Shumani Makhadi

Background: Iliofemoral vascular injuries are associated with substantial mortality and morbidity, particularly in the context of penetrating trauma, haemorrhagic shock, and concomitant truncal injury. This study evaluated outcomes and factors associated with mortality in patients presenting with traumatic iliofemoral vascular injuries to a high-volume urban trauma centre. Methods: A retrospective cohort study was conducted at a Level 1 trauma facility in South Africa, from January 2022 to December 2024. Adults with traumatic iliac or femoral vascular injuries were included. Demographic characteristics, admission physiology, biochemical markers, injury patterns, operative details, and in-hospital outcomes were analysed. Survivors and non-survivors were compared using univariable analysis. Results: Eighty patients were included. The cohort was predominantly young male patients (98.8%) with a median age of 32 years, and penetrating trauma accounted for most injuries (87.5%), primarily gunshot wounds. Femoral vessel injuries were more common (n = 66) than iliac injuries (n = 14), with the femoral artery most frequently involved. High-grade vascular injury was common across both survivors and non-survivors. Overall in-hospital mortality was 11.3% (9/80) but was substantially higher in iliac vessel injuries compared with femoral injuries. Mortality was associated with physiological derangement on presentation, including lower pH (p = 0.028), reduced bicarbonate (p = 0. 005), elevated lactate (p = 0.005), and more negative base excess (p < 0.001). Non-survivors also demonstrated significantly higher rates of concomitant intra-abdominal injury (77.8% vs 12.7%, p < 0.001). Conclusion: In hospital mortality in traumatic iliofemoral vascular injury is driven primarily by physiological collapse and associated intra-abdominal trauma rather than vascular injury extent alone. Iliac vessel injuries confer markedly higher risk due to anatomical and associated injury burden. Admission lactate, bicarbonate, and base deficit may reflect severe physiological derangement associated with mortality. Once initial resuscitation is survived, limb salvage outcomes are favorable with contemporary vascular repair strategies.

Background: Non-operative management (NOM) is the standard of care for haemodynamically stable patients with blunt splenic injury; however, failure of NOM remains clinically significant, particularly in settings where adjunctive interventions such as splenic artery embolisation are not routinely utilised. This study aimed to evaluate NOM outcomes and identify predictors of failure at a South African Level I trauma centre. Methods: A retrospective cohort study of adult patients with blunt splenic injury over a 5-year period (2020–2025) was conducted. Patients were stratified according to their initial management strategy into operative and non-operative groups. Categorical variables were compared using Fisher’s exact test, and continuous variables using the Mann–Whitney U test. Multivariable logistic regression analysis was performed to identify independent predictors of NOM failure. Results: A total of 136 patients were included. Twelve patients (8.8%) underwent immediate operative management, while 124 (91.2%) were initially managed non-operatively. NOM was successful in 112 patients (90.3%), with 12 patients (9.7%) requiring delayed operative intervention. Overall mortality was 4.4% (6/136), with all deaths attributable to associated injuries rather than isolated splenic trauma. Increased admission heart rate was independently associated with NOM failure (OR 1.04 per beat increase; 95% CI 1.01–1.08; p = 0.009). Higher Injury Severity Scores and severe traumatic brain injury were more frequent in patients with NOM failure but were not independently predictive. Splenic artery embolisation was not utilised in this cohort. Conclusions: Non-operative management is safe and effective for blunt splenic injury, with high rates of splenic preservation. Admission tachycardia predicts NOM failure and may guide early clinical decision-making. These findings support the use of NOM in low- and middle-income settings where interventional radiology is not routinely available.

