Post-traumatic stress disorder in international surgeons undertaking trauma electives in a South African trauma centre

BACKGROUND

Post-traumatic stress disorder (PTSD) is a well-documented psychiatric outcome in patients who experience physical trauma. The phenomenon is less studied in the staff involved in caring for such patients. The aim was to investigate the prevalence of PTSD in visiting international surgeons undergoing elective trauma training and to compare to local and international rates.

METHODS

A trauma screening questionnaire (TSQ) survey was conducted among surgeons completing their elective trauma service placements in the Pietermaritzburg Metropolitan Trauma Service.

RESULTS

Nineteen surveys were completed (32% response rate). Mean age was 38.9 (SD 6.5). Median postgraduate working experience was 5 (2-10) years. Median time of stay in South Africa was 6 (1-72) months. Compared to preelective experience, there was a five-fold increase in the level of trauma resuscitation experience reported during elective placement. 10.5% of surgeons scored > 5 in the TSQ suggesting probable PTSD. No statistical differences in age, years of prior experience, prior trauma rotation, number of major resuscitations, or length of stay in South Africa were observed in those scoring positive versus negative screening in the TSQ questionnaire.

CONCLUSION

Despite being exposed to increased levels of trauma related injury, we observed low rates of positive screening for PTSD in our cohort of visiting international surgeons involved in elective trauma service placements. Investigation of potential protective factors against PTSD in this South African tertiary trauma centre is warranted.

A dedicated quality improvement programme can increase access to paediatric minimal access surgery in South Africa

BACKGROUND

In this project, we reviewed our experience in minimal access paediatric surgery (MAPS) at Greys Hospital over the last decade. This information would provide an overview of our experience and would enable us to identify areas where we can strengthen our surgical service and our training programme.

METHODS

All surgical patients are captured in the hybrid electronic medical registry (HEMR). All patients aged 18 years or less who underwent a MAPS procedure between 2012 and 2021 were reviewed. Data collected included demographic information, type of surgery, nature of the surgery (elective or emergency), organ system operated on, whether trainees or consultants performed the surgeries and the morbidities and mortalities experienced. Statistical analysis included linear regression and ANOVA, which was performed using Jamovi software.

RESULTS

A total of 1 328 MAPS procedures were performed on 994 patients over nine years. There were 359 female and 635 male patients. There was a steady increase in the number of cases performed per year. The age of the patients ranged from one day of life to 18 years, with a median of 8 years. The multiple linear regression results indicated a very strong collective significant effect between the courses performed, the number of consultants, and the MAPS cases performed. The ANOVA test for the individual factors was not statistically significant, but there was a very strong combined correlation with an r-value of 0.87 and a p-value of 0.014 using the overall model test. The consultants' training also directly impacted on the teaching and training of registrars, with progressively more cases being performed by trainees over the years. Postoperative morbidity was reported in 40 patients. The morbidity rate was three per cent. There were no mortalities.

CONCLUSION

It is feasible to deliver MAPS to children in our environment. A comprehensive quality improvement strategy has yielded satisfying results. The increased use of MAPS has resulted in a general transfer of skills to junior staff. Ongoing efforts to support the rollout of MAPS in children are warranted.

The rate of iatrogenic injuries in surgical patients appears resistant to multiple interventions: what can we learn from aviation safety?

BACKGROUND

This project analyses all iatrogenic injuries from our department over the last decade and tracks their rate against several interventions.

METHODS

All patients who sustained an iatrogenic injury between 2012 and 2022 were reviewed.

RESULTS

A total of 946 iatrogenic injuries occurred in 731 patients. Sixty per cent of these patients were male; the median age was 39 years. Of 946 injuries, 574 (60.7%) occurred during an operation, and 372 (39.3%) were not related to an operation. Of the operative injuries 412 (71.8%) were enteric injuries. Of the 372 non-operative iatrogenic injuries 304 (82%) were due to indwelling devices (ID), and 34 (10%) occurred during flexible endoscopy. Fifty-five per cent of the injuries due to ID were due to central venous catheters (CVC) and urinary catheters (UC). CVC contributed toward 31% of all non-operation related iatrogenic injuries. One in 54 admissions (946/51 178) and one in 47 (574 /27 342) patients undergoing an operation sustained an iatrogenic injury. The annual rate of iatrogenic injuries did not decrease over the decade despite a multifaceted approach to reduce them. Interventions included electronic database development, procedural standardisation, and checklist implementation.

CONCLUSION

Despite multiple interventions over a decade, our rate of iatrogenic injury remains constant. Ongoing multifaceted efforts to reduce this rate must focus on engendering a culture of safety at all levels of healthcare if we hope to match the enviable safety record of the aeronautics industry.

Adverse events associated with the use of indwelling devices in surgical patients

BACKGROUND

Indwelling devices (IDs) are ubiquitous in modern healthcare and may often be associated with morbidity. This paper investigates adverse events related to IDs in surgical patients, which are generally placed into patients either to administer therapy, manage outputs or for specific therapeutic benefit.

METHODS

A retrospective electronic database-based assessment of all adverse events relating to IDs was undertaken from December 2012 to August 2021. All events were categorised by device type, event type, and event severity.

RESULTS

A total of 11 130 morbidities were captured over the study period. Of those, 2 195 entries pertained to an ID with 2 402 reported adverse events affecting 1 592 patients. Two-thirds occurred in males and injuries occurred in patients age ranging from eight days to 93 years, with an average age of 36 years. The most frequently implicated devices were surgical drains (including intercostal chest drains), accounting for 491 (20.44%) of adverse events. Central venous catheters (CVCs) and intravenous cannulae were involved in 374 (15.57%) and 332 (13.83%) events, respectively. Unplanned removal (346, 13.91%), output not measured (319, 12.82%), injury (314, 12.62%), and blockage (279, 11.21%) were the most common error types. The majority of adverse events were considered minor, however 27 (1.1%) patients experienced organ dysfunction as a result of an ID-related adverse event, and seven (0.3%) died.

CONCLUSIONS

Morbidity related to IDs in surgical patients is a relatively frequent occurrence. Standardisation of ID insertion and care, staff education, and improvements in communication have been identified as the most important strategies by which we can limit error-associated morbidity in patients with IDs.

Adult corrosive ingestions in the Pietermaritzburg Metropolitan Surgical Service

BACKGROUND

There is a paucity of data around corrosive ingestion in South Africa over the last three decades. As such, we set out to review our experience with adult corrosive ingestion in our tertiary gastrointestinal surgical service.

METHODS

A retrospective, quantitative review was performed. The parameters analysed were demographics, substance ingestion, ingestion time to first presentation to a healthcare facility, clinical presentation, severity of injury based on endoscopic classification, computed tomography (CT) findings, management and outcomes. Patients presenting within 72 hours with alarm symptoms underwent flexible upper endoscopy and injury severity grading. In patients presenting after 72 hours, a water-soluble contrast study was obtained prior to upper endoscopy. Patients with signs of sepsis, surgical emphysema or physiological instability were referred for urgent CT to exclude oesophageal perforation and mediastinitis.

RESULTS

Between January 2012 and January 2019, a total of 64 patients presented with a history of corrosive ingestion - 40 (31%) were males and 24 (19%) females. The average time from ingestion to presentation was 72 hours. In 78% of patients, the agents were intentionally ingested, whilst 22% claimed accidental ingestion. A quarter of the patients (21%) presented to the unit clinically unstable, requiring emergent cardiorespiratory support. Eight (12%) patients required urgent surgical intervention due to the extent of injury. Nine (14%) patients demised during the acute admission. Of this group, three patients had undergone surgical intervention, and six were managed conservatively. Eighty-five per cent of all patients survived their initial admission.

CONCLUSION

This paper has highlighted the problem of corrosive ingestion in our setting. It remains a complicated problem to manage associated with significant morbidity and mortality rates. The current trend in the assessment of these patients is increased use of CT scan to assess the extent of transmural necrosis. Our algorithms should change to reflect this contemporary approach.

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

BACKGROUND

Identification of at-risk patients with acute pancreatitis (AP) early on in the course of hospital admission remains a challenge. Early identification of these patients can facilitate early referral to tertiary hospitals with skilled multidisciplinary teams (MDTs) and high-dependency health care facilities. This study retrospectively reviewed the ability of the bedside index of severity in acute pancreatitis (BISAP) score and other biochemical markers to predict organ failure and mortality in acute pancreatitis.

