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Thirayan V, Kong VY, Uchino H, Clarke DL. Post-traumatic stress disorder in international surgeons undertaking trauma electives in a South African trauma centre. S AFR J SURG 2024; 62:14-17. [PMID: 38568120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
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.
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Affiliation(s)
- V Thirayan
- Mental Health and Addictions, Waikato Hospital, New Zealand
| | - V Y Kong
- Department of Surgery, University of KwaZulu-Natal, South Africa
- Department of Surgery, University of the Witwatersrand, South Africa
| | - H Uchino
- Trauma Centre, Montreal General Hospital, Canada
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, South Africa
- Department of Surgery, University of the Witwatersrand, South Africa
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Narayanan A, Naidoo M, Kong VY, Pearson L, Mani K, Fisher JP, Khashram M, Clarke DL. Broad responses and attitudes to having music in surgery (the BRAHMS study) - a South African perspective. S AFR J SURG 2023; 61:30-38. [PMID: 37052283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
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.
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Affiliation(s)
- A Narayanan
- Faculty of Medicine and Health Sciences, University of Auckland, New Zealand and Department of Surgery, University of Auckland, New Zealand and Department of Vascular Surgery, Waikato Hospital, New Zealand
| | - M Naidoo
- Department of Surgery, University of KwaZulu-Natal, South Africa and Department of Surgical Sciences, Uppsala University, Sweden
| | - V Y Kong
- Faculty of Medicine and Health Sciences, University of Auckland, New Zealand and Department of Surgery, University of Auckland, New Zealand and Department of Surgery, University of the Witwatersrand, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
| | - L Pearson
- Department of Vascular Surgery, Waikato Hospital, New Zealand
| | - K Mani
- Department of Vascular Surgery, Waikato Hospital, New Zealand and Department of Surgical Sciences, Uppsala University, Sweden
| | - J P Fisher
- Faculty of Medicine and Health Sciences, University of Auckland, New Zealand
| | - M Khashram
- Faculty of Medicine and Health Sciences, University of Auckland, New Zealand and Department of Surgery, University of Auckland, New Zealand and Department of Vascular Surgery, Waikato Hospital, New Zealand
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, South Africa and Department of Surgical Sciences, Uppsala University, Sweden
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Thirayan V, Kong VY, Elsabagh A, Xu W, Rajaretnam N, Conradie B, Cheung C, Clarke DL, Bruce JL, Laing GL, Manchev V, Bekker W. High-grade renal trauma in children and adolescents can be successfully managed non-operatively. S AFR J SURG 2023; 61:56-60. [PMID: 37052277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
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.
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Affiliation(s)
- V Thirayan
- Department of Surgery, Waikato Hospital, New Zealand
| | - V Y Kong
- Department of Surgery, Auckland City Hospital, New Zealand and Department of Surgery, University of the Witwatersrand, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
| | - A Elsabagh
- Department of Surgery, St John of God Midland Public Hospital, Australia
| | - W Xu
- Department of Surgery, University of Auckland, New Zealand
| | - N Rajaretnam
- Department of Surgery, St James's Hospital, Ireland
| | - B Conradie
- Department of Surgery, University of Auckland, New Zealand
| | - C Cheung
- Department of Surgery, Chris Hani Baragwanath Academic Hospital, South Africa
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - V Manchev
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - W Bekker
- Department of Surgery, University of KwaZulu-Natal, South Africa
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Naidoo M, Kong VY, Clarke DL, Conradie B. Experience and perceptions of laparoscopic appendectomy amongst surgical trainees in South Africa. S Afr J Surg 2022; 60:300-304. [PMID: 36477062 DOI: 10.17159/2078-5151/sajs3739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- M Naidoo
- Department of Surgery, Ngwelezana Tertiary Hospital, South Africa
| | - V Y Kong
- Department of Surgery, University of KwaZulu Natal, South Africa and Department of Surgery, Auckland City Hospital, New Zealand
| | - D L Clarke
- Department of Surgery, University of KwaZulu Natal, South Africa and Department of Surgery, University of Witwatersrand, South Africa
| | - B Conradie
- Department of Surgery, University of Auckland, New Zealand
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Lee L, Kong VY, Cheung C, Rajaretnam N, Thirayan V, Bruce JL, Manchev V, Mills RP, Laing GL, Clarke DL. The neglected epidemic of trauma from interpersonal violence against the elderly in South Africa. S Afr J Surg 2022; 60:278-283. [PMID: 36477058 DOI: 10.17159/2078-5151/sajs3794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- L Lee
- Department of Surgery, University of Auckland, New Zealand
| | - V Y Kong
- Department of Surgery, Auckland City Hospital, New Zealand and Department of Surgery, University of KwaZulu-Natal, South Africa
| | - C Cheung
- Department of Surgery, University of the Witwatersrand, South Africa and Department of Surgery, Chris Hani Baragwanath Hospital, South Africa
| | - N Rajaretnam
- Department of Surgery, St James's Hospital, Ireland
| | - V Thirayan
- Department of Psychiatry, Waikato Hospital, New Zealand
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - V Manchev
- Department of Surgery, University of Auckland, New Zealand
| | - R P Mills
- Department of Surgery, Life Entabeni Hospital, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
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Oosthuizen GV, Klopper J, Buitendag J, Variawa S, Čačala SR, Kong VY, Couch D, Allen N, Clarke DL. Correction to: Penetrating colon trauma - outcomes related to single versus multiple colonic injuries. Eur J Trauma Emerg Surg 2022; 48:4313-4314. [PMID: 35802154 DOI: 10.1007/s00068-022-01994-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- G V Oosthuizen
- Department of Surgery, Ngwelezana Hospital, Empangeni, South Africa
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J Klopper
- Division of Epidemiology and Biostatistics, University of Stellenbosch, Cape Town, South Africa
| | - J Buitendag
- Department of Surgery, University of Stellenbosch, Cape Town, South Africa
| | - S Variawa
- Department of Surgery, Khayelitsha District Hospital, Cape Town, South Africa
| | - S R Čačala
- Department of Surgery, Ngwelezana Hospital, Empangeni, South Africa
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - V Y Kong
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand.
| | - D Couch
- Department of Surgery, Queens Medical Centre, Nottingham, United Kingdom
| | - N Allen
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Oosthuizen GV, Klopper J, Buitendag J, Variawa S, Čačala SR, Kong VY, Couch D, Clarke DL. Penetrating colon trauma-the effect of concomitant small bowel injury on outcome. Injury 2022; 53:1615-1619. [PMID: 35034775 DOI: 10.1016/j.injury.2021.12.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/12/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- G V Oosthuizen
- Department of Surgery, Ngwelezana Hospital, Empangeni, South Africa; Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J Klopper
- Division of Epidemiology and Biostatistics, University of Stellenbosch, Cape Town, South Africa
| | - Johan Buitendag
- Department of Surgery, University of Stellenbosch, Milnerton, Cape Town, South Africa.
| | - S Variawa
- Department of Surgery, Khayelitsha District Hospital, Cape Town, South Africa
| | - S R Čačala
- Department of Surgery, Ngwelezana Hospital, Empangeni, South Africa; Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - D Couch
- Department of Surgery, Queens Medical Centre, Nottingham, United Kingdom
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa; Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Department of Surgery, Grey's Hospital, Pietermaritzburg, South Africa
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Gurunand A, Smith MTD, Bruce JL, Kong VY, Laing GL, Govindasamy V, Clarke DL. The quest to improve outcomes for abdominal wall incisional hernia repair in Pietermaritzburg: between Scylla and Charybdis. S AFR J SURG 2021; 59:140-144. [PMID: 34889535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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 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.
