The paediatric liver transplant experience in Johannesburg, South Africa: A broad overview and update.

BACKGROUND: The Wits Transplant Unit performed its first paediatric liver transplant in 2005. Initial experiences from the unit were published in 2012 and 2014. Since then, significant progress has been made in capacity-building the unit, improving outcomes and enhancing service delivery. This paper presents a broad overview and update of the unit's 17-year experience.   Methods: We conducted a retrospective review of all paediatric liver transplants performed in Johannesburg from 1 January 2005 to 31 December 2021 with a minimum one-year follow-up. Data were accessed from the Wits Donald Gordon Medical Centre Paediatric Liver Transplant Research Database (University of the Witwatersrand Human Research Ethics approval: M190749). The following data were collected: donor and recipient sociodemographic and clinical characteristics, details of transplant procedures, donor grafts and recipient outcomes (post-operative complications, graft and recipient survival).   Results: A total of 270 transplants were performed during the review period. Two thirds of recipients (n=180, 67%) were younger than 5 years at time of transplant and half (n=135, 50%) received a living donor graft. The most common indication for liver transplant was biliary atresia, followed by acute liver failure. Unadjusted recipient survival was 80% (95% CI: 75-85%) at one year, and 68% (95% CI: 59-75%) at five years. Waiting list mortality decreased from 27.3% in 2017 to 5.9% in 2021. One hundred and fifty-four (57.0%) recipients experienced at least one type of intervention requiring surgical complication - the most common being biliary in nature (n = 91; 33.7%).   Conclusion: Over last seventeen years, a sustainable paediatric liver transplantation service has been established in Johannesburg. Living donor, split and ABO incompatible liver transplants have been incorporated in response to the severe organ shortage in South Africa. However, our outcomes can be improved. Additionally, a national transplant initiative to coordinate timeous referrals and expand access to liver transplantation for children with severe acute and chronic liver failure is advised.

Patient perceptions of surgical training in the private sector in South Africa - a single centre survey.

BACKGROUND: As the worldwide demand for specialist surgeons increases, and to complement surgical training provided through governmental institutions, private hospitals are increasingly hosting trainees. Wits Donald Gordon Medical Centre (WDGMC) is a private academic hospital in Johannesburg with a Colorectal Unit (CRU) that hosts several trainees. While published studies demonstrate that the involvement of trainees in surgery does not adversely impact outcomes, private patients' perceptions of the role of trainees in their care have not been as widely researched. METHODS: This was a prospective, cross-sectional study using a self-administered questionnaire hosted on a REDCap database. Statistical analysis was performed using SPSS version 26. RESULTS: One hundred and seventy-four patients participated in the study, and 74.1% of respondents felt that training of doctors should occur in private hospitals in South Africa. Of the sample, 83.3% would allow a supervised trainee to perform a part of their operation, provided they had been made aware of trainee participation in advance (78%). Sixty per cent of patients felt that interaction with a trainee enhanced their care, and 52.3% of patients suggested that seeing more than one doctor a day improved their experience. CONCLUSION: Our results suggest that privately funded patients support the surgical training of medical doctors in private academic training hospitals, and they are willing to be participants in the training process. Moreover, training programmes in this setting appear to enhance the patient experience. We are optimistic that these findings could be used to advocate for expanded training opportunities across the private sector in South Africa.

The need for cardiac surgery differential tariffs in Israel at the era of aging population and emerging technology: Importance of procedure type and patient complexity as assessed by EuroSCORE.

