Research Articles (Surgery)

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The 2-deoxy-d-glucose-neutral red test and vagotomy : an experimental study
(HMPG, 1977-09) Van Rensburg, L. C. J.
The 2-deoxy-D-glucose neutral red test proved to be successful in assessing completeness of vagotomy in the baboon both intra- and postoperatively. There were no deleterious side-effects and we found that both products could be sterilized adequately. So far we have used this test on 5 patients in the immediate postoperative phase; in 1 patient, on whom the surgeon thought he had done an incomplete parietal cell vagotomy, the test was found to be positive within a week of the operation.
2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy
(BioMed Central, 2021-06-10) de Angelis, Nicola; Catena, Fausto; Memeo, Riccardo; Coccolini, Federico; Martínez-Pérez, Aleix; Romeo, Oreste M.; De Simone, Belinda; Di Saverio, Salomone; Brustia, Raffaele; Rhaiem, Rami; Piardi, Tullio; Conticchio, Maria; Marchegiani, Francesco; Beghdadi, Nassiba; Abu-Zidan, Fikri M.; Alikhanov, Ruslan; Allard, Marc-Antoine; Allievi, Niccolò; Amaddeo, Giuliana; Ansaloni, Luca; Andersson, Roland; Andolfi, Enrico; Azfar, Mohammad; Bala, Miklosh; Benkabbou, Amine; Ben-Ishay, Offir; Bianchi, Giorgio; Biffl, Walter L.; Brunetti, Francesco; Carra, Maria C.; Casanova, Daniel; Celentano, Valerio; Ceresoli, Marco; Chiara, Osvaldo; Cimbanassi, Stefania; Bini, Roberto; Coimbra, Raul; Luigi de’Angelis, Gian; Decembrino, Francesco; De Palma, Andrea; de Reuver, Philip R.; Domingo, Carlos; Cotsoglou, Christian; Ferrero, Alessandro; Fraga, Gustavo P.; Gaiani, Federica; Gheza, Federico; Gurrado, Angela; Harrison, Ewen; Henriquez, Angel; Hofmeyr, Stefan; Iadarola, Roberta; Kashuk, Jeffry L.; Kianmanesh, Reza; Kirkpatrick, Andrew W.; Kluger, Yoram; Landi, Filippo; Langella, Serena; Lapointe, Real; Le Roy, Bertrand; Luciani, Alain; Machado, Fernando; Maggi, Umberto; Maier, Ronald V.; Mefire, Alain C.; Hiramatsu, Kazuhiro; Ordoñez, Carlos; Patrizi, Franca; Planells, Manuel; Peitzman, Andrew B.; Pekolj, Juan; Perdigao, Fabiano; Pereira, Bruno M.; Pessaux, Patrick; Pisano, Michele; Puyana, Juan C.; Rizoli, Sandro; Portigliotti, Luca; Romito, Raffaele; Sakakushev, Boris; Sanei, Behnam; Scatton, Olivier; Serradilla-Martin, Mario; Schneck, Anne-Sophie; Sissoko, Mohammed L.; Sobhani, Iradj; Ten Broek, Richard P.; Testini, Mario; Valinas, Roberto; Veloudis, Giorgos; Vitali, Giulio C.; Weber, Dieter; Zorcolo, Luigi; Giuliante, Felice; Gavriilidis, Paschalis; Fuks, David; Sommacale, Daniele
ENGLISH ABSTRACT: Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4–1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.
Abdominoperineal resection in the prone position: early outcomes at a tertiary institution in the Western Cape, South Africa
(Medpharm, 2020-09) Stevenson, N.; Lambrechts, A. V. V.; Forgan, T.
