CURRENT RESEARCH PROJECTS

Transanal endoscopic operation (TEO): Local experience in a South African setting

 


A project in collaboration with Dr Parveen Karjiker and Prof Robert Baigrie.

Colorectal cancer is one of the leading causes of death in developed countries and found to be the third most common cancer in men and third most common cancer worldwide.

It is well recognised that the adenoma-carcinoma sequence is the mechanism by which most colorectal malignancies arise.  Dysplastic adenomas are the precursor lesions which can progress to adenocarcinoma. Early detection and removal can prevent rectal cancer.

Transanal endoscopic operation (TEO), which equates to the technique of transanal microsurgery (TEMS) has been widely adopted as the treatment of choice for large rectal adenomas, but has been little practised in South Africa with the exception of two centres in Cape Town, which attracted a large number of tertiary referral patients.

The excision of rectal lesions has evolved from invasive conventional rectal resection to include transanal excision, endoscopic mucosal resection, endoscopic submucosal dissection and in the last 30 years, TEMS and TEO.

The advantages of TEO over standard transanal excision include better exposure of the rectum, with lower recurrence and complication rates.

There is no data regarding the South African experience of outcomes of TEO for benign rectal adenomas and early rectal cancer.

The aim of this study is to evaluate TEO (the simpler and more affordable platform of the two) by describing the dimensions and anatomical parameters of specimens resected and using this to investigate whether any of these are predictive of recurrence, and to evaluate the incidence of complications of this less radical technique.

Diagnostic accuracy of magnetic resonance imaging in adult tuberculosis spondylitis

 


A project in collaboration with Dr Adrian Swan and Prof Michael Held.

BACKGROUND:

South Africa has an estimated tuberculosis prevalence of 696 and an incidence of 834 per 100 0000, the second highest incidence rate globally.

This high incidence is fueled by the country’s estimated human immunodeficiency virus (HIV) prevalence of 11.2%.  An estimated 61% of TB patients treated in South Africa during 2015 were HIV positive.  HIV infection is the principal risk factor for the development of active TB infection, increasing the risk from an estimated 5% – 10% per lifetime, to 5% – 15% per annum.

HIV depletes CD4+ T cells and impairs the tumor necrosis factor (TNF)-mediated macrophage response to MTB, both of which are key in granuloma formation and containment of MTB infection.  As a result musculoskeletal MTB infection in HIV positive hosts may be as high as 60% of total TB cases (20 times higher than in an immunocompetent host).

TBS makes up an estimated 50% of cases of musculoskeletal TB.

In South Africa, 28% – 40% of TBS patients are reported to be HIV positive.

Tuberculous spondylitis (TBS) is an infection by Mycobacterium tuberculosis (MTB) involving one or more components of the spine (vertebra, intervertebral discs, paraspinal soft tissues and the epidural space).

Tuberculosis (TB) continues to be a global health pandemic. Depending on a variety of host and socio-environmental factors, MTB may involve any organ system. For this reason TB has been termed “the great mimicker” and frequently relies on multiple modalities to establish a concrete diagnosis.

Imaging is an essential tool in this diagnostic armamentarium. Magnetic resonance imaging (MRI) has been proposed by many as the gold standard of imaging in suspected TBS.

For TBS, magnetic resonance imaging (MRI) is reported to have a diagnostic accuracy of 90% to 93.5%; a sensitivity of 75% to 100%; and a specificity of 75% to 88.2%.

Khalequzzaman et al included only cases of confirmed TBS in the determination of sensitivity and specificity, while Danchaivijiter et al compared confirmed cases of TBS with MRIs of other selected spinal diseases in order to calculate the diagnostic accuracy. As a result, common diagnoses of false positive MRI scans for TBS and features that may aid in distinguishing these from true cases of TBS cannot be established.

Neither of these studies made a distinction between HIV positive and negative patients. Significantly more collapse and kyphosis is seen in HIV negative patients.  This may alter the diagnostic accuracy of MRI scans for TBS in HIV subgroups.

