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Masters Degrees (Surgery)

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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.
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    Comparative study of intramedulary nailing of closed femur fractures in HIV positive and negative patients.
    (2019) Keetse, Mmakgabo Matthews.; Hardcastle, Timothy Craig.
    Introduction This study tested the hypothesis that there is no difference in both short-term infection rates and late implant sepsis and non-union rates between in HIV positive and HIV negative patients treated by reamed, closed femoral nailing for closed femur fractures. Patients and Methods Between February 2011 and December 2012 all patients with femur shaft fractures treated by reamed intramedullary nailing were recruited at a single referral hospital with a high rate of trauma and HIV prevalence. Thirty-two HIV positive patients and 80 HIV negative patients were enrolled and followed up clinically. Other variables included high or low energy injuries, age, AO/ASIF fracture pattern and CD4 counts. They were assessed for wound sepsis using the ASEPSIS method and followed up radiologically to assess for union of their nailed femurs. Follow-up was by telephonic interview to assess for late implant sepsis and non-union. Results There were no cases of early implant sepsis in either the 32 HIV positive or 80 HIV negative patients noted in the clinical and radiological follow up. Only one patient in the HIV positive cohort had a high ASEPSIS score, but this was deemed a superficial infection which resolved on antibiotics. A 3-year telephonic assessment of 32 HIV positive patients and 71 HIV negative patients with implants in situ and was undertaken. No cases of sepsis were found in the HIV group and one case of sepsis in the HIV positive group and this sepsis resolved after nail removal. Interestingly, this was in a patient who was initially HIV negative when nailed and later sero-converted. There were no cases of non-union in the HIV positive group or the HIV negative groups at 3 year follow up. Conclusions This research study found no increased risk of sepsis in closed femoral shaft fractures treated by internal fixation in HIV positive patients and adds to the limited literature regarding long term implant sepsis in HIV positive patients and concludes that there is no apparent increased risk of late, implant sepsis. There does not appear to be an increased non-union rate in HIV positive patients treated by reamed nailing fixation of closed femur fractures.
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    Early cholecystectomy for acute cholecystitis in a low income setting: a myth?
    (2018) Makitini, Goodman Mduduzi.; Kinoo, Suman Mewa.
    Laparoscopic cholecystectomy is the gold standard surgical management for acute cholecystitis (AC). Controversy exists regarding the optimal timing to perform laparoscopic cholecystectomy in AC. The Tokyo consensus guidelines 2013 (TCG13) are the most widely used and accepted management guidelines in acute cholecystitis. These guidelines advocate early laparoscopic cholecystectomy (ELC) in patients presenting within 72 hours of onset of symptoms of acute cholecystitis. This has several advantages such as sorting the patient's problem during the first admission, decrease in overall hospital costs by avoiding a second admission and averting po sible occmrence of gallstone related complications whilst awaiting delayed cholecystectomy. Traditionally a delayed cholecystectomy has been the preferred approach in acute cholecystitis with a theoretical advantage of avoiding a cholecystectomy in acutely inflamed tissues thereby avoiding complications of major ductal or vascular injuries. It has been shown in several studies however that morbidity, m01tality and conversion rates are similar in early laparoscopic cholecystectomy and in delayed laparoscopic cholecystectomy. There are only a handful of studies from the developing world regarding management and the timing of intervention in acute cholecystitis. ·We therefore studied our profile of patients and compare these to the patient populations commonly cited in literature mostly from first world countries. Late presentation outside the window for early intervention, limited availability of transport to a health care facility with expertise to perform laparoscopic cholecystectomy, limited diagnostic modalities like ultrasound and limited laparoscopic services are amongst the common challenges faced by developing countries. This may potentially exclude a large number of patients for consideration for early laparoscopic cholecystectomy. This is a retrospective chart review looking at all adult patients who were 18 years and older who presented to King Edward VIII in South Africa between 01 January 2013 and 31 December 2013, who have a confirmed diagnosis of acute cholecystitis and had a cholecystectomy. Data was retrieved from the patients' admission and in-patient files and theatre records. Diagnosis was established using clinical and laboratory criteria and a confirmatory ultrasound, as per the TCG13. We looked at the time of presentation to the health care facility from the initial onset of symptoms of acute cholecystitis, patient demographics, type of operation i.e. laparoscopic or open surgery, reasons and rate of conversion from laparoscopic to open surgery, time taken from initial presentation to time of operation. All patients meeting the inclusion criteria were included in this study. A total of 176 files were evaluated and 139 of them had complete records for inclusion in the study. Findings from this study showed that the majority of patients present late i.e. after 72 hours and after 7 days of onset of symptoms when using the two commonest definitions of early presentation. A delayed laparoscopic cholecystectomy was the most commonly performed surgical intervention for acute cholecystitis. It was shown to be a safe option and was associated with low morbidity and mortality. In low income settings DLC still has a significant role in the management of acute cholecystitis despite the cun-ent recommendations ofELC in acute cholecystitis. Clinicians in low income settings with limited radiologic and laparoscopic services can use the results of this study in managing patients who present outside the window for ELC. vii
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    Complications of laparoscopic cholecystectomy : Addington experience.
