A perspective in the management of myelomeningocoele in the KwaZulu-Natal Province of South Africa.

BACKGROUND: Myelomeningocoele (MMC) is common in the developing world. The purpose of this study was to investigate the clinical characteristics and management of myelomeningocoele and to identify factors contributing to outcomes. METHODS: This was a retrospective, observational study of consecutive children diagnosed with MMC managed in the Paediatric Neurosurgery Unit at Inkosi Albert Luthuli Central Hospital. Multiple logistic regression analysis identified clinical characteristics, demographics and surgical variables that were associated with outcome. RESULTS: A total of 309 children were managed during this period (M:F 1.3:1). The most common sites were lumbar, lumbo-sacral and sacral. Mean age at surgical repair was 4.7 ± 15.6 months. Two hundred and eight children had ventriculomegaly, of whom 158 had symptomatic hydrocephalus, requiring CSF diversion. Fifty-eight (21%) patients developed wound sepsis, of whom 13 (22%) developed meningitis (p = 0.001). The time to wound sepsis was 9.5 ± 3.6 days. The commonest organism isolated was Staphylococcus aureus followed by MRSA. Thirty-two patients (23%) developed shunt malfunction and three (11%) developed ETV malfunction. Twenty children (9%) demised during the admission period. Death was associated with meningitis (p < 0.0001), and meningitis itself was associated with wound sepsis (p < 0.0001). Hospital stay was 20.4 ± 16 days. Wound sepsis (p = 0.002) and meningitis (p < 0.0001), respectively, were associated with prolonged hospital stay. CONCLUSION: There was a slight male preponderance and hydrocephalus occurred in two thirds of cases. Wound sepsis and meningitis were associated poor outcomes.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications.

BACKGROUND: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. METHODS: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. RESULTS: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. CONCLUSIONS: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. CLINICAL TRIAL REGISTRATION: NCT03044899.

Is Clinical Research in Oesophageal Cancer in South Africa in Crisis? A Systematic Review.

Oesophageal cancer (OC) is responsible for the second highest number of cancer-related deaths in South Africa (SA). Squamous cell carcinoma is the most prevalent type with an incidence of 46.7/100,000 and 19.2/100,000 for males and females. This is a systematic review of the clinical diagnosis and management of OC within the South African context. This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42016034053) with adherence to PRISMA guidelines. An online search was performed using MEDLINE, EBSCOHost and PubMed. Eligibility criteria for articles included published, original peer-reviewed research addressing clinical management of oesophageal cancer in South Africa. Review articles, case reports, scientific letters and studies published in languages other than English or Afrikaans were excluded. The research terms were 'etiology', 'human', 'esophageal cancer', 'esophageal carcinoma', 'oesophageal cancer', and 'oesophageal carcinoma', 'squamous cell carcinoma', 'Africa' and 'South Africa'. A total of 336 articles were identified. Of these, 146 were immediately excluded and a further 159 were excluded after review. A total of 31 appropriate articles, i.e. 9.2% of searched articles, were included. Thirteen articles addressed chemotherapy and/or radiotherapy, 9 oesophageal luminal therapy, 7 oesophageal surgery and 2 screening. OC research of in SA over the last two decades has mainly been in the form of reviews and opinion papers. Clinical research, auditing and prospectively analysing OC management and outcomes in SA hospitals are sorely needed and should be promoted by both healthcare workers and policy makers alike.

What is the diagnostic yield of colonoscopy in patients with a referral diagnosis of constipation in South Africa?

