General Surgery

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Alternative modalities being promoted for breast screening
(Health & Medical Publishing Group, 2018) Edge, Jenny; Roodt, Liana
ENGLISH ABSTRACT: is a political issue as much as a medical one, and although there is an enormous amount of literature looking at the benefits of the standard modalities, there is no consensus about the efficacy of screening. South Africa (SA) does not have a national mammographic breast screening programme. There are both economic and logistical reasons for this. The absence of a policy has resulted in alternative modalities being promoted as plausible substitutes. If a new modality is to be used for screening/symptomatic evaluation of the breasts, it should be compared with any of the established and well-researched existing modalities. This editorial serves to highlight some of the problems with the three commonest modalities being promoted in this country at present.
Aneurysm of the splenic artery - a controversial entity. A case report
(Health & Medical Publishing Group, 1983-01) Du Toit, D. F.; Theron, J. C.; Groenewald, J. H.
ENGLISH ABSTRACT: The case of an asymptomatic, calcified, arteriosclerotic, intact splenic artery aneurysm in a 60-year-old woman is presented. The diagnosis was confirmed by selective coeliac arteriography and the aneurysm was successfully resected with preservation of the spleen.
The application, mechanism of action and side-effects of immunosuppressive agents in clinical transplantation
(Health & Medical Publishing Group, 1986-11) Du Toit D. F.; Heydenrych J. J.
ENGLISH ABSTRACT: The conventional agents (azathioprine and steroids) have been the mainstay of organ allograft immunosuppression for the past 20 years. The main drawback of the immunosuppressive agents at present in use is that they act nonspecifically with sequential general depression of the immune system. The introduction of cyclosporin, an undecapeptide of fungal origin, which selectively inhibits T-cell-dependent immunoreaction has made a significant impact on organ allograft survival rates. Clinical application has been complicated because of renal or hepatotoxicity. Thoracic duct drainage is of historical interest but the use of antilymphocyte serum, despite its chequered history, has recently been shown to be safe and effective in cadaver kidney transplant recipients. There has also been a resurgence of interest in the use of total lymphoid irradiation as an immunosuppressive agent. The introduction of xenogenic monoclonal antibodies with anti-T-cell specificity opened a new era in clinical immunology and OKT3-PAN has emerged as a powerful major immunosuppressive agent with low toxicity.
Bicycle accident injuries
(Health & Medical Publishing Group, 1986-09) Grundill, W. L.; Muller, R.
ENGLISH ABSTRACT: Bicycle accidents in 210 patients are analysed. Ages ranged from 1 to 59 years (mean 14,5 years) with a male predominance. In 52% of patients there was a head or facial injury, 6% being moderate to severe. Of the fractures 64% involved the upper limb, 32% being of the radius and ulna and 22% of the clavicle. The majority of abrasions and soft-tissue injuries involved the limbs.
Bone health in patients undergoing surgery for primary hyperparathyroidism at Tygerberg Hospital, Cape Town, South Africa
(Jemdsa, 2021-03) Budgea, M; Conradie, W; Beviss-Challinor, K; Martin, L; Conradie, M; Coetzee, A
Background: Increased bone resorption is a well-described consequence of primary hyperparathyroidism (PHPT). In South Africa, little is known about the impact of PHPT on skeletal health. Objective: To determine the prevalence of decreased bone mineral density (BMD), vertebral fractures and osteitis fibrosa cystica in patients with PHPT who underwent parathyroidectomy. Methods: Retrospective study of patients who underwent parathyroidectomy for PHPT at Tygerberg Hospital in Cape Town, from January 2010 to December 2019. Clinical, biochemical and BMD parameters are described. Results: Final analysis included 56 patients (median age 63.5 years; 80.4% female). Initial calcium, parathyroid hormone (PTH) and 25-hydroxyvitamin D (25[OH]D) levels were 2.93 mmol/l, 19.4 pmol/l and 34.0 nmol/l, respectively. Of the total cohort, 71.4% had decreased BMD. The prevalence of osteoporosis and osteopenia in postmenopausal women and men ≥ 50 years was 50.0% and 39.1% respectively; low bone mass for age in premenopausal women and men < 50 years was 20.0%. Vertebral fractures were seen in 21.2% of patients on radiography. Osteitis fibrosa cystica was present in five patients (9.6%). PTH levels were significantly elevated in patients with osteoporosis compared with those with normal BMD (36.4 vs. 16.1 pmol/l; p = 0.02). Conclusion: Two-thirds of patients who underwent parathyroidectomy for PHPT had decreased BMD, with osteoporosis present in 50% of postmenopausal women and older men. One in five had vertebral fractures. These findings underscore the importance of skeletal assessment in the management of PHPT.
