Histological evidence of hypertrophy and ischaemia in sigmoid volvulus among Africans.

OBJECTIVE: To document histological evidence of hypertrophy and ischaemia in sigmoid volvulus among Africans. DESIGN: Retrospective case series study of the histology of sigmoid volvulus over seven years with cadaveric controls. SETTING: King Edward VIII Teaching Hospital, University of Natal, Durban, South Africa. SUBJECTS: Fifty African patients with sigmoid volvulus and nine cadavers with normal sigmoid colon. RESULTS: There was hypertrophy of the submucosa, muscularis propria and nerve plexuses with features of ischaemia in the patients' specimens. Their veins were thrombosed and recanalized while mesentery and submucosa had fibrosis and vascular hyalinization. There was also hypertrophy and hyperplasia of Meissner's nerve plexus. In the autopsy study, normal African sigmoid specimen showed similar ischaemic features but specimens from the four Indian patients in the study did not have such abnormalities. CONCLUSION: We postulate that chronic ischaemia may account for postoperative anastomosis dehiscence in some cases where the resection margins involved the hypertrophic segment. The benefit of an extended resection with anastomosis being effected on the bowel with apparent normal thickness to avoid this possibility should be investigated.

Hyponatraemia--a prospective analysis of surgical patients.

A prospective study of 71 patients with hyponatraemia was undertaken over an 18-month period in one surgical unit at King Edward VIII Hospital, Durban, to study the incidence and pattern of hyponatraemia. Electrolytes and urea values were measured serially in all patients. Hyponatraemia was defined as a serum sodium level of < 130 mmol/l. The incidence of hyponatraemia was 2.2%, the most common type being normovolaemic hypotonic hyponatraemia. Hyponatraemia was either mild (sodium level 120-130 mmol/l) or moderate (111-120 mmol/l). No patient had severe hyponatraemia (< 110 mmol/l). Hyponatraemia was corrected within 1-6 days using normal saline; in 73% of patients it was corrected within 24 hours. No patient developed neurological symptoms. A mortality rate of 28% was attributed to underlying illness, and hyponatraemia per se was asymptomatic in this study. Aggressive sodium correction was therefore not indicated.

Favourable prognosis after surgical drainage of gunshot, stab or blunt trauma of the pancreas.

The records of 152 patients with pancreatic injury treated over a 5-year period were reviewed. The diagnosis was made at laparotomy in all patients. Gunshot wounds, stab wounds and blunt trauma occurred in 63, 66 and 23 patients respectively with mean ages of 28, 28 and 30 years. Multiple organ injury was most common after gunshot wounds. Intraoperative management was by drainage of the pancreatic injury site alone in the majority of patients in all aetiological groups. The rate of fistula formation was 14 per cent after gunshot wounds, 9 per cent after stab injury and 13 per cent after blunt trauma. Death occurred after 24 h in 8, 2 and 10 per cent of patients following gunshot wounds, stab wounds and blunt trauma respectively, and was attributable to other organ damage. It is concluded that gunshot injury to the pancreas may be more extensive than other injuries, but conservative management with surgical drainage of pancreatic injury is justified irrespective of the mechanism of injury.

Sigmoid volvulus among Africans in Durban.

The pattern of presentation and management of 90 patients treated for sigmoid volvulus over a 7-year period was studied. There was a 9:1 male preponderance and 64% were under 50 years of age. Intestinal obstruction was the presenting feature in 84%, while the rest presented with acute abdomen or pain. Unlike other African series, this constituted only 8% of intestinal obstruction. Sixty-one per cent were managed by sigmoidoscopic decompression and semi-elective sigmoidectomy, and 30% had an emergency operation. A primary anastomosis was undertaken in 71% while others, mainly emergency cases, had a temporary colostomy. There was a 20% morbidity and 12% mortality, 80% of which was in the emergency operation group. It is concluded that the pattern of sigmoid volvulus among Durban Africans differs from that reported in other African countries where young males predominate, and from that in Western societies with elderly female preponderance. When volvulus necessitates emergency surgery, it carries a substantial mortality even in relatively young patients and therefore we advocate resection in all patients during the same hospital admission even in those whose torsion is easily reduced at sigmoidoscopy lest a recurrence fails to reduce.

Early operative management of chylothorax by thoracic duct ligation.

Chylothorax following mediastinal mobilisation for carcinoma of the oesophagus can be devastating, especially in malnourished, debilitated patients. Early surgical management in significant chylothorax (+ 500 ml/d) is suggested before nutritional degeneration occurs. Conservative management should be reserved for those patients who drain less than 500 ml/d.