Development of a Clinical Prediction Model for In-hospital Mortality from the South African Cohort of the African Surgical Outcomes Study.

BACKGROUND: Data on the factors that influence mortality after surgery in South Africa are scarce, and neither these data nor data on risk-adjusted in-hospital mortality after surgery are routinely collected. Predictors related to the context or setting of surgical care delivery may also provide insight into variation in practice. Variation must be addressed when planning for improvement of risk-adjusted outcomes. Our objective was to identify the factors predicting in-hospital mortality after surgery in South Africa from available data. METHODS: A multivariable logistic regression model was developed to identify predictors of 30-day in-hospital mortality in surgical patients in South Africa. Data from the South African contribution to the African Surgical Outcomes Study were used and included 3800 cases from 51 hospitals. A forward stepwise regression technique was then employed to select for possible predictors prior to model specification. Model performance was evaluated by assessing calibration and discrimination. The South African Surgical Outcomes Study cohort was used to validate the model. RESULTS: Variables found to predict 30-day in-hospital mortality were age, American Society of Anesthesiologists Physical Status category, urgent or emergent surgery, major surgery, and gastrointestinal-, head and neck-, thoracic- and neurosurgery. The area under the receiver operating curve or c-statistic was 0.859 (95% confidence interval: 0.827-0.892) for the full model. Calibration, as assessed using a calibration plot, was acceptable. Performance was similar in the validation cohort as compared to the derivation cohort. CONCLUSION: The prediction model did not include factors that can explain how the context of care influences post-operative mortality in South Africa. It does, however, provide a basis for reporting risk-adjusted perioperative mortality rate in the future, and identifies the types of surgery to be prioritised in quality improvement projects at a local or national level.

Laparoscopic Common Bile Duct Exploration Use of a Rigid Ureteroscope: A Single Institute Experience.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is used to treat choledocholithiasis. Flexible choledochoscopy is usually performed; however, this instrument is fragile and liable to breakage. MATERIALS AND METHODS: Data were collected and reviewed retrospectively from a prospectively maintained database. All cases of attempted LCBDE with the rigid ureteroscope at the institution since January 2014 were included. Demographic characteristics, preoperative attempted endoscopic retrograde cholangiopancreatography (ERCP), size of the bile duct, findings at laparoscopy, use of drain or T-tube, conversions, and morbidity or mortality were documented. RESULTS: A total of 37 patients were identified. The median age was 51 years (32-71). The male to female ratio was 1:5. Twenty-eight patients had failed ductal clearance at ERCP (75.7%). The mean common bile duct (CBD) diameter was 11.4 mm (10-13.5). There were five conversions. Cirrhosis in 2 patients, bleeding in 1 patient, impacted stone in 1, and equipment failure in 1. T-tubes were placed in 5% of cases. N = 8 (21.6%) of the patients had a Mirizzi syndrome. Average hospital stay was 4 days (3-7). Two patients had complications postoperatively-bleeding and collections. CONCLUSIONS: LCBDE using the rigid ureteroscope is feasible. It can be performed with acceptable morbidity. Use of the rigid ureteroscope represents a good alternative to the flexible choledochoscope with high duct clearance rates. One disadvantage is cirrhosis where the scope may not be negotiated into the CBD due to a stiff liver. It is a viable option when preoperative ERCP has failed to clear the CBD.

Diagnostic Laparoscopy for Trauma: How Not to Miss Injuries.

INTRODUCTION: Diagnostic laparoscopy (DL) is a well-accepted approach for penetrating abdominal trauma (PAT). However, the steps of procedure and the systematic laparoscopic examination are not clearly defined in the literature. The aim of this study was to clarify the definition of DL in trauma surgery by auditing DL performed for PAT at our institution, and to describe the strategies on how to avoid missed injuries. METHODS: The data of patients managed with laparoscopy for PAT from January 2012 to December 2015 were retrospectively analyzed. The details of operative technique and strategies on how to avoid missed injuries were discussed. RESULTS: Out of 250 patients managed with laparoscopy for PAT, 113 (45%) patients underwent DL. Stab wounds sustained 94 (83%) patients. The penetration of the peritoneal cavity or retroperitoneum was documented in 67 (59%) of patients. Organ evisceration was present in 21 (19%) patients. Multiple injuries were present in 22% of cases. The chest was the most common associated injury. Two (1.8%) iatrogenic injuries were recorded. The conversion rate was 1.7% (2/115). The mean length of hospital stay was 4 days. There were no missed injuries. In the therapeutic laparoscopy (TL) group, DL was performed as the initial part and identified all injuries. There were no missed injuries in the TL group. The predetermined sequential steps of DL and the standard systematic examination of intraabdominal organs were described. CONCLUSIONS: DL is a feasible and safe procedure. It accurately identifies intraabdominal injuries. The selected use of preoperative imaging, adherence to the predetermined steps of procedure and the standard systematic laparoscopic examination will minimize the rate of missed injuries.

Laparoscopic-Assisted Approach for Penetrating Abdominal Trauma: An Underutilized Technique.

