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SAMJ: South African Medical Journal

versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.104 no.7 Pretoria Jul. 2014


(in alphabetical order according to presenting author)



Changing patterns of incidence, aetiology and mortality from acute pancreatitis at Kalafong Hospital, Pretoria, 1988 - 2007



Chamisa I; Mokoena T; Luvhengo TE

Kalafong Hospital. Department of General Surgery, University of Pretoria



BACKGROUND: Literature reports from Western countries have suggested an increasing incidence of acute pancreatitis (AP) and changing patterns over the past two decades. The aim of this study was to document the incidence, aetiology and mortality from AP in a single instituition over two decades (1988 - 2007) and to examine any emerging trends.
METHODS: A retrospective study of all confirmed cases of AP admitted to the surgical department over a 20-year period was performed. Discharge letters and summaries of all AP patients were retrieved from a computer database. Patient demographics, year of admission, number of attacks, aetiology, management, number of days in hospital, outcome and readmission were entered on a special study proforma.
RESULTS: In all 707 attacks of AP (602 males and 105 females) were recorded. The absolute number of AP admissions between the two decades (n=417, n=290) decreased in proportion to the total number of surgical admissions (34 128 and 26 723), the percentages being 1.2% and 1.1% respectively. There was an increase in gallstone AP (3.1% and 12.8%) attributed to changing demographics but also an absolute increase in blacks. In both decades, alcohol was the main aetiological factor for AP. Drug and endoscope-related AP increased and more whites with AP were admitted in the second decade (n=5, n=57). The in-hospital mortality rate during the respective decades was 6.5% and 3.1%. Mortality for alcohol-induced AP decreased from 6.9% to 2.0% but that for gallstone AP decreased less, from 7.7% to 5.4%.
CONCLUSION: The overall incidence rate for AP decreased proportionately to the total number of surgical admissions over the two decades. Gallstone-related AP increased, and alcohol-related AP decreased. There was a downward trend in mortality from AP, probably attributed to better management.

Keywords: Acute pancreatitis; epidemiology; incidence; mortality.



Early experience with laparoscopic splenectomy for haematological conditions



Ferndale L; Naidoo M; Bhaila SH; Thomson SR; Bassa F

Departments of Surgery1 and Medicine1, IALCH and Nelson R Mandela School of Medicine, UKZN



INTRODUCTION: Laparoscopic splenectomy has become the preferred method for removing the spleen in haematological conditions. We present the early experience from this unit.
PATIENTS: Between January 2007 and March 2008 16 patients underwent splenectomy at the Specialised General Surgery Unit at Inkosi Albert Luthuli Central Hospital. The indications were idiopathic thrombocytopenic purpura (11 patients); Hodgkin's disease (1); auto-immune haemolytic anaemia (1); systemic lupus erythematosus (1) and portal hypertension (1). The average age was 26 years and the female to male ratio was 7:1.
METHOD: Patients were placed in the supine position with a sandbag placed under the left subcostal area. Four ports were used, a 15 ml port supraumbilically; a 10 ml camera port parallel to first port in midclavicular line; a 5 ml epigastric port to left of midline and a 5 ml port in anterior axillary line parallel to supraumbilical port. The spleen is mobilised using an energy device and removed using an endopouch. All spleens were morcelated except where histology was needed.
RESULTS: The rate of conversion to an open procedure was 25%. All conversions were due to bleeding from the hilar region. Two patients required a cholecystectomy in addition to a splenectomy. One patient required a liver and lymph node biopsy in addition to a splenectomy. There were no mortalities and the only serious morbidity was portal vein thrombosis. The average hospital stay was 5 days. The average follow up time was 3.8 months. During follow up, one patient with ITP had a relapse of thrombocytopenia. All other patients were well at follow up.
CONCLUSION: Early experience with laparoscopic splenectomy is safe and encouraging despite a conversion rate of 25% largely for haemorrhage control. These conversions may be part of the learning curve as they occurred early in the experience.



A prospective audit of diagnostic laparoscopy in the diagnosis of abdominal tuberculosis



Islam J; Clarke DL; Ghimenton F; Wilson D; Thomson SR

Departments of Surgery and Internal Medicine, Edendale Hospital and University of Kwa-Zulu Natal



INTRODUCTION: HIV/AIDS has resulted in a resurgence of abdominal tuberculosis in South Africa. Confirming the diagnosis can be difficult. The role of laparoscopy in making the diagnosis is undefined. This prospective audit looks at the role of laparoscopy in establishing the diagnosis of abdominal TB.
METHOD: All patients with clinically suspected but histologically or microbiologically unconfirmed abdominal tuberculosis are jointly assessed by an infectious diseases physician and a general surgeon. If a histological diagnosis of TB cannot be made by any alternative route then the patient will be offered a formal diagnostic laparoscopy under general anaesthetic.
RESULTS: Since January 2008 24 patients with suspected abdominal tuberculosis have been referred for assessment (12 males, 12 females, mean age 34.7 (14 - 73)). Nine patients died before any procedures (2 males and 7 females, mean age 32 (14 - 39)). All 9 of them were HIV positive. Five patients required emergency laparotomy (3 for bowel obstruction and 2 for peritonitis; 4 were males and 1 female, mean age 34.2 (23 - 41); 3 patients were HIV positive and 2 were unknown and refused to test). All 5 of these patients had positive histology for TB. Ten patients went for diagnostic laparoscopy (6 males and 4 females, mean age 37.4 (23 - 73); 2 patients were HIV negative, 2 were unknown and 6 were positive). All patients underwent U/S abdomen and 9 patients had a CT abdomen. One patient was found to have appendicitis. In all others there was macroscopic evidence of chronic inflammation. Only 3 patients had positive histology for TB. Four patients had evidence of chronic inflammation on histology. The histology in the remaining 2 was normal. There were no major complications post procedure. One patient died nine days after the laparoscopy.
CONCLUSION: Laparotomy remains an effective way of definitively diagnosing TB abdomen. Our experience with laparoscopy is small. Laparoscopy is useful to diagnose alternative surgical pathologies that need treatment. Histology confirmed the presence of TB in a third of cases. The presence of chronic inflammation without evidence of TB bacilli is confusing.






