South African Journal of Surgery - Volume 47, Issue 4, 2009
Volume 47, Issue 4, 2009
Fibrolamellar hepatocellular carcinoma at a tertiary centre in South Africa : a case series : general surgerySource: South African Journal of Surgery 47, pp 108 –111 (2009)More Less
Background. Fibrolamellar carcinoma (FLC) is an uncommon malignant tumour of hepatocyte origin that differs from hepatocellular carcinoma (HCC) in aetiology, demographics, condition of the affected liver, and tumour markers. Controversy exists whether FLC demonstrates a more favourable prognosis than typical HCC. A review of existing literature reveals a dearth of FLC data from the African continent.
Methods. We utilised the prospective liver resection database at Groote Schuur Hospital to identify all patients who underwent surgery for FLC between 1990 and 2008.
Results. Seven patients (median age 21 years, range 19 - 42, 5 men, 2 women) underwent surgery for FLC. No patient had underlying liver disease or an elevated alpha fetoprotein (AFP) at either initial presentation or recurrence. Six patients had a solitary tumour at diagnosis (mean largest diameter = 12cm), and underwent left hepatectomy (N=2), right hepatectomy (N=1), extended right hepatectomy (N=1), and segmentectomies (N=2). Three patients underwent a portal lymphadenectomy for regional lymphatic tumour involvement. One patient with advanced extrahepatic portal nodal metastasis was unresectable. No peri-operative deaths occurred. Recurrence occurred post resection in all 6 patients. Median overall survival was 60 months, and overall 5-year survival was 4 out of 7 (57%). Post-resection survival (N=6) was 61 months, with a 5-year survival rate of 4 out of 6 (67%). The patient with unresectable disease survived 38 months after tumour embolisation with Lipiodol.
Conclusion. Our series suggests that despite (i) a high resection rate of solitary lesions with clear tumour resection margins, and (ii) absence of underlying liver disease, FLC has a high recurrence rate with an ultimately poor clinical outcome. These findings concur with recent international experience of FLC.
Long-term prospective randomised clinical and manometric comparison between surgical and chemical sphincterotomy for treatment of chronic anal fissure : general surgerySource: South African Journal of Surgery 47, pp 112 –114 (2009)More Less
Aim. To compare surgical and chemical sphincterotomy for treatment of chronic anal fissure.
Methods. The 160 patients studied were randomly divided into four equal groups, treated by lateral internal sphincterotomy (group S), local diltiazem ointment (group D), local glyceryl trinitrate ointment (group GTN), or injection of botulinum toxin into the internal anal sphincter (group BT). Anal manometry was performed before and 3 months after treatment. Patients were followed up for 5 years.
Results. Complete pain relief was achieved in means (± standard deviation) of 5.7±7.8 days (group S), 15.7±5.9 days (group D), 15.6±5.9 days (group GTN) and 2.7±3.6 days (group BT). The mean times to healing were 4.5±1.2 weeks (group I), 5.1±1.1 weeks (group D), 5.0±1.1 weeks (group GTN) and 5.1±1.3 weeks (group BT). Mean resting and squeeze anal pressures decreased significantly after sphincterotomy. Recurrence rates were 10% in group S, 65% in group D, 57.5% in group GTN and 52.5% in group BT.
Conclusion. Lateral internal sphincterotomy is an easy procedure with satisfactory results, minimal complications and a low recurrence rate. Medical sphincterotomy is safe and easy, with mild complications. Its effect is reversible, and relapse is common. We recommend that medical sphincterotomy be tried before surgery or in patients who are unable or unwilling to undergo surgery.
Source: South African Journal of Surgery 47, pp 116 –118 (2009)More Less
Introduction. The aim of this study was to determine the prevalence of tuberculosis (TB) in anal fistulas at a referral hospital in Cape Town, and to document the clinical features and course of patients with tuberculous anal fistulas.
Patients and methods. This was a prospective study of all patients who underwent surgery for anal fistulas at the Colorectal Surgery Unit at Groote Schuur Hospital, Cape Town, from 2004 to 2006. Tissue was submitted for histopathological examination, Ziehl-Neelsen (ZN) staining and TB culture. The patients with proven TB were followed up until January 2008.
Results. During the 3-year study period, 117 operations were performed on 96 patients. TB was diagnosed in 7 of the 96 patients (7.3%). In 5 of these 7 cases, the diagnosis of TB could be proven on histological examination and ZN staining, while in 2 cases the diagnosis could only be made on TB culture. None of the 7 patients had systemic features suggestive of TB, and only 1 had evidence of TB on a chest radiograph. Five patients were HIV-negative, and 2 declined testing. After a median follow-up of 2 years, 5 of 7 patients had evidence of recurrent or persistent fistulas, despite having completed 6 months of TB treatment.
