Randomised controlled trial of intramuscular tramadol versus transdermal buprenorphine patch for early postoperative surgical pain.

BACKGROUND: This study assesses the efficiency of the buprenorphine patch system compared to the routine use of tramadol intramuscular injections in the context of the South African public healthcare sector. METHODS: Patients were randomised into two groups, who received routine tramadol injections 100 mg every 8 hours intramuscular and buprenorphine patches 5 mcg every hour. The study assessed the first 48 hours postoperatively. A visual discrete pain scale was used to assess the level of postoperative pain as well as all complications associated with insufficient analgesic administration. RESULTS: The sample size included 75 patients in the tramadol group and 75 patients in the buprenorphine patch group. Nine patients (12%, p-value < 0.0001) who received the buprenorphine patch subsequently required additional analgesia. The pain score was found to be significantly less in the buprenorphine patch group on both day 1 and day 2, as were complications such as vomiting, nausea, nightmares, sweating and insomnia. The pain score in the buprenorphine group as significantly lower compared to the tramadol group. The use of the buprenorphine patch showed a slight increase in costs compared to the tramadol group (R7 800.75 vs R7 537.50; p-value 0.483) in the whole study. CONCLUSION: The study showed that the use of the buprenorphine patch is a reliable and effective method of postoperative analgesia, although it is slightly more expensive compared to the routine use of tramadol. The buprenorphine patch showed significantly better results in all assessed parameters; thus, it may be recommended for use at the Dr George Mukhari Academic Hospital (DGMAH).

Failed extubation in a tertiary-level hospital intensive care unit, Pretoria, South Africa.

Background: A prospective cohort study sought to measure the incidence and outcomes of failed extubation in Dr George Mukhari Academic Hospital intensive care unit (ICU), as well as to identify possible factors associated with failed extubation. Methods: Data were collected over a 6-month period from 1 July 2015 to 31 December 2015. Pre-intubation parameters recorded on the data collection sheet included secretions, Glasgow Coma Scale (GCS), fluid balance, Tobin index, partial pressure of carbon dioxide (pCO2 ), partial pressure of oxygen (PaO2 ), comorbidities and weaning method. Results: A total of 242 patients were enrolled over the 6-month study period. Of the 242 patients, 86 were excluded owing to pre-set exclusion criteria (death before extubation; tracheostomy before extubation; re-intubation >72 hours post extubation). An extubation failure rate of 16.7% (n=26) was observed. The incidence of ventilator-associated pneumonia in the failed extubation group was 19.23%, whereas death was recorded in 42.31% of patients who failed extubation. The average length of ICU stay in the reintubated group was 11.58 days, and 4.04 days for successfully extubated patients. Only low GCS had a statistically significant impact on failed extubation: p=0.0025; odds ratio (OR) for low v. normal 5.13 (95% confidence interval (CI) 1.78 - 14.79). Other predictor variables measured did not reach statistical significance. Weaning method: p=0.3737, OR for No T-piece v. T-piece 1.65 (95% CI 0.547 - 4.976); comorbidities: p=0.5914, OR for two or more comorbidities v. no comorbidities 2.079 (95% CI 0.246 - 17.539), no comorbidities v. single comorbidity 0.802 (95% CI 0.211 - 3.043); fluid balance: p=0.6625, OR for negative v. positive fluid balance 0.571 (95% CI 0.170 - 1.916), OR for neutral v. positive fluid balance <0.001 (95% CI <0.001 - >999.999); pCO2 : p=0.7510, OR for high v. normal pCO2 1.344 (95% CI 0.346 - 5.213), OR for low v. normal pCO2 1.515 (95% CI 0.501 - 4.576); PaO2 : p=0.4405, OR for high v. normal 1.156 (95% CI 0.382 - 3.494); OR for low v. normal PaO2 2.638 (95% CI 0.553 - 12.587); Tobin index (Fischer's exact test): p=0.7476. Conclusion: Low pre-extubation GCS is a predictor of failed extubation. Contributions of the study: The study is a prospective observational study conducted in a high-volume referral hospital. It adds valuable scientific information to a growing body of data on the topic of extubation failure. It further reinforces the importance of extubation failure and the requirement for due diligence to be paid before a patient is extubated.

Laterality of breast cancer at Dr George Mukhari Academic Hospital.

