INTRODUCTION: The femoral artery (FA) is the most common peripheral vessel injured in trauma. The incidence has been as high as 70%. Most experience with vascular trauma comes from the military where the incidence of FA injury is 67% of all vascular injuries. Up to 88% of these injuries are as a result of penetrating trauma. The Groote Schuur hospital trauma unit is a level one centre. It is a quaternary hospital and a referral center for all surrounding secondary level hospitals. Femoral vessel injuries are the second most common peripheral vascular injury (18.8%) seen after brachial artery injuries (48.2%) at our unit. AIM: This study aims to review a single centre experience with femoral artery injuries and identify factors associated with limb loss. METHOD: A 11 year retrospective chart review of patients with femoral artery injuries managed from 1 January 2002 to 31 December 2012 at the trauma unit, GSH. RESULTS: There were 158 patients with femoral artery injuries, 144 men and 14 women with a mean age of 28. Ninty-five percent had penetrating injuries. The most common artery injured was the superficial femoral artery (87%). The most common type of arterial injury was a laceration (39%) and transection (37%). Eighty-one patients had a primary repair (51%), fifty-three patients had a vein interposition graft (33.5%) and sixteen patients (10%) had a prosthetic graft. There were 78 (51%) concomitant venous injuries, 11 were repaired and 1 vein patch was done (15.4%). The rest were ligated (84.6%). There were 4 (2.5%) primary amputations and 10 (6.5%) secondary amputations. One primary amputation resulted from a delay to theatre with a threatened limb. The other three presented with a non-viable limb. Nine of the ten secondary amputations presented with a threatened limb. One viable limb was lost due to bleeding from a false aneurysm secondary to sepsis. One secondary amputation was the result of a delayed fasciotomy for compartment syndrome post revascularisation of a threatened limb. The rest were due to prolonged ischemic time despite attempted revascularization. There were no deaths in this study. Univariate analysis showed that statistically significant risk factors for secondary amputation were: presentation with signs of a threatened (ischemic) limb (p<0.0001), the temporary vascular shunt group (p<0.001) and the lack of a palpable distal pulse post repair (p<0.01). Statistically insignificant factors were: concomitant femur fracture, compartment syndrome, fasciotomy, unstable hemodynamics on presentation, venous ligation and 'In hospital ischemia time'. CONCLUSION: The outcome of threatened limbs due to femoral vessel injury is good provided there is no delay to surgery. This study has a primary amputation rate of 2.5% and secondary amputation rate of 6.5%, 91% of the limbs were salvaged.

In the last few years a very high incidence of deep vein thrombosis has been reported in the literature. Venous thrombosis and its sequel, pulmonary embolus account for 12. 5% of all postoperative deaths and is the single greatest threat to recovery after surgical operations. This study was undertaken to investigate the incidence of postoperative deep vein thrombosis occurring at Groote Schuur Hospital using the newer methods of diagnosis. No previous similar study has been conducted in South Africa. The high-risk factors predisposing to venous thrombosis have been assessed and the techniques of diagnosis using Radio-active fibrinogen, Doppler ultrasound and Venography have been studied. The local findings reported in this study confirmed the high reported incidence. Methods of prevention of venous thrombosis using low doses heparin and sodium pentosan polysulphate have been assessed.

