Suture material use and procurement: an audit of a public hospital surgical system in Gauteng, South Africa.

BACKGROUND: Surgical systems are integral to successful, safe and cost effective clinical practice and must balance surgical demands on consumable items and their costs. Suture material is a key consumable resource, and was evaluated in an audit of consumable use and cost as well as the procurement systems within the South African Gauteng public health care sector. AIMS: To determine suture use and cost in the four commonest general surgical procedures - abdominal wall closure, mastectomy, appendicectomy and inguinal hernia repair - in three academic Gauteng hospitals. Performance and availability were evaluated as a secondary aim in suture material use. METHOD: A prospective observational study. Suture use was documented by the surgeon at the time of the procedure and qualitative investigation at relevant hospital departments determined suture material procurement and expenditure. RESULTS: The surgeons in three facilities documented consistent material type and average number of units used; however, in some cases there was a lack of availability of appropriate material and breakage of generic material intraoperatively. There is no consistent and consolidated electronic record-keeping of suture stock and cost in all three hospitals, therefore cost of suture material used was not obtainable. CONCLUSION: Clinical deficiencies in availability and quality of material may have adverse implications for patient health, healthcare costs and budgets through procedure-related complications and should be investigated. There is a lack of communication between the financial management, procurement officers, hospital and theatre stores and theatre staff. It is suggested that clinical protocols and system-based strategies be put in place to manage surgical consumables.

Lessons learned from the endovascular management of blunt thoracic aortic injuries: A single-centre experience.

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) remain a leading cause of death after blunt trauma. In severe injuries, thoracic endovascular aortic repair (TEVAR) has provided a less invasive alternative to conventional open repair. OBJECTIVE: To report the TEVAR-related complications and uncertainties in patients who presented with traumatic pseudoaneurysms (grade III BTAI). METHODS: From April 2004 to February 2012, 55 patients (42 male, mean age 34.7 years) with severe BTAI were treated with stent grafts. Computed tomography (CT) was used to diagnose the injuries, and follow-up scans were planned at 6 and 12 months. We report the complications and the technical uncertainties related to the procedure. RESULTS: Successful sealing of the injury sites was achieved in all patients, either with a thoracic stent graft (53/55) or infrarenal aortic aneurysm extender cuffs (2/55). During hospitalisation, 13 patients died after TEVAR (mean 14 days). Procedure-related complications included left common carotid artery coverage (1/55), ischaemic left leg (1/55) and graft collapse (1/55). The procedurerelated uncertainties included excessive graft oversizing (15/55), poor graft apposition to the inner curve of the aorta (19/55) and left subclavian artery coverage (24/55). CONCLUSION: Stent grafts appear safe and effective in treating pseudoaneurysms caused by BTAI. However, they are likely to be associated with long-term complications and monitoring strategies of >30 years may be necessary.

Exposure to key surgical procedures during specialist general surgical training in South Africa.

BACKGROUND: The logged experience of specialist general surgical trainees has made it possible to analyse their surgical procedural exposure. METHOD: Logbooks submitted and meeting the minimum requirements for the six final examinations for the fellowship of the College of Surgeons of the CMSA between August 2010 and March 2013 were selected. Consolidated surgical procedural experience was analysed according to procedural category, extent of supervision, procedure complexity and university at which the trainee performed the procedures. RESULTS: The 95 logbooks entered into the study recorded 144 499 procedures, 60.6% of which were unsupervised, 18.5% supervised and 20.9% assisting another surgeon. Major and minor procedures made up 40.4% and 54.6%, respectively, with the remaining 5% categorised as 'other'. A breakdown of procedural exposure per category, including the main contributing or key procedure for each category, is presented. CONCLUSION: Large numbers of procedures are logged by trainees during their surgical training. Inter-university and trainee key procedural exposure in SA differ to a small degree but are striking in some categories. Exposure to key procedures is insufficient in some categories. We are currently unable to assess the quality of training and quality of surgical skills from such logbooks. A standardised electronic logbook will facilitate future analyses of trainee procedural exposure, but other tools will be required to assess the quality of surgical skills training.

A mismatch between aortic pulse pressure and pulse wave velocity predicts advanced peripheral arterial disease.