Golhotra et al prospectively looked at MRI scans for TBS and pyogenic spondylitis. They found a sensitivity and specificity of 75% for the diagnosis of TBS on non-contrasted scans. The specificity is improved to 90% on contrasted scans.

AIMS:

Primary – To perform a retrospective case control study of a consecutive cohort of patients to determine the diagnostic accuracy of MRI for tuberculous spondylitis in: HIV positive and HIV negative patients.

Secondary – To describe MRI findings in confirmed cases of tuberculous spondylitis for HIV positive and HIV negative subgroups.  To determine the common diagnoses of false positive MRI’s.

Emergency hernias: Surrogate of failure or incidentalomas?

A project in collaboration with Drs boitumelo Nkgudi, Christo Kloppers, and Shreya Rayamajhi.

BACKGROUND:

Hernia emergencies are a common encounter of the general surgeon and are associated with high morbidity and mortality. These emergencies occur when the hernia; a disruption or weakness in the fibromuscular tissues that make up the abdominal wall resulting in protrusion of one or more internal organ, is complicated by incarceration (in which the hernia contents cannot be reduced back into the peritoneal cavity), bowel obstruction or strangulation (in which case the blood supply to the hernia contents is compromised and may lead to visceral ischemia and necrosis) .

Emergency hernia surgery is associated with increased morbidity and mortality for the patient; it is technically more challenging for the surgeon and results in higher costs. A review of the factors that lead to the emergency presentation could expose those that are amenable to improvement and better outcomes.

AIM:

The primary aim is to elucidate patient and system factors that are associated with emergency presentations.

The outcome of patients suffering thoracoabdominal gunshot wound injuries managed at a district hospital

A project for the MBChB special studies module.

The healthcare system of many countries suffer from the burden of gunshot wounds.  This includes first-world nations such as the United States, with an overall mortality rate of around 8%.  Mortality rates of as high as 30% has been shown locally.

Death from serious injury follows a three-modal pattern: (1) Immediate (on scene) death, (2) early intra-hospital death (usually from hemorrhage), and (3) later death from multiorgan failure.    Due to systems of improved care, Gunst et al shows a move towards a bimodal distribution with fewer cases of late death.  This leaves the burden of a further improvement in care to prevention and better early care.

Not all cases of severe injury such as thoracoabdominal gunshot wounds occur within proximity to an urban trauma unit.  Such proximity has been shown to influence outcome.

In the Cape Town metropolitan area, two large academic hospitals serve as level I trauma units.  Mitchells Plain Hospital (MPDH) is a district-level hospital in an area known as the Cape Flats, well known for it high level of interpersonal violence.  The hospital is situated 20 km away from one of these trauma units. As a district-level hospital, MPDH has no critical care unit or on-site blood bank. According to current protocol, patients with thoracoabdominal gunshot wounds are brought to the hospital by the emergency ambulance service.  Patients who are deemed unfit for transfer to the nearest level I trauma unit and then managed at MPDH. These patients will remain in the operating room theatre after surgery until transport can be arranged.

Surgical mortality at a district hospital

A project for the MBChB special studies module.

Surgical mortality rates are used more frequently as a measure of medical service quality.  Many factors have been identified as influencing mortality rates, including volume of surgery.

Procedures that have been identified as quality measures are coronary artery bypass graft surgery, repair of abdominal aortic aneurysms, pancreatic resection, esophageal resection, pediatric heart surgery, craniotomy, and hip replacement.  None of these procedures are performed at district hospitals in South Africa.

The Lancet Commission on Global Surgery has identified the bellwether procedures indicative of adequate access to care.  In their vision for 2030, they classify must do, should do, and can do surgical procedures to serve as a framework for first-level care.   The general surgical procedures in the first category include laparotomies and wound debridement.  Hernia repair, superficial soft tissue tumor resection, upper gastrointestinal endoscopy, cholecystectomy, thyroidectomy, and mastectomy are listed in the second.  Rectal-prolapse repair is listed in the first. All but thyroidectomies and rectal prolapse repair are offered at Mitchells Plain Hospital (MPDH).