Introduction: Primary Hyperparathyroidism (PHPT) is characterized by hypersecretion of PTH leading to hypercalcaemia with successful surgery being the only definitive cure. Broadly, three techniques of parathyroidectomy exist: open bilateral neck exploration and minimally invasive parathyroidectomy, which is subdivided into open focused approaches and endoscopic focused approaches. A focused parathyroid gland exploration guided by pre-operative imaging is associated with less morbidity compared to a bilateral approach. Focused explorations may target either the side or the specific parathyroid gland identified. Aim: The primary aim of this study was to evaluate the accuracy of pre-operative localisation for PHPT in a single centre. The secondary aim was to review the type of parathyroid surgery performed and the final Parathyroid Hormone (PTH) levels in patients who have undergone parathyroidectomy for PHPT. Methods: This is a retrospective review of all patients who underwent primary surgery for PHPT between 2005 and 2015. Patients were identified from a general operative database. Data was collected from pathology records, operative notes, nuclear medicine and radiology reports and captured on a confidential data sheet. Results: Records of 98 patients were found and included. Sestamibi had a sensitivity of 88%, a positive predictive value of 83% and an accuracy of 75%. Ultrasound had a sensitivity of 52%, a positive predictive value of 78% and an accuracy of 44%. The total number of cases in which both ultrasound and sestamibi were done was 73. Sestamibi and ultrasound showed concordant results in 25 cases. The overall surgical success rate was 94% (92/98). The cure rate for patients in whom sestamibi and ultrasound were concordant, was 96% (24/25). The minimum and maximum calcium levels in the cohort were 2.2 and 4.41 respectively, with a mean of 2.86. PTH levels ranged between 4.2 and 186 with a mean of 33.8. One double adenoma was proven on histology. The rest were all single adenomas. The total number of malignancies were 3 of which 1 was part of a MEN syndrome. Conclusion: Our surgical success rate was 94%. When imaging modalities were concordant, surgical success was achieved in 24 cases, thus in 96% of the subgroup. Our figures compare favourably with international standards. There is scope for improvement in the accuracy of both ultrasound (46%) and sestamibi (75%) localization. Currently a combination of both imaging modalities is still recommended.

Introduction: Long-term mortality after lower extremity amputation is not well reported in low- and middleincome countries. The primary aim of this study was to report 30-day and one-year mortality after lower extremity amputation in South Africa. The secondary objective was to report risk factors for one-year mortality. Methods: This was a retrospective cohort study of patients undergoing lower extremity amputations at New Somerset Hospital from October 1, 2015, to October 31, 2016. A medical record review was undertaken to identify co-morbidities, operation details, and perioperative mortality rate. Outcome status was defined as alive, dead, or lost to follow-up. Outcomes at 30 days and one year were reported. Results: There were 152 patients; 90 (59%) males and the median age (interquartile range, IQR) was 60 (54-67) years. At 30 days, 102 patients were traced and 12 (12%) were dead. At one year, 86 (57%) were traced and 37 (43%) were dead. Conclusion: At this South African hospital, 43% of patients undergoing lower extremity amputations were dead after one year. In resource-constrained settings, mortality data are necessary when considering resource allocation for lower extremity amputations and essential surgical care packages.

Includes bibliographical references. / The vast majority of patients with penetrating cardiac injuries do not reach the hospital alive as the pre-hospital mortality rate for these injuries is in the region of 86%. The patients that do reach the hospital alive are potential survivors and it is obviously crucial that any cardiac injury is detected and managed appropriately. Most of these injuries present with either cardiac tamponade or hypovolaemic shock and are relatively straightforward to diagnose and require immediate surgery. There is, however, a group of patients that are relatively stable with an underlying cardiac injury and it is in these patients that a potential or occult cardiac injury needs to be identified.

