Scielo RSS <![CDATA[South African Journal of Surgery]]> vol. 50 num. 3 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Percutaneous transhepatic self-expanding metal stents for palliation of malignant biliary obstruction</b>]]> BACKGROUND: Malignant biliary obstruction is often inoperable at presentation and has a poor prognosis. Percutaneously placed self-expanding metal stents (SEMS) have been widely used for palliation of malignant biliary obstruction as an alternative to major bypass surgery or when endoscopic drainage is not technically feasible. The success rate, procedural complications and outcomes in patients who underwent placement of SEMS in a tertiary referral centre are presented. METHODS: All patients who had percutaneous transhepatic cholangiography (PTC) and SEMS for palliation of malignant biliary obstruction between May 2008 and July 2010 at Groote Schuur Hospital, Cape Town, were reviewed. A retrospective chart review was undertaken using multidisciplinary case notes of all patients. The data analysed included demographic information, diagnosis, level of biliary obstruction, number and type of procedures, efficacy and complications of SEMS insertion. Boston Scientific 69 mm by 10 mm Wallstent SEMS were used in all patients. RESULTS: Fifty patients (28 men, 22 women, mean age 61 years, range 48 - 80 years) underwent percutaneous SEMS placement. Twenty-one patients had biliary obstruction at the level of the hilum involving the hepatic duct bifurcation, 5 in the mid-common bile duct and 24 in the low common bile duct. In 20 patients (40%) SEMS were placed at the time of initial biliary drainage (one-stage procedure), while the remaining 30 patients underwent stent placement within 2 - 23 days of biliary drainage as a two-stage procedure because of difficult access through the lesion during the initial procedure. Five patients (10%) required bilateral SEMS insertion. Stent placement was successful in all patients and biliary obstruction was relieved in all. The mean serum bilirubin level decreased by a mean of 56% from 294 µmol/l to 129 µmol/l measured 5 days after stent insertion. Mean hospital stay after stent insertion was 4.1 days. The average length of hospital stay for patients who underwent a one-stage procedure was 3.2 days (range 1 - 11 days), and for patients who underwent a two-stage procedure 7.6 days (range 3 - 23 days). Nine patients (18%) developed a procedure-related complication, which included cholangitis after stent insertion (n=4), cholangitic liver abscesses (n=1), subphrenic liver collection (n=1), bile leakage (n=1) and cholecystitis (n=2). Three patients (6%) developed complications unrelated to SEMS insertion, which included myocardial ischaemia (n=2) and pneumonia (n=1). Stent occlusion occurred in 4 patients (8%) within a week as result of stent migration (n=3) or presumed biliary sludge (n=1); 2 (4%) stents occluded between 7 days and 1 month. Four patients (8%) died during hospital admission due to pre-existing biliary sepsis (n=3) and pneumonia (n=1). Nine patients developed duodenal obstruction due to disease progression and required endoscopic duodenal stenting. Four patients (8%) survived less than 1 month, 12 (24%) between 1 month and 3 months, 11 (22%) between 3 and 6 months, and 10 (20%) beyond 6 months. Follow-up was not possible for 9 patients (18%) from distant referral sites. CONCLUSION: These results demonstrate that percutaneously placed SEMS achieved satisfactory palliation with a low complication rate in a high-risk patient group with advanced malignant biliary obstruction. <![CDATA[<b>Laparoscopic cholecystectomy in acute cholecystitis</b>: <b>An analysis of the risk factors</b>]]> BACKGROUND AND AIM: Laparoscopic cholecystectomy (LC) is increasingly being used as the initial surgical approach in patients with acute cholecystitis (AC). We describe our experience with LC in the treatment of AC. MATERIALS AND METHODS: In this study 2 412 patients underwent LC, in 315 cases for AC. The diagnosis was based on clinical, laboratory and intra-operative findings. Rates of conversion, complications, length of hospital stay, operating times, and factors associated with conversion or morbidity were analysed. RESULTS: Conversion to open cholecystectomy was necessary in 60 patients (19.04%) with AC. Factors associated with conversion were age >65 years, male gender, presence of empyema, previous abdominal surgery, and fever (temperature >37.5°C). There were no deaths, and the complication rate was 6.4%. The only risk factor for morbidity was a bilirubin level of >20.52 µmol/l. The operating time and hospital stay were significantly longer in AC than in elective cases. CONCLUSIONS: LC for AC is technically demanding but safe and effective. With patience, experience, careful dissection and identification of vital structures, the laparoscopic approach is safe in the majority of cases. <![CDATA[<b>Oesophageal pouches and diverticula: A pictorial review</b>]]> Diverticula of the oesophagus are rare. They can occur at any level, and are often defined by their anatomical location. Three categories are recognised, namely pharyngo-oesophageal, parabronchial and epiphrenic. Although these diverticula are often asymptomatic, patients can develop significant problems with dysphagia, regurgitation and aspiration. The causation of oesophageal diverticula is controversial; however, the popular current belief is that most occur because of oesophageal dysmotility. This paper demonstrates the categories of oesophageal diverticula pictorially, including the radiological features and underlying pathology. <![CDATA[<b>The histology of <i>peau d'orange</i> in breast cancer - what are the implications for surgery?</b>]]> INTRODUCTION: Surgery is sometimes performed on patients with peau d'orange (dermal oedema) of the breast. This may be done to achieve local control of cancer after neo-adjuvant chemotherapy or in resectable locally advanced disease. Conventional practice is not to place excision lines through areas of peau d'orange for fear of recurrence in such an area. The question can be asked whether this wisdom is still valid in modern practice. No formal cohort studies documenting the histopathology of the skin in areas of peau d'orange have been published, and available descriptions are scanty. AIM: To describe the histopathological features of peau d'orange. METHOD: Consecutive patients undergoing mastectomy for cancer in whom peau d'orange was present were selected over a period of 2 years. Blocks of skin were excised from areas of peau d'orange and examined histologically. The presence, nature and location of malignant cells were recorded and correlated with lymph node pathology. Prior administration of neo-adjuvant chemotherapy was noted. RESULTS: Twenty-six mastectomy specimens were examined. Tumour islands in lymphatics were identified in 10 of the 26 specimens. These tumour groups were found in lymph vessels of both the superficial and deep dermal plexuses. In 1 specimen the presence of malignant cells was equivocal. Metastatic tumour was present in axillary lymph nodes in 19 of 22 specimens. Fourteen patients had been treated with neo-adjuvant chemotherapy, and 5 of their specimens exhibited the presence of tumour cell groups in lymphovascular channels. CONCLUSION: Tumour cells were present in the lymphatic vessels in areas of peau d'orange in 38% of the specimens studied. It would be expected that placing an excision line in such an area would result in an incomplete cancer operation in a high percentage of, but not all, cases. <![CDATA[<b>Single-centre comparison of a novel single-step balloon inflation device and Amplatz sheath dilatation during percutaneous nephrolithotomy: A pilot study</b>]]> OBJECTIVE: A new second-generation balloon dilatation device for percutaneous nephrolithotomy (PCNL) has been launched, promising to challenge the traditional Amplatz serial dilators (ASDs). This device allows for the polyurethane sheath to be deployed on balloon inflation. Our primary objective in this pilot study was to determine whether the use of this new device impacted on overall patient outcome when compared with the traditional ASD system. DESIGN: Retrospective chart review. SETTING: Department of Urology, Inkosi Albert Luthuli Central Hospital, Durban. SUBJECT: Single-centre comparison of a novel single-step balloon inflation device and Amplatz sheath dilatation during percutaneous nephrolithotomy - a pilot study. OUTCOME MEASURES: Single procedure success rates, retreatment rates, hospital stay, haemoglobin concentration, calculi volume, calculi configuration, patient demographics. RESULTS: The stone-free rates after a single procedure were 30% (3/10) in the Amplatz sheath dilatation arm (series 1) and 80% (8/10) in the single-step balloon inflation device arm (series 2). Correspondingly, 11 individual repeat procedures in 7 patients (4 relook PCNLs, 5 ureteroscopies and 2 extracorporeal shockwave lithotripsies) were required in series 1 to render the remaining 70% stone free. Mean hospital stay was 5.2 days (range 3 - 10 days) in series 1 and 3.8 days in series 2. The mean fall in haemoglobin concentration after treatment was 1.79 g/dl in the whole group, 2.1 g/dl in series 1, and 1.5 g/dl in series 2. CONCLUSION: The single-step balloon dilatation device is found to have an improved patient outcome compared with ASDs. <![CDATA[<b>Treatment of male urethral strictures - possible reasons for the use of repeated dilatation or internal urethrotomy rather than urethroplasty</b>]]> OBJECTIVE: To investigate the possible reasons for repeated urethral dilatation or optical internal urethrotomy rather than urethroplasty in the treatment of male urethral strictures. PATIENTS AND METHODS: Men referred to the stricture clinic of our institution during the period April 2007 - March 2008 were reviewed and the operative urological procedures performed in the same period were analysed. Statistical analysis was performed using Student's t-test and Fisher's exact test (p<0.05 statistically significant). RESULTS: The mean age of the 125 men was 49.9 years (range 12.8 - 93.4 years). Previous stricture treatment had been given 1 - 2, 3 - 4 and 5 - 6 times in 52%, 32% and 12% of patients, respectively (4% had not undergone treatment). In these groups, previous treatment was dilatation in 70%, 76% and 72%, urethrotomy in 26%, 15% and 28%, and urethroplasty in 4%, 9% and 0, respectively. The group with 5 - 6 compared with 1 - 2 previous treatments was significantly older (mean age 60.2 v. 46.6 years) and had a significantly greater proportion with underlying co-morbidities (80% v. 52%). The group that had undergone urethroplasty compared with 5 - 6 repeated dilatations or urethrotomies was significantly younger (mean