South African Journal of Surgery - Volume 49, Issue 2, 2011
Volume 49, Issue 2, 2011
Author M.C. KewSource: South African Journal of Surgery 49, pp 51 –86 (2011)More Less
Source: South African Journal of Surgery 49, pp 52 –56 (2011)More Less
Sometimes the most difficult aspect of research is finding a place to start. There are various techniques for generating focused research questions and logical ways to find 'gaps' in the literature. Advice on how to make a project feasible within the time and resources available, is also useful. Certainly, research cannot start if there is no clear research topic, hypothesis or question. Even these words may be confusing; a topic is a broad area of research such as 'Ulcers', or perhaps 'Duodenal ulcers'. A hypothesis is simply a proposition regarding the outcome of a study, e.g. 'Lifestyle factors influence the severity of duodenal ulcers'. Research is much easier to plan if there is a clear, concise research question that ends in a question mark and conceptually has an answer, e.g. 'What lifestyle factors increase the risk of duodenal ulcers?' Once one has a question, the research can be focused to answer that question, and it becomes relatively easy to structure the protocol accordingly.
Pancreatic injuries after blunt abdominal trauma : an analysis of 110 patients treated at a level 1 trauma centre : general surgerySource: South African Journal of Surgery 49, pp 58 –67 (2011)More Less
Background and objective. Injuries to the pancreas are uncommon, but may result in considerable morbidity and mortality. This study evaluated the management of blunt pancreatic injuries using a previously defined protocol to determine which factors predicted morbidity and mortality.
Methods. The study design was a retrospective chart review of all adult patients with blunt pancreatic injuries treated at a level 1 trauma centre between March 1981 and June 2009.
Results. One hundred and ten patients (92 men, 18 women; mean age 30 years, range 13 - 68 years) were treated during the study period. Forty-six patients had American Association for the Surgery of Trauma (AAST) grade 1 or 2 pancreatic injuries and 64 had AAST grade 3, 4 or 5 pancreatic injuries. Injuries involved the head (N=21), neck (N=15), body (N=48) and tail (N=26) of the pancreas. The mean number of organs injured was 2.7 per patient (range 1 - 4). One hundred and one patients underwent a total of 123 operations, including drainage of the pancreatic injury (N=73), distal pancreatectomy (N=39) and Whipple resection (N=5). The overall complication rate was 74.5% and the mortality rate 16.4%. Only 2 of the 18 deaths were attributable to the pancreatic injury. Shock on presentation was highly predictive of death; 17 of 39 patients with shock died, compared with 1 of 71 patients who were not shocked (p<0.0001). Fourteen of 46 patients with grade 1 and 2 pancreatic injuries died compared with 4 of 64 patients with grades 3, 4 and 5 injuries (p<0.001). Mortality increased exponentially as the number of associated injuries increased. Two of 57 patients with injury to the pancreas only or one associated injury died, compared with 16 of 53 with two or more associated injuries (p<0.0013).
Conclusions. This study demonstrated a significant correlation between the AAST grade of injury and pancreas-specific morbidity and between shock on admission, the number of associated injuries and death, in patients with blunt pancreatic injuries. Although morbidity and mortality rates after blunt pancreatic trauma are high, death was usually the result of major associated injuries and not related to the pancreatic injury.
Liver resection for non-cirrhotic hepatocellular carcinoma in South African patients : general surgerySource: South African Journal of Surgery 49, pp 68 –74 (2011)More Less
Background. We describe the clinicopathologic features and outcome of South African patients who have undergone hepatic resection for hepatocellular carcinoma (HCC) arising in a non-cirrhotic liver.
Methods. We utilised the prospective liver resection database in the Surgical Gastroenterology Unit at Groote Schuur Hospital, Cape Town, to identify all patients who underwent surgery for HCC with non-cirrhotic liver parenchyma between 1990 and 2008.
Results. Twenty-two patients (10 men, 12 women, 3 black, 19 white, median age 47 years, range 21 - 79 years) underwent surgery for non-cirrhotic HCC. Sixteen patients had non-fibrolamellar HCC (Group 1); 6 patients had fibrolamellar HCC (Group 2). Group 1 had a median age of 55 years, and 6 (38%) were men; group 2 had a median age of 21 years, and 5 (83%) were men. Most patients had a solitary tumour at diagnosis; median largest tumour diameters in Groups 1 and 2 were 10 cm (range 4 - 21) and 12 cm (range 4 - 17), respectively. Patients in Group 1 underwent extended right hepatectomy (N=3), right hepatectomy (N=3), left hepatectomy (N=3), partial hepatectomy (N=7), cholecystectomy (N=6), and appendicectomy (N=1). Patients in Group 2 underwent extended right hepatectomy (N=1), right hepatectomy (N=1), left hepatectomy (N=2), segmentectomy (N=2), and portal lymphadenectomy (N=3). Recurrence rates in Groups 1, 2, and overall were 81%, 100% and 86%, respectively. Median overall survival was 46 months, with 1-, 3-, and 5-year survival rates of 95%, 59% and 45%, respectively. In Group 1, median survival was 39 months, with 1-, 3-, and 5-year survival rates of 100%, 56% and 38% respectively. In Group 2, median survival was 61 months, with 1-, 3-, and 5-year survival rates of 83%, 67% and 67%, respectively.
