South African Journal of Surgery <p>The <em>South African Journal of Surgery </em>is published by the South African Medical Association and publishes papers related to surgery.</p> <p>Other websites related to this journal: <a href="" target="_blank" rel="noopener"></a></p> en-US Material submitted for publication in the South African Medical Journal (SAMJ) is accepted provided it has not been published elsewhere. Copyright forms will be sent with acknowledgement of receipt and the SAMJ reserves copyright of the material published. The SAMJ does not hold itself responsible for statements made by the authors. (Mrs Susan Parkes) (Editor) Fri, 12 Oct 2018 10:56:11 +0000 OJS 60 Surgical resources in South Africa: a review of the number of functional operating theatres <p><strong>Background</strong>: Surgery has previously been neglected as a development initiative, despite the obvious effect of surgical illnesses on morbidity and mortality. Recently, greater attention has been given to surgical services, as there is growing evidence of cost-effectiveness of surgical interventions. Operating theatre numbers have been used as a measure of surgical capacity, despite there being limitations associated with this use of this metric. This study aims to analyse part of the surgical resources in South Africa.<br /><strong>Methods</strong>: A descriptive analysis of surgical infrastructure in all nine provinces was performed. The total number of functional operating theatres was documented for all public and private hospitals in South Africa. Hospitals were contacted during the period from 1 October 2014 until 31 December 2014.<br /><strong>Results</strong>: The results showed 3.59 operating theatres per 100 000 population. This fell below the global average of 6.2 operating theatres per 100 000 as well as other developed countries. Theatres were concentrated in metropolitan areas, and there were a greater number of private operating theatres per insured population than in the uninsured public sector.<br /><strong>Conclusion</strong>: Strengthening surgical systems will reduce the surgical burden of disease and improve health outcomes globally. Little is known about the available surgical resources such as operating theatre density, although using this metric to evaluate surgical capacity has its limitations.<br /><strong></strong></p><p><strong>Key words</strong>: Global surgery, Surgical Resources</p> AJ Dell, D Kahn Copyright (c) Surgery for giant tumours of the breast: a 15 year review <p><strong>Background</strong>: Giant tumours of the breast tend to occur in the adolescent age group. Racial predilection has been noted in the literature. The mass often occupies most of the breast, leading to its distortion. Many authors have advocated a mastectomy for benign tumours that severely distort the breast. Giant benign tumours when treated by simple excision risk persistence of asymmetry. To avoid this asymmetry, some authors have resorted to excision and immediate reduction mammaplasty. The aim of this retrospective study was a report on giant tumours of the breast presenting to a plastic surgery unit and to analyse demographic factors, clinical presentations, tumour pathology, management, complications, as well as patient and breast outcomes.<br /><strong>Methods</strong>: Medical records of patients with giant tumours were retrospectively analysed for assessing demographic factors, clinical presentation, tumour pathology, the technique of surgery performed and patient and breast outcomes in a single hospital setting. Breast outcomes were rated by panel of 4 experienced plastic surgeons using the 4 Point Likert scale. Their ratings were statistically analysed for inter-rater agreement.<br /><strong>Results</strong>: Twenty-three subjects were identified to have giant tumours of the breast. Of these South African patients, 19 were black, 3 were Indian and 1 was of mixed ethnicity. The age range was 12–49 years(y) with an average of 19y. All masses were palpable. The final pathological diagnosis was fibrocystic disease in 3, giant fibroadenoma in 14, phyllodes tumour in 4, and hamartoma in 2. The size range was 10–45 cm with a median size of 18 cm. All but one patient had simple excision followed by immediate reduction mammaplasty. Twenty patients were assessed after operation. A minimum of 1 to a maximum of 4 patients per reviewer showed unsatisfactory outcomes and a minimum of 18 to a maximum of 21patients per reviewer showed satisfactory to excellent outcomes. The overall agreement between assessors for this was 84%.