Establishing and integrating datasets beyond instilling a culture of capture

Whilst the double-blind, randomised clinical trial has established itself at the apex of the evidence pyramid for modern medicine, surgical research has always suffered from a degree of epistemological elitism and snobbery by the medical disciplines. This is because the majority of surgical progress has been made as a result of the lowly surgical audit rather than the double-blind, randomised control trial (RCT). This is unfair as the benefits of clinical audit in surgery are manifest. Ambrose Pare was an early example of a surgeon who, out of necessity, applied his mind and came up with a pragmatic but radical solution to a pressing clinical problem. During the interminable internecine wars of the Renaissance period, he began to apply linen dressings to wounds rather than cautery, and so changed the practice of surgery for the better. The same can be said of Semmelweis, an early adopter of surgical asepsis, at a time when the germ theory was still not conceived. Without any theory to support his praxis, he advocated hand washing for medical students returning from their morning post-mortem session, before beginning work in the maternity wards. His simple intervention radically reduced hospital-related maternal mortality rates. Semmelweis paid a heavy professional price for his radical disruption of vested interests. He was driven from Vienna and ended his days working far from the major hospitals of Vienna. He is posthumously referred to as the Saviour of the mother.

A long walk to freedom: the epidemiology of penetrating trauma in South Africa – analysis of 4 697 patients over a six-year period at Chris Hani Baragwanath Academic Hospital

South Africa is a developing country with an exceptional past, our legacy is that of a prolonged freedom struggle, characterised by singular political violence and state-mandated oppression. Defined by constitutional racial seclusion and exploitation, this has finally given way to a non-racial democracy. At its core, the political conflict has largely receded, yet alarmingly high levels of interpersonal violence remain, fuelled by rapid urbanisation and continuing socioeconomic inequalities. News of violent crime frequently makes headlines, and Johannesburg is now regarded as one of the most dangerous cities in the world – with the Gauteng province consistently having the highest gross numbers for murder for the 2010–2018 period.

Damage control laparotomy outcomes in a major urban trauma centre

Trauma remains a worldwide leading cause of death. The Western Cape has a particularly high rate of interpersonal trauma, with a high proportion being penetrating in nature. This fact lends itself to specific injury patterns that victims present to hospital requiring specialised trauma and surgical care. Among these surgical techniques is the concept of damage control surgery (DCS). Originally documented by Pringle in 19022 as a staged laparotomy, the innovation of damage control (DC) progressed through the middle and late 1900s. Its use waxed and waned, gaining traction in the Second World War, but then being largely abandoned during the Korean and Vietnam wars where it was seen as a sign of poor surgical skills. It was not until Stone et al. and then, a decade later, Rotondo et al. showed its benefit, that DC was finally accepted into mainstream trauma surgery. ‘Damage Control’ mode starts in the trauma unit with well-defined damage control resuscitation interventions and goals.

Never to be missed again – an analysis of 55 consecutive cases of traumatic diaphragmatic hernia

Traumatic diaphragmatic hernia (TDH) is defined as theprotrusion of the abdominal structures through an injured diaphragm into the thoracic cavity. The relative incidence of blunt and penetrating diaphragmatic injury (DI) reflects differences in geographic regions and socioeconomic characteristics of these regions. Blunt trauma (BT) is often common in developed regions; however, less developed regions have higher rates of penetrating injuries. A recent review of 3 783 patients with DI suggested that 67% were diagnosed with penetrating trauma (PT) and 33% with BT. PTs are commonly associated with gunshot wounds (GSW) (66%), while BTs are commonly associated with motor vehicle collisions (MVC) (63%).

An audit of trauma laparotomy in children and adolescents highlights the role of damage control surgery and the need for a trauma systems approach to injury in this vulnerable population

Trauma and injury contribute significantly to the burden of surgical disease in the world and are a leading cause of death and disability in young people and children. Children in the developing world are particularly at risk for sustaining trauma as injury prevention programmes are not well established, and enforcement of traffic and health and safety regulations often ineffective. In addition, poverty in itself appears to be a risk factor for sustaining trauma. In most countries, the incidence of intentional trauma in children is relatively low and this means that most of the trauma in these countries is non-intentional and blunt in nature. Blunt abdominal trauma is increasingly managed non-operatively, and this means that the need for laparotomy in children following abdominal trauma is decreasing. For all these reasons, experience with laparotomy for trauma in children may well be decreasing.

