Favourable Outcome After Resection for Contained Malignant Colorectal Perforation

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Exposure to Human Immunodeficiency Disease. What Precautions for the Healthcare Professional?

Background: The Human Immunodeficiency Virus (HIV) epidemic is more pronounced in sub-Saharan Africa. The ever-increasing prevalence of HIV infection and the continued improvement in clinical management has increased the likelihood of these patients being managed by healthcare workers. The aim of the review was to assess current literature on the risks of transmission of HIV infection and protection of the healthcare worker.Methods: A literature review was performed using MEDLINE articles addressing ‘human immunodeficiency virus’, ‘HIV’, ‘Acquired immunodeficiency syndrome’, ‘AIDS’, ‘HIV and Surgery’. We also manually searched relevant surgical journals and completed the bibliographic compilation by collecting cross references from published papers.Results: Transmission is by contamination with body fluids for example needle-stick injury and blood splashes. The risk of HIV transmission from patient to healthcare worker always exists. The risk of transmission is very small and depends on the type of discipline and type of procedure. Hollow needles are more dangerous than suture needles. Sero-conversion is, however, very minimal. Universal precautions are emphasised. In case of needle-stick injury or splash it is important that affected healthcare workers take post-exposure prophylaxis.Conclusion: Occupational HIV transmission is lower than that for other infections. However, protection of all health care personnel should be the prime objective. Universal infection control guidelines must be accepted and strictly enforced. A prompt response to blood contact is crucial and post-exposure prophylaxis is essentia

Compulsory testing of alleged sexual offenders – implications for human rights and access to treatment

Rape is a major criminal and public health problem in South Africa. Not only does it inflict major trauma on the victim, but it also affects the integrity and dignity of the victim and puts him or her at risk of contracting various sexually transmitted diseases such as HIV and other sexually transmitted infections (STIs). This paper proceeds with the current definition of rape, the provisions of the Criminal Law (Sexual Offences and Related Matters) Amendment Act 32 of 2007 and the arguments relating to compulsory HIV testing of perpetrators, and post-exposure prophylaxis for rape victims/survivors. It reviews the legal and ethical issues relating to compulsory HIV testing of perpetrators, as well as the access to antiretroviral treatment of rape victims and perpetrators if they are diagnosed with HIV infection. It concludes that compulsory testing may provide a feeling of reassurance to victims/survivors but does not protect them from infection, since they have to take all the necessary precautions that they would otherwise have taken had they not demanded the HIV test of the perpetrator

The South African Surgical Outcomes Study: A seven-day prospective observational cohort study: preliminary results

Background: Non-cardiac surgical morbidity and mortality is a major global public health burden. Data from sub-Saharan African countries on perioperative outcomes are sparse. South Africa presents a unique public health problem simultaneously engulfed by four epidemics of poverty-related diseases,  noncommunicable diseases, human immunodeficiency virus and related diseases, and injury and violence. Understanding the effects of these epidemics on perioperative outcomes may provide an  important perspective on both South African and surgical global health.Objectives: The objective was to understand the associations with perioperative mortality and critical care admission in South Africa.Method: A seven-day national, multicentre, prospective, observational cohort study was conducted in 50 government-funded hospitals in South Africa. This study is known as the South African Surgical Outcomes Study (SASOS). Participants included patients ≥ 16 years of age undergoing inpatient, non-cardiac surgery between 19 May and 26 May 2014.Outcomes: The primary outcome was in-hospital mortality. Secondary outcomes included duration of hospital stay, admission to the critical care unit after surgery and the duration of the critical care stay. The proportional contribution of noncommunicable diseases, communicable diseases and injuries to perioperative mortality and critical care admission were calculated using population attributable risk statistics.Results: Data on nearly 98% of all eligible patients were submitted from recruiting hospitals. Crude in-hospital mortality was 3.1%, with a postoperative admission to critical care figure of 6.5%. Over 40% of critical care admissions were unplanned. Over half the surgeries in South Africa were classified as urgent or emergent surgery. Urgent or emergent surgery has a population attributable risk for mortality of 26%, and for admission to critical care of 24%.Conclusion: Most patients in South Africa undergo urgent and emergent surgery, which has a strong association with mortality, unplanned critical care admissions and longer critical care stay. Noncommunicable diseases have a larger proportional contribution to morbidity and mortality than infections and injuries. This study was registered on ClinicalTrials.gov (NCT02141867).Funding: This study was funded by the South African Society of Anaesthesiologists and the Vascular Society of Southern Africa.Keywords: The South African Surgical Outcomes Study, SASOS, preliminary result

Procedure for prolapsed haemorrhoids vs excisional haemorrhoidectomy: A systematic review and meta-analysis