BACKGROUND: Extra-levator abdominoperineal resection (ELAPE) performed in the prone jack-knife position is a new technique in the developing world. Literature on the outcomes of ELAPE in a developing country context is scarce. The objective was to assess early outcomes after ELAPE in the prone jack-knife position, and to compare outcomes of patients who underwent the abdominal part of the procedure performed laparoscopically with an open group, at a tertiary institution in Cape Town. METHODS: Records of patients who underwent ELAPE for rectal adenocarcinoma from February 2011 to February 2017 at Tygerberg Hospital were retrospectively reviewed. Variables of interest included staging, rate of circumferential resection margin involvement (CRMI), intraoperative tumour perforation (IOP), perineal wound complications, early postoperative morbidity, length of intensive care unit (ICU) stay, duration of postoperative hospital stay and 30-day mortality rate. RESULTS: 52 patients (median age: 59 years) were included in the analysis. CRMI was evident in 16% (8/49) of patients and IOP in 6% (3/52). Perineal wound complications occurred in 32% (16/50) of patients. Median length of ICU and postoperative hospital stay was 3 days and 7 days, respectively. Overall morbidity was 47% (24/51) and the 30-day mortality rate was 3% (2/52). A significant difference in length of hospital stay was evident between the open and laparoscopic groups (11.5 days vs 6 days CONCLUSION: Prone abdominoperineal resection (APR), ELAPE, and laparoscopic ELAPE are acceptable and feasible procedures for patients with rectal cancer in the developing world, with outcomes being comparable to those determined in the developed world.
Acute abdomen in a patient with situs inversus : a case report
(Health and Medical Publishing Group -- HMPG, 1986-02) Du Toit, D. F.; Greeff, M.
The case of a man with situs inversus who presented with acute abdomen is reported. Acute left-sided appendicitis was considered before operation, but at laparotomy an omental abscess of unknown aetiology was drained. The appendix, localized in the left iliac fossa, was removed but was normal on histological examination.
Alan Blyth - my halfeeu op Ladismith
(Health and Medical Publishing Group -- HMPG, 1983-06) Van Zyl, J. J. W.
No abstract available
Alcohol levels in trauma victims
(Health and Medical Publishing Group -- HMPG, 1986-11) Muller, R.; Van Rensburg, L. C. J.
A group of 142 patients injured in motor vehicle accidents or assaults was investigated to ascertain patterns of alcohol usage and blood alcohol levels; 77% were positive for blood alcohol (range 0,01 0,492 g/dl; mean 0,212 g/dl). A correlation between alcohol levels and injury severity was found. In assaults. multiple injuries were associated with high alcohol levels because of less effective selfdefence. Injured young pedestrians as well as injured occupants of motor vehicles showed alarmingly high alcohol levels. The increasing load placed on trauma services and the resultant burden to the taxpayer necessitates an urgent programme of public education designed to alter attitudes towards alcohol consumption.
An analysis of adverse events and human error associated with the imaging of patients at a major trauma centre in South Africa
(Health & Medical Publishing Group, 2019) Bashir, A. A.; Kong, V. Y.; Buitendag, J. J. P.; Manchev, V.; Bekker, W.; Bruce, J. L.; Laing, G. L.; Brysiewicz, P.; Clarke, D. L.
