Background: The occurrence of the considered rare anal cancer has not been documented in the South African context. Patients and methods: Analysis of data extracted from a prospectively collected KwaZulu-Natal anal cancer database for the... more
Background: The occurrence of the considered rare anal cancer has not been documented in the South African context. Patients and methods: Analysis of data extracted from a prospectively collected KwaZulu-Natal anal cancer database for the period 2000–2014. Data analysed included demographics, clinical picture, pathology, treatment and outcome. The study outcome measures were clinicopathologic spectrum, treatment and outcome. Results: The study population comprised 244 patients of mean age 50.1 (SD 14.0) years. The age at presentation was lowest for Black African patients compared to Whites and Indians (p < 0.001) and lower for HIV positive vs HIV negative patients (p < 0.001). Histology was squamous carcinoma in 208 patients (margin 152, canal 56), adenocarcinoma in 34 (all anal canal), neuroendocrine tumour (1) and melanoma (1). Mean age for squamous carcinoma was 48.8 (SD 14.1) years compared to 58.7 years (SD 11.1) for adenocarcinoma. Metastatic disease occurred in 22 patients (9%). Patients received definitive (139), palliative (53) and no (52) oncological therapy. Thirty patients (12%) underwent resection, seven of whom had positive margins. Seventy-six patients (31%) have been confirmed dead. The 5-year survival rate was 33.4% (95% CI: 23.4–44.6%). There was a highly significantly worse prognosis for adenocarcinoma compared to squamous cell carcinoma (p = 0.038). No significant difference was found in survival prospects based on race and tumour location. Conclusion: Squamous carcinoma was more common and presented at a young age. Black African patients and HIV positive patients were younger. Adenocarcinoma was associated with poorer prognosis. Race and tumour location had no influence on survival.
We report on the rare entity of transvaginal small bowel herniation following a transvaginal hysterectomy. The risk factors, presentation, initial management and various surgical approaches are discussed. It is a condition that requires... more
We report on the rare entity of transvaginal small bowel herniation following a transvaginal hysterectomy. The risk factors, presentation, initial management and various surgical approaches are discussed. It is a condition that requires prompt surgical intervention. This report serves to highlight awareness of the condition, and how knowledge of the various methods of addressing an ischaemic bowel and a ruptured vaginal vault can result in a favourable outcome.
BACKGROUND Alcohol consumption leads to violence and poor judgement. The resultant trauma is the leading cause of emergency department visits. In South Africa, alcohol-related emergency visits can be as high as 57%. The purpose of this... more
BACKGROUND Alcohol consumption leads to violence and poor judgement. The resultant trauma is the leading cause of emergency department visits. In South Africa, alcohol-related emergency visits can be as high as 57%. The purpose of this prospective study was to establish the prevalence of positive blood alcohol and Blood Alcohol Concentration (BAC) at a tertiary trauma unit in Durban, and to correlate it with injury severity, length of hospital stay and resource utilization. METHOD A total of 100 patients from King Edward trauma unit were analysed prospectively during the period December 2014 to February 2015. The BAC was correlated with Injury Severity Score (ISS), mechanism of injury, length of stay, and in-hospital mortality. Pearson chi-square test, Wilcoxon rank sum and student t-test were used for statistical analysis. RESULTS Eighty-eight patients were male. The mean age was 30 ± 9.3 years. Forty-seven patients tested positive for blood alcohol, of whom 81% were above the lega...
Background: Alcohol consumption leads to violence and poor judgement. The resultant trauma is the leading cause of emergency department visits. In South Africa, alcohol-related emergency visits can be as high as 57%. The purpose of this... more
Background: Alcohol consumption leads to violence and poor judgement. The resultant trauma is the leading cause of emergency department visits. In South Africa, alcohol-related emergency visits can be as high as 57%. The purpose of this prospective study was to establish the prevalence of positive blood alcohol and Blood Alcohol Concentration (BAC) at a tertiary trauma unit in Durban, and to correlate it with injury severity, length of hospital stay and resource utilization. Method: A total of 100 patients from King Edward trauma unit were analysed prospectively during the period December 2014 to February 2015. The BAC was correlated with Injury Severity Score (ISS), mechanism of injury, length of stay, and in-hospital mortality. Pearson chi-square test, Wilcoxon rank sum and student t-test were used for statistical analysis. Results: Eighty-eight patients were male. The mean age was 30 ± 9.3 years. Forty-seven patients tested positive for blood alcohol, of whom 81% were above the legal limit for professional drivers. The mean BAC among the alcohol positive patients was 0.146 g/dL. Positive blood alcohol was associated with significantly higher ISS scores (p = 0.0004). Injuries due to interpersonal violence were seen in 83 patients of whom 42 (51%) had positive blood alcohol. Hospital stay for alcohol positive patients was significantly longer compared to alcohol negative patients (p < 0.001). Conclusion: The prevalence of blood alcohol in the trauma population is high. Positive blood alcohol is associated with high ISS and longer hospital stays.