METHODS

All patients presenting to Grey's Hospital with AP between 2012 and 2020 were included in the study. The BISAP score and other biomarkers were evaluated at presentation in predicting organ failure (≥ 48 hours duration) and mortality.

RESULTS

A total of 235 patients were included in the study. A total of 144 (61%) were male and 91 (39%) were female. Alcohol (81%) and gallstones (69%) were the commonest aetiological factors amongst males and females respectively. A total of 42 (29%) males and 10 (11%) females developed organ failure during their hospital stay. The mortality rate was 11.8% for males, 6.59% for females, with an overall mortality of 9.8%. A BISAP score of 2 had a sensitivity of 87.98% and specificity of 59.62% at predicting organ failure (positive predictive value [PPV] = 88.46%, negative predictive value [NPV] = 58.49%, 95% confidence interval [CI], p = 0.001). A BISAP score of 3 and above had a sensitivity of 98.11% and specificity of 69.57% at predicting mortality (PPV = 96.74%, NPV = 80%, 95% CI, p = 0.001). A multivariate analysis of biomarkers bicarbonate, base excess, lactate, urea and creatinine either failed to reach statistical significance or had specificity that is too low to prognosticate organ failure and mortality.

CONCLUSION

The BISAP score has limitations at predicting organ failure, but it is a reliable tool for predicting mortality in AP. Due to its simplicity of use, it should be used in resource-constrained settings to triage at-risk patients in smaller hospitals, for early referral to tertiary hospitals.

Broad responses and attitudes to having music in surgery (the BRAHMS study) - a South African perspective

BACKGROUND

Music is played in operating theatres (OTs) throughout the world, though controversy around its use exists. While some clinicians may find background music favourable to the theatre mood and a way to augment surgical performance, there is concern raised over its distracting and noise-creating properties.

METHODS

In this prospective observational study, between August and December 2021, 110 surgeons and registrars in South Africa responded to a survey investigating the way they use music, and their perceptions and attitudes towards its effect on the OT environment.

RESULTS

In this cohort, 66% were male, 29% were consultants and the most common age range was 30-39 years old. Eighty per cent of respondents reported that music was played at least "sometimes", with 74% reporting that they enjoyed it. Easy Listening was the most played and preferred genre followed by Top 40/Billboard hits. Overwhelmingly, respondents reported that background music in the OT improved temperament, focus, mood, and performance, though over a quarter felt it worsened communication. Thirty-one per cent of respondents reported that the choice of music depended on the type of operation, and 70% would turn music down or off during crises. Those who enjoyed music in their spare time were significantly more likely to enjoy music in the OT and perceive it positively.

CONCLUSION

This study provides a window into the surgeons' use of and attitudes to intraoperative music in South Africa. While overall, music is viewed positively by this cohort, some concerns remain regarding communication and distractedness. Further interventional and qualitative studies would be useful.

High-grade renal trauma in children and adolescents can be successfully managed non-operatively

BACKGROUND

This paper reviews our experience with management of renal injuries in children and adolescents with a focus on the outcome of non-operative management (NOM).

METHODS

Retrospective review of the clinical characteristics, injury grade (I-III, low grade and IV and V high grade), management and outcomes of children ≤ 18 years old with renal trauma presenting to a major trauma centre in South Africa between December 2012 and October 2020.

RESULTS

Sixty-one children with a renal injury were identified with a median age of 13 (range 0-18) years. Forty-five were boys; blunt and penetrating mechanisms of trauma were sustained by 55 (90%) and six (10%) children, respectively. The median American Association for the Surgery of Trauma (AAST) grade of renal injury was 3 (range 1-5): this included eight (13%) with grade I, six (10%) with grade II, 17 (28%) with grade III, 20 (46%) with grade IV and 10 (16%) with grade V injuries. Forty children (66%) were successfully managed non-operatively and 21 required a laparotomy; of these six (28%) required nephrectomy. The overall renal salvage rate was 55/61 (90%). Children who required laparotomy were significantly more likely to have sustained a penetrating mechanism of injury (24% vs 2%) and have greater length of hospital stay (median 9 vs 3 days) compared to children managed non-operatively (p < 0.05). Children who underwent a nephrectomy had a significantly greater length of hospital stay (median 9 vs 4 days, p = 0.03); however, their demographics, outcomes developed complications. Two children (3%) died; one managed non-operatively and one with a laparotomy.

CONCLUSION

Paediatric renal trauma can be successfully managed non-operatively in over two-thirds of cases in this middle-income country. High grade of renal injury does not absolutely predict need for surgery or nephrectomy and can be managed non-operatively.

Transdiaphragmatic pericardial washout post penetrating cardiac injury found incidentally at diagnostic laparoscopy

A 22-year-old male presented following a precordial stab. He was haemodynamically and metabolically normal. Initial investigations did not reveal pericardial fluid or haemothorax. At diagnostic laparoscopy, we encountered haemoperitoneum and a diaphragmatic injury through which the heart was visible. After pericardial washout, laparoscopic repair was effected. This case highlights a potential problem with extended focused assessment with sonography in trauma (eFAST) in that it will only be positive if there is an accumulation of pericardial fluid. It also confirms the utility of diagnostic laparoscopy for penetrating left thoracoabdominal injuries and shows that principles of open surgery can be safely applied laparoscopically in select patients.

Technology alone does not achieve error reduction - a study of handwritten, tick-sheet, ink stamp and electronic medical prescriptions

BACKGROUND

Technology in the form of electronic record systems and prescriptions have been touted as a potential solution to human error. In South Africa, a middle-income country where health facilities have large variations in technological capacity, prescription errors can be complex and varied. We evaluated different prescribing methods to find if the increased use of technology in prescriptions will assist in reducing error rates.

METHODS

A retrospective, non-randomised study compared prescriptions, error rates and types in four hospitals with different prescribing methods: these were handwritten, ink stamp, tick-sheet and electronic prescriptions. A modern human error theory data collection tool was designed which included patient complexity. Cataract surgery was chosen as the single common procedure.

RESULTS

One thousand six hundred and sixty-one individual scripts had 1 307 prescription errors. Increasing patient complexity was not an indicator of error rate. Handwritten and tick-sheet prescriptions had the fewest errors (49% and 51%, respectively). Electronic (96%) and ink stamp scripts (101%) had almost twice as many errors as handwritten scripts (p < 0.001) mainly due to systemic inbuilt errors.

CONCLUSION

The application of increasing degrees of technological complexity does not automatically reduce error rate. This is especially apparent when technology is not integrated into human factors engineering and persistent critical assessment.

Experience and perceptions of laparoscopic appendectomy amongst surgical trainees in South Africa

BACKGROUND

TThis study is a survey amongst surgical trainees in South Africa (SA) designed to document their exposure to laparoscopic appendicectomy (LA) and their perceptions about the procedure and to identify possible barriers to its uptake.

METHODS

A structured survey was developed using a combination of quantitative and qualitative questions designed to determine the clinical exposure of surgical trainees to laparoscopic appendectomy and then probe possible factors limiting their access to the procedure. A questionnaire was created online, and a link was distributed to various surgical trainees in Southern Africa. A list of trainees was obtained from the Surgreg Training Association of South Africa (STA).

RESULTS

One hundred and thirty-two (47%) trainees completed the survey out of an estimated 280 general surgery registrars. Ninety-five (72%) were male and 37 (28%) were female respondents. Their median age was 31 years (25-36). There were 14 (11%) year-1 and 21 (16%) year-2, 32 (24%) year-3, 37 (28%) year-4 and 28 (21%) year-5 trainees. The breakdown according to region was area 1 (inland and central) 47 (36%), area 2 (western seaboard) 12 (9%) and area 3 (eastern seaboard) 73 (55%). Forty-three (33%) respondents experienced face-to-face teaching on how to perform a LA. Forty-two (32%) had exposure to laparoscopic simulators. Respondents reported a general lack of experience in performing this procedure. Sixty-nine (52%) had performed this procedure without a senior (i.e., solo) and 13 (10%) had only assisted a senior to perform this procedure. Seventy-four (56%) respondents felt confident performing a LA independently. One hundred and thirteen (86%) respondents expected to be taught this procedure. One hundred and five respondents (80%) were keen to learn to perform LA. One hundred and five respondents (80%) stated that they would be interested in attending an online course on LA. The respondents felt that the following were the significant barriers to performing LA: resource constraints 49 (37%) and time constraints 46 (35%). Thirty per cent of respondents (22) in area 3 reported a reluctance by seniors to teach the procedure.