Isolated ductal carcinoma in situ in patients presenting to two breast units in Johannesburg

Ductal carcinoma in situ (DCIS) is a non-obligatory premalignant condition characterised by neoplastic cells confined to the breast ductal system. It carries a potential risk of progressing into invasive breast cancer, more so in high-grade DCIS.3The overall breast cancer-specific mortality for DCIS at 20 years is 3.3%.

Magseed placement before neoadjuvant chemotherapy to facilitate subsequent breastconserving surgery – a single-centre audit

Adjuvant or postoperative systemic therapy has been the main form of treatment for early-stage breast cancer for many years and neoadjuvant chemotherapy (NACT), referring to the use of systemic therapy before surgery, was reserved for the treatment of inoperable, locally advanced disease. However, recently published guidelines document a shift in practice to using NACT in patients with early breast cancer. Multidisciplinary teams are now using tumour biology rather than stage to guide treatment, with the result that patients with smaller tumours now receive NACT. Among the benefits of NACT is an increase in the feasibility of breast-conserving surgery (BCS) among women with early breast cancer who would otherwise require mastecto my due to unfavourable breast-to-tumour ratio, and an increase in the cosmesis ofbreast-conserving surgery among BCS candidates who might otherwise achieve inferior cosmetic results due to unfavourable breast-to-tumour ratio. With the development of new chemotherapeutic agents, dramatic response rates can be achieved in patients receiving NACT.

Triple-negative breast cancer – a retrospective audit of 151 cases seen at the Charlotte Maxeke Johannesburg Academic Hospital Breast Unit

Using DNA micro-arrays constructed from samples of human breast cancers and analysing patterns of gene expression, Perou et al. were able to divide breast cancers (BCs) into five molecular groups, each associated with specific receptor profiles. These are luminal A, luminal B, HER2 expressed, basal and normal-like. The luminal subgroups are characterised by hormone receptor expression and HER2 with amplification of the HER2 receptor. The basal subgroup lacks all three receptors and is described as triple-negative. The normal-like subgroup consists of breast stroma and few tumour elements. Triple-negative breast cancer (TNBC) is an aggressive, rapidly lethal malignancy, the proportion of which varies from 7% to 85% depending on age, menopausal status, ethnicity and the geographic location of the women with breast cancer. Gene expression profiling has identified marked heterogeneity within the triple-negative subgroup, in which, six subtypes have been identified. Seventy to 80% of TNBCs have the basal-like genome with gene clusters encoding for basal cytokeratin and epidermal growth factor receptor proteins.

Impact of COVID-19 on breast cancer diagnostic and surgical services at a South African academic hospital

Breast cancer is the most common cancer amongst women worldwide and the leading cause of cancer-related death. Women from low- to middle-income countries (LMIC) are particularly affected by resource limitations. Maintaining an optimal breast cancer service whilst mitigating the risks associated with COVID-19 in already strained clinical services has been a challenge for health systems throughout the world. Recommendations for the prioritisation of breast cancer care during the pandemic as well as strategies for the resumption of breast cancer services have been published. These recommendations are focused on balancing individual cancer risk against COVID-19 risk by stratifying patients according to tumour size and tumour biology. Although these recommendations do suggest strategies for prioritising cancer care in a resource-limited setting, there is a scarcity of data published from LMICs where this balance is particularly challenging.

The spectrum and outcome of paediatric emergency surgical admissions – a regional hospital analysis

Maternal and child health remains a priority for many low- and middle-income countries (LMICs), including South Africa. This is despite achieving a 53% decrease in the under-5 mortality rate since the adoption in 2000 of the Millennium Development Goals. The United Nations has set a new goal of less than 25 deaths per 1 000 live births by 2030. The attainment of this goal includes environmental, social and economic, as well as healthcare strategies. Recently, there has been a realisation that acute surgical care of the paediatric population plays an important role in improving child health and decreasing preventable deaths and resulted in the establishment of the Global Initiative for Children’s Surgery (GICS). This initiative was established in 2016 and aimed at identifying solutions to problems in children’s surgical care in LMICs by encouraging LMIC–LMIC and high-income countries (HICs)-LMIC partnerships targeting improvement in infrastructure, service delivery, training and research by using the resources of HICs and leadership and experience of LMICs in an attempt to improve children surgical care.

