Browsing by Author "Nicol, Andrew J"

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    Civilian extraperitoneal rectal gunshot injuries: Surgical management made simpler
    (2007) Navsaria, Pradeep H; Edu, Sorin; Nicol, Andrew J
    Background: Rectal injuries are associated with significant morbidity and mortality. Controversy persists regarding routine presacral drainage, distal rectal washout (DRW), and primary repair of extraperitoneal rectal injuries. This retrospective review was performed to determine the outcome of rectal injuries in an urban trauma center with a high incidence of penetrating trauma where a non-aggressive surgical approach to these injuries is practiced. Methods: The records of all patients with a full-thickness penetrating rectal injury admitted to the Trauma Center at Groote Schuur Hospital over a 4-year period were reviewed. These were reviewed for demographics, injury mechanism and perioperative management, anatomical site of the rectal injury, associated intra-abdominal injuries and their management. Infectious complications and mortality were noted. Intraperitoneal rectal injuries were primarily repaired, with or without fecal diversion. Extraperitoneal rectal injuries were generally left untouched and a diverting colostomy was done. Presacral drainage and DRW were not routinely performed. Results: Ninety-two patients with 118 rectal injuries [intraperitoneal (7), extraperitoneal (59), combined (26)] were identified. Only two extraperitoneal rectal injuries were repaired. None had presacral drainage. Eighty-six sigmoid loop colostomies were done. Two (2.2%) fistula, one rectocutaneous, and one rectovesical, were recorded. There were nine (9.9%) infectious complications: surgical site infection (4), buttock abscess (1), buttock necrosis (1), pubic ramus osteitis (1), septic arthritis (2). No perirectal sepsis occurred. Conclusions Extraperitoneal rectal injuries due to low-velocity trauma can be safely managed by fecal diversion alone.
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    Implementation of a structured surgical quality improvement programme
    (2016) Spence, Richard Trafford; Chang, David; Nicol, Andrew J
    As surgery assumes a greater position in the global health agenda, the need to not only improve access to surgical care but also improve the quality of surgical care, is paramount. Surgical quality improvement programmes have been shown to reduce morbidity and mortality following surgery. A key first step to the design and implementation of a structured surgical quality improvement programme is the collection and analysis of high-quality data. To quote Dr. Margaret Chan, the director general of the World Health Organisation, '…the real need (in global health) is to close the data gaps, especially in low and middle-income countries, so that we no longer have to rely heavily on statistical modeling for data on disease burden.' In this thesis it was hypothesized that emerging m-Health technology, defined as medical and public health practices supported by the use of mobile devices, would provide a solution to close such data gaps. Various m-Health applications were used to develop three databases describing the outcomes of major surgery performed within the Cape Metro West health district during the study period. After reviewing the design and analytical rationale of the American College of Surgeons National Surgical Quality Improvement Programme and Trauma Quality Improvement Programme, these de novo databases were used to develop three quality improvement programmes designed for local implementation: The Essentials programme for general and vascular surgery, a Procedure-targeted programme and a trauma quality improvement programme. Key to these programmes was the derivation and validation of prediction rules which reliably estimate the probability of an adverse outcome following major surgery in a risk-adjusted manner. Such rules promote internal and external benchmarking over time to identify opportunities for quality improvement and critically appraise the impact of any corrective action implemented. In order to improve the quality of surgical care we provide, a continuous cycle of monitoring, assessment, and management should be performed routinely. This thesis provides some guidance of how this can be done within the Cape Metro West health district.
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    Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa
    (BioMed Central, 2018-01-24) Chowdhury, Sharfuddin; Nicol, Andrew J; Moydien, Mahammed R; Navsaria, Pradeep H; Montoya-Pelaez, Luis F
    Abstract Background The optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death. Methods Prospective audit of patients presenting to GSH trauma center following penetrating or blunt chest, abdominal, neck and peripheral vascular trauma who underwent surgery over a 4-month period was performed. Post-operative complications were graded according to Clavien-Dindo classification of surgical complications. Results One-hundred six patients underwent surgery during the study period. One-hundred two (96.2%) cases were related to penetrating trauma. Stab wounds comprised 71 (67%) and gunshot wounds (GSW) 31 (29.2%) cases. Of the 106 cases, 6, 47, 40, and 13 patients were booked as red, orange, yellow, and green, respectively. The median delay for green, yellow, and orange cases was within the expected time. The red patients took unexpectedly longer (median delay 48 min, IQR 35–60 min). Thirty-one (29.3%) patients developed postoperative complications. Among the booked red, orange, yellow, and green cases, postoperative complications developed in 3, 18, 9, and 1 cases, respectively. Only two (1.9%) postoperative deaths were documented during the study period. There was no statistically significant association between operative triage and post-operative complications (p = 0.074). Conclusion Surgical case categorization has been shown to be useful in prioritizing emergency trauma surgical cases in a resource constraint high-volume trauma center.