Exosomes are secreted membrane vesicles (30-100 nm) found in tissue culture media and various body fluids that have potential as therapeutics and disease biomarkers. Current literature has reported regenerative benefits for blood-derived exosomes but the majority of these studies purified exosomes using ultracentrifugation (UC), a method that has been found to have high levels of protein contamination. Here the regenerative capacity of exosomes isolated by size exclusion chromatography (SEC), a method shown to reduce protein contamination, from human serum was assessed. SEC isolates were found to contain suitably sized vesicles and exosomal markers (CD9, CD81 and TSG101). These isolates allowed for cellular uptake of a range of fluorescent labels and enhanced cellular fibroblast proliferation and endothelial sprout formation in a 3D spheroid-based angiogenesis assay. Further to this, functionality was shown to be retained after incubation of the isolates for 21 days at 37°C. Though a promising indication of regenerative potential, it was found that the isolates contained significant levels of ApoB containing lipoproteins (up to 15 µg ApoB/ml). It was shown that these lipoproteins were predominately the very low and intermediate density lipoproteins. It was found that low-density lipoprotein can impact exosome uptake studies that use fluorescent nucleic acid, protein and lipid dyes. As a substantial extraneous lipoprotein content could also interfere with other downstream applications and analyses such as proteomic analysis, a multistep purification method was developed. A simple 3-step density gradient (DG) UC was introduced prior to SEC that incorporated a high-density iodixanol cushion overlaid by a 18% iodixanol step containing UC concentrated human serum that was then overlaid with 6% iodixanol. This DG relied on flotation to remove lipoproteins. After the multi-step purification (UC DG SEC) ApoB and ApoA1 were not detectable by enzyme-linked immunosorbent assay and western blotting respectively. The UC DG SEC isolates were positive for CD9 and TSG101 and morphologically, as viewed by transmission electron microscopy, had the canonical exosome shape and size. Nanoparticle tracking analysis showed that though exosome marker levels were similar, there were 100 times more particles in SEC purified isolates relative to those from UC DG SEC, emphasising the extent of lipoprotein removal. Proteomic analysis identified 224 proteins in UC DG SEC isolates relative to the 135 from SEC, with substantial increases in exosome-associated proteins and reductions in lipoproteins. The UC DG SEC exosomes still elicited a significant increase in cell proliferation of human dermal fibroblasts but no increase in endothelial sprout formation. After subcutaneous implantation in a rat model, the highly purified exosomes potentially increased an angiogenic response. In conclusion, we show that serum SEC-derived exosomes with much reduced protein content do have regenerative properties but contain contaminating lipoproteins. Our new isolation technique isolated purer serum exosomes that retained cell proliferation stimulation and potentially enhanced an in vivo angiogenic response. This approach should render the isolated exosomes more suitable for biomarker discovery, molecular composition determination and biological function analysis.

Includes bibliographical references. / Introduction: Upper limb ischaemia (ULI) is a relatively uncommon, but well recognized vascular entity. The sequalae of impaired function or amputation of an arm can be devastating to the individual with loss of independence and / or livelihood. There remains much to be learned that can only be established through good quality studies. This project was aimed at developing a comprehensive, but broad overview of ULI, specific to the population we serve. Aims: The objective was to review the Vascular Surgery Unit’s experience with ULI, with particular emphasis on defining the pattern and distribution of disease and pathological profile, describing key demographic and clinical features and reporting on conventional clinical outcomes. Areas of interest, with the potential for further research, were identified. Methods: Retrospective descriptive study. All patients that underwent a surgical intervention for ULI between January 2000 and December 2011, were included in the audit. Approval from the Department of Surgery Research Committee and Human Research Ethics Committee was obtained prior to accessing data (Appendix 1 & 2).A research folder was compiled for each patient. On completion of the data collection process, the findings were analyzed and compared to current literature on this topic. Results: Sixty-four patients with ULI were managed surgically during the 12 year study period. A male: female ratio of 0.60 (as opposed to 0.96 from 2011 Census figures), was reported. The thrombo-embolic subgroup of patients (n=30), were notably younger than expected (mean age of 55 years) compared to the UEAOD subgroup (n=12, mean age of 57 years). Approximately 48% were of mixed ethnicity, correlating well with 2011 Census figures. Referrals were predominately received from Secondary Hospitals (84%) situated within the Cape Metropole. 55% Presented with acute ULI, of which 40% were classified as Rutherford grade IIa and 17% diagnosed with established compartment syndrome. The majority of chronic ULI patients, presented with signs of tissue necrosis (48%).Other indications for intervention included upper extremity claudication symptoms (31%), rest pain (14%) as well as neuro-vascular symptoms (7%). A disproportionately high prevalence of cigarette smoking (83%,with an average of 31 pack years)was identified in the UEAOD subgroup. 27% Of patients were not receiving adequate pharmacological therapies aimed at addressing pre-existing risk factors, as proposed by the TASC II document. Thrombo-embolism was the single largest aetiological factor identified (47%),with the majority of occlusions (57%) occurring at the level of the brachial artery. A left-sided predominance with a ratio of 2:1, was noted. Approximately 47% of patients with UEAOD, were younger than 55 years. A clear proximal pattern of disease was observed (66% of lesions within the subclavian artery). Eighty-nine procedures were performed in 64 patients (78 open, 5 exclusively endovascular with a combined open / endovascular approach implemented in 6 patients). The 30-day mortality rate was 7.8%. Systemic complications were observed in 13% with 23% sustaining some form of procedural complication. Twenty amputations were performed in 64 patients, of which 6 were major amputations. The 30-day amputation rate after an attempt at revascularization, was 12.5%. Adherence to follow-up was poor (51% at 6 months), limiting interpretation of follow-up data. Conclusion: Although few firm conclusions could be drawn, this review has expanded our overall perspective of ULI, specific to the population we serve. It is anticipated that the publication of our institutional data will create a clinical awareness and facilitate future research projects in this field. A collaborative research effort between South African vascular units will facilitate comparison of different institutional experiences and enable pooled data analysis, perhaps further defining the pattern of upper limb vascular disease by identifying distinct geographical confounders.

