Browsing by Author "Numanoglu, Alp"

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    Advantages of MesoRex shunt compared with distal splenorenal shunt for extrahepatic portal vein occlusion in children
    (2023) Khamag, Omer; Numanoglu, Alp
    Background: Portal hypertension (PH) is a common complication of chronic liver or portal vein pathology in children. It is defined as a pathological increase in the pressure of the portal venous system. There are two leading causes for PH in children, pre and post sinusoidal liver disease and pre-hepatic non-cirrhotic portal vein obstruction, also referred to as extrahepatic portal vein obstruction (EHPVO). Management of EHPVO is primarily surgical, with surgical portosystemic shunting representing a safe and effective method for the long-term management of portal hypertension in the paediatric population. Although different shunts have been proposed for EHPVO, both the MesoRex shunt and distal splenorenal shunt have shown the most promising results as effective and definitive approaches to alleviating EHPVO. Aim: To review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children's Hospital (RXH) and compare MesoRex shunt (MRS) with distal splenorenal shunt (DSRS). To determine and compare the shunt success rate, defined as longterm patency at 24 months of the MesoRex shunt and distal splenorenal shunt, the factors that could have influenced the patency of the Rex vein and the effect of these procedures on the long-term synthetic liver function. Methods: This study followed a retrospective study design, conducted at a single centre documenting pre- and post-operative data in 21 children, 14 MRS and 7 DSRS, All patients presented to RCWMCH with EHPVO over an 18-year period (2001-2019) were eligible for inclusion either for MRS or DSRS. Exclusion criteria included patients lost to follow up, patients who had atypical shunts not falling into either the DSRS or MRS operation and those with insufficient or missing clinical records over 18 years. Details of patient demographics included age, gender, aetiology, preoperative symptomatology, Rex vein patency, history of neonatal umbilical vein catheterization (UVC), age at shunt surgery and shunt patency were compiled over an average follow up period of 11 years (2-18). Bloodwork analysis included albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalized ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets prior to and two-years-post shunt surgery. Rex vein patency was assessed preoperatively. Statistical significance was determined at P<0.05 following a two-tailed t-test. Results: Out of 23 patients presenting with EHPVO, two children lost follow up immediately after diagnosis and were excluded. Twenty-one patients were operated on and followed up long term, with 14 patients (66%) in the MesoRex shunt group and seven patients (33%) in the distal splenorenal shunt group. Fourteen of the 15 MesoRex procedures (93%) were deemed successful in comparison to five out of seven (71%) in the distal splenorenal shunt group. Significant improvements were seen in MesoRex shunt recipients regarding the levels of Albumin, PT, PTT, and platelets. The other liver functions measured, including INR, fibrinogen, total bilirubin, ALT, AST, GGT, and ALP, were within the normal physiological range. The distal splenorenal shunt cohort only yielded a significant improvement in the platelet count, increasing from a mean value of 100 to 149.83 (P = 0.02). Out of those who showed successful surgical intervention in the long term (14 in MRS and 5 in DSRS cohorts), only one child with MRS experienced 2 episodes of variceal bleeding despite having patent shunt with adequate flow (more than 20cm/second). However, no further surgical intervention was needed, and the bleeding resolved spontaneously. Conclusion: This study highlights that MesoRex shunt has a better long-term outcome in extra hepatic portal vein obstruction and improves liver synthetic function and must be considered as the primary definitive intervention. DSRS does control variceal bleeding due to extra hepatic portal hypertension but may have a negative effect on liver function on long term and is only considered when MRS is not technically feasible or as a salvage procedure when MRS fails.