Background: Damage control laparotomy (DCL) is an established life-saving strategy for critically injured patients presenting with the lethal triad of hypothermia, acidosis, and coagulopathy. While outcomes in high-income countries (HICs) are well documented, evidence from low- and middle-income countries (LMICs), as classified by the World Bank, remains fragmented. This systematic review synthesises available evidence on DCL outcomes in LMICs. Methods: A systematic search of PubMed, Scopus, Google Scholar, the Cochrane Library, and African Journals Online was conducted from January 2004 to February 2026. Studies reporting mortality outcomes after DCL for civilian trauma in World Bank–classified LMICs were included. Proportional meta-analysis using a DerSimonian-Laird random-effects model with logit-transformed proportions was performed. The protocol was prospectively registered on PROSPERO (CRD42025639498). The detailed search strategy is provided in S1 Table. Results: Ten retrospective studies comprising 914 patients from five countries (South Africa, Pakistan, India, Oman, and Brazil) met the inclusion criteria. Six of the ten studies (n = 704, 77.0%) were from South Africa. The pooled mortality rate was 37.77% (95% CI: 31.38%–44.62%; 95% prediction interval: 20.1%–59.1%), with substantial heterogeneity (I² = 74.46%), based on 327 deaths among 914 patients. Subgroup analysis showed a pooled mortality of 31.61% (95% CI: 28.27%–35.15%, I² = 0.00%) in South African studies and 53.62% (95% CI: 44.47%–62.54%, I² = 31.65%) in non–South African LMIC studies (Cochran Q-test for subgroup differences: Q = 14.23, df = 1, p < 0.001). Conclusions: DCL mortality in LMICs appears higher than mortality rates reported in HIC series, though direct comparison is limited by differences in study populations, injury profiles, case-mix, and the predominance of South African data in the available literature. The pooled estimate should be interpreted cautiously given the small number of studies, high heterogeneity, and retrospective study designs. Pre-hospital care, emergency theatre access, blood banking infrastructure, ICU capacity, and infection prevention represent potential areas for targeted improvement. Further prospective, multi-centre studies with standardised outcome definitions are needed to better characterise DCL outcomes across diverse LMIC settings.

Background: Damage control surgery (DCS) is a life-saving strategy for critically injured patients in extremis . Identifying predictors of mortality in this population may help guide clinical decision making and resource allocation in low- and middle-income countries. This study aimed to identify independent predictors of in-hospital mortality following DCS. Methods: We conducted a retrospective analysis of 219 consecutive patients who underwent DCS at a trauma centre, over 3 years, between June 2021 and June 2024. Patient demographics, physiological parameters, laboratory values, transfusion requirements, operative details and outcomes were compared between survivors and non-survivors. Multivariable logistic regression analysis was performed to identify independent predictors of mortality. Results: The overall in-hospital mortality rate was 11.0% (n = 24). Patients were predominantly male (93.5%) with penetrating trauma (84.5%). Non-survivors demonstrated significantly lower Glasgow Coma Scale scores (13.0 vs. 15.0, p < 0.001), lower arterial pH (7.07 vs. 7.29, p < 0.001), higher lactate levels (13.4 vs. 6.3 mmol/L, p < 0.001) and greater transfusion requirements (p < 0.001). Multivariable analysis identified three independent predictors of mortality: elevated lactate (OR 4.33 per SD increase), lower Glasgow Coma Scale (OR 0.56 per SD increase) and lower arterial pH (OR 1.34 per SD decrease). The predictive model demonstrated excellent discrimination (AUC 0.912). Conclusions: Lactate, Glasgow Coma Scale and arterial pH are independent predictors of mortality following DCS. These readily available clinical parameters may assist in prognostication and guide resuscitation efforts in this high-risk patient population.

Background: Renal trauma is a major cause of morbidity and mortality among trauma patients, especially in low- and middle-income countries (LMICs) where penetrating injuries are common. Although international evidence increasingly supports selective non-operative management (SNOM) for haemodynamically stable patients, data from resource-limited settings remain scarce. This study sought to assess the management outcomes of patients with traumatic renal injury at a South African tertiary trauma centre, describing management patterns and outcomes and identifying predictors of in-hospital death. Methods: A retrospective audit was carried out on all consecutive trauma patients presenting with renal injuries at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) between July 2021 and June 2024. Patient demographics, injury mechanism and grade, admission physiological parameters, management strategies, complications, and outcomes were documented. Associations with in-hospital mortality were analysed using bivariate methods and Cox proportional hazards regression. Results: Of 161 patients included, 91.3% were male, with a median age of 32 years (interquartile range [IQR] 26–38). Penetrating trauma accounted for 80.1% of cases, predominantly gunshot wounds (GSWs; 49.7%). Most injuries were classified as American Association for the Surgery of Trauma (AAST) grades III–V (74.5%), and 68.3% required surgical intervention, although direct renal procedures were necessary in only 42.7% of operated patients. Nephrectomy accounted for 80.9% of renal-specific surgical interventions (38 of 47 patients who underwent a direct renal procedure). The overall in-hospital mortality rate was 17.4%. On multivariable analysis, admission lactate (hazard ratio [HR] 1.09; 95% confidence interval [CI] 1.00–1.18; p = 0.049), admission creatinine (HR 1.56; 95% CI 1.29–1.89; p < 0.001), and blood product transfusion within 24 h (HR 3.27; 95% CI 1.14–9.41; p = 0.028) were independently associated with mortality in the adjusted model. Conclusions: Admission lactate, creatinine, and early blood transfusion requirements were independently associated with in-hospital mortality in the adjusted model in this high-acuity cohort. These readily available physiological markers may facilitate early identification of high-risk patients in resource-limited settings; however, in the absence of ISS data, these variables may partly reflect the global burden of physiological insult from polytrauma rather than renal-specific predictors of death. A proportion of patients were managed non-operatively; however, given the inherent selection bias in management allocation and the absence of SNOM-specific outcome data stratified by AAST grade, no conclusions regarding the efficacy or safety of non-operative management can be drawn from this descriptive audit.