CONCLUSION

There appears to be a lack of exposure to and confidence with LA amongst South African surgical trainees. This implies a deficiency in formal surgical training programmes. Addressing this deficiency will require innovative solutions.

The neglected epidemic of trauma from interpersonal violence against the elderly in South Africa

BACKGROUND

Geriatric injuries comprise a significant burden in the developed world but much less are known in the developing world setting. This study aims to review our experience of geriatric injuries with a focus on interpersonal violence (IPV) managed at a major trauma centre in South Africa.

METHODS

This was a retrospective study on all patients who were aged > 65 years admitted to our trauma centre from January 2013 to December 2020, based in Pietermaritzburg, South Africa.

RESULTS

Over the 8-year study period, 323 cases were included (62% male, mean age 72 years). Mechanism of injury: 80% blunt, 16% penetrating and 4% others. The median injury severity score (ISS) was 9. The median Charlson comorbidity index (CCI) for all 323 cases was 3. Diabetes (n = 53) was the most prevalent comorbidity which was followed by pulmonary disease (n = 23), cerebral vascular accidents (n = 16) and myocardial infarction (n = 15). Fifteen patients were on antiretroviral therapy (5%). Twenty-four per cent required surgical intervention. Eight per cent of cases experienced one or more complications. Twenty-five per cent (80/323) were related to IPV, 61% (49/80) of these were penetrating injuries and the remaining 31 cases were blunt injuries. Of the 49 cases of penetrating injuries, 33 were gunshot wounds (GSWs) and 16 were stab wounds (SWs) (1 GSW and 2 SWs were self-inflicted and were not included in IPV). Those cases that resulted from IPV were significantly more likely to require operative intervention, experience complications and longer lengths of hospital stay. Geriatric patients had poorer outcomes than non-geriatric patients and rural geriatric patients had worse outcomes than urban geriatric patients.

CONCLUSION

Although the burden of geriatric trauma in South Africa appears to be relatively low, it is associated with significant morbidity and mortality. Trauma from interpersonal violence is especially common and is associated with significantly worse outcomes than that of non-interpersonal violence-related trauma. Elderly rural trauma victims have worse outcomes than their urban counterparts.

Defining the role of bilateral groin dissection for squamous cell carcinoma of the penis in South Africa

BACKGROUND

The current recommendation for the management of penile cancer is that all patients with palpable groin nodes should undergo a routine lymph node dissection (LND). This study reviews our yield from LND in patients with palpable lymph nodes (LNs) and penile cancer.

METHODS

All patients with a penile cancer, who presented to the urology departments of St Aidan's and Grey's hospitals in KwaZulu-Natal province (KZN) were reviewed. Clinical data records and histological reports of all the patients who underwent a penectomy and inguinal lymph node dissection (ILND) were analysed.

RESULTS

A total of 93 cases of penile cancer were managed between 2014 and 2019. Of this total overall cohort, 38 patients had palpable groin nodes and underwent a bilateral ILND. The majority (84%) of these patients were human immunodeficiency virus (HIV) positive and none were circumcised. Tumour grade was mostly grade II (84%), and tumour size was an average of 6.2 cm with a range from 1.5 to 12 cm. The overall incidence of metastatic inguinal lymph nodes (ILNs) in the group undergoing dissection was 23.7%. In the remainder there was only reactive lymphadenopathy.

CONCLUSION

ILND performed in patients with penile cancer and bilateral palpable ILN in our setting has a low yield. This might be a reflection on our high rate of HIV. Local validation of international cancer guidelines is essential prior to adopting them in the South African context.

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

BACKGROUND

This project is the first formal usability review of the hybrid electronic medical registry (HEMR) since its implementation in 2012.

METHODS

A synchronous usability evaluation by novice operators was followed by a survey of veteran users. The usability evaluation was done by moderated think-aloud interview while completing tasks for a mock patient. The veteran survey was paper-based and focused on satisfaction of the system.

RESULTS

A total of 141 comments on system errors were identified by the novice doctors. These consisted of 123 unique problems, of which three were hardware faults and were thus excluded. The identified issues were categorised into errors of control (27%), minimalist (21%), error (17%), match (13%), flexibility, visibility and consistency (9% each), and history (4%). Every unique usability violation was evaluated by the three experts who agreed that 82 of the 141 errors (58%) were valid and applicable. The other 59 items were rejected, not only because of the inability to reproduce some errors or programme shortcomings, but also because a series of "hurdles" were purposely included in the software to decrease cognitive dissonance and reduce error by the users. The survey of veteran users showed high levels of contentment with the system with regards to efficiency, satisfaction and preference.

CONCLUSION

Despite many usability complaints by novices, almost half of them were rejected. Although usability in electronic health systems is important, it can often be sacrificed for more imperative aims such as safety, error filtering and clinical decision support.

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

BACKGROUND

This study reviews the indications and outcome of emergency laparotomy for paediatric trauma in a South African trauma centre.

METHODS

This was a retrospective study of all children less than 18 years of age who underwent an emergency laparotomy for trauma between December 2012 and October 2020 at Grey's Hospital in Pietermaritzburg.

RESULTS

During the eight-year period under review, a total of 136 children of which 107 were male underwent a laparotomy for trauma. The median age was 14 years. There were 80 (57.1%) blunt mechanisms, and the rest were penetrating mechanisms. A total of 46 (33%) patients required ICU admission. Thirty-four patients developed a complication. These included nine cases of pneumonia, one case of renal failure, two patients developed abdominal collections, three woundrelated complications, three neurological complications and one miscellaneous complication. There were seven (5%) deaths. The penetrating cohort were older than the blunt cohort. Solid viscera were more likely to be injured in the blunt cohort and hollow viscera more likely in the penetrating cohort. A total of 16 (11%) patients underwent damage control surgery (DCS). Of this cohort, there were three female children. Six sustained blunt trauma and ten penetrating trauma. A total of six (37%) of these children died.

CONCLUSION

Emergency laparotomy for trauma in children is not infrequent in Pietermaritzburg and there is a high incidence of penetrating trauma in this cohort. The response to increased degrees of physiological derangement is the application of DCS. Ongoing efforts to develop and strengthen a paediatric trauma service appear to be justified.

Penetrating colon trauma-the effect of concomitant small bowel injury on outcome

INTRODUCTION

There is limited evidence to suggest that patients with penetrating colon injury have higher complication rates when there is concomitant small bowel (SB) injury.

AIM

We performed a retrospective study looking at outcomes of penetrating colonic trauma in patients with- and without concomitant SB injury.

METHODS

We interrogated our electronic registry over an eight-year period (2012-2020) for all patients over 18 years who had sustained penetrating colon injury and who had survived beyond 72 h. Demographic data, admission physiology, and Injury Severity Score (ISS) were recorded. Two groups of patients were observed: those with colonic injury (no SB injury) and those with combined colon and SB injury. Outcomes observed included leak rates, length of Intensive Care Unit (ICU) stay, length of hospital stay (LOS), morbidity and mortality.

RESULTS

A total of 450 patients were eligible for analysis, of which 257 had colon injury without SB injury and 193 had a combination of colon and SB injury. There was no difference in mechanism of injury between groups. Admission physiology was similar between groups but arterial blood gas values were worse in the combined group. Rates of damage control surgery and ICU admission were higher in the combined group. Primary repair was done in equal proportions between groups but anastomosis was more frequently performed in the combined group. There was no difference in complication rates, including gastro-intestinal complications and suture line leaks. Length of ICU stay, LOS, and mortality were similar between groups. Univariable analysis demonstrated that the presence of concomitant small bowel injury was not an independent risk factor for colonic suture line failure or death.

CONCLUSION

There is no evidence from this data that the presence of a combined penetrating colon and SB injury should change management priorities. Each injury should be treated on its own merit, in the context of the patient's physiology.

Double jeopardy avoided by thorough investigation

Penetrating junctional torso trauma with multiple and complex injuries presents the clinician with many investigational and management decisions. This situation has been termed double jeopardy in the literature. The management of this multiple gunshot victim's injuries - massive haemothorax and severe liver and kidney injuries - describes how this pathway can be negotiated with a successful outcome.

The quest to improve outcomes for abdominal wall incisional hernia repair in Pietermaritzburg: between Scylla and Charybdis

BACKGROUND

The repair and outcomes of incisional abdominal wall hernias have not yet been benchmarked to allow comparison with recommended best practice in a South African context. This study aimed to address his deficit.