BACKGROUND: Constipation is a common problem for referral to surgical and colorectal units. Its association with colorectal cancer is controversial. Some authors have found an increased incidence while others have not. The aim of this study is to investigate the incidence of colorectal cancer (CRC) and other significant colonoscopic pathologies in patients undergoing colonoscopy for constipation. METHOD: All colonoscopy reports for constipation were retrieved from our database from January 2011 to 30 June 2014. Data extracted included demographics, colonoscopic findings and adequacy of bowel preparation. Exclusion criteria included patients with other symptoms known to be associated with colonic neoplasia such as lower GIT bleeding, loss of weight, patients with associated anaemia, those with abnormalities on imaging, patients with personal or family history of colorectal cancers or colorectal polyps and patients with inflammatory bowel disease. The primary outcome was the presence of neoplasia at colonoscopy and the secondary outcomes were other colonoscopy findings. RESULTS: A total of 985 colonoscopies were performed from January 2011 to June 2014 of which 144 were done for a referral diagnosis of constipation. Eighty eight (61.1%) were female. Their mean age was 58.6 + 13.8 years (range 19-95 years). There were 61 (42.4%) African patients, 38 (26.4%) White, 33 (22.9%) Asians and 12 (8.3%) Coloured patients. Eighty seven (60.4%) patients had a normal colonoscopy, 20 (13.9%) diverticular disease, 14 (9.7%) polyps of which 6 (4.2%) were neoplastic, and 9 (6.3%) had colorectal cancer. CONCLUSION: Constipation is associated with CRC. The presence of constipation should be a criterion for colonoscopy regardless of age or any other associated clinical features.

Does gender impact on female doctors'experiences in the training and practice of surgery? A single centre study.

BACKGROUND: Surgery has been identified as a male-dominated specialty in South Africa and abroad. This study explored how female registrars perceived the impact of gender on their training and practice of surgery. METHOD: A self-administered questionnaire was used to explore whether females perceived any benefits to training in a male-dominated specialty, their choice of mentors and the challenges that they encountered during surgical training. RESULTS: Thirty-two female registrars participated in the study. The respondents were mainly South African (91%) and enrolled in seven surgical specialties. Twenty-seven (84%) respondents were satisfied with their training and skills development. Twenty-four (75%) respondents had a mentor from the department. Seventeen (53%) respondents perceived having received differential treatment due to their gender and 25 (78.2%) thought that the gender of their mentor did not impact on the quality of the guidance received in surgery. Challenges included physical threats to female respondents from patients and disrespect, emotional threats and defaming statements from male registrars. Additional challenges included time-constraints for family and academic work, poor work-life balance and being treated differently due to their gender. Seventeen (53%) respondents would consider teaching in the Department of Surgery. CONCLUSION: Generally, females had positive perceptions of their training in Surgery. They expressed concern about finding and maintaining a work-life balance. The gender of their mentor did not impact on the quality of the training but 'bullying' from male peers and selected supervisors occurred. Respondents will continue to recommend the specialty as a satisfying career to young female students.

Does the reporting of gastro-intestinal endoscopy meet the minimal terminology standard at King Edward VIII Hospital?

BACKGROUND: The Minimal Standard Terminology (MST) was developed to standardise endoscopic reporting. This study is aimed at assessing current reporting at a tertiary hospital and whether it meets this Minimal Standard Terminology. METHOD: This was a retrospective observational study of upper endoscopy reports between January and December 2014. The data extracted were compared to the current reporting standard listed in the MST. To assess and grade the quality of reporting we developed a Gastrointestinal Reporting Score, which incorporates MST variables in addition to demographic details, indication for endoscopy, report legibility, sedation and the use of classification systems to describe pathology. Variables were classified as blank, partially complete or complete and assigned a score of 1-3. The reports were graded according to their overall score for all variables (Max 40) into Grade A (> 36), B (28-36) and C (< 28). RESULTS: There were 100 patients of which 58 were female. Thirty-seven per cent were from the 60-75 year age group. Fiftyfour endoscopies were performed by trainee specialists. Junior and senior consultants performed 36 and 9 upper endoscopies respectively. Indications for upper endoscopy were stated in 51 reports. The use of pre-procedural sedation was not stated in 51 reports. Four reports were illegible; one was conducted by a junior consultant, two by a fourth year trainee specialist and one by an unknown endoscopist whose name was illegible. Common classification systems for oesophagitis, gastropathy features, ulcer characteristics, and ulcer location are not routinely used. Based on the Gastrointestinal Reporting Score there were no Grade A reports, 16 Grade B and 84 Grade C reports. CONCLUSION: The MST is not routinely utilised in our setting and reports are incomplete. There is a need for optimal upper endoscopic reporting, incorporating the MST guidelines.

Serum alcohol levels correlate with injury severity and resource utilization.

