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Background:This study aimed to ascertain the microbiology, severity stratification, and clinical outcomes of cellulitis based on our current management for comparison with international reports.Methods:A retrospective chart review was conducted of all patients with cellulitis treated by the department of surgery at Ngwelezana Hospital over an 18-month period. Severity of cellulitis was graded, and a comparison was made of the Eron and Modified Dundee classifications. Superficial swabs were taken for culture on patients who had cellulitis with open wounds or blisters. Culture results, antibiotics used, need for surgical intervention, and length of hospital stay were documented and analysed.Results:One hundred and thirty-four patients had cellulitis. Severity grading for classes I–IV in the Eron classification was 3%, 57%, 39% and 1%, respectively, and for the Modified Dundee classification, 47%, 11%, 38%, and 4%, respectively. Co-amoxiclav was the most used antibiotic (73%). Superficial skin swabs were taken from 49 patients and 34 cultured 44 specific organisms. The most common organism identified was Staphylococcus aureus (30%). Several gram-negative and anaerobic organisms were cultured. Fifty-three patients required surgical debridement of the infected area and one patient required an above-knee amputation. Mean hospital stay for patients who did not receive surgical intervention was 6 days (IQR 3) and 7 days (IQR 4) for those who did. There were no deaths.Conclusion:The Dundee classification triages fewer patients as class 2 severity than the Eron system and its use has the potentail to reduce the number of patients hospitalised. Gram-positive organisms predominated in those cultured, but gram-negative cultures were frequent compared to other reported series. Co-amoxiclav is effective as first-line antimicrobial therapy in our environment.

We present a case of a young male patient with no previously known medical, surgical or psychiatric history, who was referred to our institution as an irreducible left inguinal hernia with signs of strangulation. Intraoperative findings, however, revealed a retained foreign body at the rectosigmoid junction, which had previously perforated through the floor of the inguinal canal, essentially sealing off the contamination into the inguinal canal and contributing to the clinical presentation of a left inguinal hernia. This is, to our knowledge, the first published case report locally and internationally concerning rectosigmoid-inguinal canal perforation with the working end of a screwdriver.

BackgroundSnakebites are an underappreciated health concern in middle- and lower-income countries. The lack of national data vastly impacts funding for this health crisis, as well as strategies for treatment and prevention. Children are particularly vulnerable to snakebite and data in this group is limited.MethodsThis study included paediatric patients, aged 13 years old or younger, admitted to Ngwelezana Tertiary Hospital, Department of Surgery with a snakebite or snakebite related complication, from 1 September 2008 to 31 December 2013. Data captured included demographics, time of presentation, syndromic symptoms, blood results and patient management.ResultsA total of 274 patients were included in this study. The median age at presentation was 8 years, with approximately 70% of the patients aged between 6 and 13 years, with a male predominance (56%). The median time of presentation after sustaining a snakebite was 7 hours (interquartile range 4–13 hours). The majority of patients (71%) presented with cytotoxic manifestations. A total of 53 patients received antivenom of whom 25% suffered adverse reactions. Fifty-six patients underwent one or more procedures on their affected limbs. Three patients required admission to the intensive care unit; all were part of the cytotoxic group and received antivenom. There were no recorded mortalities.ConclusionThe majority of snakebites are cytotoxic in nature. One-fifth of the paediatric population require antivenom and one-fifth require a surgical procedure post envenomation. Adverse effects post antivenom use are common but manageable. Prevention programmes are needed to help reduce this burden of disease and a nationwide snakebite registry is long overdue.

SummaryPenetrating junctional torso trauma with multiple and complex injuries presents the clinician with many investigational and management decisions.1-3 This situation has been termed double jeopardy in the literature.4-6 The management of this multiple gunshot victim’s injuries – massive haemothorax and severe liver and kidney injuries – describes how this pathway can be negotiated with a successful outcome.6

