Fournier's gangrene reconstruction: A 10-year retrospective analysis of practice at Guys and St Thomas's NHS Foundation Trust.

Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.

FDP avulsion: A washer technique.

BACKGROUND: Flexor digitorum profundus (FDP) avulsion injuries occur following forced hyperextension of the distal interphalangeal joint (DIPJ). METHODS: We highlight a case report of FDP avulsion injury fixed using a single hole of a plate in combination with a cortical screw to act as a washer. A search and discussion of the literature is included.

Recurrent pneumothorax following chest tube removal in thoracic stab wounds: a comparative study between end inspiratory versus end expiratory removal techniques at a major trauma centre in South Africa.

BACKGROUND: Tube thoracostomy (TT) insertion is a commonly performed procedure in trauma that is standardised, but the optimal removal technique based on the timing in relation to the respiratory cycle remains controversial. METHODS: A prospective study was undertaken at a major trauma centre in South Africa over a 4-year period from January 2010 to December 2013, and included all patients with pneumothorax secondary to thoracic stab wounds. TTs were removed by either end of inspiration technique (EIT) or end of expiration (EET) technique and the rate of recurrent pneumothorax (RPTX) following removal was compared. We hypothesized that there is no difference in the rate of RPTX between the end inspiratory (EI) and end expiratory (EE) removal technique. RESULTS: A total 347 patients were included. Of the 184 TTs removed by EIT, there were 17 (9%) RPTXs. Of the 163 with EET, there were 11 RPTXs (7%), (9% versus 7%, chi-squared, P = 0.395). Of the total 28 (9%) patients with RPTXs following removal of chest tubes, two (7%) required reinsertion of chest tube (0.5% (1/184) in EIT and 0.6% (1/163) in EET, P = 0.747). CONCLUSIONS: Timing of TT removal in relation to the respiratory cycle does not appear to influence the incidence of RPTX in patients with thoracic stab wounds. Technique of removal may well be a more important consideration and more attention must be focused on refining the optimal technique.

Damage control or definitive repair? A retrospective review of abdominal trauma at a major trauma center in South Africa.

BACKGROUND: This study set out to review a large series of trauma laparotomies from a single center and to compare those requiring damage control surgery (DCS) with those who did not, and then to interrogate a number of anatomic and physiologic scoring systems to see which best predicted the need for DCS. METHODS: All patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These groups were then compared in terms of demographics and spectrum of injury, as well as clinical outcome. The following scores were worked out for each patient: Penetrating Abdominal Trauma Index (PATI), Injury Severity Score, Abbreviated Injury Scale-abdomen, and Abbreviated Injury Scale-chest. RESULTS: A total of 562 patients were included, and 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. The mechanism was penetrating trauma in 81% of cases (453 of 562). A large proportion of trauma victims were male (503 of 562, 90%), with a mean age of 29.5±10.8. An overall mortality rate of 32% was recorded for DCS versus 4% for non-DCS (p<0.001). In general patients requiring DCS had higher lactate, and were more acidotic, hypotensive, tachycardic, and tachypneic, with a lower base excess and lower bicarbonate, than patients not requiring DCS. The most significant organ injuries associated with DCS were liver and intra-abdominal vascular injury. The only organ injury consistently predictive across all models of the need for DCS was liver injury. Regression analysis showed that only the PATI score is significantly predictive of the need for DCS (p=0.044). A final multiple logistic regression model demonstrated a pH <7.2 to be the most predictive (p=0.001) of the need for DCS. CONCLUSION: DCS is indicated in a subset of severely injured trauma patients. A pH <7.2 is the best indicator of the need for DCS. Anatomic injuries in themselves are not predictive of the need for DCS. LEVELS OF EVIDENCE: Level III.

Laparotomy for organ evisceration from abdominal stab wounds: A South African experience.

INTRODUCTION: Organ evisceration following abdominal stab wound (SW) is currently considered as an absolute indication for mandatory laparotomy due to the high incidence of associated intra-abdominal injuries, but literature describing the spectrum of organ injury encountered is limited. MATERIALS AND METHODS: We reviewed our experience of 301 consecutive patients who were subjected to mandatory laparotomy over an eight-year period at a major trauma centre in South Africa. RESULTS: Of the 301 patients with organ evisceration, 92% were male (mean age: 28 years). Ninety per cent (270/301) of the laparotomies were positive (85% (229/270) therapeutic, 15% (41/270) non-therapeutic). The frequencies of eviscerated organs were small bowel (70%), large bowel (26%), and stomach 3%. Three (1%) patients had combined evisceration of more than one of the above organs. The most commonly injured organs were small bowel and large bowel. The mean length of hospital stay was nine days. Seven patients required intensive care admission. The morbidity rate was 21% and mortality was 2%. CONCLUSIONS: The spectrum of injury associated with abdominal SW with organ evisceration is similar to smaller published series. Multiple organ injuries are common. The most commonly eviscerated organs were small bowel, large bowel and stomach, while the most commonly injured organs were small bowel and large bowel.

