Strategies for recovery of a surgical service in the COVID-19 era

The elective surgery backlog

The COVID-19 pandemic has brought unparalleled change and challenges to the healthcare system. The surging waves of ill and critically ill patients have necessitated a dramatic redistribution of various resources, including those allocated to the provision of elective surgery. The global backlog of elective cases after the first wave was estimated to be around 30 million, a backlog that would take almost a year to clear if hospitals increased their normal surgical volumes by at least 20%. Local data from six Western Cape secondary level hospitals showed that during the first wave, total surgeries decreased by 44% and elective surgeries by 74%. The surgical backlog in these hospitals would take from 4 to 14 months to clear if each hospital performed one additional operation per weekday. A tertiary academic centre in the KwaZulu-Natal province reported a deficit of 1 260 cases in the first wave, which would take them 315 days to clear if four additional cases were done per weekday. There is no data on the cumulative impact of the second and third waves on elective surgery backlogs, but an estimate from our centre, another tertiary academic hospital in the Western Cape province, is that 1 500 lists were lost, resulting in the cancellation of around 8 000 elective operations. In the unlikely scenario of no further disruption to the regular elective service by further COVID-19 waves, opening an extra theatre to do four cases per weekday would take over 8 years to recover this backlog.

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

There is a lack of data which describes the efficiency of transdermal analgesia against conventional opioid use in general surgical patients after major surgical interventions.  Buprenorphine in a transdermal form can be used because of its convenience, decreased nursing work, cost-effectiveness  and it is less time consuming. In contrast to the transdermal system, the conventional use of an analgesic in the form of a tramadol injection is associated with some inconveniences,  such as pain at the site of the injection, substantial nursing  labour and inadequate pain relief (pain may be substantial in between the injections).

A randomised control trial of intraoperative and early outcome in scalpel versus monopolar diathermy for midline abdominal incisions

Skin incisions have traditionally been made using a scalpel.1,2 The alternative is cutting diathermy despite the perception that it impairs healing, increases infection risk and has worse cosmesis. This study aimed to compare the intraoperative and early postoperative outcomes of midline abdominal incisions made using scalpel with monopolar diathermy. The primary endpoints were to compare incision time and volume of blood loss, while the secondary endpoint was to compare surgical site infection rates.

Striking a balance between usability and quality control in electronic health records

With the increased use and capacity of smart technology in everyday life, electronic medical records systems are no longer passive repositories, but present an opportunity to integrate human factors engineering concepts into the ergonomics of clinical practice. This should be done in such a way as to improve clinical outcomes of patients and to support human clinical decision making. Such systems are known as clinical decision support systems (CDSS). There has been widespread interest in the development of such systems in sub-Saharan Africa as they may well augment scarse clinical resources and may act as a force multiplier in relatively low resource environments. Unfortunately, poor design often results in systems that are cumbersome and which hamper clinical workflow and decision making, rather than supporting and enabling them.

A comparison of invasive lobular carcinoma with other invasive breast cancers at Tygerberg Academic Hospital

Breast cancer is the most common cancer afflicting women in the developed and developing world. In 2014, the incidence of breast cancer in South African women was estimated to be 33 per 100 000 per year and made up approximately 22% of all cancer in women. It is therefore paramount to have a good understanding and approach to the diagnosis and treatment of the disease. Invasive lobular carcinoma (ILC) is the second most common histological subtype of breast carcinoma. ILC differs from invasive breast carcinoma of no special type (IBC-NST) in terms of risk factors, behavioural pattern and morphology.

An audit of clinically triaged women at low risk for breast cancer presenting to the Helen Joseph Mammography Unit

Breast cancer remains the foremost cancer in females in both high and middle-to-low-income countries. The 2018 Ekurhuleni Population Based Cancer Registry demonstrated that breast cancer was the most common cancer amongst the female population within this Johannesburg district.

Feasibility and impact of a one-stop thyroid clinic in a low- and middle-income country

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent due to awareness and adoption of ultrasonography (USG). In developed countries, patients are referred to a specialist thyroid surgeon by a primary care physician and/or endocrinologist after adequate evaluation and often with a diagnosis. But in many low- and middle-income countries (LMICs), the system of referral is not that robust and a substantial number of patients with a thyroid nodule are referred without the basic investigations.