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    Birth prevalence of ano-rectal malformations for the Western Cape Province, South Africa
    (2016) Theron, André Pieter; Numanoglu, Alp
    Background: Anorectal malformations (ARMs) are a major birth anomaly worldwide. South Africa has ethnically and geologically diverse populations. A recent publication indicated an increased birth prevalence of ARMs in the Witwatersrand referral area between 2005 and 2010. The purpose of this study was to determine the birth prevalence of ARM and its various sub - types in the Western Cape referral district over an 8 year period Methods: For an eight year period from 01 January 2005 to 31 December 2012; retrospective data was collected from the Paediatric Surgical Departments of Red Cross War Memorial Children's Hospital, Tygerberg Children's Hospital as well as the private sector health registries. The number of live births per year for a specific municipal district was obtained from the National Department of Health. The Chi square for trend test was used to determine statistical significance. Results: The birth prevalence for ARM in the Western Cape Province in 2012 was shown to be 1:5572 live births (1.79/10 000 live births). The West Coast Municipality district had the highest average birth prevalence rate of 1:3063 (3 .26/10 000) live births for years studied. There was a male predominance (1.6:1), the most common ARM was the vestibular fistula (19.2%) and in 26% of the patients there was an initial delay in the diagnosis. Conclusion: This study has provided some recent data for ARMs for the Western Cape Province. There was no statistical significant change in the prevalence of ARMs over the eight year period for the Western Cape Province as well as in any of the individual six municipal health districts. ( χ2 for trend p=0.52) . The number of delayed diagnosis of ARM is of concern.
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    Correlation of 99mTc Sucralfate scan and endoscopic grading in caustic oesophageal injury: An observational analytic study at Red Cross War Memorial Children’s Hospital
    (2018) Nondela, Babalwa Bukeka; Numanoglu, Alp
    Introduction: Technecium (Tc) 99m Sucralfate scan has been shown to be a reliable and non-invasive screening modality after caustic substance ingestion, followed by oesophagoscopy under general anaesthesia to grade the extent and severity of injury. Aim: To determine a correlation between the 99mTc Sucralfate scan and the endoscopy findings in children presenting with caustic oesophageal injury. Methods: An observational analytic study of children who had both 99mTc Sucralfate scan and endoscopy after caustic substance ingestion at Red Cross War Memorial Children’s Hospital in a period between January 2009 and September 2016. The oesophageal injury was classified into low grade and high grade according to the degree of adhesion on 99mTc Sucralfate scan and modification of Zargar endoscopic grading. Approval of the study by the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee was obtained, REF. 049/2017. Results: Out of a total of 197 children, 40 children were identified who had both investigations done on average 26hours post injury. Low grade adhesion on 99mTc Sucralfate scan was found in 27 children (68%), and all had low grade Zargar’s oesophageal injuries. None of these subsequently developed residual pathology. Thirteen had high grade adhesion and five of these had high grade injury on endoscopy. Three (23%) developed oesophageal strictures. Correlation of 99mTc Sucralfate and endoscopic findings reached statistical significance with a p-value of 0.0014. No morbidity was associated with either the scan or endoscopy. Conclusions: Low grade Sucralfate scan finding has potential to successfully eliminate the need for invasive endoscopy under general anaesthesia and thereby reducing procedure related morbidity, hospitalization and associated costs. However, mandatory endoscopy is required in children with high grade adhesion seen on 99mTc Sucralfate scan. This requires confirmation using a larger prospective study.
