Burn-injured patients - the preferably unheard.

BACKGROUND: Data on colorectal cancer (CRC) diagnosis to treatment interval (DTI), an index of quality assurance in high-income countries (HICs) is lacking in South Africa. This study aimed to determine DTIs and their impact on CRC survival in a South African cohort. METHODS: Participants (n = 289) from the Colorectal Cancer in South Africa (CRCSA) cohort were identified for inclusion. The DTI was defined as the duration between the diagnosis and initial definitive treatment and categorised into approximate quartiles (Q1-4). The DTI quartiles were 0-14 days, 15-28 days, 29-70 days, and ≥ 71 days. Overall survival (OS) was illustrated using the Kaplan-Meier method and compared between DTI groups using Cox proportional hazards (PH) regression. RESULTS: There was no significant impact of the DTI (as quartiles) on overall CRC survival. The median length of time between DTI in this cohort was 29 days. Significant associations were identified between the DTI and self-reported ethnicity (p-value = 0.025), the site of the malignancy (colon vs rectum) (p-value < 0.0001), multidisciplinary team (MDT) review (p-value = 0.015) and the initial treatment modality (p-value < 0.0001). CONCLUSION: Prolonged DTIs did not significantly impact survival for those with CRC in the CRCSA cohort. Symptom to diagnosis time should be investigated as a determinant of survival.

Use of the OVESCO OTSC® Proctology Clip for closure of fistula-in-ano at Wits Donald Gordon Medical Centre - a single centre experience.

BACKGROUND: Definitive closure of fistula-in-ano poses an ongoing surgical challenge. The OVESCO OTSC® Proctology Clip (proctology clip) purports to offer improved preservation of the anal sphincter whilst at the same time curing the fistula by closure. METHODS: A retrospective record review was conducted for patients who received the proctology clip as part of the management of fistula-in-ano in the Colorectal Unit at Wits Donald Gordon Medical Centre (WDGMC). RESULTS: There were 19 cases of fistula-in-ano treated with the proctology clip. All were cryptoglandular in origin. The median age was 50 years (IQR 44-56 years) and post-procedure, the median follow-up duration was 145 days (IQR 63-298 days). Overall, 9 procedures were successful (47%). Success rates were higher for simple (66.7%) as opposed to complex (38.5%) fistula-in-ano. For patients who underwent placement of the proctology clip as a primary procedure, the success rate (50%) was slightly better than those who received the clip as a secondary procedure (44.4%). CONCLUSION: This preliminary data presents our initial experience using the proctology clip. While these data may serve as a "proof of concept", a multi-centre controlled trial comparing this method to the rectal mucosal advancement flap (RMAF) is needed to determine the role of the proctology clip in the management of fistula-in-ano.

It's contrary - comorbidity does not affect survival of South Africans with colorectal cancer: An analysis from the Colorectal Cancer in South Africa cohort.

BACKGROUND: The Colorectal Cancer South Africa (CRCSA) study is an observational cohort of patients with colorectal cancer (CRC) in Johannesburg, South Africa (SA). We found that the mean age at the time of CRC diagnosis was 56.6 years, consistent with studies from SA and sub-Saharan Africa. In high-income settings, comorbidity adversely affects CRC survival, and patients are substantially older at the time of CRC diagnosis. Given the younger age at CRC diagnosis in the CRCSA cohort, we hypothesised that comorbidity may be less prevalent and have little impact on CRC survival. OBJECTIVES: To determine the prevalence of comorbidity and whether comorbidity adversely affects overall survival (OS) of CRC patients. METHODS: Patients enrolled in the CRCSA study between January 2016 and July 2018 were included. The cohort comprised a convenience sample of adults with histologically confirmed CRC, treated at the University of the Witwatersrand Academic Teaching Hospital Complex. Demographic, clinical and histological variables were collected at baseline and participants were followed up for OS. The Charlson comorbidity index (CCI) scoring system was used to classify participants as 'no comorbidity' (CCI score 0) and '1 or more comorbidities' (CCI score ≥1). A descriptive analysis of the cohort was undertaken, while survival across comorbidity groups was compared by the Kaplan-Meier method and Cox proportional hazards (PH) regression models. Multivariable Cox PH regression was performed to examine the effect of comorbidity on survival (unadjusted) and then adjusted for variables. RESULTS: There were 424 participants, and the mean (standard deviation) age was 56.6 (14.1) years (range 18 - 91). Only 19.1% of participants had ≥1 comorbidities, of which diabetes mellitus was most frequent (12.3%), followed by chronic obstructive pulmonary disease (4.7%) and cardiovascular disease (3.1%). There was no significant difference in unadjusted and adjusted risk of death for the group with ≥1 comorbidities compared with those with no comorbidity. However, an incidental finding showed a significantly increased risk of death for those receiving potentially curative treatment later than 40 days after CRC diagnosis. CONCLUSIONS: In the CRCSA cohort from Johannesburg, comorbidity is uncommon, with no significant adverse effect on OS. If potentially curative treatment is initiated within 40 days of CRC diagnosis, OS could be improved. To fully understand the epidemiology of CRC in SA, population-based registries are essential, and future research should aim to identify health system failures that lead to delays in intervention beyond 40 days in patients with CRC.

