Includes bibliographical references. / The primary outcome will be the incidence of hernia recurrence. Secondary outcomes will be the incidence of post-operative and long-term pain and complications.

Background: Human Papillomavirus (HPV) is a common sexually transmitted infection, associated with condylomata acuminata, anogenital squamous intraepithelial lesions, and ultimately invasive squamous cell carcinoma. HPV types 16 and 18 are the most common subtypes in individuals with cervical cancer. The association with these two subtypes in individuals with squamous carcinoma of the anus is fundamentally the same as with cervical cancer, and also affects the same high risk phenotype. Human imunnodeficiency virus (HIV) positive transplant patients have two modes of immunosuppression - the disease itself and the additional immunosuppression required after transplantation, which intuitively places them at a higher risk for this type of infection, if compared to their HIV negative counterparts. Aim: The first aim is to determine the prevalence of HPV-associated cytological and pathological abnormalities of the anus in HIV positive kidney transplant recipients and the second aim is to determine if HIV positive solid organ recipients carry higher risk for having HPV of the anus than HIV negative solid organ recipients. Materials and methods: This is a cross sectional study, conducted at the Transplant unit of Groote Schuur Hospital. 14 HIV positive renal transplant recipients and 14 age matched HIV negative renal transplant recipients with similar immunosuppression regimens and time from transplantation were selected. Ethical approval for the study was obtained from the UCT Ethics committee (HREC/REF: 595/2014). Informed consent was obtained from all participants. Samples for cytology and histology were taken from the anal canal. Demographic data was collected, date of HIV diagnosis, duration on anti-retroviral drugs, time since transplant, type of immunosuppression, whether there was visible condylomata or not and if there were any lesions suspicious of cancer. Cytology and histology was correlated with clinical findings. The statistics were analysed with Stata® software. Results: Mean age was 40.8y ±7.5 (range 27-52) in the HIV positive study group and 41y ±14.4 (range20-62) in the HIV negative control group. HIV positive patients were screened 40.1 months ± 21 (range 13-74.6m) post renal transplant. HIV negative patients were screened 55.9 months ± 23.3 (range 8.9-80 m) post renal transplant. Two HIV positive patients had anal warts, compared to 1 in the HIV negative group. No statistically significant difference could be demonstrated between the occurrence of intra-epithelial neoplasm on cytology in the HIV positive and negative groups. However, HIV positive patients had a higher incidence of HPV on histology that was statistically significant. There was no evidence of squamous intra-epithelial neoplasm found on histology in either group. Conclusions: Evidence of HPV of the anus was demonstrated in both groups, there was no demonstrable statistical significance in occurrence between the two groups' cytology. Histology, however, yielded a significant number of patients with HPV in the HIV positive group. None of the patients had evidence of invasive malignancy.

Background: Delorme's perineal repair has remained a procedure reserved for full-thickness rectal prolapse in elderly or co-morbid patients due to its low morbidity and complications. Reported recurrence rates are higher than in abdominal approaches. Aim: The study assesses long-term outcomes after Delorme's procedure (DP), specifically recurrence and postoperative bowel function, in both a multi-surgeon public hospital and a single surgeon cohort in the private sector (Groote Schuur Hospital and Kingsbury Hospital). Patients and Methods: This retrospective cohort study includes all patients who underwent DP between February 2001 and March 2014 at both study sites. The primary outcome was absence of recurrence. Secondary outcomes were bowel function (incontinence and constipation), postoperative mortality and morbidity and length of hospital stay. Patient data was collected from electronic records (Kingsbury Hospital) and paper folders/op notes (Groote Schuur Hospital) and current status was acquired by telephonic interview with either the patient, a family member or caregiver, as appropriate. Results: Seventy patients underwent DP: 37 private and 33 public, mean age 71yrs. There were 16 (23%) recurrences (7 private, 9 public), of which 8 (11%) underwent reoperation. Mean time to recurrence was 30 months (48 private; 15 public). There were 2 postoperative deaths (pneumonia, myocardial infarction), 6 major complications (rectal bleeding requiring transfusion or reoperation, bowel obstruction, pneumonia, myocardial infarction), and 6 minor complications (rectal pain, rectal bleeding not requiring reoperation or transfusion, urinary retention, confusion, hyponatraemia). The mean postoperative hospital stay was 4 days. Conclusion: Long-term outcome from this large series compares favorably with most other published series, specifically a low recurrence rate. Proposed reasons for this will be presented, within the context of the published literature.

