Introduction

An observational cross-sectional study to assess teaching, knowledge and resource availability to provide surgical burn care by surgical trainees in hospitals in KwaZuluNatal, South Africa

The definitive treatment for a deep burn injury is excision and skin grafting using simple equipment such as the Humby knife and electric dermatome. These are techniques established a century ago and are the mainstay of surgical care for burns. The multidisciplinary team (MDT) has more recently become a recognised component of care, with involvement of a dietician, occupational therapist and physiotherapist essential for improved outcomes. In KwaZulu-Natal, the burden of burden injury is difficult to estimate, with previous publication estimates ranging from 7 000–30 000 admissions. Within the provincial Department of Health, there is a single burn unit at Inkosi Albert Luthuli Hospital. Most burn-injured patients requiring surgery are therefore managed in district and regional or tertiary hospitals by general surgeons. A paper published by the Luthuli unit stated that 44% of adults and 30% of children were inappropriately referred from a specialist surgical unit. The authors clearly state that “burn care should for the time being remain part of the armamentarium of the general surgeon, and it should therefore be imperative that any surgeon training for a career in Africa spends time in a burn unit to be taught the skills of burn care, including tangential excision and skin grafting.” The aim of this study is to quantify the current access to training and basic equipment available to surgical trainees who are placed in regional hospitals around the province. This will aid in understanding the current resource capacity to perform basic surgical procedures for burn injuries in KwaZulu-Natal, as well as assess the current level of knowledge in surgical concepts around burn injuries requiring surgery. The findings will inform future training programmes as well highlight challenges in training surgeons in burn management in KwaZulu-Natal.

Interpretation of emergency CT angiograms in vascular trauma – vascular surgeon vs radiologist

In severe trauma, radiology is key to the early diagnosis and management of the injured patient. Computed tomography (CT) scanning is utilised as an important diagnostic tool in the assessment of trauma patients. CT angiography (CTA) is a non-invasive and rapid imaging technique with high sensitivity and specificity in the detection of vascular injuries. CTA is considered the initial diagnostic imaging examination of haemodynamically stable patients with suspected arterial injuries. The use of Duplex Doppler ultrasonography for diagnosis in the emergency setting has not been widely used where CT scanners are available as it has a lower sensitivity and is dependent on operator skill. The urgent nature of trauma and in particular vascular injury necessitates accuracy and speed in diagnosis and management.

The clinicopathological spectrum and treatment outcomes in metastatic colorectal cancer in the KwaZulu-Natal province of South Africa

Stage IV colorectal cancer (CRC) is defined as CRC with the presence of distant metastases. Approximately 17–20% or more of patients with CRC have metastatic disease at the time of diagnosis, and a further 4–11% will develop metachronous metastases. The liver is the most common site of metastases but this is dependent on the accuracy and resources to stage these patients. In 10–25% of patients with metastatic CRC (mCRC), the metastases become resectable following the use of chemotherapy. With improving surgical techniques of liver and lung resections in high-income countries (HICs), more patients are becoming candidates for resections.

Sentinel lymph node biopsy in a resourcelimited setting: a retrospective comparison of sentinel lymph node biopsy before and after the introduction of Sentimag at an academic breast unit

Cancer is increasing worldwide and in low- to middle-income countries (LMICs), the mortality rate is higher than that of high-income countries (HICs). Studies estimate that by 2035, developing countries will harbour two-thirds of the new cancer cases. This projected increased burden of disease in LMIC demands that breast units are able to provide up-to-date surgical treatment of the axilla in women with early breast cancer (BC).

Rectal suction biopsies to diagnose Hirschsprung’s disease in a low-resource environment – optimising cost-effectiveness

Hirschsprung’s disease (HD) is a congenital condition characterised by absence of ganglion cells and hypertrophied nerve trunks in the colon, causing a functional distal bowel obstruction. It is prudent to investigate for HD in newborns with failure of passage of meconium in the first 24 hours of life, abdominal distension and bilious vomiting. The older child with HD may present with chronic constipation and failure to thrive. In addition to these clinical features, plain abdominal radiograph, contrast enema, anorectal manometry and abdominal ultrasound can be useful to identify patients who may require biopsy and help to exclude other differential diagnoses. Ultimately, to diagnose HD a histological confirmation is required.

The utility of the bedside index of severity in acute pancreatitis at prognosticating adverse outcomes

Acute pancreatitis (AP) is a common emergency condition. Whilst most incidents of AP are self-limiting, a subset of patients will develop severe AP. As the severity of pancreatitis increases, so does the morbidity, mortality and healthcare costs. In KwaZulu-Natal, AP carries a mortality risk of 5.7–9%. Most of the deaths occur within the first two weeks following admission. This contrasts with high-income countries where most deaths occur later than two weeks. Patients with severe AP are more likely to require intensive care unit (ICU) admission, organ support and surgery than patients with mild attacks. The clinical challenge is that this process evolves over time and severity may not always be apparent on admission. This is problematic as many patients present at district hospitals with limited capacity for organ support. A simple scoring system would be helpful to prioritise patients who may require early transfer for eventual organ support. Available prognostic scoring systems for AP, including the Ranson, Glasgow and acute physiology and chronic health evaluation II (APACHE-II) scores all have limitations.

