Bioring® gastric banding for obesity in a private South African hospital.

BACKGROUND: Obesity is a significant health problem in South Africa. Surgery is the most effective means of durable weight loss for the morbidly obese. Of the surgical options, laparoscopic adjustable gastric banding is the most controversial. We aimed to assess a single surgeon's experience with a specific band. METHODS: A retrospective observational study of a continuous cohort of laparoscopic adjustable gastric Cousin Bioring® band placements from a single private South African hospital was conducted. Three hundred and fifty bands were placed in 347 patients, 75% were female. Variables analysed were BMI obesity class, comorbidities, weight loss, diabetes resolution, adherence to aftercare, patient satisfaction, complications and death. RESULTS: Outcomes were assessed in 343 patients (4 patients lost to follow-up). The mean follow-up was 39 months (IQR 29-66 months). The mean preoperative BMI was 43.3 kg/m2 (IQR 37.4-47.6 kg/m2). Most weight loss occurred in the first year, and 66% achieved > 40% excess weight loss. Resolution of type 2 diabetes and prediabetes occurred in 56.4% and 89.8% of patients respectively. Increasing age (p = 0.002), class 3 obesity (p < 0.001) and suboptimal aftercare (p < 0.001) were associated with failure. One patient developed band erosion and 40 developed band slippage, 34 of whom underwent secondary surgery (32 removals, 2 revisions). All complications were grade I-III. There was no high grade complication, and no death. CONCLUSIONS: Bioring® gastric banding achieved moderately good weight loss and resolution of type 2 diabetes with a low complication rate. BMI > 60 and suboptimal aftercare predicted poor outcome.

Traumatic renal injury: Five-year experience at a major trauma centre in South Africa.

BACKGROUND: This study is intended to assess the current optimal management of traumatic renal injuries (TRIs), with a focus on high-grade and penetrating injuries. METHODS: The Pietermaritzburg Metropolitan Trauma Service registry was interrogated retrospectively for patients managed for TRI between 1 January 2012 and 31 December 2016. RESULTS: Of 13,315 inured patients treated by the PMTS, 223 (1.7%) had TRIs with an incidence of 1.5 per 100,000 population per year. The majority were males between 20 and 39 years of age. The distribution of mechanism of injury was 56.1% (n = 125) blunt and 43.9% (n = 98) penetrating trauma with no association between mechanism and grade of injury. Penetrating trauma was associated with hollow viscus and diaphragm injuries and blunt trauma with solid organ injuries. A total of 118 patients (52.9%) were managed non-operatively, 60 (26.9%) were not explored at operation, 27 (12.1%) underwent initial nephrectomy and 8 (3.6%) underwent renorraphy. Low-grade injuries (AAST I and II) and high-grade injuries (AAST III-V) were managed without renal intervention (non-operatively or not explored at laparotomy for associated injuries) in 88.7% (n = 87) and 72.0% (n = 91) of cases respectively. Blunt and penetrating injuries were managed without renal intervention in 87.9% (n = 109) and 70% (n = 69) of cases respectively. The initial nephrectomy rate was 1% (n = 1) and 20.6% (n = 26) for low- and high-grade injuries respectively, and 6.5% (n = 8) and 19% (n = 19) for blunt and penetrating injuries respectively. High grade (AAST III-V) injury (OR 14.94; 95% CI 3.36 - 66.34; p<0.001), penetrating mechanism (OR 4.99; 95% CI 1.98 - 12.52; p = 0.001) and metabolic acidosis (OR 2.73; 95% CI 1.04 - 7.20; p = 0.042) were significant risk factors for nephrectomy. Four patients (1.8%) underwent ureteral stent insertion and 2 (0.9%) underwent embolisation. The failure rate of initial non-operative management was 1.1%. The mortality rate was 8.1% (n = 18), but no patients with solitary renal injuries died. CONCLUSION: Even in high-grade injuries and penetrating trauma, the majority of patients with TRI can be managed non-operatively or with the assistance of endourological or endovascular techniques, with good outcomes. Risk factors for nephrectomy include the presence of high-grade injuries, penetrating trauma and metabolic acidosis on presentation.

The presentation, management and outcomes of Fournier's gangrene at a tertiary urology referral centre in South Africa.