Background. There is growing realisation that human error contributes significantly to morbidity and mortality in modern healthcare. A number of taxonomies and classification systems have been developed in an attempt to categorise errors and quantify their impact. Objectives. To record and identify adverse events and errors as they impacted on acute trauma patients undergoing a computed tomography (CT) scan, and then quantify the effect this had on the individual patients. It is hoped that these data will provide evidence to develop error prevention programmes designed to reduce the incidence of human error. Methods. The trauma database was interrogated for the period December 2012 - April 2017. All patients aged >18 years who underwent a CT scan for blunt trauma were included. All recorded morbidity for these patients was reviewed. Results. During the period under review, a total of 1 566 patients required a CT scan at our institution following blunt trauma. Of these, 192 (12.3%, 134 male and 58 female) experienced an error related to the process of undergoing a CT scan. Of 755 patients who underwent a CT scan with intravenous contrast, detailed results were available for 312, and of these 46 (14.7%) had an acute deterioration in renal function. According to Chang’s taxonomy, physical harm occurred as follows: grade I n=6, grade II n=62, grade III n=45, grade IV n=11, grade V n=27, grade VI n=21, grade VII n=15, grade VIII n=3 and grade IX n=2. Adverse events were performing an unnecessary scan (n=24), omitting an indicated scan (n=23), performing the scan incorrectly (n=8), scanning the wrong body part (n=7), equipment failure (n=18), omitting treatment following the scan (n=6), incorrect interpretation of the scan (n=65), deterioration during the scan (n=6) and others (n=35). The setting for the error was the ward (n=19), the radiology suite (n=126), the emergency department (n=45) and the operating theatre (n=2). The staff responsible for the adverse events were medical (n=155), nursing (n=4) and radiology staff (n=15). There were 67 errors of commission and 125 errors of omission. The primary cause was a planning problem in 78 cases and an execution problem in 114. Conclusions. Errors and adverse events related to obtaining a CT scan following blunt polytrauma are not uncommon and may impact significantly on the patient. Communication is essential to eliminate errors related to performing the wrong type of scan. The commonest errors relate to misinterpretation of the scan.
Baseline bone health status in multi-ethnic South African postmenopausal breast cancer patients at initiation of aromatase inhibitor therapy : a descriptive study
(PLoS, 2019-04-02) Baatjes, Karin J.; Kotze, Maritha J.; McCaul, Michael; Conradie, Magda
Introduction: Osteoporosis (OP) risk factor assessment and bone mineral density (BMD) testing are frequently omitted at baseline in aromatase inhibitor (AI) studies, which may lead to misinterpretation of AI associated bone loss. The present study describes bone health of South African postmenopausal women of predominantly Mixed Ancestry, prior to AI treatment. Methods: This descriptive baseline study, nested in a prospective AI cohort study, included postmenopausal women with endocrine sensitive breast cancer, aged 50 to 80 years. A baseline questionnaire documented demographic-, medical-, lifestyle- and fracture history. Body weight was assessed clinically, and body composition and BMD measured via dual energy absorptiometry (DXA). Data was analysed in STATA 14 using descriptive and inferential statistics. Results: 101 participants were recruited, with a mean age of 61±7 years. Nearly a third (n = 32) of women at baseline fulfilled global criteria for bone protection (BMD T-score ≥-2SD (n = 18); BMD T-score -1.5SD to < -2SD with risk factors (n = 14). Lower body weight, body mass index (BMI), fat mass index and lean mass index were significantly associated with the participants with a BMD measurement in keeping with a diagnosis of OP (p <0.001). Low vitamin D was present in 93% of the cohort tested (n = 95), whilst deficient vitamin D status (<20ng/ml) was documented in 52 women (55%). Conclusions: In this study, a third of postmenopausal women considered for AI therapy fulfilled international criteria for bone protective pharmacological intervention. This emphasizes the need for clinical risk and BMD assessment in postmenopausal breast cancer patients at baseline. Body composition and bone health associations highlight bone fragility associated with lower body weight.
Bleeding from varicose veins -still potentially fatal. A case report
(Health & Medical Publishing Group, 1985-02) Du Toit, D. F.; Knott-Craig, C.; Laker, L.
A 57-year-old woman was admitted to hospital with spontaneous profuse haemorrhage from a small acute varicose ulcer of the left leg. She was in shock, semicomatose and anaemic because of blood loss. The haemorrhage was easily controlled by elevating the leg, applying compression bandages and administering a blood transfusion. The patient made an uneventful recovery.
The bleeding gastric ulcer - will it bleed again, and if so, why
(Health & Medical Publishing Group, 1984-07) Shuttleworth, R. D.; Falck, V. G.