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Affiliation(s)
- A Gurunand
- Department of General Surgery and Trauma, Grey's Hospital, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
| | - M T D Smith
- Department of General Surgery and Trauma, Grey's Hospital, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
| | - J L Bruce
- Department of General Surgery and Trauma, Grey's Hospital, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
| | - V Y Kong
- Department of Surgery, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - V Govindasamy
- Department of General Surgery and Trauma, Grey's Hospital, South Africa
| | - D L Clarke
- Department of General Surgery and Trauma, Grey's Hospital, South Africa; Department of Surgery, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
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Rhimes P, Moffatt S, Kong VY, Bruce JL, Smith MTD, Bekker W, Laing GL, Clarke DL. The spectrum of blunt abdominal trauma in Pietermaritzburg. S AFR J SURG 2021; 59:90-93. [PMID: 34515423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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 welldefined subset require a laparotomy. Imaging is central to the management of patients with BAT.
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Affiliation(s)
- P Rhimes
- Critical Care Directorate, Nottingham University Hospitals, United Kingdom
| | - S Moffatt
- Emergency Department, University Hospital Coventry, United Kingdom
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - M T D Smith
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - W Bekker
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
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Kong VY, Keizer AA, Donovan MM, Weale RD, Rajaretnam NS, Bruce JL, Elsabagh A, Clarke DL. The correlation between full moon and admission volume for penetrating injuries at a major trauma centre in South Africa. S AFR J SURG 2021; 59:94-96. [PMID: 34515424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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.
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Affiliation(s)
- V Y Kong
- Department of Surgery, University of the Witwatersrand, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
| | - A A Keizer
- Department of Surgery, Alrijne Hospital, The Netherlands
| | - M M Donovan
- Department of Surgery, Stanford University School of Medicine, United States of America
| | - R D Weale
- Department of Surgery, North West Deanery, United Kingdom
| | | | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - A Elsabagh
- Department of Surgery, Flinders Medical Centre, Australia
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, South Africa and Department of Surgery, University of KwaZulu-Natal, South Africa
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Ashkal A, Kong VY, Blodgett JM, Smith MTD, Bekker W, Bruce JL, Laing GL, Clarke DL. A review of blunt pelvic injuries at a major trauma centre in South Africa. S AFR J SURG 2021; 59:26a-26e. [PMID: 33779102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- A Ashkal
- Department of Orthopaedic Surgery, University of KwaZulu-Natal, South Africa
| | - V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
| | - J M Blodgett
- MRC Unit for Lifelong Health and Ageing at UCL, United Kingdom
| | - M T D Smith
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, South Africa
| | - W Bekker
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
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Gurunand A, Smith MTD, Bruce JL, Kong VY, Laing GL, Govindasamy V, Clarke DL. The quest to improve outcomes for abdominal wall incisional hernia repair in Pietermaritzburg: between Scylla and Charybdis. S AFR J SURG 2021. [DOI: 10.17159/2078-5151/2021/v59n4a3513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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
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Rhimes P, Moffatt S, Kong VY, Bruce JL, Smith MTD, Bekker W, Laing GL, Clarke DL. The spectrum of blunt abdominal trauma in Pietermaritzburg. S AFR J SURG 2021. [DOI: 10.17159/2078-5151/2021/v59n3a3476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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
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Kong VY, Keizer AA, Donovan MM, Weale RD, Raj aretnam NS, Bruce JL, Elsabagh A, Clarke DL. The correlation between full moon and admission volume for penetrating injuries at a major trauma centre in South Africa. S AFR J SURG 2021. [DOI: 10.17159/2078-5151/2021/v59n3a3528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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
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Ashkal A, Kong VY, Blodgett JM, Smith MTD, Bekker W, Bruce JL, Laing GL, Clarke DL. A review of blunt pelvic injuries at a major trauma centre in South Africa. S AFR J SURG 2021. [DOI: 10.17159/2078-5151/2021/v59n1a3200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mbambo T, Smith MTD, Ferndale LC, Bruce JL, Laing GL, Kong VY, Clarke DL. Predictors of the need for surgery in upper gastrointestinal bleeding in a resource constrained setting: the Pietermaritzburg experience. S AFR J SURG 2020; 58:199-203. [PMID: 34096206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- T Mbambo
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - M T D Smith
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - L C Ferndale
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, South Africa
| | - V Y Kong
- Department of Surgery, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
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Buitendag JJP, Kong VY, Laing GL, Bruce JL, Manchev V, Clarke DL. A comparison of blunt and penetrating pancreatic trauma. S AFR J SURG 2020; 58:218. [PMID: 34096212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- J J P Buitendag
- Department of Surgery, Tygerberg Hospital, Stellenbosch University, South Africa
| | - V Y Kong
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
| | - G L Laing
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa
| | - J L Bruce
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa
| | - V Manchev
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa
| | - D L Clarke
- Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu-Natal, South Africa and Department of Surgery, University of the Witwatersrand, South Africa
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Uchino H, Kong VY, Pantelides A, Anderson J, O'Neill H, Bruce JL, Laing GL, Clarke DL. The scourge of knife crime: trends in knife-related assault managed at a major centre in South Africa. S AFR J SURG 2020; 58:150-153. [PMID: 33231008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- H Uchino
- Department of Surgery, Department of Critical Care Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa and Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - A Pantelides
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J Anderson
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - H O'Neill
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Keizer AA, Arkenbosch JHC, Kong VY, Hoencamp R, Bruce JL, Smith MTD, Clarke DL. Blunt and Penetrating Liver Trauma have Similar Outcomes in the Modern Era. Scand J Surg 2020; 110:208-213. [PMID: 32693697 DOI: 10.1177/1457496920921649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- A A Keizer
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands
| | - J H C Arkenbosch
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - R Hoencamp
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.,Defence Healthcare Organization, Ministry of Defence, Utrecht, The Netherlands
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - M T D Smith
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
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Kong VY, Weale RD, Blodgett JM, Madsen A, Laing GL, Clarke DL. Selective Nonoperative Management of Abdominal Stab Wounds with Isolated Omental Evisceration is Safe: A South African Experience. Scand J Surg 2020; 110:214-221. [PMID: 32090686 DOI: 10.1177/1457496920903982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - R D Weale
- Department of Surgery, North West Deanery, Manchester, United Kingdom
| | - J M Blodgett
- Department of Epidemiology, University College London, London, United Kingdom
| | - A Madsen
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.,Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
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Salem MS, Urry RJ, Kong VY, Clarke DL, Bruce J, Laing GL. Traumatic renal injury: Five-year experience at a major trauma centre in South Africa. Injury 2020; 51:39-44. [PMID: 31668576 DOI: 10.1016/j.injury.2019.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/16/2019] [Accepted: 10/14/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- M S Salem
- Department of Urology, University of KwaZulu-Natal, Durban, South Africa
| | - R J Urry
- Department of Urology, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa.