Bone health in post-menopausal patients with breast cancer treated with aromatase inhibitors: factors predicting the risk for osteoporosis.
(Stellenbosch : Stellenbosch University, 2018-12) Baatjes, Karin Jeanné; Kotze, Maritha J.; Conradie, M.; Apffelstaedt, Justus P.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Surgical Sciences: Surgery.
ENGLISH ABSTRACT: Aromatase inhibitors (AI), the gold standard for treatment of postmenopausal women with hormone-sensitive breast cancer, add an additional burden to the risk of osteoporosis in the postmenopausal population. Individual variation in AI associated bone loss is related to clinical risk factors as well as genetic variations in drug metabolism. The aim of the study is to identify postmenopausal breast cancer patients at highest risk for AI- associated bone loss by utilizing clinical, biochemical and genetic parameters. In parallel, clinically meaningful patient reports were developed from a secure online genomics database resource, enriched during the study. This prospective study was conducted at the Tygerberg Hospital Breast Clinic in affiliation with Stellenbosch University. Postmenopausal women with endocrine sensitive breast cancer, aged 50 to 80 years, were enrolled after obtaining informed consent. A baseline questionnaire documented demographic-, lifestyle- and medical history before commencing AI treatment. Clinical, biochemical and bone mineral density (BMD) measurements were obtained at baseline. Cytochrome P450 19A1 (CYP19A1) genotyping was performed using real-time polymerase chain reaction (PCR), and a screening algorithm applied to select patients for whole exome sequencing (WES). Results relevant to breast cancer diagnosis, comorbidities and treatment response were integrated into an adaptable report format for clinical application. Descriptive statistics were used to analyze the data. A total of 101 participants were recruited, with a mean age of 61±7 years. Thirty-two women fulfilled global criteria for bone protection at baseline [BMD T-score ≥-2SD (n=18); BMD T-score -1.5SD to < -2SD with risk factors (n=14)]. In women with osteoporosis, significantly lower body weight, body mass-, fat mass- and lean mass index were documented (p <0.001). Low vitamin D status was present in more than 90% of the cohort tested (n=95). After one year of AI treatment, 72 patients remained in the study, of whom 10 (14%) experienced more than 5% bone loss at the lumbar spine. Genotyping for the CYP19A1 rs10046 in 72 patients revealed that patients with two copies of the A-allele are 7,37 times more likely to have a higher percentage bone loss at the total hip compared to those without this allele (CI of 1.101- 49.336, p=0.04). At the lumbar spine, CYP19A1 rs10046 AA homozygotes were 10.79 times more likely to have a higher percentage bone loss compared to patients with the GA or GG genotypes (CI of 1.771- 65.830, p=0.01). Extended genetic testing using Sanger sequencing and WES in the 10 patients with more than 5% bone loss supported the clinical findings. None of the 34 patients without bone loss at the lumbar spine at month 12 were homozygous for the functional CYP19A1 polymorphism. At baseline, a third of women fulfilled global criteria for bone protection. This highlights bone fragility associated with body composition variables of postmenopausal women in our predominantly Mixed Ancestry study cohort. Homozygosity for CYP19A1 rs10046 provides additional information for individual risk stratification to optimize bone health maintenance. New insights gained into the mechanisms impacting bone health merit continued health outcome studies embedded in routine clinical practice.
Buerger's disease. A case report and review of the literature
(Health & Medical Publishing Group, 1984) Du Toit, D. F.; Maritz, J.; Klompje, J.
A case of thrombo-angiitis obliterans (Buerger's disease) in a 30-year-old man is reported. Irremediable gangrene necessitated amputation of both legs, and distal amputation of the fingers and thumb of the right hand.
Carcinoma of the breast in children : a case report and review of the literature
(Health & Medical Publishing Group, 1980) Heydenrych, J. J.; Villet, W. T.; Von der Heyden, U.
The case of a 10-yr-old girl with juvenile carcinoma of the breast is presented. The literature is reviewed and current thoughts relating to the treatment of breast carcinoma in children are discussed. The major controversy seems to revolve around the choice between radical and local excision in cases of juvenile or secretory breast cancer.
