A decade long overview of damage control laparotomy for abdominal gunshot wounds.

PURPOSE: Over the last three decades, damage control laparotomy (DCL) has become important in the management of abdominal gunshot wounds (GSW). This paper reviews the experience of a single institution over a decade with the use of DCL for GSW of the abdomen. METHODS: Longitudinal data (2013-2022) was collected from the Hybrid Electronic Medical Registry database to identify all patients with an abdominal GSW over the study period. The data was stratified based on patients who underwent DCL and those who did not. Descriptive analysis was completed to summarise the raw data. Univariate and multivariate analysis was completed to identify variables associated with undergoing DCL. RESULTS: There were 135 patients (32%) who underwent DCL and 290 patients (68%) who did not. Colonic, small bowel, mesenteric, hepatic, pancreatic and intra-abdominal vessel injuries were associated with the need for DCL (P<0.05). In total, 85 of the 135 (63%) patients who underwent DCL required more than one damage control technique. There were 45 (33%) mortalities in the DCL group compared to 16 mortalities (6%) in the non-DCL group (P<0.001). CONCLUSION: One third of patients who underwent a laparotomy following a gunshot wound to the abdomen had a DCL. The indications for DCL include both physiological criteria and injury patterns. DCL is associated with significant morbidity and mortality. Efforts need to be directed towards refining the indications for DCL in this group of patients to prevent inappropriate application of this potentially lifesaving technique.

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds.

INTRODUCTION: This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso. METHODS: Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020. RESULTS: A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study. CONCLUSIONS: Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

AAST grade of liver injury is not the single most important consideration in decision making for liver trauma.

BACKGROUND: The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms. METHODS: Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models. RESULTS: 709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort. CONCLUSION: AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.

Two-edge-resolved three-dimensional non-line-of-sight imaging with an ordinary camera.

We introduce an approach for three-dimensional full-colour non-line-of-sight imaging with an ordinary camera that relies on a complementary combination of a new measurement acquisition strategy, scene representation model, and tailored reconstruction method. From an ordinary photograph of a matte line-of-sight surface illuminated by the hidden scene, our approach reconstructs a three-dimensional image of the scene hidden behind an occluding structure by exploiting two orthogonal edges of the structure for transverse resolution along azimuth and elevation angles and an information orthogonal scene representation for accurate range resolution. Prior demonstrations beyond two-dimensional reconstructions used expensive, specialized optical systems to gather information about the hidden scene. Here, we achieve accurate three-dimensional imaging using inexpensive, and ubiquitous hardware, without requiring a calibration image. Thus, our system may find use in indoor situations like reconnaissance and search-and-rescue.

Management of thoracoabdominal gunshot wounds - Experience from a major trauma centre in South Africa.

INTRODUCTION: The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade. MATERIALS AND METHODS: A retrospective study was conducted at a major trauma centre in South Africa over a ten-year period from December 2012 to January 2022. RESULTS: Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and median ISS: 17 (IQR: 10-19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic Blood Pressure (SBP): 119 mmHg, Temperature (T): 36.2 °C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) underwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed. CONCLUSIONS: Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches.

The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa.

BACKGROUND: Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis. METHODS: The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay). RESULTS: Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]). CONCLUSION: HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.

The Efficacy of VAMMFT Compared to "Bogota Bag" in Achieving Sheath Closure Following Temporary Abdominal Closure at Index Laparotomy for Trauma.