BackgroundBreast cancer is a significant global health concern. Primary endocrine therapy (PET) and primary chemotherapy (PCT) are employed to manage hormone receptor positive breast cancers in the neoadjuvant setting. We hypothesise that PET is as effective as chemotherapy to treat axillary metastases.MethodologyAll patients treated for breast cancer at Tygerberg Hospital Breast Unit during the period of 2016–2019 were included. Patients who did not receive PCT or PET were excluded, as were patients who did not undergo axillary lymph node dissection (ALND).ResultsThe sample consisted of 176 patients. The median age was 49.2 years (IQR = 42.4–57.9 years; range = 25.1–84.6 years), and 174/176 (98.9%) were female. Of the 176 patients, 35/176 (19.9%) had luminal A cancers, while 141/176 (80.1%) had luminal B cancers. Among these patients, 150/176 (85.2%) underwent PCT while 26/176 (14.8%) received PET. The lymph node burdens found via ALND were similar for patients who underwent PCT (median = 25.0%; IQR = 0.0–50.0%) and PET (median = 16.8%; IQR = 0.0–89.0%; p = 0.66). The rates of patients with no nodal involvement were also similar for patients who underwent PCT (47/150 = 31.3%) and PET (9/26 = 34.6%; p = 0.74). Multivariate analysis showed that there were no significant confounding effects due to age, sex, HIV status, molecular subtype or AJCC stage.ConclusionOur study showed no statistically significant difference in the lymph node burden regardless of whether PET or PCT was given to patients with a hormone receptor positive breast cancer.

BackgroundCOVID-19 was first identified in Wuhan, China, in December 2019, where it spread over a wide geographic area until it reached the status of a pandemic in 2020. We postulated that patients who were diagnosed with incidental COVID-19, and underwent surgery, did not have a worse outcome due to the COVID-19 virus compared to their counterparts who did not have the virus.MethodsThis retrospective study included surgical patients (COVID-19 incidentals and COVID-19 negatives) who were admitted to the surgical intensive care unit (SICU) at Tygerberg Academic Hospital between 1 May 2020 and 31 December 2021.ResultsThe sample consisted of 578 patients. Forty-one (41) patients had incidental COVID-19 infection, and 537 patients were COVID-19 naïve. The mean age was 43.9 years (SD = 16.7 years; range = 13.0–82.0 years) and 181 (31.3%) were female. The rates of complications in patients with COVID-19 infection (7.3%) and those without (5.0%) were similar (p = 0.64). Grades of complications, as measured using the Clavien-Dindo classification were also similar between patients with and without COVID-19 infection (p = 0.19). The mortality rates of patients with COVID-19 infection (17.1%) and those without (13.6%) were similar (p = 0.53).ConclusionThis study demonstrates that surgery among asymptomatic PCR-positive patients was not associated with increased mortality or morbidity in the SICU. This also adds a valuable contribution to the growing body of literature regarding COVID-19 infections. Further prospective and multicentred studies are required to provide more robust results.

Background: This project reviews our experience with managing pancreatic trauma from 2012 to 2018. Methods: All patients over the age of 15 years with a pancreatic injury during the period December 2012-December 2018 were retrieved from the Hybrid Electronic Medical Registry at Grey's Hospital and reviewed. Results: During the study period 161 patients sustained a pancreatic injury. The mechanism of trauma was penetrating in 86 patients (53%) and blunt in 75 (47%). The blunt mechanisms included MVA in 27, PVA in 15, falls in four and assaults in the remaining 29. There were 52 stab wounds and 34 gunshot wounds of the pancreas. A total of 26 patients (16%) were shocked on presentation with a systolic blood pressure of 90 mm Hg or less. The median injury severity score was 16. There were 90 patients with American Association for the Surgery of Trauma (AAST) grade I injury to the pancreas, 36 AAST grade II, 27 AAST grade III, 7 AAST grade IV and a single AAST grade V Fifty-four patients (34%) were initially treated non-operatively of which three eventually required surgery. Of the patients who required surgery, 26 (16%) underwent a distal pancreatectomy. The remainder simply underwent pancreatic drainage. The overall mortality rate was 13% (21/161). The operative mortality was 11% (18/161). Thirteen patients (8%) with penetrating injuries and eight patients (5%) with blunt injuries died. Of the 21 patients who died, 14 had multiple injuries. Five patients died due to overwhelming sepsis. One patient died due to hypovolemic shock and another due to a traumatic brain injury. Conclusion: Our centre not infrequently deals with pancreatic trauma secondary to both blunt and penetrating trauma. We follow the general principles outlined in the literature. Despite this, pancreatic trauma is still associated with significant morbidity and mortality. Keywords: trauma, blunt, penetrating, pancreas