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J Bruce
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
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Uchino H, Kong VY, Pantelides A, Anderson J, O'Neill H, Bruce JL, Laing GL, Clarke DL. The scourge of knife crime: trends in knife-related assault managed at a major centre in South Africa. S AFR J SURG 2020. [DOI: 10.17159/2078-5151/2020/v58n3a3251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Green S, Smith MTD, Kong VY, Skinner DL, Bruce JL, Laing GL, Brysiewicz P, Clarke DL. Compliance with the Surviving Sepsis Campaign guidelines for early resuscitation does not translate into improved outcomes in patients with surgical sepsis in South Africa. S AFR J SURG 2019; 57:8-12. [PMID: 31773925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- S Green
- Department of Anaesthesia, Critical Care and Pain Management, University of KwaZulu-Natal, Durban, South Africa
| | - M T D Smith
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - V Y Kong
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa and Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - D L Skinner
- Department of Anaesthesia, Critical Care and Pain Management, University of KwaZulu-Natal, Durban, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - P Brysiewicz
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa and Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Kong VY, Blodgett JM, Weale R, Bruce JL, Laing GL, Smith M, Bekker W, Clarke DL. Discrepancy in clinical outcomes of patients with gunshot wounds in car hijacking: a South African experience. S AFR J SURG 2019; 57:25-28. [PMID: 31773928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - J M Blodgett
- MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
| | - R Weale
- Department of Surgery, North West Deanery, Manchester, United Kingdom
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - M Smith
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - W Bekker
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa and Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
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Wessels EU, Kong VY, Buitendag J, Moffatt S, Weale R, Ras AB, Ras M, Smith MTD, Laing GL, Bruce JL, Bekker W, Manchev V, Clarke DL. The spectrum of animal related injuries managed at a major trauma centre in South Africa. S AFR J SURG 2019; 57:54. [PMID: 31392866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- E U Wessels
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa and Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J Buitendag
- Department of Surgery, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - S Moffatt
- Department of Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - R Weale
- Department of Surgery, North West Deanery, Manchester, United Kingdom
| | - A B Ras
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - M Ras
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - M T D Smith
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - W Bekker
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - V Manchev
- Department of Surgery, University of KwaZulu-Natal, Durban, South Afric
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa and Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
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Bekker W, Smith M, Kong VY, Bruce JL, Laing G, Manchev V, Clarke DL. Isolated free fluid on computed tomography for blunt abdominal trauma. Ann R Coll Surg Engl 2019; 101:552-557. [PMID: 31219321 DOI: 10.1308/rcsann.2019.0078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The clinical significance of isolated free fluid on abdominal computed tomography (CT) in patients with blunt abdominal trauma is unclear. This audit reviews our unit's experience with isolated free fluid and attempts to refine our clinical algorithms for the assessment of patients with blunt abdominal trauma. MATERIALS AND METHODS All patients who sustained blunt abdominal trauma between December 2012 and December 2017 who were subjected to multidetector CT of the abdomen as part of their initial investigation were included in this study. RESULTS During the five-year period under review, a total of 1066 patients underwent abdominal CT following blunt poly trauma. A total of 84 (7.9%) patients died. There were 148 (14%) patients with CT finding of isolated free fluid. Of these, 128 (67%) were selected for non-operative management, which included a period of serial abdominal examinations. In this non-operative group, five patients failed their abdominal observations and underwent laparotomy. Findings in these five cases were negative (1), non-therapeutic (1), splenic injury (1), Pancreatic and splenic injury (1) and bladder injury (1). Thirteen patients (10%) died, none of whom had surgery. The causes of death were exsanguination from a major traumatic lower limb injury (1), multiple organ failure (1), traumatic brain injury (10) and spinal cord injury (1). The remaining 20 patients underwent laparotomy. The indications were failed non-operative management (5), abdominal distension (1) and suspicion of a missed hollow viscus injury (14). In this group there were 11 therapeutic and 6 non-therapeutic surgeries and three negative laparotomies. For the 15 patients selected for operative management, the findings were as follows: hollow viscus injury (3), mesenteric bleeds (2), splenic and pancreatic injury (1), liver and bladder injury (1), splenic and bladder injury (1), non-therapeutic (4), negative (3). The finding of isolated free fluid on CT is 98% sensitive and 96% specific for true isolated free fluid (chi square 331.598; P = 0.000). This finding predicts successful non-operative management with a positive predictive value of 93% and a negative predictive value of 96%. DISCUSSION In patients with blunt abdominal trauma, the finding of isolated free fluid on abdominal CT alone is no longer an indication for laparotomy. Other clinical factors must be taken into account when deciding on the need for laparotomy, such as haemodynamic status, clinical abdominal findings and the ability to reliably assess the abdomen. In the absence of a clinical indication for urgent laparotomy, patients with isolated free fluid may be observed.