BACKGROUND: Reimbursement for cardiac surgical procedures in Israel is uniform and does not account for diversity in costs of various procedures or for diversity in patient mix. In an era of new and costly technology coupled with higher risk patients needing more complex surgery, these tariffs may not adequately reflect the true financial burden on the caregivers. In the present study we attempt to determine whether case mix and complexity of procedures significantly affect cost to justify differential tariffs. METHODS: We included all patients undergoing cardiac surgery at Shaare Zedek Medical Center between the years 1993-2016. Patients were stratified according to (1) type of surgery and (2) clinical profile as reflected by the predicted operative risk according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Approximate cost of each group of patients was estimated by the average number of days in the Intensive Care Unit and days in the postoperative ward multiplied by the respective daily costs as determined by the Ministry of Health. We then added the fixed cost of the components used in the operating room (manpower and disposables). The final estimated cost (the outcome variable) was then evaluated as it relates to type of surgery and clinical profile. ANOVA was used to analyze cost variability between groups, and backward regression analysis to determine the respective effect of the abovementioned variables on cost. Because of non-normal distribution, both costs and lengths of stay were Log-transformed. RESULTS: Altogether there were 5496 patients: 3863, 836, 685 and 112 in the isolated CABG, CABG + valve, 1 valve and 2 valves replacement groups. By ANOVA, the costs in all EuroSCORE subgroups were significantly different from each other, increasing with increased EuroSCORE subgroup. Cost was also significantly different among procedure groups, increasing from simple CABG to single valve surgery to CABG + valve surgery to 2-valve surgery. In backward stepwise multiple regression analysis, both type of procedure and EuroSCORE group significantly impacted cost. ICU stay and Ward stay were significantly but weakly related while EuroSCORE subgroup was highly predictive of both ICU stay and ward stay. CONCLUSIONS: The cost of performing heart surgery today is directly influenced by both patient profile as well as type of surgery, both of which can be quantified. Modern day technology is costly yet has become mandatory. Thus reimbursement for heart surgery should be based on differential criteria, namely clinical risk profile as well as type of surgery. Our results suggest an urgent need for design and implementation of a differential tariff model in the Israeli reimbursement system. We suggest that a model using a fixed, average price according to the type of procedure costs, in addition to a variable hospitalization cost (ICU + ward) determined by the patient EuroSCORE or EuroSCORE subgroup should enable an equitable reimbursement to hospitals, based on their case mix.

[Minimally invasive lumbopelvic stabilization of sacral fracture and sacroiliac injury]. / Minimal-invasive lumbopelvine Stabilisierung bei Sakrumfraktur und Sprengung des Iliosakralgelenks.

OBJECTIVE: Rapid mobilization with full weight bearing by minimally invasive fixation of Os ilium to L5 in fractures of the sacrum and disruption of the sacroiliac joint (SIJ). INDICATIONS: Unstable injuries of the posterior pelvic ring in fractures of the sacrum and disruption of the SIJ. CONTRAINDICATIONS: Fracture of ilium and not injury related implants in the screw trajectory, neurological deficits regarding the fracture, decubitus in the area of surgical approach. SURGICAL TECHNIQUE: Minimally invasive screw placement in the pedicles of L5, access of ilium screw via the posterior superior iliac spine. Radiological display for the iliacal screw bearing trajectory in Os Ilium as a drop-shaped/triangle canal. Insert a Jamshidi needle orthograde in the beam path, change to guide wire and placement of iliacal screw after resection of the bone in the screw head area. Submuscular insertion of the longitudinal rods, in case of double-sided instrumentation similar procedure on the opposite side, reduction of the fracture and fixation of the rods to screws. POSTOPERATIVE MANAGEMENT: Postoperative mobilization with full weight bearing under physiotherapeutic guidance. RESULTS: Patients treated with lumbopelvic stabilization in our facility between 2012 and 2017 were identified via the hospital database and retrospectively evaluated. In 24 patients with median age of 60.1 years and a follow-up-time of 11.8 months, we found no implant displacement, infection and no wound healing problems. Full weight bearing was permitted in 21 of 24 cases, in 3 cases partial load bearing due to other injuries. Three patients reported moderate mechanical irritation of iliacal screws; 1 patient reported severe irritability with removal of the implants after bony healing of fracture 1 year postoperatively.

[Treatment-process analysis of orthopaedic trauma surgery patients at an outpatient setting in a university hospital]. / Prozessanalyse der ambulanten Behandlung unfallchirurgischer Patienten an einer universitären Poliklinik.

