Browsing by Author "Madiba, Thandinkosi Enos."

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Aortobifemoral bypass for aorto-iliac occlusive disease in the population of KwaZulu-Natal: an in-depth assessment.
(1995) Madiba, Thandinkosi Enos.; Robbs, John Vivian.
Abstract available in PDF.
Complicated colorectal cancer : prevalence in KwaZulu-Natal teaching hospitals.
(2018) Mothae, Sibongile Joalane.; Madiba, Thandinkosi Enos.
Background Colorectal cancer (CRC) is the third most common +cancer in the world. According to National Cancer Registry in 2004, was listed the 4th most common cancer in South Africa. The average person’s lifetime risk of CRC is 5%. Majority of CRC is sporadic, with only 20% associated with inherited and inflammatory bowel disorders. Incidence increases with increasing age and genetic mutations. CRC incidence higher in people aged 50 and older. Unfortunately the incidence of CRC is escalating in patients younger than 50. Young age is considered a poor prognostic factor, usually presenting in advanced stages, with more aggressive histopathologic features. Other risk factors depend on lifestyle and behaviour (diet, smoking, alcohol, obesity). Survival depends on the stage at diagnosis. Five year survival for localized disease is 90%, 60% for regional disease and 10% for metastatic disease. Due to lack of recognized screening programs in South Africa, a large number of patients with CRC present to surgical units with complications of colorectal cancer. Morbidity and mortality associated with emergency surgery is very high. It is estimated that about 30% of patients with CRC present with complications such as obstruction, perforation, bleeding and fistulas. Of these 8-10% present with obstruction, and approximately 3% with perforation. These complications are associated with the worst prognosis. Aim There is a lack of data on complicated colorectal cancer in South Africa. The study was therefore undertaken in order to establish the prevalence of complicated colorectal cancer among patients presenting to the KwaZulu-Natal teaching hospitals. 8 Methods This is a retrospective analysis of a prospectively collected data. The on-going KwaZulu-Natal colorectal cancer database was established in 2000. The database now comprise 1944 patients with colorectal cancer (CRC). Of these, 448 patients presented with complicated colorectal carcinoma and these patients form the basis of this analysis. Results Four hundred and forty eight patients with complicated colorectal carcinoma were accrued during the period 2000 - 2016. There were 244 (54.5%) males and 204 (45.5%) female. There were 165 Indians, 163 Africans, 92 White and 28 Coloured patients. The mean age at presentation was 56.4± 14.4years. Seventy patients (16.1%) were young patients, presenting at or under the age of 40 years. A total of 382 (20%) patients presented with malignant obstruction, 71 (4%) with perforation and 28 (1.5%) with malignant fistula. Twenty-five patients presented with combined obstruction and perforation and eight had combined malignant obstruction and fistula. The most common sites for malignant obstruction were sigmoid and rectum; the sigmoid colon and caecum were the most common sites for perforation and the rectum and sigmoid colon predominated among patients with malignant fistula. The majority of the patients presented as stages II, III and IV at 26.3%, 26.6% and 29.7% respectively. The median follow up period was 11 months for all three groups of complications (range 1-180 months for malignant obstruction, 1-94 months for perforation and 1-94 months for malignant fistula) 9 Discussion The proportion of patients with complicated colorectal cancer was 23%.The mean age for the cohort was 56.4±14.4 years, considerably less than 63-72 years reported in the world literature. The age at presentation for Blacks was the youngest being about one to two decades younger than the other population groups. Whites were oldest at presentation in comparison to other races and their mean age approximated the world literature. These population differences in age distribution mimic that seen in the general population of patients with CRC in KwaZulu-Natal, where Blacks were a decade younger than the other population groups. The proportion of patients presenting with obstructing CRC in this study was 20%, it fell within the range of published series and did not differ between races or gender. Perforation was the second most common complication (4%) in this study. Contrary to obstruction and fistula, perforation seemed to have an equal sex incidence. The 1.5% fistula rate in this series compares favourably with the literature. In malignant obstruction resection rate was 68% with a five-year survival rate of 70%. Patients with perforation had the highest resection rate at 97% and they achieved the best an overall five-year survival of 85%. Malignant fistula had the lowest resection rate at 32% and the five-year survival was the poorest at 60% compared to the other neoplastic complications in this series. Conclusion The prevalence of complicated colorectal cancer in our setting is similar to that reported in the literature. The prevalence is the same across all population groups and the sex incidence is similar, but the age at presentation is younger in Blacks. The site distribution varied according to the complication, with obstruction associated more frequently with left-sided disease and fistula involving the sigmoid and rectum. 10 The resection rate was dependent on the type of complication. The resection rate was better for malignant perforation and obstruction than malignant fistula. The fistula population also had a worst survival rate. Patients who underwent resection had a zero in-hospital mortality rate. The perforation status did not impact on long-term outcome. Patients with malignant fistula appeared to have the worst outcome. Presentation of CCC (and CRC in general) at a younger age in our setting in Black patients highlights the need for more research in developing countries.