The spectrum of injuries resulting from abdominal stab wounds with isolated omental evisceration: A South African experience.

INTRODUCTION: The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature in the specific setting of isolated omental evisceration is limited. MATERIALS AND METHODS: We reviewed our experience of 244 consecutive patients with established indications for laparotomy over an eight year period at a major trauma centre in South Africa. RESULTS: Of the 244 patients (93% male, mean age: 27 years), 224 (92) underwent immediate laparotomy (IL). Twenty were initially observed and eventually required a laparotomy (delayed laparotomy, DL). The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), <6 h in 6% (14/244), <12 h 2% (4/244) and <18 h in 1% (2/244). Ninety-eight per cent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic. The mostly commonly injured organ encountered on laparotomy were small bowel, stomach and colon. CONCLUSIONS: The most commonly injures encountered are intestinal and gastric. Clinicians must remain vigilant as injuries may be subtle.

Lessons learnt from the Pietermaritzburg experience with damage control laparotomy for trauma.

INTRODUCTION: The modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience. METHODS: All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0. RESULTS: A total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453/562). A great proportion of trauma victims were male (503/562, 90%), with a mean age of 29.5±10.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28±0.15) with a raised lactate (5.25 mmol/L±3.71). Our primary repair rates for enteric injuries were surprisingly high. CONCLUSION: Just under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.

Ethics of Burn Wound Care in a Low-Middle Income Country.

This review focuses on burn care in low- and middle-income countries (LMICs). It attempts to put the burden of disease in perspective by showing that burn care is under-resourced across the spectrum of LMICs and by interrogating the ethical dilemmas and challenges that staff face in caring for burn patients in this environment, with a focus on South Africa. More specifically, it will attempt to address the following issues: the threshold for utilizing the intensive care unit (ICU), how to balance treatment against cost, the percentage burn considered survivable and how it should be determined, the use of skin from both cadavers and living related donors, and the appropriate ethical guidelines for LMICs.

Management of intra-abdominal vascular injury in trauma laparotomy: a South African experience.

BACKGROUND: Intra-abdominal vascular injury (IAVI) is uncommon but continues to be associated with high mortality rates despite technological advances in the past decades. In light of these ongoing developments, we reviewed our contemporary experience with IAVI in an attempt to clarify and refine our management strategies and the outcome of these patients. METHODS: We retrospectively reviewed the charts of all patients admitted between January 2011 and December 2014 at a major trauma centre in South Africa who were found to have an IAVI during laparotomy for trauma. We collected demographic and clinical data including mechanism of injury, location and severity of the injury, concurrent injuries, physiologic parameters and clinical outcome. RESULTS: We identified 110 patients with IAVIs, of whom 98 had sustained penetrating injuries (55 gunshot wounds and 43 stab wounds). There were 84 arterial injuries (including 21 renal and 17 mesenteric) and 74 venous injuries (including 21 renal and 17 inferior vena caval). Combined venous and arterial injuries were found in almost one-third of patients (34 [30.9%]). Fifty-seven patients (51.8%) required intensive care admission. The overall mortality rate was 28.2% (31 patients); the rate was 62% for aortic injuries and 47% for inferior vena cava injuries. Liver injury, large bowel injury, splenic injury and elevated lactate level were all associated with a statistically significantly higher mortality rate. CONCLUSION: The mortality rate for IAVI remains high despite decades of operative experience in high-volume centres. Open operative techniques alone are unlikely to achieve further reduction in mortality rates. Integration of endovascular techniques may provide an alternative strategy to improve outcomes.

