Analysis of Surgical Mortalities Using the Fishbone Model for Quality Improvement in Surgical Disciplines.

BACKGROUND: The healthcare industry is complex and prone to the occurrence of preventable patient safety incidents. Most serious patient safety events in surgery are preventable. AIM: This study was conducted to determine the rate of occurrence of preventable mortalities and to use the fishbone model to establish the main contributing factors. METHODS: We reviewed the records of patients who died following admission to the surgical wards. Data regarding their demography, diagnosis, acuity, comorbidities, categorization of death and contributing factors were extracted from the Research Electronic Data Capture (REDCap) database. Factors which contributed to preventable and potentially preventable mortalities were collated. The fishbone model was used for root cause analysis. The study received prior ethical clearance (M190122). RESULTS: Records of 859 mortalities were found, of which 65.7% (564/859) were males. The median age of the patients who died was 49 years (IQR: 33-64 years). The median length of hospital stay before death was three days (IQR: 1-11 days). Twenty-four percent (24.1%) of the deaths were from gastrointestinal (GIT) emergencies, 18.4% followed head injury and 17.0% from GIT cancers. Overall, 5.4% of the mortalities were preventable, and 41.1% were considered potentially preventable. The error of judgment and training issues accounted for 46% of mortalities. CONCLUSION: Most surgical mortalities involve males, and around 46% are either potentially preventable or preventable. The majority of the mortality were associated with GIT emergencies, head injury and advanced malignancies of the GIT. The leading contributing factors to preventable and potentially preventable mortalities were the error of judgment, inadequate training and shortage of resources.

Demographic and histological subtypes of Hurthle cell tumours of the thyroid in a South African setting.

BACKGROUND: Report of Hurthle cells following fine needle aspiration cytology from a thyroid nodule raises possibility of Hurthle cell carcinoma (HCC), which is a distinct entity and accounts for 3-10% of thyroid malignancies. AIM: To determine if there are demographic and histopathological features which may be used to differentiate HCC from Hurthle cell adenoma (HCA). METHOD: Histopathology records of patients who had thyroidectomy from January 2001 to October 2015 were reviewed. Data retrieved included indications for thyroidectomy, patients' demographics, histology and preoperative FNAC results. RESULTS: At total of 2641 records were reviewed of which 25.6% (676/2641) were for neoplasms. 15.8% (107/676) of the neoplasms were Hurthle cell neoplasms (HCNs) and 25.2% (27/107) of HCNs were HCCs. 77.2% (71/92) of HCAs and 77.8% (21/27) of HCCs were from female patients. Preoperative FNAC results were available for 54.2% (58/107) and were suspicious of HCN in 12.1% (7/58). Average tumour size for HCCs and HCAs was 4.9 ± 2.7 cm and 3.5 ± 2.0 cm, respectively. The difference was statistically significant with a p-value of 0.016. The risk of malignancy increased from 11.1% in HCNs less than 1 cm to 53.8% for tumours which were greater than 4 cm in diameter. CONCLUSION: HCNs are more common in females. The likelihood of HCC rises as the size of the HCN increases. Malignancy rate exceeds 50% for HCNs which are greater than 4 cm in diameter.

Registrar perceptions on general surgical training in South Africa: A report by the South African Society of Surgeons in Training (SASSiT).

BACKGROUND: Surgical training varies significantly amongst universities within the same country. This trend is reflected in South Africa and provides an opportunity for innovation to improve the quality of general surgical training. OBJECTIVE: To assess the perceptions of South African general surgery registrars regarding surgical training. METHOD: A prospective descriptive study was performed by means of a confidential questionnaire distributed to general surgical registrars at all eight training centers in South Africa. Participants were asked to give comments regarding adequacy of formal academic teaching, level of supervision during surgical procedures, exposure to and training in minimally invasive surgery (MIS), and preparation for examinations. Descriptive statistics were generated with Microsoft Excel. Ethics clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee. RESULTS: Of 200 questionnaires distributed 105 (52.5%) were returned. 44% (105/241) of all registrars from six training institutions participated. 89.5% (94/105) of respondents reported that they attended less than six hours of formal academic teaching per week and 71.4% (75/105) indicated that their institution offered less than six hours of formal academic teaching per week. 76.2% (80/105) of respondents regarded lack of protected academic time as the greatest obstacle to their surgical training and 95.2% (99/105) reported that clinical responsibilities prevented them from attending formal academic teaching regularly. Overall, only 31.4% (33/105), 41.9% (44/105) and 37.1% (39/105) were satisfied with the amount of formal academic teaching, level of supervision during theatre procedures and exposure to minimally invasive surgery respectively. Lack of resources and lack of appropriate skills were identified as a hindrance to MIS training by 47.6% (50/105) and 28.6% (30/105) of respondents respectively. CONCLUSION: Surgical registrars are dissatisfied with the amount of formal academic teaching and protected academic time, level of supervision in theatre and their exposure to MIS. These challenges compromise trainees' ability to practice independently after qualification. Numerous interventions are necessary and possible to address these challenges.

