South African Journal of Surgery

Minimal access surgical research and training in South Africa – A scoping review

H Mangray, S Madziba, A Ngobese, Y Govender, DL Clarke — Tue, 06 May 2025 00:00:00 +0000

Background: Minimal access surgery (MAS) has been on the rise internationally; however, there seems to be limited information regarding research and training in the general and paediatric surgical (GPS) disciplines in South Africa (SA). We performed a scoping review to identify knowledge gaps that will assist us in developing strategies to improve the delivery and training of MAS within the GPS disciplines in SA.

Method: The method of the review – 2020 JBI guide and PRISMA for scoping reviews. We searched online databases and websites for publications from 1990 to 2022. Interviews were conducted with senior MAS trainers from training sites.

Results: Full texts of 194 articles were reviewed. Most publications were related to trauma, followed by laparoscopic appendicectomy and laparoscopic cholecystectomy. Paediatric MAS comprised 11.9% (21), and training was the focus in 4.5% (7) of all the publications. Published limitations regarding MAS included access to training and equipment.

Conclusion: This scoping review has summarised the current MAS research and training within the GPS disciplines in SA. We have highlighted the limitations that exist, which can direct the focus of research and training to improve the delivery of MAS within the GPS disciplines.

Breast tuberculosis – A review and diagnostic pathway

H Alzarooni, H Molabe, F Malherbe — Tue, 06 May 2025 00:00:00 +0000

Breast tuberculosis (TB) is a rare form of extrapulmonary tuberculosis, accounting for 0.1% of all breast conditions globally, with a higher incidence in endemic regions such as India, East Asia, and sub-Saharan Africa. It can mimic breast carcinoma, complicating timely diagnosis. Early recognition and proper treatment are crucial for favourable outcomes in breast TB. This review offers a detailed examination of breast TB, and presents a diagnostic pathway designed to improve the diagnosis and management of the disease. This literature review considers the epidemiology, pathophysiology, clinical features, and diagnostic approaches, highlighting the need for a high level of clinical suspicion, particularly in TB-endemic areas. By providing a structured diagnostic framework, this paper aims to improve prompt and accurate diagnosis of breast TB, enhancing patient care and outcomes.

Gastro-colic fistula – A rare iatrogenic complication of Nissen fundoplication

IN Palkowski, ML Kemp — Tue, 06 May 2025 00:00:00 +0000

We present a case of an iatrogenic gastro-colic fistula following a Nissen fundoplication which was complicated by extensive adhesions. While gastro-colic fistulae are not an identified complication of Nissen fundoplication, it is, however, a known rare and late complication primarily associated with surgical interventions involving the stomach. The mainstay of treatment remains nutritional and electrolyte support followed by surgical resection.

Superior mesenteric artery syndrome in an adolescent male

T van der Merwe, E Georgiou — Tue, 06 May 2025 00:00:00 +0000

This report describes a 13-year-old male patient admitted with superior mesenteric artery syndrome (SMAS) requiring urgent surgery for decompression due to worsening pain and elevated lactate levels. SMAS is a rare cause of upper gastrointestinal obstruction and in this case may have been due to a rapid growth spurt.

Primary musculoskeletal hydatid disease – A case report

M Mercouris, F Gool, M Kariem, N Govender — Tue, 06 May 2025 00:00:00 +0000

This case report describes a 33-year-old male with HIV on antiretroviral therapy who presented to a district-level hospital with a progressively enlarging back mass. Contrast-enhanced CT revealed a large multiseptated cystic mass in the posterior thoracoabdominal wall. Hydatid serology was positive. Management included antiparasitic treatment and surgical excision. This report underscores the need to consider hydatid disease in the differential diagnosis of cystic masses, especially in endemic areas, highlighting the importance of early detection and treatment. This contributes to a growing body of literature on atypical extrahepatic and extrapulmonary hydatid disease presentations.

Video available at: https://ojs.sabinet.co.za/index.php/sajs/article/view/962

Incarcerated trans-stomal herniation resembling a stomal prolapse – A case report

N Shaikh, RV Blanco, M Vente, R Ebrahim — Tue, 06 May 2025 00:00:00 +0000

Trans-stomal herniation, where abdominal contents protrude through the stomal aperture and lie between the two intestinal walls of the stoma is a very rare complication of stomas and can resemble a stomal prolapse. We describe a unique case of a stomal prolapse and concurrent trans-stomal small bowel herniation, which required emergency stoma refashioning for incarceration.