INTRODUCTION: The open abdomen (OA) is a necessary component of damage control surgery and closure is often challenging. Our aim was to review our ten-year experience with OA in trauma patients and to compare the success of a dual closure technique termed vacuum-assisted, mesh-mediated fascial traction (VAMMFT) to an exclusively Bogota Bag (BB) approach. METHODS: A retrospective analysis was performed using the HEMR database from 2012 to 2022, comparing demographics, mechanism of injury, admission vitals and biochemistry between patients with BB and VAMMFT applications. Rate of secondary abdominal closure and complications were assessed in both groups. Logistic regression was used to find predictors of closure. RESULTS: OA was required by 348 patients at index laparotomy. Of these, 133 (38.2%) were managed with VAMMFT and 215 (61.8%) exclusively with a BB. There were no statistical differences between the BB and VAMMFT groups in terms of demographics, injuries, admission vitals and biochemistry. The VAMMFT group achieved a closure rate of 73% compared to 54.9% in the BB group (OR of 2.2 [1.4-3.7]). There was no significant difference in fistulation rate between the two groups (p = 0.103). Length of hospital stay was 30 versus 17 days in the VAMMFT and BB groups, respectively (OR 1.41 [1.30-1.54]). There were no independent predictors of closure identified in the VAMMFT group. Older patients were less likely to achieve closure when BB was used (OR 0.97 [0.95-0.99]). VAMMFT failure was commonly due to lack of stock (39%) and protocol violations (33%). CONCLUSION: The VAMMFT approach to the OA is efficacious and safe. VAMMFT achieves a much higher rate of secondary closure than BB alone with a low rate of enteric fistula formation.

A comparison of myopia control in European children and adolescents with defocus incorporated multiple segments (DIMS) spectacles, atropine, and combined DIMS/atropine.

PURPOSE: To evaluate the efficacy of a myopia control spectacle lens (DIMS) at slowing the progression of myopia in a population of European children in comparison with 0.01% atropine and combined DIMS and atropine. METHODS: The study was a non-randomised experimenter-masked prospective controlled observational study of individuals aged 6-18 years with progressing myopia but no ocular pathology. Participants were allocated, according to patient/parent choice, to receive 0.01% atropine eyedrops, DIMS (Hoya® MiyoSmart®) spectacles, combined atropine+DIMS or single vision spectacle lenses (control group). The key outcome variables, cycloplegic autorefraction spherical equivalent refraction (SER) and axial length (AL), were measured at baseline and after three, six, and 12 months. RESULTS: Of the 146 participants (mean age 10.3y ±3.2), 53 received atropine, 30 DIMS spectacles, 31 atropine+DIMS, and 32 single vision control spectacles. Generalized linear mixed model analysis revealed for SER, whilst controlling for age and SER at baseline, at each stage all treatment groups had significantly reduced progression compared with the control group (p<0.016). For AL, whilst controlling for baseline age and AL, at 6 and 12 months all treatment groups had significantly less progression than the control group (p<0.005). For SER only, in pairwise comparisons at 12 months the atropine+DIMS group had significantly reduced progression compared with the DIMS only and Atropine only groups (p<0.001). CONCLUSION: In a European population, DIMS and atropine are effective at reducing myopia progression and axial elongation in progressing myopia and are most successful at reducing myopia progression when used in combination.

Laparotomy for Abdominal Stab Wound With Combined Omental and Organ Evisceration: 10-Year Experience From a Major Trauma Centre in South Africa.

INTRODUCTION: Combined omental and organ evisceration following anterior abdominal stab wound (SW) is uncommon and there is a paucity of literature describing the management and spectrum of injuries encountered at laparotomy. METHODS: A retrospective study was undertaken on all patients who presented with anterior abdominal SW involving combined omental and organ evisceration who underwent laparotomy over a 10-year period from January 2008 to January 2018 at a major trauma centre in South Africa. RESULTS: A total of 61 patients were eligible for inclusion and all underwent laparotomy: 87% male, mean age: 29 years. Ninety-two percent (56/61) had a positive laparotomy whilst 8% (5/61) underwent a negative procedure. Of the 56 positive laparotomies, 91% (51/56) were considered therapeutic and 9% (5/56) were non-therapeutic. In addition to omental evisceration, 59% (36/61) had eviscerated small bowel, 28% (17/61) had eviscerated colon and 13% (8/61) had eviscerated stomach. A total of 92 organ injuries were identified. The most commonly injured organs were small bowel, large bowel and stomach. The overall complication rate was 11%. Twelve percent (7/61) required intensive care unit admission. The mean length of hospital stay was 9 days. The overall mortality rate for all 61 patients was 2%. CONCLUSIONS: The presence of combined omental and organ evisceration following abdominal SW mandates laparotomy. The small bowel, large bowel and stomach were the most commonly injured organs in this setting.