<br /><strong>Conclusion</strong>: Benign giant tumours (&gt; 10 cm) of the breast are suitably managed by excision of the mass and a reduction mammoplasty technique of reconstruction.<br /><strong></strong></p><p><strong>Keywords</strong>: Giant tumour breast reduction mammaplasty, giant fibroadenoma of breast, phyllodes tumour, hamartoma breast</p> M Daya, T Balakrishnan Copyright (c) Spectrum of disease and outcome of primary amputation for diabetic foot sepsis in rural KwaZulu-Natal <p><strong>Background</strong>: Primary amputation (stump closure) for diabetic foot sepsis is perceived to have a higher re-amputation rate due to stump sepsis. A guillotine amputation with elective stump closure is widely practised due to the lower risk of stump sepsis and re-amputation.<br /><strong>Aims</strong>: To provide an epidemiological analysis of the spectrum of disease and outcomes of primary amputation for diabetic foot sepsis in a regional rural hospital.<br /><strong>Methods</strong>: A prospective cohort study of 100 patients who underwent surgery for diabetic foot sepsis over a 5-year period was undertaken at Madadeni Provincial Hospital, in northern KwaZulu- Natal. Demographic data, co-morbid profile, radiographic features, anatomical level of vascular occlusion and type of surgery performed were recorded. The Wagner classification (Wag) was used to classify disease severity. Outcome measures included length of hospital stay, in-hospital mortality and re-amputation rates.<br /><strong>Results</strong>: Of the 100 patients, females (n = 50) accounted for 50% of admissions. The median age was 61 years (range: 29 to 80 years). Most patients presented with advanced disease: Wag 5, n = 71 (71%); Wag 4, n = 20 (20%); Wag 3, n = 7 (7%); Wag 2, n = 2 (2%). The anatomic levels of vascular occlusion comprised: aortoiliac disease n = 2 (2%), femoropopliteal n=21(21%) and tibioperoneal disease n = 77 (77%). The following surgical procedures were undertaken: above knee amputation (AKA), n = 35 (35%); below knee amputation (BKA), n = 46 (46%); transmetatarsal amputation (TMA), n = 8 (8%); toe ectomy, n = 8 (8%) and debridement, n = 3 (3%). The re-amputation rate to above knee amputation was n = 2/46 (4.3%). All AKA stumps healed completely. The overall in-hospital mortality was n = 7 (7%) and median length of hospital stay was 7.8 ± 3.83 days.<br /><strong>Conclusion</strong>: Most patients present with advanced disease requiring a major amputation. A definitive one stage primary amputation is a safe and effective procedure for diabetic foot sepsis with distinct advantages of a short hospital stay, low reamputation rates and mortality. A guillotine amputation should be reserved for physiologically unstable patients.<br /><strong></strong></p><p><strong>Keywords</strong>: amputation; diabetic foot; guillotine; re-amputation</p> S Cheddie, CG Manneh, B Pillay Copyright (c) Demographic and histological subtypes of Hurthle cell tumours of the thyroid in a South African setting <p><strong>Background</strong>: Report of Hurthle cells following fine needle aspiration cytology from a thyroid nodule raises possibility of Hurthle cell carcinoma (HCC), which is a distinct entity and accounts for 3–10% of thyroid malignancies.<br /><strong>Aim</strong>: To determine if there are demographic and histopathological features which may be used to differentiate HCC from Hurthle cell adenoma (HCA).<br /><strong>Methods</strong>: Histopathology records of patients who had thyroidectomy from January 2001 to October 2015 were reviewed. Data retrieved included indications for thyroidectomy, patients’ demographics, histology and preoperative FNAC results.<br /><strong>Results</strong>: At total of 2641 records were reviewed of which 25.6% (676/2641) were for neoplasms. 