Includes abstract. / Includes bibliographical references. / Colonic self-expanding metallic stents (SEMS) are proven to be safe and effective in the management of selected cases of malignant colonic obstruction. Since 2005, we have used endoscopic decompression with SEMS as the primary treatment of all patients with left-sided obstructing colorectal cancer, in the absence of perforation. The purpose of the study was to assess the safety and efficacy of this management protocol.

Includes bibliographical references. / Combined modality treatment (CMT) is the preferred treatment for anal squamous cell carcinoma, but a small subgroup needs a defunctioning colostomy with temporary intent. The aim of this study was to evaluate the stoma closure rate of patients needing defunctioning colostomies prior to CMT for anal squamous cell carcinoma (SCC) at Groote Schuur Hospital (GSH). The key objective was to assess if abdomino-perineal resection (APR) should be offered as primary treatment modality for the subgroup of patients needing a defunctioning stoma and CMT.

Aim: The primary intention of the current study was to discover if there are international standards in renal transplantation. Method: A questionnaire was created using an online survey tool (Qualtrics ®), and distributed to a list of email addresses supplied by the unit's senior transplant surgeon. A literature review was performed on the questions and on the history of transplantation. Ethics was approved by FHS HREC number 193/2015. Results: A total of 30 surveys were completed from a total of 147 emails sent (20.4%). Two thirds of respondents work exclusively in the public sector and almost two-thirds (63.3%) of the respondents had been involved in transplantation for over 10 years. Two thirds of the surgeons estimate that their units perform more than 60 transplants per annum. Only 30% (9/30) use living donors in more than 50% of their surgeries. Most (53.3%) perfuse the kidneys both in the donor (in situ) and outside (ex situ or ex vivo). If no anatomic abnormalities were noted in open living donor nephrectomy, 63.3% would prefer to use the left kidney, and the recipient transplantation would be performed on the right side (76.7%). The majority (90%) of surgeons would preserve the vas deferens, but sacrifice the round ligament and inferior epigastric vessels (76.7% and 80% respectively). There is no marked difference for use of either the internal or external iliac artery for the arterial anastomosis, but most use the external iliac vein for venous anastomosis (86.7%). 80% use a ureteroneocystostomy with a tunnel, and 60% use a DJ stent or ureteric catheter and closed suction drain routinely. Two thirds would remove the transurethral catheter on day 4-7 post operatively. 80% routinely biopsy the kidney, and 63.3% would biopsy prior to treating for possible acute renal rejection. Discussion: These results compare with some of the studies found in the literature and operative textbooks. There do appear to be standards noted between most of the respondent's answers. Conclusion: There do appear to be standards for renal transplantation and these are appreciated globally.