Browsing by Author "Navsaria, Pradeep"

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    Open Access
    Foley catheter balloon tamponade for penetrating neck injuries at Groote Schuur hospital: an update
    (2020) Scriba, Matthias Frank; Navsaria, Pradeep
    Introduction Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is an effective, readily available and easy-to-use technique. This study aims to audit the technique and highlight current investigative and management strategies. Methods All adult patients (18 years and older) with PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were included. Data was captured from an approved electronic registry and analysed. Analysed parameters included demographics, major injuries, imaging, management and outcomes. Results Over the study period a total of 628 patients with PNI were managed at GSH, in which 95 patients (15.2%) FCBT was utilised. The majority were men (98%) with an average age was 27.9 years. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior to arrival at GSH (1.1% prehospital, 45.3% at clinic level and 34.7% at district hospital level). Computerised tomography (CT) angiography was used in 92.6% of patients, while 8 patients (8.4%) required formal angiography. Of these, 2 were purely diagnostic and 6 were performed for definitive endovascular management. A total of 34 arterial injuries (19 major and 15 minor) were identified in 29 patients. Ongoing bleeding was noted in three patients, equating to a 97% success rate at haemorrhage control. Thirteen (13.7%) patients requried open neck surgery. Seventy-two (75.8%) patients without major arterial injury had removal of the catheter at 48-72 hours post injury. Only two of these had bleeding on catheter removal. Fifteen patients required ICU admission. A total of 36 separate morbidities were documented in 28 patients (29.5%). There were 4 deaths (4.2% mortality rate), with only one of these attributable to uncontrolled haemorrhage from the neck wound. Conclusion This large series shows the current use of FCBT for PNI. It highlights ease of use, high rates of success at haemorrhage control (97%) and good outcomes with the technique. Venous injuries and minor arterial injuries can be managed with this technique definitively.
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    Impact of SARS-COV2 pandemic on emergency surgical services at Groote Schuur Hospital
    (2024) Dookhony, Koshlen; Navsaria, Pradeep
    Background: An international survey (98 collaborators from 31 countries) on the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on emergency surgery services revealed an 87.8% decrease in procedures. The aim of the study was to determine the impact of the coronavirus 19 (COVID-19) pandemic on the number of emergency surgical operations performed at Groote Schuur Hospital, Cape Town, South Africa. Methodology: The study was a retrospective cross-sectional study, comparing the number of emergency surgical operations performed before the COVID-19 pandemic to those performed during the COVID-19 lockdowns at Groote Schuur Hospital in Cape Town, South Africa. the data was retrieved from the Web Surgibank and Clinicom databases. Results: The total number of surgeries performed during the study period (April 2019 – March 2021) was 13715. The most frequently performed surgeries were orthopaedics (18.6%), hands (16.3%), acute surgery (16.5%), neurosurgery (10.5%) and trauma (10.1%). There were statistically significant differences in the number of surgeries before COVID-19 and during COVID-19 (p=.002). There was a 19.5% reduction in the number of surgeries. The mean number of surgeries during the pandemic was less compared to the pre COVID-19 period (p<.001). The patterns in the types of surgeries performed were similar before and during the various levels of the pandemic. There was a statistically significant difference in the number of surgeries performed across the various stages of the alcohol lockdowns. The increases and decreases varied across different conditions. From the first full alcohol ban (March to May 2020) to the first and 2nd alcohol partial ban (June to July 2020) – the numbers of emergency surgeries in thirteen out of the seventeen types of conditions continued to decrease while they increased in three conditions. The types of conditions that increased between the complete and partial alcohol ban were trauma (increased by 70.4%), ENT (increased by 41.1%), eyes (increased by 68.5%) and hands (increased by 3.4%). Conclusion: COVID-19 has significantly impacted the number of surgeries performed during the pandemic at Groote Schuur Hospital. In addition, alcohol ban has also significantly impacted the pattern of surgeries performed in our institution. This overall reduction was less compared to international centres. The lesser reduction is likely due to high incidence of trauma in South Africa as well as local hospital policy to maintain a contingency plan to avoid total collapse of the surgical system.