A one year audit of the Colorectal Unit at Wits Donald Gordon Medical Centre: 2016-2017.

BACKGROUND: Colorectal surgery has developed into an established surgical subspecialty in South Africa, however there is a paucity of data regarding the epidemiology and surgical outcomes of patients with colorectal disease in this country. The objective is to present the findings of a one-year audit of the Wits Donald Gordon Medical Centre (WDGMC) Colorectal Unit with specific reference to indications, surgical procedures and patient outcomes. METHOD: Patient files from December 2016 to November 2017 were included in a retrospective analysis. The Mann-Whitney U test was used to analyse continuous variables and the Chi-squared test was used to compare categorical variables. RESULTS: During the audit period, 1264 patients were admitted to the Colorectal Unit and a further 564 outpatient endoscopic procedures were performed. There were 306 emergency admissions. 139 elective colorectal resections took place, with a 16% major complication rate, a 12% anastomotic leak rate and no deaths. Rectal resections constituted 66% of the operations and 34% were colonic resections. The median length of stay for all patients undergoing resection was 9 days and there was no statistically significant difference in length of stay between open and laparoscopic cases. CONCLUSION: The WDGMC Colorectal Unit manages a high volume of patients presenting with the full spectrum of colorectal disease.

Efficacy of porcine dermal collagen (PermacolTM) injection for passive faecal incontinence in a dedicated Colorectal Unit at the Wits Donald Gordon Medical Centre.

BACKGROUND: Passive faecal incontinence (FI) due to a defect of the internal anal sphincter is a distressing condition and can be difficult to manage medically and surgically. The use of a trans-anally injected bulking agent to improve continence has been published internationally with contradictory results. METHOD: Patients with passive FI due to confirmed internal anal sphincter deficits that had been treated with PermacolTM injections were followed up. They were asked to complete the Wexner faecal incontinence scores and Rockwood QoL scores for both their pre- and post-treatment continence state. RESULTS: Of the 14 patients who completed the questionnaires, most were women with a mean (SD) age of 56.4 (13.4) years. The majority of the patients had a history of a predisposing event. They reported a significant improvement in both the Wexner scores (p < 0.0005) and the Rockwood QoL (p=0.004), including all subsections. The Wexner scores and the Rockwood scores were significantly correlated post-procedure (r= -0.6186; p=0.0183). There were no significant correlations between change in scores and time after procedure. CONCLUSION: Trans-anal submucosal PermacolTM injections produced a significant improvement in both faecal continence and quality of life scores in patients with passive faecal incontinence for up to two years.

Concepts in malignant transformation.

The precise biochemical nature of malignant transformation remains elusive. This article reviews some of the current theories of oncogenesis and aims to synthesize these concepts into a possible schema for the origins of malignant transformation, using a cell-programmed origin for neoplastic progression. It is proposed that cell transformation in malignancy is initiated by injury but finds ultimate promulgation through cellular, self-determined, epigenetic events. Explanations for this arrangement are sought in evolutionary models and our knowledge of cell biology. The proposed mechanisms have not been experimentally validated, but will hopefully stimulate further research.

Evolving concepts in the management of colonic injury.

PURPOSE: The management of colonic injury has changed in recent years. This study sought to evaluate current surgical management of injuries to the colon in a busy urban trauma centre, in the light of our increasing confidence in primary repair and evolving understanding of the concepts and practice of damage control surgery. METHODS: A retrospective analysis was made of consecutive patients presenting with colonic injury from January 1 to December 31 1998. Patients without full-thickness lesions of the colon were excluded, as were patients who died within 24 h of admission. Demographic data, wounding patterns and clinical course were studied. RESULTS: One hundred twenty-seven patients were analyzed. Management without colostomy was achieved in 84% of cases. Patients who underwent diversion of the faecal stream had increased morbidity and hospital stay compared to equivalent patients who were repaired primarily. The important subgroup of patients who underwent damage control or abbreviated laparotomy is discussed. CONCLUSION: This study further strengthens the validity of direct repair or resection and primary anastomosis for colonic injury. Strategies to deal with the subgroup of patients at very high risk of postoperative complications are suggested.