BACKGROUND: The cost pressure in a competitive environment forces hospitals and physicians to optimize clinical processes. In order to secure competitive advantages, a continuous evaluation of relevant processes is necessary. OBJECTIVE: Administrative and medical processes in a university outpatient department for orthopedics and traumatology were evaluated using the lean method in order to reduce patient waiting times. MATERIAL AND METHODS: Over a period of 2 weeks all patients who were treated in the department for orthopedic and trauma surgery on an outpatient basis were included in the assessment of the process. Personnel in the policlinic were prepared and trained to record times for appointments made by telephone, arrival time at the hospital, first contact, administrative procedure, first contact with the doctor, length of stay in the radiology and anesthesiology departments and completion of treatment. In addition, potential inefficiencies were identified through patient flow analysis and personal interviews with personnel in the administration and outpatient departments as well as residents and senior physicians. RESULTS: A total of 126 patients were enrolled in the study. The average length of stay of patients in the outpatient clinic was 144 min (range 30-371 min). A necessary imaging examination increased the length of stay by an average of 53 min and a necessary premedication by an average of 78 min compared to patients with no further consultations. CONCLUSION: By analyzing the pathways and times of patients, various reasons for waiting times in the university outpatient clinic could be shown. This study shows that a structured application of lean management and a dedicated analysis create added value for patients by reducing waiting times.

[Process optimization in the operating room area]. / Prozessoptimierung im operativen Bereich.

BACKGROUND: The operating room (OR) accounts for the highest fraction of hospital costs and also has the largest proportion of revenue. Classical goals of optimizing OR efficiency are to increase the quality of treatment and economic success. As the reduction of qualified personnel as the largest cost factor was favored for many years, nowadays a shortage of nursing personnel is threatening the surgery departments in many German hospitals. OBJECTIVE: Which improvements are possible while the OR already suffers from restrictions? What are critical resources, what are the critical burdens and how can they be optimized? MATERIAL AND METHODS: An analysis of the OR organization of an orthopedic and traumatology department with reduced OR capacity due to a shortage of OR and anesthesia nursing personnel was performed. This was followed by the evaluation of possible alterations with the corresponding advantages and disadvantages. After selection and implementation, the qualitative and quantitative differences were examined before and after the alterations. RESULTS: Multifaceted problem areas could be identified. The establishment of a fast track OR with concentration of additional resources on many fast points in an OR instead of on a few complex cases was selected and implemented. The installation of a holding area for patients waiting for surgery eliminated transportation delays almost entirely. Alterations in the OR planning and capacity distribution reduced nocturnal operating times. Despite reduction of the OR capacity both the number of operations performed and the incision to suture times could be increased. CONCLUSION: Optimization of the processes in the OR is possible and necessary, despite the lack of personnel. Even only a few structural changes can eliminate bottlenecks, resulting in qualitative and quantitative improvements.

Reimagining liver transplantation in South Africa: A model for justice, equity and capacity building - the Wits Donald Gordon Medical Centre experience.

The challenge of providing effective and integrated liver transplant services across South Africa's two socioeconomically disparate healthcare sectors has been faced by Wits Donald Gordon Medical Centre (WDGMC) since 2004. WDGMC is a private academic hospital in Johannesburg and serves to supplement the specialist and subspecialist medical training provided by the University of the Witwatersrand. Over the past 14 years, our liver transplant programme has evolved from a sometimes fractured service into the largest-volume liver centre in sub-Saharan Africa. The growth of our programme has been the result of a number of innovative strategies tailored to the unique nature of transplant service provision. These include an employment model for doctors, a robust training and research programme, and a collaboration with the Gauteng Department of Health (GDoH) that allows us to provide liver transplantation to state sector patients and promotes equality. We have also encountered numerous challenges, and these continue, especially in our endeavour to make access to liver transplantation equitable but also an economically viable option for our hospital. In this article, we detail the liver transplant model at WDGMC, fully outlining the successes, challenges and innovations that have arisen through considering the provision of transplant services from a different perspective. We focus particularly on the collaboration with the GDoH, which is unique and may serve as a valuable source of information for others wishing to establish similar partnerships, especially as National Health Insurance comes into effect.