Background. The procedure for prolapse and haemorrhoids (PPH) was introduced to address the postoperative pain following excisional haemorrhoidectomy (EH). Objective. To assess the efficacy of both procedures to treat haemorrhoids. Data sources. Literature review using MEDLINE. Articles addressing PPH and EH were included. Study selection. RCTs comparing EH and PPH with ≥20 patients. Data extraction. Primary endpoints were pain, operative time, hospital stay, satisfaction with procedure and time to return to normal activity. Secondary endpoints such as recurrence and complications were collated for descriptive analysis. A metaanalysis was performed using the random effects model on studies reporting ‘mean' and SD or SEM. Data synthesis. PPH was associated with less postoperative pain, less operative time, shorter hospital stay and earlier return to normal activities compared with EH. There appears to be no significant difference in satisfaction with the procedure. There was no difference between the two procedures in terms of complications. There were more recurrences after PPH. Conclusion. Compared with EH, PPH is associated with less postoperative pain, reduced operative time and hospital stay and earlier return to normal activity, and a trend towards improved patient satisfaction. The rate of recurrence appears higher with PPH. South African Medical Journal Vol. 99 (1) 2009: pp. 43-5

A systematic review of online resources to support patient decision-making for full-thickness rectal prolapse surgery

BACKGROUND: The internet is becoming an increasingly popular resource to support patient decision-making outside of the clinical encounter. The quality of online health information is variable and largely unregulated. The aim of this study was to assess the quality of online resources to support patient decision-making for full-thickness rectal prolapse surgery. METHODS: This systematic review was registered on the PROSPERO database (CRD42017058319). Searches were performed on Google and specialist decision aid repositories using a pre-defined search strategy. Sources were analysed according to three measures: (1) their readability using the Flesch-Kincaid Reading Ease score, (2) DISCERN score and (3) International Patient Decision Aids Standards (IPDAS) minimum standards criteria score (IPDASi, v4.0). RESULTS: Overall, 95 sources were from Google and the specialist decision aid repositories. There were 53 duplicates removed, and 18 sources did not meet the pre-defined eligibility criteria, leaving 24 sources included in the full-text analysis. The mean Flesch-Kincaid Reading Ease score was higher than recommended for patient education materials (48.8 ± 15.6, range 25.2-85.3). Overall quality of sources supporting patient decision-making for full-thickness rectal prolapse surgery was poor (median DISCERN score 1/5 ± 1.18, range 1-5). No sources met minimum decision-making standards (median IPDASi score 5/12 ± 2.01, range 1-8). CONCLUSIONS: Currently, easily accessible online health information to support patient decision-making for rectal surgery is of poor quality, difficult to read and does not support shared decision-making. It is recommended that professional bodies and medical professionals seek to develop decision aids to support decision-making for full-thickness rectal prolapse surgery

Functional outcome after perineal stapled prolapse resection for external rectal prolapse

<p>Abstract</p> <p>Background</p> <p>A new surgical technique, the Perineal Stapled Prolapse resection (PSP) for external rectal prolapse was introduced in a feasibility study in 2008. This study now presents the first results of a larger patient group with functional outcome in a mid-term follow-up.</p> <p>Methods</p> <p>From December 2007 to April 2009 PSP was performed by the same surgeon team on patients with external rectal prolapse. The prolapse was completely pulled out and then axially cut open with a linear stapler at three and nine o'clock in lithotomy position. Finally, the prolapse was resected stepwise with the curved Contour^®Transtar™ stapler at the prolapse's uptake. Perioperative morbidity and functional outcome were prospectively measured by appropriate scores.</p> <p>Results</p> <p>32 patients participated in the study; median age was 80 years (range 26-93). No intraoperative complications and 6.3% minor postoperative complications occurred. Median operation time was 30 minutes (15-65), hospital stay 5 days (2-19). Functional outcome data were available in 31 of the patients after a median follow-up of 6 months (4-22). Preoperative severe faecal incontinence disappeared postoperatively in 90% of patients with a reduction of the median Wexner score from 16 (4-20) to 1 (0-14) (<it>P </it>< 0.0001). No new incidence of constipation was reported.</p> <p>Conclusions</p> <p>The PSP is an elegant, fast and safe procedure, with good functional results.</p> <p>Trial registration</p> <p>ISRCTN68491191</p

Colorectal and uterine movement and tension of the inferior hypogastric plexus in cadavers

Background: Hypotheses on somatovisceral dysfunction often assume interference by stretch or compression of the nerve supply to visceral structures. The purpose of this study is to examine the potential of pelvic visceral movement to create tension of the loose connective tissue that contains the fine branches of the inferior hypogastric nerve plexus. Methods: Twenty eight embalmed human cadavers were examined. Pelvic visceral structures were displaced by very gentle 5 N unidirectional tension and the associated movement of the endopelvic fascia containing the inferior hypogastric plexus that this caused was measured. Results: Most movement of the fascia containing the inferior hypogastric plexus was obtained by pulling the rectosigmoid junction or broad ligament of the uterus. The plexus did not cross any vertebral joints and the fascia containing it did not move on pulling the hypogastric nerve. Conclusions: Uterine and rectosigmoid displacement produce most movement of the fascia containing the hypogastric nerve plexus, potentially resulting in nerve tension. In the living this might occur as a consequence of menstruation, pregnancy or constipation. This may be relevant to somatovisceral reflex theories of the effects of manual therapy on visceral conditions.Ian P Johnso

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700