Nine patients qualified for surgery for a bleeding gastric ulcer - all had a 'visible vessel'. Three of these vessels were thrombosed including 2 in patients who had been in shock. The smallest patent vessel was 0,35 mm in diameter, and 6 of the bleeding vessels were subserosal. The features thought to predispose to further bleeding were vessel size, a lateral hole in the main trunk of the vessel and, possibly, previous recanalization or ingestion of a drug which affected haemostasis. Five of 6 patent arteries had a cap of thrombus over the breach forming a false aneurysm. It is suggested that clinically these should pulsate, enlarge, leak - with persistent fresh thrombus in the ulcer crater on repeat endoscopy - and finally rupture. Where the underlying vessel is thrombosed the stigmata of a non-pulsatile 'visible vessel' or thrombus in the ulcer should disappear on repeat endoscopy. The sizes of the arteries in the normal antrum are tabulated.
Bolus obstruction of the intestine : case reports
(Health and Medical Publishing Group -- HMPG, 1985-06) Knott-Craig, C. J.; Du Toit, D. F.; Van Schalkwyk, P.; Van Rensburg, L. C. J.
Two cases of intestinal obstruction caused by peaches are reported. In the first case steamed dried peaches were eaten by a 56-year-old woman who had undergone a Billroth I gastrectomy 18 years previously, while in the second case canned peach halves were swallowed whole by a 75-year-old edentulous man. The cases both typify the usual clinical setting of bolus obstruction, certain aspects of which are discussed. The responsibility of the attending practitioner to advise his high-risk patients with regard to their diets is emphasized.
Breast-conserving treatment for stage I and II cancer: tumours excision, axillary dissection, peri-operative interstitial irradiation, with or without peri-operative chemotherapy, followed by breast irradiation - the Tygerberg Hospital experience
(Health & Medical Publishing Group, 1989) Van Zyl, J. A.; Muller, A. G. S.
Since 1984 breast-conserving treatment has been the treatment of choice for patients at Tygerberg Hospital with early breast cancer. Peri-operative interstitial brachytherapy in breast cancer is described in detail. In the 221 patients treated (225 breasts), 197 breasts received iridium implants and 26 patients received peri-operative chemotherapy (POPFAC). There were 6 recurrences in treated breasts, 3 within the booster area and 3 outside. There were 5 salvage mastectomies, and 1 patient was treated by excision and radiotherapy. Metastases developed in 27 patients. Two patients underwent mastectomy for severe radiation changes and 7 developed postoperative wound infection after POPFAC. Five patients, who had re-excisions and prolonged seroma formation, developed delayed wound infection after POPFAC. Five patients, who had re-excisions and prolonged seroma formation, developed delayed wound infection. The importance of mammography, patient selection, tumour-free margins and radiation dosage are discussed.
Can computed tomographic angiography accurately exclude digestive tract injury after penetrating cervical trauma?
(Medpharm, 2020-12) Maritz, J. P. B.; Bagadia, A.; Lubbe, J. A.
ABSTRACT BACKGROUND: Multislice computed tomographic angiography (MCTA) has become the method of choice to screen for arterial injury in penetrating cervical trauma (PCT). There is, however, limited knowledge on its accuracy in terms of digestive tract injury (DTI). Currently, our unit liberally employs both computed tomographic angiography (CTA) and contrast swallow for platysma breaching penetrating neck injuries. This study aimed to determine the accuracy of specific computed tomography findings in the diagnosis of DTI after PCT. METHODS: This was a retrospective review of all consecutive patients with PCT who had undergone MCTA that presented at a single, tertiary, high-volume trauma centre from January 2013 until December 2015. Blinded radiological review of 140 MCTA investigations (33 in the injury group and 107 in the control group) was performed in order to calculate the diagnostic accuracy of trajectory, air, and conventional MCTA signs in the diagnosis of DTI after PCT. RESULTS: Over the study period, 906 patients presenting with PCT had undergone MCTA and a total of 33 patients (3.6%) had confirmed DTI on aggregate gold standard of diagnosis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MCTA for detecting DTI was 100%, 65.4%, 47.1%, and 100%, respectively. No injuries were missed on MCTA. CONCLUSION: Our findings suggest that DTI can be safely excluded by means of careful assessment of specific signs on CTA in patients presenting after PCT, obviating the need for further investigation.