Does gender impact on female doctors' experiences in the training and practice of surgery?
(2016) Umoetok, Flora.; Van Wyk, Jacqueline Marina.; Madiba, Thandinkosi Enos.
Abstract available in PDF file.
Revisiting the critical role of minimal invasive surgery (laparoscopy) in the management of trauma patients at a dedicated trauma unit at the Dr George Mukhari Academic Hospital, Pretoria, South Africa.
(2018) Modise, Zacharia Koto.; Aldous, Colleen Michelle.; Madiba, Thandinkosi Enos.
Background South Africa, as a low to middle income country (LMIC), is plagued by a quadruple burden on health-care, namely trauma; the human immuno-deficiency virus (HIV) with concomitant tuberculosis infection; maternal death; non-communicable diseases such as diabetes and hypertension. The impact of trauma on an already over-burdened public sector has been profound. Improving surgical outcomes is a global health priority according to the Lancet commission. One of the World Health Organization (WHO) mandates is to improve surgical care across the globe. In addressing this question, the WHO has suggested what is referred to as a list of Bellwether procedures. This is a list of important and common procedures that account for major mortalities in developing countries. The main goal of the list is to build proficiency and dexterity in these procedures so as to reduce mortality. This includes trauma laparotomy and other surgical procedures in emergencies. The traditional approach to managing trauma patients is premised on the well-established Advanced Trauma Life Support (ATLS) principles. This well documented approach has been shown to significantly improve health outcomes of trauma victims. Closely connected to this treatment pathway are surgical interventions that have also been shown to improve the health outcomes of trauma patients. At the heart of surgical intervention for abdominal trauma, is the tried and tested laparotomy. When one looks at this, from a health economics stand-point and a cost-effective platform, laparotomy has been shown to be cost-effective and life-saving. That said, laparotomy is not without major adverse outcomes; there has been significant morbidity and, in some cases, even mortality resulting from laparotomy reported by some investigators. Laparoscopy started in earnest during the 1980s with the first laparoscopic cholecystectomy described by Muhë from Germany and later popularised by Phillip Mourret of France. This was the start of a major surgical revolution that engulfed the whole surgical community. Laparoscopic cholecystectomy became the pivot around which this revolution evolved and gathered momentum. Indeed, there has been a sea-change of surgical procedures carried out laparoscopically since its evolution and rapid development of laparoscopic cholecystectomy. The benefits of laparoscopy and other minimally invasive procedures are well documented. Despite overwhelming evidence that supports the use of laparoscopy in surgery in general, there has been reluctance in the uptake of this procedure in trauma for a number of reasons; chief of which is the fear of missed injuries. This fear was fuelled by the publication by Ivatury and colleagues citing a high rate of missed small bowel injuries in trauma patients. Consequently, there was a large hiatus in the application of this technique in the management of trauma patients and, as expected, trauma has lagged behind in the uptake of laparoscopy and continues to do so today. A great deal has happened since the publication of the work by Ivatury and colleagues. The quality of laparoscopic cameras has improved significantly and more importantly, the average surgeon’s skills-set in laparoscopy has improved considerably. The rationale for my research was to look critically at our experience with laparoscopy, appraise the available data and see how this would impact on the tried and tested practice prevalent in the trauma arena, leading to a new paradigm being set in the laparoscopic management of trauma patients that are hemodynamically stable in the South African milieu. Aims The aim of this work was to critically evaluate the role and safety of laparoscopy in the management of stable trauma patients presenting