BACKGROUND: Alcohol consumption leads to violence and poor judgement. The resultant trauma is the leading cause of emergency department visits. In South Africa, alcohol-related emergency visits can be as high as 57%. The purpose of this prospective study was to establish the prevalence of positive blood alcohol and Blood Alcohol Concentration (BAC) at a tertiary trauma unit in Durban, and to correlate it with injury severity, length of hospital stay and resource utilization. METHOD: A total of 100 patients from King Edward trauma unit were analysed prospectively during the period December 2014 to February 2015. The BAC was correlated with Injury Severity Score (ISS), mechanism of injury, length of stay, and in-hospital mortality. Pearson chi-square test, Wilcoxon rank sum and student t-test were used for statistical analysis. RESULTS: Eighty-eight patients were male. The mean age was 30 ± 9.3 years. Forty-seven patients tested positive for blood alcohol, of whom 81% were above the legal limit for professional drivers. The mean BAC among the alcohol positive patients was 0.146 g/dL. Positive blood alcohol was associated with significantly higher ISS scores (p = 0.0004). Injuries due to interpersonal violence were seen in 83 patients of whom 42 (51%) had positive blood alcohol. Hospital stay for alcohol positive patients was significantly longer compared to alcohol negative patients (p < 0.001). CONCLUSION: The prevalence of blood alcohol in the trauma population is high. Positive blood alcohol is associated with high ISS and longer hospital stays.

Oesophageal squamous cell cancer in a South African tertiary hospital: a risk factor and presentation analysis.

BACKGROUND: Squamous carcinoma of the oesophagus (SCO) is the most common form of oesophageal cancer in South Africa (SA). Risk factors include male gender, smoking, alcohol consumption and low socio-economic status (SES). This study assessed the risk factors for SCO in KwaZulu-Natal. METHOD: Information on patients managed at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South Africa, between 1 October 2013 and 31 December 2014 was retrieved from a prospective database of Oesophageal Cancer (OC). Data collected included demographics, risk factors, symptoms and clinical findings. RESULTS: One hundred and fifty-nine patients (159) with SCO were identified. The site of tumour location was in the middle 96 (60.4%), distal 42(26.4%) and proximal 17(10.6%) oesophagus. The male to female ratio was 1:1 with an age range of 22-93 years (mean 60.6; SD±12.1). Females were significantly older than males (p = 0.018). Eighty-eight per cent were Black African. Dysphagia was reported in 158 (99.4%) of patients and loss of weight in 149(95.5%). Thirty-six patients were HIV positive (age 52.8; SD±9.7) and significantly younger than those without HIV infection (age 61.2; SD±11.5). Most patients had low SES and poor dental health. Male patients were significantly more likely to use tobacco (p < 0.001; Odds Ratio (OR) 7.8) and consume alcohol (p < 0.001; OR 7.7) than females who were 2.5 times more likely to report a family history of cancer (p = 0.017; OR 2.6). CONCLUSION: An equal gender distribution was observed. Male patients with SCO reported the expected risk factors; however these were not observed amongst women. SES may contribute to the development of SCO. Poor dental health may be a surrogate marker for low SES and a possible risk factor for SCO. HIV positive individuals present a decade younger when compared with HIV negative patients.

Transvaginal small bowel evisceration.

We report on the rare entity of transvaginal small bowel herniation following a transvaginal hysterectomy. The risk factors, presentation, initial management and various surgical approaches are discussed. It is a condition that requires prompt surgical intervention. This report serves to highlight awareness of the condition, and how knowledge of the various methods of addressing an ischaemic bowel and a ruptured vaginal vault can result in a favourable outcome.

The morphology of the foetal sigmoid colon in the African population: a possible predisposition to sigmoid volvulus.