    (2014) Mbatha, Sikhumbuzo Zuke.; Anderson, Frank.
    Background Laparoscopic cholecystectomy is a common surgical procedure performed for complicated gallstones. The timing of cholecystectomy is controversial with a trend toward early cholecystectomy in patients with acute cholecystitis. This study examined the presentation, timing of cholecystectomy and outcomes in a resource constrained environment. Methods A retrospective analysis of laparoscopic cholecystectomies performed from January 2010 to June 2011. The mode of presentation, ERCP (endoscopic retrograde cholangiopancreotogram) rate, and timing of cholecystectomy, complications and morbidity were analysed. Results One hundred and sixty seven patients were evaluated. The mean age was 44(17-78) years and 93% were female and 7% male. There were 44%, 24%, 21% and 14% who presented with biliary colic, pancreatitis, acute cholecystitis and jaundice respectively. They had laparoscopic cholecystectomies after a mean 34(4-90) days and 9(5.4%) patients required conversion to an open cholecystectomy. Complications occurred in 16.2% and bile duct injuries and bile leaks in 0.6% and 1.6% respectively. One patient died. Conclusions Most patients had delayed laparoscopic cholecystectomy. There was no difference in outcomes for the different presentations and the complications are similar to other reports in the literature.
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    Spectrum and cost of road traffic crashes : data from a regional South African hospital.
    (2014) Parkinson, Frances.; Clarke, Damian Luiz.; Aldous, Colleen Michelle.
    Road traffic crashes (RTCs) are a worldwide phenomenon, but a disproportionate number of deaths and injuries caused by RTCs occur in developing countries. A number of international organisations have drawn attention to the problem and called for a comprehensive public health response. Such a programme needs to be multi-faceted and use preventative and therapeutic strategies and also involve a wide range of stakeholders from government and civil society. In South Africa, the Province of KwaZulu-Natal (KZN) has the worst record for the number of deaths and injuries sustained on the roads. Despite the urgent need for such programmes in the Province there is a paucity of local research on the problem. This project sees itself as part of an ongoing systematic comprehensive quality improvement initiative. The objectives of this single-centre study are to determine common patterns of injury associated with road traffic crashes in KZN, to identify risk factors which may be targeted by specific injury prevention programmes and to establish the in-hospital cost of RTCs. This will be done by identifying a cohort of patients with injuries sustained in RTCs, gathering data on their injuries and circumstances of the crash, and costing their inpatient stay using micro-costing methods. It is hoped that this information on the burden of disease (including cost) will be incentive for investment in local healthcare and risk-reducing measures (relevant to local risk factors). The costs may also serve as a baseline for larger province-wide costing studies.
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    A symptom-specific quality of life questionnaire for dysphagia.
    (2014) Ferndale, Lucien.; Thomson, Sandie Rutherford.
