The management and outcomes of hepatocellular carcinoma in sub-Saharan Africa: a systematic review.

BACKGROUND: Hepatocellular carcinoma (HCC) is a leading cause of mortality in sub-Saharan Africa (SSA). This systematic review aimed to appraise all population-based studies describing the management and outcomes of HCC in SSA. METHODS: A systematic review based on a search in PubMed, PubMed Central, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), AfricaWide and Cochrane up to June 2023 was performed. PRISMA guidelines for systematic reviews were followed. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration no: CRD42022363955). RESULTS: Thirty-nine publications from 15 of 48 SSA countries were identified; 3989 patients were studied. The majority (74%) were male, with median ages ranging from 28 to 54 years. Chronic Hepatitis B infection was a leading aetiology and non-cirrhotic HCC was frequently reported. Curative treatment (liver resection, transplantation and ablation) was offered to 6% of the cohort. Most patients (84%) received only best supportive care (BSC), with few survivors at one year. CONCLUSION: The majority of SSA countries do not have data reporting outcomes for HCC. Most patients receive only BSC, and curative treatment is seldom available in the region. Outcomes are poor compared to high-income countries.

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 trauma to the kidney and Meckel's Diverticulum in a patient with unilateral renal agenesis.

INTRODUCTION: Emergency laparotomy for abdominal gunshot wounds is frequently performed in South Africa and remains associated with significant morbidity and mortality. The occurrence of congenital anomalies during surgery is an unexpected finding and presents a major challenge. PRESENTATION OF CASE: The successful management of a haemodynamically unstable 26-year-old man with unilateral renal agenesis, concomitant right renal and hepatic injuries, and a transected Meckel's Diverticulum following an abdominal gunshot wound is presented. DISCUSSION: Intraoperative decision-making is difficult when congenital visceral anomalies form part of the injury complex in trauma. Basic principles of damage control surgery that include initial exploration, secondary resuscitation and definite operation must be adhered to. Repair of complex injuries are delayed until the definitive laparotomy. The presence of one congenital anomaly should alert the surgeon to the possibility of further anomalies. CONCLUSION: Although congenital visceral anomalies are spectacular findings at laparotomy, they should not distract the trauma surgeon. Adhering to damage control surgery principles and careful inspection of the peritoneal cavity for further abnormalities remain the mainstay of successful management.

Enterohepatic Migration of Fish Bone Resulting in Liver Abscess.

Liver abscess formation due to enterohepatic migration of a foreign body is extremely rare. Foreign body ingestion is generally an unconscious and painless event, thus complicating preoperative diagnosis in most patients. We report the case of a 61-year-old man who presented with secondary peritonitis from a ruptured hepatic abscess after an ingested fish bone migrated into the liver.

A survey of medical students on their attitudes towards face transplantation.

The aim of this study was to assess and analyse the attitudes of medical students towards face transplantation. Medical students at the University of Cape Town were prospectively surveyed using a self-administered questionnaire. There were 402 participants; the mean age was 21 years (range 16-37 years), 35% were male and 65% were female. Only 12% were registered organ donors and 33% were interested in a surgical career. Two thirds of the respondents were in favour of face transplantation. Registered organ donors were the most willing to donate their face in the event of brain death (P = 0.00). Seventy-four percent of the respondents stated 'identity issues' as their main concern and 33% mentioned cost as a critical factor when considering the procedure. Personal experience with facial disfigurement and involvement in the care of a patient with facial disfigurement did not affect the willingness to donate or accept a face transplant, or the amount of support for the procedure (P > 0.05). This is the first study that exclusively describes the attitudes of medical students towards face transplantation.

Attitudes and beliefs of South African medical students toward organ transplantation.

The aim of this study was to assess and analyse the attitudes and beliefs of medical students regarding organ donation, procurement, and transplantation. Medical students at the University of Cape Town were prospectively surveyed using a self-administered questionnaire. There were 346 study participants; the mean age was 21 (range 18-33) yr, 38% were male and 62% was female. Only 8% of respondents were registered donors; clinical and white students constituted the majority of this group. Of the 315 "non-donors," the main reason for not donating was "I have not really thought about organ donation" (59%). Most students (91%) would accept an artificial organ; and 87% and 52% of students would accept human and animal organs respectively. Muslim students (11%, p<0.05) and those who believe in an after-life or reincarnation (18%, p=0.00) were less willing to accept human or animal organs. About 95% of respondents stated that they would like to learn more about transplantation and would keep information about it in their practice but only 18% of respondents knew where to find information for potential donors and recipients. Most students have a favorable attitude toward organ transplantation; religion and belief systems impact on willingness to receive organs.

Penetrating cardiac injury following sewing needle ingestion.

Penetrating cardiac injuries are common in South Africa. Reports describing traumatic lesions to the heart caused by caudo-cranial migration of ingested foreign bodies are however extremely rare. Delayed presentation and intervention are associated with poor outcome in these patients; cardiac tamponade remains the most serious complication. We present the case of a 19 year-old man who sustained a left ventricular injury after intentionally swallowing eight sewing needles. The impacted needle was removed through a median sternotomy and the patient recovered uneventfully.

Management of the retained knife blade.

BACKGROUND: The retained knife blade is an unusual and spectacular injury. The aim of this study was to review our experience with the management of such injuries. METHODS: A retrospective chart review of patients with retained knife blades treated at Groote Schuur Hospital Trauma Centre from January 1996 to December 2007 was undertaken. RESULTS: Thirty-three patients with retained knife blades were identified. Site of wound entry was the thorax in 13 patients (40%), the neck and back in 7 patients (21%) each, upper and lower extremities in 4 (12%), and the face and abdomen in 1 patient (3%) each. Thirty patients (91%) were hemodynamically stable on admission; two (6%) presented with wound abscesses, and one patient (3%) with active bleeding required emergency surgery. All 33 blades were extracted after clinical and radiological assessment. Simple withdrawal of the blade was possible in 19 cases (58%) and the likelihood of post-extraction bleeding was only 5%. Thirteen patients (40%) required an open surgical approach through dissection of the entry wound, laparotomy, or thoracotomy. Video-assisted thoracoscopic removal was used in one case. Retained thoracic blades were significantly associated with postoperative sepsis (P = 0.0054). There were no deaths. CONCLUSIONS: All impacted knife injuries require careful clinical and radiological assessment. Simple withdrawal can be performed safely in the emergency room provided potential life-threatening vascular and solid organ injuries have been excluded. There should be a low threshold for investigating and treating patients with retained intrathoracic blades for postoperative sepsis.

First case report of pharyngeal cysticercosis.

An 86-year-old woman with pharyngeal cysticercosis presented to Victoria Hospital, Cape Town, South Africa in February 2007 with active neurocysticercosis and subcutaneous tissue involvement. Diagnosis was based on clinical, radiological and histopathological grounds. The patient was successfully managed with surgical excision of the oropharyngeal cyst and subsequent chemotherapy with albendazole. This was a rare case of pharyngeal cysticercosis and illustrates that Taenia solium can invade the upper aerodigestive tract. The occurrence of cysticercosis in pharyngeal tissue adds a new dimension to the manifestation of this disease and should alert to more severe generalised disease.