OBJECTIVES: To determine whether increases in central aortic pulse pressure (PPc), but decreases in carotid-femoral pulse wave velocity (PWV) predict the presence of advanced peripheral arterial disease (PAD). METHODS: Applanation tonometry and vascular ultrasound were employed to assess carotid-femoral PWV, PPc, and carotid intima media thickness (IMT) in 136 patients of African ancestry with chronic critical lower limb ischaemia (CLI) and in 1,030 randomly selected healthy adults of African ancestry, 194 of whom were age- and sex matched (controls). RESULTS: With adjustments for confounders, compared with age- and sex-matched controls, participants with CLI had an increased carotid IMT (p = .0001) and PPc (p < .0001), but a markedly reduced PWV (m/second) (CLI = 5.7 ± 3.7, controls = 8.6 ± 3.4, p < .0001). PWV was correlated with PPc in controls (r = .52, p < .0001), but not in CLI (r = -.06). A PPc/PWV mismatch index showed increased values in participants with CLI over the full adult age range assessed. With carotid IMT, PPc, or aortic augmentation index in the same regression model, an increase in the PPc/PWV mismatch index was independently associated with CLI (p < .0001) and a PPc/PWV value upper 95% confidence interval in the community sample predicted CLI (odds ratio = 32 [6-169], p < .0001). PPc/PWV predicted CLI with a similar level of performance and accuracy and a greater specificity (98%) than that of IMT (82%). CONCLUSION: In CLI, while PPc increases, carotid-femoral PWV is markedly reduced. A PPc/PWV mismatch may be a new risk marker for advanced PAD.

Vascular surgical education in a medium-income country.

Medium income country such as South Africa face a dilemma on the need to offer high quality vascular surgical care in a resource constrained environment, where the vast majority of population has inadequate access to even the most basic health care provision. At the same time with rapid development in technology there is also the need to provide high technological treatment to a small population that can afford high cost therapy. This apparent dichotomy in health care provides a challenge and the solution is for all role players in the health care provision to find a solution which will suite the population at large.

Proximal suture line support in open abdominal aortic aneurysm repair: a comparative study.

OBJECTIVES: The aim of this study was to determine whether the collar graft (standard dacron graft with a customized flexible collar attached to the proximal rim) decreased anastomotic bleeding and the overall clamp time. DESIGN: Prospective randomised single center study. METHODS: Between November 2003 and January 2006, 21 patients were treated with a collar graft and 19 with a standard dacron graft. Routine endoaneurysmorraphy was used. Only infra-renal aneurysms between 5.5cm and 6.5cm were included. Aneurysms were diagnosed by CT scans. The total number of bleeding points, the total clamp time, and the number of teflon felt pledgets, was determined. RESULTS: The total number of bleeding points; the number of aortic re-clamps and total clamp time (minutes) per patient were all significantly lower in the collar graft group (1.2 versus 2, p<0.04; 0.5 versus 2.0, p<0.001; 13.6 versus 20.1, p<0.003 respectively). The number of teflon felt pledgets and new sutures used was significantly lower in the collar graft group (p<0.001 and p<0.003 respectively). CONCLUSION: The collar graft resulted in fewer anastomotic bleeding points and a shorter clamp time.

General surgery in crisis--the critical shortage.

INTRODUCTION: General surgery is facing a serious crisis. There has been a significant decline in the number of applicants for registrar posts and an inability to attract and retain general surgical specialists in the state sector. The Association of Surgeons of South Africa (ASSA) undertook this study to determine the extent and cause of the problem. METHODS: The study involved a combination of desk research and structured interviews. In addition, the Health Professions Council of South Africa (HPCSA) database was reviewed and compared with the South African Medical Association (SAMA) and ASSA databases. The medical schools provided information about student numbers and demographics, and the National Department of Health pro vided information about the status of medical practitioner and specialist posts in the state sector. RESULTS: Overall, 26.1% of the specialist posts were vacant. The situation was particularly critical in Mpumalanga and the Eastern Cape, where 84% and 58% of the specialist posts were vacant. Using a predictive model, a conservative estimate of the need for general surgeons was found to be at least 50 per year. Currently the eight medical schools graduate about 25 general surgeons per year. The changing demographics of medical students may be partly responsible for the decline in registrar applicants. CONCLUSION: The findings from this study have revealed that the shortage of general surgeons in the state sector has reached critical levels.

General surgery in crisis--comparatively low levels of remuneration.