AIM: This study aimed to determine the morphological types of the foetal sigmoid colon and establish if the anatomical predisposition to sigmoid volvulus is present in Black African foetuses. Sigmoid volvulus affects Black Africans in our province more frequently than other ethnic groups, and males more than females. Its aetiology remains speculative, with factors being proposed that do not suggest the pathogenetic mechanisms or the gender bias. Previous anatomical studies have suggested that Black Africans have a predisposition to sigmoid volvulus due to an elongated sigmoid colon. We investigated whether this phenomenon occurred during foetal development. METHOD: Foetuses were donated from local hospitals. Population groups were defined as Black African and non-African. After dissection, the anatomy of the sigmoid colon was described according to level of origin, classic or elongated type and shape (broad or narrow). RESULTS: A total of 296 Black African foetuses and 37 non-African foetuses were donated. The sigmoid colon in the majority of foetuses in all gestational age groups had a low level of origin. An elongated colon was seen in 68% of Black African and 17% of non-African foetuses (P < 0.0001). Among Black Africans there was a higher proportion of elongated sigmoid colon among male (73%) than female foetuses (62%) (P = 0.044). In foetuses with an elongated sigmoid colon the broad shape was more common in females than males and the long-narrow shape was more common in males (P = 0.038). CONCLUSION: The elongated sigmoid colon seen in Black Africans is present in utero and occurs more frequently in Black African males. A narrow shape is more common in male foetuses and the broad shape is more common in female foetuses. These anatomical features may be the cause of the predisposition to sigmoid volvulus in Black African adults.

Predicting gallstone pancreatitis in HIV infected patients.

BACKGROUND: Human immunodeficiency virus (HIV) infection, low cluster of differentiation (CD)4 counts and antiretroviral therapy can cause cholestasis and raised transaminases. In acute pancreatitis, this may render biochemical predictors of a gallstone aetiology inaccurate. METHODS: In a prospective observational study, acute pancreatitis was diagnosed by standard criteria. Cholecystolithiasis and bile duct diameter were diagnosed by ultrasound. Cholestasis was defined as two of the following: bilirubin ≥ 21 umol/l, γ glutamyl transferase ≥ 78 U/l, alkaline phosphatase ≥ 121 U/l. Cholangitis was defined as cholestasis and any two sepsis criteria: (temperature > 38˚C, WCC > 12.6 ×109/L, pulse > 90 beats/min). Cholangitis, cholestasis, and bile duct diameter greater that 1 cm were indications for endoscopic retrograde cholangiopancreatography (ERCP). These parameters' ability to predict gallstone pancreatitis (GSP) and choledocholithiasis were compared in HIV+ve and HIV-ve patients. RESULTS: Sixty-two (26%) of 216 patients had GSP. Twenty four were HIV+ve patients. More HIV+ve patients had cholestasis (p = 0.059) and ERCP (p = 0.004). In HIV+ve patients alanine aminotransferase (ALT) > 100 U/L, gamma glutamyl transferase (GGT) > 2 upper limit of normal and cholestasis had a negative predictive value of 92%, 96.7% and 95.2% respectively. In HIV-ve patients, negative predictive value (NPV) was 84%, 83.8% and 84.6% respectively. Bile duct stones were demonstrated at ERCP in 6 (25%) and 3 (8%) of HIV+ve and HIV-ve patients respectively (p = 0.077). Five of 14 ERCP patients had no bile duct stones. HIV+ve and HIV-ve groups had two deaths each. CONCLUSION: Absence at presentation of the abnormal parameters analysed were good predictors of a non-gallstone aetiology particularly in HIV+ve patients. Prior, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) would reduce the number of non-therapeutic ERCPs.

The clinicopathological spectrum and treatment outcomes in metastatic colorectal cancer in the KwaZulu-Natal province of South Africa.

BACKGROUND: In high-income countries (HICs) 17-20% of colorectal cancer (CRC) patients have metastatic CRC (mCRC) at the time of diagnosis, of which 10-25% are or become resectable, and a further 4-11% of patients will develop metachronous metastases. The study aimed to establish the prevalence and pattern of metastatic CRC to document treatment outcomes in KwaZulu-Natal (KZN), and to compare results to international norms. METHODS: The study population comprised patients with mCRC presenting between 2000 and 2019. Demographics, primary tumour site, spectrum of metastatic disease and resection rate were assessed. RESULTS: MCRC occurred in 33% of the CRC patient population. Eight hundred and thirty-six patients had metastatic disease, comprising Africans (325, 38.8%), Indians (312, 37.3%), Coloureds (37, 4.4%) and Whites (161, 19.2%). Six hundred and fifty-four patients (79%) had synchronous metastases and 182 patients had metachronous metastases (21%). Single organ metastases occurred in 596 patients (71.2%) (M1A) and multiple organ metastasis occurred in 240 patients (28.7%) (M1B). Metastases occurred in the liver (613), lung (240) and peritoneum (85). Fifty-two patients (6.2%) underwent resection of their metastases. CONCLUSION: The prevalence of stage IV CRC in our setting is at the upper limit of international norms. mCRC occurred in 33%, with similar proportions in all races. Resection rate for metastases is low.

