A Study Comparing Outcomes of Appendectomy between HIV-Infected and HIV-Negative Patients.

Background: The high prevalence of Human Immunodeficiency Virus (HIV) has added a new dimension to the management and outcomes of many general surgical conditions in South Africa. However, there is a paucity of data describing the impact of HIV status on surgical outcomes in our setting. Appendicitis is a most common gastrointestinal emergency, and its surgical outcomes in areas of high HIV prevalence are poorly described in the literature. Thus, the aim of this study is to describe and compare the outcomes of appendectomy between HIV-infected (HIV+) and HIV-negative (HIV-) patients. Methods: This is a retrospective cohort study of patients undergoing appendectomy at a large regional hospital over a 12-month period. Demographic data, duration of pre-hospital symptoms, HIV status, surgical approach, operative findings, histopathology reports, hospital stay and complications were recorded. Data for the HIV+ and HIV- patient cohorts were then described, analysed and compared. Results: The study group comprised 134 patients; 18 (13.4 %) tested positive for HIV. HIV+ patients were significantly older (mean age of 29.3 vs. 20.3 years, P= 0.002) and had longer duration of pre-hospital symptoms (mean of 3.94 vs. 2.57 days, P= 0.03). Postoperative complications (44.4 % vs. 17.2 %, P= 0.03) and lengthier hospital stays (7.28 days vs. 5.95 days, P= 0.004) were also more frequently seen in the HIV+ patients. There were no differences in appendiceal rupture rates, histopathological findings and mortality. Conclusions: Presentation in HIV+ patients was delayed and surgery was associated with significant postoperative morbidity and longer hospital stay.

A clinical-scale BioArtificial Liver, developed for GMP, improved clinical parameters of liver function in porcine liver failure.

Liver failure, whether arising directly from acute liver failure or from decompensated chronic liver disease is an increasing problem worldwide and results in many deaths. In the UK only 10% of individuals requiring a liver transplant receive one. Thus the need for alternative treatments is paramount. A BioArtificial Liver machine could temporarily replace the functions of the liver, buying time for the patient's liver to repair and regenerate. We have designed, implemented and tested a clinical-scale BioArtificial Liver machine containing a biomass derived from a hepatoblastoma cell-line cultured as three dimensional organoids, using a fluidised bed bioreactor, together with single-use bioprocessing equipment, with complete control of nutrient provision with feedback BioXpert recipe processes, and yielding good phenotypic liver functions. The methodology has been designed to meet specifications for GMP production, required for manufacture of advanced therapy medicinal products (ATMPs). In a porcine model of severe liver failure, damage was assured in all animals by surgical ischaemia in pigs with human sized livers (1.2-1.6 kg liver weights). The BioArtificial liver (UCLBAL) improved important prognostic clinical liver-related parameters, eg, a significant improvement in coagulation, reduction in vasopressor requirements, improvement in blood pH and in parameters of intracranial pressure (ICP) and oxygenation.

Urological complications following unstented pediatric renal transplantation.

Urological complications which develop post-renal transplantation can be associated with significant morbidity especially in children. We evaluated the occurrence and management of all urological complications in a series of unstented pediatric renal transplants in a tertiary pediatric hospital. We reviewed the medical records of children who underwent unstented renal transplant between January 1996 and December 2014. Postoperative urological complications and the outcomes of their management were analyzed. A total of 160 unstented renal transplants were performed, and 32 urological complications were noted in 29 transplants (18%). There were 20 boys and nine girls with an age range of 2.5 years to 18.4 years. Nine (31%) of these patients had LUTD. The most common complication was VUR occurring in 17 patients (10.6%). Urine leaks occurred in six patients (3.8%) and ureteric obstruction in six patients (3.8%), and three patients (1.9%) had unexplained hydronephrosis. Loss of graft occurred in three patients (1.9%), and one patient died from sepsis post-uretero-ureterostomy. Patients with LUTD had more urological complications (P = .037). Unstenting is feasible in most pediatric renal transplants. LUTD is associated with a higher incidence of urological complications, especially VUR.