MPDH is a district level hospital in an area known as the Cape Flats.  The hospital provides healthcare services through various clinical departments.  This includes a general surgery department. Service within the department is delivered by three full-time consultants, four medical officers, a registrar in training from Groote Schuur Hospital, and six medical interns.  As a district level hospital, MPDH had no critical care facility or on-site blood bank. All cases deemed inappropriate for care at the facility are discussed with personnel at Groote Schuur Hospital for possible transfer.  Emergency cases that require urgent surgical intervention and that cannot be safely transferred as taken to the operating room for their intervention prior to transfer.

The logistics around the management of complex cases can be a factor in the cause of mortality.  Before working towards providing the full list of services as indicated by the Lancet Commission, a quantitative look at mortality rates in the surgical service of MPDH is proposed.

Breast cancer surgery at a district hospital

Breast cancer provides challenges in care in a health system burdened with the care of communicable disease and trauma.  The current challenges are exacerbated by the prediction that Sub-Saharan African is predicted to see an 85% increase in cancer burden by 2030.  Strategies to deliver a quality service are needed and, once implemented, also measured.

Mitchells Plain Hospital (MPDH) is a district level hospital in an area known as the Cape Flats.  The hospital provides healthcare services through various clinical departments. This includes a general surgery department.  Service within the department is delivered by three full-time consultants, four medical officers, a registrar in training from Groote Schuur Hospital, and six medical interns.  The department runs a specialist breast clinic on Monday.

Patients are diagnosed with breast cancer and referred to the breast clinic at Groote Schuur Hospital where a formal decision on further management is made.  A select group of patients are identified for surgical management at MPDH. This is done with the patient’s consent and is usually due to the proximity of the hospital to the patient’s home.  The service also attempts to alleviate the overburdened capabilities of Groote Schuur Hospital.

This project aims to quantify the surgical care of surgical breast care for cancer at MPDH.

An audit of cholecystectomies at a district hospital

A project for the MBChB special studies module.

Cholecystitis as a complication of cholelithiasis is a world-wide phenomenon.  Since its introduction, the laparoscopic approach rapidly became the standard of care for this complication, in those without contra-indications to this approach.  This statement holds true for both urban and rural hospitals.  This procedure is not without its dificulties or complications.

Mitchells Plain Hospital (MPDH) is a district level hospital in an area known as the Cape Flats.  The hospital provides healthcare services through various clinical departments. This includes a general surgery department.  Service within the department is delivered by three full-time consultants, four medical officers, a registrar in training from Groote Schuur Hospital, and six medical interns.  Experience has shown acute cholecystitis to be a very common admission diagnosis. Laparoscopic cholecystectomies are furthermore one of the most common elective surgical procedures performed at the hospital.  While the timing of the procedure is of importance, all laparoscopic cases are performed on an elective, deferred basis.

This project aims to quantify the performance of laparoscopic cholecystectomies at MPDH.

Disease profile diagnosed by colonoscopy at a district hospital

A project for the MBChB special studies module.

Colonoscopy by flexible video endoscope is the gold standard for diagnosing colorectal conditions.  The procedure is costly, time-intensive, and not without risk.

Mitchells Plain Hospital (MPDH) is a district level hospital in an area known as the Cape Flats.  The hospital provides healthcare services through various clinical departments. This includes a general surgery department.  Service within the department is delivered by three full-time consultants, four medical officers, a registrar in training from Groote Schuur Hospital, and six medical interns.

Performing colonoscopies away from central locations have been described.  MPDH provides an elective colonoscopy service jointly run by the Departments of Internal Medicine and General Surgery.  Only a single procedure can be performed. Booking is strictly done through medical personnel at the hospital (wards or outpatient clinics).  This requires patients to be seen in the hospital despite a request being completed by a doctor from a referring clinic or supporting general practice.