A South African central hospital's experience with malignant colorectal obstruction.

BACKGROUND: The spectrum and outcome of colorectal cancer (CRC) presenting with obstruction is not well studied in low- to middle-income countries (LMIC) and could have implications for health policy. This study aimed to address this deficit in an LMIC setting. METHODS: A retrospective analysis was conducted of patients with large bowel obstruction, during the period 2000-2019 from the prospective Inkosi Albert Luthuli Central Hospital (IALCH) CRC registry data. Data analysed included the site of CRC, tumour differentiation, management of patients with obstructive CRC, resection margins post resection, oncological management and reasons for failure to receive oncological therapy. Patient follow-up and recurrence were recorded. RESULTS: Malignant obstruction from CRC occurred in 510 patients (20% of the CRC registry). Median age at presentation was 57 years (IQR 48-67). One hundred and seventy-six (34.5%) and 135 (26.5%) had stage III and IV disease respectively. Moderately differentiated cancer was seen in 335 (65.6%). Management was resection (370; 72.5%), diverting colostomy (123; 24.1%) and stent insertion (55; 10.8%). Twenty-one patients (5.7%) had positive resection margins. Recurrence occurred in 34 patients (6.7%), all of whom had initially undergone resection, giving a recurrence rate of 9.8% in those receiving surgery. Median disease-free interval for patients developing recurrence was 21 months (IQR 12-32). CONCLUSION: One in five patients with CRC presented with obstruction. These patients were younger than in high incomecountry (HIC) series. Over 70% underwent resection. Stomas were used twice as frequently as stents to relieve the obstruction, a finding that is the reverse of that in HICs.

How far has the pendulum swung in the surgical management of sigmoid volvulus? Experience from the KwaZulu-Natal Teaching Hospitals and review of the literature.

AIM: Sigmoid volvulus is common in sub-Saharan Africa. The aim of the study was to document the clinicopathological patterns of sigmoid volvulus in KwaZulu-Natal. METHOD: Analysis was performed of prospectively collected data of patients presenting with sigmoid volvulus at the KwaZulu-Natal Teaching Hospitals from 2000 to 2009. Data collected included demographics, clinical presentation, operative findings, management and outcome. RESULTS: There were 135 patients (122 male) of mean age 39.3 ± 17 years. Management was by emergency surgery (103), elective surgery (23), no surgery (9). The level of the twist was at the pelvic brim. Fifty-four patients had gangrenous bowel and 81 had viable bowel. Resection was accompanied by primary anastomosis (80) and Hartmann's procedure (46). Complication and mortality rates were 47% and 17% respectively. Mortality rates for emergency and elective surgery were 19% and 9% (P = 0.330), and those for primary anastomosis and Hartmann's procedure were 14% and 24% respectively (P = 0.305). Mortality rates for gangrenous and viable bowel were 21% and 15% respectively (P = 0.624). Twenty-eight (22%) patients required intensive care in the intensive care unit (ICU) with an ICU stay of 8.8 ± 8 days. Hospital stay was 10.5 ± 14.4 days. CONCLUSION: The clinicopathological picture of sigmoid volvulus resembles that in the rest of Africa in that it affects predominantly young African males. The level of the twist is at the pelvic brim. The timing of surgery, the type of anastomosis and the viability of the bowel does not influence outcome.

A South Africa tertiary centre experience with redo mitral valve replacement.

