South African Journal of Surgery - Volume 45, Issue 1, 2007
Volume 45, Issue 1, 2007
Palliation of malignant hilar obstruction at a single centre - review of operative and non-operative techniques : general surgerySource: South African Journal of Surgery 45, pp 12 –16 (2007)More Less
Introduction. Jaundice secondary to a malignant hilar obstruction can be relieved by operative bypass or percutaneous stenting. Comparative trials involving these techniques are scarce. We reviewed our experience with these competing techniques in the palliation of malignant hilar obstruction.
Patients and methods. All patients with malignant hilar obstruction managed at our institution during the period 1992 - 2002 were identified for review.
Results. a total of 36 deeply jaundiced patients with hilar obstruction were identified. Twenty-two patients underwent exploration with the intention of performing an operative bypass and 14 patients underwent percutaneous transhepatic cholangiography (PTC) with intention to stent. Procedure-related mortality was similar in both groups. Morbidity was much higher in the operative group. Effective symptom relief was achieved with both techniques. In the PTC group recurrent biliary obstruction in 2 patients necessitated salvage non-operative procedures. Although survival rates were slightly longer in the operative group, this was not significant. There were no long-term survivors.
Conclusion. Operative bypass provides better sustained relief of jaundice than PTC. However long-term survival in both groups is poor and operative bypass is best reserved for younger patients with no technical contraindications. Despite early and late procedural failures PTC is the method of choice for patients with advanced-stage disease and those with significant co-morbidities.
Biochemical and immunohistochemical characterisation of mucins in 8 cases of colonic disease - a pilot study : general surgerySource: South African Journal of Surgery 45, pp 18 –23 (2007)More Less
Objectives. To characterise mucins in cancer of the colon and compare these with controls using stringent biochemical measures to avoid endogenous proteolysis.
Design. Crude mucus scrapings were collected from 12 specimens obtained by colectomy. Specimens from 3 traumatic colectomies and 1 sigmoid volvulus were used as controls, and compared with 6 specimens from colons resected for adenocarcinoma and 2 irradiated colons.
Subjects. The median age of the 4 female patients was 76 years (range 49 - 82 years), and of the 8 male patients 46.5 years (range 16 - 74 years).
Results and conclusions. The crude mucus scrapings in the 9 specimens ranged in weight from 353 mg to 7 697 mg (median 4 928 mg). The median of purified mucin in the 9 specimens was 0.72 mg/mg wet weight of scraped material. Eight samples gave non-extractable pellet material, and were treated with DTT to reduce disulphide bonds for further analysis. One of these 8 pellets was resistant to reduction and had to be digested with papain before analysis. Only 5 of these pellets had mucin. Gel filtration and SDS-PAGE (sodium dodecyl sulphate polyacrylamide gel electrophoresis) analysis revealed different populations of mucin based on size and extent of degradation. Western blotting and immunohistochemical analysis confirmed the presence of MUC2 in all samples, MUC5AC in 2 and MUC5B in 5 diseased specimens. Immunohistochemical analysis showed that there was no MUC1 in the normal specimens, MUC1 apoprotein (MUC1 core) in 2 cancer specimens and MUC1 in 1 cancer specimen. Histochemical analysis showed that normal tissue expressed neutral and acidic mucins and diseased specimens predominantly expressed acidic mucins. The electrophoretic behaviour of MUC2 in sigmoid volvulus was different from that in cancer of the colon.
Trial of self-expandable metallic stents in the palliation of tracheo-oesophageal fistula in carcinoma of the oesophagus : general surgerySource: South African Journal of Surgery 45, pp 24 –27 (2007)More Less
Subjects. Fifty-eight patients with cancer of the oesophagus were studied from July 2002 to November 2005. Thirty-seven patients presented with strictures and 21 presented with tracheo-oesophageal fistula (TOF).
Methods. There were 35 males and 23 females. Mean age was 57 years. Stents were positioned under fluoroscopic guidance, in the majority of cases under conscious sedation. Contrast study was done on day 1 to assess stent expansion and sealing of the TOF. Data were analysed using Stata Statistcal Software, release 8.0. Survival was calculated using kaplan-Meier methodology and log-rank tests were used to assess differences. A p-value < 0.05 was considered to be statistically significant.
Results. Stenting was successful in 57 of the 58 patients; 1 perforation occurred at the time of insertion. In total, 68 stents were inserted in 58 patients. Re-stenting was necessary in 10 patients, because of tumour overgrowth (N = 5), stent migration (N = 3) and recurrent fistula (N = 2). Dysphagia improved from a mean score of 2.98 to 1.08. All lesions were squamous cell carcinoma. The positions of the fistulas were proximal (N = 4), middle (N = 14) and distal (N = 3). Over half of the patients in the TOF group had concomitant pneumonia at presentation with decreased survival (p = 0.010) and a hazard ratio of 10.86. Two patients died, on days 4 and 7 respectively. Median survival was 91 days (range 0 - 273 days) for the stricture group and 62 days (range 3 - 413 days) for the TOF group, but these differences were not significant (p = 0.945).
Conclusion. Covered self-expandable metallic stents provide an acceptable option for the palliation of TOF due to cancer of the oesophagus.