The International Association of Student Surgical Societies: creation and dissemination.

SUMMARY: While initiatives exist to address the worldwide need for surgeons, none involve a student-driven solution from low- and middle-income countries (LMICs). In response to falling surgical residency enrolment in South Africa, the students at the University of Cape Town (UCT) founded the UCT Surgical Society and were subsequently instrumental in creating the International Association of Student Surgical Societies (IASSS). The IASSS currently includes 25 societies in 15 countries. Its primary objectives are building sustainable networks for mutually beneficial exchanges, supporting student-driven projects, understanding issues impacting student interest in surgery, promoting global fellowship, creating an elective database and providing assistance to student surgical societies. The IASSS is a unique student-led initiative trying to improve surgical care in LMICs.

Penetrating trauma to the kidney and Meckel's Diverticulum in a patient with unilateral renal agenesis.

INTRODUCTION: Emergency laparotomy for abdominal gunshot wounds is frequently performed in South Africa and remains associated with significant morbidity and mortality. The occurrence of congenital anomalies during surgery is an unexpected finding and presents a major challenge. PRESENTATION OF CASE: The successful management of a haemodynamically unstable 26-year-old man with unilateral renal agenesis, concomitant right renal and hepatic injuries, and a transected Meckel's Diverticulum following an abdominal gunshot wound is presented. DISCUSSION: Intraoperative decision-making is difficult when congenital visceral anomalies form part of the injury complex in trauma. Basic principles of damage control surgery that include initial exploration, secondary resuscitation and definite operation must be adhered to. Repair of complex injuries are delayed until the definitive laparotomy. The presence of one congenital anomaly should alert the surgeon to the possibility of further anomalies. CONCLUSION: Although congenital visceral anomalies are spectacular findings at laparotomy, they should not distract the trauma surgeon. Adhering to damage control surgery principles and careful inspection of the peritoneal cavity for further abnormalities remain the mainstay of successful management.

Enterohepatic Migration of Fish Bone Resulting in Liver Abscess.

Liver abscess formation due to enterohepatic migration of a foreign body is extremely rare. Foreign body ingestion is generally an unconscious and painless event, thus complicating preoperative diagnosis in most patients. We report the case of a 61-year-old man who presented with secondary peritonitis from a ruptured hepatic abscess after an ingested fish bone migrated into the liver.

Screening for occult penetrating cardiac injuries.

OBJECTIVE: To determine the sensitivity of emergency department ultrasonography (US) in the diagnosis of occult cardiac injuries. BACKGROUND: Internationally, US has become the investigation of choice in screening patients for a possible cardiac injury after penetrating chest trauma by detecting blood in the pericardial sac. METHODS: Patients presenting with a penetrating chest wound and a possible cardiac injury to the Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 were prospectively evaluated. All patients were hemodynamically stable, had no indication for emergency surgery, and had an US scan followed by subxiphoid pericardial window exploration. RESULTS: There were a total of 172 patients (median age = 26 years; range, 11-65 years). The mechanism of injury was stab wounds in 166 (96%) and gunshot wounds in 6. The sensitivity of US in detecting hemopericardium was 86.7%, with a positive predictive value of 77%. There were 18 false-negatives. Eleven of these false-negatives had an associated hemothorax and 6 had pneumopericardium. A single patient had 2 negative US examinations and returned with delayed cardiac tamponade. CONCLUSIONS: The sensitivity of US to detect hemopericardium in stable patients was only 86.7%. The 2 main factors that limit the screening are the presence of a hemothorax and air in the pericardial sac. A new regimen for screening of occult injuries to make allowance for this is proposed.

HIV-positive-to-HIV-positive kidney transplantation--results at 3 to 5 years.