Includes bibliographical references (leaves 54-62). / Living donor liver transplantation (LDLT) is now well established and performed on a routine basis in many major centres around the world. LDLT is feasible because of the capacity of both the remnant donor liver and the transplanted partial liver to undergo liver regeneration. However it has been demonstrated that liver regeneration in the recipient is rapid, whereas restoration of liver mass in the donor is delayed. This discrepancy in the rate of regeneration could be due to the presence of hepatotrophic factors and the use of immunosuppression in the recipient. The aims of the studies were to determine if hepatotrophic factors and immunosuppression (Cyclosporine) could modify the restoration of the liver mass after partial hepatectomy in rats.

Background: The need to exclude occult diaphragmatic injury in left thoracoabdominal (TA) stab wounds continues to be controversial. Current trauma guidelines recommend either routine diagnostic thoracoscopy or laparoscopy and repair of an injury if found. Objective: To determine if asymptomatic patients with left sided (TA) stab wounds can be safely treated with careful clinical and chest X-ray follow up to ascertain healing of occult injuries. Methods: A parallel-group, prospective, randomized control study was conducted at the Trauma Centre at the Groote Schuur Hospital from 01 September 2009 through to 01 November 2014. All patients with asymptomatic left TA stab wounds included in the trial were randomized into two groups. Group A underwent diagnostic laparoscopy to exclude a diaphragm injury, and Group B underwent clinical and radiological follow up. Results: Twenty-seven patients were randomized to Group A (n=27) and thirty-one to Group B (n=31). All patients were young males with a median age of 26 years (range from 18 to 48). The incidence of occult diaphragm injury in group A was 29%. Occult injuries found at laparoscopy were all repaired. All patients in group 2 had normal chest X-rays and no symptoms at their last visit. The mean follow up time was 24 months (range of 0 to 58). There was no morbidity nor mortality associated with the conservative management of occult diaphragmatic injuries. The mean hospital stay for the patients in Group A was 5 days (SD 1.3), compared to a mean hospital stay of 2.9 days (SD, 1.5) p < 0.001, in Group B. Conclusions : Clinical and radiological follow up is feasible and appears to be safe in patients with occult diaphragm injuries after left TA stab wounds.

It has been reported that there is a 100% incidence of ulceration of the squamous pars oesophagea of the pig's stomach following bile duct ligation. The reproducibility of this model has made possible its use in the investigation of the biochemical aspects of mucus secretion in both the normal state and at various states of ulceration. The main findings are summarised below: Mucus scrapings of the cardiac gland region of the pig stomach had a higher water and total protein content in the pre-ulcerated, ulcerated and post-ulcerated states. Gel chromatography on Sepharose CL-4B indicated larger amounts of degraded mucins relative to native mucins in the samples obtained from pre-ulcerated, ulcerated and post-ulcerated stomachs, as compared with the normal and control samples. The amounts of purified mucins obtained after isopycnic centrifugation in CsCl and gel chromatography on Sepharose CL-2B decreased from the normals and controls to the bile duct-ligated pigs. An analysis on SDS-PAGE revealed a considerable degree of proteolytic degradation of the pig gastric mucins in the bile duct-ligated pigs as compared with the normal and control animals. Staining reagents specific for both the protein and the carbohydrate components of the mucus glycoprotein were employed in gel electrophoresis, which also revealed the presence of contaminating protein, viz. haemoglobin, pepsin, albumin and smaller glycoproteins, to a greater extent in the ulcerated than in the normal and control states. Since pig gastric mucins contain 75% of carbohydrate, the determination of the proportions of monosaccharide constituents was essential. This was performed by GLC analysis of the alditol acetate derivatives of the sugars, which were characterised by mass spectrometry as well as by their retention times, relative to standards, on both packed and capillary columns. The most striking changes indicated by the GLC analyses were a decrease in the fucose content of the mucins from the normal to the ulcerated states and an increase in the proportion of N-acetylglucosamine in mucins from sham-operated animals. The control (sham-operated) pig behaved very similarly to the normal pig for up to 24 hours after the surgical procedure. At 48 hours, however, slight changes resembling those following bile duct ligation occurred. This could be due to the trauma of the sham-operation, which involved the surgical insertion of a cannula in the body region of the pig's stomach. It is possible that, under such stress biosynthesis of the mucins may be affected.