15.8% (107/676) of the neoplasms were Hurthle cell neoplasms (HCNs) and 25.2% (27/107) of HCNs were HCCs. 77.2% (71/92) of HCAs and 77.8% (21/27) of HCCs were from female patients. Preoperative FNAC results were available for 54.2% (58/107) and were suspicious of HCN in 12.1% (7/58). Average tumour size for HCCs and HCAs was 4.9 +/- 2.7 cm and 3.5 +/- 2.0 cm, respectively. The difference was statistically significant with a p-value of 0.016. The risk of malignancy increased from 11.1% in HCNs less than 1 cm to 53.8% for tumours which were greater than 4 cm in diameter.<br /><strong>Conclusion</strong>: HCNs are more common in females. The likelihood of HCC rises as the size of the HCN increases. Malignancy rate exceeds 50% for HCNs which are greater than 4 cm in diameter.<br /><strong></strong></p><p><strong>Key words</strong>: Hurthle cell neoplasm, Hurthle cell carcinoma, FNA, tumour size</p> V Malith, I Bombil, N Harran, TE Luvhengo Copyright (c) Requiem for Nigro or is anal squamous carcinoma still a surgical problem: Abdominoperineal excision rather than a defunctioning stoma? <p><strong>Background</strong>: Combined multimodal treatment (CMT) is the preferred treatment for anal squamous carcinoma with radical surgery reserved for treatment failure. Some patients require a defunctioning stoma prior to CMT. Successful closure of such a stoma is unlikely. Abdominoperineal excision (APE) may be suitable as primary treatment in these patients.<br /><strong>Objectives</strong>: To evaluate organ preservation in the treatment of anal squamous cancer and the closure rate of pre-treatment, temporary diverting colostomy, thereby assessing whether APE could be offered as primary treatment in those requiring a pre-treatment colostomy.<br /><strong>Methods</strong>: A retrospective review of all patients with anal squamous carcinoma was undertaken. Patients who required defunctioning colostomies prior to CMT were analysed for potential resectability of tumour prior to CMT and rate of permanent stoma.<br /><strong>Results</strong>: One hundred and twenty-five patients were included of which 58 were males. The mean age was 56 years. 107 were treated with curative intent. Six received primary APE and 12 salvage APE. Thirty (22 males) required pretreatment diverting colostomies. Three (10%) stomas were successfully reversed. Forty-eight (38%) of the 125 completed treatment with a permanent colostomy. Six patients who needed a stoma prior to CMT were deemed resectable.<br /><strong>Conclusion</strong>: Organ preservation was not possible in about a third of patients. Defunctioning stomas prior to CMT were likely to be permanent. We propose that APE could be considered as an alternative in selective cases where the tumour is resectable with low morbidity and a stoma is indicated.<br /><strong></strong></p><p><strong>Key words</strong>: Anal squamous carcinoma, defunctioning stoma, Nigro protocol, abdominoperineal excision</p> JC Kloppers, B Robertson, PA Goldberg, EDT Coetzee Copyright (c) Novel technique for endoscopic retrieval of a ring-shaped gastric foreign body <p><strong>Summary</strong>: We present a novel technique for retrieval of a retained ring-shaped gastric FB that is accessible, safe, reliable and cost-effective.<br /><strong></strong></p><p><strong>Keywords</strong>: Gastric foreign body, ring, endoscopy</p> B Nondela, M Arnold, S Cox Copyright (c) Obscure upper GIT haemorrhage: Primary renal artery aneurysm with duodenal and inferior venocaval fistulae <p><strong>Summary</strong>: We present a case of primary renal artery aneurysm presenting as obscure overt upper gastrointestinal bleeding due to an arterioenteric and arteriovenous fistula in a HIV patient not on HAART. Despite the low incidence of visceral artery aneurysms, complications and clinical presentations demand rapid intervention to avoid high reported mortality rates. We highlight the diagnostic and treatment dilemmas of this fatal complication in an immunocompromised patient.