Outcomes of patients with thoraco-abdominal gunshot wounds operatively managed at a district hospital in Cape Town, South Africa.

AIM: Trauma is a leading cause of morbidity and mortality in the first four decades of life. Thoracoabdominal gunshot wounds carry a significant risk of mortality. This risk of death is reduced if patients are managed in dedicated units. This study examines the outcome of these patients managed in a district level hospital. METHOD: In this retrospective review, patients with thoracoabdominal gunshot wounds were identified from operating room registry for the period of January 2015 to December 2018. Data was collected retrospectively from folders and analysed for the primary outcome of mortality. RESULTS: Sixty-eight thoracoabdominal gunshot wounds were managed operatively over the period described. Only six patients were female. The median age was 29.5 years. Fourteen patients required postoperative transfer to a level 1 trauma unit. Thirteen patients died, nine at the district hospital and four at the level 1 unit. Significant differences in organ injuries were noted in the patients that died compared to the survivors. DISCUSSION: The in-hospital mortality rate of patients managed at the district hospital was 13.2% which is comparable to international rates of 12-18%. However, the subset of patients that required postoperative transfer to a level 1 trauma unit had a high mortality rate of 28.6%. The DH is committed to managing unstable and unresponsive patients once they present. Improved mortality rates will only occur with better prehospital transport policies and by equipping the DH to manage these patients postoperatively. CONCLUSION: Management of these patients can be successful at a district hospital. However, significant obstacles exist to their optimal care, as demonstrated by the high mortality patients requiring postoperative transfer.

Percutaneous Cholecystostomy Placement in Cases of Non-operative Cholecystitis: A Retrospective Cohort Analysis.

BACKGROUND: Acute (calculous) cholecystitis (AC) is an extremely common surgical presentation, managed by cholecystectomy. Percutaneous cholecystostomy (PC) is an alternative; however, its safety and efficacy, along with subsequent cholecystectomy, are underreported in South Africa, where patients often present late and access to emergency operating theatre is constrained. The aim of the study was to demonstrate the outcomes of PC in patients with AC not responding to antimicrobials. MATERIALS AND METHODS: A retrospective cohort review of patient records, who underwent PC in Groote Schuur Hospital, Cape Town, between May 2013 and July 2016, was performed. Patients with PC for malignancy or acalculous cholecystitis were excluded. Technical success, clinical response, procedure-related morbidity and mortality were recorded. Interval LC parameters were investigated. RESULTS: Technical success and clinical improvement was seen in 29 of 37 patients (78.38%) who had PC. Malposition (8.11%) was the most common complication. Two patients required emergency surgery (5.4%), while one tube was dislodged. Median tube placement duration was 25 days (range 1-211). Post-procedure, 16 patients (43.24%) went on to have LC, of which 50% (eight patients) required conversion to open surgery and 25% (four) had subtotal cholecystectomy. Median surgical time was 130 min. There were no procedure-related mortalities but eight patients (21.62%) died in the 90-day period following tube insertion. CONCLUSION: In patients with AC, PC is safe, with high technical success and low complication rate. Subsequent cholecystectomy should be performed, but is usually challenging. The requirement for PC may predict a more complex disease process.

Logistical factors associated with adverse outcomes following emergency surgery in an acute care surgical unit.

PURPOSE: The Acute Care Surgical Unit at Groote Schuur Hospital was established in 2010 and is the first of its kind in Africa. The aim of this study was to describe the outcomes of emergency surgical cases, as well as determine the logistical factors associated with adverse outcomes following surgery within the unit. METHODS: This study was a retrospective audit which reviewed the folders of adult patients who underwent an emergency surgical procedure from July 2016 to July 2017. The primary outcome was a major adverse event (AE) which was defined by a Clavien-Dindo score of 3-5. A number of logistical factors related to patient admission and operation were evaluated for association with outcomes. RESULTS: A total of 271 patients were included with a mean age of 47 years, with 48% females and 52% males. A major AE was recorded for 13% of patients. The following factors were found to be predictive of a major AE: referral from outside the hospital, urgent booking colour code, reoperation, and consultant most senior surgeon present during procedure. Patient admission/surgery performed outside of normal working hours, being booked for surgery on admission, as well as delay to surgery beyond colour code were not associated with a major AE. CONCLUSION: Apart from the traditional clinical parameters, factors related to perioperative logistics may contribute to the risk of a major AE after emergency surgery and should be considered for inclusion in more comprehensive predictive models for adverse outcomes within an acute care surgery unit.

A Study Comparing Outcomes of Appendectomy between HIV-Infected and HIV-Negative Patients.