BACKGROUND: The outcome of kidney transplantation in human immunodeficiency virus (HIV)-positive patients who receive organs from HIV-negative donors has been reported to be similar to the outcome in HIV-negative recipients. We report the outcomes at 3 to 5 years in HIV-positive patients who received kidneys from HIV-positive deceased donors. METHODS: We conducted a prospective, nonrandomized study of kidney transplantation in HIV-infected patients who had a CD4 T-cell count of 200 per cubic millimeter or higher and an undetectable plasma HIV RNA level. All the patients were receiving antiretroviral therapy (ART). The patients received kidneys from deceased donors who tested positive for HIV with the use of fourth-generation enzyme-linked immunosorbent assay at the time of referral. All the donors either had received no ART previously or had received only first-line ART. RESULTS: From September 2008 through February 2014, a total of 27 HIV-positive patients underwent kidney transplantation. Survivors were followed for a median of 2.4 years. The rate of survival among the patients was 84% at 1 year, 84% at 3 years, and 74% at 5 years. The corresponding rates of graft survival were 93%, 84%, and 84%. (If a patient died with a functioning graft, the calculation was performed as if the graft had survived.) Rejection rates were 8% at 1 year and 22% at 3 years. HIV infection remained well controlled, with undetectable virus in blood after the transplantation. CONCLUSIONS: Kidney transplantation from an HIV-positive donor appears to be an additional treatment option for HIV-infected patients requiring renal-replacement therapy. (Funded by Sanofi South Africa and the Roche Organ Transplantation Research Foundation.).

Acute appendicitis in the public and private sectors in Cape Town, South Africa.

BACKGROUND: South Africa has a low incidence of acute appendicitis, but poor outcomes. However, South African studies on appendicitis focus solely on public hospitals, neglecting those who utilize private facilities. This study aims to compare appendicitis characteristics and outcomes in public and private hospitals in South Africa. METHODS: A prospective cohort study was conducted among two public and three private hospitals in the Cape Town metropole, from September 2013 to March 2014. Hospital records, operative notes, and histology results were reviewed for patients undergoing appendectomy for acute appendicitis. Patients were interviewed during their hospitalization and followed up at monthly intervals until normal function was attained. RESULTS: A total of 134 patients were enrolled, with 73 in the public and 61 in the private sector. Education and employment were higher among private sector patients. Public sector patients had a higher rupture rate (30.6 vs 13.2 %, p = 0.023). Times to presentation were not statistically different between the two cohorts. Public sector patients had longer hospital stays (5.3 vs 2.9 days, p = 0.036) and longer return to work times (23.0 vs 12.1 days, p < 0.0001). Although complication rates were similar, complications in public hospitals were more severe. CONCLUSIONS: Public sector patients in South Africa with appendicitis have higher rupture rates, worse complications, longer hospital stays, and longer recoveries than private sector patients. Patients with perforation had longer delays in presentation than patients without perforation.

The RWOPS debate - yes we can!

Remunerated work outside of public service (RWOPS) has largely been seen in a negative light. This is partly a result of the Public Service Commission review undertaken in 2004, but attitudes are also shaped by unsubstantiated reports of abuse. There are, however, potential advantages for both patients and doctors if RWOPS is done without neglecting public sector service and academic commitments. We explore some of the issues around controlling RWOPS, and the experience with this in the Department of Surgery at the University of Cape Town, South Africa.

Laparoscopic kidney donation - giving in the best way possible.

Laparoscopic donor nephrectomy is the preferred method of living kidney donation at most transplant centres. There are various techniques, all with their own reported benefits. This editorial gives a brief overview of the various methods in the context of ensuring maximum safety and benefit to the donor without compromising kidney transplant outcomes.

The flaws of laser Doppler in negative-pressure wound therapy research.