INTRODUCTION: Several factors, including comparatively low remuneration, may be responsible for the decline in applicants to general surgery. In this study, the levels of remuneration of general surgeons in the state sector were compared with other professionals in the state sector and general surgeons overseas. METHODS: The study involved a combination of desk research and structured interviews. The Paterson system of job evaluation was used to compare general surgeons with other professionals. The levels of remuneration of general surgeons in the state sector were compared with those of other professionals. RESULTS: There was a significant difference in the levels of remuneration between state-employed medical practitioners and other professional positions such as legal professionals, municipal managers and airline pilots. At senior levels (senior specialist) the remuneration was only +/- 55% of that paid to the selected comparator group. There was also a significant differential between the remuneration of state-employed general surgeons and their overseas counterparts. CONCLUSION: Levels of remuneration of state-employed medical practitioners continue to lag behind other professionals.

General surgery in crisis--factors that impact on a career in general surgery.

INTRODUCTION: The Association of Surgeons of South Africa (ASSA), because of a concern about the decline in the number of applicants for registrar posts, undertook this study into the various factors that may influence the choice of surgery as career option. METHODS: The study involved a combination of desk research and structured interviews with heads of departments, specialists, and registrars in general surgery. RESULTS: The reasons for choosing general surgery as a career included the immediately visible results of a surgeon's efforts and the practical and intellectual challenge of the specialty. General surgery continued to enjoy a high status in society. The greater focus on primary health care has affected facilities at tertiary and secondary institutions. General surgeons worked excessively long hours, which was associated with increased levels of stress and placed severe strains on family life. All respondents felt that their levels of remuneration were 'poor' in relation to other disciplines and professions. CONCLUSION: In this study we identified various factors that impacted either positively or negatively on the choice of general surgery as a career option.

Efficacy of vitamin E compared with either simvastatin or atorvastatin in preventing the progression of atherosclerosis in homozygous familial hypercholesterolemia.

Over a 4-year period, antioxidant therapy (vitamin E) was compared with high-dose statin therapy in 15 patients with homozygous familial hypercholesterolemia. Carotid intima-media thickness, used as an in vivo assessment of atherosclerosis, progressed rapidly during the period of vitamin E therapy but regressed on statin therapy.

Popliteal artery entrapment syndrome: more common than previously recognized.

PURPOSE: This report summarizes our experience with the popliteal entrapment syndrome in 88 limbs (48 patients) treated during a 10-year period. METHOD: The study cohort consisted of a retrospective analysis of those patients who were seen with symptoms of claudication or severe ischemia by a single surgical group and in whom unequivocal evidence of popliteal entrapment was shown either with angiography or at the time of operation. The cases were collected prospectively in a private vascular surgical practice. RESULTS: Bilateral popliteal entrapment was found in 40 of the 48 patients. The mean age at the time of presentation was 35.0 years (SD, 11.6 years). Claudication was the most frequent presenting symptom (70 of 88 limbs). Types I, II, III, and IV popliteal entrapment were found in 58 limbs (15 arteries occluded), and 30 limbs (three occlusions) were seen with a "functional" popliteal artery entrapment (apparent absence of a developmental anatomic abnormality). Of the 18 limbs with severe ischemia and associated occlusion of the popliteal artery, 15 underwent bypass grafting with reversed saphenous vein grafts, all of which remained patent during the follow-up period (median follow-up, 4.2 years; range, 1 to 10 years). One popliteal artery occlusion that was treated with thrombectomy and vein patching occluded within 6 months and necessitated subsequent vein grafting. Two limbs with inoperable occluded popliteal arteries were not subjected to reconstruction (one necessitated amputation because of advanced ischemia, and the second had extensive thrombosis of the distal run-off). In two patients (four limbs), moderate presenting symptoms abated without surgery after the discontinuation of an extreme exercise program. The remaining limbs underwent surgical decompression (all popliteal arteries remained patent, with a median follow-up of 3.9 years). CONCLUSION: The popliteal entrapment syndrome is more prevalent than has formerly been appreciated. On the basis of observations made in this series and in the surgical literature, we advise surgical correction in all cases of types I, II, III, and IV entrapment at the time of diagnosis to avoid occlusion as a result of continued arterial wall degeneration. In contrast, decompression is only advised in those patients with "functional entrapment" if they have discrete and typical symptoms because up to 50% of the normal population may display transient popliteal artery compression with extremes of plantar flexion or dorsiflexion. On the basis of the severe histologic changes found in those popliteal arteries that had undergone occlusion at the time of presentation, it is advised that the popliteal artery should be completely replaced, ideally with a vein graft, when significant degeneration or occlusion of the popliteal artery is noted at the time of operation.

Low-density lipoprotein cholesterol bulk is the pivotal determinant of atherosclerosis in familial hypercholesterolemia.

This study's aim was to determine whether biochemical risk factors such as lipoprotein(a), fibrinogen, homocysteine, and insulin, as well as low-density lipoprotein (LDL) particle size, were predictive of carotid intimamedia thickness (IMT), an early marker of atherosclerosis, in subjects with familial hypercholesterolemia (FH). We also determined whether plasma 8-isoprostane, as a marker of in vivo lipid oxidation, correlated with carotid IMT. Twenty-two homozygous and 20 heterozygous subjects with FH were compared with 20 normocholesterolemic controls. On univariate analysis, plasma total and LDL cholesterol, the cholesterol-years score (CYS), lipoprotein(a), and fibrinogen, but not homocysteine or insulin, were positively related, and high-density lipoprotein (HDL) cholesterol was negatively related to carotid IMT. However, on multivariate analysis, only LDL cholesterol and the CYS predicted carotid IMT (multiple r = 0.82; r2 = 0.68; p <0.0001). The subjects with FH had large rather than small dense LDL particles, and plasma 8-isoprostane levels were not increased. LDL cholesterol and the CYS, or "cholesterol bulk" are the pivotal determinants of atherosclerosis and are the strongest predictors of carotid IMT in FH.

Retrograde balloon angioplasty of brachiocephalic or common carotid artery stenoses at the time of carotid endarterectomy.

OBJECTIVES: This study was performed to demonstrate the value and durability of intraoperative retrograde angioplasty for stenotic lesions of the aortic arch branches at the time of carotid endarterectomy for the treatment of tandem proximal and bifurcation carotid lesions. DESIGN: Retrospective analysis of the clinical data. METHODS: Forty-four patients were included in this study when they presented with symptomatic extracranial vascular disease due to stenosis of both a proximal aortic arch branch and carotid bifurcation disease. Tandem disease was detected in the vascular laboratory and confirmed by angiography. Each patient was subjected to conventional carotid endarterectomy, and at the time of operation, the proximal lesion was subjected to transluminal angioplasty through the endarterectomy arteriotomy (brachiocephalic 24; left common carotid 15; right common carotid artery five). Patients were then followed up clinically and by non-invasive tests at 6-monthly intervals. RESULTS: Forty-three successful dilatations were achieved. The single initial technical failure was due to heavy calcification of a brachiocephalic artery. In the follow-up period restenosis was noted in four patients. All restenosis occurred within 24 months. No restenosis at the angioplasty site was noted on subsequent follow-up of the remaining 39 patients. No perioperative stroke or death was encountered. A surprisingly high mortality rate was noted on follow-up in this group of patients, suggesting the presence of more aggressive and advanced diffuse vascular disease. CONCLUSION: Retrograde intraoperative angioplasty of the proximal component of a tandem extracranial lesion has in this series proven to be a safe and durable therapeutic option. This technique has an acceptable restenosis rate in a subset of patients who have been demonstrated to have a shortened life expectancy and a high mortality rate in the follow-up period.

A method for creating reversible ureteric obstruction in the primate.

A technique has been developed for the establishment of a state of reversible, ureteric obstruction in the primate. Ten adult males had baseline 99mTc-DTPA renogram studies. A randomly selected ureter was totally occluded and obstruction confirmed on renogram. The occlusion was reversed and subsequent renograms confirmed recovery of activity in the obstructed kidneys of the eight animals who survived the reversal procedure. Seven were alive on conclusion of the study. Prevention of ureteric strictures was achieved with an intra-ureteric silastic tube. Autopsies demonstrated patency of every previously occluded ureter. This is the first study to be reported in primates, and the second overall, in which complete ureteric obstruction and its successful reversal has been confirmed on renogram using this surgical method. The technique is suitable for the study of the effect of reversible ureteric obstruction on renal function.

The glomerular filtration rate, effective renal plasma flow, and renal blood flow in the adult male chacma baboon (Papio ursinus).

The radionuclide determination of glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) has been validated in man, but not in the primate. GFR, ERPF, and renal blood flow (RBF) were measured in a group of 12 adult male chacma baboons using radiopharmaceuticals. GFR was determined using 99mtechnetium-labelled diethylenetriamine-pentacetic acid. ERPF was measured with 131iodine-labelled hippuran. RBF, body surface area, and kidney weights were calculated using standard formulae. GFR was 49 +/- 11 ml/min and ERPF was 237.9 +/- 54.2 ml/min. Calculated RBF was 430.7 +/- 111.9 ml/min and 507.4 +/- 138.4 ml/min/100 g of renal tissue. The results are in agreement with those obtained using more laborious nonradioisotopic techniques such as para-aminohippurate (PAH) and creatinine clearance and could serve as baseline normal values in the adult male chacma baboon.

An unusual cause of back pain in a patient with an abdominal aortic aneurysm. A case report.

A case of a 50-year-old man with chronic back pain, an abdominal aortic aneurysm and bony erosion of the lumbar spine due to a chondrosarcoma is reported. This report shows that the lumbar erosion seen in association with an aneurysm is unlikely to be a result of pressure erosion of the spine by the aneurysm, and that an extensive metastatic and septic work-up is required in such patients.

Arterial wall changes in type 2 diabetic subjects.

Arterial ultrasonic appearances using high resolution ultrasound were studied in 97 subjects with Type 2 diabetes and age- and sex-matched controls. The intima-media thickness of both common carotid arteries was measured 2 cm proximal to the bifurcation and the presence or absence of plaque on both common and femoral bifurcations was recorded. The mean intima-media thickness in subjects with diabetes was 0.82 +/- 0.22 mm while in the controls 0.66 +/- 0.13 mm (p < 0.001). Multiple regression in diabetic subjects only showed no correlation between age, sex, body mass index, smoking, duration of diabetes, systolic or diastolic blood pressure, cholesterol, HDL, LDL, triglycerides, HbA1 and the common carotid artery intima-media thickness. Type 2 diabetes is associated with increased intima-media thickness which has been found to be a marker of cardiovascular events in the general population.

Renal allograft preservation: a comparison of University of Wisconsin solution and of hypothermic continuous pulsatile perfusion.

A study was performed to compare early allograft function in kidneys preserved with University of Wisconsin (UW) solution to kidneys preserved by hypothermic pulsatile perfusion. The study consisted of two sets of data. The first set was a donor-paired study (matched data) of 30 heart-beating, hemodynamically stable donors. After removal from the donor each cooled kidney was individually prepared for preservation. One kidney was flushed with +/- 500 ml of UW solution and stored in UW solution on slushed ice. The other kidney was continuously perfused with cooled (4-6 degrees C) cryoprecipitated plasma. The kidneys were transplanted into suitable recipients in a random sequence. Twelve donors were excluded from the study because one or both kidneys were transplanted into recipients who had previously been transplanted. The remaining 36 kidneys were implanted into two similar groups after a mean of 19 hours in the pulsatile perfusion group and 18 hours in the UW solution group. The second set of data consisted of all the kidneys preserved in UW solution (n = 62) at our institution and of 57 kidneys preserved by hypothermic continuous pulsatile perfusion during the same period (mixed data) and was used to evaluate the effect of prolonged preservation (longer than 24 hours) on delayed graft function. Both of these groups were also comparable. Acute tubular necrosis (ATN) was defined as the need for dialysis during the 1st week after transplantation, and delayed function as the delayed clearance of creatinine during the early post-operative phase.(ABSTRACT TRUNCATED AT 250 WORDS)

Successes and failures of endoscopic injection haemostasis for bleeding peptic ulcers. A prospective clinical study.

Fifty-two consecutive patients with upper gastrointestinal haemorrhage, shock (systolic blood pressure less than 100 mmHg) and a peptic ulcer showing endoscopic stigma of recent haemorrhage underwent attempts at endoscopic haemostasis. The ulcers were injected with a dilute solution of adrenaline followed by 5% ethanolamine oleate. Active bleeding was present in 22 patients (42%) at initial endoscopy. Bleeding was controlled in 40 patients (77%) in hospital. Failure occurred more frequently in duodenal ulcers than gastric ulcers (46% v. 7%; P < 0.004), and in giant (more than 2 cm diameter) duodenal ulcers (6/7) than smaller duodenal ulcers (3/15). We recommend early surgery for large posterior duodenal ulcers in preference to endoscopic injection methods.