Surgical training and capacity development in the South African internship programme.

Medical practitioners in South Africa manage a quadruple burden of disease. Junior doctors, who contribute significantly to the health workforce, must complete 2 years of internship training and 1 year of community service work in state health facilities after graduation to register as an independent medical practitioner. The aim of this article is to give a critical appraisal of the current national internship programme and why it was implemented, and outline suggestions for future changes. There is a compelling need to train competent, confident doctors while ensuring that the requirements and demands of our health system remain a central concern.

Laparoscopic splenopexy for wandering spleen with absorbable mesh fixation.

SUMMARY: Wandering spleen is a rare condition characterised by lack of fixation of the spleen to its usual position in the left upper quadrant. Laparoscopic splenopexy has become the standard of care. Although a number of methods have been described, the use of an absorbable mesh to secure the spleen to the left upper quadrant has been shown to be safe, effective and quick to perform. We present a case of a 32-year-old female with this condition and describe our surgical technique for fixation of the spleen using an absorbable mesh.

Surgery for Pheochromocytoma: A Single-Center Review of 60 Cases from South Africa.

BACKGROUND: There is a paucity of data on the presentation and surgical management of pheochromocytoma in developing nations, particularly in Africa. METHODS: This study was a retrospective review, which included all patients managed by the Groote Schuur Hospital/University of Cape Town Endocrine Surgery unit for pheochromocytoma and abdominal paragangliomas, from January 2002 to June 2019. RESULTS: Sixty patients were included in the study, of which 33% were male and 67% female. The mean age was 47 years (range 14-81). The median tumor size was 6 cm, with 45% larger than 6 cm. 92% were located in the adrenal gland (87% unilateral, 5% bilateral), and 8% were extra-adrenal. The conversion rate for laparoscopic cases was 20%, with 55% of cases overall completed laparoscopically. Eleven patients with tumors > 6 cm were initially attempted laparoscopically, of which 3 were converted to open, without any associated increased morbidity. A major adverse event was recorded for 5 cases (8%), including 1 mortality. Overall morbidity, blood loss, operating time and hospital stay were all significantly reduced in the laparoscopic group. There were 5 patients with malignant disease (8%). CONCLUSION: This large series, from an established academic endocrine surgery unit in Africa, can serve as a benchmark for units with similar settings and resource limitations, to compare their surgical management and perioperative outcomes.

LKB1 loss is associated with glutathione deficiency under oxidative stress and sensitivity of cancer cells to cytotoxic drugs and γ-irradiation.

The liver kinase B1 (LKB1) gene is a tumor suppressor associated with the hereditary Peutz-Jeghers syndrome and frequently mutated in non-small cell lung cancer and in cervical cancer. Previous studies showed that the LKB1/AMPK axis is involved in regulation of cell death and survival under metabolic stress. By using isogenic pairs of cancer cell lines, we report here that the genetic loss of LKB1 was associated with increased intracellular levels of total choline containing metabolites and, under oxidative stress, it impaired maintenance of glutathione (GSH) levels. This resulted in markedly increased intracellular reactive oxygen species (ROS) levels and sensitivity to ROS-induced cell death. These effects were rescued by re-expression of LKB1 or pre-treatment with the anti-oxidant and GSH replenisher N-acetyl cysteine. This role of LKB1 in response to ROS-inducing agents was largely AMPK-dependent. Finally, we observed that LKB1 defective cells are highly sensitive to cisplatin and γ-irradiation in vitro, suggesting that LKB1 mutated tumors could be targeted by oxidative stress-inducing therapies.

Nodal disease predicts recurrence whereas other traditional factors affect survival in a cohort of South African patients with differentiated thyroid carcinoma.