</p> B Puttergill, I Bombil, S Pather Copyright (c) The causes of burn wounds among adult patients treated at Pelonomi Tertiary Hospital, Bloemfontein <p><strong>Background</strong>: Burn injuries account for approximately 180 000 deaths per annum, mostly in low- and middle-income countries.<br /><strong>Aim</strong>: This study sought to determine the causes of burn wounds among adults admitted to the Burn Wound Unit at Pelonomi Tertiary Hospital in Bloemfontein for treatment.<br /><strong>Methods</strong>: This was a prospective, cross-sectional study. The target population consisted of adult patients, hospitalised for burn wounds at Pelonomi Tertiary Hospital in Bloemfontein, between July 2016 and early January 2017. Relevant data was collected by means of a structured interview using a questionnaire.<br /><strong>Results</strong>: A total of 49 patients were interviewed during the study period. Almost two-thirds of the patients were male (65.3%, n=32). The median age was 33 years (range 18 to 64 years). In most cases, the injury occurred at home (77.6%, n=38). Three quarters of the reported incidents (77.6%, n=38) were considered accidental of which 68.4% (n=26) were related to domestic activities. At the time of the accidental incident, 39.5% (n=15) patients had consumed alcohol. Eleven (22.4%) of the incidents were intentional with 63.6% (n=7) attributed to assault. The two main causes of burn injuries were flames including flaming liquids (59.2%, n=29) and hot liquids (22.5%, n=11). The most frequent area of injury was the left front thigh.<br /><strong>Conclusion</strong>: The predominant cause of burn wounds was flames including flaming liquids, and injuries were mostly accidental in nature. Alcohol consumption and domestic activities were common in accidental burns.</p> B Daffue, D Moolman, S Ferreira, L Roos, L Schoeman, SJA Smit, G Joubert Copyright (c) Be aware although it’s rare! Toxic Shock Syndrome following Endoscopic Sinus Surgery and Septoplasty <p><strong>Summary</strong>: This case report illustrates the rapid and fulminant course of Staphylococcal Toxic Shock Syndrome as a potential postoperative complication of sino-nasal surgery, and serves as an aid to otorhinolaryngologists for its recognition and early goal-directed therapy.</p> S Naidoo, O Edkins Copyright (c) Serotonin syndrome in burns patients <p><strong>Summary</strong>: This case report illustrates the pitfalls of abnormal neurocognitive behaviour in a burns patient and reviews the vagaries of the diagnosis and treatment of serotonin syndrome.</p> A Kenny, W Kleintjes Copyright (c) Evaluation of locally manufactured patient-specific custom made implants for cranial defects using a silicone mould <p><strong>Background</strong>: Cranial vault defects can pose a significant problem for neurosurgeons where autologous bone is no longer available for cranioplasty. Numerous materials exist to create implants which include polymethyl methacrylate (PMMA) and titanium. A technique using 3-dimensional CT scan reconstruction of a cranial defect and creating a silicon mould which can be autoclaved in theatre to create a PMMA implant was developed.<br /><strong>Objectives</strong>: The aim of this study is to evaluate the efficacy, cosmetic result, safety and cost-effectiveness of this procedure and compare this to existing techniques. Methods: An ambispective study was performed in patients requiring cranioplasty with a custom made implant. Patients were assessed for risk factors and cosmetic outcome, surgical technique was described and complications and cost compared to existing literature between 2010 and 2016.<br /><strong>Results</strong>: Thirty retrospective and 30 consecutive prospective patients were recruited into the study. Overall sepsis rate was 8.3%. All septic cases had superficial sepsis of which 2 grafts were removed due to cerebrospinal fluid leakage resulting in wound breakdown. A 100% accurate implant to defect ratio was achieved leading to a high satisfaction rate. Average cost was 5 times cheaper than the closest market related product.<br /><strong>Conclusion</strong>: Patient specific moulds using PMMA to create custom implants are safe, have excellent cosmetic results and are a very cost-effective option to manage cranial defects. Accurate planning strategies for large craniotomies, where bone will potentially be discarded, add to surgical effectiveness and cost-saving to the patient.