METHOD

Patients who underwent an incisional hernia repair between December 2012 and December 2018 were analysed in respect to the following variables: demographics, comorbidities, indication for surgery, site, size, surgical approach, mesh usage, operating times, complications and 30-day mortality.

RESULTS

Of the cohort of 224 patients, 185 underwent elective repair. There were 152 open and 72 laparoscopic procedures, and 17 patients (8%) required a repeat operation with an overall in-hospital mortality rate of 6% (13). Eight patients developed an enteric leak. There were nine cardiovascular complications, 24 respiratory complications, 22 surgical site infections and 13 patients developed an acute kidney injury (AKI). There were 39 emergency operations. The emergency cohort were older than the elective with a higher rate of cardiovascular or surgical (CVS) complications and AKI. Eight patients developed an enteric leak. Mortality rates of were significantly higher in the emergency operation cohort compared to the elective group (18% vs 3%). The 13 in-hospital deaths were older, more likely to have undergone an emergency operation, to be diabetic (46% vs 10%), hypertensive (92% vs 33%), have a bowel anastomosis (39% vs 9%), experience an enteric leak (46% vs 1%) and require repeat operation than the patients who survived.

CONCLUSION

Incisional abdominal wall hernias are difficult to manage as the patients often have several comorbidities which when coupled with an emergency operation leads to poor outcomes. Improving outcomes requires strategies that address comorbidities and shift the focus to elective rather than emergency repair.

Childhood and adolescent trauma in Pietermaritzburg is a neglected sub-epidemic within a larger epidemic and warrants a dedicated service

BACKGROUND

This study reviews our experience with paediatric trauma to help plan and strengthen ongoing strategies to deal with trauma in our region.

METHODS

All children and adolescents less than 18 years of age who were admitted to our centre following trauma between December 2012 and October 2020 were reviewed.

RESULTS

Over the 8-year period, 2 091 children were admitted with trauma to Grey's Hospital. There were 1 479 (71%) male patients, median age: 10 years. One thousand four hundred and fifty-eight (70%) patients were referral from rural regions. In 1 597 (76%) patients, the mechanism of injury was blunt trauma. A total of 387 (19%) patients underwent a surgical intervention, whilst 1 641 (78%) patients were managed non-operatively. In 63 patients, management records were missing. Multiple patients required multiple surgical procedures. A total of 144 patients had a laparotomy, 70 a soft tissue debridement procedure, 40 an orthopaedic procedure, 53 a neurosurgical procedure, which included 37 patients who underwent craniotomy, and 18 patients underwent a fasciotomy for compartment syndrome. There were 82 patients who required miscellaneous procedures. A total of 213 (10%) patients required ICU admission. There were 48 (2.3%) deaths.

CONCLUSION

The volume of child and adolescent trauma managed is significant and suggests that a dedicated paediatric trauma service in the region is warranted. It is hoped that future partnering with appropriate stakeholders will allow this service to continue to mature and provide leadership in all aspects of care of injured children in the region.

The spectrum of blunt abdominal trauma in Pietermaritzburg

BACKGROUND

This study reviews the Pietermaritzburg Metropolitan Trauma Service (PMTS) experience with the management of blunt abdominal trauma (BAT).

METHODS

A retrospective review of the hybrid electronic medical registry (HEMR) between December 2012 and September 2019 was conducted. All patients admitted following BAT were included.

RESULTS

During the study period, 1 123 BAT patients were managed by the PMTS. The mean age was 29.19 years (SD 14.03). Of these admissions, 73.6% were male. The most common mechanism was road traffic crashes (RTCs) - 435 motor vehicle collisions (MVCs) and 250 pedestrian vehicle collisions (PVCs). There were 186 assaults, 118 falls, 62 community assaults, 22 accidents related to agriculture, construction or industry, 11 sporting injuries, nine animal injuries, seven patients injured by falling objects, five injured by trains, two hangings, one burn-related fall and two other causes. The mechanism of injury was unknown in 22 cases. There were 445 abdominal CT scans and 270 whole body CT scans. Surgical management was required for 395 patients. There were 259 index laparotomies and 176 repeat laparotomies. Four patients underwent selective arterial embolisation. Laparoscopy was undertaken in ten, and subsequently converted to laparotomy in five. There were 106 orthopaedic operations. Hospital stay ranged from 0-155 days (median stay three days). ICU admission was required in 24.9% of patients. The mortality rate was 7.5%.

CONCLUSION

BAT is common in South Africa. Whilst the vast majority of patients require non-operative treatment, a welldefined subset require a laparotomy. Imaging is central to the management of patients with BAT.

The correlation between full moon and admission volume for penetrating injuries at a major trauma centre in South Africa

BACKGROUND

The possible effect of full moon on admission volume of trauma centres is a well-mentioned phenomenon that has been perpetuated worldwide. We aimed to review the correlation between full moon and admission volume and to interrogate any possible relationship on admission for penetrating trauma.

METHODS

A retrospective study from 2012 to 2018 at Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa.

RESULTS

A total of 8 722 patients were admitted. Eighty-three per cent (7 242/8 722) were male and the mean age was 29 years. The total number of days during the study period was 1 953, 66 of which were 'full moon' (FM) days and 1 887 were 'non-full moon' (NFM) days. There was no significant difference between gender or age distribution. The mean number of admissions per day on FM days compared with NFM days was not significant (4.1 vs 4.5, p = 0.583). A total of 3 332 patients with penetrating trauma were admitted. This constituted 42% (113/271) of admission on FM days and 38% (3 219) on NFM days, which is not statistically significant (p = 0.229). Subgroup analysis did not demonstrate any significant difference between the number of stab wounds - 28% (77/113) vs 25% (2 124/3 219) - or gunshot wounds - 13% (16/113) vs 12% (990/3 219) - between FM and NFM days.

CONCLUSION

The correlation between full moon and trauma admission is unfound in our setting. The perpetuating notion that 'it must be full moon tonight' is likely to be an urban myth with no scientific evidence for such a claim.

The management of ocular and peri-ocular trauma needs to be co-ordinated according to ATLS principles and requires multi-disciplinary collaboration

INTRODUCTION

This project set out to focus on ocular (globe) and peri-ocular trauma and to describe the spectrum of injuries seen in a busy South African trauma unit and to document their management and outcome.

RESULTS

During the period November 2012 to April 2020, a total of 12 115 patients were managed by the Pietermaritzburg Metropolitan Trauma Service (PMTS) at Greys Hospital in Pietermaritzburg, South Africa. Of these 2194 (11%) sustained ocular or peri-ocular injury. Of these 2194 patients, 1069 (83%) were male. 83% of injuries (n=1076) were classified as primarily blunt injury and 17% as a primarily sharp/penetrating mechanism. A substantial number of patients required a life-saving emergency intervention. These included resuscitation in 242 cases (19%) and active airway intervention was in 290 (22%). In total 919 (71%) patients required urgent surgery to the peri-ocular region. Slightly over half (55%) of these the surgery was performed by a single discipline. The rest needed procedures by two or more disciplines. The disciplines involved included ophthalmology, maxillofacial, plastic, ENT and neurosurgery. Plastic surgery was involved in 683 cases (53%). A total of 341 distant surgeries were required - These included orthopaedic operations, laparotomy and vascular operations. Of the 1294 cases in this study, 42 (3%) died before discharge and 99 (8%) were discharged with a GCS lower than 10. The primary skill set for management of these injuries is identified.

CONCLUSION

Although the management of immediate life and organ threatening injuries takes priority, ocular and peri-ocular trauma may damage a number of important structures and their comprehensive management requires a multi-disciplinary team of specialists or, in austere environments, a font-line medical team with a diverse skill set.

Patient Reported Experiences and Delays During the Diagnostic Pathway for Pulmonary Fibrosis: A Multinational European Survey

Introduction: Pulmonary fibrosis includes a spectrum of diseases and is incurable. There is a variation in disease course, but it is often progressive leading to increased breathlessness, impaired quality of life, and decreased life expectancy. Detection of pulmonary fibrosis is challenging, which contributes to considerable delays in diagnosis and treatment. More knowledge about the diagnostic journey from patients' perspective is needed to improve the diagnostic pathway. The aims of this study were to evaluate the time to diagnosis of pulmonary fibrosis, identify potential reasons for delays, and document patients emotions.