Primary endocrine therapy can be effective in decreasing lymph node burden in hormone receptor positive breast cancers

J Buitendag, A Diayar, L de Jager, W Conradie, J Edge — Tue, 06 May 2025 00:00:00 +0000

Background: Breast cancer is a significant global health concern. Primary endocrine therapy (PET) and primary chemotherapy (PCT) are employed to manage hormone receptor positive breast cancers in the neoadjuvant setting. We hypothesise that PET is as effective as chemotherapy to treat axillary metastases.

Methodology: All patients treated for breast cancer at Tygerberg Hospital Breast Unit during the period of 2016–2019 were included. Patients who did not receive PCT or PET were excluded, as were patients who did not undergo axillary lymph node dissection (ALND).

Results: The sample consisted of 176 patients. The median age was 49.2 years (IQR = 42.4–57.9 years; range = 25.1–84.6 years), and 174/176 (98.9%) were female. Of the 176 patients, 35/176 (19.9%) had luminal A cancers, while 141/176 (80.1%) had luminal B cancers. Among these patients, 150/176 (85.2%) underwent PCT while 26/176 (14.8%) received PET. The lymph node burdens found via ALND were similar for patients who underwent PCT (median = 25.0%; IQR = 0.0–50.0%) and PET (median = 16.8%; IQR = 0.0–89.0%; p = 0.66). The rates of patients with no nodal involvement were also similar for patients who underwent PCT (47/150 = 31.3%) and PET (9/26 = 34.6%; p = 0.74). Multivariate analysis showed that there were no significant confounding effects due to age, sex, HIV status, molecular subtype or AJCC stage.

Conclusion: Our study showed no statistically significant difference in the lymph node burden regardless of whether PET or PCT was given to patients with a hormone receptor positive breast cancer.

Extremity fasciotomy in the developing world setting – A South African experience

A Bok, VY Kong, J Ko, J Wang, JL Bruce, GL Laing, DL Clarke — Tue, 06 May 2025 00:00:00 +0000

Background: This study aims to determine the cause, spectrum and outcomes of acute fasciotomy for compartment syndrome in a developing world setting. This study serves as an overview of the Pietermaritzburg Metropolitan Trauma Service (PMTS) experience of acute fasciotomy.

Methods: All patients who underwent a fasciotomy between December 2012 and September 2020 were identified from the Hybrid Electronic Medical Registry (HEMR).

Results: During the eight-year period under review, a total of 97 patients required fasciotomy. The mean age was 27.96 years. Of these patients, 88% (85/97) were male and 12% (12/97) were female. There were 57 penetrating injuries, 23 snakebite-related injuries and 17 blunt trauma-related injuries resulting in compartment syndrome requiring fasciotomy. Of these, 52% of injuries involved the lower limb and 47% involved the upper limb, with 1% involving an injury to both upper and lower limbs. The average hospital stay was 12 days, and the mortality rate was 3%.

Conclusion: A broad range of injuries may precipitate acute compartment syndrome (ACS) of the extremity and mandate fasciotomy. Clinicians must actively exclude ACS when managing these conditions. Once identified, ACS requires fasciotomy. In an environment with long prehospital times there seems to be little role for expectant treatment of ACS.

A single centre audit of genetic testing in early-onset breast cancer

CA Pillay, W Ngwisanyi, CA Benn — Tue, 06 May 2025 00:00:00 +0000

Background: This paper serves to audit the number of women who received genetic testing after diagnosis with breast cancer ≤ 35 years. Patients were diagnosed or sought treatment at the Breast Care Centre of Excellence (BCCE), a private accredited specialist breast unit in Johannesburg, South Africa. This study focuses specifically on genetic testing for pathogenic variants of the BRCA 1 and BRCA 2 genes.

Methods: Files of patients diagnosed ≤ 35 years were retrieved, and medical information was extracted. These patient files were then compared to records from the University of the Witwatersrand genetic service facility and the GC Network Pty (Ltd) genetic service facility, and genetic service data was recorded. All data was then compiled and analysed.