Double Jeopardy Injuries: Improved Clinical Outcomes With FAST Imaging and Subxiphoid Pericardial Window for Combined Cardiac and Abdominal Stab Wounds.

BACKGROUND: This study reviews our experience with combined cardiac and abdominal stab wounds over 12 years and reviews how changes in technology and clinical approaches have impacted our management of these patients. MATERIALS AND METHODS: A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included. RESULTS: Twenty-two cases were identified (100% male, mean age: 27 years). Mean values of admission physiology: systolic blood pressure (SBP): 85 mmHg, pH: 7.2, base excess: -10.2 mmol/L and serum lactate 6.7 mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9 days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013. DISCUSSION: Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed.

Penetrating buttock trauma is morbid but rarely fatal - A South African experience.

BACKGROUND: Penetrating injuries to the buttock are relatively rare but are associated with significant morbidity. This study aimed to review our experience in managing penetrating trauma to the buttocks to contextualize the injury, document the most common associated injuries, and generate an algorithm to assist with the management of these patients. METHODS: A retrospective study was conducted at a major trauma center in South Africa over 8 years (January 2012 to January 2020). All patients presenting with a penetrating buttock injury were included. RESULTS: Our study included 40 patients. Gunshot wounds accounted for 93% (37/40), stab wounds accounted for 5% (2/40), and 1 case was gored by a cow. The majority (98%) underwent further investigation in the form of imaging or endoscopy. Forty percent (16/40) required surgical intervention. Of these 16 cases, 14 required a laparotomy, and 2 required gluteal exploration. Fifty-six percent (9/16) required a stoma. Five percent (2/40) experienced one or more complications, both of whom had stomas. The median length of stay for all patients was 3 days, whereas for the patients with stomas was 7 days. There were no ICU admissions or mortality in this study. Only 3 of the 9 stomas were reversed, and the median time to reversal was 16 months. CONCLUSION: Penetrating trauma to the buttock may result in injuries to surrounding vital structures, which must be actively excluded. Rectal injury was the most common injury, and most required a defunctioning colostomy as part of the management resulting in significant morbidity.

Identification of risk factors for postoperative pulmonary complications in general surgery patients in a low-middle income country.

BACKGROUND: Postoperative pulmonary complications (PPCs) are an important cause of perioperative morbidity and mortality. Although risk factors for PPCs have been identified in high-income countries, less is known about PPCs and their risk factors in low- and middle-income countries, such as South Africa. This study examined the incidence of PPCs and their associated risk factors among general surgery patients in a public hospital in the province of KwaZulu-Natal, South Africa to inform future quality improvement initiatives to decrease PPCs in this clinical population. METHODS: A retrospective secondary analysis of adult patients with general surgery admissions from January 1, 2013 to December 31, 2017 was conducted using data from the health system's Hybrid Electronic Medical Registry. The sample was comprised of 5352 general surgery hospitalizations. PPCs included pneumonia, atelectasis, acute respiratory distress syndrome, pulmonary edema, pulmonary embolism, prolonged ventilation, hemothorax, pneumothorax, and other respiratory morbidity which encompassed empyema, aspiration, pleural effusion, bronchopleural fistula, and lower respiratory tract infection. Risk factors examined were age, tobacco use, number and type of pre-existing comorbidities, emergency surgery, and number and type of surgeries. Bivariate and multivariable logistic regression models were conducted to identify risk factors for developing a PPC. RESULTS: The PPC rate was 7.8%. Of the 418 hospitalizations in which a patient developed a PPC, the most common type of PPC was pneumonia (52.4%) and the mortality rate related to the PPC was 11.7%. Significant risk factors for a PPC were increasing age, greater number of comorbidities, emergency surgery, greater number of general surgeries, and abdominal surgery. CONCLUSIONS: PPCs are common in general surgery patients in low- and middle-income countries, with similar rates observed in high-income countries. These complications worsen patient outcomes and increase mortality. Quality improvement initiatives that employ resource-conscious methods are needed to reduce PPCs in low- and middle-income countries.