</p> AJ Vlok, S Naidoo, AS Kamat, D Lamprecht Copyright (c) Fournier’s gangrene: outcome analysis and prognostic factors <p><strong>Background</strong>: Fournier’s gangrene is an infective necrotising fasciitis of the external genitalia and perineum associated with significant morbidity and mortality. The factors associated with non survival have been described but are not universally accepted. The identification of prognostic factors remains critical to improve outcomes.<br /><strong>Objectives</strong>: To determine the hospital based mortality and factors associated with non-survival among subjects with a clinical diagnosis of Fournier’s gangrene.<br /><strong>Methods</strong>: A prospective hospital based observational study on 51patients with a clinical diagnosis of Fournier’s gangrene over a 2-year period. A comparison was made between survivors and non-survivors to establish prognostic factors associated with non survival.<br /><strong>Results</strong>: The disease related hospital mortality was 27% (14/51). The mean age of the 51, all male patients was 47 years. An older age was significantly associated with non-survival (p=0.02). The presence of renal dysfunction (p=0.001), severe sepsis (p=0.000), delay in surgical debridment (p=0.04), urogenital source of infection (p=0.01), a body surface area involvement of greater than 5% (p=0.006), abdominal wall involvement (p=0.02) on admission were significant factors associated with mortality. The presence of either HIV infection or diabetes mellitus was not a prognostic indicator of mortality. The clinical and biochemical parameters on admission associated with non survival were a high respiratory rate (p=0.03), a low hemoglobin(p=0.0001), an elevated blood urea nitrogen (p=0.005) and creatinine (p=0.01). Multivariate logistic regression analysis did not show any independent factors associated with non survival.<br /><strong>Conclusion</strong>: Fournier’s gangrene remains a fatal condition with a hospital mortality of 27%. Prognostic factors for non survival include an advanced age, a urogenital source of infection, abdominal involvement, severe sepsis and renal dysfunction.</p> CS Meki, TI Mangwiro, J Lazarus Copyright (c) Human immunodeficiency virus (HIV) infection in men with penile carcinoma is associated with increased prevalence of human papilloma virus infection and younger age at presentation <p><strong>Background</strong>: We investigated the prevalence of HIV and human papilloma virus (HPV) infection in men with penile carcinoma.<br /><strong>Method</strong>: This retrospective study investigated all men with penile carcinoma at the Universitas Academic Hospital in Bloemfontein, South Africa (January 2000–December 2008). Patients' age, HIV status, histological type of carcinoma and evidence of HPV infection were recorded. Statistical analyses included Student's t-test and Fisher's exact test where appropriate (2-tailed p-value &lt; 0.05 indicated statistical significant).<br /><strong>Results</strong>: Among 65 patients (mean age 50.9 years, range 37–69), the most common histological type was squamous cell carcinoma (80.0%). HIV status was known for 48 patients; 27 (56.2%) were HIV-positive. The mean age at presentation was 43.7 years (range 26–69) years in the HIV-positive and 57.2 years (range 26–89) years in the HIV-negative group. Approximately 55% of HIV-positive and 24% of HIV-negative patients showed histological evidence of HPV infection (p = 0.04). No significant difference was found with regard to histological type of carcinoma.<br /><strong>Conclusion</strong>: Patients with penile carcinoma had a high prevalence of HIV infection. The HIV-positive group were significantly younger at presentation, with a higher prevalence of HPV infection, suggesting that HIV may contribute to HPV-associated penile cancer at a younger age.