Methods: Members of European patient organisations, with a self-reported diagnosis of pulmonary fibrosis, were invited to participate in an online survey. The survey assessed the diagnostic pathway retrospectively, focusing on four stages: (1) time from initial symptoms to first appointment in primary care; (2) time to hospital referral; (3) time to first hospital appointment; (4) time to final diagnosis. It comprised open-ended and closed questions focusing on time to diagnosis, factors contributing to delays, diagnostic tests, patient emotions, and information provision.

Results: Two hundred and seventy three participants (214 idiopathic pulmonary fibrosis, 28 sarcoidosis, 31 other) from 13 countries responded. Forty percent of individuals took ≥1 year to receive a final diagnosis. Greatest delays were reported in stage 1, with only 50.2% making an appointment within 3 months. For stage 2, 73.3% reported a hospital referral within three primary care visits. However, 9.9% reported six or more visits. After referral, 76.9% of patients were assessed by a specialist within 3 months (stage 3) and 62.6% received a final diagnosis within 3 months of their first hospital visit (stage 4). Emotions during the journey were overall negative. A major need for more information and support during and after the diagnostic process was identified.

Conclusion: The time to diagnose pulmonary fibrosis varies widely across Europe. Delays occur at each stage of the diagnostic pathway. Raising awareness about pulmonary fibrosis amongst the general population and healthcare workers is essential to shorten the time to diagnosis. Furthermore, there remains a need to provide patients with sufficient information and support at all stages of their diagnostic journey.

The microbiology of ulcerative skin cancers: does the presence of pathogenic bacteria increase the risk of postoperative complications?

BACKGROUND

To document the microbiology of ulcerative skin cancers, histological types, anatomical distribution and post-surgical complications among patients in KwaZulu-Natal and to determine whether a link exists between the presence of these bacteria and postoperative complications after resectional surgery and reconstruction.

METHODS

One hundred swabs from ulcerative cancer wounds were collected from October 2015 to August 2017. The swabs were taken on admission according to swabbing protocol in the ward. Variables analysed were histology, anatomical site, microbiology, management and outcomes and patient specific risk factors - age, smoking, comorbidities and retroviral disease (RVD) status.

RESULTS

Of the 100 skin cancer wounds, 87 cultured pathogenic bacteria: the majority were squamous cell carcinomas (SCC) (48%); the remaining tumours were sarcomas (17%), basal cell carcinomas (BCC) (14%), melanomas (14%) and other carcinomas (3%). Among the bacteria cultured, Staphylococcus aureus was the most common pathogen found in 47% of the wounds, followed by Pseudomonas (25%) and beta-haemolytic Streptococcus (15%). The most virulent of pathogens: beta-haemolytic Streptococcus was most frequently found in melanomas. Of the 74 wounds that underwent reconstruction, 24 had complications (wound sepsis, dehiscence, graft loss, flap sepsis). Although wound complications are multifactorial, it was observed that all 24 of the wounds that complicated cultured pathogenic bacteria (Staphylococcus aureus, Streptococcus and Pseudomonas). It was also found that there were 13 wounds that did not culture any pathogenic bacteria; these showed no complications on follow-up.

CONCLUSION

Although complications post-reconstruction of these lesions are multifactorial, the data from this study shows that pathogenic bacteria may play a role in increasing the post-surgical complication risk.

A review of blunt pelvic injuries at a major trauma centre in South Africa

BACKGROUND

The collective five-year experience with the acute management of pelvic trauma at a busy South African trauma service is reviewed to compare the usefulness and applicability of current grading systems of pelvic trauma and to review the compliance with current guidelines regarding pelvic binder application during the acute phase of resuscitation.

METHODS

A retrospective review was conducted over a 5-year period from December 2012 to December 2017 on all polytrauma patients who presented with a pelvic fracture. Mechanism of injury and presenting physiology and clinical course including pelvic binder application were documented. Pelvic fractures were graded according to the Young- Burgess and Tile systems.

RESULTS

There was a cohort of 129 patients for analysis. Eighty-one were male and 48 female with a mean age was 33.6 ± 13.1 years. Motor vehicle-related collisions (MVCs) were the main mechanism of injury (50.33%) and pedestrian vehicle collisions (PVCs) were the second most common (37.98%). The most common associated injuries were abdominal injuries (41%), chest injury (37%), femur fractures (21%), tibia fractures (15%) and humerus fracture (14.7%). Thirty patients in this cohort (23%) underwent a laparotomy. They were mainly in the Tile B (70%) and lateral compression (63%) groups. Nine patients underwent pelvic pre-peritoneal packing. Thirty-five (27%) patients were admitted to ICU. Fifteen (12%) patients died. The Young-Burgess classification had a greater accuracy in predicting death than the Tile classification. Forty per cent of deaths occurred in ICU, 33% died secondary to a traumatic brain injury (TBI). Twenty per cent died in casualty and 6.6% in the operating room from ongoing haemorrhage. A pelvic binder was not applied in 66% of patients. In the 34% of patients who had a pelvic binder applied, it was applied post CT scan in 24.8%, in the pre-hospital setting in 7.2%, and on arrival in 2.4% of patients. In 73% of deaths, a binder was not applied, and of those deaths, 54% showed signs of haemodynamic instability.

CONCLUSION

It would appear that our application of pelvic binders in patients with acute pelvic trauma is ad hoc. Appropriate selection of patients, who may benefit from a binder and it's timely application, has the potential to improve outcome in these patients.

The quest to improve outcomes for abdominal wall incisional hernia repair in Pietermaritzburg: between Scylla and Charybdis

ABSTRACT BACKGROUND: The repair and outcomes of incisional abdominal wall hernias have not yet been benchmarked to allow comparison with recommended best practice in a South African context. This study aimed to address this deficit METHOD: Patients who underwent an incisional hernia repair between December 2012 and December 2018 were analysed in respect to the following variables: demographics, comorbidities, indication for surgery, site, size, surgical approach, mesh usage, operating times, complications and 30-day mortality RESULTS: Of the cohort of 224 patients, 185 underwent elective repair. There were 152 open and 72 laparoscopic procedures, and 17 patients (8%) required a repeat operation with an overall in-hospital mortality rate of 6% (13). Eight patients developed an enteric leak. There were nine cardiovascular complications, 24 respiratory complications, 22 surgical site infections and 13 patients developed an acute kidney injury (AKI). There were 39 emergency operations. The emergency cohort were older than the elective with a higher rate of cardiovascular or surgical (CVS) complications and AKI. Eight patients developed an enteric leak. Mortality rates of were significantly higher in the emergency operation cohort compared to the elective group (18% vs 3%). The 13 in-hospital deaths were older, more likely to have undergone an emergency operation, to be diabetic (46% vs 10%), hypertensive (92% vs 33%), have a bowel anastomosis (39% vs 9%), experience an enteric leak (46% vs 1%) and require repeat operation than the patients who survived CONCLUSION: Incisional abdominal wall hernias are difficult to manage as the patients often have several comorbidities which when coupled with an emergency operation leads to poor outcomes. Improving outcomes requires strategies that address comorbidities and shift the focus to elective rather than emergency repair Keywords: incisional, hernia

The surgical burden of breast disease in KwaZulu-Natal province

ABSTRACT BACKGROUND: The current surgical workload assessments in KwaZulu-Natal (KZN) are inadequate to inform strategies to improve surgical services. Breast diseases have a well-defined spectrum and surgical treatment options, analysis of which could guide health policy in the field. This project aimed to quantify and analyse the operative workload for breast pathology in KZN METHOD: A retrospective review of breast-related operations conducted at public sector hospitals in KwaZulu-Natal province between 1 July and 31 December 2015 was undertaken. Data was collected from theatre operative registers and manually categorised as follows: sepsis, benign pathology, malignant pathology, and by hospital, according to geographic location, and complexity of care to determine factors to improve the service for breast care in the province RESULTS: In the 6-month study period, 13 282 general surgical procedures were performed of which 776 (5.8%) were breast-related operations. There were 372 (47.9%) operations for breast sepsis, 140 (18%) for benign breast lesions, 17 (2.2%) for cosmetic indications and 27 (3.5%) for diagnostic procedures. There were 223 (28.7%) procedures for non-benign disease: 21 (2.6%) wide local excisions (WLE), 203 (26.2%) mastectomies of which 161 (72.2%) mastectomies had an axillary lymph node dissection and 26 (11.7%) were performed as onco-plastic procedures. Hospitals in the Durban and Pietermaritzburg metropolitan areas performed 75% of the breast-related procedures. The majority (69.6%) of sepsis-related procedures were performed at secondary/regional facilities, while 58.3% of non-benign breast surgeries were performed at tertiary and quaternary centres CONCLUSION: Breast sepsis accounts for almost 50% of the surgery and is mainly dealt with at hospitals above district level. One-third of breast surgery in KZN province is for non-benign disease. There is a paucity of breast-conserving surgery. Elucidation of these observations can guide improvement in the provincial breast care service Keywords: breast surgery, breast pathology, breast cancer, general surgery

