How far has the pendulum swung in the surgical management of sigmoid volvulus? Experience from the KwaZulu-Natal Teaching Hospitals and review of the literature.

AIM: Sigmoid volvulus is common in sub-Saharan Africa. The aim of the study was to document the clinicopathological patterns of sigmoid volvulus in KwaZulu-Natal. METHOD: Analysis was performed of prospectively collected data of patients presenting with sigmoid volvulus at the KwaZulu-Natal Teaching Hospitals from 2000 to 2009. Data collected included demographics, clinical presentation, operative findings, management and outcome. RESULTS: There were 135 patients (122 male) of mean age 39.3 ± 17 years. Management was by emergency surgery (103), elective surgery (23), no surgery (9). The level of the twist was at the pelvic brim. Fifty-four patients had gangrenous bowel and 81 had viable bowel. Resection was accompanied by primary anastomosis (80) and Hartmann's procedure (46). Complication and mortality rates were 47% and 17% respectively. Mortality rates for emergency and elective surgery were 19% and 9% (P = 0.330), and those for primary anastomosis and Hartmann's procedure were 14% and 24% respectively (P = 0.305). Mortality rates for gangrenous and viable bowel were 21% and 15% respectively (P = 0.624). Twenty-eight (22%) patients required intensive care in the intensive care unit (ICU) with an ICU stay of 8.8 ± 8 days. Hospital stay was 10.5 ± 14.4 days. CONCLUSION: The clinicopathological picture of sigmoid volvulus resembles that in the rest of Africa in that it affects predominantly young African males. The level of the twist is at the pelvic brim. The timing of surgery, the type of anastomosis and the viability of the bowel does not influence outcome.

Setting the records straight--a prospective audit of the quality of case notes in a surgical department.

BACKGROUND: A high standard of medical record keeping is important for safe patient care and provides information for research, audit and medicolegal purposes. Standards exist on what entries should contain, but as far as we are aware these standards are not regularly used in South Africa. We compared surgical case notes at Prince Mishyeni Hospital with guidelines from the Royal College of Surgeons of England. PATIENTS AND METHODS: A prospective series of 204 case notes was randomly selected and reviewed. RESULTS: There was an 80% compliance rate for 16/35 standards, and 100% was achieved for 8 operation sheet standards. The following fell short of 80% compliance: patient's name on every page (71%), hospital number on every page (50%), every entry timed (16%), clinician's name printed on every note (8%), clinician's designation on every entry (2%), an entry each weekday (77%), type of admission (9%), presenting complaint (61%), history of presenting complaint (65%), previous medical history (76%), drug history (47%), allergies (59%), social history (34%), family history (11%), each entry legible (65%), and anaesthetist's name (69%). Test results were signed and radiograph test results initialled in 25% and 17% of cases respectively. CONCLUSION: Legal requirements, good practice, research and teaching all demand notes that are detailed and of high quality. This study shows that medical records are grossly inadequate in many respects. Better education of junior staff and regular auditing of medical records could improve this.

Outcome of head injuries in general surgical units with an off-site neurosurgical service.

INTRODUCTION: In order to cope with bed shortages in the only neurosurgical unit (NSU) in KwaZulu-Natal, it has become necessary to manage head injured patients in a general surgical unit (GSU) at the referral hospitals in consultation with the NSU. This study was undertaken to assess the outcome of patients with head injuries managed in a GSU in consultation with a regional NSU. PATIENTS AND METHODS: A prospective pilot study was carried out in a single surgical unit over an 18-month period (July 1997-December 1998), followed by a larger prospective study over a 6-month period (January-June 2001). All patients with head injuries severe enough to warrant admission to hospital (GCS < or =15 or 15 with localising signs) were included. RESULTS: The pilot study comprised 86 patients and the subsequent study comprised 230 patients, giving a total of 316 patients in the whole study. The mean age was 31 +/- 12 years. Following consultation with the NSU, 265 (84%) patients were managed in the GSU and 51 (16%) required transfer to the NSU. Forty-one patients died giving a mortality rate of 13%. Twenty eight of the 42 patients with GCS < or =8 died (67%) compared to 13 out of 274 with GCS >8 (5%) (p<0.0001). Eleven of the 51 patients destined to the NSU died (22%) compared to 30 of 265 in the GSU (11%) (p=0.046). The average hospital stay was 10 +/- 18 days. Forty surviving patients (17%) from the GSU and 20 from the NSU (51%) were discharged with neurological sequelae (p<0.001). CONCLUSION: Head trauma is associated with high morbidity and mortality. Non-surgical treatment of traumatic brain injury at the referral hospital by the GSU is acceptable practice. Outcome is determined primarily by the GCS on presentation. NSU patients had a significantly higher mortality rate. A delay before surgery did not seem to affect outcome.