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Affiliation(s)
- W Bekker
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Mtd Smith
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - V Y Kong
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - G Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - V Manchev
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Bashir AA, Kong VY, Weale RD, Bruce JL, Laing GL, Bekker W, Clarke DL. Quantifying the burden of trauma imaging on the CT scan service at a major trauma centre in South Africa. S AFR J SURG 2019; 57:48-53. [PMID: 31342684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Imaging is an integral part of trauma management and the huge burden of trauma in South Africa places substantial pressures on radiology resources. This study aims to provide a holistic overview of the burden of trauma imaging and the cost of trauma to a busy CT scanning facility at a tertiary hospital in South Africa. METHOD We set out to describe and quantify the impact of blunt poly-trauma on CT scanning services at Grey's Hospital in Pietermaritzburg. We aimed to provide a holistic assessment in terms of use of equipment and staff, cost to the hospital and overall usage of CT scanning. RESULTS Over the four-year study period, 1572 patients required a CT scan following blunt torso trauma (mean age: 30 years, 81% males). Of the 1572 patients, 625 had a chest radiograph (40%), 383 a cervical spine X-ray (24%), 347 a pelvic X-ray (22%), 292 a skull X-ray (18%), 193 a limb X-ray (12%), 133 an abdominal radiograph (8%), and 86 a FAST scan (5%). The 1572 CT included: 967 head, 568 neck, 65 chest, 241 abdominal, 228 pelvic, 12 upper limb, 38 lower limb and 394 had full body (Pan) CT scan. The mean total cost of the CT scanning for blunt poly-trauma is ZAR 12 000. The total cost of CT scanning for blunt poly-trauma is 0.92% of the total hospital expenditure. Roughly 7.8% of the total hours worked by the CT scanner over the time period under review was dedicated to blunt poly-trauma. CONCLUSION Blunt poly-trauma is a preventable disease, which has a major financial impact on the healthcare system in general. This study has documented the tremendous burden it places on an already stretched CT scanning service.
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Affiliation(s)
- A A Bashir
- Department of Radiology, University of KwaZulu Natal, Durban, South Africa
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa and Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - R D Weale
- Department of Surgery, North West Deanery, Manchester, United Kingdom
| | - J L Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - W Bekker
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa and Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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Moffatt SE, Kong VY, Weale RD, Buitendag JP, Ras AB, Ras M, Smith M, Bruce JL, Laing GL, Clarke DL. The spectrum of self inflicted injuries managed at a major trauma centre in South Africa. S AFR J SURG 2019; 57:65. [PMID: 31342690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Infantile hypertrophic pyloric stenosis (IHPS) is the thickening of both muscle layers of the pylorus and is most commonly found in first-born males. It usually presents with projectile, non-bilious vomiting. Late presentation leads to severe dehydration and malnutrition with deranged serum-electrolytes and acid-base imbalance delaying treatment and prolonging hospital stay. This study aims to evaluate the profile, management and outcome of IHPS at a tertiary hospital in Bloemfontein, South Africa. METHOD The study was a retrospective, descriptive record review including all patients with IHPS admitted to Universitas Hospital from January 2008 to February 2016. Of the 22 patients admitted, files for 19 patients were available for inclusion. RESULTS Sixteen (84.2%) of the 19 patients were male. Of the 11 patients with available birth order, two were first-, two second-, six third- and one fourth-born. The patients' ages ranged from 27 to 194 days (median 51 days). The most common symptoms were projectile vomiting (78.9%) and poor weight gain (68.4%). Six patients had no ultrasound done, and 17 patients underwent a Ramstedt-pyloromyotomy. Eight patients received atropine as part of their initial management. The duration of symptoms ranged from 1 to 58 days (median 14 days). There was no reported mortality. The length of stay ranged from 2 to 60 days (median 7 days). CONCLUSION The gender distribution and age at presentation were in keeping with the literature but not the birth order. The delay before surgery emphasises the poor general health and deranged biochemical state the patients present at the hospital.
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Affiliation(s)
- S E Moffatt
- Department of Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa and Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - R D Weale
- Department of Surgery, North West Deanery, Manchester, United Kingdom
| | - J P Buitendag
- Department of Surgery, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - A B Ras
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - M Ras
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - M Smith
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa and Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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Weale RD, Kong VY, Bekker W, Bruce JL, Oosthuizen GV, Laing GL, Clarke DL. Primary repair of duodenal injuries: a retrospective cohort study from a major trauma centre in South Africa. Scand J Surg 2019; 108:280-284. [PMID: 30696350 DOI: 10.1177/1457496918822620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS The management of duodenal trauma remains controversial. This retrospective audit of a prospectively maintained database was intended to clarify the operative management of duodenal injury at our institution and to assess the risk factors for leak following primary duodenal repair. MATERIALS AND METHODS This was a retrospective study undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. Operative techniques used for duodenal repair were recorded. Our primary outcome was duodenal leak in the postoperative period. Patients from January 2012 to December 2016 were included. All duodenal injuries were graded according to the American Association for the Surgery of Trauma (AAST) grading. Only patients who had a primary repair were included in the final analysis. RESULTS During the five-year data collection period, a total of 562 patients underwent a trauma laparotomy; of which 94 patients sustained a duodenal injury. A primary pyloric exclusion and gastro-jejunostomy (PEG) was performed in three patients. These three were then excluded from further analysis. Of the 91 primary duodenal repairs, seven (8%) subsequently leaked. These were managed by PEG in three and by secondary repair and para-duodenal drainage in four. The two physiological parameters most associated with subsequent leak were lactate and pH level. There was a significantly higher mortality rate for those who leaked vs those who did not leak. Chi-squared test revealed a significant difference in the leak rate between AAST I (0%), AAST-II (1.6%) and AAST-3 (66.7%) grade injuries (p <0.01). CONCLUSION The trend towards primary repair of duodenal injuries appears to be justified. However duodenal leak remains a significant risk in certain high risk patients and strategies to manage injuries in this subset requires further work.