Recent studies, using modalities other than laser Doppler, have indicated that perfusion during negative-pressure wound therapy (NPWT) is reduced, contrary to world literature. The aim of the present study was to evaluate whether the measuring technique of the laser Doppler could be influenced by the compressive nature of NPWT dressings and whether this could explain the conflicting findings. A hypothesis that it may be possible for laser Doppler to record similar readings to those obtained during NPWT by merely compressing tissues manually was tested on 12 NPWT dressings, with each undergoing an alternating series of manual compressive forces and NPWT (-125 mmHg). During the periods of NPWT (n = 12), the mean perfusion recording increased in five experiments, reduced in six, and remained unchanged in one. During the period when manual pressure was applied (n = 12), there was a mean increase in perfusion in six experiments and a reduction in six. The type of change in perfusion (increase or decrease) was the same for both NPWT and manual pressure in 10 of the 12 experiments. In conclusion, laser Doppler can incorrectly record increased perfusion when tissues are compressed, implying that it is flawed in the field of NPWT research as tissues are always compressed to some degree by the NPWT dressing.

Management of a pneumopericardium due to penetrating trauma.

INTRODUCTION: A pneumopericardium presenting after penetrating chest trauma is a rare event. The surgical management of this clinical problem has not been clearly defined. The aim of this study was to document the mode of presentation and to suggest a protocol for management. PATIENT AND METHODS: A review of a prospectively collected cardiac database of patients presenting to Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 with a pneumopericardium on chest X-ray after penetrating trauma. RESULTS: There were 27 patients with a pneumopericardium (mean age 25 years, range 17-36). The mechanism of injury was a stab wound to the chest in 26 patients and a single patient with multiple low velocity gunshot wounds. Six patients (22%) were unstable and required emergency surgery. One of these patients presented with a tension pneumopericardium. Twenty-one patients were initially stable. Two of these (10%) patients later developed a tension pneumopericardium within 24-h and were taken to theatre. The remaining 19 patients were managed with a subxiphoid pericardial window (SPW) at between 24 and 48h post admission. Ten of these 19 patients (52%) were positive for a haemopericardium. Only 4 of the 19 underwent a sternotomy and only two of these had cardiac injuries that had sealed. There were no deaths in this series. CONCLUSION: Patients with a penetrating chest injury with a pneumopericardium who are unstable require emergency surgery. A delayed tension pneumopericardium developed in 10% of patients who were initially stable. It is our recommendation that all stable patients with a pneumopericardium after penetrating chest trauma should undergo a SPW. A sternotomy is not required in stable patients.

The influence manufacturers have on negative-pressure wound therapy research.

BACKGROUND: Studies investigating the effects of negative-pressure wound therapy using the Chariker-Jeter system (gauze-based interface) and the vacuum-assisted closure system often have outcomes that favor one particular system. This study attempts to examine whether manufacturer involvement could be related to the outcomes of these scientific studies. METHODS: A literature review was undertaken to identify a cohort of studies that compared these two forms of negative-pressure wound therapy. Clinical outcomes studies, basic research studies, and published conference abstracts were included. Allthe articles' abstracts and conclusions were given to five surgeons, who were blinded to the titles and authors. They were individually asked to record what they would consider to be the take-home message of each article (in terms of which system is superior). After categorizing each study according to the system that it appears to favor, the level of manufacturer involvement in each study was evaluated. The relationship between the outcome of a study and the level of manufacturer involvement in that study was then investigated. RESULTS: Of the total of 24 studies found to match the inclusion criteria, 22 were considered to favor a particular system (the other two were categorized as impartial). Of the 24 studies, 19 had some form of manufacturer involvement. Of the 19 that had some form of manufacturer involvement, 18 had outcomes that were deemed beneficial to the involved manufacturer, whereas one was deemed to have an impartial outcome. CONCLUSIONS: This study suggests that manufacturer involvement in these studies (regardless of level) correlates with the outcomes being beneficial to the involved manufacturer in almost all cases. Potential reasons for this and the implications thereof are discussed.

Sternotomy or drainage for a hemopericardium after penetrating trauma: a randomized controlled trial.