This project aims to describe the referral patterns for colonoscopies vis-à-vis the presenting clinical complex and the logistics of the referral.  It furthermore aims to describe the pathology diagnosed by this investigative modality.

Provision of acute and elective general surgical care at a tertiary facility in the era of subspecialisation

 


BACKGROUND:
The need for an acute care and general surgical unit (ACGSU) to provide care for patients previously managed on an ad hoc basis by subspecialist units was recognised by the provincial government of the Western Cape Province, South Africa, the management of Groote Schuur Hospital (GSH) and the Department of Surgery.

OBJECTIVE:
To describe the resulting ACGSU and its functioning.

METHODS:
Data available from administrative records, patient files and operating room forms were collected in spreadsheet form for the period July 2013 – November 2016 inclusive.

RESULTS:
The ACGSU comprised a medical care team of four consultants and four to five trainees. A total of 7 571 patients were seen during the study period, the majority (66.1%) referred from the GSH Emergency Centre. Skin and soft-tissue infections formed the major disease complex. A total of 3 144 operative records were available. The most common procedures were wound debridement and inguinal hernia repairs. Trainees acted as primary surgeon in most cases. Complications (Clavien-Dindo grades I – V) were noted in 25.0% of patients.

CONCLUSIONS:
The ACGSU provides patient management that would otherwise complicate care in the subspecialist surgical units. It serves as a training ground for registrars and stands as a model for other institutions. Further research into the effect on patient care is planned.

South African surgical registrar perceptions of the research project component of training: Hope for the future?

BACKGROUND:
The Health Professions Council of South Africa requires that a research project be submitted and passed before registration as a specialist.

METHOD:
Ethics clearance was received before commencing the study. A questionnaire was developed to collect feedback from surgical registrars throughout South Africa (SA). Completed questionnaires underwent descriptive analysis using MS Excel. Fisher’s exact test and the χ2 test were used to compare perceptions of the research-experienced and research-naive groups.

RESULTS:
All medical schools in SA were sampled, and 51.5% (124/241) of surgical registrars completed the questionnaire. Challenges facing registrars included insufficient time (109/124), inadequate training in the research process (40/124), inadequate supervision (31/124), inadequate financial resources (25/124) and lack of research continuity (11/124). Of the registrars sampled, 67.7% (84/124) believed research to be a valuable component of training. An overwhelming percentage (93.5%, 116/124) proposed a dedicated research block of time as a potential solution to overcoming the challenges encountered. Further proposals included attending a course in research methodology (79/124), supervision by a faculty member with an MMed or higher postgraduate degree (73/124), and greater research exposure as an undergraduate (56/124). No statistically significant differences were found between the perceptions of the research experienced and research-naïve groups.

CONCLUSION:
Challenges facing surgical registrars in their efforts to complete their research projects were identified and solutions to these problems proposed. It is heartening that respondents have suggested solutions to the problems they encounter, and view research as an important component of their careers.

Penetrating femoral artery injuries: an urban trauma centre experience

AIM:
This study reviews a single centre experience with penetrating femoral artery injuries.

PATIENTS AND METHODS:
The records of all patients with femoral artery injuries admitted to the Trauma Centre at Groote Schuur Hospital from January 2002 to December 2012 were reviewed. These were analysed for demographics, injury mechanism, perioperative, and surgical management. Outcome was categorised by limb salvage.

