Compliance to the South African ventral hernia guidelines: inaugural results from the HIG(SA) registry.

BACKGROUND: The Hernia Interest Group (HIG) of South Africa (SA), following the publication of their inguinal and ventral hernia guidelines (in 2015 and 2016 respectively), developed a hernia registry, the HIG(SA) hernia registry. METHODS: A retrospective analysis of the prospectively maintained HIG(SA) hernia registry from 1 February 2019 to 29 February 2020. Compliance to six recommendations made in the HIG(SA) ventral hernia guidelines were assessed in both the public and private healthcare systems. RESULTS: Three hundred and fifty-three ventral hernia repair cases were included in the study. Fifty-four per cent were private and 46% were public sector cases. Laparoscopic repair for patients with a BMI > 35 kg/m2 occurred in 38% of eligible cases and a minimum 5 cm of mesh overlap was achieved in 50% of cases. Overall, 80% of elective cases occurred in non-smokers; 97% of the intraperitoneal on-lay mesh (IPOM) repairs used composite mesh; 96% of ventral hernias with defects of larger than 2 cm and 95% of incisional hernias were repaired with mesh. Non-smokers undergoing repair numbered 72% in public and 85% in private practice, p = 0.01. CONCLUSION: Ventral hernia repair practices in SA facilities overall had good compliance to four out of the six HIG(SA) ventral hernia guidelines highlighted for the purposes of this study. The two guidelines that had poor compliance overall were 'laparoscopic repair for patients with a BMI of > 35 kg/m2' and 'ensuring a mesh overlap of 5 cm'. The public sector had higher rates of current smokers undergoing elective ventral hernia repair.

Colorectal surgical outcomes following implementation of an enhanced recovery after surgery programme in Cape Town.

BACKGROUND: Colorectal surgery is commonly performed for benign and malignant colorectal disease. The aim of this study was to describe length of stay (LOS), complications and its associated factors in patients undergoing elective colorectal surgery following implementation of an enhanced recovery after surgery (ERAS) programme in South Africa (SA). METHODS: Socio-demographic, pre- intra- and postoperative clinical details and compliance to the ERAS guidelines were recorded in all patients undergoing colorectal surgery in a private practice in Cape Town, SA. Means and standard deviations or medians and interquartile range (IQR), as appropriate, were used to describe continuous variables and frequencies and percentages for categorical variables. Bivariate and multivariate analyses using linear regression of log transformed LOS and logistic regression for development of complications were performed. RESULTS: Between 2015 and 2019, 457 patients had elective colorectal surgical procedures. The median LOS was 5 days (IQR 3-7). Pre- and intraoperative compliance was 92% and 86% respectively. In total, 203 (44%) patients developed 346 complications, of which 61% were minor. On bivariate analysis, increased intraoperative compliance was associated with a significant decrease in LOS (coefficient [ß] = 0.987, 95% confidence interval [CI] 0.984-0.991) and complications (odds ratio [OR] 0.457, 95/5 CI 0.266-0.787). For every additional 30 minutes of theatre time, irrespective of type of procedure, LOS increased by 8% and complications by 12%. On multivariate analysis, laparoscopic compared to open surgery was also associated with a shorter LOS (exp [ß] = 0.667, 95% CI 0.580-0.767 p < 0.001) and reduced complications (OR 0.457, 95% CI 0.266-0.787). CONCLUSION: Our results show that high compliance to the ERAS guidelines is possible in the private sector in SA and that a significant reduction in LOS can be achieved without placing the patient at a higher risk of complications.

Can an Enhanced Recovery After Surgery(ERAS) programme improve colorectal cancer outcomes in South Africa?

Colorectal cancer (CRC) is the third most common cancer worldwide and the fourth most common cause of cancer related deaths. It is estimated that CRC is amongst the top five malignancies in South Africa (SA) with an age standardised incidence rate of 10.2 and 6.1 per 100 000 for males and females respectively. The incidence is projected to increase in South Africa as a result of ageing, a growing population and an increase in prevalence of risk factors.

Enhanced recovery after surgery (ERAS) in penetrating abdominal trauma: A prospective single-center pilot study.