Background: Human immunodeficiency virus (HIV) infection and trauma are significant contributors to the burden of disease in South Africa. There is an increase in prevalence of HIV sero-positivity in trauma patients. However, there are conflicting reports about the influence of HIV in outcomes after trauma or surgery. Although HIV and the acquired immunodeficiency syndrome (AIDS) can potentially affect outcomes, there have been few studies comparing trauma outcomes in HIV positive versus HIV negative patients. To the best of our knowledge, there have been no studies to date that have compared HIV positive and HIV negative patients with penetrating (gunshot or stab) abdominal wounds requiring an explorative laparotomy. The purpose of this study was to determine whether the outcome of hemodynamically stable patients undergoing explorative laparotomy for penetrating abdominal trauma differed in HIV positive patients versus HIV negative patients. Methods: This was an observational prospective study over a 16-month period from February 2016 to May 2017. All hemodynamically stable patients with penetrating abdominal trauma requiring a laparotomy were included in the study. To evaluate the impact of HIV on outcome, the mechanism of injury, the HIV-status, age, the penetrating abdominal trauma index (PATI), and the revised trauma score (RTS) were entered into a binary logistic regression model. Outcome parameters were in-hospital death, morbidity (defined as one or more distinct complications) during hospitalization was graded as per Clavien-Dindo classification of complications, admission to intensive care unit (ICU), relaparotomy within 30 days, and length of stay longer than 30 days. Variables were sought in bivariate analysis. Results: A total of 209 patients, 94% male, with a mean age of 29 ± 10 years were analysed. Twenty-eight patients (13%) were HIV positive. The mean CD4 count in the HIV positive group was 401 ± 254. The two groups were comparable except for race; 79% were black in the HIV positive group vs. 41% in the HIV negative group. All patients underwent explorative laparotomy of which 10 (4.8%) laparotomies were negative. There were two (0.96%) deaths, both in HIV negative group. The complication rate was 34% (n=72). There was no association between CD4 count and complications (p=0.234). Twenty-nine patients (14%) were admitted to the ICU. A higher PATI, advancing age, and a lower RTS were significant risk factors for worsened outcome. After 30 days, 12 patients (5.7%) were still in hospital. PATI was the single independent predictor in multivariate analysis. Twenty-four patients (11%) underwent a second laparotomy and the PATI was again the only significant predictor of outcome. Conclusion: The incidence of HIV in our cohort is 13%, which is similar to the reported incidence of HIV in the Western Cape of 15%. There were no significant baseline differences between the HIV positive and negative groups. Our results further showed that HIV status was not an independent predictor for morbidity, admission to ICU, relaparotomy, prolonged hospital stay or mortality. The patient's HIV status does not influence their outcomes in penetrating abdominal trauma.

Background: There is evidence to show that delays in breast cancer management are detrimental to patient outcome. The aim of this study was to determine time trends and causes of delay in a newly established diagnostic breast clinic based at a district hospital in South Africa. Method: All patients who presented to Mitchells Plain District Hospital Breast Clinic from January to December 2015 and had a diagnosis of breast cancer were included in this study. The intervals between the time she first noted her symptoms to initial contact with a health professional and delivery of definitive therapy was documented. Patient delay referred to the interval from when the patient first noted her symptoms to her initial contact with a health care provider. Provider delay referred to the interval between the first hospital visit and onset of therapy. Result: A total of 33 patients were enrolled in this study. The median overall total delay (time lapse between the moment the patient first noticed her symptoms to time definitive anti-cancer treatment was started) was 157days, (range 29 to 839 days). Median patient delay (time lapse between the moment the patient first noticed her symptoms and the visit to a health professional) was 56 days, (range 7 to 730 days). Median overall provider delay (time lapse between the patients' first encounter with a clinician to time definitive anti-cancer treatment was started) was 84 days, (range 22 to 338 days). Median Referral delay was 11 days (range 4 to 39 days). Median Diagnostic delay was 15 days (range 9 to 135 days) and median treatment delay was 45 days (range 5 to 246 days). Conclusion: The median overall total delay for patients diagnosed with breast cancer at Mitchells Plain District Hospital does not compares well with institutions in developed nations but it is similar to studies done in developing nations. The largest contributor to this delay was patient delay. The main contributors to provider delay was related to diagnosis (almost exclusively related to tissue diagnosis) and treatment (mainly patients who received surgery as their first definitive therapy).

Bibliography: leaves 61-75. / The optimal therapy for most patients with end stage renal disease is renal transplantation. This form of therapy results in improved quality of life, decreased medical expense, and perhaps a survival advantage for the recipient. Renal transplantation is however a complex form of therapy which may be associated with significant complications. The most common allograft complication post transplantation is the development of delayed graft function with a reported incidence of between 23 to 34%. This is a costly complication requiring ongoing dialysis and prolonged hospitalization. It also has a significant emotional impact on the patient and their family. Of greater concern though are the reports in the literature which associate delayed graft function with decreased graft survival. With current organ shortages organ donor criteria have been expanded to match the shortage. It is thus imperative that we should understand the mechanisms of graft damage which may result in delayed graft function. A better understanding of the relationship between delayed graft function and graft survival might significantly impact on our practice in certain settings such as in the use of organs harvested from a marginal donor.

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.