BACKGROUND: The purpose of this descriptive study was to determine and compare the incidence of left-sided and rightsided breast cancer at Dr George Mukhari Academic Hospital from January 2000 to June 2016. It aimed to determine if there was a significant variation in laterality of breast cancer at our institution. METHOD: A retrospective study. Medical records of breast cancer (BC) patients who were newly diagnosed from January 2000 to June 2016 were reviewed. Emphasis was on biopsy results (histology and/or cytology) and/or history of chemotherapy, and breast cancer laterality. RESULTS: Out of 1482 patients, 1427 had unilateral BC and 55 (3.7%) bilateral cancer. A total of 789 (55.3%) patients had left-sided breast cancer (LSBC) and 638 (44.7%) had right BC. Left BC was 10.6% more common than right BC with a left to right laterality ratio (LRR) of 1.24. There was a statistically significant relationship between laterality and stage (p = 0.050), with the right breast having more advanced stage cancers (88.7%) compared to the left breast (85%). There was no statistically significant difference between age, site and histological type of BC and laterality (p = 0.740, p = 0.052, p = 0.394 respectively). CONCLUSION: Left to right BC excess does exist in patients that were newly diagnosed at Dr George Mukhari Academic Hospital, South Africa, from January 2000 to June 2016.

Laparoscopy for blunt abdominal trauma: a challenging endeavor.

BACKGROUND AND AIMS: Laparoscopy in blunt abdominal trauma is challenging because of multiple associated injuries, higher trauma score values and higher morbidity and mortality, as compared with patients with penetrating abdominal trauma. The aim of this study was to investigate the role of laparoscopy in the management of blunt abdominal trauma patients and to highlight related challenges. MATERIAL AND METHODS: Over a 4-year period, patients managed laparoscopically for blunt abdominal trauma were retrospectively analyzed. Perioperative details, indications for laparoscopy and conversion, complications, and length of hospital stay were discussed. RESULTS: A total of 35 stable patients underwent laparoscopy. The mean Injury Severity Score was 12 (4-38). Therapeutic laparoscopy was performed in 15 (56%) and diagnostic in 12 (44%) patients. Eight (23%) patients were converted to therapeutic laparotomy. Intraoperative bleeding, complex injuries, visualization problem, and equipment failure necessitated conversion. Three (30%) patients with negative computed tomography scan had therapeutic laparoscopy for mesenteric injuries. There were no missed injuries. The mean length of hospital stay was 11 days in both groups. CONCLUSION: Laparoscopy for stable patients is feasible and safe. Multiple injuries make laparoscopy more difficult, and advanced laparoscopic skills are required. The conversion rate is high; however, the non-therapeutic laparotomies were completely eliminated in this study.

Registrar perceptions on general surgical training in South Africa: A report by the South African Society of Surgeons in Training (SASSiT).

BACKGROUND: Surgical training varies significantly amongst universities within the same country. This trend is reflected in South Africa and provides an opportunity for innovation to improve the quality of general surgical training. OBJECTIVE: To assess the perceptions of South African general surgery registrars regarding surgical training. METHOD: A prospective descriptive study was performed by means of a confidential questionnaire distributed to general surgical registrars at all eight training centers in South Africa. Participants were asked to give comments regarding adequacy of formal academic teaching, level of supervision during surgical procedures, exposure to and training in minimally invasive surgery (MIS), and preparation for examinations. Descriptive statistics were generated with Microsoft Excel. Ethics clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee. RESULTS: Of 200 questionnaires distributed 105 (52.5%) were returned. 44% (105/241) of all registrars from six training institutions participated. 89.5% (94/105) of respondents reported that they attended less than six hours of formal academic teaching per week and 71.4% (75/105) indicated that their institution offered less than six hours of formal academic teaching per week. 76.2% (80/105) of respondents regarded lack of protected academic time as the greatest obstacle to their surgical training and 95.2% (99/105) reported that clinical responsibilities prevented them from attending formal academic teaching regularly. Overall, only 31.4% (33/105), 41.9% (44/105) and 37.1% (39/105) were satisfied with the amount of formal academic teaching, level of supervision during theatre procedures and exposure to minimally invasive surgery respectively. Lack of resources and lack of appropriate skills were identified as a hindrance to MIS training by 47.6% (50/105) and 28.6% (30/105) of respondents respectively. CONCLUSION: Surgical registrars are dissatisfied with the amount of formal academic teaching and protected academic time, level of supervision in theatre and their exposure to MIS. These challenges compromise trainees' ability to practice independently after qualification. Numerous interventions are necessary and possible to address these challenges.