Congenital choledochal cyst : a case report
(Health and Medical Publishing Group (HMPG), 1986-07) Du Toit, D. F.; Warren, B. L.
A congenital choledochal cyst presented as an upper abdominal mass in a non-jaundiced woman; at laparotomy total cystectomy was performed and biliary enteric continuity re-established by a hepaticojejunostomy Roux-en-Y anastomosis.
Deep-vein thrombosis in pregnancy : a case report
(Health & Medical Publishing Group, 1985) Du Toit, D. F.; McCormich, M.; Laker, L.
The incidence of thrombo-embolic complications in pregnancy varies between 2 and 5 per 1 000 deliveries. Deep-vein thrombosis (DVT) is classically associated with pulmonary embolism and chronic venous insufficiency, which are leading causes of maternal morbidity and mortality. An accurate diagnosis of iliofemoral or calf vein thrombosis should be confirmed by either Doppler ultrasonography, impedance plethysmography or ascending phlebography. Full-dose continuous intravenous heparin for 5-10 days is the established method of therapy for acute DVT and pulmonary embolism occurring during pregnancy or in the puerperium. Thereafter, long-term treatment with self-administered subcutaneous injections of heparin in low doses is feasible and effective. During pregnancy. coumarin administration results in embryopathy as it readily crosses the placenta; it should be avoided until after delivery. In view of its safety and effectiveness, low-dosage intravenous heparin or heparin by subcutaneous injection seems to be the anticoagulant of choice for the expectant mother.
Delivering sustainable solutions through improved mix and structural design functions for bitumen stabilised materials
(Hindawi, 2020) Jenkins, K. J.; Rudman, C. E.; Bierman, C. R.
ENGLISH ABSTRACT: The evolution of cold recycling using bitumen stabilisation technology has been supported by progressive research initiatives and best practice guidelines. The first generic guidelines for bitumen stabilised materials (BSMs) were published only in 2002. These guidelines provided a generic approach for the analysis of foamed bitumen and bitumen emulsion technologies. From that point, bitumen stabilisation became the common term for the inclusion of either of the two bituminous binders. The TG2 2nd edition guideline of 2009 took a bold step recognising the shear properties of the bitumen stabilised material (BSM) as the key performance indicators. In addition, advancements in structural design and application of BSMs provided practitioners with robust guidelines. The subsequent decade has provided an opportunity to interrogate data from more than 300 BSM mix designs and 69 LTPP sections. The data have led to research developments including significant new performance properties of BSMs, refined mix design methods, and updated new pavement design methods. This includes an entire design process that has been updated with a streamlined mix design procedure and a new frontier curve for the pavement number design method, as well as a new mechanistic design function. It is anticipated that the research findings and implementation of the newly developed technology will lead to improved application in BSM technology.
Duodenal erosion with bleeding from a non-functioning islet cell tumour. A case report
(Health & Medical Publishing Group, 1988-05) Shuttleworth, R. D.
A patient with a clinically non-functioning pancreatic islet cell tumour in the medial wall of the duodenum with erosion of the overlying mucosa presented with gastro-intestinal bleeding. At gastroduodenoscopy, the tumour with its apical ulcer was thought to be a leiomyoma. The lesion was excised locally and two other non-functioning APUDomas were shelled out of the body and tail of the pancreas.
Efficacy and patterns of use of antimicrobial prophylaxis for gunshot wounds in a South African hospital setting : an observational study using propensity score-based analyses
(Medpharm, 2020-03) Visbeek, M. C.; Taljaard, J. J.; De Boer, M. G. J.; Cronje, U. J.; Steyn, E.