    Dysphagia is a common clinical problem. It is a distressing symptom which impacts negatively on the quality of life (QOL) of patients. There is increasing recognition that assessing QOL gives a broader perspective when deciding on and assessing the effect of treatment of our patients. An abstract concept, QOL is perceived by many clinicians in South Africa as difficult to measure and hence they are reluctant use it to help with therapeutic decision making. There is a dearth of QOL information from third-world countries and there is no locally developed or validated tool to measure it. If we are to provide more holistic health care to our patients this situation needs to be rectified and an appropriate tool developed. Aim: To develop a quality of life questionnaire specific for dysphagia relevant to our local population and validated it against established international questionnaires. The newly developed questionnaire needs to be comprehensive enough to measure general QOL as well as specific enough to be able to detect differences in QOL before and after treatment. Furthermore it needs to be brief and simple so as to be clearly understood and completed by our patient population with varied literacy competencies. Methods: We formulated a questionnaire related to dysphagia and other symptoms commonly associated with it and named it the Greys Dysphagia Quality of Life (GREYS DQOL) questionnaire. The questionnaire contained questions pertaining to generic QOL issues as well as to dysphagia-related QOL issues. We administered the questionnaire to a sample of patients together with two other internationally used questionnaires. One of the international questionnaires, the Short Form 36 (SF-36) quality of life questionnaire is a fully validated generic quality of life questionnaire which is extensively used world-wide and in South Africa. The other, the Dysphagia Score (DS), is a dysphagia-specific questionnaire used internationally to assess patients with conditions presenting with dysphagia. We compared the results of the three questionnaires as well as the compliance of patients in answering the three questionnaires. Demographic data collected included age, gender and level of education. Results: One hundred patients were entered into the study. The majority were males in their sixth and seventh decade of life. Most patients had no established diagnosis at the time of the study, but of those who did have a diagnosis, the most common cause of the dysphagia was malignant obstruction of the oesophagus. The literacy level amongst our patients was found to be low. Twenty three patients received no formal schooling and only 11 patients completed school to matriculation level. The quality of life of our sample population was poor according to all three questionnaires. The mean score for patients on the SADQOL questionnaire was 61 where a score of 0 indicates the best quality of life possible and a score of 100 indicates the worst quality of life possible. The mean score for patients on the SF-36 was 30, where 0 indicates the worst possible quality of life and 100 the best possible quality of life. The mean score for patients on the dysphagia score was 7, where 0 is the best score and 10 the worst. The results of the new questionnaire correlated well with that of the international questionnaires, confirming test-validity. The compliance of patients in answering questions in the GREYS DQOL questionnaire was superior to that of the internationally used questionnaires. The level of education influenced the scores of the SF-36 but not those of the GREYS DQOL and DS. This makes the GREYS DQOL more appropriate for use in our patient population. Conclusion: The GREYS DQOL questionnaire is simpler to comply with and correlates well with established international tools. We therefore consider it to be a good tool for assessing quality of life of patients presenting with dysphagia in South Africa. It can be used to assess QOL in our patients at initial presentation and after treatment is administered and is understood well by our patient population.
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    Neurogenic thoracic outlet syndrome : an indepth review.
    (2014) Redman, Laura.; Robbs, John Vivian.
    No abstract available.
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    Complex regional pain syndrome (CRPS) and the role of sympathectomy in the management : a review.
    (2012) Kinoo, Suman Mewa.; Singh, Bhugwan.
    Complex Regional Pain Syndrome (CRPS) is an extremely debilitating condition, characterized by chronic pain with associated trophic changes. The 1st description of this condition dates back to 1864. The condition has been variously described over the years as “causalgia”, “Sudeck’s dystrophy” and “reflex sympathetic dystrophy”. In 1993 the International Association for the Study of Pain (IASP) introduced the term Complex Regional Pain Syndrome (CRPS) with diagnostic criteria that are currently used. CRPS was subdivided into type I and type II. CRPS type I is diagnosed when there is no obvious nerve injury, whereas CRPS type II refers to cases with nerve injury. It follows that the present diagnostic criteria depend solely on meticulous history and physical examination without any confirmation by specific gold standard tests. The pathophysiology of this pain syndrome is poorly understood; however there is growing evidence for an inflammatory or sympathetic cause. It is therefore not surprising that there is no uniform approach to its management. Therapy is often based on a multi-disciplinary team approach with use of non –pharmacological therapy (physiotherapy and occupational therapy), pharmacological therapy (analgesics, neuroleptics, bone metabolism drugs), and invasive therapy (stellate ganglion blocks and sympathectomy). This review acknowledges the humble beginnings of this condition, and provides an understanding for the evolution of its terminology. It objectively reviews the current IASP diagnostic criteria, challenging its efficacy and sensitivity. Despite its pathophysiology remaining an enigma, the latest pathophysiological advances are reviewed in the endeavour to better understand this condition and enhance treatment options. The role of surgical sympathectomy for this condition is reviewed, highlighting its importance and underappreciated success in the management of CRPS.