Trauma laparoscopy: A prospect of skills training (cohort study).

BACKGROUND: Diagnostic laparoscopy is well-accepted in management of penetrating abdominal trauma (PAT) with the rate of missed injuries below 1%. However, there is a reluctance to accept therapeutic laparoscopy in trauma society. The possible reason is a lack of laparoscopic skills by trauma surgeons. Moreover, no formal laparoscopy training program for trauma exists. The aim of this study was to interrogated our laparoscopy training particularly in trauma setting, and to investigate a possible relation between the seniority of surgeons performing the procedures and the complication rates. METHODS: All patients managed laparoscopically for PAT from January 2012 to December 2015 were analyzed. The seniority of operating surgeon was correlated with adverse outcomes, and with conversion. Surgeon-consultant (SC), assistant-consultant (AC), surgeon-senior-resident (SSR) and surgeon-junior-resident (SJC) groups were identified. Laparoscopic maneuvers used in this cohort were investigated and the set of essential laparoscopic skills was identified. The laparoscopic training program at our institution was described and discussed. RESULTS: Out of 283 patients with PAT approached with laparoscopy 33 (11.7%) were converted to laparotomy. Majority (49.6%) of laparoscopy was performed by senior resident. Consultant was an operating surgeon in 21.2% and an assistant in 8% of cases. Consultant was involved in cases with higher severity of injury and the complication rate was higher in the SC and AC groups. Essential laparoscopic skills were camera navigation, mobilization of intraabdominal organs, bowel run and intracorporeal suturing. During training, a senior resident was involved in 19% of operations for trauma. Trauma constituted 16% of all laparoscopy. CONCLUSION: Laparoscopy for trauma can be safely performed by residents under appropriate supervision. Laparoscopic skills should preferably be obtained during elective non-trauma procedures and transferred to trauma setting. Multimodal goal-directed, proctored training with regular assessments and feedback is effective and skills are transferable to trauma setting.

Registrar perceptions on general surgical training in South Africa: a report by the South African Society of Surgeons in Training (SASSiT)

Background: Surgical training varies significantly amongst universities within the same country. This trend is reflected in South Africa and provides an opportunity for innovation to improve the quality of general surgical training. Objective: To assess the perceptions of South African general surgery registrars regarding surgical training.Method: A prospective descriptive study was performed by means of a confidential questionnaire distributed to general surgical registrars at all eight training centers in South Africa. Participants were asked to give comments regarding adequacy of formal academic teaching, level of supervision during surgical procedures, exposure to and training in minimally invasive surgery (MIS), and preparation for examinations. Descriptive statistics were generated with Microsoft Excel. Ethics clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee. Results: Of 200 questionnaires distributed 105 (52.5%) were returned. 44% (105/241) of all registrars from six training institutions participated. 89.5% (94/105) of respondents reported that they attended less than six hours of formal academic teaching per week and 71.4% (75/105) indicated that their institution offered less than six hours of formal academic teaching per week. 76.2% (80/105) of respondents regarded lack of protected academic time as the greatest obstacle to their surgical training and 95.2% (99/105) reported that clinical responsibilities prevented them from attending formal academic teaching regularly. Overall, only 31.4% (33/105), 41.9% (44/105) and 37.1% (39/105) were satisfied with the amount of formal academic teaching, level of supervision during theatre procedures and exposure to minimally invasive surgery respectively. Lack of resources and lack of appropriate skills were identified as a hindrance to MIS training by 47.6% (50/105) and 28.6% (30/105) of respondents respectively. Conclusion: Surgical registrars are dissatisfied with the amount of formal academic teaching and protected academic time, level of supervision in theatre and their exposure to MIS. These challenges compromise trainees' ability to practice independently after qualification. Numerous interventions are necessary and possible to address these challenges

An investigation of diverticular disease among black patients undergoing colonoscopy at Dr George Mukhari Academic Hospital, Pretoria, South Africa.