OBJECTIVE: To determine if stable patients with a hemopericardium detected after penetrating chest trauma can be safely managed with pericardial drainage alone. BACKGROUND: The current international practice is to perform a sternotomy and cardiac repair if a hemopericardium is detected after penetrating chest trauma. The experience in Cape Town, South Africa, on performing a mandatory sternotomy in hemodynamically stable patients was that a sternotomy was unnecessary and the cardiac injury, if present, had sealed. METHODS: A single-center parallel-group randomized controlled study was completed. All hemodynamically stable patients with a hemopericardium confirmed at subxiphoid pericardial window (SPW), and no active bleeding, were randomized. The primary outcome measure was survival to discharge from hospital. Secondary outcomes were complications and postoperative hospital stay. RESULTS: Fifty-five patients were randomized to sternotomy and 56 to pericardial drainage and wash-out only. Fifty-one of the 55 patients (93%) randomized to sternotomy had either no cardiac injury or a tangential injury. There were only 4 patients with penetrating wounds to the endocardium and all had sealed. There was 1 death postoperatively among the 111 patients (0.9%) and this was in the sternotomy group. The mean intensive care unit (ICU) stay for a sternotomy was 2.04 days (range, 0-25 days) compared with 0.25 days (range, 0-2) for the drainage (P < 0.001). The estimated mean difference highlighted a stay of 1.8 days shorter in the ICU for the drainage group (95% CI: 0.8-2.7). Total hospital stay was significantly shorter in the SPW group (P < 0.001; 95% CI: 1.4-3.3). CONCLUSIONS: SPW and drainage is effective and safe in the stable patient with a hemopericardium after penetrating chest trauma, with no increase in mortality and a shorter ICU and hospital stay. (ClinicalTrials.gov Identifier: NCT00823160).

A survey of medical students on their attitudes towards face transplantation.

The aim of this study was to assess and analyse the attitudes of medical students towards face transplantation. Medical students at the University of Cape Town were prospectively surveyed using a self-administered questionnaire. There were 402 participants; the mean age was 21 years (range 16-37 years), 35% were male and 65% were female. Only 12% were registered organ donors and 33% were interested in a surgical career. Two thirds of the respondents were in favour of face transplantation. Registered organ donors were the most willing to donate their face in the event of brain death (P = 0.00). Seventy-four percent of the respondents stated 'identity issues' as their main concern and 33% mentioned cost as a critical factor when considering the procedure. Personal experience with facial disfigurement and involvement in the care of a patient with facial disfigurement did not affect the willingness to donate or accept a face transplant, or the amount of support for the procedure (P > 0.05). This is the first study that exclusively describes the attitudes of medical students towards face transplantation.

A straight left heart border: a new radiological sign of a hemopericardium.

BACKGROUND: Detection of a cardiac injury in a stable patient after a penetrating chest injury can be difficult. Ultrasound of the pericardial sac may be associated with a false negative result in the presence of a hemothorax. A filling in of the left heart border inferior to the pulmonary artery, called the straight left heart border (SLHB), is a radiological sign on chest X-ray that we have found to be associated with the finding of a hemopericardium at surgery. The aim of the present study was to determine if this was a reliable and reproducible sign. METHODS: This was a prospective study of patients with a penetrating chest injury admitted between 1 October 2001 and 28 February 2009, who had no indication for immediate surgery, and were taken to the operating room for creation of a subxiphoid pericardial window (SPW). The chest X-ray was reviewed by a single trauma surgeon prior to surgery. RESULTS: A total of 162 patients with a possible occult cardiac injury underwent creation of a SPW. Fifty-five of the 162 patients (34 %) were noted to have a SLHB on chest X-ray and a hemopericardium confirmed at SPW. The sensitivity of the SLHB sign was 40 %; specificity, 84 %; and positive predictive value, 89 %. (p = 0.005, Odds ratio 3.48, lower 1.41, upper 8.62). CONCLUSIONS: The straight left heart border is a newly described radiological sign that was highly significant in predicting the presence of a hemopericardium and should alert the clinician to a possible occult cardiac injury.