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Affiliation(s)
- R D Weale
- Department of Surgery, North West Deanery, Manchester, United Kingdom
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.,Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - W Bekker
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G V Oosthuizen
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.,Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
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Green S, Smith MTD, Kong VY, Skinner DL, Bruce JL, Laing GL, Brysiewicz P, Clarke DL. Compliance with the Surviving Sepsis Campaign guidelines for early resuscitation does not translate into improved outcomes in patients with surgical sepsis in South Africa. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n4a2856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Buitendag JJP, Ras A, Kong VY, Bruce JL, Laing GL, Clarke DL, Brysiewicz P. An overview of penetrating traumatic brain injuries at a major civilian trauma centre in South Africa. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2018/v57n1a2711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bashir AA, Kong VY, Weale RD, Bruce JL, Laing GL, Bekker W, Clarke DL. Quantifying the burden of trauma imaging on the CT scan service at a major trauma centre in South Africa. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n2a2836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Wessels EU, Kong VY, Buitendag J, Moffatt S, Weale R, Ras AB, Ras M, Smith MTD, Laing GL, Bruce JL, Bekker W, Manchev V, Clarke DL. The spectrum of animal related injuries managed at a major trauma centre in South Africa. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n3a2854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kong VY, Blodgett JM, Weale R, Bruce JL, Laing GL, Smith M, Bekker W, Clarke DL. Discrepancy in clinical outcomes of patients with gunshot wounds in car hijacking: a South African experience. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n4a3032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Moffatt SE, Kong VY, Weale RD, Buitendag JP, Ras AB, Ras M, Smith M, Bruce JL, Laing GL, Clarke DL. The spectrum of self inflicted injuries managed at a major trauma centre in South Africa. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n2a2897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dayananda KSS, Kong VY, Bruce JL, Oosthuizen GV, Laing GL, Brysiewicz P, Clarke DL. A selective non-operative approach to thoracic stab wounds is safe and cost effective - a South African experience. Ann R Coll Surg Engl 2018; 100:1-9. [PMID: 30286652 PMCID: PMC6204512 DOI: 10.1308/rcsann.2018.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Penetrating thoracic trauma is common and costly. Injuries are frequently and selectively amenable to non-operative management. Our selective approach to penetrating thoracic trauma is reviewed and the effectiveness of our clinical algorithms confirmed. Additionally, a basic cost analysis was undertaken to evaluate the financial impact of a selective nonoperative management approach to penetrating thoracic trauma. MATERIALS AND METHODS The Pietermaritzburg Metropolitan Trauma Services electronic regional trauma registry hybrid electronic medical records were reviewed, highlighted all penetrating thoracic traumas. A micro-cost analysis estimated expenses for active observation, tube thoracostomy for isolated pneumothorax greater than 2 cm and tube thoracostomy for haemothorax. Routine thoracic computed tomography does not form part of these algorithms. RESULTS Isolated thoracic stab wounds occurred in 589 patients. Eighty per cent (472 cases) were successfully managed nonoperatively. Micro-costing shows that active observation costs 4,370 ZAR (£270), tube thoracostomy for isolated pneumothorax costs 6,630 ZAR (£400) and tube thoracostomy for haemothorax costs 21,850 ZAR (£1,310). DISCUSSION Penetrating thoracic trauma places a striking financial burden on our limited resources. Diligent and serial clinical assessments, alongside basic radiology and stringent management criteria, can accurately stratify patients to correct clinical algorithms. CONCLUSION Selective nonoperative management for penetrating thoracic trauma is safe and effective. Routine thoracic computed tomography is unnecessary in all patients with isolated thoracic stab wounds, which can be reserved for a select group who are identifiable clinically. Routine thoracic computed tomography would not be financially prudent across Pietermaritzburg Metropolitan Trauma Services. Government action is required to reduce the overall incidence of such trauma to save resources and patients.
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Affiliation(s)
- KSS Dayananda
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - VY Kong
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - JL Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - GV Oosthuizen
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - GL Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - P Brysiewicz
- Department of Public Health Medicine, University of KwaZulu Natal, Durban, South Africa
| | - DL Clarke
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Weale RD, Kong VY, Blodgett JM, Buitendag J, Ras A, Laing G, Bruce JL, Bekker W, Manchev V, Clarke D. Lessons learnt from the Pietermaritzburg experience with damage control laparotomy for trauma. J ROY ARMY MED CORPS 2018; 164:428-431. [PMID: 29950299 DOI: 10.1136/jramc-2018-000950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience. METHODS All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0. RESULTS A total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453/562). A great proportion of trauma victims were male (503/562, 90%), with a mean age of 29.5±10.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28±0.15) with a raised lactate (5.25 mmol/L±3.71). Our primary repair rates for enteric injuries were surprisingly high. CONCLUSION Just under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.
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Affiliation(s)
| | - V Y Kong
- Department of Surgery, Pietermaritzburg Metropolitan Trauma Service, Durban, South Africa
| | - J M Blodgett
- Department of Epidemiology, MRC Unit, University College London, London, United Kingdom
| | - J Buitendag
- Department of Surgery, Pietermaritzburg Metropolitan Trauma Service, Durban, South Africa
| | | | | | | | | | | | - D Clarke
- Department of Surgery, Pietermaritzburg Metropolitan Trauma Service, Durban, South Africa.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
Penetrating neck injuries are serious as there is a high concentration of vital structures in close proximity to each other in a compressed anatomical area. Penetrating neck injuries can be immediately life threatening due to massive bleeding from vascular structures or due to airway compromise. Injury to the digestive tract in the neck may also result in delayed and potentially life-threatening conditions. The majority (79%) of penetrating neck injuries can be managed conservatively. The clinician caring for such a patient requires a structured and comprehensive approach to managing these injuries. This article will provide a general overview of penetrating neck injuries, including resuscitation, epidemiology, surgical management and the use of appropriate imaging.
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Affiliation(s)
- R Weale
- Department of General Surgery, Wessex Deanery, Wessex, UK
| | - A Madsen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - VY Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - DL Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Bekker W, Kong VY, Laing GL, Bruce JL, Manchev V, Clarke DL. The spectrum and outcome of blunt trauma related enteric hollow visceral injury. Ann R Coll Surg Engl 2018; 100:290-294. [PMID: 29484938 PMCID: PMC5958856 DOI: 10.1308/rcsann.2018.0013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction This audit focused on patients who sustained enteric injury following blunt abdominal trauma. Methods Our prospectively maintained electronic registry was interrogated retrospectively, and all patients who had sustained blunt abdominal trauma between December 2011 and January 2016 were identified. Results Overall, 2,045 patients had sustained blunt abdominal trauma during the period under review. Seventy per cent were male. The median age was 28 years. Sixty patients (2.9%) sustained a small bowel injury (SBI). Thirty-five of these were peritonitic on presentation. All patients with a SBI had a chest x-ray and free air was present in seven. In 18 patients with a SBI, computed tomography (CT) was performed, which revealed isolated free fluid in 12 and free intraperitoneal air in 5. In five cases, the CT was normal. A total of 32 patients (1.5%) sustained blunt duodenal trauma (BDT). All patients with BDT had a chest x-ray on presentation. Free intraperitoneal air was not present in any. CT was performed on 17 patients with BDT. This revealed isolated free fluid or retroperitoneal air in 12. The median delay between injury and presentation for these enteric injures was 15.5 hours (interquartile range [IQR]: 8-25 hours) while between presentation at hospital and operation, the median delay was 6 hours (IQR: 3-13 hours). Conclusions Blunt trauma related enteric hollow visceral injury remains associated with delayed diagnosis and significant morbidity. It can be caused by a disparate array of mechanisms and is difficult to diagnose even with modern imaging strategies.