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    Gastroschisis in KwaZulu-Natal.
    (2008) Sekabira, John.; Hadley, Grenville Peter.
    Gastroschisis is a full thickness abdominal wall defect, usually to the right of the umbilicus, through which a variable amount of viscera herniates, without a covering membrane. Newborns with gastroschisis present challenging problems to paediatric surgeons. The incidence of gastroschisis is rising worldwide. In developed countries, advances in neonatal intensive care have improved survival of patients with gastroschisis. In the few reported studies from Africa, mortality rates of patients with gastroschisis are high. The aim of this study was to evaluate outcome of gastroschisis from a centre in Africa with modern neonatal intensive care facilities. Methods: A retrospective analysis of all neonates admitted with the diagnosis of gastroschisis at Inkosi Albert Luthuli Central Hospital (IALCH) over a 6-year period (2002-2007). Proportions in percentages were used for categorical variables. For continuous variables the mean with standard deviation (SD) were derived. Two sampled t-test was used to show the pvalue for the time to reduction between the non-survivors and survivors with a 95% confidence interval. Results: There was a significant increase in the prevalence of gastroschisis among neonatal surgical admissions from 6.2% in 2003 to 15.2% in 2007. There were more females 53.4%, the majority (71.7% had low birth weight and 64.2% were born prematurely. Although 75% (n=79) of the mothers attended antenatal clinic, antenatal diagnosis by ultrasound was made in only 13 (n=12%)). Most of the babies 90.6% were out-born, with 70.8% delivered by normal vaginal delivery (NVD), and 57.4% of the mothers were primiparous. Primary closure was achieved in 73.5% of the patients. The overall mean (SD) time from birth to primary surgical intervention was 16 (13.04) hours and was higher 17(9.1) hours in those who died compared to survivors 15 (16.0), but the difference was not statistically significant, p=0.4465 and mortality was 43% with sepsis as the leading cause. Staged closure with a plastic silo bag was associated with more than double the mortality as compared to primary closure. Conclusion: The prevalence of gastroschisis among neonatal surgical admissions has increased in accordance with international trends. Due to lack of antenatal diagnosis, most of the babies were out-born resulting into delay in offering surgical treatment. Mortality is still high despite the presence of modern intensive care.
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    The influence of diabetes mellitus on early outcome following vascular surgical interventions.
    (2012) Mulaudzi, Thanyani Victor.; Robbs, John Vivian.
    Objective. To assess the influence of diabetes mellitus on early morbidity and mortality following open vascular surgical interventions. Methods. Clinical data on patients subjected to open vascular surgical procedures over a 5 year period at the Durban Metropolitan Vascular Service was culled from a prospectively maintained computerized database. They were divided according to the type of surgical procedure performed. These were open abdominal aortic surgery, peripheral bypass surgery, lower extremity major amputation and carotid endarterectomy. They were further subdivided into 2 groups, diabetic and non-diabetic. Results. 1104 charts were analysed. There were no significant differences in demographics and risk factors between the two groups. 273 patients had open abdominal aortic surgery. 217 (79%) were non-diabetic. diabetic patients had significantly higher incidence of myocardial infarction (p=0.00001) (6 of 6 patients), graft sepsis (p=0.000001) (7 of 7 patients) and mortality rate (p=0.0335) (5 of 10 patients). 337 patients had peripheral bypass procedures. 204 (60%) of these were non-diabetic. There was a high prevalence of smokers among non-diabetics and of hypertension among diabetics. Diabetic patients had a preponderance of graft infection (p=0.0015) (15 of 20 patients) and cardiovascular complications (p=0.0072) (7 of 8 patients). 230 patients had lower extremity major amputations, 81 (35%) were diabetic and 149 (65%) non-diabetic. Myocardial infarction and death (6 of 8 patients each) were significantly higher among diabetics (p =0.04). 264 patients had carotid endarterectomy, 170 (64%) being non-diabetic. The surgical outcome was similar between the two groups. Conclusions. This is retrospective study and as such it has some its limitations. Not all patients might have been included in the study and some of the information might have been lost. The numbers in this study are large and these limitations would appear not to have influenced the outcome of this study. This study has shown that diabetes mellitus had diverse influence on the early outcome following different vascular surgical procedures. Diabetes mellitus significantly increased the incidence of graft sepsis among those who had aorto-bifemoral bypass and peripheral bypass procedures. The incidence of peri-operative cardiovascular morbidity was significantly increased among diabetics who had peripheral bypass procedures, open abdominal aortic surgery and lower extremity major amputations. Diabetes mellitus had no influence on the surgical outcome following carotid endarterectomy.