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    Management of civilian penetrating rectal injuries in an urban trauma centre
    (2025) Govender, Terron; Navsaria, Pradeep
    Background: Rectal injuries are associated with significant morbidity. Primary repair of extraperitoneal rectal injuries, presacral drainage (PSD) and distal rectal washout (DRW) have become historical adjuncts. Aim: A retrospective review was performed to determine the outcome of rectal injuries in an urban trauma centre with a high incidence of penetrating trauma where a simple surgical management approach to these injuries is practiced. Methods: The records of all patients with a full-thickness penetrating rectal injury admitted to the Trauma Centre at Groote Schuur Hospital over a 10-year period (January 2010 – December 2019) were reviewed. Basic demographics, injury mechanism and perioperative management, anatomical site of the rectal injury, associated intra-abdominal injuries and their management were recorded. Infectious complications and mortality were noted. Intraperitoneal rectal injuries were primarily repaired, with or without faecal diversion. Extraperitoneal rectal injuries were generally left untouched, and a diverting loop colostomy done. Intraperitoneal bladder injuries were primarily repaired and extraperitoneal bladder injuries were repaired from within the bladder. Pelvic and spinal fractures were copiously lavaged. Presacral drainage and DRW were not performed. Results: One-hundred and four (101: gunshot; 3: stab) patients with 134 rectal injuries [intraperitoneal (10), extraperitoneal (64), combined (30)] were identified. Transpelvic trajectory was identified in 75 (72.12%) patients. Associated genitourinary tract injuries occurred in 42 (40.38%) patients and included 27 (25.96%) bladder injuries [intraperitoneal (9), extraperitoneal (4), combined (14)] and seven (6.73%) distal ureter injuries. Fifty patients 6 (48.08%) had associated bony injuries: sacrum (22), iliac (9), pubic rami (5), coccyx (1), acetabulum (3), femur (6), vertebral fractures (3) and pelvic joints (5). Eight (7.69%) patients had an associated vascular injury [iliac veins (4), iliac arteries (4)]. Two extraperitoneal rectal injuries were repaired. Diverting loop colostomies (91) and three Hartmann's type procedures were done for the remaining untouched extraperitoneal rectal injuries. None had PSD or DRW. Nine (6.7%) fistulae were recorded: three rectocutaneous, three rectovesical, one small bowel cutaneous, one vesicocutaneous and one entero-enteric. There were 27 infectious complications: surgical site infection (13), iliac blade and sacral osteitis (2), other soft tissue infections (12). Conclusion: Extraperitoneal rectal injuries due to low-velocity trauma can be safely managed by faecal diversion, without repair, DRW and PSD with minimal morbidity.
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    Negative pressure wound therapy management of the "open abdomen" following trauma: a prospective study and systematic review
    (BioMed Central Ltd, 2013) Navsaria, Pradeep; Nicol, Andrew; Hudson, Donald; Cockwill, John; Smith, Jennifer
    INTRODUCTION: The use of Negative Pressure Wound Therapy (NPWT) for temporary abdominal closure of open abdomen (OA) wounds is widely accepted. Published outcomes vary according to the specific nature and the aetiology that resulted in an OA. The aim of this study was to evaluate the effectiveness of a new NPWT system specifically used OA resulting from abdominal trauma. METHODS: A prospective study on trauma patients requiring temporary abdominal closure (TAC) with grade 1or 2 OA was carried out. All patients were treated with NPWT (RENASYS AB Smith & Nephew) to achieve TAC. The primary outcome measure was time taken to achieve fascial closure and secondary outcomes were complications and mortality. RESULTS: A total of 20 patients were included. Thirteen patients (65%) achieved fascial closure following a median treatment period of 3 days. Four patients (20%) died of causes unrelated to NPWT. Complications included fistula formation in one patient (5%) with spontaneous resolution during NPWT), bowel necrosis in a single patient (5%) and three cases of infection (15%). No fistulae were present at the end of NPWT. CONCLUSION: This new NPWT kit is safe and effective and results in a high rate of fascial closure and low complication rates in the severely injured trauma patient.