Penetrating atherosclerotic ulcer aneurysm of the innominate artery.

Penetrating atherosclerotic ulcer of the aorta is uncommon, and usually develops in the descending thoracic aorta. Rarely this condition involves the branch vessels of the aorta. We report a case of ruptured aneurysm of the innominate artery resulting from penetrating atherosclerotic ulcer. Open surgery was the treatment of choice for the ruptured aneurysm, while conservative treatment was recommended for the associated penetrating atherosclerotic ulcers of the descending aorta.

Right heart haemodynamics after lung resection; the role of the transthoracic echo-doppler cardiography.

We analyzed 80 patients with lung resections due to lung carcinoma operated at the Clinic for Thoracic Surgery. We performed lobectomy or bilobectomy in all cases, the patients were between 50 and 70 years old and the preoperative preparing was the same. The patients were divided in 2 groups; group A -- the patients with anamnesis for myocardial infarction, arrhythmia, pulmonary hypertension or restrictive respiratory disease and group B -- patients without such a history. Echo Doppler cardiography was performed in all cases to measure the main parameters that present the heart-lung hamodynamics. We found some changes even in group B (increased RVEDV, decreased EF, increased pulmonary systolic pressure) which can be a reason for cardiac complications after this type of surgery. The echo-Doppler cardiography is a sensitive and non-invasive method to obtain all valid parameters to present heart-lung haemodynamics.

Atrial tachycardia as the presenting sign of a left atrial appendage aneurysm.

A patient presented with atrial tachycardia. The work-up, guided by the tachycardia morphology, led to the diagnosis of left atrial appendage aneurysm. Surgical removal of the atrial appendage resulted in cure of the tachycardia and associated symptoms.

Hospital-acquired brevundimonas vesicularis septicaemia following open-heart surgery: case report and literature review.

Brevundimonas vesicularis (B. vesicularis) is a pseudomonad rarely encountered in human infection. A case of nosocomial septicaemia with this organism following open-heart surgery is presented, with a review of the literature. The isolate demonstrated resistance to ciprofloxacin and aztreonam, which has not yet been reported. Treatment with piperacillin/tazobactam resulted in full recovery. A review of the literature reveals that B. vesicularis is a virulent organism involved in serious infections such as central nervous system infection or bacteraemia, some of which are nosocomial. Meanwhile, empiric therapy for B. vesicularis infection should include a broad-spectrum antimicrobial agent until susceptibility results are known.

Perioperative complications in combined aortic valve replacement and extraanatomic ascending-descending bypass.

BACKGROUND: In adult patients, the combination of severe aortic valve stenosis and coarctation is rare. Surgical options comprise either a two-stage approach with valve replacement and subsequent repair of the coarctation or a one-stage repair involving valve replacement and insertion of an extraanatomic bypass graft from the ascending to the descending aorta. METHODS: We report the cases of 2 adult patients with this combined lesion who underwent simultaneous aortic valve replacement and transpericardial bypass of the coarctation. RESULTS: Weaning from extracorporeal circulation and restoration of spontaneous circulation required resuscitative measures. By increasing mean arterial perfusion pressure using norepinephrine, the observed hemodynamic instability could be controlled effectively. CONCLUSIONS: Changes in the hemodynamics of the thoracic vascular bed resulting in coronary malperfusion are discussed to be the major cause of heart failure and life-threatening ventricular arrhythmias seen in our patients after aortic valve replacement and insertion of an ascending-descending aorta bypass graft. Awareness of the complications described is considered important for successful management of these high-risk patients.

Late outcome of valve replacement with the Cross-Jones caged-lens prosthesis.

A 58 year old woman underwent re-replacement of a Cross-Jones caged-lens mitral prosthesis 23 years after the first operation. She represented one of the 38 patients who received 42 Cross-Jones prostheses two decades earlier. Continued adequate performance for more than two decades in five patients bears a surprising testimony to the longevity of this historic low profile prosthesis.