<br /><strong></strong></p><p><strong>Key words</strong>: penis; carcinoma; human immunodeficiency virus (HIV); human papilloma virus (HPV)</p> SW Wentzel, LP Vermeulen, CA Beukes, J Thiart, G Joubert, J Goedhals Copyright (c) Tympanoplasty surgery: a retrospective audit of surgical outcomes at a regional hospital <p><strong>Background</strong>: Chronic Suppurative Otitis Media (CSOM) is a common condition in our setting, resulting in tympanoplasty surgery being one of the common surgical procedures performed. Little is published regarding outcomes of tympanoplasty surgery in patients living with Human Immunodeficiency Virus (HIV), which has a high prevalence in South Africa.<br /><strong>Aims</strong>: To audit the outcomes of tympanoplasty surgeries performed, including outcomes in patients with HIV.<br /><strong>Methods</strong>: A retrospective review of all tympanoplasty surgeries performed at our institute. Outcomes of surgery according to patient demographics, documented HIV status, seniority of surgeon, type and techniques of graft placement and hearing outcomes were reviewed.<br /><strong>Results</strong>: Successful closure of perforations was 84.4%. Closure rates in the 10 patients known to be HIV positive were 100%. The number of patients meeting the criteria for The Belfast Rule of Thumb (BROT) increased from 26.3% (n = 20) preoperatively to 68.4% (n = 52) postoperatively.<br /><strong>Conclusions</strong>: The results are comparable to both the results obtained at a tertiary hospital and those published internationally. Successful outcomes are obtainable in patients infected with HIV; however, as to the optimal timing of this surgery, this would require further investigation.<br /><strong></strong></p><p><strong>MeSH Keywords</strong>: Tympanoplasty, Belfast Rule of Thumb, Chronic Suppurative Otitis Media in HIV</p> S Naidoo, O Edkins, V Naran, S Liebenberg Copyright (c) Abdominal wall reconstruction with reconstructive tissue matrix <p><strong>Summary</strong>: A giant desmoid tumour required full thickness excision of the lower abdominal wall. The resultant massive defect was closed with reconstructive tissue matrix (Strattice™). The mesh acted as successful scaffold for regenerative repair enabling skin grafting of a stable granulation bed giving a satisfactory mechanical and cosmetic result. This mesh should be explored further as a simpler alternative to complex plastic reconstructive techniques for large abdominal soft tissue defects.</p> I Bombil, B Puttergill, BS Ngutshane Copyright (c) Fibroadenoma in the axillary accessory breast <p><strong>Summary</strong>: A 30-year-old female noted a mass in her right axilla for 6 years. The mass was painless, slowly growing, causing discomfort, had cyclical changes in consistency and was of cosmetic concern to the patient. Examination revealed normal breasts and a soft, non-tender, broad based mass in the right axilla. Sonography was non-diagnostic. Diagnostic doubt, cosmetic concern and discomfort to the patient prompted excisional biopsy which revealed a 1 cm fibroadenoma with surrounding breast tissue and a diagnosis of fibroadenoma arising in accessory breast tissue was made. Surgical excision is recommended for symptomatic accessory breast tissue where diagnostic doubt exists and for cosmetic reasons.<br /><strong></strong></p><p><strong>Keywords</strong>: Fibroadenoma in Supernumerary breast, Fibroadenoma in Ectopic breast, Fibroadenoma in Accessory breast, Fibroadenoma in polymastia.</p> M Motsumi, M Narasimhamurthy, M Gabolwelwe Copyright (c) Timely diagnosis of vascular Ehlers Danlos syndrome – the need for genetic testing and counselling <p><strong>Summary</strong>: We present a case of a young female patient diagnosed clinically and molecularly with V-EDS and briefly review the published literature on this severe condition. Additionally, the case is used to highlight the need for early confirmation of diagnosis and appropriate referral to allow surveillance, intervention and genetic counselling.</p> C Feben, J Kromberg, A McDonald, A Krause Copyright (c) A case of Amyand’s hernia in a preterm infant <p><strong>Summary</strong>: The findings of a normal or inflamed appendix in a hernia sac is a rare finding intraoperatively. It is referred to as an Amyand’s hernia, named after Claudius Amyand who first described it in 1735. We present a case of a 7-week-old male, born prematurely at 32 weeks’ gestation, who presented clinically with an incarcerated right inguinal hernia. Intra-operative findings revealed an inflamed and ruptured appendix in the hernia sac. An appendectomy and herniotomy was performed with good results.</p> K Pillay, V Gonzalez, T Rangaka Copyright (c) Laparoscopic pancreaticoduodenectomy at Dr George Mukhari Academic Hospital <p><strong>Summary</strong>: Laparoscopic pancreaticoduodenectomy (PD) represents the culmination of advanced laparoscopy. PD is a challenging procedure performed open with few centres worldwide offering the surgery using minimal access techniques (laparoscopic and robotic).1,2 We report our institution’s first case of PD performed laparoscopically.</p> NC Kalenga, O Mongale, T Mosasi, M Govender Copyright (c) Hepatic rupture as the initial manifestation of HELLP syndrome <p><strong>Summary</strong>: A 34-year-old normotensive nulliparous woman at 38 weeks’ gestation developed sudden onset of severe right upper quadrant pain, fetal distress, hypotension, and a generalised seizure. At urgent Caesarean section, a ruptured subcapsular liver haematoma was found. A healthy infant was delivered. Haemostasis was obtained with a Pringle manoeuver and liver packing. Subsequent bloodwork diagnosed HELLP syndrome. Both the patient and the infant made a full recovery. This case demonstrates the effectiveness of prompt application of these surgical manoeuvres.</p> L Thiessen, J Shaw Copyright (c) Pneumatosis intestinalis in HIV patient with gastric outlet obstruction <p>Summary: We report the case of a 39-year-old HIV positive female with gastric outlet obstruction. At laparotomy, she had extensive pneumatosis intestinalis (PI) of the ileum. This incidental finding of extensive PI in an HIV positive patient who was being managed non-operatively supports that the mere presence of PI is not an absolute indication for bowel resection in the absence of necrosis, perforation, or obstruction.<br /><strong></strong></p><p><strong>Key words:</strong> Pneumatosis intestinalis, HIV infection, gastric outlet obstruction</p> AG Bedada, A Georges, S Sheikh, MA Kayembe, M Hsiao Copyright (c) Post-exertional thoracic pseudomeningocoele in a 41-year-old woman: a rare cause of interscapular pain <p><strong>Summary</strong>: We present an unusual case of a previously healthy 41-year-old lady who acutely developed severe, disabling interscapular pain while lifting heavy boxes. She had no associated neurological deficits. She was found to have dorsal thoracic pseudomeningocoeles on magnetic resonance imaging (MRI) that were successfully managed surgically. While post-exertional spine pain is a common occurrence in every day clinical practice, this is often due to sprains and strains of muscles, tendons and ligaments. In a few cases, imaging reveals lesions such as annular disc tears, disc protrusions, or fractures of osteoporotic vertebra. Pseudomeningocoeles are generally described as complicating surgery or trauma to the spine. This case is unique as it follows exertional stress, which, to our knowledge, is not commonly described in the literature. Further, she had no risk factors such as connective tissue disorders that might have predisposed her to this development.</p> J R Ouma, S Makhure Copyright (c) Kaposi sarcoma: an unusual cause of intussusception in an adult patient <p><strong>Summary</strong>: Kaposi sarcoma (KS) is a multifocal, low-grade tumour of the vascular endothelium and is the most common neoplasm in patients with human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS). Although KS is known to cause cutaneous lesions, involvement of the gastrointestinal tract (GIT) is not uncommon. Intussusception secondary to KS however, is exceedingly rare and is a difficult diagnosis to make due to the vague symptomatology. In this case report, we describe the presentation and discuss controversies in the management of such a patient. We also highlight the value of cross sectional imaging in making the diagnosis pre-operatively.</p> OO Jolayemi, JC Mogambery Copyright (c)