BACKGROUND AND AIM: Information on patients with differentiated thyroid carcinoma in South Africa is limited. The objective of this study was to review demographics and tumour characteristics in a cohort of patients with differentiated thyroid carcinoma, presenting to Groote Schuur Hospital and evaluate risk factors for recurrence and survival. PATIENTS AND METHODOLOGY: Retrospective demographic and clinical data were collected on all patients referred between January 2003 and December 2013. Prognostic factors for recurrence free survival and cancer specific survival were assessed using univariate and multivariate analyses. RESULTS: The total number of patients was 231.The median age at presentation was 44 years and 82% were female patients. The pathological sub-types were papillary (60.6%), follicular (38.9%) and poorly differentiated (0.5%). Total thyroidectomy was performed in 191 patients and 30 patients required neck dissections. A total of 171 (74%) patients received 131Iodine. The recurrence free and cause specific survival rates at 10 years were 83 and 91%, respectively. Nodal disease at presentation was the only significant risk factor for recurrence (p <  0.001) on multivariate analysis. Significant risk factors for cause specific mortality were age ≥ 45 years (p = 0.006), follicular pathology (p = 0.004), extra-thyroid extension (p = 0.013) and residual tumour (p = 0.004). CONCLUSIONS: Consistent with international trends, patients with differentiated thyroid carcinoma treated at Groote Schuur Hospital had a favourable prognosis. The known risk factors associated with recurrence and survival in this South African cohort were consistent with those reported in developed countries.

ROS homeostasis and metabolism: a dangerous liason in cancer cells.

Tumor cells harbor genetic alterations that promote a continuous and elevated production of reactive oxygen species. Whereas such oxidative stress conditions would be harmful to normal cells, they facilitate tumor growth in multiple ways by causing DNA damage and genomic instability, and ultimately, by reprogramming cancer cell metabolism. This review outlines the metabolic-dependent mechanisms that tumors engage in when faced with oxidative stress conditions that are critical for cancer progression by producing redox cofactors. In particular, we describe how the mitochondria has a key role in regulating the interplay between redox homeostasis and metabolism within tumor cells. Last, we will discuss the potential therapeutic use of agents that directly or indirectly block metabolism.

Migration of surgeons ("brain drain"): the University of Cape Town experience.

BACKGROUND: The large-scale migration of doctors, including surgeons, from South Africa, has had a major impact on healthcare resources in this country. Although previous studies have suggested that the University of Cape Town (UCT) is of the main institution contributing to this "brain drain", the extent of the problem has not been documented previously. The aim of this study was to investigate where UCT trained surgical registrars go after completing their training. METHOD: General surgery registrars who trained at UCT and who wrote and passed the FCS final examination between 1992 and 2011 were included in the study. The data for this study were obtained from the examinations office of the Colleges of Medicine of South Africa. The number of registrars writing and passing the final examination, the number of registrars who went overseas, the number of registrars in private practice, and the number of registrars in subspecialist practice, were recorded. RESULTS: A total of 102 UCT-trained registrars wrote and passed the FCS final examination during the study period. Only 13% of the South African UCT-trained registrars left the country. Only 31% of the registrars who remained in South Africa went into private practice. A large proportion of the UCT-trained registrars (43%) elected to subspecialise. CONCLUSION: "Brain drain" with respect to UCT-trained surgical registrars was not as extensive as anticipated.

The challenges of managing breast cancer in the developing world - a perspective from sub-Saharan Africa.

Communicable diseases are the major cause of mortality in lower-income countries. Consequently, local and international resources are channelled mainly into addressing the impact of these conditions. HIV, however, is being successfully treated, people are living longer,and disease patterns are changing. As populations age, the incidence of cancer inevitably increases. The World Health Organization has predicted a dramatic increase in global cancer cases during the next 15 years, the majority of which will occur in low- and middle-income countries. Cancer treatment is expensive and complex and in the developing world 5% of global cancer funds are spent on 70% of cancer cases. This paper reviews the challenges of managing breast cancer in the developing world, using sub-Saharan Africa as a model.

Solid pseudopapillary epithelial neoplasm--a rare but curable pancreatic tumour in young women.

