Out-patient visits for gastrointestinal cancer at a quaternary South African hospital-trends and geospatial distribution

BackgroundThis study sought to determine trends in out-patient visits for gastrointestinal cancer (GC) at a quaternary hospital in KwaZulu-Natal (KZN), South Africa; and identify geographical regions which contribute most to GC-related out-patient clinic utilization at this hospital.MethodData for GC-related outpatient visits over an 11-year period was obtained from the hospital''s administrative database. Trends were analyzed using simple regression and trend line analyses. Patient residential postal codes from the administrative database were used to determine the geospatial distribution of complex GC in KZN.ResultsStrong increasing trends in GC-related out-patient visits were noted for age >65 years old (R²=0.8014), male (R²=0.7020), female (R²=0.7292), lower GC (R²=0.7094), and rural residence (R²=0.7008). Moderate increasing trends in GC-related out-patient visits were noted for age ≤65 years old (R²=0.6556), upper GC (R²=0.6498), and urban residence (R²=0.6988). The magnitude at which the number of out-patient visits increased was greater for urban residence when compared with rural residence (p=0.006). Urban centers and some regions along the North and South coast of KZN contributed the most toward GC-related out-patient visits.ConclusionOut-patient visits for complex GC in KZN are increasing. Several regions have been identified for anti-cancer interventions and decentralized out-patient services.     

Trends in Demographics and Management of Obstructing Colorectal Cancer

Introduction

Obstructing colorectal cancer (CRC) has an aggressive clinical course and poorer prognosis. With the increasing incidence and differing clinical and pathologic spectrum of CRC among Black patients, as well as a paucity of African studies, regional analysis is required. Our aim was to describe the demographics and management of obstructing CRC among the different racial groups in South Africa and to compare these parameters with international standards.

Patients and methods

Patients referred to Inkosi Albert Luthuli Central Hospital, Durban, South Africa, with CRC between 2000 and 2012 were followed prospectively. Demographic information, site of obstruction, and management of patients who underwent emergency surgery for malignant large bowel obstruction were analyzed separately.

Results

CRC was diagnosed in 1,425 patients. A total of 203 three patients (14.3 %) required emergent treatment for acute large bowel obstruction. The mean age at presentation with obstructing CRC was 59 years. Black patients presented significantly younger (50 years) than White (64), Indian (60), or Colored (61) patients (p < 0.001). The most common sites of obstruction were the sigmoid colon and rectum. A total of 58 patients (29 %) had concomitant metastatic disease. No difference was found between race, sex, and sex per race in patients with concurrent metastatic disease (p = 0.227, p = 0.415, p = 0.798, respectively). Of the 203 patients, 128 (63 %) were managed by resection, 37 (18 %) by colonic stenting, 35 (17 %) by colostomy, and 3 (2 %) by colonic bypass. Stenting was unsuccessful in six patients.

Conclusion

Tumor location of patients presenting with obstruction is comparable to that cited in international literature; however, the age of presentation among Black patients is more than a decade earlier than in other ethnic groups. Surgical management should be individualized. Stenting remains a reliable alternative in select cases.     

The management of retroperitoneal haematoma discovered at laparotomy for trauma

Aim

To review our local experience with presentation and management of retroperitoneal haematomas (RPH) discovered at laparotomy and factors affecting outcome.

Methods

Patients with retroperitoneal haematomas (RPHs) were identified from a prospective database. Data collected included demographics, clinical presentation, zones and organs involved, management and outcome.

Results

Of a total of 488 patients with abdominal trauma, 145 (30%) with RPH were identified 136 of whom were male (M:F = 15:1). Mean age was 28.8 (SD 10.6) years and median delay before surgery was 7 h. The injury mechanisms were firearms (109), stabs (24), and blunt trauma (12). Twenty-four patients (17%) presented with shock. There were 58 Zone I, 69 Zone II, and 38 Zone III haematomas. The median injury severity score (ISS) was 9. Fifty-two patients (36%) developed complications and 26 (18%) patients died. Sixty-four (44%) patients required ICU with median ICU stay of 3 days. All Zone I injuries were explored; Zones II and III were explored selectively. The mortality for Zones I, II, III and IV was 14%, 4%, 29% and 35%, respectively. Mortality was highest for blunt trauma and lowest for stabs (p = 0.146). Twelve of 24 patients with shock died (50%) compared to 14 of 121 (12%) without shock (p < 0.0001). Eighteen of 64 patients with <6-h delay before surgery died (28%) compared to 8 of 81 (10%) with >6-h delay (p < 0.017). Mortality increased with increasing ISS. Median hospital stay was 8 days.

Conclusion

RPH accounted for 30% of abdominal trauma. Injury mechanism, presence of shock, delay before surgery and ISS showed a significant association with mortality.     

Perforated gastric ulcer--reappraisal of surgical options

BACKGROUND: The available operative procedures for perforated gastric ulcer are gastrectomy, ulcer excision and omental patch closure. This study analysed the outcome of these operative options in a single institution. PATIENTS AND METHODS: Seventy-two patients (mean age 43 years, 62 males) with perforated gastric ulcers were managed by laparotomy. There were 34 lesser curve (incisural) and 38 antral ulcers. RESULTS: Partial gastrectomy was performed in 27 patients, ulcer excision in 27 and simple patch closure in 18. Two ulcers were malignant. The mortality rate was 18% (26% for gastrectomy, 19% for ulcer excision and 5% for patch closure). Shock on admission (p = 0.006) and Candida (p = 0.020) in the histological specimen were predictive of poor outcome. Hospital stay was similar in the 3 groups. CONCLUSION: Omental patch closure and ulcer excision are as effective as gastrectomy in the management of perforated gastric ulcer and merit consideration as first-line therapy in technically applicable cases.     