The clinical value of ERCP-guided cholangiopancreatoscopy using a singleoperator system
(BioMed Central, 2019) Reuterwall, Marcus; Lubbe, Jeanne; Enochsson, Lars; Lundell, Lars; Konradsson, Magnus; Swahn, Frederik; Del Chiaro, Marco; Lohr, Matthias; Arnelo, Urban
Background: Single-operator, per-oral cholangiopancreatoscopy (SOPCP) enables direct biliopancreatic ductal visualization, targeted tissue sampling, and therapeutic intervention. At Karolinska University Hospital, SOPCP was introduced early and has since been extensively utilized according to a standardized protocol. We analysed the clinical value of SOPCP in the diagnosis and treatment of biliopancreatic diseases in a single high volume center. Methods: All SOPCP procedures performed between March 2007 and December 2014 were retrospectively reviewed. Each procedure’s diagnostic yield and therapeutic value was evaluated using a predefined 4 grade scale; 1 - no diagnostic or therapeutic value, 2 - information gained did not impact clinical decision-making and in case of a therapeutic intervention, did not alter the clinical course of the patient, 3 - information gained had an impact on clinical decision-making and in the case of a therapeutic intervention, assisted subsequent disease management, and finally, 4 - information gained was essential and critical for clinical decision-making and in case of a therapeutic intervention, solved the clinical problem requiring no further therapeutic actions. Descriptive statistics were used to analyse results, with uni- and multivariate analyses completed to assess risk of adverse events. Results: During the study period, 365 SOPCP procedures were performed. We found SOPCP of pivotal importance (grade 4) in 19% of cases, and of great clinical significance (grade 3) in 44% of cases. SOPCP did not affect clinical decision-making or alter clinical course (grade 1 and 2) in 37% of cases. Conclusion: SOPCP offers direct access to the biliopancreatic ducts for both diagnostic and therapeutic purposes, adding significant clinical value in 64% of cases.
Damage control or definitive repair? a retrospective review of abdominal trauma at a major trauma center in South Africa
(BMJ Publishing Group, 2019-01-20) Weale, Ross; Kong, Victor; Buitendag, Johan; Ras, Abraham; Blodgett, Joanna; Laing, Grant; Bruce, John; Bekker, Wanda; Manchev, Vassil; Clarke, Damian
Background: This study set out to review a large series of trauma laparotomies from a single center and to compare those requiring damage control surgery (DCS) with those who did not, and then to interrogate a number of anatomic and physiologic scoring systems to see which best predicted the need for DCS. Methods: All patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These Methods All patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These groups were then compared in terms of demographics and spectrum of injury, as well as clinical outcome. The following scores were worked out for each patient: Penetrating Abdominal Trauma Index (PATI), Injury Severity Score, Abbreviated Injury Scale-abdomen, and Abbreviated Injury Scale-chest. Results: A total of 562 patients were included, and 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. The mechanism was penetrating trauma in 81% of cases (453 of 562). A large proportion of trauma victims were male (503 of 562, 90%), with a mean age of 29.5±10.8. An overall mortality rate of 32% was recorded for DCS versus 4% for non-DCS (p<0.001). In general patients requiring DCS had higher lactate, and were more acidotic, hypotensive, tachycardic, and tachypneic, with a lower base excess and lower bicarbonate, than patients not requiring DCS. The most significant organ injuries associated with DCS were liver and intra-abdominal vascular injury. The only organ injury consistently predictive across all models of the need for DCS was liver injury. Regression analysis showed that only the PATI score is significantly predictive of the need for DCS (p=0.044). A final multiple logistic regression model demonstrated a pH <7.2 to be the most predictive (p=0.001) of the need for DCS. Conclusion: DCS is indicated in a subset of severely injured trauma patients. A pH <7.2 is the best indicator of the need for DCS. Anatomic injuries in themselves are not predictive of the need for DCS.
Distal malignant biliary obstruction : a prospective randomised trial comparing plastic and uncovered self-expanding metal stents in the palliation of symptomatic jaundice
(Health and Medical Publishing Group, 2018) Bernon, M. M.; Shaw, J.; Burmeister, S.; Chinnery, G.; Hofmeyr, S.; Kloppers, J. C.; Jonas, E.; Krige, J. E. J.