As global initiatives increase patient access to surgical treatments, there is a need to define optimal levels of perioperative care. Our aim was to describe the relationship between the provision and use of critical care resources and... more
As global initiatives increase patient access to surgical treatments, there is a need to define optimal levels of perioperative care. Our aim was to describe the relationship between the provision and use of critical care resources and postoperative mortality. Planned analysis of data collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. We used risk-adjusted mixed-effects logistic regression models to evaluate the association between admission to critical care immediately after surgery and in-hospital mortality. We evaluated hospital-level associations between mortality and critical care admission immediately after surgery, critical care admission to treat life-threatening complications, and hospital provision of critical care beds. We evaluated the effect of national income using interaction tests. 44,814 patients from 474 hospitals in 27 countries were available for analysis. Death was more frequent amongst patients admitted direct...
The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Prospective analysis of data from the International Surgical... more
The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (1...
BACKGROUND Constipation is a common problem for referral to surgical and colorectal units. Its association with colorectal cancer is controversial. Some authors have found an increased incidence while others have not. The aim of this... more
BACKGROUND Constipation is a common problem for referral to surgical and colorectal units. Its association with colorectal cancer is controversial. Some authors have found an increased incidence while others have not. The aim of this study is to investigate the incidence of colorectal cancer (CRC) and other significant colonoscopic pathologies in patients undergoing colonoscopy for constipation. METHOD All colonoscopy reports for constipation were retrieved from our database from January 2011 to 30 June 2014. Data extracted included demographics, colonoscopic findings and adequacy of bowel preparation. Exclusion criteria included patients with other symptoms known to be associated with colonic neoplasia such as lower GIT bleeding, loss of weight, patients with associated anaemia, those with abnormalities on imaging, patients with personal or family history of colorectal cancers or colorectal polyps and patients with inflammatory bowel disease. The primary outcome was the presence of...
BACKGROUND The optimal management of resources within South African state hospitals has been hampered by a paucity of data due to a lack of robust auditing information systems. This study reviews the use of a Hybrid Electronic Medical... more
BACKGROUND The optimal management of resources within South African state hospitals has been hampered by a paucity of data due to a lack of robust auditing information systems. This study reviews the use of a Hybrid Electronic Medical Record (HEMR) system to capture and aggregate data pertaining to the inpatient service demands on a South African tertiary surgical service. This dataset was used to analyse the appropriateness of tertiary surgical resource utilisation. METHOD The HEMR system was implemented at Greys Hospital, in the city of Pietermaritzburg, Kwa-Zulu Natal, South Africa on 1 January 2013. Inpatient data pertaining to surgical admissions and operative interventions were captured prospectively. Following an 18-month study period, the data were extracted, aggregated and analysed. The district referral hospitals were mapped, and district surgical procedures performed within the tertiary center were identified and quantified. Results: 7314 patients were admitted and manage...
BACKGROUND: The repair and outcomes of incisional abdominal wall hernias have not yet been benchmarked to allow comparison with recommended best practice in a South African context. This study aimed to address this deficit METHOD:... more
BACKGROUND: The repair and outcomes of incisional abdominal wall hernias have not yet been benchmarked to allow comparison with recommended best practice in a South African context. This study aimed to address this deficit METHOD: Patients who underwent an incisional hernia repair between December 2012 and December 2018 were analysed in respect to the following variables: demographics, comorbidities, indication for surgery, site, size, surgical approach, mesh usage, operating times, complications and 30-day mortality RESULTS: Of the cohort of 224 patients, 185 underwent elective repair. There were 152 open and 72 laparoscopic procedures, and 17 patients (8%) required a repeat operation with an overall in-hospital mortality rate of 6% (13). Eight patients developed an enteric leak. There were nine cardiovascular complications, 24 respiratory complications, 22 surgical site infections and 13 patients developed an acute kidney injury (AKI). There were 39 emergency operations. The emerg...
To review our local experience with presentation and management of retroperitoneal haematomas (RPH) discovered at laparotomy and factors affecting outcome. Patients with retroperitoneal haematomas (RPHs) were identified from a prospective... more
To review our local experience with presentation and management of retroperitoneal haematomas (RPH) discovered at laparotomy and factors affecting outcome. Patients with retroperitoneal haematomas (RPHs) were identified from a prospective database. Data collected included demographics, clinical presentation, zones and organs involved, management and outcome. Of a total of 488 patients with abdominal trauma, 145 (30%) with RPH were identified 136 of whom were male (M:F=15:1). Mean age was 28.8 (SD 10.6) years and median delay before surgery was 7h. The injury mechanisms were firearms (109), stabs (24), and blunt trauma (12). Twenty-four patients (17%) presented with shock. There were 58 Zone I, 69 Zone II, and 38 Zone III haematomas. The median injury severity score (ISS) was 9. Fifty-two patients (36%) developed complications and 26 (18%) patients died. Sixty-four (44%) patients required ICU with median ICU stay of 3 days. All Zone I injuries were explored; Zones II and III were explored selectively. The mortality for Zones I, II, III and IV was 14%, 4%, 29% and 35%, respectively. Mortality was highest for blunt trauma and lowest for stabs (p=0.146). Twelve of 24 patients with shock died (50%) compared to 14 of 121 (12%) without shock (p&lt;0.0001). Eighteen of 64 patients with &lt;6-h delay before surgery died (28%) compared to 8 of 81 (10%) with &gt;6-h delay (p&lt;0.017). Mortality increased with increasing ISS. Median hospital stay was 8 days. RPH accounted for 30% of abdominal trauma. Injury mechanism, presence of shock, delay before surgery and ISS showed a significant association with mortality.