at the dedicated trauma unit of the Dr George Mukhari Academic Hospital (DGMAH). Objectives We set out to investigate the role of laparoscopy in the following ways, in trauma scenarios: • laparoscopy as a diagnostic tool and how the risk of missed injuries should be addressed and minimized; • the role of laparoscopy in the management of thoraco-abdominal injuries, including right-sided injuries and also in patients with generalized peritonitis who are hemodynamically stable; • the appropriate access technique by a way of randomized controlled trial when offering these patients laparoscopy; • diagnostic accuracy of laparoscopy in trauma - how not to miss injuries; laparoscopic-assisted techniques as a strategy to address multiple injuries and therefore address gaps in skills-set and shorten the operative time of these trauma victims; • laparoscopic management of hemodynamically stable patients with blunt abdominal trauma; • the role of laparoscopy in the management of penetrating retroperitoneal injuries in hemodynamically stable patients. Methods The Trauma Unit of DGMAH has a prospectively collected database which was used to peruse the records of recruited participants for this work. Permission was sought from the Institutional Review Board of the Sefako Makgatho Health Sciences University (SMU) in accordance with the Helsinki Declaration that guides the conduct of biomedical research. Inclusion criteria were set for the various objectives of the study. We investigated the cohort of patients where laparoscopy was used within the setting of diagnosis of abdominal injuries and identified defined primary endpoints and outcomes. We also analysed the interventional strategies that were employed to achieve the desired end result. To begin with a laparoscope, the first step is safe access into the peritoneal cavity. A one-toone computer-generated randomized study was carried out comparing the traditional laparoscopic access to peritoneal cavity using Veress needle with the open Hasson technique. Unlike other studies, in this series we included patients who had had a previous laparotomy to address the question of safe abdominal access during laparoscopic procedures. We identified all major and minor complications as the primary outcome. We determined the outcomes of patients offered laparoscopic procedure in the following situations: thoraco-abdominal injuries where the primary focus was diaphragmatic injuries both on the left and right diaphragms. In this study we included patients with both peritonitis and right sided thoraco-abdominal injuries. We studied the outcomes of laparoscopy in the case of blunt trauma, penetrating retroperitoneal injuries. We also investigated the role of laparoscopy in the context of diagnosis and specifically identified factors that mitigate against missing injuries and suggested a management pathway to minimize the incidence of missed injuries. The overall primary outcome was all-cause mortality and complications. Findings Fifty (52%) patients were randomized to the closed Veress needle and 46 (48%) patients to the open Hasson technique. Six (6%) adverse events were recorded in the Veress needle arm (p=0.03). The Veress needle technique failed to establish pneumoperitoneum in three patients (6%), the port-site bleeding was observed in one (2%) and extraperitoneal insufflation in two (4%) patients. All patients with the adverse events had previous abdominal surgery. There were no adverse events in the open Hasson group. In the work on laparoscopy and how not to miss injuries, out of 250 patients managed with laparoscopy for penetrating abdominal trauma(PAT), 113(45%) underwent diagnostic laparoscopy (DL), of these 94(83%) of patients underwent stab wounds. The penetration of the peritoneal cavity or retroperitoneal cavity or peritoneal cavity was documented in 67(59%) of the patients. Organ evisceration was present in 21(19%) of patients. Multiple injuries were present in 22% of cases. The chest was most common associated injury. Two (1,8%) iatrogenic injuries were recorded. There was conversion rate of 1,7%(2/115). The mean length of hospital stay was 4 days. There were no missed injuries. Laparoscopic assisted approach (LAA)in