Results: Over 10 years, 196 patients were diagnosed with breast cancer ≤ 35 years, while only 5 received genetic testing.

Conclusion: In order to understand the relationship between BRCA1/2 genetic diagnosis and cancer diagnosis, greater emphasis must be placed on the availability of genetic services and testing. Ensuring that these services are available, accessible, and funded by either the State or medical insurance will greatly enhance the understanding between BRCA diagnosis, breast cancer diagnosis, risk reduction procedures, and quality of life in many young women.

Photo- and video-documentation of gastrointestinal endoscopy in under-resourced settings

MF Scriba, GE Chinnery, SR Thomson — Tue, 06 May 2025 00:00:00 +0000

Summary

A visual record of standardised anatomical landmarks and specific pathology in gastrointestinal endoscopy is now considered by international endoscopy and gastroenterology societies as a mandatory component of the procedural report.1-4 Photo and video documentation of gastrointestinal endoscopy procedures accurately monitor key performance indicators (KPAs) for trainees and consultants, which are essential to assess the attainment and maintenance of competency. In addition, visual documentation is an excellent adjunct for feedback during training, enables remote teaching and mentorship, is essential for multidisciplinary teams (MDTs) and the conducting of clinical audits, and may be invaluable for medicolegal purposes. The endoscopy equipment of all the major manufacturers in South Africa (Fuji Film, Olympus and Pentax) allows for image capturing directly from buttons on the control handle to a Universal Serial Bus (USB) flash drive. The flash drive can be used to transfer images, and in some instances video, to a reporting computer, but involves time-consuming manual transfers. Some systems have polaroid reproduction systems which are usually single-print photographs attached to reports and generally only document pathology. Commercial medical video hardware and software technology is costly. For example, one of the manufacturers has reporting software and hardware, at a cost of about ZAR 250 000 per stack, that allows direct video and image capture.5 Such major costs highlight the major hurdle to routine photo or video documentation in under-resourced settings. We describe the development in the Groote Schuur Hospital Gastrointestinal Unit of a simple, low-cost method of still-image and video capture that can be set up on current endoscopy equipment to provide routine still-image and video capture. This system makes use of inexpensive hardware and open access software. It has been implemented and is in routine use for oesophagogastroduodenoscopy, colonoscopy, and advanced interventional endoscopy.

Epidemiology of vascular injury in trauma-ICU patients over a decade – the KZN experience

VC Ntola, TC Hardcastle, NM Nkwanyana — Tue, 06 May 2025 00:00:00 +0000

Background: Vascular injuries are among the causes of preventable death and disabilities. Vascular injuries are observed in both the civilian and combat setting. The vessel injured and mechanism of injury are important considerations prior to the management.

Methods: This was a combined retrospective and prospective study from January 2013 until December 2022 and included patients with vascular trauma requiring trauma-ICU admission. Frequencies and percentages were calculated to summarise categorical data. Median, quartiles and range were calculated to summarise numerical data. Ethical clearance was granted by the University of KwaZulu-Natal BREC (BREC 0004353/2022) and the Department of Health.

Results: A total of 2 805 trauma patients were treated by the author’s institution over a period of 10 years. From this number, there were 153 (5.5%) patients with vascular injuries who met the criteria to be enrolled in the study. The most commonly injured vessel was the CCA, with a total of 26 (13.5%) and the most common associated injury was bone fractures with a total number of 66 (53.2%). Penetrating trauma accounted for 99 (64.7%) of the cases, which is significantly higher than the blunt trauma component of 54 (35.2%) cases. Of the penetrating injuries 51 (33%) were due to stab wounds, 46 (30%) were due to gunshots, one (0.6%) was due to a bush knife and one (0.6%) due to a bicycle spoke accident.

Conclusion: This study makes an important contribution to the literature because it focuses on the epidemiology of vascular injury only in a subset of patients that are in ICU, whereas most studies focus on all patients. In order to prevent these injuries and associated injuries, the Department of Health with other government departments needs to develop practical and effective preventive measures.

Impact of SARS-CoV-2 pandemic on emergency surgical services at Groote Schuur Hospital

K Dookhony, S Rayamajhi, S Peters, P Navsaria — Tue, 06 May 2025 00:00:00 +0000

Background: The impact of the SARS-CoV-2 pandemic on emergency surgery services internationally revealed an 87.8% decrease in procedures. The aim of the study was to determine the impact of the pandemic on the number of emergency surgical operations performed at Groote Schuur Hospital, Cape Town, South Africa.

