The South African Journal of Surgery is the official journal of the Association of Surgeons of South Africa (ASSA). It is an internationally indexed, quarterly, general surgical journal. It carries research articles and letters, editorials, clinical practice and other surgical articles and personal opinion, South African health-related news, obituaries and general correspondence. Please contact Robyn Marais if you have any queries.
Journal stewardship: Walking the surgical editorial tightrope
The South African Journal of Surgery (SAJS), established in 1962, is the official publication of the Association of Surgeons of South Africa. As a quarterly, peer-reviewed journal, the SAJS plays a vital role in disseminating surgical research, clinical insights, and commentary relevant to South Africa and the broader continent. The journal is listed and indexed internationally on MEDLINE and locally for academic subsidy purposes on the Scientific Electronic Library Online (SciELO SA). At its helm, the editor, deputy editors, and editorial board serve not merely as administrators, but as custodians of academic integrity, scientific rigor, and editorial quality.
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Roux-en-Y gastric bypass: Pilot study results from a resource constrained setting
Background: Obesity is a growing global health issue, with significant implications for comorbid conditions and overall mortality. Metabolic and bariatric surgery (MBS), particularly Roux-en-Y gastric bypass (RYGB), has proven effective in achieving sustained weight loss and improving comorbidity resolution. MBS is limited in the public sector within South Africa due to cost. This pilot study, taking into consideration the resource constrained setting in South Africa, aims to assess the outcomes of RYGB surgery in a low resource setting, focusing on weight loss, comorbidity resolution, and complications over a 3-year period. Methods: A retrospective analysis was conducted on 17 patients who underwent RYGB at New Somerset Hospital, South Africa, between August 2017 and February 2020. The primary outcomes included percentage total weight loss (%TWL), excess weight loss (%EWL), and excess body mass index (BMI) loss (%EBMIL), while secondary outcomes involved the resolution of type 2 diabetes, hypertension, gastro‑oesophageal reflux disease (GERD), and dyslipidaemia. Results: At 3 years, the mean BMI decreased from 48.3 kg/m² to 38.35 kg/m², with a mean %TWL of 20.3%, %EWL of 42.5%, and %EBMIL of 43.2%. Notably, there were significant improvements in comorbidities, with a 50% resolution of type 2 diabetes, 71.4% resolution of GERD, and 66.7% resolution of dyslipidaemia. The complication rate was low, with one reported port site hernia. Conclusion: This study highlights the feasibility and effectiveness of MBS in a resource-constrained setting and demonstrates its potential for improving patient outcomes in the context of the obesity epidemic in South Africa. Further studies with larger cohorts and longer follow-up are needed to validate these findings and explore the long-term impact of MBS on public health.
Amyand’s hernia is a rare condition characterised by the presence of the appendix within an inguinal hernia sac. We describe a case of a complicated right-sided Amyand’s hernia, where imaging demonstrated a ruptured hernia containing a perforated appendix with an appendicolith and a rim-enhancing scrotal abscess, necessitating urgent surgical intervention. This case highlights the importance of computed tomography (CT) imaging in evaluating atypical groin sepsis, the value of multidisciplinary management, and the critical role of timely surgery. It further emphasises the need for individualised operative strategies when addressing complicated Amyand’s hernia with perforation and associated soft-tissue infection.
Median arcuate ligament syndrome without weight loss: A challenging diagnosis
Median arcuate ligament syndrome (MALS) is a rare vascular compression disorder of the celiac artery, typically presenting with postprandial abdominal pain and weight loss. We report a 44-year-old woman with chronic postprandial epigastric pain and nausea, but without weight loss. Her medical history included hypothyroidism, which may have masked this classical feature. Duplex ultrasonography revealed hemodynamically significant celiac artery compression with elevated peak systolic velocities. The patient underwent successful laparoscopic decompression of the median arcuate ligament, with sustained resolution of symptoms. This case highlights the diagnostic challenges of atypical MALS presentations and emphasises duplex ultrasonography as a valuable tool.
New hope for scar revision with a modified skin culture technique: a case report
Cultured epidermal autografts (CEA) are seldom used in scar revision despite evidence of favourable outcomes. We report a case using a modified technique, Kleintjes Cultured Skin (KCS), for revision of childhood burn scars on the lower legs. Keratinocytes were enzymatically isolated, seeded onto the dressing, and incubated for two weeks. KCS was applied directly onto the excised scars. Scar appearance, assessed with the Vancouver Scar Scale, improved from 4 preoperatively to 2 at a follow-up of two and six years, with progressive re-pigmentation, softness, and pliability. The biopsy site also healed favourably. This case supports the potential role of KCS in cosmetic scar revision.
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Preventing the preventable: Adolescent hepatocellular carcinoma and implications for hepatitis B virus prevention policy in South Africa
Background: Hepatocellular carcinoma (HCC) is a fatal disease of the young in sub-Saharan Africa (SSA) and chronic hepatitis B virus (HBV) infection remains the predominant aetiology. There is paucity of data regarding HCC in the adolescent population globally. Methods: Adolescents, defined as individuals aged 10 to 19 years according to the World Health Organization (WHO), with HCC treated at Groote Schuur Hospital (GSH) in South Africa from 1 January 2012 and 31 December 2024 were studied. Results: Five (0.5%) of the 726 HCC patients managed at GSH during the study period were adolescents. The median age was 18 (13-19) years and three were female. All five had chronic HBV infection and most presented with pain (60%) and/or an abdominal mass (40%). All had advanced disease, with four (80%) having Barcelona Clinic Liver Cancer (BCLC) stage C and one (20%) with BCLC stage D. Two (40%) had extrahepatic metastases and three (60%) had portal vein tumour thrombosis. Treatment included liver resection (1), sorafenib (1), lenvatinib (1), and best supportive care (2). At the time of the study, only one patient was alive. The median survival was 137 (25–425) days. Conclusions: Despite national HBV vaccination programmes in South Africa, in our experience adolescent HCC was HBV-related in all five patients. Extrahepatic metastases and macrovascular invasion were frequently reported and restricted patient access to curative- intended therapies (ablation, liver resection, transplantation). These findings highlight the urgent need for improved early detection and prevention strategies against perinatal HBV transmission in South Africa, including the rollout of the WHO-recommended universal hepatitis B birth-dose vaccination rather than the current targeted prevention approach.