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    Non-operative management of abdominal stab wounds- an analysis of 186 patients
    (Health and Medical Publishing Group, 2007) Navsaria, Pradeep H; Berli, Jens U; Edu, Sorin; Nicol, Andrew J
    Background: The modern management of abdominal stab wounds remains controversial and subject to continued reappraisal. In the present study we reviewed patients with abdominal stab wounds to examine and validate a policy of selective non-operative management with serial physical abdominal examination in a busy urban trauma centre with a high incidence of penetrating trauma. Methods: Over a 12-month period (2005), the records of all patients with abdominal stab wounds were reviewed. Patients with abdominal stab wounds presenting with peritonitis, haemodynamic instability, organ evisceration and high spinal cord injury underwent emergency laparotomy. No local wound exploration, diagnostic peritoneal lavage or ultrasound was used. Haematuria in patients without an indication for emergency surgery was investigated with a contrasted computed tomography (CT) scan. Patients selected for non-operative management were admitted for serial clinical abdominal examination for 24 hours. Patients in whom abdominal findings were negative were given a test feed. If food was tolerated, they were discharged with an abdominal injury form. Results: One hundred and eighty-six patients with abdominal stab wounds were admitted. There were 171 (91.9%) males, with a mean age of 29.5 years. Seventy-four patients (39.8%) underwent emergency laparotomy. There were 5 negative laparotomies (6.8%). The remaining 112 patients (60.2%) were assigned for abdominal observation. One hundred (89.3%) of these patients were successfully managed non-operatively. The remaining 12 patients underwent delayed laparotomy, which was negative in 2 cases (16.7%). Non-operative management was successful in 53.8% of patients overall. The overall sensitivity and specificity of serial abdominal examination was 87.3% and 93.5%, respectively. Conclusion: Serial physical examination alone for asymptomatic or mildly symptomatic patients with abdominal stab wounds enables a significant reduction in unnecessary laparotomies.
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    Penetrating renal injuries: an observational study of non-operative management and the impact of opening Gerota’s fascia
    (2022-06-20) Clements, Thomas W; Ball, Chad G; Nicol, Andrew J; Edu, Sorin; Kirkpatrick, Andrew W; Navsaria, Pradeep
    Background Non-operative management has become increasingly popular in the treatment of renal trauma. While data are robust in blunt mechanisms, the role of non-operative management in penetrating trauma is less clear. Additionally, there is a paucity of data comparing gunshot and stab wounds. Methods A retrospective review of patients admitted to a high-volume level 1 trauma center (Groote Schuur Hospital, Cape Town) with penetrating abdominal trauma was performed. Patients with renal injuries were identified and compared based on mechanism [gunshot (GSW) vs. stab] and management strategy (operative vs. non-operative). Primary outcomes of interest were mortality and failure of non-operative management. Secondary outcomes of interest were nephrectomy rates, Clavien-Dindo complication rate, hospital length of stay, and overall morbidity rate. Results A total of 150 patients with renal injuries were identified (82 GSW, 68 stab). Overall, 55.2% of patients required emergent/urgent laparotomy. GSWs were more likely to cause grade V injury and concurrent intra-abdominal injuries (p > 0.05). The success rate of non-operative management was 91.6% (89.9% GSW, 92.8% stab, p = 0.64). The absence of hematuria on point of care testing demonstrated a negative predictive value of 98.4% (95% CI 96.8–99.2%). All but 1 patient who failed non-operative management had associated intra-abdominal injuries requiring surgical intervention. Opening of Gerota’s fascia resulted in nephrectomy in 55.6% of cases. There were no statistically significant risk factors for failure of non-operative management identified on univariate logistic regression. Conclusions NOM of penetrating renal injuries can be safely and effectively instituted in both gunshot and stab wounds with a very low number of patients progressing to laparotomy. Most patients fail NOM for associated injuries. During laparotomy, the opening of Gerota’s fascia may lead to increased risk of nephrectomy. Ongoing study with larger populations is required to develop effective predictive models of patients who will fail NOM.
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    A prospective evaluation to define optimal surgical strategies in the management of complex pancreatic injuries based on the analysis of patients treated at a major South African academic institution
    (2017) Krige, Jacobus Edmund Joubert; Nicol, Andrew J
    In order to address crucial existing limitations in the assessment and analysis of pancreatic injuries due to the lack of robust data and deficient surgical strategies, this thesis focused on priority topics to resolve existing unanswered and under-researched questions in the management of complex pancreatic injuries. Each of the twelve clinical studies in this thesis evaluated a specific aspect of pancreatic trauma based on the detailed analysis of prospective granular data from a large cohort of patients treated in an academic surgery and trauma centre with substantial experience in civilian operative trauma care in which standard and uniform protocols were applied.