Background: The aim of this study was to determine the safety and clinical effectiveness of 10Fr plastic biliary stents compared to uncovered self-expanding metal stents (SEMS) for palliative treatment of patients with inoperable extra-hepatic malignant biliary obstruction in a public hospital in South Africa. Methods: From January 2009 to December 2013, 40 patients who were admitted to a tertiary academic centre because of distal malignant biliary obstruction were enrolled in a prospective randomized study. Patients were randomly assigned to receive an uncovered SEMS or a plastic stent deployed through the biliary stricture during endoscopic retrograde cholangiopancreatography (ERCP). Results: Patient survival time in the two groups did not differ significantly (median: SEMS – 114 days; plastic – 107 days). Stent failure was more common in the plastic stent group (7/19 vs. 1/21). The results became significant after 6 months of follow-up. There was no significant difference between the two groups in the incidence of serious adverse events. Conclusions: SEMS had a longer duration of patency than plastic stents, which recommends their use in the palliative treatment of patients with biliary obstruction due to distal malignant biliary obstruction.
Early decreased neutrophil responsiveness is related to late onset sepsis in multitrauma patients : an international cohort study
(Public Library of Science, 2017-07-30) Groeneveld, Kathelijne M.; Koenderman, Leo; Warren, Brian L.; Jol, Saskia; Leenen, Luke P. H.; Hietbrink, Falco
Background: Severe trauma can lead to the development of infectious complications after several days, such as sepsis. Early identification of patients at risk will aid anticipating these complications. The aim of this study was to test the relation between the acute (<24 hours) inflammatory response after injury measured by neutrophil responsiveness and the late (>5 days) development of septic complications and validate this in different trauma populations. Methods and findings: Two prospective, observational, cohort series in the Netherlands and South Africa, consisting of severely injured trauma patients. Neutrophil responsiveness by fMLF-induced active FcγRII was measured in whole blood flowcytometry, as read out for the systemic immune response within hours after trauma. Sepsis was scored daily. Ten of the 36 included Dutch patients developed septic shock. In patients with septic shock, neutrophils showed a lower expression of fMLF-induced active FcγRII immediately after trauma when compared to patients without septic shock (P = 0.001). In South Africa 11 of 73 included patients developed septic shock. Again neutrophils showed lower expression of fMLF induced active FcγRII (P = 0.001). In the combined cohort, all patients who developed septic shock demonstrated a decreased neutrophil responsiveness. Conclusions: Low responsiveness of neutrophils for the innate stimulus fMLF immediately after trauma preceded the development of septic shock during admission by almost a week and did not depend on a geographical/racial background, hospital protocols and health care facilities. Decreased neutrophil responsiveness appears to be a prerequisite for septic shock after trauma. This might enable anticipation of this severe complication in trauma patients.
Endoscopic investigation for gastric cancer in a high-risk group
(Health & Medical Publishing Group, 1992) Louwrens, H. D.; Jaskiewicz, K.; Van Wyk, M. J.; Kotze, T. J. V. W.; Brits, T. A.
Early gastric cancer (EGC) was diagnosed in only a small percentage (<1%) of gastric cancer cases seen at Tygerberg Hospital over a 10-year period (1976-1985). This study, aimed at increasing the yield of EGC, was conducted in some high-incidence areas for gastric cancer. Coloured men, who are at high risk for gastric cancer, were identified by their medical practitioners and investigated. A total of 272 coloured males with nonspecific foregut symptoms underwent upper gastro-intestinal endoscopy and multiple biopsy specimens were obtained from all localised mucosal lesions. Twelve gastric cancers were histologically verified, of which 11 were diagnosed in males over 40 years of age. Two EGCs were diagnosed in older males, resulting in a markedly higher proportion of EGC in this subgroup (18,2%) than the proportion of EGC in inpatients at our institution (0,9%). Twenty-two per cent of males over 40 years of age had gastric ulcers compared with 9,2%. of younger males. Chronic atrophic gastritis was present in 56,2% of older males but in only 24,6% of younger males. Those over 40 years of age emerged as a subgroup with a high prevalence of gastric cancer and EGC, and concomitant conditions.
Endoscopy outreach : how worthwhile is it
(Health and Medical Publishing Group (HMPG), 2010) Voss, M.; Forward, L. M.; Smits, C. A. G.; Duvenage, R.
Ethico-legal aspects of the protocol for needlestick injuries
(Health & Medical Publishing Group, 2000) Edge, J. M.; Van Rensburg, E. J.; Mostert, E.
[No abstract available]
Four-year review of admissions to a South African regional hospital general surgery department
(Health & Medical Publishing Group, 2019) Pape, J.; Swart, O.; Duvenage, R.