Editorial overview: Eco-evolutionary dynamics in microbiology comes of age.

The intimate linkage of ecology and evolution is central to our understanding of biodiversity. The traditional perspective was to separate these fields based on timescales, but rapid, contemporary evolution is widely accepted and perhaps even more so in microbial systems. The study of eco-evolutionary dynamics is advancing at great pace and microorganisms are at the forefront of emerging paradigms, driven by conceptual and technological advances, such that we can move beyond the widely studied eco to evo aspects of the field and develop our understanding of how microorganisms shape virtually all processes on the planet (evo to eco).

Adherence to insulin therapy and associated factors among type 1 and type 2 diabetic patients on follow up in Madda Walabu University Goba Referral Hospital, South East Ethiopia.

BACKGROUND: Non-adherence to insulin therapy is a major global public health issue that has a causal relationship with increased diabetic complications that leads to further increase in the health care cost. However, adherence to insulin therapy and associated factors among diabetic mellitus (DM) patients are still not studied adequately in Ethiopia. OBJECTIVE: To assess the adherence to insulin therapy and associated factors among type 1 and type 2 diabetic patients on follow-up at Madda Walabu University-Goba Referral Hospital, South East Ethiopia. METHOD: An institution-based, cross-sectional study was employed among 311 both type 1 and type 2 diabetic patients, Madda Walabu University-Goba Referral Hospital from March 4 to April 30, 2020. Study participants were recruited with simple random sampling method. Adherence to insulin therapy was measured by 8-item Morisky medication adherence scale. Therefore from these 8-items, those who score 6 or more are considered as adherent to insulin therapy. The data were collected through interviewer administered questionnaires by trained graduating class nurse students. The data were entered to Epidata version 3.1, and analyzed with SPSS version 25. Bivariate and multivariable logistic regression analyses were used to identify factors associated with adherence to insulin therapy. Statistical significance were declared at p <0.05. RESULT: A total of 311 patients participate in the study with response rate of 100%. Among these only 38.9% of them were adherent to insulin therapy with a CI of [33.5, 44.3]. Having glucometer (AOR = 3.88; 95% CI [1.46, 10.35]), regular hospital follow-up (AOR = 3.13; 95% CI [1.12, 8.70]), being knowledgeable (AOR = 3.36; 95% CI [1.53, 7.37]), and favorable attitudes (AOR = 4.55; 95%CI [1.68, 12.34]) were the factor associated with adherence to insulin therapy. CONCLUSION: This study concluded that adherence to insulin therapy was low in the study area. Having glucometer, regular hospital follow-up, being knowledgeable, and favorable attitudes were the factor associated with adherence to insulin therapy. Attention should be paid to help diabetic patients on acquiring knowledge regarding the need of consistent adherence to insulin therapy and its complications.

Foley Catheter Balloon Tamponade for Actively Bleeding Wounds Following Penetrating Neck Injury is an Effective Technique for Controlling Non-Compressible Junctional External Haemorrhage.