Childhood and adolescent trauma in Pietermaritzburg is a neglected sub-epidemic within a larger epidemic and warrants a dedicated service

ABSTRACT BACKGROUND: This study reviews our experience with paediatric trauma to help plan and strengthen ongoing strategies to deal with trauma in our region METHODS: All children and adolescents less than 18 years of age who were admitted to our centre following trauma between December 2012 and October 2020 were reviewed RESULTS: Over the 8-year period, 2 091 children were admitted with trauma to Grey's Hospital. There were 1 479 (71%) male patients, median age: 10 years. One thousand four hundred and fifty-eight (70%) patients were referral from rural regions. In 1 597 (76%) patients, the mechanism of injury was blunt trauma. A total of 387 (19%) patients underwent a surgical intervention, whilst 1 641 (78%) patients were managed non-operatively. In 63 patients, management records were missing. Multiple patients required multiple surgical procedures. A total of 144 patients had a laparotomy, 70 a soft tissue debridement procedure, 40 an orthopaedic procedure, 53 a neurosurgical procedure, which included 37 patients who underwent craniotomy, and 18 patients underwent a fasciotomy for compartment syndrome. There were 82 patients who required miscellaneous procedures. A total of 213 (10%) patients required ICU admission. There were 48 (2.3%) deaths CONCLUSION: The volume of child and adolescent trauma managed is significant and suggests that a dedicated paediatric trauma service in the region is warranted. It is hoped that future partnering with appropriate stakeholders will allow this service to continue to mature and provide leadership in all aspects of care of injured children in the region Keywords: multiple trauma, general surgery, paediatrics

The spectrum of blunt abdominal trauma in Pietermaritzburg

ABSTRACT BACKGROUND: This study reviews the Pietermaritzburg Metropolitan Trauma Service (PMTS) experience with the management of blunt abdominal trauma (BAT METHODS: A retrospective review of the hybrid electronic medical registry (HEMR) between December 2012 and September 2019 was conducted. All patients admitted following BAT were included RESULTS: During the study period, 1 123 BAT patients were managed by the PMTS. The mean age was 29.19 years (SD 14.03). Of these admissions, 73.6% were male. The most common mechanism was road traffic crashes (RTCs) - 435 motor vehicle collisions (MVCs) and 250 pedestrian vehicle collisions (PVCs). There were 186 assaults, 118 falls, 62 community assaults, 22 accidents related to agriculture, construction or industry, 11 sporting injuries, nine animal injuries, seven patients injured by falling objects, five injured by trains, two hangings, one burn-related fall and two other causes. The mechanism of injury was unknown in 22 cases. There were 445 abdominal CT scans and 270 whole body CT scans. Surgical management was required for 395 patients. There were 259 index laparotomies and 176 repeat laparotomies. Four patients underwent selective arterial embolisation. Laparoscopy was undertaken in ten, and subsequently converted to laparotomy in five. There were 106 orthopaedic operations. Hospital stay ranged from 0-155 days (median stay three days). ICU admission was required in 24.9% of patients. The mortality rate was 7.5% CONCLUSION: BAT is common in South Africa. Whilst the vast majority of patients require non-operative treatment, a well-defined subset require a laparotomy. Imaging is central to the management of patients with BAT Keywords: blunt abdominal trauma, hybrid electronic medical registry

The correlation between full moon and admission volume for penetrating injuries at a major trauma centre in South Africa

ABSTRACT BACKGROUND: The possible effect of full moon on admission volume of trauma centres is a well-mentioned phenomenon that has been perpetuated worldwide. We aimed to review the correlation between full moon and admission volume and to interrogate any possible relationship on admission for penetrating trauma METHODS: A retrospective study from 2012 to 2018 at Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa RESULTS: A total of 8 722 patients were admitted. Eighty-three per cent (7 242/8 722) were male and the mean age was 29 years. The total number of days during the study period was 1 953, 66 of which were 'full moon' (FM) days and 1 887 were 'non-full moon' (NFM) days. There was no significant difference between gender or age distribution. The mean number of admissions per day on FM days compared with NFM days was not significant (4.1 vs 4.5, p = 0.583). A total of 3 332 patients with penetrating trauma were admitted. This constituted 42% (113/271) of admission on FM days and 38% (3 219) on NFM days, which is not statistically significant (p = 0.229). Subgroup analysis did not demonstrate any significant difference between the number of stab wounds - 28% (77/113) vs 25% (2 124/3 219) - or gunshot wounds - 13% (16/113) vs 12% (990/3 219) - between FM and NFM days CONCLUSION: The correlation between full moon and trauma admission is unfound in our setting. The perpetuating notion that 'it must be full moon tonight' is likely to be an urban myth with no scientific evidence for such a claim Keywords: emergency medicine, trauma, epidemiology, full moon, lunar cycle

Predictors of the need for surgery in upper gastrointestinal bleeding in a resource constrained setting: the Pietermaritzburg experience

BACKGROUND

This review from a tertiary centre in South Africa aims to describe the spectrum and outcome of upper gastrointestinal bleeding (UGIB) and identify risk factors for surgical management and death.

METHODS

This was a retrospective review of a prospectively entered database of all adults presenting with UGIB between December 2012 and December 2016. Demographics, presenting physiology, risk assessment scores, outcomes of endoscopy endo-therapy and surgery were reviewed. Comparisons were made between patients who required operative therapy and those who did not, and between survivors and non-survivors.

RESULTS

During the review period, 632 patients were admitted with suspected UGIB. Out of these, 406 (64%) had an identifiable potential source of bleeding and 226 (36%) had no identifiable potential source of UGIB. The latter were excluded from further analysis. Of the 406 patients with a potential source of haemorrhage, there were 249 males (61%) and 157 females (39%). Nine of these were expedited directly to the operating room and never underwent an endoscopy. Of the 397 (98%) who had upper endoscopy 107 (26%) had endotherapy. Forty-six patients (11%) required surgery. They had significantly higher shock index (SI), increased need for transfusion, higher international normalised ratio (INR) and higher serum lactate than the non-operative group. Nine patients went to the operating room without endoscopy. Of the 46 patients who required surgery, 37 underwent an attempt at endoscopic intervention. Transfusion and transfusion volume increased the probability of requiring a laparotomy (p = 0.015) and (0.003) respectively. The independent predictors of need for operation were a raised shock index or serum lactate and Forrest Ia and Ib ulcers. Thirty-nine patients died, giving a mortality rate of 9.6%; ten had a gastric ulcer and 16 had a duodenal ulcer. Survival was significantly higher in the non-operative group (93.1% versus 68.2%; p < 0.001). The odds ratio for mortality in the laparotomy group is 6.73, 95% CI (3.15-14.17). Receiver operator curve (ROC) analysis showed that the pre-endoscopic Rockall score (PER), total Rockall score (TR) and the SI were poor predictors of mortality.

CONCLUSION

Patients with UGIB in our setting are younger than in high-income countries (HIC) and a larger number fail endoscopic therapy and require open surgery. The mortality in this subset is very high. Detailed analysis of failed endotherapy has the potential to reduce mortality.

A comparison of blunt and penetrating pancreatic trauma

BACKGROUND

This project reviews our experience with managing pancreatic trauma from 2012 to 2018.

METHODS

All patients over the age of 15 years with a pancreatic injury during the period December 2012-December 2018 were retrieved from the Hybrid Electronic Medical Registry at Grey's Hospital and reviewed.

RESULTS

During the study period 161 patients sustained a pancreatic injury. The mechanism of trauma was penetrating in 86 patients (53%) and blunt in 75 (47%). The blunt mechanisms included MVA in 27, PVA in 15, falls in four and assaults in the remaining 29. There were 52 stab wounds and 34 gunshot wounds of the pancreas. A total of 26 patients (16%) were shocked on presentation with a systolic blood pressure of 90 mm Hg or less. The median injury severity score was 16. There were 90 patients with American Association for the Surgery of Trauma (AAST) grade I injury to the pancreas, 36 AAST grade II, 27 AAST grade III, 7 AAST grade IV and a single AAST grade V. Fifty-four patients (34%) were initially treated non-operatively of which three eventually required surgery. Of the patients who required surgery, 26 (16%) underwent a distal pancreatectomy. The remainder simply underwent pancreatic drainage. The overall mortality rate was 13% (21/161). The operative mortality was 11% (18/161). Thirteen patients (8%) with penetrating injuries and eight patients (5%) with blunt injuries died. Of the 21 patients who died, 14 had multiple injuries. Five patients died due to overwhelming sepsis. One patient died due to hypovolemic shock and another due to a traumatic brain injury.