Incidental cancer in multinodular goitre post thyroidectomy.

BACKGROUND: The risk of malignancy in patients with multinodular goitre (MNG) is approximately 7.2%. The gold standard for diagnosis of thyroid cancer is fine-needle aspiration biopsy (FNAB). Unsuccessful, inconclusive or suspicious results mandate further investigations. The concern is that with a benign FNAB result there is no indication for surgery unless the patient has compression symptoms or cosmetic issues, but the risk of missed malignancy is nevertheless present. OBJECTIVE: To determine the prevalence and histological features of incidental cancers in patients who had thyroidectomy for MNG. METHOD: Records of patients who underwent thyroidectomy between January 2005 and December 2010 at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, were retrospectively reviewed. Data retrieved included demographic characteristics of the patients, type of thyroidectomy, thyroid function test results, FNAB cytology and final histology results. RESULT: A total of 166 thyroidectomies were performed on 162 patients, the majority (139) of whom were females. The mean age was 46 years (range 15 - 79 years). A total of 120 pre-operative FNABs were available for analysis, 78 of which were suggestive of benign nodular goitre; 70 benign FNAB results were histologically confirmed to be MNG after thyroidectomy. Incidental malignancy was found in four of 70 cases of MNG (5.7%); all were papillary carcinomas, predominantly (75.0%) the follicular variant. CONCLUSION: The risk of missing cancer in patients with MNG was 5.7%. The commonest histological subtype of thyroid cancer found in MNG was papillary carcinoma.

Early-onset malignant solid tumours in young adult South Africans - an audit based on histopathological records of patients seen at the three academic hospitals in Johannesburg.

BACKGROUND: Malignant tumours in adolescents and young adults (AYA) are referred to as early-onset cancers. This study analysed the histopathological profile of malignant solid tumours in AYA. METHODS: Records of patients who had confirmed malignant solid tumours were retrieved. Data collected included the treating hospital, year of presentation, age and histological diagnosis. The commonly diagnosed malignant tumours in AYA were compared with tumours in older adults. A p-value below 0.05 was considered significant. RESULTS: A total of 61 828 records were retrieved and 29 974 were excluded. Additionally, 1 055 post-excision results from AYA were excluded. Of the remaining 30 799 records, 13.1% (4 032/30 799) were diagnosed in AYA, of which 18.2% (734/4 032) were in-situ lesions. Overall, 11% (3 298/30 065) of invasive tumours were from the AYA. The majority, 81.1% (3 269/4 032), of invasive and non-invasive malignant tumours in AYA were from females. Breast and cervical cancer constituted 29.2% (962/3 298) and 23.2% (766/3 298) of diagnosed cancers in AYA, respectively. Ten (0.3%) cases of prostate and 0.4% (12/3 298) of lung cancers were reported in AYA. CONCLUSION: Eleven per cent of invasive malignancies were diagnosed in AYA and 81% involved females. Cancers of the breast, cervix, skin, and colon were the top four most common tumours in AYA. The burden of breast and colorectal cancer was higher in AYA than in older adults. Prostate cancer is rare in AYA and lung cancer was not among the top 10 malignant tumours in our setting. Over 11% of primary malignant tumours of the anus, breast, cervix, colon, conjunctiva, liver and rectum were diagnosed in AYA.

Gastro-intestinal stromal tumours (GISTs) - the Pretoria experience and a literature review.

AIM: To analyse the presentation and management of patients with gastrointestinal stromal tumours (GISTs) at Pretoria hospitals. DESIGN: A retrospective study was done in which all available clinical records of primary c-KIT positive GISTs were analysed. SETTING: Secondary and tertiary care institutions in Pretoria, including both private and public hospitals. Subjects. The population studied included all individuals treated at Pretoria hospitals from 17 July 2000 to 1 April 2009 who had a GIST confirmed with immunohistochemical c KIT staining. Patients with incomplete or inaccessible clinical records were excluded. Outcome measures. Patient demographics including gender, age and race; presenting symptoms and signs; results of special investigations; and treatment. RESULTS: Fifty-four cases were identified for inclusion in the study. The age of the subjects ranged from 15 to 83 years. The male-to-female ratio was 1.5:1. The organ most commonly affected was the stomach, and abdominal pain and weight loss were the most common presenting symptoms. Seventy-six per cent of the patients were treated surgically, and 24% received Imatinib. CONCLUSION: GISTs often present late with non-specific symptoms, and are frequently discovered incidentally. Large tumours tend to be malignant.

A 10-year audit of burns at Kalafong Hospital.

Kalafong Hospital is a secondary hospital situated to the west of Pretoria. It serves as the regional burns centre for Gauteng province north of the Jukskei river. It mainly serves a poor population. This is a retrospective review of a 10-year period, looking at both numbers and the aetiology of burns treated by this unit. Only adult cases--patients over the age of 12--were assessed. Over this period, a total number of 1046 patients were admitted and treated by this unit, consisting of 634 males and 406 females. The period covered, includes a period when the government has been expending massive amounts of funds to electrify townships and rural areas. Despite this, however, the majority of burn wounds are still caused by open flames and paraffin stoves.