BACKGROUND: Limited evidence supports the efficacy of antimicrobial prophylaxis (AP) in prevention of gunshot wound-related (GSW-related) infection in resource restricted areas. At Tygerberg Hospital, South Africa, it is standard care for GSW patients to receive one dose of broad-spectrum AP. For various reasons, this protocol is not consistently followed. This study aimed to assess the efficacy of AP in the reduction of in-hospital GSW-related infection and to identify opportunities for practice improvement METHODS: All patients admitted with GSW over a three-month period were eligible for inclusion. Patients who did and did not receive AP were identified retrospectively the morning of admission; thereafter, data was collected prospectively. Data regarding circumstances of the incident, injury characteristics, type of AP and surgery was obtained. The occurrence of in-hospital GSW-related infection was recorded over 30 days or until discharge. Propensity score matching (PSM) and inverse probability weighting (IPW) methods were utilised to assess the effect of AP on the prevention of GSW-related infection RESULTS: 165 consecutive patients were assessed, of which 103 received AP according to protocol within 12 hours of admission. PSM showed a reduced in-hospital GSW infection risk of 12% (95% CI, 0.2-24%, p = 0.046) with AP. IPW showed that AP reduced the risk for infection by 14% (95% CI, 3-27%, p = 0.015 CONCLUSIONS: Providing AP to GSW patients in a civilian setting appeared to result in a modest but clinically relevant lower risk of in-hospital GSW-related infection. In this study setting, optimisation of AP for all patients with GSWs should significantly lower the burden of wound infection.
Elective cholecystectomy via a 5 cm subcostal incision
(Health & Medical Publishing Group, 1992) Warren, B. L.; Marais, A. W.
This report describes a technique whereby elective cholecystectomy is performed through a 5 cm abdominal incision. Initial results in 18 patients compared with 112 historical control patients undergoing conventional cholecystectomy suggest an encouraging reduction in postoperative hospitalisation time, analgesic requirements and period of recuperation. The procedure takes no longer to perform than conventional cholecystectomy and obesity is not a limiting factor, as originally thought. This technique deserves a place alongside laparoscopic and conventional cholecystectomy in future studies seeking the optimal method of managing symptomatic cholelithiasis.
Endoscopic stenting for malignant biliary obstruction: results of a nationwide experience
(Korean Society of Gastrointestinal Endoscopy, 2021-05) Lubbe, Jeanne; Sandblom, Gabriel; Arnelo, Urban; Jonas, Eduard; Enochsson, Lars
Background/Aims: Many unanswered questions remain about the treatment of malignant hilar obstruction. We investigated endoscopic stenting for malignant biliary strictures, as reported in a nationwide registry. Methods: All endoscopic retrograde cholangiopancreatography (ERCP) procedures entered in the Swedish Registry of Gallstone Surgery and ERCP from January 2010 to December 2017 in which stenting was performed for malignant biliary stricture management were included in this study. Patency was estimated by determining the time to reintervention. Results: Endoscopic stenting was performed for malignant stricture management in 4623 ERCP procedures, of which 1364 (29.5%) were performed for hilar strictures. Of the hilar strictures, 320 (23.5%) were intrahepatic strictures (Bismuth–Corlette III– IV). Adverse events were more common after hilar stenting than after distal stenting (17.2% vs. 12.0%, p<0.0001). The 6-month reintervention rate was 73.4% after hilar stenting compared with 55.9% after distal stenting (p<0.0001). The 6-month reintervention rates for Bismuth–Corlette types I, II, IIIa, IIIb, and IV were 70.4%, 75.6%, 90.0%, 87.5%, and 85.7%, respectively. In multivariate analysis, the risk for reintervention was three times higher after hilar stenting than after distal stenting (hazard ratio 3.47, 95% confidence interval 2.01–6.00, p<0.001). Conclusions: This study with a relatively large patient cohort undergoing endoscopic stenting confirms that stenting for malignant hilar obstruction has more adverse events and lower patency than stenting for distal malignant obstruction. Clin Endosc 2021;54:713-721

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