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    Outcomes of failure of selective non-operative management of penetrating abdominal trauma
    (2022) Almgla, Naser Khalifa; Navsaria, Pradeep
    Background: Selective nonoperative management (SNOM) of penetrating abdominal trauma (PAT) is routine at our centre. The aim of this observational study is to report the outcomes of patients who have failed SNOM. Methods: All patients for the period (May 2015 – January 2018) who presented with penetrating abdominal trauma were reviewed. The patients were categorised into two groups: immediate laparotomy and delayed operative management (DOM) groups. The outcomes of the two groups were compared in terms of postoperative complications as a primary outcome, mortality and length of hospital stay as secondary outcomes. Results: A total of 944 patients with PAT were managed over the 33-month study period. After excluding 100 patients undergoing damage control surgery; 402 (47.6%) and 542 (52.4%) patients were treated with SNOM and immediate laparotomy, respectively. In the NOM cohort, 359 (89.3%) were managed successfully without laparotomy. Thirty-seven (86.0%) patients in the DOM group had a therapeutic laparotomy and six (14.0%) had an unnecessary laparotomy. Nine (20.9%) patients in the DOM group developed complications. There was no significant difference in the complication rates between the immediate laparotomy and DOM group. The hospital length of stay (LOS) was comparable between the two groups. There was no mortality reported in the SNOM group. Conclusion: Delayed laparotomy for PAT in patients initially selected for NOM, irrespective of mechanism, results in morbidity, mortality and hospital stay comparable to those who underwent immediate laparotomy.
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    Penetrating Abdominal Trauma: Spectrum of disease in a Level 1 Trauma Centre
    (2019) Sander, Anthony; Navsaria, Pradeep
    Background: Penetrating abdominal trauma (PAT) in South Africa represents a significant burden of disease. The current global trend has seen management shift towards selective conservatism. The purpose of this study is to describe the presentation, management and outcomes of PAT in a level I trauma unit, which routinely practices selective non-operative management (SNOM). Methods: This was a retrospective descriptive audit of prospectively collected data. The Setting was Groote Schuur Hospital Trauma Centre, Cape Town, South Africa over 24 months (1 May 2015 to 30 April 2017). All patients presenting to the centre with PAT during the study period were included. The data captured and analysed included: basic demographics; admission vital signs; blood investigations; number of traumatic insults; penetrating wound positions; radiological investigations and interventions; indication for laparotomy; operative or nonoperative management; laparotomy findings: negative, therapeutic or non-therapeutic; abdominal visceral injuries and associated injuries. The Revised Trauma Score (RTS); Injury Severity Score (ISS); Penetrating Abdominal Trauma Index (PATI); and Kampala Trauma Score (KTS) were then calculated. The descriptive end points included the following: Length of hospital stay (LOS); ICU admission time; relaparotomy; readmission; mortality; and in-hospital complications. Results: During the study period, 805 patients with penetrating abdominal trauma were managed. There were 502 (62.4%) and 303 (37.6%) patients with gunshot and stab wounds, respectively. The majority were young men (762 – 94.7%) with a mean age of 28.3 (95%CI: 27.7-28.9) years. The median trauma scores were as follows: RTS – 7.84 (IQR: 7.00-7.84); ISS: 13 (IQR: 9-22), PATI: 6 (IQR: 1-14); and KTS: 14 (IQR: 14-15). Abdominal penetration was thoracoabdominal in 332 (41.2%), abdominal in 694 (86.5%), and pelvic in 192 (23.9%) patients. Immediate laparotomy was performed in 446 (55.4%) patients for: haemodynamic instability – 42 (5.2%); peritonism – 296 (36.8%); evisceration - 27 (3.4%); unreliable clinical evaluation – 24 (3.0%); and positive radiological findings – 57 (7.1%). There were 406 (50.4%) therapeutic laparotomies; 18 (2.3%) negative laparotomies; and 22 (2.7%) nontherapeutic laparotomies in the immediately operated group. Initial SNOM was performed in 359 (44.5%) patients, of which 208 (68.7%) sustained stab wounds and 151 (30.1%) gunshot wounds. Thirty-five (4.3%) patients failed SNOM and underwent delayed laparotomy. Should a policy of mandatory laparotomy have been implemented in this series, 206 (68.0%) SW and 163 (32.5%) GSW patients would have underwent unnecessary exploration. Overall non-fatal complications were 179 (22.2%) which were then further classified according to the Clavien-Dindo grading system. The median hospital stay was 4.5 (IQR: 3-7) and 7 (IQR: 5-12) days for SW and GSW, respectively. Overall 114 (14.2%) patients required admission to critical care unit for a median stay of 3 (IQR: 2-5) days. Total mortality was 7.2% (n=58). Conclusion: Clinical evaluation (haemodynamic instability, peritonism and evisceration) was remarkably accurate in determining the need for early laparotomy. The unnecessary laparotomy rate of this group was 5.0% (negative: 2.3% and nontherapeutic: 2.7%) overall. Selective nonoperative management was performed in 44.5% of patients with a successful SNOM rate of 90.3%. The overall mortality was 7.2 %.