The performance of fine needle aspiration cytology (FNAC) compared to histology in the preoperative diagnosis of thyroid cancer: a single centre study
Background: Thyroid cancer is the most common endocrine malignancy globally. Fine needle aspiration cytology (FNAC) is used in the diagnostic workup of thyroid nodules. There have been discrepancies between FNAC and histology at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). This prompted a study to determine the performance of FNAC compared to histology in diagnosing thyroid cancer at CMJAH. Methods: A retrospective review of patients who underwent thyroid surgery at CMJAH between 1 January 2015 and 1 September 2022 was conducted. Patient details were accessed via the theatre registry and the department of nuclear medicine. FNAC and histology results were accessed using the National Health Laboratory Service (NHLS) website. The data was collected and entered into a Microsoft Excel spreadsheet. STATA statistical software was used to analyse the data. Results: A total of 369 patients were screened, of which 222 were included in the study. We found the prevalence of thyroid cancer at CMJAH to be 35.6%. FNAC was found to have a sensitivity of 83.6% and a specificity of 88.7%. Its accuracy was 0.861 and it had a PPV of 81.2% and a NPV of 90.3%. The likelihood ratio generated was 7.39. PTC was found to be the most prevalent subtype with the FNAC malignancy detection rate of 85%. Conclusion: Our study showed that FNAC performed well in diagnosing thyroid cancer preoperatively. Therefore, it should continue to be used in the diagnostic workup of thyroid nodules at CMJAH.
Follicular thyroid carcinoma in South Africa: Insights from 103 cases
Background: Follicular thyroid carcinoma (FTC) accounts for approximately 17–20% of well-differentiated thyroid cancer (WDTC) worldwide. In South Africa (SA), FTC is more common than reported internationally, however, available SA studies included small patient numbers. This multi-institutional study comprehensively describes FTC patients who underwent surgery over a 5-year period, focusing on presentation, diagnosis, and management. Methods: A retrospective review of all patients with FTC operated at 13 academic hospitals throughout SA between January 2015 and December 2019 was conducted. The Thyroid Cancer Group of South Africa collectively entered data on the presentation, diagnosis, management, and short-term outcomes of 464 thyroid cancer patients into a REDCap database. Descriptive statistical analysis was performed. Results: Of 464 cases captured in the database, 103 (22.1%) were FTCs. WDTC was reported in 87.9% (408/464) of operations, with FTC comprising 25.2% (103/408). Of the 103 FTC patients, 82.5% (n = 85) were female and 16.5% (n = 17) male. The mean age was 51.8 years (SD 17.3). In cases where staging was reported, more than half (53.9%) presented with T3 tumours. Distant metastases were found in 12.6% of patients. Thyroid lobectomy was the most performed procedure (57.4%), followed by total thyroidectomy (37.6%). Conclusions: SA presents a multifaceted picture of FTC, with a higher incidence than in developed countries but lower than some other African nations. Patients are frequently symptomatic, which may predict worse outcomes. Standardised reporting and a national thyroid registry could assist in treatment planning and consistency of care.
The spectrum of thyroid disease requiring surgery: a single centre experience in South Africa
Background: Thyroid disease is a frequently encountered condition for the general surgeon. Limited literature on surgery for thyroid disease is available from the study area in KwaZulu-Natal which has a largely rural Black population of over three million people. The aim of the study is to audit the spectrum of surgically managed thyroid disease in a tertiary hospital. Methods: Descriptive analysis of six-years of prospectively collected thyroid surgery data from a tertiary hospital. Demographics, surgical indications, procedures, and histologies were studied and comparative analysis performed. Results: 346 patients with a female:male ratio of 22:1; age: 19–91 years, mean 51. The majority (77%) were Black ethnicity. 377 operations were performed. 346 patients had either a lobectomy (64.7%), subtotal thyroidectomy (13.6), or total thyroidectomy (21.7%) at the initial surgery. Re-do surgery was performed in 31 patients. The majority of surgery was for therapeutic indications, 65% for symptomatic multinodular goitre (MNG). Thyroid carcinoma (TC) was more frequently diagnosed in older female patients and 91.8% were well-differentiated TC. Two-thirds of diagnostic thyroid procedures found an adenoma. Conclusion: Thyroid pathology is prevalent in the study region. Most thyroid surgery was for middle-aged women with MNG which harboured TC in 11.2% of cases. A larger thyroid nodule did not correlate with the increased likelihood of TC. Follicular carcinoma was higher than international studies as was follicular variant of papillary thyroid cancer which may be explained by the study population. A national database is needed to audit the spectrum of thyroid disease requiring surgery across South Africa.