CONCLUSION

Our centre not infrequently deals with pancreatic trauma secondary to both blunt and penetrating trauma. We follow the general principles outlined in the literature. Despite this, pancreatic trauma is still associated with significant morbidity and mortality.

The scourge of knife crime: trends in knife-related assault managed at a major centre in South Africa

BACKGROUND

Knife wounds are common and represent a major burden to the South African healthcare system. This study reviews trends in spectrum, management and outcome of these injuries at a single trauma centre in KwaZulu-Natal(KZN).

METHOD

The regional hybrid electronic registry (HEMR) was reviewed for the period January 2013 - December 2018, and all patients who suffered a knife-related assault were identified and reviewed.

RESULTS

During the period under review, a total of 2117 patients suffered a knife-related assault. Regions injured were as follows: head 445, neck 572, face 258, chest 939, abdomen 649, pelvic/urogenital 49, upper limb 418, and lower limb 105. The median ISS was 9 (4-10). Imaging comprised 1242 chest X-rays, 315 abdominal X-rays, 162 abdominal ultrasounds/ FAST, and 929 CT scans of which 634 were CT angiograms. A total of 783 (37%) patients required an operation. The rate of laparotomy was 447/649 (69%) and of thoracotomy/sternotomy/thoracoscopy 95/939 (10%). The rate of vascular exploration for upper and lower limb vascular injury was 101/523 (19%). Mortality was 49/2117 (2.3%)..

CONCLUSION

Although our clinical outcomes over this period appear to be consistent, suggesting a familiarity with managing knife-related trauma, the persistently high rate of knife-related injury suggests that we have failed to develop a preventative strategy to try and reduce this scourge.

Avoiding the diagnostic pitfalls of a pancreatic cystic lesion

Cystic pancreatic lesions present a diagnostic challenge. Accurate characterisation of an isolated cystic pancreatic lesion is therefore vital as this dictates the management strategy which may vary from radical resection to simple observation. This report describes how a detailed preoperative assessment led to the correct diagnosis of an isolated pancreatic lesion and appropriate safe and curative surgical management.

Blunt and Penetrating Liver Trauma have Similar Outcomes in the Modern Era

BACKGROUND

The trend in liver trauma management has progressively become increasingly conservative. However, a vast majority of literature focuses heavily on the management of blunt trauma. This study reviews the management of hepatic trauma at a major trauma center in a developing world setting, in order to compare blunt and penetrating liver trauma and to define current management algorithms and protocols.

METHODS

All patients who sustained liver trauma between 2012 to 2018 were identified in the Hybrid Electronic Medical Registry and extracted for further analysis.

RESULTS

A total of 808 patients with hepatic trauma were managed by our trauma center. There were 658 males and 150 females. The mean age was 30 years (standard deviation 13.3). A total of 68 patients died (8.2%) and a total of 290 (35%) patients required intensive care unit admission. The mean presenting shock index was 0.806 (standard deviation 0.67-1.0), the median Injury Severity Score was 18 (interquartile range 10-25) and the mean Revised Trauma Score was 12 (standard deviation 11-12). There were 367 penetrating and 441 blunt liver injuries. The age distribution was similar in both groups. There were significantly less females in the penetrating group. The shock index and the Injury Severity Score on presentation were significantly worse in the blunt group, respectively: 0.891 (standard deviation 0.31) versus 0.845 (standard deviation 0.69) (p < 0.001) and score 21 (interquartile range 13-27) versus 16 (interquartile range 9-20) (p < 0.01). The opposite applied to the Revised Trauma Score of 11.75 (standard deviation 0.74) versus 11.19 (standard deviation 1.3) (p < 0.001). There were significantly more associated intra-abdominal injuries in the penetrating group than the blunt group, in particular that of hollow organs, and 84% of patients with a penetrating injury underwent a laparotomy while only 33% of the blunt injuries underwent a laparotomy. The mortality rate was comparable between both groups.

CONCLUSION

Hepatic trauma is still associated with a high morbidity rate, although there have been dramatic improvements in mortality rates over the last three decades. The mortality rates for blunt and penetrating liver trauma are now similar. Non-operative management is feasible for over two-thirds of blunt injuries and for just under 20% of penetrating injuries.

Correlation between the level of the external wound and the internal injury in penetrating neck injury does not favour an initial zonal management approach

Background

Many current protocols for managing penetrating neck injuries (PNIs) still suggest zonal approaches. This study was undertaken to determine the correlation between the zone of the external wound and the level of the internal injury, and to verify whether a ‘no‐zone’ approach to PNI is valid.

Methods

Patients admitted with a PNI to a tertiary trauma care centre between January 2011 and May 2018 were identified from a trauma database. Those with confirmed injury to the vascular system or an aerodigestive tract injury (ADTI) were included in the study. The medical records of each patient were reviewed with regard to the zone of the external wound and the level of internal injury, and the findings were compared.

Results

In the period under review, 1075 patients were treated for a PNI. Of these, 298 (27·7 per cent) had a confirmed vascular injury or ADTI and were included in the cohort. In 176 patients (59·1 per cent) the site of the internal injury was in the same zone as the external wound. In a further 70 patients (23·5 per cent) there was no correlation between the site of the internal injury and the external wound, and in the remaining 52 patients (17·4 per cent) the correlation could not be determined. In this cohort, all clinically assessable patients with significant injuries had either physical signs suggestive of injury or deep surgical emphysema on radiological examination.

Conclusion

An approach to PNI based on zones is questionable, and this study supports a no‐zone approach based on imaging guided by clinical examination.

Penetrating trauma in children and adolescents in Pietermaritzburg

BACKGROUND

This project aims to review the spectrum and outcome of penetrating trauma in children and adolescents with the objective of defining the extent of the problem and of developing strategies to reduce the incidence and severity of this form of trauma.

METHODS

All patients less than eighteen years of age who were admitted to the Pietermaritzburg Metropolitan Trauma Service (PMTS) following penetrating trauma between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry (HEMR).

RESULTS

During the five-year period under review, a total of 164 patients less than eighteen years of age sustained penetrating trauma and were admitted to the PMTS. There were 138 males and 26 females. The mean age was 13.29 years and the median age 15 years. There were 70 stab wounds (SW) and 73 gunshot wounds (GSW). There were 21 non-intentional impalement injuries. The mean ISS was 9.04 and the median was 9. A total of 155 plain X-rays were performed, 50 CT scans and 51 CT angiograms in this cohort of patients. Only two ultrasound examinations were performed. A total of 76 patients required an operation, which included 50 laparotomies. Of the patients who underwent a laparotomy, 18 required a repeat laparotomy. There were 46 other procedures undertaken in this cohort of patients, which included two thoracotomies, three laparoscopies and two thoracotomies. The median hospital stay was 2 days and 17 (10%) patients required ICU admission and 7 (4%) died.

CONCLUSION

Penetrating trauma in children and adolescents is associated with significant mortality and morbidity. There are similarities with the management of these injuries in adults, but further work is required to ensure that paediatric management algorithms are evidence based.

Selective Nonoperative Management of Abdominal Stab Wounds with Isolated Omental Evisceration is Safe: A South African Experience

BACKGROUND AND AIMS

Selective nonoperative management of abdominal stab wound is well established, but its application in the setting of isolated omental evisceration remains controversial. The aim of the study is to establish the role of selective nonoperative management in the setting of isolated omental evisceration.

MATERIALS AND METHODS

A retrospective study was conducted over an 8-year period from January 2010 to December 2017 at a major trauma center in South Africa to determine the outcome of selective nonoperative management.

RESULTS

A total of 405 consecutive cases were reviewed (91% male, mean age: 27 years), of which 224 (55%) cases required immediate laparotomy. The remaining 181 cases were observed clinically, of which 20 (11%) cases eventually required a delayed laparotomy. The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), 3-6 h in 6% (14/244), 6-12 h 2% (4/244), and 12-18 h in 1% (2/244). There was no significant difference between the immediate laparotomy and the delayed laparotomy group in terms of length of stay, morbidity, or mortality. Ninety-eight percent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic.