RESULTS:
One-hundred and fifty-eight (158) patients with femoral artery injuries were identified. There were 144 (91%) men and 14 women with a mean age of 28 years. Ninety-five percent (N = 150) sustained penetrating injuries. The superficial femoral artery (87%) was most commonly injured. The most common type of arterial injury was a laceration (39%) and transection (37%). Eighty-one (51%) patients had a primary repair, 53 (33%) patients had a vein interposition graft, and 16 patients (10%) had a prosthetic graft. There were 78 (51%) concomitant venous injuries, 11 were repaired, and 1 vein patch repair was performed (15.4%). There were 4 (2.5%) primary amputations and 10 (6.5%) secondary amputations. There were no deaths. Statistically significant risk factors for secondary amputation derived by univariate analysis were: ischaemia (p < 0.0001), neurological deficit due to ischemia (p < 0.001), temporary vascular shunting (p < 0.001), and the absence of a palpable pulse post-repair (p < 0.01).

CONCLUSION:
This study has a primary and secondary amputation rate of 2.5 and 6.5%, respectively. There was greater than 90% limb salvage rate. The outcome of threatened limbs due to femoral artery injury is good, provided that there is no delay to surgery.

An analysis of the inequalities between the public and private sector in South Africa

BACKGROUND:
The full extent of the global burden of surgical disease is largely unknown, however, the scope of the problem is thought to be large. Despite the substantial burden of surgical disease, surgical services are inaccessible to many of those who need them most. There are disparities between public and private sectors in South Africa, which compounds inequitable access to surgical care.

METHOD:
This study involved a descriptive analysis of surgical resources and included the total number of hospitals, of hospital beds, the number of surgical beds, the number of general surgeons (specialist and non-specialist), and the number of functional operating theatres in South Africa. A comparison was performed between the public and private sectors. Hospitals were contacted during the period from the 1st October 2014 until the 31st of December 2014.

RESULTS:
Surgical resources were concentrated in metropolitan areas of urban provinces. There were striking differences between the public and private sectors, where private resources were comparable to those available in high income countries (HICs).

CONCLUSION:
Improving access to surgical services in lower middle income countries (LMICs) requires addressing gaps between the public and private sector regarding infrastructure, personnel, as well as equipment. South Africa is unique in that although it is classified as an upper middle income country (UMIC), is comprises of two sectors; a public sector which has resources similar to other LMICs, and a private sector which has resources similar to HICs. These data identified disparities between geographic regions which may be contributing to ongoing inequity in South Africa, and by doing so allows for evidence-based planning towards improving surgical infrastructure and workforce.

A retrospective evaluation of the Modified Alvarado Score for the diagnosis of acute appendicitis in HIV-infected patients

BACKGROUND:
The aim of this study was to evaluate and compare the diagnostic value of a Modified Alvarado Score (MAS) ≥7 for acute appendicitis in both Human Immunodeficiency Virus (HIV)-negative (HIVneg) and positive (HIVpos) patientcohorts.

METHODS:
This retrospective study included all HIV-tested patients undergoing appendectomy at a regional hospital from March 2010 to March 2011. The MAS was calculated for all patients, as well as for the HIVneg and HIVpos groups separately. Two subgroups were considered for each of these: MAS ≥7 (high likelihood of appendicitis) and MAS <7 (low likelihood of appendicitis). These subgroups were then analysed against histopathological findings of the resected appendix. MAS specificities and sensitivities were determined by comparing Receiver Operator Characteristic (ROC) curves for the various scores.

RESULTS:
The study comprised 133 patients. Eighty-six (65%) were men and the median age was 20 years (range 4-64); 18 patients (14%) were HIVpos. Appendicitis was confirmed histologically in 113 patients, 100 in the HIVneg group and 13 in the HIVpos group. Specificity and sensitivity of a MAS ≥7 for HIVneg patients was 73 and 85% respectively. Based on the ROC curves, HIVpos patients only showed similar sensitivities (69%) and specificities (80%) at a MAS ≥8.

CONCLUSION:
A MAS ≥7 is a reliable predictor of acute appendicitis in HIVneg patients. In HIVpos patients, the MAS threshold required to accurately predict appendicitis is 8. The use of a MAS ≥7 in this group of patients will result in unnecessary surgical intervention