Research Articles (Surgery)

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    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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    Extra anatomical bypass for common femoral artery pseudoaneurysm following Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
    (Orebro University Hospital, 2021-06-04) Kruger, HJ; Couch, JH; Oosthuizen, GV
    Background: Improvements in the instrumentation and guidelines for the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) have increased its use as an adjunct in managing haemorrhagic shock. REBOArelated complications continue to be assessed and described. Methods: We describe a case of a femoral artery pseudoaneurysm within an infected groin wound after REBOA usage in a 25-year-old male after several bouts of sepsis and complications related to the initial penetrating injury and associated stay in the intensive care unit. Results: An extra-anatomical external iliac-to-superficial femoral artery bypass was performed using a 6-mm polytetrafluoroethylene graft to treat the femoral artery pseudoaneurysm successfully. Conclusion: REBOA is a well-described adjunct in the management of haemorrhagic shock. The immediate and delayed complications should be not overlooked. Deviations from the expected post-operative course should be promptly recognised and managed by a clinician with appropriate expertise.
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    Microsurgical testicular sperm extraction for testicular failure: the South African experience and first successful pregnancy
    (Medpharm Publications, 2021-06) Zarrabi, A. D.; Kruger, T. F.
    BACKGROUND: In men with non-obstructive azoospermia (NOA), biological fatherhood is only possibly by specialised microsurgical sperm retrieval techniques (micro-TESE), only recently introduced to South Africa. This study aimed to analyse the spectrum of causes of NOA and the outcomes of micro-TESE, including live births, following the use of this technique in South Africa METHODS: This was a retrospective review of all micro-TESE cases performed in South Africa by a single surgeon from 2014 to 2018. Data collected prospectively included: patient demographics, preoperative blood results, cause of azoospermia, intraoperative findings and postoperative complications. The primary outcome measured was surgical success of micro-TESE, which was defined as testicular sperm successfully retrieved and cryopreserved. Subsequent live births from assisted reproductive technology (ART) using the cryopreserved sperm were also documented RESULTS: Twenty-six men with NOA underwent micro-TESE between May 2014 and April 2018. Mean preoperative total testosterone level was 12.0 nmol/l (IQR 5.2) and follicle-stimulating hormone level 23.5 IU/l (IQR 15.6). Genetic testing was performed as part of the preoperative work-up in only 10 of the 26 patients. A specific cause of NOA was identified in 9 of the 26 patients and included Klinefelter syndrome (1 patient), Y-chromosome AZFc microdeletion (1 patient), undescended testicles (5 patients) and chemotherapy (2 patients). The average testicular volume was 9.05 ml (IQR 5.6), and the mean duration of surgery 95.8 minutes (IQR 28.0). The overall sperm retrieval rate was 34.6%. A single pregnancy and subsequent live birth were recorded from a total of eight cycles of intracytoplasmic sperm injection (ICSI): four female partners had one ICSI cycle each and two females underwent two cycles each. Frozen and thawed sperm was used in seven of the ICSI cycles and fresh sperm in one cycle CONCLUSION: In this South African series, sperm retrieval rates of micro-TESE for non-obstructive azoospermia were comparable to those reported internationally. Preoperative genetic testing should be increased to optimise the selection of surgical candidates
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    Global surgery : a South African action plan
    (SAJS, 2020-11-30) Hardcastle, T. C.; Chu, K. M.
    ENGLISH ABSTRACT: Global surgery is the study, research, and practice of improving access for all people to quality and timely surgical care locally and transnationally. This relatively new academic field was kick started in 2015 with the launch of the Lancet Commission on Global Surgery1 and a World Health Assembly declaration that essential and emergency surgical care (EESC) is an essential component of universal health coverage.2 What does global surgery mean to the South African surgeon and how can it improve healthcare provision for surgical conditions within our region? Surgical care is an indispensable, cross-cutting health service that is necessary to improve health in diverse areas, such as cancer, injury, cardiovascular disease, infection, and maternal/child health. The high burden of trauma, noncommunicable diseases (including cancer), maternal and child-health challenges, and communicable diseases (HIV and TB in particular) are a quadruple threat to the health and well-being of South Africans.3 Poor access to highquality surgical, obstetric and anaesthesia care remains a major contributor to the global disease burden, accounting for large numbers of deaths worldwide.
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    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.