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    Global Surgery - A review of the paediatric surgical workforce in South Africa
    (2018) Dell, Angela June; Numanoglu, Alp; Arnold, Marion
    There is limited data with regard to the available paediatric surgical workforce in South Africa as well as their employment prospects upon completion of their specialisation training. These data are essential in developing a National Surgical Plan to address the burden of surgical disease as well as determining where resource allocation is needed. In addition, specialist paediatric surgeons who are unable to find suitable employment are more likely to emigrate, leading to further collapse of the surgical health care system. This aim of this study was to quantify and analyse the paediatric surgical workforce in South Africa as well as to determine their geographic and sector distribution. This research builds on previous research conducted in the field of general surgery and continues to grow the national database on surgical resource in South Africa. This study involved a quantitative descriptive analysis of all registered specialist as well as training paediatric surgeons in South Africa, and included their demographic data, the geographic location of their practice, as well as the sector in which they work. Quantitative data included their plans for public, private or dual practice once they have completed their specialization training. The results showed 2.6 paediatric surgeons per one million population under 14 years. More than half (69%) were male and the median age was 46.8 years. There were however, more female surgical registrars currently in training. The majority of the paediatric surgical practitioners were found in Gauteng (43%), followed by the Western Cape (26%) and Kwa-Zulu Natal (16%). The majority of specialists reportedly worked in the public sector (40.9%), however this number may have been over-reported as hours spent in public practice were not specified. Interprovincial differences as well as intersectoral differences were marked indicating geographic and socioeconomic maldistribution of paediatric surgeons. The public sector paediatric surgeon density (per million population under 14 years) was 2.4 which fell below the private sector paediatric surgeon density of 9.4. These numbers fell far below developed countries such as the United States, Germany and the Netherlands but the private sector density compared favourably with Ireland and Canada. Access to paediatric surgical care requires an adequate supply of experienced surgeons distributed over a wide geographical area. Additionally, paediatric surgeons require a wide range of ancillary support staff and hospital facilities. Without these resources, surgical access for the most vulnerable of populations is limited. Addressing the maldistribution of paediatric surgical workforce requires concerted efforts to expand existing training posts as well as equipping the remainder of level three hospitals to provide paediatric surgical training.
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    Local anesthetic wound infusion versus standard analgesia in paediatric post-operative pain control : a randomised control trial
    (2015) Machoki, Mugambi Stanley; Millar, Alastair; Numanoglu, Alp
    Post-operative analgesia currently relies on multimodal therapy including epidural analgesia, intravenous morphine and/or paracetamol (Perfalgan ®) infusion. Local wound infusion has been effectively utilized in adults with promising results but has not been prospectively tested in children undergoing different abdominal operations. The aim of this study was to compare continuous local anesthetic wound infusion to the current standard of care in post-operative pain control in children. Methods: We conducted a prospective randomized, pain assessor blinded trial comparing Bupivacaine wound infusion {Continuous Local Anaesthetic Wound Infusion - CLAWI) in addition to intravenous paracetamol (Perfalgan®) and morphine for rescue analgesia. This was compared to: (a) epidural bupivacaine plus intravenous morphine and Perfalgan® [EPI] for children undergoing open abdominal surgery and (b) intravenous morphine and Perfalgan® infusion alone [standard post-operative analgesia - SAPA] in children undergoing Lanz incision laparotomy for complicated appendicitis. Patients aged between 3 months and 12 years undergoing laparotomy or open appendectomy were randomly selected for local anesthetic wound infusion (CLAWI) versus EPI or CLAWI versus (SAPA) respectively. Exclusion criteria were neurological impairment, post-operative ventilation and history of adverse reaction to bupivacaine. Consent from the guardian, assent from patients above the age of 7 years and ethics approval from the University of Cape Town Human Ethics Research Committee was obtained. The wound infusion catheter ('lnfiltralLong', PANJUNK®) was placed sub-fascially after suture of the peritoneum and 0.2 % bupivacaine 2mls/kg infused on anesthetic reversal followed by 0.2ml/kg/hour thereafter for 48 hours. Pain assessments were performed for each patient at regular intervals by a single assessor who had training in pediatric pain management and who was blinded to the group allocation. The duration of surgery, length of incision, perioperative antibiotics, wound class risk of surgical site infection, time to return to full feeds, drug reactions; hospital stay, surgical site infection and wound catheter and epidural catheter complications were recorded for each patient. Primary outcome measure was total morphine used in the appendectomy-SAPA vs appendectomy-CLAW! group and rescue morphine requirements in the laparotomy-EPI vs laparotomy-CLAWI group. The secondary outcomes were pain control as measured using the FLACC scale, time to full feeds, mobilization and requirement for urinary catheter.