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    Trauma Unit volumes: Is there a relationship with weather, sporting events and week/month-end times? An audit at an urban tertiary trauma unit in Cape Town
    (2015) Milford, Karen; Navsaria, Pradeep H; Nicol, Andrew J
    Background: The Trauma Unit at Groote Schuur Hospital is a mature, tertiary, high-volume trauma referral centre. The number of patients being treated in the unit at any given time can vary greatly. There is evidence to suggest that these fluctuations may be related to external and environmental factors, such as time of the day, week and month, local weather and significant home-team sport matches. Objective: The objective of this audit was to determine the relationship between volumes of patients in the unit, and environmental factors. Specifically, we aimed to determine whether the numbers of patients presenting after motor vehicle collisions and interpersonal violence was related in any way to temporal factors (time of day, week and month), weather variables (temperature and precipitation), and whether or not major or home-team soccer matches were being played. Methods: Trauma Unit admission records were examined retrospectively, and the numbers of patients presenting to the unit per shift for a total of 17 months was recorded. Patients were grouped according to their presenting complaints. Weather data, Premier Soccer League and Bafana Bafana match locations and results, and information regarding public holidays and long weekends were obtained for the relevant shifts. Average daily attendances for interpersonal violence (IPV)-related injuries and motor vehicle collisions (MVCs) were compared across the various external factors described. Poisson regression models were fitted using Stata 13 (StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP). and used to express the relative incidence of attendances. These results were expressed using incidence rate ratios (IRRs). Results: In total, 16 706 attendances were recorded over 1 074 shifts. Of these, 7 350 (44%) attendances were due to injuries sustained as a result of interpersonal violence (IPV), and 3 188 (19%) were due to MVCs. Predictors of increased attendances due to MVC-related injuries were week day shifts, and night shifts on long weekends, and on weekends that fell on the last day of the month. Weekend nights shifts were busier than week night shifts from this perspective. Public holiday shifts were shown to have less MVC-related attendances than an ordinary week day. The presence of precipitation was also shown to increase the number of MVC-related attendances. IPV-related attendances were always increased on night shifts compared to day shifts, except on public holidays, long weekends, and on weekends that fell on the last day of the month. All weekend shifts were busier than their corresponding week day shifts from an IPV-related perspective, and this effect was enhanced on weekends that fell on the last day of the month. Long weekends showed very similar trends to ordinary weekends, and public holidays showed similar trends to ordinary week days. Increasing temperatures are associated with increased attendances due to IPV. Soccer matches and their outcomes have no significant effect on attendances due to IPV. Conclusions: Temporal and weather factors can be used to predict which trauma unit shifts will be busiest.
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    Video-assisted Thoracoscopic pericardial window for penetrating cardiac trauma
    (Health and Medical Publishing Group, 2006) Navsaria, Pradeep H; Nicol, Andrew J
    Objective: To report our experience with thoracoscopic pericardial window (TPW) for occult penetrating cardiac injury. Patients and methods: During the study period (1 January - 31 December 2000), a small group of haemodynamically stable patients with anterior leftsided praecordial wounds were selected for TPW. All patients underwent general anaesthesia with doublelumen intubation and collapse of the left lung. A rigid laparoscope was inserted through a 2 cm incision in the 5th intercostal space in the anterior axillary line. Another 3 cm incision was made in the fourth intercostal space over the cardiac silhouette. Conventional instruments were used to grasp and open the pericardium. Any myocardial injury identified was an indication to proceed to sternotomy. In the absence of a myocardial injury and bleeding, the procedure was terminated and considered therapeutic. Results: Seventy-one patients with suspected penetrating cardiac injuries were seen. TPW was successfully completed in 13 patients. All were men, with a mean age of 29.8 (range 19 - 38) years. Ten and 3 patients sustained stab and gunshot wounds, respectively. The mean revised trauma score was 7.84. Ultrasound was performed in 12 patients; the results were equivocal for 2 patients, and positive for an effusion in 4 patients. Haemopericardium was found in 3 patients, 2 of whom proceeded to sternotomy. No cardiac injury was found in 1, a left ventricular contusion was identified in the second, and the third patient had no further procedure after good video-thoracoscopic visualisation of the anterior myocardium revealed no injury. In another patient, pericardial bruising was evident without any haemopericardium. The mean operative time was 13.4 (range 10 - 15) minutes, with a mean hospital stay of 5.4 (range 3 - 8) days. There were no complications. The use of a double-lumen endotracheal tube increased the cost of TPW by 23% when compared with subxiphoid pericardial window (SPW). Conclusion: TPW is a feasible, although in our setting not cost-effective, diagnostic option for occult penetrating cardiac injuries.