multiple injuries is work aimed at addressing the problem of multiple injuries in laparoscopy. This work demonstrates the utility of laparoscopy in this setting. The procedure is to evaluate the effect LAA in multiple injuries. Over 2-year period 23 patients were managed with LAA and of these 13 were patients with stab wounds and 10 with gunshot wounds. Commonly performed procedure was repair of hollow viscus injury For thoracoabdominal injury, a total of 83 patients with thoracoabdomial injuries met the seletcion criteria. The injury sverity score (ISS) ranged from 8 to 24 with a median of 18. The incidence of diaphragmatic hernia was 54%. Majority (46,8%) had grade3 (2-10cm) laceration. Associated injuries encountered reqiring interventions we encountered in 28(62%). At least 93,3% of the patients wee treated exclusively with laparoscopy . the morbidity was encountrerd in 7(16%) of the patients. The commonest was cloteed hemothorax Clavian Dindo (ii)b , but only one patient required decortication.There was one procedure related mortality. In laparoscopy management of retropritoneal injuries in hemodynamically stable patients, of 284 with PAT 56 had involvement of the retroperitoneum. Stab wounds accounted accounted for 62,5% of the patients . the mean ISS score was 7,4(4-20). Amongst the the retroperitoneal injuries the colon (27%) was the most commonly injured hollow viscus followed bt the duodenum (5%). The kidney (5%) and pancrease(4%) were the commonly injured solid organs. The conversion rate was 19,6% and this was mainly due to active bleeding. Significantly more patients were with GSW had their procedures converted to open laparotomy(38% vs 9%). Therapeutic laparoscopy wa sperformed in 36% of the pateints. The were no recorded missed injuries. Five (9%) patients developed Clavien-Dindo grade 3 complications , three were managed with reoperation, one with drainage and one with endovascular technique In laparoscopy for blunt trauma, a chalenging endeavour- Thirty-five stable patients underwent laparoscopy. The mean Injury Severity score was 12 (4-38). Therapeutic laparoscopy was performed in 15 (56%) and diagnostic in 12 (44%) patients. Eight (23%) patients were converted to therapeutic laparotomy. Intraoperative bleeding, complex injuries, visualization problem and equipment failure necessitated conversion. Three (30%) patients with negative CT scan had therapeutic laparoscopy for mesenteric injuries. There were no missed injuries. The mean length of hospital stay was 11 days in both groups. This series of studies shows that laparoscopy in all the stated objectives was safe and feasible. Multiple laparoscopic interventions in the different trauma scenarios have demonstrated the safety of laparoscopy in haemodynamically stable trauma patients. Contrary to the suggestion by other investigators, that laparoscopy is contraindicated in retroperitoneal injuries, the current study in retroperitoneal trauma has shown that it was safe and accurate in this cohort of patients. Therapeutic laparoscopy was feasible in 36% of the patients and the conversion rate was 19%. Importantly there were no missed injuries or mortality when managing penetrating trauma patients with retroperitoneal injuries. Therapeutic laparoscopy was feasible in thoraco-abdominal injuries and these patients were successfully managed, including those with generalized peritonitis. The study of thoracoabdominal injuries, including those with peritonitis, also included patients with injuries to the right side of the abdomen, as well as individuals with generalized peritonitis. We were able to offer therapeutic and diagnostic laparoscopy to this cohort of patient. Conclusions In conclusion, laparoscopy is feasible and safe in hemodynamically stable trauma patients in the context of thoraco-abdominal injuries, blunt abdominal trauma, in the presence of peritonitis as well as in laparoscopic-assisted setting, both as a strategy to reduce the incidence of nonremedial laparotomies as well as a diagnostic tool.
The role of carcinoembryonic antigen in predicting colorectal cancer in resource poor setting of Kwazulu-Natal, South Africa.
(2019) Naicker., Yugan Dylan.; Madiba, Thandinkosi Enos.; Moolla, Zaheer.