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    The scope and spectrum of challenges presented to the general surgeon by patients affected with the human immunodeficiency virus (HIV) : a review.
    (2012) Ebrahim, Sumayyah.; Singh, Bhugwan.; Ramklass, Serela Samita.
    Background: Surgical disease related to HIV is scantily documented with a paucity of data detailing the manifestations of HIV in surgery especially in resource-poor, high prevalence settings such as in South Africa. This review provides an update on the topical issues surrounding HIV and surgery. Objectives: The objective of the study was to determine the incidence, pathogenesis, clinical presentation, aspects of diagnosis and management of: HIV- associated salivary gland disease in particular parotid gland enlargement; Kaposi’s sarcoma (KS) and lower limb lymphoedema; AIDS- related abdominal malignancies due to KS and lymphoma; Acalculous cholecystitis and HIV- cholangiopathy and HIV- associated vasculopathy. Methods: A collective review of the literature was performed and data sourced from a search of relevant electronic medical databases for literature from the period 2000 to the present date. Studies under each section were selected based on inclusion and exclusion criteria. Content analysis was used to analyse data. Results: The HIV pandemic has resulted in an increased frequency of benign lymphoepithelial cysts making it the commonest cause of parotidomegaly in most surgical practices. KS should be considered in the differential diagnosis of a patient with chronic lymphoedema. Lymphoedema may be present without cutaneous lesions, making clinical diagnosis of KS difficult. The gastrointestinal tract is the commonest site of extra- cutaneous KS. Surgical management of the lymphoma patient is restricted nowadays to determining the diagnosis and in some cases to evaluate disease stage. Highly active antiretroviral therapy (HAART) is an important part of the management of biliary tract conditions in addition to relevant surgical procedures. HIV- vasculopathy represents a distinct clinico- pathological entity characterized by a vasculitis with probable immune- mediated or direct HIV- related injury to the vessel wall. Conclusion: The rising incidence of HIV in South Africa and other developing countries has been associated with new and unusual disease manifestations requiring surgical management for diagnostic, palliative or curative intent. It is crucial that surgeons remain abreast of new developments related to the challenging spectrum of HIV and its protean manifestations.
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    A prospective audit of the use of diagnostic laparoscopy to establish the diagnosis of abdominal tuberculosis.
    (2011) Islam, Jahangirul.; Wilson, Douglas Paul Kinghurst.; Dawood, Halima.; Thomson, Sandie Rutherford.; Clarke, Damian Luiz.