Methodology: The study was a retrospective cross-sectional study, comparing the number of emergency operations performed before the pandemic to those performed during the pandemic lockdowns at Groote Schuur Hospital in Cape Town, South Africa. The data were retrieved from the Web Surgibank and Clinicom databases.

Results: The total number of operations performed during the study period (April 2019 – March 2021) was 13 715. The most frequently performed procedure types were orthopaedics (18.6%), hands (16.3%), acute care surgery (16.5%), neurosurgery (10.5%) and trauma (10.1%). There was a 19.5% reduction which was statistically significant (p = 0.002) in the number of surgeries before COVID-19 and during COVID-19. The mean number of operations during the pandemic was less compared to the pre-COVID-19 period (p < 0.001).

Conclusion: COVID-19 significantly impacted the number of operations performed during the pandemic at Groote Schuur Hospital. This overall reduction was less compared to international centres.

Urinary pH as a prognosticator of acute kidney injury in crush syndrome

MZS Mkhize, N Ndlovu, G Oosthuizen — Tue, 06 May 2025 00:00:00 +0000

Background: Crush syndrome arises from community assault when perpetrators of crime within a community are beaten resulting in muscle damage of varying degrees. The insult to the muscles leads to the development of acute kidney injury which may lead to the need for renal replacement therapy, intensive care unit (ICU) admission for cardiovascular and respiratory support, or death. There are various known methods used to prognosticate patients with crush syndrome. The current literature only provides limited information about the role of urinary pH when it comes to risk stratifying patients with crush syndrome, thus the aim of the study is to reveal whether a urinary pH of 6 or less could potentially predict poor outcomes in those who present with this pathology.

Methods: This paper is a quantitative retrospective review of 107 patients who were diagnosed with myorenal syndrome at Ngwelezana Hospital between September 2021 and September 2023.

Results: Sixty out 107 patients developed an acute kidney injury and three patients died. All participants who died had a urine pH of < 6; however, patients who required dialysis or needed ICU admission had urine pH of 5 and 6 showing no correlation between urine pH and adverse outcomes.

Conclusions: Urine pH may not serve as a marker of complications related to acute kidney injury in patients with crush syndrome but may help to prognosticate patients to predict death.

Peptic ulcer disease-related gastric outlet obstruction – Does surgery still play a role?

M Scriba, I Balde, P Aclavio, E Jonas, G Chinnery — Tue, 06 May 2025 00:00:00 +0000

Background: Gastric outlet obstruction (GOO) due to peptic ulcer disease (PUD) has seen a global decline, with endoscopic management now considered first-line therapy. Modern surgeons have limited exposure to PUD GOO, with a lack of recent literature and contemporary guidelines to aid in surgical decision-making. This study aims to review a cohort of PUD GOO patients with specific focus on those needing surgical intervention.

Methods: All patients managed for PUD GOO at a single South African centre over a four-year period were included. Those requiring surgery were sub-analysed and multivariate analysis performed to identify factors associated with increased morbidity.

Results: A total of 84 PUD GOO patients were included. Forty-five were selected for endoscopic balloon dilatation (EBD), with only 21 (46.7%) successfully managed with EBD. Thirteen patients required only medical therapy, eight were selected for upfront surgery and 18 patients were managed with stenting. A total of 31 patients (36.9%) required surgery, with 33 separate operations performed (12 resections and 21 bypass operations). The surgical procedure performed was the only variable shown to be significantly associated with postoperative morbidity, with both pyloroplasty and partial gastrectomy having higher complication rates when compared to gastro-jejunal bypass (50.0% and 66.7% vs 5.6%, OR:17.0 and 8.5, p = 0.016 and p < 0.001 respectively).

Conclusions: In our setting obstructed PUD often requires surgical management. The choice of surgical procedure should be individualised. Due to the multifactorial complexity of these patients, they are best managed in multidisciplinary team settings with input from dieticians, endoscopists and surgeons.

South African Journal of Surgery: SAJS CPD Questions

Susan Parkes — Tue, 06 May 2025 00:00:00 +0000

No abstract.