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    Predicting mortality in damage control surgery for major abdominal trauma
    (Academy of Science of South Africa, 2010) Timmermans, Joep; Nicol, Andrew; Kairinos, Nick; Teijink, Joep; Prins, Martin; Navsaria, Pradeep
    Damage control surgery (DCS) has become well established in the past decade as the surgical strategy to be employed in the unstable trauma patient. The aim of this study was to determine which factors played a predictive role in determining mortality in patients undergoing a damage control laparotomy. Materials and methods. A retrospective review of all patients undergoing a laparotomy and DCS in a level 1 trauma centre over a 3-year period was performed. Twenty-nine potentially predictive variables for mortality were analysed. Results. Of a total of 1 274 patients undergoing a laparotomy for trauma, 74 (6%) required a damage control procedure. The mean age was 28 years (range 14 - 53 years). The mechanism of injury was gunshot wounds in 57 cases (77%), blunt trauma in 14 (19%) and stabs in 3 (4%). Twenty patients died, giving an overall mortality rate of 27%. Factors significantly associated with increased mortality were increasing age (p=0.001), low base excess (p=0.002), pH (p<0.001), core temperature (p=0.002), and high blood transfusion requirement over 24 hours (p=0.002). Conclusion. The overall survival of patients after damage control procedures for abdominal trauma is excellent (73%). The main factors that are useful in deciding when to initiate DCS are age, base excess, pH and the core temperature.
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    Review of Damage Control Laparotomy (DCL) outcomes in a Major Urban Trauma Center
    (2020) Kruger, Andries Michiel; Navsaria, Pradeep
    Introduction Damage control laparotomy (DCL) in an urban trauma centre is associated with high mortality. Aim The purpose of this prospective study was to review the outcomes of DCL in a level one urban trauma centre, looking particularly at primary closure rate and other factors influencing outcomes. Methods All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were retrieved from the prospectively recorded eTHR data base. Data retrieved were basic demographics, mechanism of injury, perioperative vitals and biochemical parameters. Injury severity was described by the Revised Trauma Score (RTS), Penetrating Abdominal Trauma Index (PATI), Injury Severity Score (ISS) and Trauma and Injury Severity Score (TRISS). Indications for DCL were determined as well as length of ICU stay, days of ventilation, number of procedures and primary abdominal closure rates. Complications and mortality were recorded. Results During the study period, 51 patients underwent DCL. Three patients sustained stab wounds and 47 patients suffered from gunshots. Only 1 female was included in the study with the other 50 being male. The mean age was 28 years and 4 months (range 15 to 48 years). Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The means for the different severity scores were RTS 7.36, ISS 17.5, TRISS 93.76 and PATI 28. Means were calculated for different physiological markers of trauma (lowest pH 7.12, highest lactate 7.11, lowest core temp 34.9˚C and lowest systolic BP 63.8 mmHg). The organs most commonly injured, in decreasing frequency, were small bowel (n = 33), large bowel (n = 25), abdominal vasculature (n = 22), liver (n = 18), stomach (n = 14), kidney (n = 10), diaphragm (n = 10), spleen (n = 9) and pancreas (n = 8). DCL procedures performed were abdominal packing (n = 36), bowel ligation (n = 30), vascular shunting (n = 5) and shunting of the ureter (n = 1). The median number of laparotomies done per patient was 3, with a primary fascial closure rate of 69%. The mortality rate was 29%. Conclusion DCL in our setting is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24hours and median PATI score more than 47 are independent factors associated with increased mortality.