Colorectal cancer in South Africa study on the effect of delayed diagnosis to treatment intervals on survival

The South African National Cancer Registry (NCR), a division of the National Health Laboratory Service (NHLS), is a pathology-based cancer registry based on inputs from public and private health facilities, the South African Oncology Consortium, Hospice Association, Childhood Cancer Foundation South Africa and the NHLS. Data from the NCR shows that incidence and mortality from colorectal cancer (CRC) are rising. Between 2002 and 2014, the NCR reported a 2.5% rise in age-standardised incidence rates (ASIR) and a 1.3% rise in age-standardised mortality rates (ASMR).1 CRC has the third-highest incidence of all cancers in the NCR.

Thirteen-year audit of the management of anorectal fistulae in a tertiary colorectal unit

An anorectal fistula (fistula-in-ano) is a common benign colorectal condition, and is defined as an abnormal tract connecting two epithelial surfaces, usually the rectal mucosa and perianal skin. Typically, it includes an internal opening, a tract, and an external opening. The cryptoglandular aetiology of anorectal fistula involves the initial development of an anorectal abscess from an infected anal gland. The anal crypts are epithelial-lined tracts that penetrate the submucosa at the bottom of the rectal columns of Morgagni and occasionally extend into and through the internal sphincter.

A comparative analysis of the upper gastrointestinal endoscopic reporting systems within the Durban Metropolitan complex

There is currently no universal/uniform reporting system for upper gastrointestinal endoscopic procedures that is shared between the different hospitals in Durban, South Africa. Each of the five hospitals in the Durban Metropolitan complex performs upper gastrointestinal endoscopy for various indications based on symptoms or disease processes, and the system of reporting may vary from handwritten reports to simplistic, computerised data collection (word processor) type reporting. Previous authors have suggested standardised endoscopic reporting, which could be used by individual hospitals. This would serve as a guideline for accurate and uniform reporting which would allow for inhospital and inter-hospital data analysis

Spectrum and surgical outcomes of gastrointestinal stromal tumours

Gastrointestinal stromal tumours (GIST) arise from the interstitial cells of Cajal which are essential to motility of the gastrointestinal tract. These cells as well as GIST cells stain for the c-kit tyrosine kinase receptor which transmits signals from the cell membrane into the cell by way of signal transduction. Although rare, GISTs are the most common mesenchymal tumours in the digestive tract, and the stomach is the most frequent site followed by the small bowel. 

Aortoenteric fistulas – our experiences with surgeons’ nightmare

Aortoenteric fistulas (AEFs) are a medical emergency and one of the rare causes of fatal gastrointestinal (GI) bleeding, often occurring after aortic aneurysm surgery and rarely as a result of primary aortic or intestinal pathologies. While most AEFs are regarded as a secondary complication following prior aortic surgery, they seldom develop primarily. The location of the fistula usually occurs between the abdominal aorta and the duodenum.

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

The publication of “To err is human” at the turn of the millennium drew attention to the problem of human error in health care. Since then, it has been widely accepted that human error contributes substantially to morbidity and even mortality in health care. The response to this has been to deepen our understanding of human error and to attempt to develop error reduction strategies. These strategies accept that error is endemic and more likely to occur in so-called error-prone environments. Variations in human responses to an external milieu can be both harmful and very positive 

Oncoplastic surgery for breast carcinoma in South Africa – an audit of outcomes from a single breast unit

Breast carcinoma is the most common carcinoma in women worldwide. According to the 2019 South African National Cancer Registry, the incidence of breast carcinoma was 33.86/100 000 females. Surgery is an important component in the multimodal treatment of breast cancer. The NSABP B-6 trial found no significant difference in overall survival (OS) or disease-free survival (DFS) between patients undergoing lumpectomy or a modified radical mastectomy for early breast cancer. These results were maintained after 20 years of follow up. Breast-conserving surgery (BCS) aims to minimise the morbidity associated with breast cancer surgery; however, the amount of breast tissue which can be excised without compromising cosmesis is often limited.

Factors influencing the outcomes of patients with severe traumatic brain injury following road traffic crashes

Traumatic brain injury (TBI) is a significant cause of death, disability and socioeconomic problems worldwide and is often called the ‘silent epidemic’. The estimated incidence of TBI worldwide is 939 per 100 000. Nell and Brown, in 1991, estimated the incidence of TBI in South Africa (SA) to be 316 per 100 000 population per year.

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

The world is facing a divergent demographic future. Globally, the geriatric population will more than double, from 900 million in 2015 to about 2 billion by mid-century. Most developed countries experience an ageing population and an alarming reduction in fertility rates. This is in stark contrast to the developing world where there is a burgeoning population. Countries such as Nigeria are set to have an excess population of 400 million people by mid-century. Trauma is a significant cause of preventable mortality and morbidity in the elderly worldwide. In high-income countries (HICs), geriatric trauma currently accounts for up to 25% of all trauma admissions.

Mediastinoscopy as a diagnostic tool in a South African tertiary hospital

Mediastinoscopy is a surgical procedure that entails endoscopic visualisation of the superior and middle mediastinum. It was first described by Carlens in 1959 and involved insertion of a laryngoscope through a supraclavicular incision with biopsies of lymph nodes done. It is mainly used for staging of lung cancer by assessing the N2 nodes and also for diagnosis of other mediastinal masses.

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

Squamous carcinoma of the penis is a relatively uncommon urological malignancy. Even in high-income countries (HICs), the social stigma surrounding the disease means that patients generally present late, with advanced disease. The situation in sub-Saharan Africa is not well described. However, it is likely that these delays in presentation and treatment are even more pronounced. Most of the guidelines for the management of penile cancer are formulated in HIC. It is unclear whether these guidelines can be applied directly in the South African context.

A surgeon’s dress code – the patients’ perspective

The perception of how surgeons should present themselves dates back to the time of Hippocrates (460 BC–370 BC) who recommended that physicians be “clean in person, welldressed”. The dress code of a surgeon has been one that has been contested recently, as evidenced by the updated guidelines on appropriate surgeon attire by the American College of Surgeons in 2016. The surgeon’s attire is an important component of the patient-doctor relationship; the basis of a good patient-physician relationship depends on mutual trust, confidence, and respect. Therefore, to some degree, first impressions of appearance and/or professional attire have a bearing on the patient-doctor relationship; the basis of a good patient-physician relationship depends on mutual trust, confidence, and respect.

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

Acute appendicitis (AA) is the commonest surgical emergency globally and in South Africa (SA). According to international guidelines, the recommended treatment for AA is laparoscopic appendectomy (LA). In high-income countries (HICs) such as the UK and the USA, AA is managed predominantly by LA and is associated with low morbidity and mortality. However, in South Africa, AA is still associated with significant morbidity and mortality. SA has a dual healthcare system, and the approach to AA varies between the public and private sectors. Most AA is managed by a formal laparotomy or an appendectomy via a local incision. 

A case of bowel perforation secondary to burn conversion

The depth and total body surface area (TBSA) of a burn wound influence morbidity and mortality. Depth of the wound determines wound management principles. Wounds that are deep partial-thickness or full-thickness will require skin grafting and carry an increased morbidity, increased length of hospital stay, and scar formation compared to superficial partial-thickness burns that heal spontaneously. Inappropriate initial resuscitation of a burn could compromise the recovery process by means of burn conversion. 

Delayed management of paediatric burn sepsis resulting in limb loss

BM is a previously healthy 6-month-old who presented to a district hospital with 15% hot water scald of superficial partial depth to the feet, lower legs and thighs. He was appropriately resuscitated and transferred early to the regional hospital due to the age of the patient and the size of the burn. About a week later, he developed severe sepsis and septic shock. Resuscitation was commenced with referral to the paediatric intensive care unit (PICU), who advised obtaining source control prior to admission to PICU. The patient was taken to theatre for debridement by a burn naïve surgeon. The surgery was, in fact, not indicated for the superficial partial nature of the burn. 

Orbital metastases of breast carcinoma

Orbital metastasis (OM) is a rare finding in systemic cancer, with few case reports and less frequent elucidation of the primary tumour. Histologically confirmed OM are diagnosed once or twice at larger academic centres per year and most of the literature is from single case reports. Breast carcinoma is the most likely primary tumour, accounting for 29–35% of all tumours in the orbit. In a series by Raap et al., just over 25% of patients with breast carcinoma and OM, presented initially with OM. 

Spontaneous pneumomediastinum in two young women

SPM is a rare clinical condition to be considered in a patient presenting with mediastinal emphysema without clinical signs of mediastinitis. Aerodigestive injury should be ruled out by imaging and/or endoscopy. Management of SPM is supportive and may warrant multidisciplinary input to treat the precipitating condition. In our cases, this was the psychiatrist and the obstetrician. SPM spontaneously resolves, and a good outcome can be expected. 

Colonic perforation in a right atraumatic diaphragmatic hernia

Atraumatic diaphragmatic hernias are virtually unheard of in the adult population, with left-sided hernias being more common than right. The most common aetiology of diaphragmatic hernias is thought to be trauma secondary to penetrating or blunt force, followed by congenital malformations of the diaphragm. Other possible causes include a pseudopneumoperitoneum, such as Chilaiditi’s syndrome, whereby colon is interposed between the superior surface of the liver and inferior surface of the right hemidiaphragm, giving the impression of free intraabdominal air similar to that seen in Figure 1.  

Gall bladder torsion masquerading as appendicitis in a teenage boy

Gallbladder torsion as a pathology is extremely rare with only 50 documented cases in the last 40 years according to Atahan et al.1 Furthermore, a systematic review by Reilly et al., which reviewed all reported cases of gallbladder torsion over a one hundred and fourteen year period (1898–2012) and included 500 publications, found the median age of presentation to be 77 years of age as well as a female to male preponderance of 4:1. The same systematic review found only 51 cases of gallbladder torsion in individuals under the age of 18.2 This case is interesting as teenage boys are the least common patient population to suffer from gallbladder torsion. 

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

Penetrating thoracic and thoracoabdominal trauma is a common reason for presentation to emergency departments across South Africa. All patients presenting with penetrating thoracoabdominal injuries are investigated and managed according to standard protocols. Those who require urgent surgery are offered such. Those who do not immediately meet criteria for operative management are assessed for their suitability for SNOM, a decision based on haemodynamic and metabolic status, radiographic findings, as well as clinical thoracic and abdominal assessment. Those with left-sided thoracoabdominal penetrating injuries are offered diagnostic laparoscopy to assess for diaphragmatic injury. Similarly, the assessment and management of penetrating precordial injuries follow a standard protocol. Those who need surgery upfront receive it. 

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