BACKGROUND: Enhanced recovery after surgery (ERAS) programmes employed in elective surgery have provided strong evidence for decreased lengths of hospital stay without increase in postoperative complications. The aim of this study was to explore the role and benefits of ERAS implemented in patients undergoing emergency laparotomy for penetrating abdominal trauma. METHOD: Institutional University of Cape Town Human Research Ethics Committee (UCT-HREC) approved study. A prospective cohort of 38 consecutive patients with isolated penetrating abdominal trauma undergoing emergency laparotomy were included in the study. The enhanced recovery protocols (ERPs) included: early urinary catheter removal, early nasogastric tube (NGT) removal, early feeding, early mobilisation/physiotherapy, early intravenous line removal and early optimal oral analgesia. This group was compared to a historical control group of 40 consecutive patients undergoing emergency laparotomy for penetrating abdominal trauma, prior to the introduction of the ERP. Demographics, mechanism of injury, injury severity scores (ISS) and penetrating abdominal trauma index (PATI) were determined for both groups. The primary end-points were length of hospital stay (LOS) and incidence of postoperative complications (Clavien-Dindo classification) in the 2 groups. The difference in means was tested using the t-test assuming unequal variances. Statistical significance was defined as p-value less than 0.05 (p < 0.05). RESULTS: The two groups were comparable with regards to age, gender, mechanism of injury, ISS and PATI scores. The mean time to solid diet, urinary catheter and nasogastric tube (NGT) removal was 3.6 (non-ERAS) and 2.8 (ERAS) days [p < 0.035], 3.3 (non-ERAS) and 1.9 (ERAS) days [p < 0.00003], 2.1 (non-ERAS) and 1.2 (ERAS) days [p < 0.0042], respectively. There was no difference in time from admission to time of laparotomy 313 (non-ERAS) vs 358 (ERAS) minutes [p < 0.07]. There were 11 and 12 complications in the non-ERAS and ERAS groups, respectively. When graded as per the Clavien-Dindo classification, there was no significant difference in the 2 groups (p < 0.59). Hospital stay was significantly shorter in the ERAS group: 5.5 (SD 1.8) days vs. 8.4 (SD 4.2) days [p < 0.00021]. CONCLUSION: This pilot study shows that ERPs can be successfully implemented with significant shorter hospital stays without any increase in postoperative complications in trauma patients undergoing emergency laparotomy for penetrating abdominal trauma.

Ventral Hernia - South Africa 2016.

Ventral hernia repair is one of the most common general surgical procedures. An estimated 20 million patients with hernias are operated on worldwide every year. An incisional hernia will develop in 10-15% of patients with an abdominal incision. The risk increases to 23% in those who develop surgical site infection. Recurrence rates of up to 69% have been reported in high-risk patients.

Injured pedestrians in Cape Town--the role of alcohol.

OBJECTIVE: To establish a profile of injured adult pedestrians and attempt to define the role which alcohol plays in this regard. DESIGN: Prospective survey of injured pedestrians who presented consecutively over 9 weeks to Groote Schuur Hospital. Data on fatally injured pedestrians were retrospectively collected from the State Mortuary. SETTING: Hospital-based study conducted at the trauma unit, Groote Schuur Hospital. PARTICIPANTS: A total of 321 pedestrians--196 injured and 35 'dead on arrival'. MAIN OUTCOME MEASURES: Sociodemographics, blood alcohol concentration (BAC) and injury severity. RESULTS: Patients were predominantly male and, on average, 35.6 years old. They were most frequently injured at night and over weekends. The BAC was positive in 62.1% of pedestrians, and the mean BAC was 0.19 g/dl. Most pedestrians had at least one lower limb injury and nearly half had a head injury; however, BAC-positive pedestrians were 2.6 times more likely to have a head injury (P = 0.0009). Furthermore, BAC-positive pedestrians sustained more severe injuries, more frequently required admission to the ICU, had longer hospital admission and were more likely to die of their injuries. The overall case fatality rate was 19.5%. CONCLUSIONS: The influence of alcohol intoxication among injured adult pedestrians in Cape Town is high, suggesting that alcohol plays a major role in these accidents. Consequently, there should be some degree of culpability in those who cross the road while in an intoxicated state. However, equal attention should be given to safe and convenient crossing points, good lighting and education with regard to the wearing of reflective clothing after dark.