INTRODUCTION: Diagnostic laparoscopy is well accepted in the management of penetrating abdominal trauma (PAT). Therapeutic laparoscopy, on the other hand, remains controversial. In patients with multiple hollow viscera injuries, laparoscopy is usually converted to laparotomy. We aim at describing the laparoscopic-assisted technique in the management of patients with PAT. Using our experience with laparoscopy, we tailored the technique to the setting of PAT. METHODS: The laparoscopic-assisted approach (LAA) was adapted to a trauma setting and prospectively evaluated. The technical details and indications for the technique were investigated. The distinctive steps of the technique were identified and described descriptively. The decision-making process was described as a separate step in the technique. TECHNIQUE: After having established pneumoperitoneum and ports placement, the source of bleeding is identified and controlled. Systematic inspection of intraperitoneal and retroperitoneal organs is done. In the case of multiple injuries, the hollow viscera are exteriorized via the 4-8 cm incision and extracorporeal inspection, repair, resection, and anastomosis are performed. The other part of the procedure is completed intracorporeally. Over a 2-year period, 23 patients were managed with LAA, 13 patients with stab wounds, and 10 patients with gunshot wounds. Commonly performed procedures were hollow viscera repairs, resections, and anastomoses. There were neither missed injuries nor conversion among patients managed with LAA. CONCLUSION: The LAA is underutilized for PAT. This technique can be successfully used as a diagnostic and therapeutic tool in the management of stable patients. It offers the advantages of minimally invasive surgery and the speed and versatility of an open procedure.

The role of laparoscopy in management of stable patients with penetrating abdominal trauma and organ evisceration.

BACKGROUND: Organ evisceration after penetrating abdominal trauma (PAT) carries a high rate of significant intra-abdominal injuries. There is uniform agreement that organ evisceration warrants immediate laparotomy. Nonoperative management of stable asymptomatic patients with evisceration is associated with a high failure rate. Most authors exclude patients with organ evisceration from laparoscopic management.The aims of this study were to determine the significance of organ evisceration in stable patients with PAT and to assess the feasibility of laparoscopic management of this group. MATERIALS AND METHODS: Intraoperative findings, performed surgery, and complications in stable patients who underwent laparoscopy for PAT and evisceration between January 2012 and December 2014 were retrospectively analyzed. All unstable patients underwent laparotomy and were excluded. RESULTS: A total of 189 stable patients were treated with laparoscopy for PAT. Thirty-nine patients (20.6%) had organ evisceration; 37 patients had stab wounds and 2 patients had gunshot wounds. Fifteen patients had bowel evisceration and 24 had omental evisceration. In total, 25 patients (64%) had significant injuries (colon, small bowel, etc.) and required therapeutic laparoscopy. The rate of therapeutic laparoscopy was 73% in patients with bowel evisceration and 58% in patients with omental evisceration. This difference was not statistically significant. The most commonly injured organ was the small bowel. The small-bowel repair, resection, and anastomosis were the most commonly performed procedures. We did not have any missed injuries. There were neither conversions nor significant complications in the postoperative period. Fourteen patients avoided nontherapeutic laparotomy. CONCLUSION: Organ evisceration in stable patients with PAT is associated with a high rate of significant intra-abdominal injuries and mandates abdominal exploration. Laparoscopic management is feasible, has a high accuracy in identifying intra-abdominal injuries, provides all benefits of minimal invasive surgery, and avoids nontherapeutic laparotomy. LEVEL OF EVIDENCE: Therapeutic study, level V.

The Role of Laparoscopy in Penetrating Abdominal Trauma: Our Initial Experience.

BACKGROUND: Diagnostic and therapeutic laparoscopy is a known approach in managing patients with penetrating abdominal trauma (PAT). However, multiple controversies exist on indications, contraindications, and its appropriateness. The aim of this study was to evaluate the appropriateness of diagnostic and therapeutic laparoscopy in patients with PAT at Dr George Mukhari Academic Hospital, Pretoria, South Africa. MATERIALS AND METHODS: This was a retrospective, observational study. All patients with PAT managed by diagnostic and therapeutic laparoscopy during 2012-2013 were included. Recorded indications and contraindications, the mechanism of injury, the anatomical location of injury, intraoperative findings, reasons for conversion, and adverse outcomes (complications, reoperations and mortality) were analyzed in every case. RESULTS: One hundred fourteen patients were included. Stab injuries were sustained by 81 (71%) patients, and 33 (29%) patients sustained gunshot wounds (GSW) to the abdomen. The conversion rate was 7%. The operation was completed laparoscopically in 106 patients: 79 with stab wounds (74.5%) and 27 with GSW (25.5%). Laparoscopy was diagnostic for 44 patients (41.5%) and therapeutic for 62 patients (58.5%). In total, 13 patients (12%) required re-intervention, and 2 patients died (1.9%). The complications were not specific to the laparoscopic approach. No missed injuries were reported in the study. CONCLUSIONS: Diagnostic and therapeutic laparoscopy in patients with PAT is an appropriate management in hemodynamically stable patients or those responsive to initial resuscitation. The location of injuries is not a limiting factor, although it affects placement of ports. The conversion is not a complication but rather the correct way of completing the operation in an appropriate situation. It should be considered in patients with extensive intraabdominal bleeding suggesting the possibility of major vessel injury, a significant deterioration of the patient, and the complexity of injuries requiring a prolonged laparoscopic procedure.