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Affiliation(s)
- W Bekker
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - VY Kong
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - GL Laing
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - JL Bruce
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - V Manchev
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
| | - DL Clarke
- University of Kwa Zulu-Natal, Pietermaritzburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
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Kong VY, Odendaal J, Sartorius B, Clarke DL, Bruce JL, Laing GL, Esterhuizen T. Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score. Ann R Coll Surg Engl 2018; 100:97-100. [PMID: 29022788 PMCID: PMC5838685 DOI: 10.1308/rcsann.2017.0141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Cerebral gunshot wounds are highly lethal and literature on the clinical scores for mortality prediction is limited. Materials and methods A retrospective study was undertaken over a 5-year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. A simplified clinical prediction score was developed based on clinical and/or physiological variables readily available in the resuscitation room. Results A total of 102 patients were included; 92% (94/102) were male and the mean age was 29 years; 22% (22/102) died during the admission. The presence of visible brain matter (odds ratio 12.4, P = 0.003) and motor score less than 5 (odds ratio 89.6, P < 0.001) allows the prediction success of 92% (sensitivity 73% and specificity 98%). The area under the receiver operating characteristic curve was 94% (95% confidence interval 88-100%, P < 0.001). Conclusions The presence of visible brain matter, together with a motor score of less than 5, allows accurate identification of non-survivors of cerebral gunshot wounds. Further study is required to validate this score.
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Affiliation(s)
- V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - J Odendaal
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - B Sartorius
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal , Durban , South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
- Department of Surgery, University of the Witwatersrand , Johannesburg , South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - T Esterhuizen
- Centre for Evidence Based Health Care, Department of Global Health, University of Stellenbosch , Stellenbosch , South Africa
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Kong VY, Odendaal JJ, Weale R, Liu M, Keene CM, Sartorius B, Clarke DL. The correlation between ATLS and junior doctors' anatomical knowledge of central venous catheter insertion at a major trauma centre in South Africa. Injury 2018; 49:203-207. [PMID: 29137701 DOI: 10.1016/j.injury.2017.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/06/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To review the ability of junior doctors (JDs) in identifying the correct anatomical site for central venous catheterization (CVC) and whether prior Advanced Trauma Life Support (ATLS) training influences this. DESIGN We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact site for CVC insertion via the internal jugular (IJV) and the subclavian (SCV) approach. This study was conducted in a large metropolitan university hospital in South Africa. RESULTS A total of 139 JDs were included. Forty-four per cent (61/139) were males and the mean age was 25 years. There were 90 PGY1s (65%) and 49 PGY2s (35%). Overall, 32% (45/139) were able to identify the correct insertion site for the IJV approach and 60% (84/139) for the SCV approach. Of the 90 PGY1s, 34% (31/90) correctly identified the insertion site for the IJV approach and 59% (53/90) for the SCV approach. Of the 49 PGY2s, 29% (14/49) correctly identified the insertion site for the IJV approach and 63% (31/49) for the SCV approach. No significant difference between PGY1 and 2 were identified. Those with ATLS provider training were significantly more likely to identify the correct site for the IJV approaches [OR=4.3, p=0.001]. This was marginally statistically significant (i.e. p>0.05 but <0.1) for the SCV approach. CONCLUSIONS The majority of JDs do not have sufficient anatomical knowledge to identify the correct insertion site CVCs. Those who had undergone ATLS training were more likely to be able to identify the correct insertion site.
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Affiliation(s)
- V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J J Odendaal
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - R Weale
- Department of General Surgery, Wessex Deanery, United Kingdom.
| | - M Liu
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - C M Keene
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - B Sartorius
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa; Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Steenkamp CJ, Kong VY, Bruce JL, Laing GL, Clarke DL. A selective vacuum assisted mesh mediated fascial traction approach following temporary abdominal containment for trauma laparotomy is effective in achieving closure. S AFR J SURG 2018. [DOI: 10.17159/2078-5151/2018/v56n4a2674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Weale R, Kong VY, Blodgett J, Oosthuizen GV, Bruce JL, Bekker W, Manchev V, Laing GL, Clarke DL. Is direct consultant supervision of all trauma laparotomies necessary? S AFR J SURG 2018. [DOI: 10.17159/2078-5151/2018/v56n4a2649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Oosthuizen GV, Weale R, Kong VY, Bruce JL, Urry RJ, Laing GL, Clarke DL. The effect of a concomitant renal injury on the outcome of colonic trauma. Am J Surg 2017; 216:230-234. [PMID: 29287924 DOI: 10.1016/j.amjsurg.2017.11.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 11/21/2017] [Accepted: 11/28/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND The management of colon injuries has steadily evolved over the course of the last half century. So too has the management of renal trauma. It is not clear from the literature as to whether concomitant colon and renal injuries carry increased risk of morbidity and mortality, and whether this combination of injuries necessitates a specifically tailored management approach. METHODS A retrospective review was carried out for the period January 2012 to December 2016. All patients over the age of 18 years who were subjected to laparotomy for penetrating trauma (gunshot wounds or stab wounds) and who sustained an intra-operatively proven colonic injury were included in this study. Operative management and outcomes were investigated. A direct comparison was made between patients with a combined colonic and renal injury and those with only a colonic injury. RESULTS Over the five-year period a total of 268 patients sustained a colonic injury. The 239 patients with a colonic injury (Group A) were compared to the 29 patients with a combined colonic and renal injury (Group B). Regarding the management of the colonic injuries, there were no differences in the rates of primary repair, anastomosis, exteriorization, or damage control surgery between groups A and B. As for the management of the renal injury, 14 were not explored at laparotomy; in 12 a nephrectomy was performed and in 3 the renal injury was repaired. The nephrectomy cohort were more likely to have undergone damage control surgery, to be admitted to ICU, to receive a colostomy, and had higher mortality. While there was no difference in the need for damage control surgery or mortality between groups, Group B had a significantly greater need for ICU admission. Morbidity was similar between the two groups - in particular, there was no difference in the rates of either gastro-intestinal complications or acute kidney injury between the two groups. CONCLUSION In patients with combined colon and renal injuries, it seems reasonable to treat each organ on its own merit, without the expectation of increased morbidity or mortality. In the non-damage control setting, most colonic injuries may be safely repaired, and a peri-renal haematoma that is not expanding or actively bleeding may be safely left alone.
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Affiliation(s)
- G V Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
| | - R Weale
- Department of General Surgery, Wessex Deanery, United Kingdom.
| | - V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
| | - R J Urry
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa; Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.