    HIV epidemic is one of the major challenges to the South Africa’s socio-economic development. The incidence of tuberculosis is rising in sub-Saharan Africa, and in 2009 South Africa had the second highest incidence of tuberculosis in the world. Approximately 80% of incident tuberculosis cases in South Africa are HIV positive. In HIV positive individual, abdominal tuberculosis has been reported as the most common form of extra-pulmonary tuberculosis. HIV/AIDS has resulted in a resurgence of abdominal tuberculosis in South Africa. Making the diagnosis of abdominal tuberculosis is still difficult, though the condition is common. The role of laparoscopy in making the diagnosis is undefined. Method: All patients with clinically and radiologically suspected but histologically or microbiologically unconfirmed abdominal tuberculosis were referred to the investigating team and laparoscopy was performed to diagnose abdominal tuberculosis. Histology was performed on tissue biopsy specimens and TB culture on ascitic fluid and peripheral blood specimens. Results: From January 2008 to June 2010 a total of 190 patients were referred to us. No surgical intervention was taken in 60 patients; all of them were HIV positive. Twenty six of them died (43%) in the hospital during the evaluation period before the diagnostic laparoscopy, and the rest (57%) were unfit for anaesthesia. Forty nine patients required emergency laparotomy either for bowel obstruction or peritonitis and 39% of them died. Eighty one patients underwent diagnostic laparoscopy and 77% of them were HIV positive, in 16% the HIV status was unknown. Two percent had clinical ascites. Laparoscopic findings included intra-abdominal lymphadenopathy in 56, minimal ascitic fluid in 46, intra-abdominal mass in 17, and deposits on bowel wall, peritoneum or omentum in 20 patients. Fifty five patients (68%) had positive histology for tuberculosis. In 15 patients (19%) histology revealed non-specific inflammation, no pathology was found in one patient and no specimen was taken from one patient. Eighty percent of peritoneal deposits and 77% of lymph nodes were positive for tuberculosis, whereas 35% ascitic fluid culture was positive. In nine patients (11%) an alternative diagnosis was found (appendicitis, adenocarcinoma, lymphoma). Conclusion: Laparoscopy was feasible and showed a high yield to establish the diagnosis of abdominal tuberculosis and to provide an alternate diagnosis. Laparoscopy was useful to establish the gross features of abdominal tuberculosis and to provide the adequate specimens for examinations. Very poor follow negated the evaluation of the clinical response to anti tuberculosis therapy.
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    Laser doppler assessment of gastric mucosal blood flow in normals and its relationship to the systemic activity of growth peptides in healing and non healing gastric ulcers.
    (1999) Clarke, Damian Luiz.; Thomson, Sandie Rutherford.
    The pattern of mucosal blood flow in normal human stomachs, and benign gastric ulcers was assesed with laser Doppler flowmetry and the relationship between a single determination of ulcer blood flow and the systemic level of growth factors was investigated. A significant ascending gradient in mucosal blood flow from the antrum to fundus was demonstrated. Different levels of cellular activity in the regions of the stomach may explain this gradient. In the gastric ulcers that healed on standard medical therapy mucosal blood flow was significantly increased in comparison to normal stomachs. In the ulcers that were refractory to standard medical therapy mucosal blood flow was significantly lower than in normal stomachs and healing ulcers. Higher systemic levels of the growth factor bFGF were demonstrated in healing ulcers compared to non-healing ulcers. Gastric mucosal blood flow can increase in response to the increased metabolic demands of healing, however impairment of this response may be an important factor preventing healing of benign gastric ulcers. It would appear that non-healing of gastric ulcers can be predicted at initial diagnosis by reduced peri-ulcer gastric mucosal blood flow and low blood levels of bFGF.
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    An evaluation of the use of transcutaneous oxygen pressure measurement in the non-invasive vascular laboratory : with special reference to selection of amputation level.
    (2001) Mars, Maurice.; Robbs, John Vivian.
    Transcutaneous oxygen pressure measurement (TCp02) using a miniaturised Clarke electrode and a heating thermistor was developed independently by Huch et al and Eberhardt et al in 1972. After its initial use to non invasively monitor arterial partial pressure (Pa02) in neonates it was proposed as a useful test of skin blood flow and possibly amputation wound healing level selection in patients with peripheral vascular disease. Unfortunately a wide range of predictive values emerged with some authors reporting amputations healing when the TCp02 value was 0 mmHg. The investigation, while still considered useful, has not gained widespread support. This study investigates the use of TCp02, establishes a value for the use of the TCp02 Index to predict amputation wound healing potential and examines the hypothesis that the use of the TcpO Index to select amputation level can reduce patient morbidity and mortality. The literature is