BACKGROUND: Solid pseudopapillary epithelial neoplasms (SPENs) of the pancreas are rare but curable tumours that have a low-grade malignant potential and occur almost exclusively in young women, with an excellent prognosis after complete resection. This study examines the clinicopathological characteristics of these tumours and evaluates the role of surgery in relation to their size and location. STUDY DESIGN: We reviewed the pre-, intra- and postoperative data on 21 patients with SPENs who underwent resection during a 30-year period. Data including demographic information, presenting symptoms and signs, extent of operation, histology, tumour markers and postoperative complications were evaluated to establish the optimal surgical management. RESULTS: All 21 tumours occurred in women (mean age 24.6 years, range 13-51 years). Sixteen patients presented with nonspecific abdominal complaints and a palpable abdominal mass, in 1 patient the tumour was found during emergency laparotomy for a complicated ovarian cyst, 1 patient presented with severe abdominal pain and shock due to a ruptured tumour, and in 3 patients the tumour was detected incidentally during imaging. The correct pre-operative diagnosis of SPEN was made in 10 patients. Incorrect preoperative diagnoses included hydatid cyst (3 patients), mesenteric cyst (2), pancreatic cystadenoma (2), ovarian cysts (1), islet cell tumour of the pancreas (1), and cavernous haemangioma of the liver (1). The mean diameter of the tumours was 12.5 cm (range 8 - 20 cm), and they occurred in the head (8), neck (5), body (2), and tail (6) of the pancreas. All SPENs were resected. Five patients had a pylorus-preserving pancreaticoduodenectomy, 4 a central pancreatectomy with distal pancreaticogastrostomy, 8 a distal pancreatectomy, 3 a local resection and one a total pancreatectomy and portal vein graft. In 1 patient, 2 liver metastases were resected in addition to the pancreatic primary tumour. The patient who presented in shock with tumour rupture and bleeding into the lesser sac later died of multiple organ failure after successful resection. Postoperative complications included a stricture at the hepaticojejunostomy after pancreaticoduodenectomy, which resolved after stenting, and a pancreatic duct fistula after local tumour resection, which required a distal pancreatectomy. Other complications were bleeding (2 patients) requiring re-operation and intraabdominal fluid collections requiring percutaneous drainage (3) or operation (1). Mean postoperative hospital stay was 16 days (range 6 - 40 days). Twenty patients are alive and well without recurrence, including the patient with metastases, with a mean follow-up of 6.6 years (range 6 months-15 years). CONCLUSIONS: This study demonstrated that SPENs of the pancreas are uncommon, but should be considered in the differential diagnosis of a cystic mass of the pancreas in a young woman. Despite the indolent biological behaviour of SPENs, most patients required major pancreatic resection. Surgery is curative regardless of the size or location of the tumour. Metastases are rare, as is recurrence after complete surgical resection.

Self-expanding metal stents as an alternative to surgical bypass for malignant gastric outlet obstruction.

BACKGROUND: Gastroduodenal obstruction due to malignancy can be difficult to palliate. Self-expanding metal stents (SEMS) are gaining acceptance as an effective alternative to surgical bypass. METHODS: Patients not suitable for surgical bypass, with complete gastric outlet obstruction as a result of malignancy, were offered palliation with SEMS from November 2004 to December 2008. The procedure was performed under fluoroscopic guidance and conscious sedation. Data were collected prospectively. RESULTS: Seventy patients underwent SEMS placement (hepatobiliary and pancreatic malignancy, 44; antral gastric carcinoma, 19; other, seven). Follow-up was complete in 69 patients (99 per cent). Technical and clinical success rates were 93 and 95 per cent respectively. Median hospital stay was 2 (range 1-18) days, median survival was 1.8 (0.1-19.0) months, and 87 per cent had improved intake after SEMS placement, as determined by Gastric Outlet Obstruction Severity Score before and after stenting (P < 0.001). Complications included two episodes of minor bleeding. CONCLUSION: The use of SEMS to alleviate complete malignant gastric outlet obstruction in patients with limited life expectancy is successful in re-establishing enteral intake in most patients, with minimal morbidity, no mortality and a short hospital stay.