Twelve tips for setting up a national registry in South Africa: Principles and practice
Background: Patient- and disease-specific registries provide valuable real-world data and often demonstrate greater generalisability compared to randomised controlled trials. A national thyroid surgery registry in South Africa (SA) can promote collaboration among surgeons nationwide, guide resource allocation, inform local guidelines, improve the quality of care, and support research. Although numerous global guidelines exist on creating and implementing disease registries, there is a paucity of data from SA. This study aimed to explore the perspectives and experiences of stakeholders to establish a national thyroid registry. Methods: A qualitative study incorporated a survey and semi-structured interviews. Study groups included clinicians who (1) were recently involved in the Thyroid Cancer Group of SA (TCGSA) audit, (2) initially expressed interest in the TCGSA audit but could not participate, and (3) individuals who were involved in existing patient registries in SA. Participant perceptions and experiences with registries were discussed, and thematic analysis was performed on the transcribed data. Results: Twelve practical recommendations were synthesised based on the participants’ perspectives. The twelve tips emphasise establishing independent, well-governed, and accessible registries that clearly communicate their goals, encourage clinician use, ensure confidentiality, provide support, and promote simplicity and incentives to drive effective participation. This study is unique as the tips provided are based on stakeholder surveys and interviews, rather than relying solely on a literature review. Conclusion: Our findings reflect South African realities, including clinicians’ attitudes and administrative gaps, as well as experience-based tips. These stakeholder-informed, SA-specific recommendations can be adapted for use in other surgical disciplines aiming to establish a registry.
Outcomes of emergency abdominal surgery in an upper-middle income country urban health care system
Background: Abdominal emergencies are common and often require emergency surgery with mortality between 14% and 20%. Strategies have been introduced to reduce complications after emergency abdominal surgery, but resources in low- and middle-income countries (LMICs) countries are limited. There is a paucity of data on emergency abdominal surgery from the developing world. We aim to audit the mortality and morbidity of emergency laparotomies in the unique South African public health care system. Secondary endpoints were to identify system shortfalls to allocate quality improvement programmes to improve outcomes of acute abdominal emergencies. Methods: A retrospective review of a prospectively maintained database was conducted on emergency surgical procedures at all the public-funded health facilities in the Cape Town Metro West, South Africa. Results: There were 1471 patients who required emergency abdominal operations. The mean age was 36.7 (standard deviation (SD) = 15.95) with a male preponderance of 64.7%. The median duration of symptoms was 2 days (interquartile range (IQR) = 0–84). Overall 30-day mortality was 8% (n = 118) where 0.95% (n = 14) demised within 24 hours postsurgery. Factors associated with mortality were higher ASA class, higher Eastern Cooperative Oncology Group (ECOG) score, increasing age, higher Codman score, length of the procedure, presence of consultant during procedure, faecal contamination, contamination of more than one abdominal quadrant and use of inotropes intraoperatively. Conclusion: Despite resource constraints, patients presenting with abdominal emergencies requiring emergency abdominal surgery received care with mortality outcomes comparable to reported literature. This audit can be used as guide to identify healthcare system shortfalls to improve outcomes.
Confronting South Africa’s obesity crisis: Surgery or medication as the way forward?
In the writings of Claudius Aelian (170-235 A.D.), the statesman Dionysius concealed his big frame from his followers by hiding in a tower from which only his head emerged.1 Because he suffered from “difficult breathing” his doctors inserted long thin needles into him while in deep sleep, pushed until sensate flesh was reached. We do not know what happened to Dionysius, but the stigma surrounding obesity and the acknowledgement of its severe consequences is readily evident in ancient Greek writing.
Pharmacological treatment for obesity: a scalable solution for South Africa
Obesity is a disease with many complications, both directly and indirectly linked to adipose tissue excess and dysfunction. Type 2 diabetes (T2DM), stroke and cardiovascular disease account for the top causes of death nationally.1 Our country is confronted with an urgent national emergency and, much like the HIV epidemic, the obesity crisis now demands rapid, scalable, and equitable intervention to protect the nation’s health.
Recurrence of hepatocellular carcinoma after liver transplantation: Isolated splenic metastasis
Despite strict selection criteria for transplantation, relapse of disease after transplantation is observed. With the improvement in survival following treatment and advances in patient monitoring and management, extrahepatic metastases have gained increasing clinical significance. Extrahepatic hepatocellular carcinoma (HCC) recurrences are usually observed in the lungs, lymph nodes, bones, and adrenal glands. The spleen has been reported rarely as a metastatic site of HCC. There is no consensus for the management of HCC recurrence after liver transplantation. Surgical resection is usually the first choice of treatment because curative-intent treatments have better survival. In this case report, we will share a rare splenic recurrence in a patient who underwent liver transplantation due to HCC.
Bariatric surgery should lead South Africa’s obesity treatment strategy
Obesity is a chronic relapsing disease driven by complex biological, environmental, and socio-economic factors. South Africa (SA) has one of the highest obesity prevalence rates in sub-Saharan Africa, with obesity representing a major driver of non-communicable disease morbidity and mortality, including cardiovascular disease, chronic kidney disease, non-alcoholic fatty liver disease, obstructive sleep apnoea, osteoarthritis, and obesity-related malignancies.1,2 Despite its scale and cost, obesity care in SA remains fragmented and largely focused on managing downstream complications rather than treating obesity as a primary disease. In a resource-constrained healthcare system, interventions that provide durable clinical benefit and long-term economic value are essential. The robust clinical effectiveness and cost-effectiveness of metabolic and bariatric surgery (MBS) position it centrally in SA’s obesity treatment strategy for patients with severe disease.
Acuphagia: Insights into a rare surgical emergency
Acuphagia, the intentional ingestion of sharp metallic objects, is a high-risk form of pica associated with significant morbidity, including perforation, bleeding, and sepsis. This case series highlights key clinical lessons: a high index of suspicion is required due to unreliable histories, and imaging is essential for diagnosis and monitoring of multiple or migrating foreign bodies. Management must be individualised, ranging from conservative observation to endoscopic or surgical intervention depending on presentation. Recurrent ingestion and underlying psychiatric disease are common, necessitating early multidisciplinary involvement. In resource-limited settings, delays in presentation further increase the risk of complications, underscoring the need for structured diagnostic pathways and coordinated care.