The impact of non-closure of the platysma muscle layer on the cosmesis of thyroidectomy scar – a randomised double-blind controlled trial

Thyroidectomy is the most common endocrine surgical procedure performed throughout the world. In the city of Ibadan, Oyo State, Nigeria, it is one of the common elective surgical procedures performed. Open thyroidectomy is indicated for both benign and malignant thyroid conditions. Access to the thyroid gland usually commences by cutting through the skin and the platysma, which is a broad sheet of thin muscle located immediately under the subcutaneous fat, and covering the anterior neck as well as the upper chest regions on both sides. Due to its insertion to the skin, the platysma plays a part in facial expression, and may assist in opening the mouth.

Early-onset malignant solid tumours in young adult South Africans – an audit based on histopathological records of patients seen at the three academic hospitals in Johannesburg

Cancer is among the leading causes of death in adults below the age of 70 years in high-income countries (HICs). Cancers are categorised into haematological and nonhaematological malignancies, and the non-haematological malignancies are referred to as malignant solid tumours. Lung, breast, prostate, colon, non-melanoma skin cancers and tumours of the urinary bladder are the most common malignant solid tumours globally. Breast cancer is the most common solid tumour in adult females in most countries including in Africa.6 More than 60% of cancers in adults occur in individuals in low- and middle-income countries (LMICs).

Chronic groin pain in Desarda versus Lichtenstein hernia repair – a randomised controlled study

The incidence and prevalence of inguinal hernia are not precisely known but are estimated at 1.7%. The lifetime risk of a person requiring inguinal hernia surgery is 27% in men and 3% in the case of women. In 1987, Lichtenstein described reinforcement of the posterior wall using a mesh resulting in tension-free repair. Today this method is widely used owing to its ease of application and lower recurrence rates. However, many mesh-related complications have been noted in clinical practice, including infection, pain, foreign body sensation, seroma, mesh rejection, mesh migration, adhesions, fibrosis, calcification, and thrombosis. To prevent these complications, Desarda in 2001 described a technique of tissue repair based on the concept of providing a robust, mobile and physiologically dynamic posterior inguinal wall.

Reflections on the development of the Hybrid Electronic Medical Registry in Pietermaritzburg

The senior author has spent almost all of his surgical training and career at University of KwaZulu-Natal (UKZN) and as such has been influenced by the rich surgical heritage of the surgical department and its affiliated hospitals. The surgical department developed in an environment of a huge patient load and limited resources, while being tasked to provide care and undertake research. It was evident to the former head of surgery at the time, Professor Lynne Baker, that the contribution to surgical knowledge was going to be focused on common diseases in the region and was going to be based on surgical audit.

A surgeon’s journey into the world of IT: the database

The need for quality data at Worcester Hospital became apparent in the early 2000s when monthly reporting of “surgical wound infections” was introduced by the hospital administration as a quality-of-care indicator in surgical wards. Nursing staff were tasked to capture the data, and an inordinate monthly number of “surgical wound infections” were reported directly to hospital management, who entered this into a provincial health information system. Closer scrutiny revealed a system designed without the guidance of surgeons that erroneously collected data on patients with soft tissue infection and diabetic foot sepsis and not as intended only those with surgical site infections. The lesson learnt was poor design means garbage in, and hence you will get garbage out. Clinicians should take the lead in monitoring their specialty-specific outcomes, by starting with a welldefined question and work backwards to enable database design.

The George Hospital theatre documentation and information system

George Hospital is a secondary level hospital in the Garden Route district of the Western Cape. Its theatre complex consists of five theatres and an endoscopy suite. The main stakeholders in the theatre complex are the surgical disciplines, the nursing staff and anaesthesiology. The thread that connects all stakeholders of theatre is the documentation requirements of every case that passes through the complex. This process has historically been associated with two specific frustrations: the legibility of notes and the duplication of information evident in creating the necessary documents for the surgeon, anaesthetist, and nursing staff. The information recorded was often illegible, uncoded and incomplete.


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South African Journal of Surgery - June 2022 - Vol 60 No 2