CONTEXTE: Les lésions vasculaires intraabdominales (LVIA) sont rares, mais elles sont toujours associées à un taux de mortalité élevé, malgré les progrès technologiques des dernières décennies. À la lumière de ces renseignements, nous avons passé en revue l'expérience récente en matière de LVIA afin de clarifier et de parfaire nos stratégies de prise en charge et d'améliorer les résultats des patients. MÉTHODES: Nous avons examiné de manière rétrospective les dossiers de tous les patients admis entre janvier 2011 et décembre 2014 dans un grand centre de traumatologie d'Afrique du Sud chez qui une laparotomie a révélé la présence d'une LVIA. Nous avons recueilli des données démographiques et cliniques portant notamment sur le mécanisme lésionnel, la localisation et la gravité de la lésion, les blessures concomitantes, les paramètres physiologiques et l'issue clinique. RÉSULTATS: Nous avons recensé 110 patients atteints de LVIA, dont 98 avaient subi des blessures par pénétration (55 causées par un projectile d'arme à feu et 43 par une arme blanche). Nous avons dénombré 84 lésions artérielles (dont 21 rénales et 17 mésentériques) et 74 lésions veineuses (dont 21 rénales et 17 touchant la veine cave inférieure). Dans l'ensemble, nous avons constaté des lésions veineuses et artérielles chez près du tiers des patients (34 patients, soit 30,9 %). Cinquante-sept patients (51,8 %) ont dû être admis à l'unité des soins intensifs. Le taux de mortalité global était de 28,2 % (31 patients); il était de 62 % pour les cas de lésions aortiques et de 47 % pour les lésions touchant la veine cave inférieure. Les lésions au foie, au gros intestin et à la rate ainsi que les taux élevés de lactate ont tous été associés à une hausse statistiquement significative du taux de mortalité. CONCLUSION: Le taux de mortalité associé aux LVIA reste élevé malgré des décennies d'expérience chirurgicale dans des centres de traumatologie traitant un grand nombre de patients. Les techniques opératoires ouvertes seules sont peu susceptibles de donner lieu à une baisse de ce taux. L'intégration des techniques endovasculaires pourrait constituer une solution de rechange pour améliorer les résultats.

Routine cervical spine immobilisation is unnecessary in patients with isolated cerebral gunshot wounds: A South African experience.

OBJECTIVE: Routine immobilisation of the cervical spine in trauma has been a long established practice. Very little is known in regard to its appropriateness in the specific setting of isolated traumatic brain injury secondary to gunshot wounds (GSWs). METHODS: A retrospective study was conducted over a 5 year period (January 2010 to December 2014) at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa in order to determine the actual incidence of concomitant cervical spine injury (CSI) in the setting of isolated cerebral GSWs. RESULTS: During the 5 year study period, 102 patients were included. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-eight per cent of the injuries were secondary to low velocity GSWs. Twenty-seven (26%) patients had cervical collar placed by the Emergency Medical Service. The remaining 75 patients had their cervical collar placed in the resuscitation room. Fifty-five (54%) patients had a Glasgow Coma Scale (GCS) of 15 and underwent plain radiography, all of which were normal. Clearance of cervical spine based on normal radiography combined with clinical assessment was achieved in all 55 (100%) patients. The remaining 47 patients whose GCS was <15 all underwent a computed tomography (CT) scan of their cervical spine and brain. All 47 CT scans of the cervical spine were normal and there was no detectable bone or soft tissue injury noted. CONCLUSION: Patients who sustain an isolated low velocity cerebral GSW are highly unlikely to have concomitant CSI. Routine cervical spine immobilisation is unnecessary, and efforts should be directed at management strategies aiming to prevent secondary brain injury. Further studies are required to address the issue in the setting of high velocity GSWs.

Spectrum of injuries resulting from gunshot wounds in car hijacking: a South African experience.

BACKGROUND: Car hijacking, known as "carjacking", is a form of aggravated robbery of a vehicle from the driver frequently involving firearm and is common in South Africa. There is, however, little literature on the spectrum of injuries sustained by victims of car hijacking. The study aimed to describe the spectrum of gunshot wound-related (GSW) injuries and review our experience of management of victims of car hijacking in our trauma center based in South Africa. METHODS: A retrospective review was conducted during an 8-year period from January 2010 to January 2018 on all patients who presented with any form of GSW after a car hijacking incident. RESULTS: During the 8-year study period, a total of 101 patients were identified. Seventy-four percent were male (75 of 101) and the mean age was 34 years. The mean time from injury to arrival at our trauma center was 7 hours (rural district: 10 hours, urban district: 4 hours; p<0.001). Seventy-five percent (76 of 101) of all patients sustained GSWs to multiple body regions, whereas the remaining 25% (25 of 101) were confined to a single body region. The most common region involved was the chest (48 cases), followed by the abdomen (46 cases) and neck (34 cases). Sixty-three of the 101 (62%) patients required one or more operative interventions. The most common procedure was laparotomy (28 cases), followed by vascular (20 cases) and neck (14) exploration. Eighteen percent (18 of 101) of all patients required intensive care unit admission. The mean length of hospital stay was 7 days. The overall morbidity was 13% (16 of 101) and the overall mortality was 18% (18 of 101). DISCUSSION: The spectrum of injuries from GSW related to car hijacking commonly involves close range GSWs to multiple body regions. Torso trauma is common and a substantial proportion of victims require major operative interventions. The mortality from these injuries is significant. LEVEL OF EVIDENCE: Level III.