Turning the tide: combined resection and radiofrequency ablation of synchronous liver metastases in colorectal cancer
Colorectal cancer (CRC) frequently metastasises to the liver, where multimodal therapy offers the best survival outcomes. We report a 45-year-old woman with rectosigmoid adenocarcinoma and synchronous liver metastases who showed an excellent response to neoadjuvant chemotherapy, evidenced by tumour marker decline and radiologic regression. She underwent single-stage colorectal and hepatic resection (HR) with intraoperative radiofrequency ablation. Follow-up imaging confirmed complete metabolic remission and nine months of disease-free survival. This case underscores the effectiveness of integrated systemic therapy and parenchymal-sparing hepatic surgery in synchronous colorectal liver metastasis.
Ileus following duodenal stent fracture and migration: a rare occurrence
An 80-year-old male with a history of intermittent, colicky, abdominal pain for one month duration, presented with acute exacerbation of his symptoms. The patient had had a covered, duodenal stent placed 10 years earlier due to a benign stricture. The cause of obstruction was revealed to be stent fracture with subsequent migration and embedding of a stent fragment into the jejunal wall. The affected jejunum was resected. Postoperative recovery was uneventful. To the best of the authors’ knowledge, no similar complication has been reported. Further research is needed into outcomes for duodenal stents indicated for benign strictures.
A rare case of H-type tracheoesophageal fistula associated with congenital oesophageal stenosis
H-type tracheoesophageal fistula (TOF) occurring in conjunction with congenital oesophageal stenosis (CES) is an infrequently reported condition. We present such a case in an infant with respiratory difficulty since birth. This report displays the challenges in diagnosis and the subsequent surgical management of this complex anomaly. A staged surgical approach, prioritising surgical ligation of the TOF followed by balloon dilatation of the CES proved to be effective with a favourable outcome.
A rare case of laryngeal spindle cell lipoma
We report a rare case of an intrinsic spindle cell laryngeal lipoma in a young immunocompromised adult causing acute upper airway obstruction. We discuss the management objectives and key points relating to the case. There are only 165 reported cases of laryngeal lipomatous lesions in the literature, with 30 being intrinsic lipomas and 50 being liposarcomas. It is challenging to differentiate between lipomas and liposarcomas of the larynx clinically and even histopathologically. Long-term follow-up is therefore recommended, and there should be a high level of clinical suspicion for liposarcoma in recurrences of surgically excised laryngeal lipomas.
Gallstone pancreatitis masking malignancy: when is additional imaging warranted?
Gallstones are common and they are a common cause of acute pancreatitis. Gallstones are themselves also a recognised risk factor for biliary malignancy, along with advancing age and female sex. We report two cases that highlight how presumed gallstone pancreatitis can mask coexisting malignancy. They illustrate that when patients present with gallstone pancreatitis in the presence of additional risk factors or constitutional features such as unintentional weight loss or anaemia, clinicians should maintain a high index of suspicion and pursue further diagnostic work-up to detect and stage any underlying malignancy.
Upper gastrointestinal endoscopy training: impact of the COVID pandemic on general surgery trainees
Background: Upper gastrointestinal endoscopy (UGE) is a vital skill for general surgeons, yet the adequacy of training in low-resource settings like South Africa remains unclear. This study assesses endoscopy training for general surgery registrars at Groote Schuur Hospital, with a focus on the impact of the COVID-19 pandemic. Methods: A retrospective analysis of the Upper Gastrointestinal Surgery Registry was conducted from 1 April 2018 to 30 September 2024. Data on diagnostic and interventional UGEs were reviewed across three periods: pre-COVID-19, during COVID-19, and post-COVID-19. Registrar exposure was evaluated based on the number of procedures performed during a standard three-month rotation. Descriptive and comparative statistical methods were applied (p < 0.05). Results: Of 12 455 UGEs, 6 901 (55.3%) were performed by registrars. Diagnostic procedures accounted for 66.9% of all UGEs, with registrars performing 64.1%, while interventional procedures made up 33.1%, with 37.8% performed by registrars. Training during the COVID-19 period was significantly reduced, with only two registrars completing full rotations, compared to the usual 12–18. Although procedural volume increased post-COVID – 21.8% for diagnostic and 60.2% for interventional UGEs – median registrar exposure per rotation dropped from 131 pre-COVID to 112 post-COVID. This indicates that despite increased service delivery, registrar training opportunities did not return to pre-pandemic levels. Conclusion: General surgery registrars at Groote Schuur Hospital receive substantial endoscopy exposure; however, the COVID-19 pandemic disrupted training significantly. Enhancing simulation-based learning and optimising rotations are crucial to ensure adequate competency in UGE.
Background: Individuals with intellectual disability (ID) are a uniquely vulnerable subset of South Africa’s trauma population, yet their injury patterns and outcomes remain poorly documented. This study aims to describe the epidemiology, mechanisms, and outcomes of trauma in this population. Methods: A retrospective review was conducted at the Pietermaritzburg Metropolitan Trauma Service between December 2012 and December 2023. Patients with a documented diagnosis of ID were identified from the Hybrid Electronic Medical Registry. Demographic data, injury characteristics, management, and outcomes were analysed. Subgroup analysis compared intentional and unintentional injuries. Results: Seventy-one patients with ID sustained trauma over the study period (0.4% of all admissions). The mean age was 25 years; 24% were female. Blunt trauma accounted for 90% of cases. Falls (27%) and pedestrian injuries (22%) were the most common mechanisms. Intentional trauma accounted for 21%, including gunshot (6%) and stab wounds (4%). The head was the most frequently injured region (77%). Morbidity was 51%, with neurological complications predominating. Admission to the intensive care unit (ICU) was required in 13%, and mortality was (1/71) 1.4%. Patients with intentional trauma were significantly older (mean 38 vs 21 years; p = 0.003). Conclusions: Patients with ID are highly vulnerable to trauma, particularly involving the head. Although falls are the predominant mechanism in our environment, a significant proportion of patients are victims of intentional trauma.