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    Paediatric Surgery training in South Africa: Trainees' perspectives
    (2021) Jooma, Uzair; Numanoglu, Alp
    Purpose: There is very little documented evidence regarding the training of paediatric surgeons in South Africa since its inception as a formal speciality in 2007. This study aims to assess South African paediatric surgical trainees' perspectives regarding their training. Methods: A prospective study was conducted via an emailed electronic survey. The sample population included all current paediatric surgical trainees in South Africa. The questionnaire covered the trainees' demographics, exposure to different aspects of paediatric surgery, extent of after-hours clinical service, self - reported surgical competency and consultant supervision. Results: Forty one (95%) out of 43 trainees responded to the survey with 29 (71%) being female. Reported training deficits included lack of exposure to burn care in 12 trainees (30%), no urology exposure in 8 (20%), no paediatric trauma or minimally invasive surgery exposure in 6 (15%). Eighteen trainees (44%) reportedly worked more than 65 hours per week with clinical responsibilities being the biggest hindrance to attending academic teaching. Trainees were more comfortable performing open procedures compared to laparoscopic but most respondents felt adequately supervised. Conclusion: There exists a significant heterogeneity amongst the different training institutions with protected academic time and exposure to burns, urology and minimally invasive surgery remaining major obstacles in training.
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    Situs inversus abdominalis and duodenal atresia
    (2009) Brown, Craig; Numanoglu, Alp; Rode, Heinz; Sidler, Daniel
    Fewer than 20 patients born with situs inversus and duodenal atresia have been reported in the literature. We present a patient with this condition. A newborn baby presented shortly after birth with persistent bilious vomiting. An abdominal radiograph showed a right-sided stomach bubble and a second bubble on the left - typical of duodenal atresia but with mirror image configuration. Laparotomy confirmed the diagnosis of situs inversus abdominalis, which was also demonstrated by contrast studies and ultrasound. Duodenoduodenostomy was performed and the patient discharged on day 8 postoperatively. Situs inversus is associated with other congenital malformations including splenic malformations, left-sided liver and cardiac abnormalities; it is rarely associated with duodenal atresia. Duodenal obstruction in the presence of situs inversus has been described, including obstruction due to a web, stenosis, pre-duodenal portal vein and complete atresia. The patient presented in this paper had a duodenal web in the second part of the duodenum. Before undertaking surgery it is important to establish the presence of associated gastrointestinal and cardiac abnormalities.
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    The evolving management of Burkitt's lymphoma at Red CrossChildren's Hospital
    (2006) Davidson, Alan; Desai, Farieda; Hendricks, Marc; Hartley, Patricia; Millar, Alastair; Numanoglu, Alp; Rode, Heinz
    Background. Treatment for Burkitt’s lymphoma at Red Cross Children’s Hospital has evolved from the use of aggressive surgery and less intensive chemotherapy to a conservative surgical approach with more intensive chemotherapy. Methods. The study was a retrospective folder review of patients diagnosed with Burkitt’s lymphoma at RCCH between 1984 and 2004. Results. Ninety-two children were treated for Burkitt’s lymphoma at RCCH between 1984 and 2004. There were 10 patients with group A or fully resected disease, 52 with group B or extensive localised disease, and 30 with dissemination to the bone marrow and/or central nervous system or group C disease. Protocol 1 (less intensive chemotherapy based on the COMP regimen) was used from 1984, with protocol 2 (more intensive chemotherapy based on the LMB regimen) introduced in 1988 for group C disease, 1991 for group B disease and 1996 for group A disease. Overall 5-year survival increased from 20% with protocol 1 to 66% with protocol 2 for group C disease, and from 76.5% with protocol 1 to 88.2% with protocol 2 for group B disease. There were more admissions for neutropenic fever in patients on protocol 2 and more episodes of mucositis, and these patients required more red cell and platelet transfusions. With a more conservative surgical approach, biopsy largely replaced attempts to partially resect the tumour at primary surgery, and there was a consequent decline in surgical complications. Conclusions. Intensive chemotherapy with protocol 2 has resulted in improved survival for group C and group B patients, but with more morbidity. Protocol 1, which is less intensive with less morbidity, remains a viable strategy for group A and group B disease in resource-poor settings.