Victor Kong | University of Natal (original) (raw)

Papers by Victor Kong

Introduction: Organ evisceration following abdominal stab wound (SW) is currently considered as a... more Introduction: Organ evisceration following abdominal stab wound (SW) is currently considered as an absolute indication for mandatory laparotomy due to the high incidence of associated intra-abdominal injuries, but literature describing the spectrum of organ injury encountered is limited. Materials and methods: We reviewed our experience of 301 consecutive patients who were subjected to mandatory laparotomy over an eight-year period at a major trauma centre in South Africa. Results: Of the 301 patients with organ evisceration, 92% were male (mean age: 28 years). Ninety per cent (270/301) of the laparotomies were positive (85% (229/270) therapeutic, 15% (41/270) non-therapeutic). The frequencies of eviscerated organs were small bowel (70%), large bowel (26%), and stomach 3%. Three (1%) patients had combined evisceration of more than one of the above organs. The most commonly injured organs were small bowel and large bowel. The mean length of hospital stay was nine days. Seven patients required intensive care admission. The morbidity rate was 21% and mortality was 2%. Conclusions: The spectrum of injury associated with abdominal SW with organ evisceration is similar to smaller published series. Multiple organ injuries are common. The most commonly eviscerated organs were small bowel, large bowel and stomach, while the most commonly injured organs were small bowel and large bowel.

The New Zealand medical journal

Vehicles hitting children in residential driveways are an important and preventable cause of chil... more Vehicles hitting children in residential driveways are an important and preventable cause of child injury and death in New Zealand. Our study investigated the demographic and environmental characteristics relating to these accidents. We found that children aged 0-4 years, particularly toddlers, were most commonly hit, and that these injuries typically occurred on the child's own home driveway with the driver most commonly being a parent or relative. We also found that long driveways, shared driveways, unfenced driveways, and driveways that were used as play areas were a common feature of the driveways where such injuries occurred. We believe that physical separation of driveways from children's play and living areas (whether by fencing, changing driveway layout, or other means) would help in preventing these injuries.

aBSTraCT INTRODUCTION Appendicitis in the developing world is a cause of significant preventable ... more aBSTraCT INTRODUCTION Appendicitis in the developing world is a cause of significant preventable morbidity. This prospective study from a regional hospital in South Africa constructs a robust cost model that demonstrates the cost effectiveness of an efficient curative surgical service in a primary healthcare-orientated system. METHODS A prospective audit of all patients with acute appendicitis admitted to Edendale Hospital was undertaken from September 2010 to September 2011. A microcosting approach was used to construct a cost model based on the estimated cost of operative and perioperative interventions together with the associated hospital stay. For cost analysis, patients were divided into the following cohorts: uncomplicated appendicitis, complicated appendicitis with localised intra-abdominal sepsis, complicated appendicitis with generalised intra-abdominal sepsis, with and without intensive care unit admission. RESULTS Two hundred patients were operated on for acute appendicitis. Of these, 36% (71/200) had uncomplicated appendicitis and 57% (114/200) had perforation. Pathologies other than appendicitis were present in 8% (15/200) and these patients were excluded. Of the perforated appendices, 45% (51/114) had intra-abdominal contamination that was localised while 55% (63/114) generalised sepsis. The mean cost for each patient was: 6,578 ZAR (£566) for uncomplicated appendicitis ; 14,791 ZAR (£1,272) for perforation with localised intra-abdominal sepsis and 34,773 ZAR (£2,990) for perforation with generalised intra-abdominal sepsis without intensive care admission. With intensive care admission it was 77,816 ZAR (£6,692). The total cost of managing acute appendicitis was 4,272,871 ZAR (£367,467). Almost 90% of this total cost was owing to advanced disease with abdominal sepsis and therefore potentially preventable. CONCLUSIONS Early uncomplicated appendicitis treated appropriately carries little morbidity and is relatively inexpensive to treat. As the pathology progresses, the cost rises exponentially. An efficient curative surgical service must be regarded as a cost effective component of a primary healthcare orientated system.

INTRODUCTION Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma ... more INTRODUCTION Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. METHODS This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. RESULTS A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20–29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted sub-cutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the 'triangle of safety' but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. CONCLUSIONS ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation.

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated wit... more Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high. The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

Introduction: Acute surgical patients are particularly vulnerable to human error. The Acute Physi... more Introduction: Acute surgical patients are particularly vulnerable to human error. The Acute Physiological Support Team (APST) was created with the twin objectives of identifying high-risk acute surgical patients in the general wards and reducing both the incidence of error and impact of error on these patients. A number of error taxonomies were used to understand the causes of human error and a simple risk stratification system was adopted to identify patients who are particularly at risk of error. Results: During the period November 2012eJanuary 2013 a total of 101 surgical patients were cared for by the APST at Edendale Hospital. The average age was forty years. There were 36 females and 65 males. There were 66 general surgical patients and 35 trauma patients. Fifty-six patients were referred on the day of their admission. The average length of stay in the APST was four days. Eleven patients were haemo-dynamically unstable on presentation and twelve were clinically septic. The reasons for referral were sepsis, 4 respiratory distress, 3 acute kidney injury AKI (38), post-operative monitoring (39), pancreatitis, 3 ICU down-referral, 7 hypoxia, 5 low GCS, 1 coagulopathy. 1 The mortality rate was 13%. A total of thirty-six patients experienced 56 errors. A total of 143 interventions were initiated by the APST. These included institution or adjustment of intravenous fluids (101), blood transfusion, 12 antibiotics, 9 the management of neutropenic sepsis, 1 central line insertion, 3 optimization of oxygen therapy, 7 correction of electrolyte abnormality, 8 correction of coagulopathy. 2 Conclusion: Our intervention combined current taxonomies of error with a simple risk stratification system and is a variant of the defence in depth strategy of error reduction. We effectively identified and corrected a significant number of human errors in high-risk acute surgical patients. This audit has helped understand the common sources of error in the general surgical wards and will inform ongoing error reduction initiatives.

INTRODUCTION Acute appendicitis in the developing world has a markedly different disease profile ... more INTRODUCTION Acute appendicitis in the developing world has a markedly different disease profile to that in the developed world. METHODS A retrospective study was undertaken over a four-year period at a university hospital in South Africa to review the disease spectrum and the clinical outcome of acute appendicitis. RESULTS A total of 1,004 patients (54% male, median age: 18 years) with intraoperatively confirmed appendicitis were reviewed. Over half (56%) were from the urban district within the city of Pietermaritzburg and the remaining 44% were from the rural health district. The median duration of illness from onset to definitive care was 4 days. Sixty per cent of appendices were perforated and associated with intra-abdominal contamination. Forty per cent of patients required reoperation to control intra-abdominal sepsis. Ten per cent required admission to the intensive care unit. The median overall length of hospital stay was 5 days. The mortality rate was 1%. Rural patients had a longer median duration of illness (3 vs 5 days, p<0.001) as well as a more advanced disease profile associated with perforation and severe intra-abdominal sepsis (19% vs 71%, p<0.001). Female patients had a longer median duration of illness (3 vs 4 days, p<0.001), were more likely to present with severe intra-abdominal sepsis (31% vs 54%, p<0.001) and were more likely to require a laparotomy (50% vs 73%, p<0.001). The total cost of managing the entire cohort of 1,004 patients over the 4-year period was £2,060,972. CONCLUSIONS Acute appendicitis in South Africa is a serious disease associated with significant morbidity. Late presentation is common. Female and rural patients have the worst clinical outcomes, with significant cost to the health system.

Background: The Alvarado score is the most widely used clinical prediction tool to facilitate dec... more Background: The Alvarado score is the most widely used clinical prediction tool to facilitate decision-making in patients with acute appendicitis, but it has not been validated in the black South African population, which has much wider differential diagnosis than developed world populations. We investigated the applicability of this score to our local population and sought to introduce a checklist for rural doctors to facilitate early referral.

Annals of The Royal College of Surgeons of England

INTRODUCTION Selective conservatism for thoracic trauma is well established but the emergence of ... more INTRODUCTION Selective conservatism for thoracic trauma is well established but the emergence of new technologies may cause management strategies to continue to evolve. METHODS A retrospective study was conducted on thoracic trauma patients managed in a single institution in South Africa over a 4-year period to determine the appropriateness of our current policy of selective conservatism. RESULTS A total of 1,239 patients were included in the study; 112 required an emergency thoracotomy, 125 were admitted for observation and 1,002 required a tube thoracostomy (TT). Ninety-one per cent of the patients were male and the median age was 24 years. Seventy-five per cent of the cases were penetrating trauma and the remaining were blunt trauma. The indications for TT were pneumothorax (PTX) (n=382, 38%), haemothorax (HTX) (n=300, 30%) and haemopneumothorax (HPTX) (n=320, 32%). A total of 13% (127/1,002) of all chest x-rays (CXR) following tube removal demonstrated residual pathologies that ...

Annals of The Royal College of Surgeons of England

INTRODUCTION The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well ... more INTRODUCTION The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited. METHODS We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa. RESULTS Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ ...

European Journal of Trauma and Emergency Surgery

Abstract Objective The selective conservative management of small pneumothoraces (PTXs) following... more Abstract Objective The selective conservative management of small pneumothoraces (PTXs) following stab injuries is controversial. We reviewed a cohort of patients managed conservatively in a high volume trauma service in South Africa. Materials and methods A retrospective review over a 2-year period identified 125 asymptomatic patients with small PTXs measuring <2 cm on chest radiograph who were managed conservatively. Results Of the 125 patients included in the study, 92 % were male (115/125), and the median age for all patients was 21 years (19–24). Ninety-seven per cent (121/125) of the weapons involved were knives, and 3 % (4/125) were screwdrivers. Sixty-one per cent of all injuries were on the left side. Eighty-two per cent (102/125) sustained a single stab, and 18 % (23/125) had multiple stabs. Thirty-nine per cent (49/125) had a PTX <0.5 cm (Group A), 26 % (32/125) were ≥0.5 to <1 cm (Group B), 19 % (24/125) were ≥1 to <1.5 cm (Group C) and 15 % (20/125) were ≥1....

European Journal of Trauma and Emergency Surgery

Traumatic tension pneumothorax (TPTX) is a life threatening condition, but literature describing ... more Traumatic tension pneumothorax (TPTX) is a life threatening condition, but literature describing this condition specifically in developing countries is scarce. We conducted a retrospective review of 115 patients with a TPTX, managed over a 4-year period in a high volume trauma service in South Africa. A total of 118 TPTXs were identified in 115 patients. Eighty-nine percent (102/115) were males, and the mean age was 26 years (SD ± 6 years). Seventy-four percent (87/118) of all TPTXs occurred on the left side. The mechanisms of injury were penetrating in 71 % (82/115) [82 stab injuries], and blunt in 29 % (33/115) [31 road traffic accidents and 2 assaults]. Ninety-seven percent (111/115) of patients presented directly to our unit, while 3 % (4/115) were referrals from other hospitals. Fifteen percent (17/115) of needle decompressions were performed in the pre-hospital setting while the remaining 85 % (98/115) were performed on arrival (73 were recognised clinically and 25 were not). ...

Annals of The Royal College of Surgeons of England

ABSTRACT INTRODUCTION Acute appendicitis in the developing world has a markedly different disease... more ABSTRACT INTRODUCTION Acute appendicitis in the developing world has a markedly different disease profile to that in the developed world. METHODS A retrospective study was undertaken over a four-year period at a university hospital in South Africa to review the disease spectrum and the clinical outcome of acute appendicitis. RESULTS A total of 1,004 patients (54% male, median age: 18 years) with intraoperatively confirmed appendicitis were reviewed. Over half (56%) were from the urban district within the city of Pietermaritzburg and the remaining 44% were from the rural health district. The median duration of illness from onset to definitive care was 4 days. Sixty per cent of appendices were perforated and associated with intra-abdominal contamination. Forty per cent of patients required reoperation to control intra-abdominal sepsis. Ten per cent required admission to the intensive care unit. The median overall length of hospital stay was 5 days. The mortality rate was 1%. Rural pat...

International Journal of Case Reports and Images, 2013

Procedural complications relating to lung injury is relatively common, and these may require tube... more Procedural complications relating to lung injury is relatively common, and these may require tube thoracostomy for management. Although a postprocedure chest X-ray is routinely undertaken in many centers, erroneous interpretation can lead to potentially incorrect and unnecessary further intervention. case report: We report a case of a 25-year-old male who had a central venous line inserted, with the chest X-ray appearance of a massive opacification of the hemithorax misdiagnosed as a hemothorax and planned tube thoracostomy. It was subsequently confirmed as a complete pulmonary collapse caused by a large mucus plug with obstruction of the main bronchus. this completely resolved after an awake flexible bronchoscopic clearance, without the need for tube thoracostomy. conclusion: Whilst chest X-ray allows identification of most mechanical complications of central venous line insertion, accurate interpretation and correct clinical correlation are absolutely critical in order to avoid unnecessary interventions.

International Journal of Case Reports and Images, 2013

Introduction: Psoas abscess is an uncommon condition seen only occasionally in daily surgical pra... more Introduction: Psoas abscess is an uncommon condition seen only occasionally in daily surgical practice. Often, its clinical presentation is nonspecific, frequently causing diagnostic uncertainty.

Irish medical journal, 2010

There is good evidence demonstrating that outpatient management of deep venous thrombosis (DVT) i... more There is good evidence demonstrating that outpatient management of deep venous thrombosis (DVT) is feasible and safe. However, few emergency departments in Ireland have implemented care pathways for outpatient management of DVT. The aim of this study was to examine the safety and efficacy of implementing an Emergency Department (ED)- care pathway for outpatient management of patients with DVT. A retrospective observational study of this care pathway introduced at our institution was performed. The primary outcome measure was the number of hospital admissions avoided by using the care pathway. Two hundred and eighty-four patients presenting to the ED with suspected lower limb DVT, were managed using the care pathway over a 6 month period. Forty-nine patients (17%) had a DVT diagnosed. Thirty-nine patients (81%) were suitable for outpatient DVT management. Ten patients (19%) were admitted to hospital. At 3 months there were no reported cases of the following complications: missed DVT,...

Annals of The Royal College of Surgeons of England, 2014

The New Zealand medical journal

Annals of The Royal College of Surgeons of England

European Journal of Trauma and Emergency Surgery

Annals of The Royal College of Surgeons of England

International Journal of Case Reports and Images, 2013

Irish medical journal, 2010

Annals of The Royal College of Surgeons of England, 2014