Background: The high prevalence of Human Immunodeficiency Virus (HIV) has added a new dimension to the management and outcomes of many general surgical conditions in South Africa. However, there is a paucity of data describing the impact of HIV status on surgical outcomes in our setting. Appendicitis is a most common gastrointestinal emergency, and its surgical outcomes in areas of high HIV prevalence are poorly described in the literature. Thus, the aim of this study is to describe and compare the outcomes of appendectomy between HIV-infected (HIV+) and HIV-negative (HIV-) patients. Methods: This is a retrospective cohort study of patients undergoing appendectomy at a large regional hospital over a 12-month period. Demographic data, duration of pre-hospital symptoms, HIV status, surgical approach, operative findings, histopathology reports, hospital stay and complications were recorded. Data for the HIV+ and HIV- patient cohorts were then described, analysed and compared. Results: The study group comprised 134 patients; 18 (13.4 %) tested positive for HIV. HIV+ patients were significantly older (mean age of 29.3 vs. 20.3 years, P= 0.002) and had longer duration of pre-hospital symptoms (mean of 3.94 vs. 2.57 days, P= 0.03). Postoperative complications (44.4 % vs. 17.2 %, P= 0.03) and lengthier hospital stays (7.28 days vs. 5.95 days, P= 0.004) were also more frequently seen in the HIV+ patients. There were no differences in appendiceal rupture rates, histopathological findings and mortality. Conclusions: Presentation in HIV+ patients was delayed and surgery was associated with significant postoperative morbidity and longer hospital stay.

Penetrating femoral artery injuries: an urban trauma centre experience.

AIM: This study reviews a single centre experience with penetrating femoral artery injuries. PATIENTS AND METHODS: The records of all patients with femoral artery injuries admitted to the Trauma Centre at Groote Schuur Hospital from January 2002 to December 2012 were reviewed. These were analysed for demographics, injury mechanism, perioperative, and surgical management. Outcome was categorised by limb salvage. RESULTS: One-hundred and fifty-eight (158) patients with femoral artery injuries were identified. There were 144 (91%) men and 14 women with a mean age of 28 years. Ninety-five percent (N = 150) sustained penetrating injuries. The superficial femoral artery (87%) was most commonly injured. The most common type of arterial injury was a laceration (39%) and transection (37%). Eighty-one (51%) patients had a primary repair, 53 (33%) patients had a vein interposition graft, and 16 patients (10%) had a prosthetic graft. There were 78 (51%) concomitant venous injuries, 11 were repaired, and 1 vein patch repair was performed (15.4%). There were 4 (2.5%) primary amputations and 10 (6.5%) secondary amputations. There were no deaths. Statistically significant risk factors for secondary amputation derived by univariate analysis were: ischaemia (p < 0.0001), neurological deficit due to ischemia (p < 0.001), temporary vascular shunting (p < 0.001), and the absence of a palpable pulse post-repair (p < 0.01). CONCLUSION: This study has a primary and secondary amputation rate of 2.5 and 6.5%, respectively. There was greater than 90% limb salvage rate. The outcome of threatened limbs due to femoral artery injury is good, provided that there is no delay to surgery.

Predictors of multiple readmissions or death in the first year after Nissen fundoplication in children.

PURPOSE: Nissen fundoplication (NF) is commonly performed in children with gastro-esophageal reflux disease (GERD). Patients undergoing NF often have co-morbidities. Reported outcomes of NF vary considerably. This study investigated which factors might predict multiple readmissions or death in the first year following NF at our institution. METHODS: A retrospective chart review of 187 children who underwent NF at our institution between January 2004 and December 2015 was undertaken. Underlying medical conditions, age, weight, presence of malnutrition, length of hospital stay prior to surgery and type of surgery were recorded. Patients who had more than one admission in the first post-operative year were compared to those who had one or none, and patients who died within the first post-operative year were compared to those who did not. RESULTS: Risk factors for multiple readmissions were underlying cardiac disease (p = 0.011), esophageal atresia (EA) (p = 0.011), and esophageal stricture (p = 0.0002). Risk factors for death included younger age (p = 0.028), need for gastrostomy tube (GT) (p = 0.01) and prolonged pre-operative hospital admission (p = 0.0003). CONCLUSION: This study identified multiple factors associated with readmission and death in the first year after NF. These findings will help with the counseling patients and caregivers regarding expectations following NF.

South African surgical registrar perceptions of the research project component of training: Hope for the future?

BACKGROUND: The Health Professions Council of South Africa requires that a research project be submitted and passed before registration as a specialist. OBJECTIVE: To describe surgical registrars' perceptions of the compulsory research project. METHOD: Ethics clearance was received before commencing the study. A questionnaire was developed to collect feedback from surgical registrars throughout South Africa (SA). Completed questionnaires underwent descriptive analysis using MS Excel. Fisher's exact test and the χ2 test were used to compare perceptions of the research-experienced and research-naive groups. RESULTS: All medical schools in SA were sampled, and 51.5% (124/241) of surgical registrars completed the questionnaire. Challenges facing registrars included insufficient time (109/124), inadequate training in the research process (40/124), inadequate supervision (31/124), inadequate financial resources (25/124) and lack of research continuity (11/124). Of the registrars sampled, 67.7% (84/124) believed research to be a valuable component of training. An overwhelming percentage (93.5%, 116/124) proposed a dedicated research block of time as a potential solution to overcoming the challenges encountered. Further proposals included attending a course in research methodology (79/124), supervision by a faculty member with an MMed or higher postgraduate degree (73/124), and greater research exposure as an undergraduate (56/124). No statistically significant differences were found between the perceptions of the research-experienced and research-naive groups. CONCLUSION: Challenges facing surgical registrars in their efforts to complete their research projects were identified and solutions to these problems proposed. It is heartening that respondents have suggested solutions to the problems they encounter, and view research as an important component of their careers.