BACKGROUND: Severe cardiac failure from mechanical mitral valve thrombosis due to poor warfarin control is a major cause of emergency redo mitral valve replacement (MVR) in South Africa. This study aimed to review the outcomes of redo MVR in patients presenting with mitral valve failure to a tertiary South African centre. METHODS: Retrospective chart review of patients undergoing redo MVR over a 10-year period (2005-2014). Patient demographics, aetiology of valve dysfunction, preoperative clinical assessment and outcomes were analysed. RESULTS: Sixty-four patients had 80 mitral valve procedures. The M:F ratio was 1:2.8 and the median age was 18 (IQR 14-28.5) and 25 (IQR 18-40) at initial surgery and at redo surgery, respectively. Median interval between original and redo MVRs was 47.5 (IQR 7.5-124) months. Rheumatic valve disease was the original pathology in 58 patients (90.6%). Fifty-two patients underwent a single redo MVR and 12 patients had multiple redo MVRs. Fifty-eight (72.5%) were emergency redo procedures. Prosthetic valve thrombosis was present in 73.8%. Ten patients (15.6%) developed postoperative complications. The median hospital stay and ICU stay were 19 (IQR 12-27.5) days and 4 (IQR 3-7) days, respectively. Two patients died in the postoperative period (3.1%). The mean patient follow-up was 42 months. Three patients died during follow-up. CONCLUSION: The majority of redo MVR procedures were undertaken as an emergency with valve thrombosis being the most common aetiology. The mortality rate was 3.1% and postoperative complication rate was 15.6%.

Quantifying the relationship of HIV infection with clinicopathological spectrum and outcome among patients with colorectal cancer in a South African population.

Introduction: Literature is limited on HIV and colorectal cancer (CRC) in sub-Saharan Africa despite it being the epicentre of the HIV epidemic. Purpose: To compare clinicopathological features and outcome of CRC in HIV-negative and HIV-positive patients. Methods: Retrospective analysis of a prospective CRC database. Demographic details, HIV status, anatomical site, disease stage, treatment and follow-up were documented. Results: Of 715 patients with CRC, 145 and 570 tested positive and negative respectively for HIV. Median age was 45 (IQR 36-53 and 57 (IQR 45-66) years among HIV-positive and HIV-negative patients respectively (p<0.0001). Tumour differentiation differed between the two groups (p=0.003) but staging was not different (p=0.6). Surgical resection rate was 52% for HIV-positive patients versus 59% for HIV-negative patients (p=0.07). Median follow-up was 9 (IQR 2-20.5) months for HIV-positive patients and 12 (IQR 6-29) months for HIV-negative patients (p=0.154). Recurrence rate was 14.7% among HIV positive patients and 6.8% in HIV negative patients (p=0.089). Conclusion: When compared with HIV-negative patients, HIV-positive patients with CRC presented at a younger age and tended to have lower surgical resection rates. There was no difference between the two groups with CRC in terms of anatomical sub-site distribution, disease staging and recurrence rates.

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

BACKGROUND: Persistent anorectal fistulae are referred for assessment in the Durban Metropolitan area to the colorectal unit at the tertiary hospital. This audit aimed to report the assessment and management of these fistulae to benchmark the outcomes from these approaches at a South African tertiary colorectal unit. METHODS: Retrospective analysis of prospectively collected data of patients with anorectal fistulae over a 13-year period at a tertiary referral centre. Data analysed included demographics, clinical presentation, comorbidity, management and outcome. Study outcomes measures were healing time and secondary outcome measures were complications of surgery. RESULTS: One hundred and thirty-three patients (median age 44 and M:F ratio 2.8:1) with 206 fistulae were accrued. The initial assessment and diagnostic procedures included insertion of seton (126), fistulectomy (14), and fistulotomy (65). Definitive procedures included two-stage seton fistulotomy (43), ligation of the inter-sphincteric fistula tract (LIFT) procedure (39), modified Hanley procedure (17), and mucosal advancement flap (5). One patient had no surgery and nine did not undergo a definitive procedure. Additional procedures included anal sphincter reconstruction (2) and repair of rectovaginal fistula (2). Residual anal incontinence occurred in 13.5%. The failure rate was 6% and healing occurred in 94%. The median healing time was 8 months after the initial surgery and 4 months following the definitive procedure. CONCLUSION: The fistula healing rate overall was 94% and was associated with an incontinence rate of 13.5%.

Sigmoid colon morphology in the population groups of Durban, South Africa, with special reference to sigmoid volvulus.