Conclusion. At a referral hospital in an endemic area, TB was present in 7.3% of anal fistulas. Histopathological examination including ZN staining was inadequate to make the diagnosis in a third of these patients. Tissue from anal fistulas should therefore routinely be sent for TB culture as well as histopathological examination and ZN staining in areas where TB is prevalent.
An audit of the quality of care of traumatic brain injury at a busy regional hospital in South Africa : traumaSource: South African Journal of Surgery 47, pp 120 –126 (2009)More Less
Access to care by a dedicated neurosurgical unit is limited in the developing world, and the vast majority of patients who sustain a head injury are managed by general surgeons.Prevention of secondary brain injury is paramount. While the principles of management are relatively straightforward, delivering this care may be difficult. This audit looks at the spectrum of head injuries presenting to a busy regional hospital and attempts to measure the quality of care offered to these patients.
Patients and methods. The audit includes three separate sections. The first is a prospective audit of all patients with a traumatic brain injury presenting to the Accident and Emergency(AE) department at Edendale Hospital, Pietermaritzburg, over a 2-month period. The next two sub-audits consist of a random review of referral letters and AE clerking notes to assess the quality of care received by these patients. A total of 25 referral letters and 28 AE inpatient notes were randomly chosen for review and compared with agreed standardised markers for quality of care.
Results. Over the 2 months October and November 2007, 150 patients with a head injury were seen in the AE department. Of these 117 were male. A total of 76 were discharged home after investigation with a head injury warning chart, 49 were admitted to the general wards, 11 were admitted to the surgical intensive care unit, 10 were referred to the neurosurgical centre in Durban, and 4 died in the AE department. Ofthe 10 who needed advanced neurosurgical care, 3 required urgent burr-holes before referral. One of these patients died.All the remaining 9 patients who were transferred to the neurosurgery unit survived. The referral letters and AE clerking notes revealed major deficits.
Conclusion. Traumatic brain injury is a common problem. Only a small subset of patients require specialised neurosurgical care. Although many patients with intracranial injury can tolerate the delay associated with transfer, some cases area cute and urgent intervention by non-neurosurgeons is needed. Prevention of secondary brain injury is poorly understood and not prioritised. This situation needs to be improved. The introduction of formalised standard referral and management sheets may help to improve care.
Situs inversus abdominalis and duodenal atresia : a case report and review of the literature : case reportSource: South African Journal of Surgery 47, pp 127 –130 (2009)More Less
Fewer than 20 patients born with situs inversus and duodenal atresia have been reported in the literature. We present a patient with this condition. A newborn baby presented shortly after birth with persistent bilious vomiting. An abdominal radiograph showed a right-sided stomach bubble and a second bubble on the left - typical of duodenal atresia but with mirror image configuration. Laparotomy confirmed the diagnosis of situs inversus abdominalis, which was also demonstrated by contrast studies and ultrasound. Duodenoduodenostomy was performed and the patient discharged on day 8 postoperatively.
Situs inversus is associated with other congenital malformations including splenic malformations, left-sided liver and cardiac abnormalities; it is rarely associated with duodenal atresia. Duodenal obstruction in the presence of situs inversus has been described, including obstruction due to a web, stenosis, pre-duodenal portal vein and complete atresia. The patient presented in this paper had a duodenal web in the second part of the duodenum. Before undertaking surgery it is important to establish the presence of associated gastrointestinal and cardiac abnormalities.
Source: South African Journal of Surgery 47, pp 131 –133 (2009)More Less
Osteopetrosis (OP) is a rare heterogeneous group of inherited skeletal dysplasias characterised by osteoclast dysfunction, impaired bone resorption and poor bone remodelling. Three groups can be categorised on the basis of clinical findings. These include neurological symptoms, haematological abnormalities and renal tubular acidosis in the first group. Increased bone density, osteomyelitis and frequent fractures are the clinical findings in the second group, and the third group have normal life expectancy but may develop cranial nerve compression and osteomyelitis. Fractures in patients with OP are common and require appropriate pre-, peri- and postoperative management. The long bones are most frequently affected, fractures of the femoral neck and proximal (upper third) shaft being particularly common. This case report proposes possible operative fracture treatment in a patient with OP and highlights the potential perioperative pitfalls in this rare surgical population.
Source: South African Journal of Surgery 47, pp 134 –136 (2009)More Less
Reconstruction of the oesophagus was not attempted until the late 19th century. Over the next 100 years, various reconstructive techniques proliferated, initially for malignant disease but subsequently for end-stage oesophageal failure from a variety of benign conditions. The earliest and simplest technique of applying a split-skin graft over a tubular stent was associated with poor graft survival and a risk of mortality from stent erosion into vital structures in the mediastinum. Management has evolved since then. The use of the pedicled colon has become a popular choice for the thoracic portion. Replacement of the cervical portion is commonly achieved by either free jejunal transfer or the free radial forearm flap. The literature is reviewed and a case report is presented in which three salvage options were exercised after partial failure of colonic transposition for total oesophageal reconstruction.