Early experience with the Clavien–Dindo classification in a major trauma unit
Background: The Clavien-Dindo system is an essential traditional approach for classifying surgical complications. This research primarily aimed to evaluate and assess the use of the Clavien-Dindo classification (CD classification) to classify complications and determine in-hospital mortality rates among patients admitted to a level one trauma facility in Johannesburg, South Africa. Methods: Data were collected retrospectively over a period of two years. We excluded patients younger than 18 years and those with incomplete clinical records. Frequencies and percentages illustrated the distributions of categorical variables. The association of each continuous variable with the complications was evaluated using Pearson’s chi-square or Fisher’s exact test. A p < 0.05 was considered statistically significant. Results: One hundred and ninety-six records of patients who developed complications were reviewed, representing a 6.3% complication rate among patients admitted to the unit during this study period, with 87.2% males and a median age of 32 years across both sex groups. Penetrating injuries accounted for 69.4% of the cases. Grade I complications (34.2%) were the most commonly reported. Wound infections had the highest reported incidence, representing 21% of the cases. Most complications, comprising 63.8%, were associated with surgical procedures across all types of CD grades. The overall mortality rate was 9.2% (grade V). Conclusions: Through this early experience we were able to test and demonstrate the applicability of the CD classification system within a real-world trauma population. This approach provides a structured method for documenting adverse events and facilitates comparability across centres. This audit demonstrated a high grade I complication rate and additionally highlighted several other trends, such as the prevalence of penetrating injuries in South Africa, and the impact of surgical procedures as a primary predictor of complications.
Trauma ICU patients requiring tracheostomy: a single-centre experience
Background: The tracheostomy is a commonly performed procedure in the context of trauma care. There is paucity of data on factors affecting outcomes after a tracheostomy. This study aims to determine complication and mortality rates of tracheostomies in trauma patients and to determine the association of these outcomes with level of surgeon, urgency of procedure and surgical approach utilised. Methods: This was a retrospective audit at a single academic hospital. All patients who had tracheostomies performed by trauma unit staff within the unit between 1 June 2016 and 31 May 2023 were included. Clinical variables and outcomes were evaluated. Results: A total of 247 patients were enrolled in the study. The overall complication rate was 4.86%. There was no significant difference in complication rates when comparing level of surgeon (p < 0.999), urgency of procedure (p = 0.469) or surgical approach (p = 0.444). Thirty-day all-cause mortality rate was 21.05%. There was no significant difference in mortality rates among the different levels of surgeons (p = 0.678) or surgical approach (p = 0.553). Mortality rates were significantly higher (p = 0.022) in elective tracheostomies than emergency tracheostomies. Conclusion: The use of different surgical approaches did not affect complication or mortality rates of tracheostomies performed. Elective procedures had a higher mortality rate than emergency procedures which suggests urgency alone may not be a risk factor and that burden of injury may need to be considered. Seniority of surgeon did not affect complication or mortality rates. This supports that structured training with adequate supervision allows junior doctors to safely perform such procedures.
Controversies in the emergency management of colorectal cancer and strategies for improved outcomes: a systematic review
Background: Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide, with approximately 1.8 million new cases diagnosed annually and over 860 000 deaths per year. Despite established screening programmes, between 15% and 45% of patients present as emergencies due to obstruction or perforation, conditions associated with significantly increased morbidity and mortality compared with elective presentations. The objective was to evaluate the management of emergency CRC patients with obstruction or perforation and assess existing controversies. Methods: A systematic search was conducted across PubMed, Cochrane Library, Embase, Scopus, and Google Scholar, focusing mainly on studies published between 2000 and 2024, including randomised controlled trials, meta-analyses, cohort studies, and clinical guidelines for managing adult emergency CRC cases. Results: Emergency CRC is associated with significantly worse outcomes than elective surgery, with 30-day mortality ranging from 15–33% for obstruction and 26–77% for perforation. Management of obstruction and perforation differs substantially. Diverting stoma remains a standard and widely accepted intervention for left-sided and rectal obstruction, particularly in settings where self-expanding metal stents (SEMS) expertise or availability is limited. Although early trials raised concerns about SEMS-related perforation and tumour dissemination, large European randomised trials (ESCO and CReST) demonstrated comparable long-term oncologic outcomes between SEMS as a bridge to surgery and emergency resection when appropriately selected. Conclusions: To improve outcomes in patients with obstructed and perforated colorectal cancer, a multidisciplinary, evidence-based approach is critical. Strategies include reducing the incidence of advanced CRC through screening and early diagnostic pathways, optimising emergency surgical management protocols, increasing access to colorectal units, centralising care to specialised colorectal units, refining the use of SEMS, adapting enhanced recovery after surgery (ERAS) protocols for emergency settings, and refining bridge-to-surgery strategies.
