Penetrating colon trauma-the effect of concomitant small bowel injury on outcome

INTRODUCTION

There is limited evidence to suggest that patients with penetrating colon injury have higher complication rates when there is concomitant small bowel (SB) injury.

AIM

We performed a retrospective study looking at outcomes of penetrating colonic trauma in patients with- and without concomitant SB injury.

METHODS

We interrogated our electronic registry over an eight-year period (2012-2020) for all patients over 18 years who had sustained penetrating colon injury and who had survived beyond 72 h. Demographic data, admission physiology, and Injury Severity Score (ISS) were recorded. Two groups of patients were observed: those with colonic injury (no SB injury) and those with combined colon and SB injury. Outcomes observed included leak rates, length of Intensive Care Unit (ICU) stay, length of hospital stay (LOS), morbidity and mortality.

RESULTS

A total of 450 patients were eligible for analysis, of which 257 had colon injury without SB injury and 193 had a combination of colon and SB injury. There was no difference in mechanism of injury between groups. Admission physiology was similar between groups but arterial blood gas values were worse in the combined group. Rates of damage control surgery and ICU admission were higher in the combined group. Primary repair was done in equal proportions between groups but anastomosis was more frequently performed in the combined group. There was no difference in complication rates, including gastro-intestinal complications and suture line leaks. Length of ICU stay, LOS, and mortality were similar between groups. Univariable analysis demonstrated that the presence of concomitant small bowel injury was not an independent risk factor for colonic suture line failure or death.

CONCLUSION

There is no evidence from this data that the presence of a combined penetrating colon and SB injury should change management priorities. Each injury should be treated on its own merit, in the context of the patient's physiology.

An audit of the outcomes of the College of Surgeons general surgery final examinations

BACKGROUND

An audit of the Fellowship of the College of Surgeons (FCS) of South Africa examination results has not been previously performed. The purpose of this study was to review and determine any predictors of outcome (pass or fail).

METHODS

The results of the FCS(SA) final examinations from October 2005 to and including October 2014, were retrieved from the College of Medicine of South Africa database. The current format of the examinations consists of two written essay question papers, an objectively structured clinical examination (OSCE), two clinical cases and two oral examinations. These were retrospectively reviewed and analysed. Predictors of failure or success were determined.

RESULTS

During the 10-year study period, 472 candidates attempted the examinations. A total of 388 (82%) candidates were successful in the written component of the examination and were subsequently invited to participate in the clinical component of the examinations. Overall, 296 (63%) candidates passed and 176 (37%) failed. There were 51 candidates who were invited to the oral examinations despite an average of less than 50% in the two papers, and 34 (67%) failed the overall examination. Similarly, 126 candidates were invited having failed one of the two papers of which 81 (64%) ultimately failed. A total of 49 candidates failed the OSCE, 82% of these candidates failed overall. There were strong correlations between the averages of the papers versus the orals (Spearman ρ = 0.51), the papers versus the cases (Spearman ρ = 0.50), and the papers versus the OSCE (Spearman ρ = 0.55).

CONCLUSION

The written papers are the main determinant of invitation to the second part of the examination. Candidates with marginal scores in the written component had an overall failure rate of 67%. Failing one paper and passing the other, resulted in an overall failure rate of 64%. Failing the OSCE resulted in an overall 82% failure rate. With the high failure rate of candidates with marginal scores and with the inter-examination variability of the papers, it might be prudent to revisit both the process of invitation selection and the decision to continue with the long-form of the written component.

Surgical resources in South Africa: an analysis of the inequalities between the public and private sector

BACKGROUND

The full extent of the global burden of surgical disease is largely unknown, however, the scope of the problem is thought to be large. Despite the substantial burden of surgical disease, surgical services are inaccessible to many of those who need them most. There are disparities between public and private sectors in South Africa, which compound inequitable access to surgical care. This study forms part of a series analysing surgical resources in South Africa.

METHOD

This study involved a descriptive analysis of surgical resources and included the total number of hospitals, of hospital beds, the number of surgical beds, the number of general surgeons (specialist and non-specialist), and the number of functional operating theatres in South Africa. A comparison was performed between the public and private sectors. Hospitals were contacted during the period from 1 October 2014 until 31 December 2014.

RESULTS

Surgical resources were concentrated in metropolitan areas of urban provinces. There were striking differences between the public and private sectors, where private resources were comparable to those available in high income countries (HICs).