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Uchino H, Kong VY, Bruce JL, Oosthuizen GV, Bekker W, Laing GL, Clarke DL. Preparing Japanese surgeons for potential mass casualty situations will require innovative and systematic programs. Eur J Trauma Emerg Surg 2017; 45:139-144. [PMID: 29119221 DOI: 10.1007/s00068-017-0871-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/31/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The ongoing state of global geo-political instability means that it is prudent to prepare civilian surgeons to manage major military-type trauma. Japan has enjoyed a prolonged period of peace and consequently it is unlikely that surgeons will have been exposed to a sufficient volume of cases. This study reviews the state of trauma training and preparedness in Japan and reviews the trauma workload of a major Japanese emergency medical center and compared with a major South African trauma center with the intention of quantifying and comparing the time needed to gain adequate exposure to major trauma at the two centers. MATERIALS AND METHODS The literature describing the surgical burden from a number of recent military missions was reviewed and the core surgical skills to manage military-type injuries were identified. We then went on to review all patients admitted to both Kurashiki Central Hospital (KCH) and Pietermaritzburg Metropolitan Trauma Service (PMTS) following trauma between the period September 2015 and August 2016. The burden of trauma at each center was quantified and the number of core surgical competencies or procedures performed at each center was then reviewed. These were then compared with the number of the core procedures which were performed on the reported military missions. RESULTS Three reports on military surgical missions were reviewed. These came from the Dutch, French and British military surgical services. The average number of each core procedures performed on each reported military surgery mission are tabulated in the text. The most common procedures were wound debridement and orthopedic fixation, followed by trauma laparotomy, neck exploration and thoracotomy. During the 12 month study period, 309 trauma patients were admitted to KCH. Of which 206 (67%) were male, and the mean age was 57 years. There were 10 penetrating injuries and 299 blunt injuries. Of the penetrating injuries there were no gunshot wounds. The mechanisms of injury for blunt trauma were as follows: Road traffic accidents (RTAs); 141 (47%), fall; 136 (46%) and other injuries; 22 (7%). In the same period, 2887 trauma patients were admitted by the PMTS. There were 1244 cases (43%) of penetrating trauma and 1644 cases (57%) of blunt trauma in PMTS. The mechanisms of injury for penetrating trauma were as follows: stab wounds (SWs); 955 (77%), gunshot wounds (GSWs); 252 (20%), and other injuries; 37 (3%) and for blunt trauma were as follows: assault; 739 (45%), RTAs; 669 (41%), fall; 166 (10%), and other injuries; 70 (4%). The exposure to all the key competencies required to manage trauma is overwhelmingly greater in South Africa than in Japan. The length of time needed to obtain an equivalent trauma exposure to that achieved in South Africa, working in Japan is prohibitively long. CONCLUSION Trauma training in Japan is hamstrung by a lack of clinical material as well as by systematic factors. Training a trauma surgeon is difficult. Developing a trauma system in the country may help address some of these deficits. South Africa in contrast has a huge burden of trauma and sufficient infrastructure to ensure that surgeons working there have adequate exposure to major trauma. Developing an academic exchange program between Japan and South Africa may allow for the transfer of trauma experience and skills between the two countries.
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Affiliation(s)
- H Uchino
- Kurashiki Central Hospital, Emergency and Critical Care Center, 1-1-1 Miwa, Kurashiki, Okayama, Japan.
| | - V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, 719 Umbilo Rd, Durban, South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, 719 Umbilo Rd, Durban, South Africa
| | - G V Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, 719 Umbilo Rd, Durban, South Africa
| | - W Bekker
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, 719 Umbilo Rd, Durban, South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, 719 Umbilo Rd, Durban, South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, 719 Umbilo Rd, Durban, South Africa
- Department of Surgery, University of the Witwatersrand, 7 York Rd, Johannesburg, South Africa
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Kong VY, Odendaal JJ, Bruce JL, Laing GL, Jerome E, Sartorius B, Brysiewicz P, Clarke DL. Quantifying the funding gap for management of traumatic brain injury at a major trauma centre in South Africa. S AFR J SURG 2017; 55:26-30. [PMID: 29227053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Trauma is an eminently preventable disease. However, prevention programs divert resources away from other priorities. Costing trauma related diseases helps policy makers to make decisions on re-source allocation. We used data from a prospective digital trauma registry to cost Traumatic Brain Injury (TBI) at our institution over a two-year period and to estimate the funding gap that exists in the care of TBI. METHOD All patients who were admitted to the Pietermaritzburg Metropolitan Trauma Service (PMTS) with TBI were identified from the Hybrid Electronic Medical Registry (HMER). A micro-costing model was utilised to generate costs for TBI. Costs were generated for two scenarios in which all moderate and severe TBI were admitted to ICU. The actual cost was then sub-tracted from the scenario costs to establish the funding gap. RESULTS During the period January 2012 to December 2014, a total of 3 301 patients were treated for TBI in PMB. The mean age was 30 years (SD 50). There were 2 632 (80%) males and 564 (20%) females. The racial breakdown was overwhelmingly African (96%), followed by Asian (2%), Caucasian (1%) and mixed race (1%). There were 2 540 mild (GCS 13-15), 326 moderate (9-12), and 329 severe (GCS ≤8) TBI admissions during the period under review. A total of 139 patients died (4.2%). A total of 242 (7.3%) patients were admitted to ICU. Of these 137 (57%) had a GCS of 9 or less. A total of 2 383 CT scans were performed. The total cost of TBI over the two-year period was ZAR 62 million. If all 326 patients with moderate TBI had been admitted to ICU there would have been a further 281 ICU admissions. This was labelled Scenario 1. If all patients with severe as well as moderate TBI had been admitted there would have been a further 500 ICU admissions. This was labelled Scenario 2. Based on Scenario 1 and Scenario 2 the total cost would have been ZAR 73 272 250 and ZAR 82 032 250 respectively. The funding gaps for Scenario 1 and Scenario 2 were ZAR 11 240 000 and ZAR 20 000 000 respectively. CONCLUSION There is a significant burden of TBI managed by the PMTS. The cost of managing TBI each year is in the order of sixty million ZAR. A significant funding gap exists in our environment. This data does not include any data on the broader social costs of TBI. Investing in programs to reduce and prevent TBI is justified by the potential for significant savings.
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Affiliation(s)
- V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J J Odendaal
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - E Jerome
- Department of Surgery, Edendale Hospital, Pietermaritzburg Metropolitan Hospital Complex, South Africa
| | - B Sartorius
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - P Brysiewicz
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa and Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Odendaal JJ, Kong VY, Liu T, Sartorius B, Oosthuizen GV, Clarke DL. Barriers to accessing ATLS provider course for junior doctors at a major university hospital in South Africa. S AFR J SURG 2017; 55:10-15. [PMID: 29227050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Advanced trauma life support (ATLS) is the international standard of care and forms the basis of trauma training in South Africa. Previous local studies demonstrated a low completion rate among junior doctors (JD). This study was designed to determine the reasons and identify possible barriers of JDs to accessing the ATLS course at a major university hospital. METHOD This was a prospective study utilising a structured survey that included all JDs who were undertaking their internship training. RESULTS A total of 105 JDs completed the survey. Sixty-two percent were female (65/105) and the mean age was 25 years. Forty-eight percent (50/105) of all JDs were post graduate year 1 (PGY 1) and the remaining 52% were post graduate year 2 (PGY 2) JDs. Sixty-two percent (65/105) of all respondents had completed their mandatory rotation in surgery. The reasons for non-attendance of ATLS were: unable to secure a place on course (52%), unable to afford course fee (18%), permission for attendance not granted (14%), unable to obtain study leave (10%) and lack of interest (5%). Subgroup analysis comparing the reasons for PGY1s vs PGY2s demonstrated that not being able to secure a place on course was more common among PGY2s [19% vs 33%, p < 0.001] while financial reasons were more common among PGY1s [18% vs 0%, p < 0.001]. CONCLUSION The primary barriers for JDs to attending ATLS training is difficulty in accessing the course due to oversubscription, financial reasons, followed by difficulty in obtaining professional development leave due to staff shortage. There is an urgent need to improve access to the ATLS training course for JDs in our environment.