Transoral endoscopic thyroidectomy via vestibular approach (TOETVA): initial experience
Background: We present our first four thyroidectomies performed via endoscopic vestibular approach. Methods: Retrospective data was collected for all four patients who had endoscopic thyroid surgeries performed at a single centre between November 2023 and September 2024. Information on patient demographics, surgical technique and postoperative outcomes was collected and reviewed. Outcomes: All four patients had transoral endoscopic thyroidectomy vestibular approach (TOETVA) successfully completed; conversion to traditional trans-cervical incision was not required in any of the cases. All patients were females aged between 29 and 63. The average operative time for the procedure was 210 minutes. The blood loss was negligible; the average length of hospital stay was 24 hours. No drains were used. No recurrent laryngeal nerve or mental nerve injuries were noted. No patient required completion thyroidectomy, as the histopathological analysis showed benign thyroid nodules in all four cases. Conclusion: TOETVA is a safe and viable option for thyroid surgery and should be routinely considered for patients who require thyroid surgery and are eligible for it. Careful patient selection and counselling are paramount to avoid undesirable outcomes. The procedure yields excellent outcomes when performed by an experienced laparoscopic and thyroid surgeon.
Predictors of poor outcomes in intensive care unit patients with intra-abdominal infection
Background: Intra-abdominal infections (IAIs) are second to respiratory-related infections as the leading cause of sepsisrelated admissions to the intensive care unit (ICU). Multiple abdominal non-traumatic sources requiring intervention are responsible for these admissions. This study aims to describe the aetiology and ICU course of patients with nontraumatic intra-abdominal infections admitted to a multidisciplinary tertiary ICU. The secondary aim is to identify factors associated with mortality within this cohort of patients. Methods: This was a single-centre, cross-sectional study conducted in a multidisciplinary ICU in a tertiary academic hospital in Johannesburg. All patients admitted to the ICU with non-traumatic secondary and tertiary IAIs post-intervention from January 2016 to December 2020 were included. The outcomes were classified ICU discharge or mortality (early, < 7 days or late, if > 8 days). Univariate and multivariate logistic regression screened for mortality-related factors. Results: A total of 390 patients met the inclusion criteria. There were multiple aetiologies of IAIs, with the dominating contributors being perforated into gastric ulcers (18%), followed by large (15%) and small (12%) bowel pathology. The primary mode of source control was laparotomy. The course of this cohort included early discharge (35%), late discharge (20%), and the overall mortality was 45.0%. The univariate and multivariate regression analysis variables associated with mortality were low albumin, elevated beta-D-glucan, low platelets, higher procalcitonin (PCT) on the day of discharge/mortality and vasopressor use. Conclusion: The outcome of patients with IAIs admitted to the ICU is poor, with a 45% mortality. Multiple elevated biomarkers and vasopressor use were associated with mortality. This may suggest poor source control of IAI.
Outcomes of patients with Hirschsprung’s disease post-pull-through procedure
Background: In low- to middle-income countries, diagnosing and managing Hirschsprung’s disease (HD) presents challenges. This study aimed to determine the outcomes of patients with HD post-pull-through (PT) surgery in the Department of Paediatric Surgery at Chris Hani Baragwanath Academic Hospital (CHBAH) between 01 January 2016 and 30 June 2024. Methods: In Section 1, demographics and complications (according to the Clavien-Dindo Classification System) were collected retrospectively. In Section 2, the functional bowel outcomes (using the Rintala Bowel Functional Score) were collected prospectively. Results: There were 78 HD-diagnosed patients in the database; 43 (55%) were included in section 1, and 32 (74%) in section 2. Thirty-seven patients (86%) were male, and 21 (49%) had inside flushing toilets. Thirty-two (74%) patients had a transition zone at the rectosigmoid junction, and five (14%) had total colonic HD. The median (IQR) age at diagnosis was 3 (22) months, and only 13 (30%) were diagnosed before 1 month. The median (IQR) age at PT was 19 (28.8) months. Eighteen (42%) patients had no postoperative complications, and 21 (49%) needed surgery-PT. Nineteen patients (59%) had excellent continence, and 11 (34%) had good continence. There was no statistically significant difference in functional outcomes, age at first diagnosis (p = 0.924), available toilet facilities (p = 0.791), or the level of disease (p = 0.624). Conclusion: The majority of HD patients at CHBAH had a delayed diagnosis and some postoperative complications following PT. However, most patients had excellent to good functional bowel outcomes.
Evaluation of a flagship business school programme in global surgery: a cross-sectional study
Background: Surgical disciplines often lack executive leadership training. To address this gap, the University of Cape Town’s Global Surgery Division partnered with its Graduate School of Business to create a novel leadership programme for surgical system strengthening in low- to middle-income countries. This study evaluated the programme’s impact on alumni careers and development. Methods: A cross-sectional study was conducted using a structured online questionnaire distributed to all 72 alumni (2022–2025) of the University of Cape Town (UCT)’s Executive Leadership in Global Surgery programme. Quantitative data on professional development, career outcomes, and programme engagement were collected. Results: A total of 43 participants completed the survey (59.70% response rate). Up to 36 participants (83.70%) found the programme transformative or partially transformative, and 37 (86.00%) rated the curriculum as highly relevant. After the programme, 29 (67.40%) reported significantly improved confidence and 13 (30.20%) reported moderate improvement. Over half (23, 53.50%) increased involvement in policy or advocacy, and 9 (20.90%) received a promotion or new leadership role. Most (35, 81.40%) applied the skills daily or weekly, and 14 (32.60%) expanded programme projects into larger initiatives. Prior training and experience were not significant predictors of leadership evolution. Key barriers included time constraints and limited institutional support. Conclusion: The UCT Executive Leadership in Global Surgery course provides practical leadership and implementation tools through a novel business-school framework. By building competence, confidence, and a professional network, this model shows potential to strengthen surgical systems across Africa and similar settings. Such programmes could be adopted by other business schools in partnership with surgical departments.