reviewed and a series of studies evaluating TCp02 use, undertaken in the Durban Metropolitan Vascular Service Non-Invasive Laboratories, are presented. TCp02 measurements were performed in a standardised manner with the subject supine breathing room air. Measurements were taken at fixed sites, on the mid dorsum of the foot (Foot), 10 cm distal to the tibial tuberosity and 2 cm lateral to the anterior tibial margin (BKA), 10 cm proximal to the patella in the midline (AKA) and on the chest in the mid-clavicular line. A TCp02 Index, the limb to chest ratio was defined. TCp02 data derived from control subjects asymptomatic of peripheral vascular disease were shown to be similar to age matched pooled data derived from the literature. In patients with peripheral vascular disease, absolute TCp02 and the TCp02 Index were shown to fall from proximal to distal sites and again were no different to pooled data derived from the literature. Based on presenting symptoms, the fall in TCp02 and the TCp02 Index was significant from proximal to distal sites. The reduction in absolute TCp02 and the TCp02 was also related to the most distal pulse present. TCp02 values were found to be no different in patients with peripheral vascular disease with or without diabetes. When comparing TCp02 and the TCp02 Index with Doppler pressure measurements at the Popliteal artery and at the foot, and the Doppler ankle brachial index (ABI), Doppler derived data were significantly higher in diabetic patients than in non-diabetic patients. No differences were noted in TCp02 data. TCp02 was compared with the 133Xe radio-isotope skin washout test. The best correlation was (r = 0.46) was obtained with a logarithmic curve y = 10.862Ln(x) + 38.751. TCp02 was compared with antibiotic concentrations (Cefoxitin) in muscle obtained from the site of amputation and the Cefoxitin Index, the ratio of muscle antibiotic concentration to plasma concentration, as an indication of the relationship of skin TCp02 to muscle blood flow. A significant correlation was shown between the Cefoxitin Index and TCp02 (r = 0.67, p = 0.035) and the TCp02 Index (r = 0.64, P = 0.045), suggesting that skin oxygen delivery may reflect muscle antibiotic delivery and hence blood flow. TCp02 and the TCp02 Index were compared with heated and unheated laser Doppler fluxmetry (LDF) in 35 patients undergoing amputation wound healing assessment. Significant correlations were shown between heated LDF, heated LDF Index and the TCp02 Index (r = 0.63 and r = 0.69, P < 0.0001). TCp02 Index values of 0.5 and 0.55 showed an accuracy of 96.2 % in predicting amputation outcome while LDF values of 3, 4 and 5 arbitrary units gave an accuracy of 88.5 %. Using receiver operator curves, a TCp02 Index of 0.55 was shown to be the best test. Over the years 1987 and 1988, TCp02 data were gathered on 193 patients undergoing lower limb amputation for peripheral vascular disease. Information on the outcome of the amputation was available for 152 amputations. Circumstances which might result in a reduced pre-operative TCp02 reading were identified and criteria were set for the use of TCp02 to predict amputation wound healing potential. 122 amputations which met the defined entry criteria were available for evaluation. A TCp02 Index of 0.50 gave a definitive predictive value below which no amputation healed. Similarly no amputation with an absolute TCp02 of less than 27 mmHg healed. Receiver operator characteristic curves showed the TCp02 Index to be a better test than absolute TCp02. A TCp02 Index of 0.55 was shown to have the best sensitivity of96.7 %, with a specificity of79.8 % and an accuracy of 90.2 %. When introduced to clinical practice, correct use of the TCp02 Index of 0.55 resulted in a reduction in amputation revision rate from 40.3 % in 1987, to 8.2 % in 1990. Initially some surgeons felt that the TCp02 Index predicted amputation wound failure at distal sites at which healing could be expected on clinical criteria, and chose amputate at sites with a TCp02 Index value less than 0.55. These amputations failed to heal. As surgeons gained confidence in the test, they chose to follow the TCp02 data more often and the percentage of amputations performed at sites predicted by the TCp02 Index to fail , fell from 35.5 % in 1987 to 6.6 % in 1990. Over a 15 year period at King Edward VIII Hospital, the amputation revision rate has fallen from an average of 32.7 % in the first five years when Tcp02 data were not available to the surgeon, to 21.4 % and 22.9 % in the two subsequent 5 year periods when Tcp02 data were available. The mortality rates were unchanged. The decline in revision rates was less than expected and relates to the fact that approximately only 42 % of patients requiring amputation undergo the test. This is because it is time consuming and available only during weekday office hours. These studies have confirmed the usefulness of Tcp02 measurement in the non-invasive vascular laboratory. The index is shown to be superior to absolute Tcp02 as a predictive test of amputation wound healing. The introduction of several criteria to define when Tcp02 use is appropriate has refined the investigation and made it clinically useful in our setting. A Tcp02 Index of 0.55 in the appropriate patient is a useful test to predict amputation wound healing and its use has resulted in reduced patient morbidity and mortality, confirming the hypothesis tested.