Background: In South Africa, 42.0% of adult females and 13.5% of adult males are classified as obese, the highest recorded numbers in Sub-Saharan Africa. Metabolic surgery has been proven to be a safe and effective treatment, yet due to demand on government resources has only been performed to a limited extent in public hospitals. The aim of this study was to describe the safety and efficacy of performing metabolic surgery at a single academic hospital in South Africa. Methods: This was a single centre retrospective review of 57 metabolic surgery procedures performed from October 2011 to September 2017 at Tygerberg Hospital, Cape Town, South Africa. The primary outcome was safety including mortality and adverse events. Secondary outcomes included effect of surgery on weight and diabetes resolution. Results: A total of 57 patients underwent laparoscopic metabolic surgery, of which 44 (83.0%) were female with a mean age (standard deviation) of 42.8 (8.0) years. Fifty-six patients (98%) underwent Roux-and-Y gastric bypass and one (2%) had a sleeve gastrectomy performed. There were no mortalities and overall morbidity was 14.0%, with 3 (5.3%) classified as major and 5 (8.8%) as minor. The follow-up rate at 1 year was 100%. Mean preoperative body mass index (BMI) was 58.8 kg/m2, and comorbidities included hypertension (59.6%), Type 2 Diabetes (42.1%), and dyslipidaemia (36.8%). There were no conversions to open surgery and at one year the mean (95% confidence interval) percentage excess body mass index loss was 50.4% (44.0-56.8%). Conclusions: Metabolic surgery can be performed safely in the public sector in South Africa, with short-term safety and efficacy outcomes comparable to international reports. Larger scale studies are needed to determine long-term outcomes and cost-effectiveness.
Globally, breast cancer is the most prevalent cancer affecting women and the incidence in low-middle income countries (LMICs) is predicted to rise as life expectancy increases. 1 The stage at the time of presentation differs between high-income countries (HICs) and LMICs. In the United States, between 35% (uninsured population) and 76% (insured population) of women, aged between 50 and 74 years, had a mammogram in the preceding 2 years. This contrasts with figures from a 2003 World Health survey where only 2.2% women in LMICs aged 40-69 received any breast screening. 2,3 While accurate statistics are not available for SA, it is estimated that between 50% and 60% of women present with locally advanced or metastatic breast cancer. 4,5 This figure compares unfavourably to those from HICs (many of whom have population-based screening programmes) where approximately 5% of women present with the metastatic disease. 6 Staging, as defined by the American Joint Committee on Cancer (AJCC), has historically been limited to anatomical staging. While the eighth version of the AJCC guidelines 7 has been altered to include tumour biology, anatomical staging still holds a place, as it allows for population studies, provides a concise summary of the patient, gives an indication of tumour biology, permits comparative population-based studies and guides treatment. However, some controversy exists Background: Staging for breast cancer patients, as defined by the American Joint Committee on Cancer (AJCC), has historically been limited to anatomical staging. However, the eighth version of the AJCC guidelines has been altered to include tumour biology. Anatomical staging still has a place especially in low-middle income countries where the majority of patients present with locally advanced or metastatic disease.Aim: This review article considers which newly diagnosed breast cancer patients should be referred for anatomical staging and the pros and cons of the different modalities available in South Africa. Method:The different modalities available were reviewed with respect to metastatic screening for asymptomatic women. The usefulness of the modalities were considered with reference to organ-specific disease rather than the stage of the patient.Results: Any person with newly diagnosed breast cancer and symptoms suggestive of systemic involvement should be investigated. All symptomatic women who present with a tumour larger than 5 cm, radiological or clinical evidence of nodal disease, triple negative or HER2+ve tumours should have metastatic screening. This gives information about the primary as well as the metastatic status. Conclusion:However, increasingly, the major determinant of treatment is the biology of the cancer and not the anatomical stage. In future, this trend is likely to increase with anatomical staging becoming less important.
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