age 48.2 v. 60.2 years) with a lower prevalence of co-morbidities (47% v. 80%). During the study period urethroplasty was performed in 16 (2%) of 821 inpatients, whereas 55 men were seen who had undergone &gt;3 previous procedures, indicating that urethroplasty was performed in less than one-third of cases in which it would have been the optimal treatment. Owing to limited theatre time, procedures indicated for malignancy, urolithiasis, renal failure and congenital anomalies were performed more often than urethroplasty. CONCLUSIONS: Factors that possibly influenced the decision to perform repeated urethrotomy or dilatation instead of urethroplasty were limited theatre time, increased patient age and the presence of underlying co-morbidities. <![CDATA[<b>Beware the left-sided gallbladder</b>]]> A left-sided gallbladder is a rare biliary anomaly with a prevalence of 0.2%. Its identification is important because of the numerous and potentially hazardous associated biliary and vascular anomalies that may be encountered during surgery. <![CDATA[<b>Diaphragmatic eventration complicated by gastric volvulus with perforation</b>]]> Eventration of the diaphragm with gastric volvulus is uncommon. Gastric perforation in these cases is rare and usually associated with acute gastric volvulus with strangulation. We describe a case of diaphragmatic eventration with chronic gastric volvulus with gastric perforation without strangulation in an elderly man. <![CDATA[<b>Isolated splenic peliosis in an immunocompromised patient</b>]]> BACKGROUND: Peliosis is a rare condition characterised by multiple cyst-like, blood-filled cavities within the parenchyma of solid organs, most commonly affecting the liver. Isolated splenic peliosis is an even more unusual phenomenon. Patients with AIDS may develop peliosis in association with bacillary angiomatosis. This is due to secondary infection with Bartonella henselae or a similar organism, Rochalimaea henselae. CASE PRESENTATION: A 45-year-old HIV-positive man on antiretroviral therapy presented with a left hypochodrial abdominal mass. Radiological and histopathological examination confirmed splenic peliosis. <![CDATA[<b>Misdiagnosis of diaphragmatic rupture in a trauma setting</b>]]> Distinguishing diaphragmatic eventration from rupture in the trauma setting can be a considerable challenge. We present a case involving a man suffering from chest pain and with a raised left hemidiaphragm on the chest radiograph after a motor vehicle injury. A review of the literature discusses the use of imaging modalities and subsequent surgical diagnostic procedures in the face of uncertainty. <![CDATA[<b>AAST grade III pancreatic injury following blunt abdominal trauma</b>]]> Isolated pancreatic trauma with major pancreatic duct disruption is a rare finding; it can present with equivocal clinical signs. Serum amylase levels and diagnostic contrast-enhanced computed tomography can facilitate the diagnostic process. <![CDATA[<b>Bilateral synchronous testicular germ cell tumours in a patient with bilateral cryptorchidism</b>]]> Bilateral testicular tumours are rare, and 80% of bilateral tumours are metachronous. The incidence of testicular tumours is high in cryptorchidism. Synchronous bilateral testicular tumours are rare, and bilateral synchronous testicular tumours in bilateral cryptorchidism extremely rare, probably not reported previously. <![CDATA[<b>Unexpected intra-operative diagnosis of a large cystic phaeochromocytoma and secondary nifedipine pharmacobezoar</b>]]> Cystic phaeochromocytoma is a rare neuro-endocrine tumour that is frequently asymptomatic and often diagnosed incidentally on imaging or intra-operatively. A pharmacobezoar is a rare complication of extended-release drug delivery systems. We present a case of a 70-year-old woman diagnosed intra-operatively with cystic phaeochromocytoma and antihypertensive pharmacobezoar. <![CDATA[<b>Enterovesical fistula in an HIV patient - reactivation of tuberculosis as part of IRIS</b>]]> Enterovesical fistula is a known complication of tuberculosis (TB) of the abdomen. We present a case of a young HIV-infected man who developed an enterovesical fistula due to reactivation of TB as part of the immune reconstitution inflammatory syndrome (IRIS). <![CDATA[<b>Intestinal prolapse through a persistent omphalomesenteric duct causing small-bowel obstruction</b>]]> Persistent omphalomesenteric duct as a cause of small-bowel obstruction is an exceptional finding. A neonate presented with occlusion due to intestinal prolapse through a persistent omphalomesenteric duct. Remnants of the duct were successfully resected, and the postoperative course was uneventful. We discuss the presentation of omphalomesenteric duct and its management. <![CDATA[<b>A 'wandering' gallstone</b>]]> When all three of the features of Rigler's triad are present on an abdominal radiograph, the cause of a small-bowel obstruction can be identified. <![CDATA[<b>The treatment of recurrent tracheo-oesophageal fistula with biosynthetic mesh</b>]]> When all three of the features of Rigler's triad are present on an abdominal radiograph, the cause of a small-bowel obstruction can be identified. <![CDATA[<b>50th SAGES/SASES Congress 9 - 11 August 2012, Durban</b>]]> When all three of the features of Rigler's triad are present on an abdominal radiograph, the cause of a small-bowel obstruction can be identified.