CONCLUSION

Improving access to surgical services in lower middle income countries (LMICs) requires addressing gaps between the public and private sector regarding infrastructure, personnel, as well as equipment. These data identified disparities between geographic regions which may be contributing to ongoing inequity in South Africa, and by doing so allows for evidence-based planning towards improving surgical infrastructure and workforce.

The excretion of radiopharmaceuticals in human breast milk: additional data and dosimetry

The amount of radioactivity excreted in breast milk following administration of 11 different radiopharmaceuticals, including technetium-99m labelled microspheres, pyrophosphate, diisopropyl-iminodiacetic acid (DISIDA) and sestamibi, has been measured. This report summarises the data collected from 60 patients. An effective decay constant for the series of samples from each patient was calculated from exponential curves fitted by least squares to the data. It is difficult to compare values from individual patients, since times of expression, volumes of milk and the activity administered are not uniform. In order to formulate reliable guidelines, we therefore calculated the total activity theoretically excreted in milk until complete decay of the radionuclide, which is usually higher than that actually measured over the actual period of collection. Of the various 99mTc compounds, pertechnetate clearly reaches the highest concentrations in breast milk. The wide variability of data from different patients who received the same radiopharmaceutical despite identical methods of sample collection and data processing confirms the impression gained from literature that transfer of radionuclides into milk varies greatly between individuals. Although we have calculated average values for each compound, very large standard deviations were obtained, and we believe that for radiation protection purposes, a "worst case" approach is the most appropriate. With new data available and the revision of ICRP recommendations, the guidelines applicable when radiopharmaceuticals are administered to breast-feeding mothers are reviewed. The effective dose resulting from close contact between patient and infant was included in these calculations. Breast feeding need not be interrupted after administration of 99mTc-DISIDA, -sulphur colloid, -gluconate and -methoxyisobutylisonitrile (MIBI). However, after administration of 99mTc-MIBI, close contact should be restricted. 99mTc-pyrophosphate and -microspheres require interruption periods of several hours. High activities of 99mTc-pertechnetate may require interruption longer than 2 days. For pertechnetate and 99mTc-labelled red blood cells, interruption of breast feeding with measurement of activity in expressed milk samples is recommended. Breast feeding is contra-indicated after administration of 67Ga and 131I. General guidelines regarding breast feeding after administration of radiopharmaceuticals are summarised.

Excretion of gallium 67 in human breast milk and its inadvertent ingestion by a 9-month-old child

The concentration of radioactivity excreted in breast milk following the administration of gallium 67 to 3 patients was measured in milk samples obtained for several days after injection. Similar values were obtained from all 3 patients, with milk samples obtained approximately 120 h after administration containing 4.3-5.7 Bq/ml per MBq of 67Ga administered. These values are lower than those previously reported. The image of a child who had inadvertently been breast-fed for 48 h after administration of 67Ga to the mother showed activity in the intestines only. Our results seem to confirm recommendations by other authors that gallium scintigraphy should be avoided in nursing mothers. Should the administration of 67Ga be inevitable, breastfeeding should be discontinued, since interruption periods of approximately 2 weeks may be required to reduce the effective dose equivalent to the infant below 1 mSv. However, close contact between mother and child need not be avoided.

Excretion of technetium 99m hexakismethoxyisobutylisonitrile in milk

The amount of radioactivity excreted in breast milk following the administration of technetium 99m hexakismethoxyisobutylisonitrile (99mTc-MIBI) to a patient referred for cold spot myocardial scintigraphy was determined. During the first 24 h after administration, only 41.2 kBq 99mTc (0.0084% of the injected dose) was excreted in 448 ml milk with the highest concentration of 0.49 kBq/ml in the first sample. The images obtained show a high concentration of 99mTc-MIBI in the lactating breasts contrary to the very small percentage excreted in the milk. Comparison with various recommendations regarding nursing after administration of radiopharmaceuticals seems to indicate that the administration of 99mTc-MIBI does not necessitate an interruption of breast-feeding.

Excretion of radioiodine in human milk following a therapeutic dose of I-131

An investigation of 131I excretion into human milk after a therapeutic dose of 5142 MBq (139 mCi) 131I, in a patient who has had a thyroidectomy is presented. During the first 36 h, 17.4% of the administered dose was excreted into the milk. In addition to the known radiation risk, this may affect the quantity of 131I retained by the thyroid and metastases.