Gastric trauma: a straightforward injury, but no room for complacency

BACKGROUND: Injuries to the stomach are common following abdominal trauma, and there are few management controversies. This study was undertaken to document experience with the management of gastric injuries in a single surgical ward in a tertiary institution. PATIENTS AND METHODS: This prospective study was of a cohort of all patients found at laparotomy to have gastric injuries, over a 7-year period (1998-2004). Demographic data, clinical presentation, findings at laparotomy, and outcomes were documented. Prophylactic antibiotics were given at induction of anaesthesia. All patients found to have gastric injuries were given antifungal therapy. RESULTS: Of the 488 patients undergoing laparotomy for abdominal trauma over this period, 99 (20%) were found to have gastric injuries, of whom 6 were female (M:F ratio 14:1). The mean age (+/- standard deviation (SD)) was 28.9 +/- 11.1 years. Mean delay before surgery was 7.6 +/- 5.2 hours. Seventeen patients presented in shock. Injury mechanisms were firearms (52), stabbing (43) and blunt trauma (4). The mean injury severity score (ISS) was 13.6 +/- 7.4. Forty-two patients required management in the intensive care unit (ICU), with a mean ICU stay of 4.7 +/- 4.6 hours. Twenty-nine patients developed complications, and 14 died. There was only 1 gastric injury-related complication. Causes of death were multiple organ dysfunction syndrome (MODS) (8) and hypovolaemic shock (4), septic shock (1) and renal failure (1). Patients presenting in shock had a significantly higher mortality than those without shock (p<0.0001). Delay before laparotomy did not influence outcome. There were 20 patients with isolated gastric injuries, none of whom died. Mean hospital stay was 8.8 +/- 7.7 days. CONCLUSION: We reaffirm that stomach injuries are common following abdominal trauma. Isolated gastric injuries are uncommon. Complications specific to gastric injuries are uncommon but devastating. Mortality is related to associated injuries.     

Granulomas in acquired immunodeficiency syndrome‐associated cutaneous Kaposi sarcoma: evidence for a role for Mycobacterium tuberculosis

Background: Co‐lesional acquired immunodeficiency syndrome‐associated cutaneous Kaposi sarcoma (AIDS‐KS) and Mycobacterium tuberculosis‐associated granulomatous inflammation are undocumented. Method: Retrospective appraisal of skin biopsies with co‐lesional AIDS‐KS and microscopic tuberculosis (TB). Results: Sixteen biopsies from nine males and seven females form the study cohort. Histological assessment confirmed nodular and plaque KS in 12 and 4 cases each, respectively. Necrotizing, non‐necrotizing and a combination of necrotizing and non‐necrotizing granulomatous inflammation were present in nine, two and five biopsies each, respectively. The identification of acid fast bacilli on Ziehl‐Neelsen staining and M. tuberculosis on polymerase chain reaction confirmed co‐lesional TB in 15/16 biopsies. Co‐lesional AIDS‐KS and lichen scrofulosorum, hitherto undocumented, were confirmed in one biopsy. The histopathological findings served as a marker of human immunodeficiency virus (HIV) infection, visceral TB, therapeutic noncompliance and multidrug resistant pulmonary TB in nine, eight, five and one patient, respectively. M. tuberculosis was cultured from sputum or nodal tissue of all patients. Conclusion: Granulomatous inflammation in KS requires optimal histopathological and molecular investigation to confirm an M. tuberculosis origin. The cutaneous co‐lesional occurrence of AIDS‐KS and microscopic TB may serve as the sentinel clue to HIV infection, systemic TB, therapeutic noncompliance or multidrug resistant TB. Ramdial PK, Sing Y, Subrayan S, Calonje E, Aboobaker J, Sydney C, Sookdeo D, Ramburan A, Madiba TE. Granulomas in acquired immunodeficiency syndrome‐associated cutaneous Kaposi sarcoma: evidence for a role for Mycobacterium tuberculosis.     

Training of public health workforce at the National School of Public Health: meeting Africa's needs

PROBLEM: The inadequate number of trained public health personnel in Africa remains a challenge. In sub-Saharan Africa, the estimated workforce of public health practitioners is 1.3% of the world's health workforce addressing 25% of the world's burden of disease. APPROACH: To address this gap, the National School of Public Health at the then Medical University of Southern Africa created an innovative approach using distance learning components to deliver its public health programmes. Compulsory classroom teaching is limited to four two-week blocks. RELEVABT CHANGES: Combining mainly online components with traditional classroom curricula reduced limitations caused by geographical distances. At the same time, the curriculum was structured to contextualize continental health issues in both course work and research specific to students' needs. LESSONS LEARNED: The approach used by the National School of Public Health allows for a steady increase in the number of public health personnel in Africa. Because of the flexible e-learning components and African-specific research projects, graduates from 16 African countries could avail of this programme. An evaluation showed that such programmes need to constantly motivate participants to reduce student dropout rates and computer literacy needs to be a pre-requisite for entry into the programme. Short certificate courses in relevant public health areas would be beneficial in the African context. This programme could be replicated in other regions of the continent.     

Ileal diverticulosis in a black patient. A case report

A 54-year-old black man presented to hospital with diarrhoea containing blood and mucus and marked loss of weight over a 1-year period. Barium enema examination revealed cobblestoning and rose-thorn ulceration with possible stricture formation of the terminal ileum. A right hemicolectomy was performed to remove inflamed sections of small and large bowel. Histological examination of the resected specimen demonstrated features of ileal diverticular disease. This is the first documented case of this disease occurring in a black patient.