Background: Colorectal cancer (CRC) is the fourth most common malignancy in South Africa. Currently the most reliable screening tool, colonoscopy, is not readily accessible in resource-deprived settings of KwaZulu-Natal. The aim of this study was to determine whether serum CEA levels in patients symptomatic for lower GI pathology correlates with the histological presence and severity of primary colorectal cancer in a large referral centre within KwaZulu-Natal. Perhaps CEA may have a larger role as a marker for CRC development in these resource deprived communities. Patients and Methods: This study was a retrospective analysis of prospectively collected clinical data of 380 patients with colorectal cancer attending a tertiary referral centre in KwaZulu-Natal. Patients were of various age groups, various population groups and both genders. Serum levels of CEA were analysed and stratified into < 5 μg/l and ≥ 5 μg/l. Data were analyzed using descriptive statistics and findings were compared with those from the existing literature. Results: CEA levels were studied in 380 consecutive patients with known pre-treatment CEA levels. The mean CEA level of the study population was 170.0 ± 623.3 μg/l. The number of participants with a CEA level < 5μg/l was 151 (39.74%) whilst the majority 229 (60.26%) had a CEA level ≥ 5 μg/l. There was no significant correlation between CEA levels and gender (p=0.8) or age (p=0.6). CEA levels were highest in the Black African race group. Pairwise comparison demonstrated a statistically significant difference between the Black and Indian population groups (p=0.02). The current study demonstrates an upregulation of CEA as the stage of CRC progresses (p<0.0001). Conclusion: There was no significant difference in CEA levels across age and gender. A positive correlation was noted between CEA level and stage of CRC. CEA levels were highest in the black race group. Low sensitivity of CEA as a screening test for CRC was confirmed.
Surgical site infections at a quaternary South African Hospital: epidemiology and impact on healthcare resources.
(2021) Naidoo, Natasha.; Moodley, Yoshan.; Madiba, Thandinkosi Enos.
ABSTRACT Background: Studies focused on the epidemiology of surgical site infection (SSI) and its impact on healthcare resource utilisation in resource-constrained African settings are rare. This information is important for two reasons: 1) It facilitates the development of setting-specific risk stratification tools for identifying patients who might benefit fro m additional preventative interventions, and 2) It can guide public health specialists’ decisions around resource and budget allocations to surgical units and the degree to which this can be optimised through SSI prevention. The research comprising this PhD thesis sought to address these gaps in the knowledge. Methodology: This research is comprised of five stand-alone analyses involving surgical patient dataobtained from a South African quaternary hospital. The data was collected through patient medical chart review, as well as accessing the hospital’s and service laboratory’s administrative systems. Study designs used in this research include cohort, trend analysis, geospatial analysis, case-control, and prognostic study designs. Results: The incidence of SSI in high-risk laparotomy patients was 16.6%. Risk factors for SSI in this group included infectious indication for surgery, preoperative non-steroidal anti-inflammatory use, preoperative hypoalbuminemia, Bogota bag use, and perioperative blood transfusion. A 10-year trend analysis of all surgeries performed at the hospital found no change in admissions for post-discharge SSI. Mortality in elderly SSI admissions declined. The