BACKGROUND: Fournier's gangrene (FG) is a clinically relevant condition with a high mortality rate. In South Africa (SA) most affected patients present at district and regional level hospitals. It is important for doctors to recognise the condition and accurately assess patients with FG to decide which of them need urgent referral to a tertiary centre. OBJECTIVES: To review the presentation, management and outcomes of patients with FG at a tertiary urology referral centre, with the specific intention of identifying prognostic factors and assessing the validity of the Fournier's Gangrene Severity Index (FGSI). METHODS: A retrospective chart review was performed of all patients treated for FG over a 5-year period at Grey's Hospital in Pietermaritzburg, SA. HIV-positive patients were compared with patients with diabetes mellitus (DM). The FGSI was calculated for each patient. Regression analysis was performed to identify risk factors. RESULTS: Forty-four patients (mean age 51 years) were treated for FG, corresponding to 8.8 patients per year. HIV was the commonest comorbidity, followed by DM. HIV-positive patients presented at a younger age than non-HIV-positive patients (p<0.001). On average the patients underwent 1.33 debridements, and 45.5% required transfusion. All were treated with broad-spectrum antibiotics. The overall mortality rate was 11.4% and the mean hospital length of stay was 26 days. There was no difference between the mean age of survivors and non-survivors (p=0.752). There was no association between mortality, HIV, DM or number of debridements. The mean (standard deviation) FGSI was significantly different in patients who died (15.4 (4.78)) and those who survived (5.92 (4.09)) (p<0.001). There was a significant association between FGSI >9 and mortality (p=0.017). FGSI >9 predicted 44.4% mortality, and FGSI ≤9 predicted 95.5% survival. A combination of FGSI >9, debridement outside the perineum (onto the abdominal wall, chest or limbs) and requirement for organ support was present in 80.0% of patients who died and was a significant risk factor for mortality (p=0.002). CONCLUSIONS: In a resource-constrained environment such as SA, outcome prediction is necessary to enable resource allocation. Patients with an FGSI >9 have a high risk of mortality and will benefit from ICU care. The combination of FGSI >9, requirement for organ support and extension beyond the perineum is associated with a very high risk of mortality and may be useful as an exclusion criterion when allocating scarce resources.

Five year review of open radical nephrectomies at a regional hospital in South Africa: room for improvement.

BACKGROUND: To review the presentation and outcomes of patients undergoing open radical nephrectomy (ORN) for renal cell carcinoma (RCC) at a regional hospital in KwaZulu-Natal, South Africa. METHOD: A retrospective chart review was performed of patients having undergone nephrectomy at St Aidan's hospital between 2010 and 2015, focusing on those with RCC. Demographic, operative, histopathology and outcomes data were collected. RESULTS: Fifty-two patients (51%) had ORN for suspected malignant disease. Forty-one RCCs were found including one incidental finding at simple nephrectomy. Data was insufficient to assess risk factors for RCC. HIV positive patients tended to present earlier (45 vs. 53 years). The mean tumour size was 10 cm and organ confined disease was present in 73.2% of patients. Only 11 patients (26.8%) had pT1 disease. The high-grade complication rate was 9.8%, in-hospital mortality rate 4.9% and transfusion rate 51.2%. The median operating time was 1h 50min and length of hospital stay 13 days. CONCLUSION: Open radical nephrectomy is the standard surgical treatment for RCC at regional level in South Africa. Patients tend to present at a younger age, particularly if HIV positive, and with large tumours. Further research into risk factors for RCC in the South African population is needed. There are high complication and transfusion rates in patients undergoing ORN. Review of accessibility of blood at St Aidan's hospital and revision of the transfusion protocol is suggested. A followup study to assess the feasibility and cost-effectiveness of laparoscopic nephrectomy in the resource-constrained South African environment is necessary.

The effect of a concomitant renal injury on the outcome of colonic trauma.

BACKGROUND: The management of colon injuries has steadily evolved over the course of the last half century. So too has the management of renal trauma. It is not clear from the literature as to whether concomitant colon and renal injuries carry increased risk of morbidity and mortality, and whether this combination of injuries necessitates a specifically tailored management approach. METHODS: A retrospective review was carried out for the period January 2012 to December 2016. All patients over the age of 18 years who were subjected to laparotomy for penetrating trauma (gunshot wounds or stab wounds) and who sustained an intra-operatively proven colonic injury were included in this study. Operative management and outcomes were investigated. A direct comparison was made between patients with a combined colonic and renal injury and those with only a colonic injury. RESULTS: Over the five-year period a total of 268 patients sustained a colonic injury. The 239 patients with a colonic injury (Group A) were compared to the 29 patients with a combined colonic and renal injury (Group B). Regarding the management of the colonic injuries, there were no differences in the rates of primary repair, anastomosis, exteriorization, or damage control surgery between groups A and B. As for the management of the renal injury, 14 were not explored at laparotomy; in 12 a nephrectomy was performed and in 3 the renal injury was repaired. The nephrectomy cohort were more likely to have undergone damage control surgery, to be admitted to ICU, to receive a colostomy, and had higher mortality. While there was no difference in the need for damage control surgery or mortality between groups, Group B had a significantly greater need for ICU admission. Morbidity was similar between the two groups - in particular, there was no difference in the rates of either gastro-intestinal complications or acute kidney injury between the two groups. CONCLUSION: In patients with combined colon and renal injuries, it seems reasonable to treat each organ on its own merit, without the expectation of increased morbidity or mortality. In the non-damage control setting, most colonic injuries may be safely repaired, and a peri-renal haematoma that is not expanding or actively bleeding may be safely left alone.