BACKGROUND: Diverticular disease was previously thought to be non-existent in the black African population. Studies over the past four decades, however, have shown a steady increase in the prevalence of the disease. OBJECTIVE: To report on the profile and current prevalence of diverticular disease in the black South African (SA) population at Dr George Mukhari Academic Hospital, Pretoria, SA. METHODS: A retrospective descriptive study was performed in black SA patients who were diagnosed with diverticular disease by colonoscopy between 1 January and 31 December 2015. RESULTS: Of 348 patients who had undergone colonoscopies and who were eligible for inclusion in this study, 47 were diagnosed with diverticular disease - a prevalence of 13.50% (95% confidence interval 10.30 - 17.50). The greatest number of patients diagnosed were in their 7th and 8th decades, with an age range of 46 - 86 (mean 67) years. There was a female predominance of 57.45%. Lower gastrointestinal bleeding was the most common (65.96%) indication for colonoscopy. The left colon was most commonly involved (72.34%), followed by the right colon (55.31%). A substantial number of patients had pancolonic involvement (27.65%). CONCLUSION: This retrospective study suggests that there has been a considerable increase in the prevalence of diverticular disease among black South Africans, possibly owing to changes in dietary habits and socioeconomic status.

An investigation of diverticular disease among black patients undergoing colonoscopy at Dr George Mukhari Academic Hospital, Pretoria, South Africa

Background. Diverticular disease was previously thought to be non-existent in the black African population. Studies over the past four decades, however, have shown a steady increase in the prevalence of the disease.Objective. To report on the profile and current prevalence of diverticular disease in the black South African (SA) population at Dr George Mukhari Academic Hospital, Pretoria, SA.Methods. A retrospective descriptive study was performed in black SA patients who were diagnosed with diverticular disease by colonoscopy between 1 January and 31 December 2015.Results. Of 348 patients who had undergone colonoscopies and who were eligible for inclusion in this study, 47 were diagnosed with diverticular disease ­ a prevalence of 13.50% (95% confidence interval 10.30 - 17.50). The greatest number of patients diagnosed were in their 7th and 8th decades, with an age range of 46 - 86 (mean 67) years. There was a female predominance of 57.45%. Lower gastrointestinal bleeding was the most common (65.96%) indication for colonoscopy. The left colon was most commonly involved (72.34%), followed by the right colon (55.31%). A substantial number of patients had pancolonic involvement (27.65%).Conclusion. This retrospective study suggests that there has been a considerable increase in the prevalence of diverticular disease among black South Africans, possibly owing to changes in dietary habits and socioeconomic status

Multiple concurrent bilateral groin hernias in a single patient; a case report and a review of uncommon groin hernias: A possible source of persistent pain after successful repair.

INTRODUCTION: The wide use of laparoscopy for groin hernia repair has unveiled "hidden hernias" silently residing in this area. During the open repair of the presenting hernia, the surgeon was often unaware of these occult hernias. These patients postoperatively may present with unexplained chronic groin or pelvic pain. PRESENTATION OF CASE: Rare groin hernias are defined according to their anatomical position. Challenges in the diagnosis and management of occult rare groin hernias are discussed. These problems are illustrated by a unique case report of multiple (six) coexisting groin hernias, whereof five were occult and two were rare. DISCUSSION: Rare groin hernias are uncommon because they are difficult to diagnose clinically and are not routinely looked for. They are often occult and may coexist with other inguinal hernias, thus posing a diagnostic and treatment challenge to the surgeon, especially if there is persistent groin pain after "successful" repair. MRI is the most accurate preoperative and postoperative diagnostic tool, if there is a clinical suspicion that the patient might have an occult hernia. CONCLUSION: Preperitoneal endoscopic approach is the recommended method in confirming the diagnosis and management of occult groin hernias. A sound knowledge of groin anatomy and a thorough preperitoneal inspection of all possible sites for rare groin hernias are needed to diagnose and repair all defects. The preperitoneal mesh repair with adequate overlap of all hernia orifices is the recommended treatment of choice.

Haemangiopericytoma/solitary fibrous tumour of the greater omentum.

We report a rare case of haemangiopericytoma/solitary _brous tumour of the greater omentum in a 41-year-old woman. It presented as a large mobile abdominal mass measuring 30 × 24 × 8 cm. A computed tomography scan con_rmed the presence of a large vascular tumour, and biochemical tumour markers were non-contributory. The tumour was removed through a conventional laparotomy incision with the aid of a Ligasure dissector. There were no macroscopic metastases, and histologically it was benign. The size of >5 cm, however, suggests that it may have been malignant. In the absence of visible metastases and in view of the favourable histological features, it was decided to follow up the patient very closely and give further treatment if necessary.