A third of patients treated at a tertiary-level surgical service could be treated at a secondary-level facility

Background. South Africa (SA) has an overburdened public healthcare system. Some patients admitted to Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), SA, may not require tertiary care, but the numbers and details are uncertain. Clinical research in SA is limited by scarce skills and limited access to data.Objective. To determine the proportion of and length of stay for secondary-, tertiary- and quaternary-level patients discharged from the Department of Surgery at CMJAH over 1 year.Methods. This is a retrospective analysis of electronic discharge (ED) summaries from the Department of Surgery at CMJAH between 1 April 2015 and 1 April 2016. An SQL query of the database generated a .csv file of all discharges with the following fields: database reference number, length of stay and level of care. The details of each record were verified by MBBCh V students, using a defined level-ofcare template and the full discharge summary. The data were reviewed by a senior clinician.Results. There were 3 007 discharge summaries – 97 were not classifiable, two were test records and one was a duplicate. These 100 records were excluded. There were no primary-level records. Secondary-level patients represented 29% (854) of those discharged and 19% of total bed days. Tertiary- and quaternary-level patients together represented 71% of the total and 81% of bed days. The average length of stay was 4.31 days for secondary, 6.98 days for tertiary and 9.77 days for quaternary level-of-care allocation.Conclusion. Almost one-third (29%) of patients discharged from CMJAH’s Department of Surgery were deemed suitable for secondarylevel care. These patients had a shorter length of stay and comprised 19% of total bed days. Students and electronic databases represent an important research resource

Variceal recurrence, rebleeding and survival after injection sclerotherapy in 306 alcoholic cirrhotic patients with bleeding oesophageal varices: original

Endoscopic therapy is the treatment of choice for bleeding oesophageal varices. This study tested the validity of the hypothesis that eradication of oesophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding oesophageal varices in a high risk cohort of patients with portal hypertension and cirrhosis. Patients and Methods: 306 alcoholic cirrhotic patients who presented to hospital with endoscopically proven variceal bleeding were assessed prospectively between 1984 and 2001. Data were entered into a computer based proforma and analysed in April 2004 to allow a minimum 26 months follow-up. The data presented is based on an endoscopic protocol using a standard injection technique, with eradication of varices the predetermined end point. The 306 patients (239 men, 67 women; mean age 51.6, range 24-87 years) underwent 387 emergency and 1067 elective injection treatments with 5% ethanolamine oleate using a combined intra and paravariceal technique during the study period. All patients undergoing endoscopic band ligation were excluded. The Child's grades were A:42, B:122, C:142. All oesophageal complications which occurred during the subsequent 2380 endoscopies following the index sclerotherapy treatment were documented. Results: Before eradication of varices was achieved 111 (36.2%) of the 306 patients had a total of 191 bleeding episodes after the initial endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 156 (81.6%) of 191 patients who survived more than 3 months, varices were eradicated after a mean of 5 injections and remained eradicated in 69 (mean follow-up: 34.6 months; range: 1-174 months). Varices recurred in 83 patients and rebled in 43 of these patients. 830 oesophageal complications were identified during follow-up in 249 (81.3%) patients. Mucosal ulceration was noted on 584 occasions in 216 patients. 27 patients developed an oesophageal stenosis of whom 15 required dilatation. Eight patients had an oesophageal perforation after repeated sclerotherapy for recurrent bleeding. Cumulative survival by life table analysis was 56%, 40%, and 24% at 1, 3 and 5 years. 213 patients (69.6%) died during follow-up. Liver failure was the most common cause of death. Conclusion: Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Complications related to sclerotherapy were common and were mostly of a minor nature but were cumulative and life-threatening in some patients. Despite control of variceal bleeding, survival at 5 years was only 24% because of death due to liver failure in most patients. SA Gastroentorology Review Vol.2(2) 2004: 8-1

Variceal Recurrence, Rebleeding, and Survival After Endoscopic Injection Sclerotherapy in 287 Alcoholic Cirrhotic Patients With Bleeding Esophageal Varices

OBJECTIVE: This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis. SUMMARY BACKGROUND DATA: Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy. METHODS: Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24–87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded. RESULTS: Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1–174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3–198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death. CONCLUSION: Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients