BACKGROUND: Music is played in operating theatres (OTs) throughout the world, though controversy around its use exists. While some clinicians may find background music favourable to the theatre mood and a way to augment surgical performance, there is concern raised over its distracting and noise-creating properties METHODS: In this prospective observational study, between August and December 2021, 110 surgeons and registrars in South Africa responded to a survey investigating the way they use music, and their perceptions and attitudes towards its effect on the OT environment RESULTS: In this cohort, 66% were male, 29% were consultants and the most common age range was 30-39 years old. Eighty per cent of respondents reported that music was played at least "sometimes", with 74% reporting that they enjoyed it. Easy Listening was the most played and preferred genre followed by Top 40/Billboard hits. Overwhelmingly, respondents reported that background music in the OT improved temperament, focus, mood, and performance, though over a quarter felt it worsened communication. Thirty-one per cent of respondents reported that the choice of music depended on the type of operation, and 70% would turn music down or off during crises. Those who enjoyed music in their spare time were significantly more likely to enjoy music in the OT and perceive it positively CONCLUSION: This study provides a window into the surgeons' use of and attitudes to intraoperative music in South Africa. While overall, music is viewed positively by this cohort, some concerns remain regarding communication and distractedness. Further interventional and qualitative studies would be useful

BACKGROUND: There is a paucity of data around corrosive ingestion in South Africa over the last three decades. As such, we set out to review our experience with adult corrosive ingestion in our tertiary gastrointestinal surgical service METHODS: A retrospective, quantitative review was performed. The parameters analysed were demographics, substance ingestion, ingestion time to first presentation to a healthcare facility, clinical presentation, severity of injury based on endoscopic classification, computed tomography (CT) findings, management and outcomes. Patients presenting within 72 hours with alarm symptoms underwent flexible upper endoscopy and injury severity grading. In patients presenting after 72 hours, a water-soluble contrast study was obtained prior to upper endoscopy. Patients with signs of sepsis, surgical emphysema or physiological instability were referred for urgent CT to exclude oesophageal perforation and mediastinitis RESULTS: Between January 2012 and January 2019, a total of 64 patients presented with a history of corrosive ingestion - 40 (31%) were males and 24 (19%) females. The average time from ingestion to presentation was 72 hours. In 78% of patients, the agents were intentionally ingested, whilst 22% claimed accidental ingestion. A quarter of the patients (21%) presented to the unit clinically unstable, requiring emergent cardiorespiratory support. Eight (12%) patients required urgent surgical intervention due to the extent of injury. Nine (14%) patients demised during the acute admission. Of this group, three patients had undergone surgical intervention, and six were managed conservatively. Eighty-five per cent of all patients survived their initial admission CONCLUSION: This paper has highlighted the problem of corrosive ingestion in our setting. It remains a complicated problem to manage associated with significant morbidity and mortality rates. The current trend in the assessment of these patients is increased use of CT scan to assess the extent of transmural necrosis. Our algorithms should change to reflect this contemporary approach

Managing training load in rugby union is crucial for optimising performance and injury prevention. Contact training warrants attention because of higher overall injury and head impact risk, yet players must develop physical, technical, and mental skills to withstand the demands of the game. To help coaches manage contact loads in professional rugby, World Rugby and International Rugby Players convened an expert working group. They conducted a global survey with players to develop contact load guidelines. This commentary aims to describe the contact load guidelines and their implementation, and identify areas where future work is needed to support their evolution.

BACKGROUND: This study is a survey amongst surgical trainees in South Africa (SA) designed to document their exposure to laparoscopic appendicectomy (LA) and their perceptions about the procedure and to identify possible barriers to its uptake. METHODS: A structured survey was developed using a combination of quantitative and qualitative questions designed to determine the clinical exposure of surgical trainees to laparoscopic appendectomy and then probe possible factors limiting their access to the procedure. A questionnaire was created online, and a link was distributed to various surgical trainees in Southern Africa. A list of trainees was obtained from the Surgreg Training Association of South Africa (STA). RESULTS: One hundred and thirty-two (47%) trainees completed the survey out of an estimated 280 general surgery registrars. Ninety-five (72%) were male and 37 (28%) were female respondents. Their median age was 31 years (25-36). There were 14 (11%) year-1 and 21 (16%) year-2, 32 (24%) year-3, 37 (28%) year-4 and 28 (21%) year-5 trainees. The breakdown according to region was area 1 (inland and central) 47 (36%), area 2 (western seaboard) 12 (9%) and area 3 (eastern seaboard) 73 (55%). Forty-three (33%) respondents experienced face-to-face teaching on how to perform a LA. Forty-two (32%) had exposure to laparoscopic simulators. Respondents reported a general lack of experience in performing this procedure. Sixty-nine (52%) had performed this procedure without a senior (i.e., solo) and 13 (10%) had only assisted a senior to perform this procedure. Seventy-four (56%) respondents felt confident performing a LA independently. One hundred and thirteen (86%) respondents expected to be taught this procedure. One hundred and five respondents (80%) were keen to learn to perform LA. One hundred and five respondents (80%) stated that they would be interested in attending an online course on LA. The respondents felt that the following were the significant barriers to performing LA: resource constraints 49 (37%) and time constraints 46 (35%). Thirty per cent of respondents (22) in area 3 reported a reluctance by seniors to teach the procedure. CONCLUSION: There appears to be a lack of exposure to and confidence with LA amongst South African surgical trainees. This implies a deficiency in formal surgical training programmes. Addressing this deficiency will require innovative solutions.

BACKGROUND. Trauma care places a significant burden on the South African (SA) healthcare system, and this has not changed significantly in recent history. We speculated that the COVID-19 lockdown regulations (travel restriction and alcohol ban) would affect trauma patterns.OBJECTIVES. To compare the burden and nature of trauma over the COVID-19 lockdown period with the equivalent period over the past 5 years using routinely collected data from the Pietermaritzburg Metropolitan Trauma Service in KwaZulu-Natal Province, SA.METHODS. All trauma patients admitted to Grey's Hospital in Pietermaritzburg between 23 March 2015 and 31 May 2020 were identified and reviewed.RESULTS. A total of 8 859 trauma patients were admitted over the 6-year period, with a total of 1 676 admitted during the periods 23 March -31 May. These 1 676 formed the study cohort. Of these patients, 998 had sustained blunt trauma, 665 penetrating trauma, and 13 a combination of blunt and penetrating trauma. A total of 14 categories of blunt trauma were reviewed, of which the three most common were assault, motor vehicle accidents (MVAs) and pedestrian vehicle accidents (PVAs). Between 23 March and 31 May 2020, a total of 23 patients were victims of blunt assault. The median number of assault victims over the equivalent period during the previous 5 years was 48. The 5 preceding years had a median of 56 MVAs and 33 PVAs, compared with 23 and 10 during the lockdown. The median number of gunshot wound (GSW) victims for the preceding years was 41, compared with 30 during the lockdown. During the lockdown, 24 stab wound victims were admitted, compared with a median of 73 for the preceding years. The proportion of females who sustained penetrating trauma and blunt assault increased significantly during the lockdown. The proportion of females sustaining a GSW or blunt trauma secondary to an MVA remained constant.CONCLUSIONS. The study showed that during the period of lockdown in SA there was a significant decrease in MVAs, PVAs and interpersonal violence. Assaults involving a knife seemed to decrease dramatically, but the rate of GSWs remained constant.

Cystic pancreatic lesions present a diagnostic challenge. Accurate characterisation of an isolated cystic pancreatic lesion is therefore vital as this dictates the management strategy which may vary from radical resection to simple observation. This report describes how a detailed preoperative assessment led to the correct diagnosis of an isolated pancreatic lesion and appropriate safe and curative surgical management.

BACKGROUND: This project aims to review the spectrum and outcome of penetrating trauma in children and adolescents with the objective of defining the extent of the problem and of developing strategies to reduce the incidence and severity of this form of traumaMETHODS: All patients less than eighteen years of age who were admitted to the Pietermaritzburg Metropolitan Trauma Service (PMTS) following penetrating trauma between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry (HEMRRESULTS: During the five-year period under review, a total of 164 patients less than eighteen years of age sustained penetrating trauma and were admitted to the PMTS. There were 138 males and 26 females. The mean age was 13.29 years and the median age 15 years. There were 70 stab wounds (SW) and 73 gunshot wounds (GSW). There were 21 non-intentional impalement injuries. The mean ISS was 9.04 and the median was 9. A total of 155 plain X-rays were performed, 50 CT scans and 51 CT angiograms in this cohort of patients. Only two ultrasound examinations were performed. A total of 76 patients required an operation, which included 50 laparotomies. Of the patients who underwent a laparotomy, 18 required a repeat laparotomy. There were 46 other procedures undertaken in this cohort of patients, which included two thoracotomies, three laparoscopies and two thoracotomies. The median hospital stay was 2 days and 17 (10%) patients required ICU admission and 7 (4%) diedCONCLUSION: Penetrating trauma in children and adolescents is associated with significant mortality and morbidity. There are similarities with the management of these injuries in adults, but further work is required to ensure that paediatric management algorithms are evidence based

INTRODUCTION: Discrepancy in outcomes between urban and rural trauma patients is well known. We reviewed our institutional experience with the management of gunshot wounds (GSWs) in the specific setting of car hijacking and focused on clinical outcome between rural and urban patients. METHODS: A retrospective review was conducted at a major trauma centre in South Africa over an 8-year period for all patients who presented with any form of GSWs in car hijacking settings. Specific clinical outcomes were compared between rural and urban patients. RESULTS: A total of 101 patients were included (74% male, mean age 34 years). Fifty-five per cent were injured in rural areas and the remaining 45% (45/101) were in the urban district. Mean time from injury to arrival at our trauma centre was 11 hours for rural and 4 hours for urban patients (p < 0.001). Seventy-six per cent (76/101) sustained GSWs to multiple body regions. Sixty-three of the 101 (62%) patients required one or more operative interventions. In individual logistic regressions adjusted for sex and number of regions injured, rural patients were 9 (95% CI: 1.9-44.4) and 7 (95% CI: 2.124.5) times more likely than urban patients to have morbidities or required admissions to intensive care respectively. The risk of death in rural patients was 36 (95% CI: 4.5-284.6) times higher than that of urban patients. CONCLUSIONS: Patients who sustained GSWs in carjacking incidents that occurred in rural areas are associated with significantly greater morbidity and mortality compared with their urban counterparts. Delay to definitive care is likely to be the significant contributory factor, and improvement in prehospital emergency medical service is likely to be beneficial in improving patient outcome.

BACKGROUND: Humans come into contact and interact with an array of animals in a number of areas and environments. We set out to review our experience with animal-related injuries in Pietermaritzburg, KwaZulu-Natal, South AfricaMETHODS: All patients who sustained an injury secondary to an interaction with an animal in the period December 2012-December 2017 were identified from the Hybrid Electronic Medical Registry (HEMRRESULTS: There were 104 patients in the study sample. The mean age of patients in the study was 32.8 years, with a range from 1 to 76 years old. 75% (n = 78) were male and 25% (n = 26) female. Out of the 104 animal-related injuries, 67 were blunt trauma, 39 penetrating trauma and 3 a combination of blunt and penetrating trauma. The species causing trauma included dogs (53), horses (29), cows (18), buffalo (1), warthog (1), impala (1) and a single goat (1). The median time from injury to hospitalisation was 46.62 hours (range from 0 to 504 hours). Injuries occurred to the head (n = 32), face (n = 9), neck (n = 32), abdomen (n = 22), urogenital system (n = 6), upper limb (n = 39) and lower limb (n = 39). The Injury Severity Score (ISS) mean for the patients was 8.16, the range 1-4, the median 9 and the standard deviation 6.88. In 49 patients the treatment was non-operative. In the remaining 55 patients, a total of 68 operative procedures were required. Operations included wound debridement/surgical washout (n = 38), laparotomy (n = 9), arterial repair/ligation (n = 8), skin graft (n = 4), craniotomy (n = 5), fasciotomy (n = 2), amputation (n = 1), and placement of an ICP monitor (n = 1). 49 of these operations were for patients with dog bite injuries. The mean hospital stay was 0.13 days with a range of 0-4 days. Four patients were admitted to the Intensive Care Unit (ICU) and two patients diedCONCLUSION: Human interactions with animals may result in injuries which require surgical treatment. The most common animal injury is a dog bite but in the case of the larger domestic farm animals, blunt force type injuries and goring can result in significant injuries which require complex surgical interventions

BACKGROUND: Self-harm behaviour is a major public health problem that is commonly underreported. This study reviews the spectrum of these self inflicted injuries managed by a major trauma centre in South Africa. METHODS: A retrospective review of the regional trauma registry was undertaken over a five-year period from December 2012 to December 2017 at the Pietermaritzburg Metropolitan Trauma Service (PMTS) in South Africa. All patients who were admitted after they had sustained an injury as a result of self-harm were included. RESULTS: During the five-year study period, a total of 179 patients were included. The mean age was 29 years (SD12) and there were 139 (77%) males and 40 (23%) females. Of these, 16 had a previously established psychiatric diagnosis and two had a prior history of having sustained self-harm. The previously diagnosed psychiatric illnesses included mood dysphoria disorders (5), schizophrenia (3), substance abuse and dependency (1), anti-social personality disorder (1) and unspecified (6). The mechanism was penetrating trauma in 47 (26%). The penetrating mechanisms included stab wounds (SW) in 33, gunshot wounds (GSW) in 10, broken glass in 2 and a single impalement. Blunt mechanisms accounted for the remaining 131 (73%) injuries. The most common mechanism of blunt self-harm was hanging in 101 patients. This was followed by vehicular related trauma (8), jumping in front of a train (1) and jumping from a height (1). In 17 patients the exact mechanism of the blunt trauma was unclear. There was no statistical difference in the mechanism of injury between male and female patients. There were 38 (28%) men and 9 (23%) women who sustained a penetrating injury and there were 100 (72%) male and 31 (78%) female patients who had a blunt mechanism of injury. A total of 53 CT scans were obtained, 40 chest X-rays, 9 abdominal X-rays and 2 ultrasounds. There were 113 neck injuries, 68 head injuries, 24 abdominal injuries, 15 upper limb and 15 lower limb injuries and four facial injuries. A total of 32 operations were performed. These included laparotomy (14), neck exploration (5), tracheostomy (4). A total of 22 patients developed a complication CONCLUSION: Self-inflicted injury is not uncommon and frequently requires investigation and or surgical treatment. Patients who sustain such an injury constitute a distinct vulnerable group who are under researched. Future research on this vulnerable patient group is needed.

BACKGROUND: This study reviews our experience with penetrating Traumatic Brain Injury (TBI) in order to define and describe the injury pattern and the outcome. A secondary aim of this study was to review the use of the Motor Score (M Score) and the Simplified Motor Score (SMS) to assess and triage patients with penetrating TBIMETHODS: All patients with a TBI secondary to a penetrating mechanism were identified from the Hybrid Electronic Medical Registry at Pietermaritzburg Metropolitan Trauma Service (PMTS) from January 2012 to December 2014. Standard demographic data, need for neuro-surgical intervention, location of external wounds, CT findings and mortality where analysed. The Glasgow Coma Scale (GCS) M score and SMS score were specifically evaluated to determine the relationship between the individual motor component and patient outcomeRESULTS: Over the two-year period January 2012-December 2014, a total of 384 patients were admitted following a penetrating TBI. There were 350 males and 34 females and of this total 7 (1.82%) died. The mechanism of injury was axe (30), bottle (34), gunshot wound (GSW) (22) and stab wound (298). The average age for axe injuries was 27 and bottle injuries was 30. The average age for firearms and knives was 29 and 30 respectively Surgery was not required for 76.67% of patients. The need for surgery varied according to mechanism of injury. Axe injuries were treated non-operatively in 47.83%, bottle injuries in 87.50%, firearms 70% and knife injuries were treated non-operatively in 86.84% of cases. The overall survival rate for a penetrating head injury in this population is 98.16%. There were a total of 368 patients with a motor score of 6 of which one died. The survival rate was 99.7% and the mortality rate 0.3%. There were only 6 patients with a motor score of 5 and only 2 with a motor score of 4. The survival rate for both these groups was 100%. There was a total of 6 patients with a motor score of 1. There was a 100% mortality rate is this group.CONCLUSION: Penetrating TBI has a good prognosis. The vast majority of cases do not require neuro-surgical intervention. Poor motor score is associated with a poor outcome

BACKGROUND: This study used data from a large prospectively entered database to assess the efficacy of the motor score (M score) component of the Glasgow Coma Scale (GCS) and the Simplified Motor Score (SMS) in predicting overall outcome in patients with traumatic brain injury (TBI). OBJECTIVE: To safely and reliably simplify the scoring system used to assess level of consciousness of trauma patients in the acute setting. METHODS: A retrospective observational review of the Pietermaritzburg Metropolitan Trauma Service hybrid electronic medical registry database was performed during the period January 2013 - December 2015. Patients were classified into three groups using their GCS as an injury severity score. These were mild TBI (GCS 13 - 15), moderate TBI (GCS 9 - 12) and severe TBI (GCS <9). The Glasgow M score was specifically evaluated to determine the relationship between the individual motor component and patient outcome. RESULTS: GCS scores and M scores were analysed in a total of 830 patients. There was a decline in survival rate when the M score on admission was <4. The decline was more significant when the M score was <3. Survival rates were 26.8% (11/41) for patients with an M score of 1, 63.6% (14/22) for those with a score of 2, 56.5% (13/23) for those with a score of 3, 80.0% (20/25) for those with a score of 4, and 95.5% (121/128) for those with a score of 5. Of 591 patients with an M score of 6, 580 (98.1%) survived. Mortality rose dramatically with declining SMS. This was highly significant. When the M score was plotted against mortality in 830 patients, there was a correct prediction in 769 cases (accuracy 92.7%, sensitivity 67.6%, specificity 95%). The area under the receiver operating characteristic (ROC) curve was 0.9037, with a standard deviation (area) of 0.0227. When comparing the SMS against mortality, the accuracy was 77.1%, the sensitivity 84.5% and the specificity 76.4%. The fitted ROC area was 0.891 and the empirical ROC area 0.86. CONCLUSION: The M score component of the GCS and the SMS accurately predict outcome in patients with TBI. In cases where the full GCS is difficult to assess, the M score and SMS can be used safely as a triage tool.

INTRODUCTION: South Africa (SA) has one of the highest global incidences of squamous cell carcinoma of the oesophagus (SCC). A decreasing incidence of oesophageal SCC in SA has been suggested. The study aimed to assess whether the incidence of these malignant histopathological subtypes has changed in this setting. METHODS: A retrospective review of histopathological reports on pre-malignant and malignant oesophageal lesions over three time periods (TP), namely: 2003-4 (TP1), 2008-9 (TP2) and 2013-14 (TP3) was carried out at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. RESULTS: A total of 1341 specimen reports were retrieved. TP1-3 consisted of 514 (39.3%), 320 (24.5%) and 474 (36.2%) patients respectively. Six hundred and forty-nine patients were male (48.3%), 642 were female (47.8%) and 50 were not specified. i.e. a sex ratio of 1.01:1. The mean age was 60.8 (± 11.8). There were 1197 Black patients (91.5%), 66 Asian (5.1%), 25 White (1.9%), 9 mixed ancestry (0.7%), and 11 of unknown race (0.8%). SCC was the most common cancer 1098 (89.1%) followed by adenocarcinoma (AC) 69 (5.6%). The ratio of SCC to AC remained fairly consistent over the total time period. Seventy-four oesophageal resections were performed with a yearly average resection rate of only 5.6%. CONCLUSIONS: SCC is still the most prevalent oesophageal cancer (OC) without an increase in the ratio of AC to SCC. The diagnosis of squamous cell dysplasia is concordant with previously cited rates. Barrett's oesophagitis remains uncommon. Resection rates for OC are low but similar to other South African referring centers. ABBREVIATIONS: SA - South Africa; SCC - Oesophageal squamous cell cancer; OC - Oesophageal cancer; BO - Barrett's oesophagitis; TP1 - Time period 1; TP2 - Time period 2; TP3 - Time period 3; IALCH - Inkosi Albert Luthuli Central Hospital; KZN - KwaZulu-Natal; AJCC - American Joint Committee on Cancer ; UICC - International Union Against Cancer ; TNM - Tumor Node Metastasis.