Conclusion. Despite aggressive surgical resection, HCC arising in normal liver parenchyma has a high recurrence rate and an ultimately poor outcome. This finding is similar to both the recent international experience of non-cirrhotic HCC and local experience of fibrolamellar HCC.
Solid pseudopapillary epithelial neoplasm - a rare but curable pancreatic tumour in young women : general surgerySource: South African Journal of Surgery 49, pp 75 –81 (2011)More Less
Background. Solid pseudopapillary epithelial neoplasms (SPENs) of the pancreas are rare but curable tumours that have a low-grade malignant potential and occur almost exclusively in young women, with an excellent prognosis after complete resection. This study examines the clinicopathological characteristics of these tumours and evaluates the role of surgery in relation to their size and location.
Study design. We reviewed the pre-, intra- and postoperative data on 21 patients with SPENs who underwent resection during a 30-year period. Data including demographic information, presenting symptoms and signs, extent of operation, histology, tumour markers and postoperative complications were evaluated to establish the optimal surgical management.
Results. All 21 tumours occurred in women (mean age 24.6 years, range 13 - 51 years). Sixteen patients presented with nonspecific abdominal complaints and a palpable abdominal mass, in 1 patient the tumour was found during emergency laparotomy for a complicated ovarian cyst, 1 patient presented with severe abdominal pain and shock due to a ruptured tumour, and in 3 patients the tumour was detected incidentally during imaging. The correct pre-operative diagnosis of SPEN was made in 10 patients. Incorrect preoperative diagnoses included hydatid cyst (3 patients), mesenteric cyst (2), pancreatic cystadenoma (2), ovarian cysts (1), islet cell tumour of the pancreas (1), and cavernous haemangioma of the liver (1). The mean diameter of the tumours was 12.5 cm (range 8 - 20 cm), and they occurred in the head (8), neck (5), body (2), and tail (6) of the pancreas. All SPENs were resected. Five patients had a pylorus-preserving pancreaticoduodenectomy, 4 a central pancreatectomy with distal pancreaticogastrostomy, 8 a distal pancreatectomy, 3 a local resection and one a total pancreatectomy and portal vein graft. In 1 patient, 2 liver metastases were resected in addition to the pancreatic primary tumour. The patient who presented in shock with tumour rupture and bleeding into the lesser sac later died of multiple organ failure after successful resection. Postoperative complications included a stricture at the hepaticojejunostomy after pancreaticoduodenectomy, which resolved after stenting, and a pancreatic duct fistula after local tumour resection, which required a distal pancreatectomy. Other complications were bleeding (2 patients) requiring re-operation and intraabdominal fluid collections requiring percutaneous drainage (3) or operation (1). Mean postoperative hospital stay was 16 days (range 6 - 40 days). Twenty patients are alive and well without recurrence, including the patient with metastases, with a mean follow-up of 6.6 years (range 6 months - 15 years).
Conclusions. This study demonstrated that SPENs of the pancreas are uncommon, but should be considered in the differential diagnosis of a cystic mass of the pancreas in a young woman. Despite the indolent biological behaviour of SPENs, most patients required major pancreatic resection. Surgery is curative regardless of the size or location of the tumour. Metastases are rare, as is recurrence after complete surgical resection.
Source: South African Journal of Surgery 49, pp 82 –84 (2011)More Less
Introduction. In triglyceridaemia-associated pancreatitis, decreasing the serum triglyceride level below 5.65 mmol/l alleviates abdominal pain and is purported to improve outcome. We analysed hypertriglyceride level normalisation and outcome in a patient cohort of acute pancreatitis.
Patients and methods. Patients presenting with pancreatitis and hypertriglyceridaemia were assessed. All patients with presenting triglycerides levels >10 mmol/l were assessed for resolution to a level below 5.65 mmol/l at days 3 and 5. Patients with triglyceride levels in excess of 10 mmol/l were treated with either standard supportive therapy or an insulin dextrose infusion.
Results. In the period June 2001 to April 2008, there were 503 admissions of 439 patients with a diagnosis of acute pancreatitis; 26 (6%) had hypertriglyceridaemia >10 mmol/l at admission. Standard therapy was used in all patients; in 6 patients, it was the sole therapy. A dextrose and insulin infusion was used in 20 cases. On day 3, 7 (32%) of the measured triglyceride levels had fallen below 5.65 mmol/l and, on day 5, all but 4 (83%) were <5.65 mmol/l. Three patients died.
Conclusion. Standard therapy was equivalent to the use of dextrose and insulin in the resolution of hypertriglyceridaemia. Our methods to reduce triglyceride levels produce morbidity and mortality rates similar to those attained when alternate lipid-lowering strategies are employed.
Source: South African Journal of Surgery 49, pp 85 –86 (2011)More Less
In the presence of portal hypertension, a recanalised para-umbilical vein and splenomegaly are diagnostic of a rare condition, namely Cruveilhier-Baumgarten syndrome. In this case demonstration of the large and tortuous vein by computed tomography (CT) imaging avoided catastrophic haemorrhage from a planned hysterectomy and served as a road map for surgical planning.
Source: South African Journal of Surgery 49, pp 90 –104 (2011)More Less