Mediastinal goitre – a South African case series

Goitre is classified by the World Health Organization (WHO) as Grade 0, 1, and 2. While grade 2 is noticeable on inspection and therefore allows for prompt investigations and appropriate management, grade 0 and 1 goitres will only be identified on imaging and on palpation respectively. Any retrosternal extension from grade 1 goitre (plunging goitre) is likely to manifest with atypical cardiorespiratory symptoms or may be discovered incidentally on imaging for investigation unrelated to the thyroid. Controversies arise regarding the definition of retrosternal extension of a goitre, but it is defined by DeSouza and Smith as a goitre with more than 50% of the gland located below the thoracic inlet. In most cases, it is possible to perform a thyroidectomy via the cervical approach alone.

The impact of thromboelastography on patients with penetrating abdominal trauma requiring intensive care

Uncontrolled haemorrhage with exsanguination is the leading cause of potentially preventable mortality in trauma patients, with rates of up to 40% of deaths due to haemorrhage. Despite a better understanding of trauma induced coagulopathy (TIC), as well as a more adjusted and tailored approach to TIC, the high rate of haemorrhage related mortality remains.

Adult corrosive ingestions in the Pietermaritzburg Metropolitan Surgical Service

The dramatic social changes in the first two decades of the new millennium have produced significant social stressors which enable and contribute to mental illness. Self-harm has emerged as a major problem globally, in both high-income countries (HIC) and low- and middle-income countries (LMICs). Self-harm places a significant burden on acute care surgical and trauma services. South Africa is an upper middle-income country with major discrepancies in wealth and access to health care. There is evidence which suggests that mental illness and self-harm are increasing in South Africa. Numerous mechanisms are associated with self-harm, including firearm-related injuries, hanging, jumping from heights, self-poisoning and the ingestion of corrosive substances. Corrosive ingestion may result in complex injuries to the upper gastrointestinal tract which necessitate prolonged and complex surgical procedures and interventions. Little has been written about corrosive ingestion in South Africa over the last three decades. The literature has mostly focused on the paediatric group. However, corrosive ingestion in adults is rising in South Africa, particularly in the indigent population. In light of this, we set out to review our experience with adult corrosive ingestion in our tertiary gastrointestinal surgical service. It was hoped that this would reignite multidisciplinary interest in this area and help us refine our algorithms to ensure that they are contemporary and appropriate.

A South African central hospital’s experience with malignant colorectal obstruction

Colorectal cancer (CRC) is the third most common type of cancer worldwide. It is estimated that around 1.4 million new cases occur each year. In South Africa, CRC is the fourth most common cancer among both men and women, with a crude incidence of 7.17/100 000/year for men and 5.80/100 000/year for women, and ranks sixth in cancer-related mortality with metastatic disease occurring in 20–25% of patients. The CRC burden is growing in sub-Saharan Africa and accounts for over 600 000 deaths annually. The data collection systems for healthcare facilities in sub-Saharan Africa are weak, which suggests that the prevalence of diseases may be underestimated.1 The disease burden is highest in countries with a high human development index. Up to 20% of patients with CRC present with obstruction which tends to be associated with an increased morbidity and mortality rate when compared to those who have elective surgery. The healthcare burden of emergency CRC presentations is substantial, as these patients spend 50% more days in hospital than those with non-emergency diagnoses, and overall treatment costs are higher in high-income countries (HIC) with universal health care available.

Fungal abscess of the parotid gland – the value of microbiological assessment

The aspirate cultured a light growth of Candida glabrata sensitive to amphotericin B. Fine needle aspiration cytology (FNAC) of the mass documented the presence of acidfluorescent bacilli along with degenerate inflammatory cells in a necrotic background. Based on the FNAC findings, he was started on empiric tuberculosis treatment but with no confirmed diagnosis of mycobacterium tuberculosis on culture and continued on tuberculosis treatment throughout his admission and on discharge. On discussion with microbiology, antifungal treatment was not initiated as it was thought to be a contaminant. He remained apyrexial on clindamycin and was continued on this antibiotic prior to referral to the ear, nose and throat (ENT) department. At that time, a tender, well-localised cystic swelling over the right parotid gland was present. 

The vagaries of diagnosis and management of traumatic lumbar artery pseudoaneurysm

Penetrating wounds in the posterior abdomen are known to cause injuries to the retroperitoneal structures, particularly the colon and kidney and less commonly the vascular structures. These injuries may be occult, requiring a high index of suspicion to be detected. Lumbar artery injury may result from blunt or penetrating trauma. In rare cases, the injury may be due to surgical procedures such as spinal surgery or renal biopsy. Frequently, the initial injury to the lumbar artery is missed and manifests as an expanding pseudoaneurysm in the retroperitoneum whose location results in an absence of symptoms and signs until it enlarges and ruptures. We would like to highlight that the doctors at the base hospital carried out the most appropriate investigation, a CTA. 

Accreditation

Health Professions Council of South Africa

MDB015/068/01/2023

3 Clinical

Certification

Attempts allowed: 2

70% pass rate





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South African Journal of Surgery - Vol 61 no 2 - 2023