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Affiliation(s)
- J J Odendaal
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - T Liu
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - B Sartorius
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - G V Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
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Madsen AS, Kong VY, Oosthuizen GV, Bruce JL, Laing GL, Clarke DL. Computed Tomography Angiography is the Definitive Vascular Imaging Modality for Penetrating Neck Injury: A South African Experience. Scand J Surg 2017; 107:23-30. [DOI: 10.1177/1457496917731187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aims: Computed tomography angiography has become central to the diagnostic algorithm for penetrating neck injury, but despite its widespread use the literature to support this adoption is limited. We reviewed our experience with computed tomography angiography for the identification of vascular trauma in hemodynamically stable patients with penetrating neck injury at a major trauma center in South Africa. Materials and Methods: A prospectively kept trauma registry capturing data in real time was retrospectively reviewed. All patients with penetrating neck injury investigated with computed tomography angiography as the initial vascular investigation during a 47-month period were included. Results: A total of 380 patients were included. Indications for computed tomography angiography were as follows: hard signs (13), soft signs (201), no signs but proximity/zone I or III wounds (141), and undefined signs of vascular injury (25). Of the 380 scans, 7 (1.8%) were indeterminate, 299 (78.7%) negative, and 74 (19.5%) positive for a vascular injury (54 arterial and 20 isolated venous injury). Eight were false positive and 4 false negative. The sensitivity, specificity, positive, and negative predictive values for detecting arterial injury were 93.9%, 97.5%, 85.2%, and 99.1%, respectively. Overall, the yield for demonstrating “true arterial injury” was 12.1% (46/380); hard signs: 76.9% (10/13), soft signs: 16.4% (33/201), and no signs: 2.1% (3/141) which all were secondary to gunshot wounds). Only 8.4% (32/380) required intervention for arterial injury and none for isolated venous injury (hard signs: 62.0%, soft signs: 11.4%, and no signs: 0.7%). No serious complications resulted from computed tomography angiography. Conclusion: Computed tomography angiography is a safe and effective imaging modality for the investigation of vascular trauma post penetrating neck injury. Asymptomatic patients with stab wounds do not need to be imaged regardless of proximity concerns. Symptomatic stable patients including a subgroup with hard signs should be imaged rather than explored. Computed tomography angiography provides an interventional road map and can identify injuries amenable to endovascular or conservative management.
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Affiliation(s)
- A. S. Madsen
- Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of Surgery, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Pietermaritzburg, South Africa
| | - V. Y. Kong
- Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of Surgery, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Pietermaritzburg, South Africa
| | - G. V. Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of Surgery, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Pietermaritzburg, South Africa
| | - J. L. Bruce
- Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of Surgery, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Pietermaritzburg, South Africa
| | - G. L. Laing
- Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of Surgery, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Pietermaritzburg, South Africa
| | - D. L. Clarke
- Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of Surgery, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Pietermaritzburg, South Africa
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Oosthuizen GV, Kong VY, Estherhuizen T, Bruce JL, Laing GL, Odendaal JJ, Clarke DL. The impact of mechanism on the management and outcome of penetrating colonic trauma. Ann R Coll Surg Engl 2017; 100:152-156. [PMID: 29022789 DOI: 10.1308/rcsann.2017.0147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Introduction In light of continuing controversy surrounding the management of penetrating colonic injuries, we set out to compare the outcome of penetrating colonic trauma according to whether the mechanism of injury was a stab wound or a gunshot wound. Methods Our trauma registry was interrogated for the 5-year period from January 2012 to December 2016. All patients over the age of 18 years with penetrating trauma (stab or gunshot) and with intraoperatively proven colonic injury were reviewed. Details of the colonic and concurrent abdominal injuries were recorded, together with the operative management strategy. In-hospital morbidities were divided into colon-related and non-colon related morbidities. The length of hospital stay and mortality were recorded. Direct comparison was made between patients with stab wounds and gunshot wounds to the colon. Results During the 5-year study period, 257 patients sustained a colonic injury secondary to penetrating trauma; 95% (244/257) were male and the mean age was 30 years. A total of 113 (44%) sustained a gunshot wound and the remaining 56% (144/257) sustained a stab wound. Some 88% (226/257) of all patients sustained a single colonic injury, while 12% (31/257) sustained more than one colonic injury. A total of 294 colonic injuries were found at laparotomy. Multiple colonic injuries were less commonly encountered in stab wounds (6%, 9/144 vs. 19%, 22/113, P < 0.001). Primary repair was more commonly performed for stab wounds compared with gunshot wounds (118/144 vs. 59/113, P < 0.001). Patients with gunshot wounds were more likely to need admission to intensive care, more likely to experience anastomotic failure, and had higher mortality. Conclusions It would appear that colonic stab wounds and colonic gunshot wounds are different in terms of severity of the injury and in terms of outcome. While primary repair is almost always applicable to the management of colonic stab wounds, the same cannot be said for colonic gunshot wounds. The management of colonic gunshot wounds should be examined separately from that of stab wounds.
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Affiliation(s)
- G V Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery , University of KwaZulu Natal, Durban , South Africa
| | - V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery , University of KwaZulu Natal, Durban , South Africa
| | - T Estherhuizen
- Centre for Evidence Based Health Care, Department of Global Health , University of Stellenbosch, Stellenbosch , South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery , University of KwaZulu Natal, Durban , South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery , University of KwaZulu Natal, Durban , South Africa
| | - J J Odendaal
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery , University of KwaZulu Natal, Durban , South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery , University of KwaZulu Natal, Durban , South Africa.,Department of Surgery, University of the Witwatersrand , Johannesburg , South Africa
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Kong VY, Oosthuizen GV, Sartorious B, Bruce JL, Laing GL, Weale R, Clarke DL. Validation of the Baragwanath mortality prediction score for cerebral gunshot wounds: the Pietermaritzburg experience. Eur J Trauma Emerg Surg 2017; 44:615-620. [DOI: 10.1007/s00068-017-0835-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 09/07/2017] [Indexed: 11/30/2022]
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