Background: Penetrating abdominal trauma with bowel or omental evisceration has traditionally mandated exploratory laparotomy due to perceived high risk of intra‐abdominal injury. Selective nonoperative management (SNOM) has gained acceptance in stable patients, but evidence specific to evisceration remains limited and controversial. Objective: To compare outcomes of operative management versus SNOM in adults with penetrating abdominal trauma and documented evisceration. Methods: Systematic review conducted per PRISMA 2020 guidelines. Databases searched were as follows: PubMed, Scopus, Wits Summon, and Google Scholar (1980–2025). Inclusion were as follows: adults ≥ 18 years, penetrating (stab/gunshot) trauma, documented bowel/omental evisceration, operative versus SNOM comparison, and outcomes (mortality, missed injuries, delayed therapeutic laparotomy, complications, and length of stay). Risk of bias via Newcastle–Ottawa Scale; evidence certainty via GRADE. Random‐effects meta‐analysis performed where feasible PROSPERO registration number: (CRD420261345559). Results: From 292 records, 152 remained after deduplication; 47 full texts assessed; 20 studies included in qualitative synthesis; and 13 in meta‐analysis. SNOM significantly reduced nontherapeutic laparotomy (pooled OR 0.61, 95% CI 0.46–0.80; I ² = 26%; and p < 0.001) without increased mortality or morbidity. Subgroup analysis showed SNOM particularly safe in isolated omental evisceration (failure < 15%), with higher therapeutic rates in bowel/organ cases. Evidence certainty was moderate (downgraded for observational design and heterogeneity). Conclusions: In hemodynamically stable patients with penetrating abdominal trauma and evisceration, SNOM appears safe and preferable in selected cases reducing unnecessary laparotomies without compromising outcomes. Prospective trials are needed to refine indications.

Background: Laparoscopy is a valuable surgical modality in trauma, yet its application remains underexplored. This study evaluates the feasibility and short-term outcomes of laparoscopy for abdominal trauma at a high-volume Level 1 trauma centre in Johannesburg. Methods: A retrospective cohort study of adult patients who underwent laparoscopy for abdominal trauma at Charlotte Maxeke Johannesburg Academic Hospital from January 2021 to June 2025 was conducted. Demographics, mechanism of injury, injury severity score, intraoperative findings, conversion rates, complications and length of stay were analysed. Results: Of 69 patients who underwent laparoscopy, 60 met the inclusion criteria. Median age was 30.5 years (IQR 27–38), with 95% male patients (95% CI: 86.3%–98.3%). Penetrating trauma accounted for 98.3% of cases. Negative laparoscopy occurred in 28.3% (95% CI: 18.5%–40.8%), potentially avoiding non-therapeutic laparotomy. Diaphragmatic injuries were the most common positive finding (15%). Conversion occurred in 23.3% (95% CI: 14.4%–35.4%), most commonly for definitive repair (15%). Complications occurred in 6.7% (95% CI: 2.6%–15.9%), with no in-hospital mortalities. Median length of stay was 4 days (IQR 3–7). Conclusion: Laparoscopy is feasible in carefully selected haemodynamically stable trauma patients, even in resource-constrained, high-volume settings. These findings support further investigation of laparoscopy in low- and middle-income countries, with investment in training infrastructure a key priority. Contribution: This study provides contemporary South African evidence on the feasibility and short-term outcomes of laparoscopy in selected trauma patients and supports further evaluation of its potential to avoid non-therapeutic laparotomy.