Refractory pancreatic ascites due to chronic pancreatitis: a real-world tertiary referral centre cohort analysis
Introduction: Pancreatic ascites (PA) is a rare complication of chronic pancreatitis (CP) and evidence regarding optimal management strategies remains limited. This study reports the experience of managing refractory PA in patients with complicated CP at Groote Schuur Hospital, Cape Town, South Africa in comparison to contemporary series. Methods: Patients identified through an ethics-approved CP registry who presented with PA between 1 January 2012 and 30 March 2025 were included. Patients with PA due to malignancy, acute pancreatitis, iatrogenic causes, or trauma were excluded. Data collected included demographics, clinical characteristics, imaging findings, management strategies, and outcomes. Results: Nine patients (median age 40, range 30–51 years) of whom six were male were included. The most common aetiology was alcohol, and the most common presentation was ascites and weight loss. Eight out of nine patients had evidence of nutritional deterioration, and the median serum albumin was 25 g/L (range 19–38). The most common imaging finding was pseudocysts, while pancreatic duct strictures and stones were demonstrated in 1 patient each. ERCP was attempted in all patients and an endoscopic cyst gastrostomy performed in one. Five patients had successful stent placement, of whom three had complete resolution of ascites, and one underwent surgery. Of the four patients in whom stent drainage could not be performed three went on to surgery. Of the four patients who were operated three underwent a longitudinal pancreatico-jejunostomy and one a left pancreatectomy and splenectomy. Two patients developed major complications, one with bleeding following an endoscopic cyst-gastrostomy and another developed infected ascites. Two patients died of hospital-acquired resistant Klebsiella infections. Conclusion: The management of PA remains challenging with substantial mortality rates in this high-risk patient group. Endoscopic intervention achieved resolution in select cases, while surgical intervention provided definitive management. Further studies are necessary to refine treatment strategies and individualised approaches to optimise patient outcomes.
Outcomes and prognostic factors of secondary and tertiary peritonitis in an ICU: a prospective analysis
Background: Intra-abdominal infections (IAIs) causing secondary and tertiary peritonitis contribute significantly to sepsis and septic shock-related mortality in African ICUs. Yet the data from low-to-middle income countries (LMICs) remain sparse. This study evaluates prognostic factors and outcomes in a tertiary care ICU in South Africa. Methods: A prospective observational study was conducted on 129 adult patients with secondary or tertiary peritonitis admitted to ICU at Dr George Mukhari Academic Hospital (DGMAH) between February 2022 and February 2023. Demographics, antimicrobial resistance, and surgical management strategies were assessed. Predictors of mortality and prolonged ICU stay were analysed using Cox regression. Results: Median patient age was 52 years (IQR 37–65); 59.7% were male. Gastroduodenal perforations (34.1%) were most common. Multidrug-resistant (MDR) organisms were isolated in 23.3%. ICU mortality was 21.7%. APACHE II ≥ 25 (HR 3.1, 95% CI: 1.7–5.7; p < 0.001), ≥ 3 relooks (HR 2.99, 95% CI: 1.2–7.3; p = 0.014), and open abdomen (HR 3.2, 95% CI: 1.3–7.9; p = 0.008) were associated with mortality. Multiple organ dysfunction syndrome (MODS) was associated with prolonged ventilation (HR 1.41; p = 0.002). Conclusion: Secondary and tertiary peritonitis in African ICUs is associated with sepsis and septic shock and high surgical burden. Early risk stratification, timely source control, and antibiotic stewardship are essential. This is among the few prospective analyses from an LMIC setting and provides actionable data for context-sensitive guidelines.
Factors influencing outcomes in a resource-constrained burns unit
Background: The treatment of burns is expensive and especially burdensome in low-income countries. We evaluated factors influencing short-term outcomes in a designated adult burns unit in a low- to middle-income country. Methods: A retrospective analysis of burn injury patients in an adult burns unit was undertaken. Patient and burn characteristics were evaluated as predictors of short-term in-hospital outcomes, namely mortality and length of hospital stay. The effects of the type of burn and severe burn injury were analysed separately. We analysed admission to ICU as a marker for resource availability. Results: Nine hundred and eighty-two patients were included. The mean TBSA was 15%, the LA5O 51% and the mortality rate 10.8%. The most common cause of injury was flame burn. Greater age (< 0.001), increased TBSA (< 0.001) and inhalation injury (< 0.001) were significantly associated with mortality, as were flame and electrical burns. Not all patients with inhalation injury or with severe burn injury were admitted to ICU. Length of hospital stay was prolonged only by TBSA (< 0.001). Age above 50 years was not associated with increased mortality (0.34) in severely burned patients. Hospital stay was marginally prolonged in patients with electrical burns. Conclusion: The LA5O is lower, length of stay longer, and mortality greater than ideal. Outcomes were predicted by greater age and TBSA, inhalation injury, flame and electrical burns. System constraints resulted in insufficient ICU admission and prolonged hospital stay.
Spinal hydatid disease: a pressing issue
Hydatid disease is a zoonotic disease caused by the Echinococcus tapeworm. The primary hosts include livestock, cats and dogs. Humans can become accidental hosts when ingesting food products or water contaminated by these animals. The most common organs to be affected in humans include the liver and lungs. Bone involvement is rare, accounting for 0.5–3% of all cases. However, when there is spread to bones, the spine is involved in 50% of that subset of cases. This case report highlights an example of spinal cord compression due to partially treated hydatid disease, and the importance of routine follow-up for these patients.