geospatial analysis found that most postdischarge SSI admissions originated from urban areas. Analysis of the laparotomy dataset showed that SSI resulted in an additional 1.06 days of hospitalisation (additional cost of ZAR8900/ $1180), but only in patients who already had short hospital stays. While preoperative hypoalbuminemia demonstrates a similar prognostic performance to the more complex SENIC/NNIS risk stratification methods (Cstatistic 0.677 versus 0.652/0.634), preoperative serum sodium is unlikely to have the same prognostic utility. Conclusions: SSI is common among South African patients undergoing high-risk surgery. A settingspecific, multifactorial risk stratification tool might be of benefit in this population. Inpatient and postdischarge SSIs contribute to unnecessary healthcare utilisation a expenditure in this resource constrained setting. There is also great potential for certain routine preoperative laboratory tests to be used as simple, cost-effective SSI risk stratification tools in African settings. Isizinda: Ucwaningo lugxile ekwakhiwenisimo sendawo ehlinziwe yokutheleleka (SSI) nomthelela wakho wokusetshenziswa komthombo wokunakekela ngokokwelapha ezizindeni esivaleleke e-Afrika nokungavamile. Lolu lwazi lubalulekile ngezizathu ezimbili: 1) Kusebenzisa intuthuko yamathuluzi okuchaza ingcuphe egxile esizindeni esiqondile sokuhlonza iziguli ezingazuza emizamweni eyongeziwe yokuvimbela, nokuthi 2) ingahola izinqumo zongoti bezempilo yomphakathi ngomthombo nokwabiwa kwezimali kuya ezikhungweni zokuhlinzwa kanye nezinga lapho enganyuswa khona ngokuvimbela nge-SSI. Ucwaningo okusekelwe kuyo le PhD kuhloswe ngalo ukubhekana nalezi zikhala olwazini. Indlelakwenza: Lolu cwaningo lunohlaziyo oluyisihlanu oluzimele olufaka imininingo yesigulo esihlinziwe olutholakele esibhedlela esisezingeni lesine. Imininingo iqoqwe ngokubuyekeza ishathi lokwelapha lesiguli, kanjalo nokufinyelela ezinhlelweni zesibhedlela kanjalo nezinsiza zaselabhorethri. Uhlelosakhiwo locwaningo olusetshenziswe kulolu cwaningo lufaka ikhohothi, ukuhlaziya okwenziwa kuleso sikhathi, ukuhlaziya umumomhlaba, ukulawula ucwaningonto, nohlelosakhiwo locwaningo oluyinhlonzasifo. Imiphumela: Ukwenzeka kwe-SSI ezigulini ezisengcupheni yelapharathomi ingama-16.6%. Izizathu zengcuphe ze-SSI kuleli qembu elifakwe izinkomba zokutheleleka, isidambisikuvuvukala okunganasteroydi angesikhathi sokuhlinzwa. Ukuhlaziya okwenzeka eminyakeni eyi-10 kokuhlinza okwenziwa esibhedlela akutholanga shintsho ekungenisweni esibhedlela emva kokukhishwa. Ukufa kwabadala ekufakweni esibhedlela nge-SSI kusukela ezindaweni zasemadolobheni. Ukuhlaziya kwedathasethi yelapharothomi ikhombise ukuthi i-SSI inomphumela wezinsuku ezi-1.06 ezongeziwe zokulaliswa esibhedlela (izindleko ezongeziwe zama-ZAR8900/$1180), kodwa yiziguli esezike zahlala kafushane esibhedlela. Ngesikhathi i-hypoalbuminemia ngaphambi kokuhlinzwa ikhombisa ukusebenza kokuhlonzwa kwesifo ezindlelenikwenza zokuchaza ingcuphe eyinkimbi ye-SENIC/NNIS (istathistikhi i-C0677 uma siqhathaniswa ne-0.652/0.634), isiramu yesodiyamu yangaphambi kokuhlinzwa okungenzeka ibe nenhlonzasifo efanayo. Iziphetho: I-SSI ivamile ezigulini zaseNingizimu Afrika ezisezingcupheni ezinkulu. Isizinda esiqondile, ithuluzi lokucacisa ingcuphe enezizathu eziningi zokuzuza eqoqwenibantu. Iziguli ezelashelwa esibhedlela nama-SSI emva kokukhishwa esibhedlela kufaka ukusetshenziswa kokunakekelwa ngokwezempilo nokusetshenziswa kulesi sizinda esincishelwe yimithombo. Kuphinde kube nokukwazi okusezingeni ngokwezivivinyo ezilungiswe ngaphambi kwesikhathi elabhorethri ukuba zisetshenziswe, njengamathuluzi alula, nashibhile okuchaza ingcuphe yama-SSI ezizindeni zase-Afrika.