The spectrum, management and outcome of cellulitis in subtropical South Africa

Cellulitis is defined as acute inflammation of the skin with involvement of the dermal and subcutaneous tissue layers secondary to bacterial infection. Cellulitis is commonly encountered with 75 838 inpatient admissions and 114 190 patients managed as outpatients annually in the UK. Multiple risk factors have been associated with the development of cellulitis. Local factors include any breach in the protective skin barrier, the presence of tinea pedis, lower limb ulcers due to venous insufficiency, pressure ulcers, untreated traumatic wounds and lymphoedema. General risk factors include raised BMI, immunocompromise, history of previous cellulitis, peripheral vascular disease and chronic alcoholism. The median age of presentation is 63 years in England compared to 52 years in Cameroon with females being more commonly affected than males in both studies.

Impact of COVID-19 on surgical specialist training as quantified by trainee complication rates for cataract surgery

The COVID-19 pandemic has placed an unprecedented burden on global health care systems. To ensure adequate hospital resources and improve patient safety, elective surgeries have been reduced or cancelled, and staff have been redeployed to COVID areas. Due to multiple waves of COVID-19 in some areas of the world, this shift in surgical priorities has become prolonged. The detrimental effect of these measures on surgical specialist training has become increasingly clear. A recent meta-analysis containing data from more than 20 countries with 5 260 surgical trainees across all specialties showed that COVID-19 reduced operative experience of surgical trainees in all studies.

Rectosigmoid screwdriver perforation presenting as a strangulated inguinal hernia

A 32-year male with no medical, surgical or psychiatric history was referred from his base hospital as an irreducible left inguinal hernia, with concern of ischaemia to the herniated bowel. He complained of a 2-week history of an allegedly previously reducible mass in his left groin, now with an acute history of abdominal pain, tenderness and irreducibility. He also had associated vomiting and constipation but was still passing flatus. The patient reported no drug or alcohol history, and worked full time as a software engineer.

Small bowel intussusception caused by a metastatic testicular germ cell tumour

A 25-year-old Caucasian male was referred with a six-month history of a progressively worsening swelling of the right hemiscrotum. There was no significant medical, surgical or family history. During the initial consultation, he had odd mannerisms, with random inappropriate outbursts and the patient’s mother confirmed a change in behaviour over the preceding four months. Vital signs were normal, there was no evidence of gynaecomastia, and no lymph nodes were palpated. The abdominal examination was normal. Palpation and bedside ultrasound of the right hemiscrotum revealed a mass on the upper pole of the testis. The left testis was normal. Serum alpha-fetoprotein (AFP – 41 ng/ml), beta-human chorionic gonadotropin (B-HCG – 640 929 miU/ml) and lactate dehydrogenase (LDH – 1 292 U/l) were all elevated. The rest of the blood work was unremarkable. An urgent right radical orchidectomy was performed.

Genital labial phyllodes tumour recurring during pregnancy – does pregnancy impact recurrence?

We previously published a case1 of a benign phyllodes tumour of the vulva excised with positive margins with a resultant risk for recurrence. In this report we present recurrence of a benign vulval phyllodes tumour in the same patient who is now 34 years old. Following the index surgery on the right side, the patient was only seen at the 4-week follow-up clinic and was subsequently lost to follow-up for a period of 3 years, apparently with no recurrence.

Nipple-areolar complex: commonest site of breast leiomyoma

Leiomyomas are benign mesenchymal tumours composed of smooth muscle tissue and account for the majority of mesenchymal neoplasms of the gastrointestinal tract and uterus. Breast leiomyomas are extremely rare and represent less than 1% of all breast neoplasms. Only a few cases have been reported in the literature. Most breast leiomyomas occur sub-areola in both males and females, and present as small to medium-sized painless lumps. Breast leiomyomas have also been described on the breast skin and intra-parenchymal in the breast.

Bizarre foreign body of the breast secondary to gender-based violence

Common breast FBs are those introduced for pre- and postoperative surgical localisation or for cosmetic augmentation. In some cases, surgical material (e.g., markers/clips transected localising wires, surgical swabs or biopsy needle tips) may unintentionally be left in the breast following diagnostic or therapeutic procedures. Bizarre, non-iatrogenic FBs of the breast are uncommon and may be introduced as a result of physical trauma, such as gender-based violence (GBV), or may be self-inflicted in patients with psychiatric disorders.

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South African Journal of Surgery - September 2022 - Vol 60 No 3