Sigmoid volvulus demonstrates geographical, racial, and gender variation. This autopsy study was undertaken to establish morphological differences of the sigmoid colon and its mesocolon in which the length and other characteristics were assessed. A total of 590 cadavers were examined (403 African, 91 Indian, and 96 White). Length and height of the sigmoid colon and mesocolon were significantly longer in Africans, and mesocolon root was significantly narrower in Africans. Mesocolic ratio for Africans, Indians, and Whites was 1.1 ± 0.8, 1.8 ± 0.7, and 1.9 ± 1.0, respectively. Africans had a significantly high incidence of redundant sigmoid colon with the long-narrow type and suprapelvic position predominating (P = 0.003); the opposite applied to the classic type. There was no difference in sigmoid colon length, mesocolon height, and width between males and females in all population groups. Among Africans, the long-narrow type was more common in males, and the classic and long-broad types were more common in females. Splaying of teniae coli and thickening of the mesentery were more common in Africans. Tethering of the sigmoid colon to the posterior abdominal wall was less common in Africans compared with other population groups. In conclusion, the sigmoid colon was longer, and the sigmoid mesocolon root was narrower in Africans compared with the other population groups, and the sigmoid colon had a suprapelvic disposition among Africans. In Africans, the sigmoid colon was longer in males with a long-narrow shape. These differences may explain geographical and racial differences in sigmoid volvulus.

Intestinal inflammatory myofibroblastic tumour.

BACKGROUND: Inflammatory myofibroblastic tumours (IMFTs) are rare tumours characterised by nosologic, histogenetic and aetiopathogenetic controversy and variable clinicopathological features. We report our experience with intestinal-IMFTs (I-IMFTs) that have been reported mainly as single case reports to date. METHODS: Five patients with I-IMFTs, identified between 2005 and 2008, formed the study cohort. The clinicopathological features were obtained from departmental and hospital records. RESULTS: The median patient age was 13 years. While 4 patients presented with symptoms and signs of intestinal obstruction, one IMFT was an incidental finding at laparotomy for trauma. Three I-IMFTs were located in the small bowel and 2 in the colon. Complete resection with end-to-end anastomoses was performed. The gross morphology included 1 polypoid myxoid tumour that served as a lead point for an intussusception, 3 multinodular whorled masses and 1 firm circumferential, infiltrative tumour. Microscopically, all tumours had typical features of IMFT with variable expression of ALK-1, a low proliferation index and tumour-free resection margins. All patients had an uneventful recovery. One patient was lost to further follow-up. Four patients were well, without local recurrence or metastases at 6 months to 3 years. CONCLUSIONS: Surgery with tumour-free resection margins is the gold standard of care of adult and paediatric I-IMFTs. Heightened recognition of I-IMFT, albeit rare, as a cause of intestinal obstruction, including intussusception, is necessary for pre-operative suspicion of I-IMFT.

Clinicopathological spectrum of small bowel obstruction and management outcomes in adults - experience at a regional academic hospital complex.

BACKGROUND: Delay in operative management of small bowel obstruction (SBO) results in increased morbidity and mortality. The objective was to evaluate clinical presentation and treatment outcome of SBO. METHOD: Prospective cohort study between 2013-2014. Adult patients presenting with SBO were included. Demographics, clinical details, investigations, operative findings, in-hospital progress and outcomes were documented. RESULTS: There were 156 patients (median age 37 [IQR 27-54 years]) with early (44) and delayed (112) presentation. M:F ratio was 1.4:1. Common causes of obstruction were adhesions (94; 60.3%) and hernias (31; 19.9%). Non-operative management was feasible in 59 patients (37.3%) with a success rate of 71.2%. Nonviable bowel was present in 45.1% (early 31%, delayed 50%; p = 0.078). Sixty-one patients (54%) underwent bowel resection; nine patients (20.5%) in the early presentation group and 52 (46.4%) in the delayed group (p = 0.003). Thirty-one patients needed ICU admission (early 5, delayed 26; p = 0.091). The delayed group had longer ICU stay (p = 0.018) and longer hospital stay (p < 0.001). There were more complications (p = 0.084) and re-laparotomies (p = 0.156) in the delayed group. Eight patients died (5.1%). CONCLUSION: The main causes of SBO were adhesions and hernias. Late presentation was associated with higher resection rate, higher critical care admission and longer hospital stay.