CONCLUSION

Selective nonoperative management for abdominal stab wound in the setting of isolated omental evisceration is safe and does not result in increased morbidity or mortality. Clinical assessment remains valid and accurate in determining the need for laparotomy but must be performed by experienced surgeons in a controlled environment.

Traumatic renal injury: Five-year experience at a major trauma centre in South Africa

BACKGROUND

This study is intended to assess the current optimal management of traumatic renal injuries (TRIs), with a focus on high-grade and penetrating injuries.

METHODS

The Pietermaritzburg Metropolitan Trauma Service registry was interrogated retrospectively for patients managed for TRI between 1 January 2012 and 31 December 2016.

RESULTS

Of 13,315 inured patients treated by the PMTS, 223 (1.7%) had TRIs with an incidence of 1.5 per 100,000 population per year. The majority were males between 20 and 39 years of age. The distribution of mechanism of injury was 56.1% (n = 125) blunt and 43.9% (n = 98) penetrating trauma with no association between mechanism and grade of injury. Penetrating trauma was associated with hollow viscus and diaphragm injuries and blunt trauma with solid organ injuries. A total of 118 patients (52.9%) were managed non-operatively, 60 (26.9%) were not explored at operation, 27 (12.1%) underwent initial nephrectomy and 8 (3.6%) underwent renorraphy. Low-grade injuries (AAST I and II) and high-grade injuries (AAST III-V) were managed without renal intervention (non-operatively or not explored at laparotomy for associated injuries) in 88.7% (n = 87) and 72.0% (n = 91) of cases respectively. Blunt and penetrating injuries were managed without renal intervention in 87.9% (n = 109) and 70% (n = 69) of cases respectively. The initial nephrectomy rate was 1% (n = 1) and 20.6% (n = 26) for low- and high-grade injuries respectively, and 6.5% (n = 8) and 19% (n = 19) for blunt and penetrating injuries respectively. High grade (AAST III-V) injury (OR 14.94; 95% CI 3.36 - 66.34; p<0.001), penetrating mechanism (OR 4.99; 95% CI 1.98 - 12.52; p = 0.001) and metabolic acidosis (OR 2.73; 95% CI 1.04 - 7.20; p = 0.042) were significant risk factors for nephrectomy. Four patients (1.8%) underwent ureteral stent insertion and 2 (0.9%) underwent embolisation. The failure rate of initial non-operative management was 1.1%. The mortality rate was 8.1% (n = 18), but no patients with solitary renal injuries died.

CONCLUSION

Even in high-grade injuries and penetrating trauma, the majority of patients with TRI can be managed non-operatively or with the assistance of endourological or endovascular techniques, with good outcomes. Risk factors for nephrectomy include the presence of high-grade injuries, penetrating trauma and metabolic acidosis on presentation.

Compliance with the Surviving Sepsis Campaign guidelines for early resuscitation does not translate into improved outcomes in patients with surgical sepsis in South Africa

INTRODUCTION

This project set out to audit our compliance with the 3-hour bundles of care for surgical sepsis and to interrogate how compliance or non-compliance impacts on the outcome of surgical sepsis in our institution.

METHODS

All emergency surgical patients over the age of fifteen years were reviewed. All patients who fulfilled the ACCP/SCCM criteria for sepsis or septic shock, with a documented surgical source of infection, were identified for review.

RESULTS

A total of 677 septic patients with a documented surgical source of sepsis were included. Of the 677 patients, 53% (360/677) had intra-abdominal sepsis, 17% (116/677) had diabetic-related limb sepsis and the remaining 30% (201) had soft tissue infections. A total of 585 operative procedures were performed. Compliance with all components of the 3-hour bundle metrics was achieved in 379/677 patients (56%), and not achieved in 298/677 patients (44%). The only significant difference between the compliant and the non-compliant groups was respiratory rate greater than 22 breaths/minute (131 vs 71, p = 0.002) in the compliant cohort. Amongst the compliant cohort 77/379 patients (20%) required admission to ICU, whilst 41/298 patients (14%) in the non-compliant cohort required admission to ICU. This difference was statistically different (p = 0.026). There was no difference in the median length of hospital stay (6 days) between the two groups. Fifty-five patients in the compliant cohort died (15%), whilst 31 (10%) of the patients in the non-compliant cohort died. This difference was not statistically different (p = 0.111).

CONCLUSION

Compliance with the SCC 3-hour bundle did not seem to improve mortality outcomes in our setting. This observation cannot be adequately explained with our current data and further work looking at management of surgical sepsis in our setting is required. Time to surgical source control is probably the single most important determinant of outcome in patients with surgical sepsis and other aspects of the care bundle are of secondary importance.

Discrepancy in clinical outcomes of patients with gunshot wounds in car hijacking: a South African experience

INTRODUCTION

Discrepancy in outcomes between urban and rural trauma patients is well known. We reviewed our institutional experience with the management of gunshot wounds (GSWs) in the specific setting of car hijacking and focused on clinical outcome between rural and urban patients.

METHODS

A retrospective review was conducted at a major trauma centre in South Africa over an 8-year period for all patients who presented with any form of GSWs in car hijacking settings. Specific clinical outcomes were compared between rural and urban patients.

RESULTS

A total of 101 patients were included (74% male, mean age 34 years). Fifty-five per cent were injured in rural areas and the remaining 45% (45/101) were in the urban district. Mean time from injury to arrival at our trauma centre was 11 hours for rural and 4 hours for urban patients (p < 0.001). Seventy-six per cent (76/101) sustained GSWs to multiple body regions. Sixty-three of the 101 (62%) patients required one or more operative interventions. In individual logistic regressions adjusted for sex and number of regions injured, rural patients were 9 (95% CI: 1.9-44.4) and 7 (95% CI: 2.1-24.5) times more likely than urban patients to have morbidities or required admissions to intensive care respectively. The risk of death in rural patients was 36 (95% CI: 4.5-284.6) times higher than that of urban patients.

CONCLUSION

Patients who sustained GSWs in carjacking incidents that occurred in rural areas are associated with significantly greater morbidity and mortality compared with their urban counterparts. Delay to definitive care is likely to be the significant contributory factor, and improvement in prehospital emergency medical service is likely to be beneficial in improving patient outcome.

The spectrum of animal related injuries managed at a major trauma centre in South Africa

BACKGROUND

Humans come into contact and interact with an array of animals in a number of areas and environments. We set out to review our experience with animal-related injuries in Pietermaritzburg, KwaZulu-Natal, South Africa.

METHOD

All patients who sustained an injury secondary to an interaction with an animal in the period December 2012-December 2017 were identified from the Hybrid Electronic Medical Registry (HEMR).

RESULTS

There were 104 patients in the study sample. The mean age of patients in the study was 32.8 years, with a range from 1 to 76 years old. 75% (n = 78) were male and 25% (n = 26) female. Out of the 104 animal-related injuries, 67 were blunt trauma, 39 penetrating trauma and 3 a combination of blunt and penetrating trauma. The species causing trauma included dogs (53), horses (29), cows (18), buffalo (1), warthog (1), impala (1) and a single goat (1). The median time from injury to hospitalisation was 46.62 hours (range from 0 to 504 hours). Injuries occurred to the head (n = 32), face (n = 9), neck (n = 32), abdomen (n = 22), urogenital system (n = 6), upper limb (n = 39) and lower limb (n = 39). The Injury Severity Score (ISS) mean for the patients was 8.16, the range 1-4, the median 9 and the standard deviation 6.88. In 49 patients the treatment was non-operative. In the remaining 55 patients, a total of 68 operative procedures were required. Operations included wound debridement/surgical washout (n = 38), laparotomy (n = 9), arterial repair/ligation (n = 8), skin graft (n = 4), craniotomy (n = 5), fasciotomy (n = 2), amputation (n = 1), and placement of an ICP monitor (n = 1). 49 of these operations were for patients with dog bite injuries. The mean hospital stay was 0.13 days with a range of 0-4 days. Four patients were admitted to the Intensive Care Unit (ICU) and two patients died.

CONCLUSION

Human interactions with animals may result in injuries which require surgical treatment. The most common animal injury is a dog bite but in the case of the larger domestic farm animals, blunt force type injuries and goring can result in significant injuries which require complex surgical interventions.