Investigation of the spatial distribution of glutathione redox-balance in live cells by using Fluorescence Ratio Imaging Microscopy.

The dynamics of redox elements in biologic systems is a major challenge for redox signaling and oxidative stress research. Oxidative stress or signaling events can affect sulfur switches differently, thus creating a variation in the spatial distribution of these redox states, which therefore act simultaneously as regulators and indicators of key cellular functions in both physiological and pathological settings. A gluthatione specific redox-sensitive protein (i.e. a mutant of the Yellow Fluorescent Protein (rxYFP)) has been found to equilibrate in vivo with the gluthatione/gluthatione disulfide (GSH:GSSG) redox couple. rxYFP, employed ratiometrically, allows to generate high resolution maps of the fraction of the reduced protein (R) inside a cell. Here we developed an analytical procedure able to investigate intracellular changes in the glutathione redox-balance, which can occur in live mammalian cells, based on the deconvolution of the histogram of redox maps of 293-TPhoenix human embryonic kidney cells. The intracellular spatial distributions of oxidized and reduced elements have been discriminated. Finally, by transfecting cells with human Glutaredoxin V (GRX-V), an enzyme deputed to maintain reduced the thiol groups of their partner proteins, we can disclose that the significant shift towards more reduced state, with respect to that recovered from non-transfected cells, consists, instead, in a shift towards reduced values of the high R region (reduced), while leaving unaltered the glutathione redox-balance of the intracellular side of the plasma membrane.

Risk of blood splashes to the eye during surgery.

BACKGROUND: With the advent of a new infectious era involving the HIV and hepatitis B and C viruses, concern has arisen about transmission of these viruses through ocular blood splashes during surgery. The purpose of the study was to determine the risk of ocular blood splashes to surgeons and their assistants during surgery. METHOD: Surgeons and assistants in several surgical disciplines were requested to wear facemasks with a transparent plastic visor. The visors were collected postoperatively and inspected for macroscopic and microscopic blood splashes. RESULTS: Fifty-nine per cent of the surgeons and assistants refused to wear facemasks with a visor. The incidence of blood splashes in those who participated was 45%. There was a trend for blood splashes to be more common during major surgery and during elective surgery. Surgeons and assistants were subject to similar risk. CONCLUSION: This study confirms the significant risk of ocular blood splashes during surgery, while also suggesting that both surgeons and assistants lack appreciation of the risk.

National survey of surgeons' attitudes to laparoscopic surgical training in South Africa.

AIM: Laparoscopic surgery forms an integral component of modern surgical practice. The perception exists that laparoscopic training in South Africa has been unplanned and under-resourced. This study set out to assess the opinions of surgeons and surgical trainees with regard to the various facets of laparoscopic surgical training. METHODS: A national survey was conducted, using a questionnaire distributed to surgical staff of all academic surgical centres. Multiple variables were assessed, predominantly using the following numerical scoring system: 5--strongly agree; 4--agree; 3--neutral; 2--disagree; 1--strongly disagree. RESULTS: There were 122 respondents: 77 trainees and 45 consultants. The majority strongly agreed that laparoscopic training is essential for local surgical registrars. Current laparoscopic training was assessed as being average. Cholecystectomy, diagnostic laparoscopy, antireflux surgery and appendicectomy were the laparoscopic procedures deemed most important in training. The average number of laparoscopic cholecystectomies respondents thought were required for competency was 24. The major hurdle to training was lack of equipment and equipment shortages, and the majority felt that laparoscopic skills facilities and laparoscopy seminars would optimally augment training. CONCLUSION: Surgeons and trainees in academic units recognise the importance of laparoscopic training, but feel that it is currently not optimal. Consensus exists on appropriate procedures and what the hurdles are to training in our context. This knowledge can be applied to improve laparoscopic surgical training in South Africa.

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.