Analysis of time to care and cost of damage control laparotomies in a tertiary centre in South Africa
Background: Damage control laparotomy (DCL) is a life-saving strategy for the management of hemodynamically unstable abdominal injuries. Although the indications are well established, factors specific to local trauma ecosystems lead to delayed implementation of DCL. Methods: A retrospective review of prospectively collected data identified all patients who underwent DCL for trauma indications at Tygerberg Hospital between 1 January 2016 and 31 December 2020. Data were analysed using Python [version 3.10]. A hybrid costing model was used to determine the cost of DCL. Results: One hundred and thirty-one (131) patients were included, of which 96.9% were male and the mean age was 33.4 years. Gunshots were the most common mechanism of injury (77.9%), followed by vehicle collisions (9.9%) and stabs (7.9%). The in-hospital mortality was 41.5%. The median time from incident to arrival at the trauma centre was 3 hours 7 minutes (187 minutes) and patients waited a median of 6 hours (360 minutes) for surgery once in hospital. The median duration of surgery was 120 minutes and the median time to relook laparotomy was 59 hours. The median ICU and ward stay was 9.7 days and 25.7 days, respectively. Cost was calculated using a hybrid costing model, with the cost of care for survivors estimated at R 464 951 (USD $25 200) and for non-survivors R 307 827 (USD $16 684). Total cost of care for this cohort was R 42 160 625 (USD $2 285 129). Conclusion: Delay in surgical care for DCL patients is worse for patients treated in our unit compared to those in other units, with associated cost placing significant economic burden on the healthcare sector.
Cumulative incidence and management of enterocutaneous fistulas owing to laparotomy for penetrating abdominal trauma: a single centre experience
Background: Enterocutaneous fistula (ECF) owing to laparotomy for penetrating abdominal trauma (PAT) is rarely reported. The quoted incidence in two recent publications is 1.9% and 1.5%, in 2224 and 2373 patients, respectively. Advances in trauma surgery including damage control surgery and the use of open abdomen techniques, have led to concerns of increasing fistula rates in trauma patients. The purpose of this study was to determine the incidence and outcomes of patients with ECF resulting from penetrating bdominal trauma. Methods: A retrospective study including patients who underwent laparotomies for PAT between 01 January 2015 and 31 August 2018 (44 months) was performed. The Groote Schuur Hospital (GSH) Trauma Centre RedCap, GSH Intestinal Failure Unit and the Stoma Therapy department databases were scrutinised by folder review. Results: Of a total of 965 patients with PAT, 597 underwent laparotomies and 586 had hollow viscus injury (HVI). Twenty-six patients (4.4%) developed an ECF or an anastomotic leak. Thirteen (50%) patients underwent damage control laparotomy. Fistulas and leaks occurred in small bowel 13 (50%), large bowel 7 (26.9%), and duodenum 6 (23.1%). Five patients with ECF spontaneously resolved with medical treatment. Six patients (42.9%) with ECF were managed in the intestinal failure unit and required surgical intervention. Five anastomotic leaks were addressed at early relook laparotomy, with a mortality rate of 58.3%. Conclusion: The anastomotic leak/ECF rate in PAT in our centre is 4.4% and is associated with a high mortality of 30.8%.
A 12-year review of equestrian related injuries at a major trauma centre in South Africa
Background: Few studies on equestrian-related injuries have specifically focused on patients in South Africa. The aim of this study was to review the spectrum of injuries and of patients treated at state-funded trauma centres in South Africa. Methods: A retrospective study was conducted over a 12-year period from July 2012 to February 2025 on all patients treated for equestrian-related injuries. Results: A total of 82 patients were included (83% male, median age: 17 years, median injury severity score (ISS): 9). The most common mechanism of injury was a fall (n = 41), followed by a kick (n = 38). Two were trampled, and one dragged. The most commonly injured body regions were head and neck (n = 49), face (n = 29), and chest (n = 17). Eighty-two percent (67/82) were managed non-operatively. The overall morbidity was 21% (17/82). Respiratory complications were the most common (n = 7). The median length of hospital stay was two days (range 0–45). There were two mortalities (2%), both due to a fall from a horse resulting in severe traumatic brain injury (TBI). Conclusions: Horse-related injuries are serious and can result in significant injuries. A significant number of patients required major operative interventions. Both riders and non-riders are at risk of injury and appropriate safety equipment and education is essential.
Management and outcomes of penetrating duodenal injuries: a retrospective cohort study from a level I trauma centre
Background: Duodenal injuries are infrequent occurrences in traumatic abdomen.1 Most common cause of duodenal trauma are gunshot wounds and stab injuries.1 The purpose of this study is to determine the surgical outcome of penetrating duodenal injuries focusing on duodenal leakage. Methods: A retrospective chart review with a descriptive-analytical design analysed medical records of 36 patients meeting inclusion criteria from a 966-patient database with penetrating abdominal trauma, admitted to Groote Schuur Hospital trauma centre, Cape Town, South Africa, over 72 months (2014–2019). Demographic data (age, sex), preoperative assessments, operative interventions, and postoperative complications were recorded, with complications graded using the Clavien-Dindo classification. Results: Out of 966 patients admitted during the study period with penetrating abdominal trauma, 36 (3.73%) had penetrating duodenal injuries. All 36 patients were male, with a mean age of 27.17 (SD 8.28) years. Thirty-three (91.67%) patients sustained gunshot wounds, and the remaining three (8.33%) had stab wounds. Fifteen (41.67%) patients underwent damage control surgery (DCS). Six (16.67%) patients developed a duodenal leak (DL). Ten (27.78%) patients died, including five DL patients, who died due to sepsis. Conclusion: Simple duodenal repair appears to be the best management option for penetrating duodenal injuries, except for severe injuries graded AAST IV-V where adjunct surgical techniques may be necessary.