Five year review of open radical nephrectomies at a regional hospital in South Africa: room for improvement

Background:To review the presentation and outcomes of patients undergoing open radical nephrectomy (ORN) for renal cell carcinoma (RCC) at a regional hospital in KwaZulu-Natal, South Africa.Methods:A retrospective chart review was performed of patients having undergone nephrectomy at St Aidan's hospital between 2010 and 2015, focusing on those with RCC. Demographic, operative, histopathology and outcomes data were collected.Results:Fifty-two patients (51%) had ORN for suspected malignant disease. Forty-one RCCs were found including one incidental finding at simple nephrectomy. Data was insufficient to assess risk factors for RCC. HIV positive patients tended to present earlier (45 vs. 53 years). The mean tumour size was 10 cm and organ confined disease was present in 73.2% of patients. Only 11 patients (26.8%) had pT1 disease. The high-grade complication rate was 9.8%, in-hospital mortality rate 4.9% and transfusion rate 51.2%. The median operating time was 1h 50min and length of hospital stay 13 days.Conclusions:Open radical nephrectomy is the standard surgical treatment for RCC at regional level in South Africa. Patients tend to present at a younger age, particularly if HIV positive, and with large tumours. Further research into risk factors for RCC in the South African population is needed. There are high complication and transfusion rates in patients undergoing ORN. Review of accessibility of blood at St Aidan's hospital and revision of the transfusion protocol is suggested. A follow-up study to assess the feasibility and cost-effectiveness of laparoscopic nephrectomy in the resource-constrained South African environment is necessary

The incidence, spectrum and outcomes of traumatic bladder injuries within the Pietermaritzburg Metropolitan Trauma Service.

INTRODUCTION: The purpose of this study is to provide a comprehensive overview of the incidence, spectrum and outcomes of traumatic bladder injury in Pietermaritzburg, South Africa, and to identify the current optimal investigation and management of patients with traumatic bladder injuries. METHODS: The Pietermaritzburg Metropolitan Trauma Service (PMTS) trauma registry was interrogated retrospectively for all traumatic bladder injuries between 1 January 2012 and 31 October 2014. RESULTS: Of 8129 patients treated by the PMTS over the study period, 58 patients (0.7% or 6.5 cases per 1,000,000 population per year) had bladder injuries, 65% caused by penetrating trauma and 35% by blunt trauma. The majority (60%) were intraperitoneal bladder ruptures (IBRs), followed by 22% extraperitoneal bladder ruptures (EBRs). There was a high rate of associated injury, with blunt trauma being associated with pelvic fracture and penetrating trauma being associated with rectum and small intestine injuries. The mortality rate was 5%. Most bladder injuries were diagnosed at surgery or by computed tomography (CT) scan. All IBRs were managed operatively, as well as 38% of EBRs; the remaining EBRs were managed by catheter drainage and observation. In the majority of operative repairs, the bladder was closed in two layers, and was drained with only a urethral catheter. Most patients (91%) were managed definitively by the surgeons on the trauma service. CONCLUSION: Traumatic bladder rupture caused by blunt or penetrating trauma is rare and mortality is due to associated injuries. CT scan is the investigative modality of choice. In our environment IBR is more common than EBR and requires operative management. Most EBRs can be managed non-operatively, and then require routine follow-up cystography. Simple traumatic bladder injuries can be managed definitively by trauma surgeons. A dedicated urological surgeon should be consulted for complex injuries.

Prostate Cancer at a regional hospital in South Africa: we are only seeing the tip of the iceberg.

OBJECTIVES: The objectives were to document the presentation of prostate cancer in the Zulu population of KwaZulu-Natal in South Africa, to identify this as a high-risk population, and to determine the potential for under-diagnosis in this population. METHOD: All histopathology results confirming prostatic adenocarcinoma from biopsies preformed at Edendale hospital from 01/11/2012 to 30/04/2014 were collected. A total of 81 participants were enrolled, and a review of their outpatient records was performed. Patient presentation was analysed, younger patients were compared to older patients, and observed incidence was compared to expected incidence. RESULTS: The majority of patients (66%, 95% confidence interval [CI]:54-76%) presented with radiographic evidence of metastatic disease or PSA greater than 100 ng/ml. The median PSA level at presentation was 154 ng/ml (Interquartile range [IQR] = 39-448). Clinically staged T4 disease was present in 44% of patients and only 10% of patients presented with PSA detected disease. Poorly differentiated tumours (Gleason grades 8, 9 and 10) were found in 43% of patients. Only 81 out of a maximum potential of 625 incident prostate cancer cases were diagnosed. CONCLUSION: Black South African men from a predominantly rural Zulu population present late and with advanced and aggressive disease. We are missing the opportunity for remission in most patients in this high risk population group. The establishment of a National Prostate Cancer Registry and further research into a prostate cancer screening programme may be beneficial to this community.