Registrar perceptions on general surgical training in South Africa: a report by the South African Society of Surgeons in Training (SASSiT)

Background: Surgical training varies significantly amongst universities within the same country. This trend is reflected in South Africa and provides an opportunity for innovation to improve the quality of general surgical training. Objective: To assess the perceptions of South African general surgery registrars regarding surgical training.Method: A prospective descriptive study was performed by means of a confidential questionnaire distributed to general surgical registrars at all eight training centers in South Africa. Participants were asked to give comments regarding adequacy of formal academic teaching, level of supervision during surgical procedures, exposure to and training in minimally invasive surgery (MIS), and preparation for examinations. Descriptive statistics were generated with Microsoft Excel. Ethics clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee. Results: Of 200 questionnaires distributed 105 (52.5%) were returned. 44% (105/241) of all registrars from six training institutions participated. 89.5% (94/105) of respondents reported that they attended less than six hours of formal academic teaching per week and 71.4% (75/105) indicated that their institution offered less than six hours of formal academic teaching per week. 76.2% (80/105) of respondents regarded lack of protected academic time as the greatest obstacle to their surgical training and 95.2% (99/105) reported that clinical responsibilities prevented them from attending formal academic teaching regularly. Overall, only 31.4% (33/105), 41.9% (44/105) and 37.1% (39/105) were satisfied with the amount of formal academic teaching, level of supervision during theatre procedures and exposure to minimally invasive surgery respectively. Lack of resources and lack of appropriate skills were identified as a hindrance to MIS training by 47.6% (50/105) and 28.6% (30/105) of respondents respectively. Conclusion: Surgical registrars are dissatisfied with the amount of formal academic teaching and protected academic time, level of supervision in theatre and their exposure to MIS. These challenges compromise trainees' ability to practice independently after qualification. Numerous interventions are necessary and possible to address these challenges

Demographic and histological subtypes of Hurthle cell tumours of the thyroid in a South African setting

Background: Report of Hurthle cells following fine needle aspiration cytology from a thyroid nodule raises possibility of Hurthle cell carcinoma (HCC), which is a distinct entity and accounts for 3­10% of thyroid malignancies. Aim: To determine if there are demographic and histopathological features which may be used to differentiate HCC from Hurthle cell adenoma (HCA). Methods: Histopathology records of patients who had thyroidectomy from January 2001 to October 2015 were reviewed. Data retrieved included indications for thyroidectomy, patients' demographics, histology and preoperative FNAC results. Results: At total of 2641 records were reviewed of which 25.6% (676/2641) were for neoplasms. 15.8% (107/676) of the neoplasms were Hurthle cell neoplasms (HCNs) and 25.2% (27/107) of HCNs were HCCs. 77.2% (71/92) of HCAs and 77.8% (21/27) of HCCs were from female patients. Preoperative FNAC results were available for 54.2% (58/107) and were suspicious of HCN in 12.1% (7/58). Average tumour size for HCCs and HCAs was 4.9 +/- 2.7 cm and 3.5 +/- 2.0 cm, respectively. The difference was statistically significant with a p-value of 0.016. The risk of malignancy increased from 11.1% in HCNs less than 1 cm to 53.8% for tumours which were greater than 4 cm in diameter. Conclusion: HCNs are more common in females. The likelihood of HCC rises as the size of the HCN increases. Malignancy rate exceeds 50% for HCNs which are greater than 4 cm in diameter

Changing Pattern of Incidence; Aetiology and Mortality from Acute Pancreatitis at Kalafong Hospital; Pretoria; South Africa;1988-2007: A Retrospective Evaluation

Background: Literature reports from Western countries suggest an increasing incidence of acute pancreatitis (AP) and changing pattern over the past two decades. The aim of thisstudy was to document the incidence; aetiology and mortality from AP over two decades and to examine any emerging trends.Methods: A retrospective study of all confirmed cases of AP admitted over a 20-year period to thesurgical department was performed. Patients' demographics; year of admission;number of attacks; aetiology; management and outcome were entered on a specialstudy proforma.Results: Altogether 707 attacks of AP (M: F; 5.7: 1) were recorded. The proportion of gallstone APincreased (3.1to 12.7) and that of alcohol-related AP decreased (84to 67.6). Alcohol was themain aetiological factor for AP. Drugs; hyperlipidaemia; human immunodeficiency virus (HIV) andendoscopic pancreatography-related AP increased in the second decade. The in-hospital mortality rateduring the respective periods was 6.5and 3.1.Conclusion: Gallstone AP increased during second decade from more Caucasian admissions and increased gallstones among Blacks. The reduced mortality was attributed to changing trends in the nature and aetiology of AP recorded; heightened awareness of the condition and improved management