergo urgent and emergency surgery, which is strongly associated with mortality and unplanned critical care admissions. Non-communicable diseases have a larger proportional contribution to mortality than infections and injuries. However, the most common comorbidity, HIV infection, was not associated with in-hospital mortality. The study was registered on ClinicalTrials.gov (NCT02141867).