INTRODUCTION When multiple repeat laparotomies are required to manage intra-abdominal sepsis, questions about futility of treatment frequently arise. This study focuses specifically on patients who required two or more repeat laparotomies and describes the spectrum of disease necessitating multiple repeat laparotomies and the associated outcomes in the hope of clarifying the issue. METHODS: This study was conducted over a 20-month period (December 2012 - July 2014) at Greys Hospital in Pietermaritzburg, South Africa. All surgical patients at Greys Hospital have admission, discharge and operative data prospectively entered into a computerised electronic registry, the Hybrid Medical Electronic Registry (HEMR). The ethics approval required to maintain this registry has been obtained from the Biomedical Research Ethics Committee (BCA221/13 BREC) of the University of KwaZulu-Natal and from the Research Unit of the Department of Health. Full ethical approval for this study was granted by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BE047/14). All patients aged 13 years and older who needed at least two repeat laparotomies were included in the study. This included general surgical and trauma patients. RESULTS: During the study period, 72 patients required more than one repeat laparotomy and a total of 182 repeat laparotomy operations were performed on this patient cohort. Demographics showed a male predominance, with 54 (75%) being male and 18 (25%) being female patients. The average age was 39 years. General surgical patients accounted for 60% and trauma patients for 40% of the total. The majority of patients required only two repeat laparotomy (65 %), while two patients required a total of 6 repeat laparotomy each, both with an initial diagnosis of appendicitis and both these patients survived. Temporary abdominal closure (TAC) was performed in 26 (36%) of initial laparotomies, while 33 (46%) of patients had an open abdomen at the time of discharge or death. Sixty percent required intensive care or high care unit (ICU/HCU) admission and 53 patients (74%) had a total of 71 documented morbidities. Total mortality for this study was 21%, however there was no correlation between number of procedures and mortality. CONCLUSION: The total number of procedures is associated with increased morbidity rates but not necessarily with increased mortality rates. This is important to consider when the issue of futility of treatment arises, as the absolute number of repeat laparotomies is a poor marker of futility and other factors must be considered.

OBJECTIVE: Blood is a limited resource in middle-income countries such as South Africa. Transfusion is associated with complications and expense. We aimed to understand our transfusion practices in burn surgery as well as ascertain the opinion of a broader group of surgeons and anaesthetists regarding transfusion triggers in order to understand the rationale and bias that drives current transfusion practice in our setting. METHODS: Firstly, we investigated the current blood practices at our regional burn service through an audit of perioperative notes for all patients receiving packed cell transfusions in a 24-month period. Secondly, we formulated a questionnaire asking for opinion on acceptable preoperative and postoperative haemoglobin targets for a list of elective, emergency and burn operations that was distributed at a number of meetings. RESULTS: Seventy-two patients received a total of 103 perioperative transfusions. The median preoperative haemoglobin was 9.8 g/dL in both children and adults and the median postoperative haemoglobin was 10.1 and 9.1 g/dL in children and adults respectively. The cohort was divided into two groups: the first surgery and the subsequent surgeries. In the adult group the mean time to first surgery post burn was 11.5 days with a median volume of 0.73 mls/kg/% operated surface area (range 0.16-1.54) of packed cells transfused per operation. In the paediatric group the mean time to first surgery post burn was 9 days (range 2-54) with a median volume of 1.1 mls/kg/% operated surface area (range 0.56-2.14) of packed cells transfused per operation. CONCLUSION: One hundred and fifty questionnaires were handed out and 103 (69%) were completed. The average proposed preoperative and postoperative haemoglobin was 9.3 g/dL and 8.4g/dL respectively. The majority of respondents (60% in elective surgery, 43% in emergency surgery and 60% in burn surgery) would like preoperative haemoglobin to be 10 g/dL and above. : Research suggests that a restrictive blood transfusion approach is being increasingly implemented as best practice. However, our surgical community does not seem to accept a restrictive strategy as part of blood management principles. A shift in this practice could result in clinical benefit by reducing complications and increasing cost saving in our resource constrained setting. We plan to protocolise earlier surgery and blood conservation strategies intraoperatively in addition to a restrictive strategy in our burn service.