Background. There are limited published data describing surgical admissions at a regional hospital level in the South African (SA) context. Objectives. To retrospectively review data from an electronic discharge summary database at a regional SA hospital from 2012 to 2016 to describe the burden of surgical disease by analysing characteristics of the patients admitted. Methods. All discharge summary records for the 4-year period were reviewed after extraction from a database created for the surgery department. Admissions were classified into 5 types: (i) elective surgery or investigations (ESI); (ii) trauma; (iii) burns; (iv) non-traumatic surgical emergencies (NTSE); and (v) unplanned readmission within 30 days. Other variables reviewed were demographic data, the International Statistical Classification of Diseases and Related Health Problems – Version 10 (ICD-10) diagnosis; area of origin; and outcome (death, tertiary referral, discharge). Data were subgrouped into 12-month periods to facilitate trend analysis. Results. Discharge summaries (N=9 805) over the 4-year study period were assessed and 9 799 were included in the analysis. All data were entered by the attending medical personnel. A total of 5 647 male patients (57.6%) and 4 152 female patients (42.4%) were admitted, with a mean age of 43.3 years (95% confidence interval (CI) 43.0 - 43.8) and a mean length of stay of 4.9 days (95% CI 4.7 - 5.1). Male patients comprised a larger proportion of trauma (83.7%) and burn (63.9%) admissions. The mean length of stay ranged from 3.5 days for elective patients to 9.1 days for burn patients. The most common diagnoses for emergency admissions were appendicitis, peripheral vascular disease and peptic ulcer disease. Common diagnoses for elective admissions were gallstone disease, inguinal hernia, anal fistulas/fissures, and ventral and incisional hernia. The most common cancer diagnoses were of the colorectum, oesophagus, breast and stomach. The overall mortality rate was 2.2%, and highest by subtype was burn patients (6.3%). Trend analysis showed a statistically significant increase in admission for NTSE (p=0.019), trauma (p<0.001) and 30-day readmission rates (p<0.001), with a decrease in admissions for ESI (p=0.001) over the 4 years. Conclusions. A precise understanding of the burden of disease profile is essential for national, provincial and district budgeting and resource allocation. Ongoing surveillance such as that performed in the study provides this critical information.
Gastric haemorrhage in a patient with neurofibromatosis : a case report
(Health & Medical Publishing Group, 1987) Du Toit, D. F.
A 54-year-old woman with upper gastro-intestinal haemorrhage, neurofibromatosis and an underlying schwannoma of the stomach is presented. Gastroscopy and barium meal examination revealed the presence of a submucosal gastric tumour with overlying ulceration. A Billroth II gastrectomy was performed with complete excision of the tumour; histologically this was revealed as a schwannoma of undetermined biological activity.
Has the character of gastric cancer changed? a descriptive study of a 10-year period
(Health & Medical Publishing Group, 1991) Louwrens, H. D.; Van Kotze, W. T. J.; Brits, D. A.; Rossouw, D. J.; Falck, V.
Over the 10-year period January 1976-December 1985, 446 patients with histologically verified adenocarcinoma of the stomach were treated at Tygerberg Hospital. Coloured patients made up 63.4% of the study population and a significant increase in the annual proportion of this group was observed. Coloured men comprised 47.6% of the total group. The mean age of white and coloured patients differed significantly (68.9 v. 56.5; P<0.001). The symptom complex was essentially similar in the two racial groups and in general the character of the symptoms had no bearing on the prevalence of resection. Although antral tumours were most common in whites and in coloureds, there was a significant increase in tumours located in the fundus in whites. The resection rate remained unchanged over the 10-year period. Only 4 cases of early gastric cancer were detected during this period without any signs of an increased yield of early lesions over time. This audit revealed no beneficial changes over time, which is in stark contrast with reports from Japan regarding the proportion of curable lesions.
Hemangiosarkoom van die bors : 'n gevallestudie en oorsig van die literatuur
(Health and Medical Publishing Group (HMPG), 1975) Van Zyl, J. A.; Van der Walt, J. J.; Van Zyl, J. J. W.
In this case of angiosarcoma of the breast in a 55 yr old woman, the time from treatment to death was 41 mth, compared with 25 mth in collected cases from the literature. The possible value of adjuvant chemotherapy is recalled. In this case Endoxan (cyclophosphamide) was tried in a dosage of 10 mg/kg body weight i.v.
Impact of COVID-19 pandemic on transplantation
(Medpharm, 2020-09) Steyn, E.; Al-Benna, S.
The evolving epidemic has led to reduced activities in organ donation and transplantation across South Africa. Similarly, transplantation programmes have been suspended in other countries because of scarce resources (especially ICU beds) and concerns regarding immunosuppressive induction regimens.

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