BackgroundSerum albumin levels decrease following major trauma, for various reasons. We postulated that the serum albumin nadir (SAN) level would correlate negatively with severity of physiological insult.MethodologyThis retrospective cohort study included all patients with abdominal trauma admitted to the Trauma Intensive Care Unit at Inkosi Albert Luthuli Central Hospital during 2017 and 2018.ResultsOf the 87 patients, 70 (80.5%) were male. Mean age was 32.48 years (SD 11.65; range 12–73). Blunt trauma comprised 54 patients (62.1%). Median SAN level was 23 g/L (IQR 20–27; range 10–38). Median SAN level was not different between patients with blunt versus penetrating trauma (p = 0.69), patients in whom inotropic support had been used/not used (p = 0.0502), and no different between patients on the various modes of feeding at the time of SAN (p = 0.14). However, median SAN level was lower for patients with hollow visceral injury (p = 0.004), for patients who had undergone laparotomy (p = 0.0006), for those who had received damage control surgery (p = 0.001), those who had received blood transfusions (p = 0.03), and patients who died compared to survivors (p = 0.02). Univariate regression analysis revealed negative coefficients for the following in relation to SAN level: blood transfusion (-2.77; p = 0.023), hollow viscus injury (-3.21; p = 0.008), laparotomy (-4.5; p < 0.001), damage control surgery (-3.60; p = 0.02), day of SAN (-0.39; p = 0.001), ICU length of stay (-0.12; p = 0.002), and death (-3.27; p = 0.03).ConclusionGreater physiological insults lead to lower levels of SAN. Serum albumin nadir level may therefore have value as a prognostic indicator in the acute trauma setting.

This study reviews our cumulative experience with the management of patients presenting with a retained knife following an abdominal stab wound (SW). A retrospective study was conducted at a major trauma centre in South Africa over a 15-year period from July 2006 to December 2020 including all patients who presented with a retained knife in the abdomen following a SW. A total of 42 cases were included: 37 males (93%) with a mean age of 26 years. A total of 18 knives (43%) were in the anterior abdomen and 24 were posterior abdomen. Plain radiography was performed in 88% (37/42) of cases and computed tomography was performed in 81% (34/42); 90% (38/42) underwent extraction in the operating theatre. Laparotomy was performed in 62% (26/42). Of all the laparotomies performed, 77% (20/26) were positive for intra-abdominal organ or visceral injury. Overall morbidity was 31%. There were two mortalities (5%). Laparotomy was less commonly required for the posterior abdomen (33% (8/24) vs 100% (18/18), <0.001). For retained knives in the anterior abdomen, 72% (13/18) of the laparotomies were positive for intra-abdominal organ or visceral injury. For the posterior abdomen, 7 of the 8 (88%) were positive for intra-abdominal organ or visceral injury. There were no differences in the need for intensive care unit admission, length of hospital stay, morbidities or mortalities. Uncontrolled extraction of a retained knife in the abdomen outside of the operating theatre must be avoided. Retained knives in the anterior abdomen usually require formal laparotomy, but this is generally not required for posterior abdomen.

Hepatic herniation through the diaphragm is a rare finding. It generally occurs due to a congenital diaphragmatic abnormality or blunt trauma resulting in a diaphragmatic defect. Making the diagnosis is difficult, as there are few definitive clinical signs and chest radiograph (CXR) findings may be non-specific. To our knowledge, only a single case report exists of penetrating right diaphragm injury leading to hepatic herniation. A 42-year-old man presented to the emergency department of a regional hospital with hyperglycaemia and exertional dyspnoea. He was diagnosed with diabetes mellitus type 2. He gave a history of smoking for 15 pack-years, was negative for retroviral disease and had no history of pulmonary tuberculosis. He had no significant surgical history but reported being stabbed with a knife in 1995. The point of entry was below the level of the nipple in the right anterior axillary line. At the time, he was treated with an intercostal drain and discharged home. CXR showed a right-sided chest mass. We considered a differential diagnosis of pulmonary consolidation, diaphragm eventration or hepatothorax. Computerized tomography of the chest and abdomen demonstrated apparent intrathoracic extension of the right liver lobe and partial attenuation of the superior vena cava and right atrium due to a mass effect. The upper border of the liver abutted the aortic arch. Surgical treatment options were discussed. The patient declined surgery and will be followed up as an outpatient.