BACKGROUND: The foley catheter balloon tamponade (FCBT) has been widely employed in the management of trauma. This study reviews our cumulative experience with the use of FCBT in the management of patients presenting with a penetrating neck injury (PNI). METHODS: A retrospective study was conducted at a major trauma centre in South Africa over a 9-year period from January 2012 to December 2020. All patients who presented with a PNI who had FCBT were included. RESULTS: A total of 1581 patients with a PNI were managed by our trauma centre, and 44 (3%) patients had an FCBT. Of the 44 cases of FCBT, stab wounds accounted for 93% (41/44) and the remaining 7% were for gunshot wounds. Seventy-five per cent of all FCBT (33/44) were inserted at a rural hospital prior to transfer to our trauma centre; the remaining 25% (11/44) were inserted in our resuscitation room. The success rate of FCBT was 80% (35/44), allowing further CT with angiography (CTA) to be performed. CTA findings were: 10/35 (29%) positive, 18/35 (51%) negative, and 7/35 (20%) equivocal. Fifteen patients required additional intervention (open surgery or endovascular intervention). The overall morbidity was 14% (6/44). Eighteen per cent required intensive care unit admission. The median length of stay was 1 day. The overall mortality rate was 11% (5/44). CONCLUSION: FCBT is a simple and effective technique as an adjunct in the management of major haemorrhage from a PNI. In highly selective patients, it may also be used as definitive management.

Trends in the Management of Abdominal Gunshot Wounds Over the Last Decade: A South African Experience.

BACKGROUND: This study aimed to review our decade-long experience with the management of abdominal gunshot wounds (GSWs), to document trends in our approach and to develop an evidence base for our contemporary management algorithms in a major trauma in South Africa. MATERIALS AND METHODS: This was a retrospective study that included all adult patients with abdominal GSWs between January 2013 and October 2020 managed at a major trauma centre in South Africa. RESULT: Five hundred and ninety-six cases were included (87% male, mean age: 32 years). The median Injury Severity Score (ISS) was 12. 52% (309/596) of cases had indications of immediate laparotomy and proceeded directly to the operating room without any CT imaging. Of this cohort, the laparotomy was positive in 292 and in the remainder (5%) was negative. Of the remaining 287 cases, 209 underwent a CT scan (35%). 78 were managed without any CT imaging. Of the 78 who did not undergo CT scan, all were managed without any operation and discharged home well. Of the 209 who underwent CT scan, 99 were observed and only one case in this group subsequently required a laparotomy. The remaining 110 cases underwent a laparotomy, which was negative in 7. There were correlations with increasing use of CT, as well as a decrease in those proceeding directly to laparotomy. The overall morbidity rate was 8% (47/596). 32% (190/596) require intensive care unit (ICU) admission. The overall mortality rate was 8% (67/596). CONCLUSIONS: The management of abdominal GSWs has continued to evolve. There is now a well-defined role for selective non-operative management in this group of patients and relies on accurate CT assessment. CT scan is now an important component in the management of abdominal GSW even in our resource-constrained environment.

Trends in Adoption of Laparoscopic Appendicectomy in a Developing Country: Closing the Gap.

BACKGROUND: This study reviews our use of laparoscopic versus open appendicectomy over the last decade to track the trends in their usage in a middle-income country. METHODS: A retrospective study was conducted on patients with intraoperative confirmed acute appendicitis from January 2013 to December 2019 at Grey's Hospital, Pietermaritzburg, South Africa. RESULTS: Eight hundred fifty-one cases of AA were included. 724 (85%) patients underwent open surgery; 435 (60%) via a midline incision and 194 (27%) via a local incision. 127 (15%) patients underwent laparoscopic appendicectomy. A significant rend was noted for an increasing proportion of surgery performed by laparoscopy compared to open surgery (p = 0.02). Patients who underwent open surgery compared to laparoscopy presented with greater peritonism (48.5% vs. 28%, p < 0.001), delay from symptom onset (3 vs. 2 days, p < 0.001), more frequently from rural areas (94% vs. 86%, p = 0.002) and with higher AAST scores (46.7% AAST ≥ 4, vs. 14.9%, p < 0.001). This former group had significantly greater morbidity (42% vs. 35%, p < 0.001) with higher Clavien-Dindo scores, were more likely to require ICU admission (8.3% vs. 2.3%, p < 0.001) and have longer hospital stay (4 days vs. 2 days, p < 0.001); no statistically significant difference in mortality was observed (1.1% vs. 0.8%, p = 0.75). CONCLUSIONS: There has been a steady increase in the uptake of laparoscopic appendicectomy and decrease in open approaches in our centre. There is still a high rate of patients with advanced disease, and it is unlikely that this cohort will be suitable for laparoscopic surgery. If we hope to increase the uptake of laparoscopic surgery for acute appendicitis even further, we must focus on identifying patients with early and low-grade disease.

Implant Site Development Using Titanium Mesh in the Maxilla: A Retrospective Study of 58 Mesh Procedures in 48 Patients.

This article presents a retrospective case series of implant site development using titanium mesh (Ti-mesh) in the maxilla. A total of 58 mesh procedures in combination with several different bone grafts (allograft, cellular allograft, and bovine xenograft) and biologics (including recombinant human platelet-derived growth factor, autogenous platelet-rich growth factor, and recombinant human bone morphogenetic protein-2) were performed in 48 patients. Ti-mesh guided bone regeneration procedures were performed 2 to 3 months after extraction of nonrestorable/hopeless teeth, and the implants were placed 6 to 8 months postaugmentation. The mean initial ridge width was 2.0 ± 1.0 mm, and the mean horizontal gain after Ti-mesh procedures was 4.7 ± 1.6 mm. The ridge width was first measured on the cross-sectional presurgical CBCT image and then confirmed clinically during surgical procedures. No statistical difference in the horizontal gain was found among different combinations of bone grafts and biomaterials. Ti-mesh exposure occurred 22% of the time. The middle-aged adults (odds ratio [OR] = 8.59; P = .046) and older adults (OR = 16.66; P = .02) had significantly higher chances of mesh exposure compared to young adults. While all implants were successfully placed, about 56% of the implants had < 2 mm of bone to the facial aspect of the osteotomy and received additional contour augmentation when placed in a prosthetically appropriate position for a screw-retained restoration. This study demonstrates that although Ti-mesh procedures result in significant bone regeneration in narrow alveolar ridges to predictably allow implant placement, the age-related mesh exposure rate and frequency of need for additional contour grafting should be discussed with patients.

Laparotomy for penetrating gastric trauma - A South African experience.

INTRODUCTION: Penetrating gastric injury (PGI) is common and although primary repair is sufficient for most injuries, several areas surrounding the peri-operative management remain contentious. This study reviews our experience in the management of PGI and review the clinical outcome at a major trauma centre in South Africa. MATERIALS AND METHODS: A retrospective study was conducted from January 2012 to April 2020 at a major trauma centre in South Africa. RESULTS: 210 cases were included (184 male, median age: 30 years). Mechanism of injury was 59% stab wounds (SWs) and 41% gunshot wounds (GSWs). The AAST grade was predominantly (92%) grade 2 for all cases. 20% (41/210) were isolated gastric injuries. All cases underwent primary repair and there were no cases of suture line failure. Eleven cases (5%) had one or more injuries not identified at the index laparotomy: 7 were unidentified gastric injuries and the remaining 4 were unidentified non gastric injuries. There was no association between unidentified injuries and mechanism of injury or outcome. Fifty-seven (27%) cases experienced one or more complications. Eighty-two cases (39%) required intensive care unit admission. The overall median length of hospital stay was 7 (IQR 4-11) days. The overall mortality was 14%. GSW injuries were more likely to have additional organ injury, higher ISS and PATI scores, longer length of hospitalization, higher likelihood of ICU stay, greater morbidity and mortality than SW injuries. There was a slight increase in the wound sepsis rate as number of associated extra gastric injuries increased but this was not statistically significant. There was no difference in wound overall sepsis rate between SW and GSW injuries (2% vs 8%, p=0.121). CONCLUSIONS: Primary repair alone is sufficient for most PGI, but laparotomy is associated with high incidence of unidentified injury and surgeons must to be cognisant of the likelihood of these occult injuries.