Klipin MJ; Sparaco A; Omoshoro Jones J; Nagdee IA*; Smith MD

Department of Surgery and Radiology*, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg



AIM: To determine outcome in patients following percutaneous transhepatic biliary drainage (PTC) at CH Baragwanath Hospital.
METHODS: Retrospective analysis of prospectively collected data. All patients undergoing PTC at CH Baragwanath from 1 May 2006 to 30 April 2007.
RESULTS: Forty nine patients had a PTC from 1 May 2006 to 30 April 2007. Complete records were available for 39; 27 females and 12 males. Average age 57.6 years (23 - 96). The aetiology of biliary obstruction was malignancy in 22, suspected malignancy in 9, benign in 5 and indeterminate in 4. Ten had a PTC as the first biliary drainage. Twenty nine had prior attempts at endoscopic biliary drainage. Twenty-five patients died before discharge. Of these, 18 had the PTC in situ at time of death. Five had their PTC internalized, 2 endoscopically and 3 percutaneously. One patient's PTC became displaced and one patient had an open bypass. In patients who died the average duration from admission to insertion of PTC was 6 (0 - 27) days. Survival following PTC insertion was on average 13 (0 - 42) days. Average hospital stay was 20 (2 - 49) days. Fourteen patients were discharged, 3 with their PTC in situ. Eight had successful internalisation, 5 endoscopically and 3 percutaneously. Two required open bypass. A single patient with a previous hepaticojejunostomy was deemed to have adequate drainage and the PTC was removed. Duration from admission to PTC insertion was 13 (4 - 27) days. Time from PTC insertion to discharge was 17 (3 - 44) days. Average hospital stay of survivors was 37 (13 - 72) days.
CONCLUSION: Percutaneous biliary drainage has a 65% in hospital mortality. The majority of patients (75%) had failed attempts at endoscopic drainage (29 of 39). Prolonged hospitalisation is common (average 24 days). There is a need to identify factors that predict poor outcome.






Kruger FCI, II; Daniels CII; Kidd MIII; Swart GIV, V; Brundyn KIV, V; van Rensburg CI; Kotze MJIV

IDivision of Gastroenterology and Hepatology, Department of Medicine, Faculty of Health Sciences, Stellenbosch University (US)
IIDurbanville Medi-Clinic, Durbanville
IIICentre for Statistical Consultation, US

IVDepartment of Anatomical Pathology, Faculty of Health Sciences, US
VNational Health Laboratory Services, Anatomical Pathology, Tygerberg Hospital, Tygerberg



BACKGROUND: Non-alcoholic steatohepatitis (NASH), the non-benign form of non-alcoholic fatty liver disease (NAFLD), can lead to cirrhosis and even hepatocellular carcinoma. The NASH fibrosis score (NFS) has proven to be a reliable, useful, non-invasive marker for the prediction of advanced fibrosis, but a recent study showed that the addition of the ELF panel improves sensitivity. The aspartate aminotransferase-to-platelet ratio index (APRI) is a simpler calculation than NFS, but has never been studied in patients with NAFLD.
AIM: To validate APRI as a non-invasive marker of liver fibrosis in subjects with NAFLD to be used in clinical practice. Furthermore, the sensitivity and specificity of APRI will be compared to NFS and aspartate aminotransferase-to-alanine aminotransferase ratio (AST/ ALT) in an attempt to develop a reliable, user-friendly algorithm for the prediction of advanced fibrosis and thereby avoiding unnecessary liver biopsies.
SUBJECTS AND METHODS: The cohort consisted of 111 patients with a histological diagnosis of NAFLD. The biopsy samples were staged and graded according to the NASH CRN criteria. These were grouped into fatty liver disease (FLD) and NASH as well as no/mild fibrosis (grade 0, 1, 2) and advanced fibrosis (grade 3 and 4). For each group APRI, NFS, AST/ALT ratio was calculated and compared to ALT.
RESULTS: The APRI was significantly higher in the advanced fibrosis group. The area under the receiver operating characteristic (ROC) curve for APRI was 0.85 with an optimal cut-off of 0.98 giving a sensitivity of 75% and a specificity of 86%. The NFS was significantly lower in the advanced fibrosis group. The ROC for NFS gave an AUC of 0.77 and a cut-off value of -1.3 with a sensitivity of 76% and specificity of 69%. The positive predictive value for APRI was 54% as opposed to 34% for NFS. The negative predictive value was 93% for APRI and 94% for NFS.
CONCLUSION: APRI compared favourably to the NFS and was superior to AST/ALT with regard to reliability for the prediction of advanced fibrosis. It is, however, less expensive and easier to calculate than APRI. We therefore propose the use of APRI in a new algorithm for the detection of advanced fibrosis.






Naidoo M; Steer D; Clarke DL; Thomson SR

Department of General Surgery, Addington Hospital and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban



INTRODUCTION: Intussusception is uncommon in adults and is usually of a more sinister nature than in the paediatric population. This review looks at the spectrum of presentation and pathology in adult intussusception.
METHODS: We approached both the private and public sectors in both Durban and Pietermaritzburg and requested information regarding any patients they had seen with intussusception. This is both a retrospective (from 2004) and prospective (from 2006) survey.
RESULTS: Twenty-two patients with 23 intussusceptions were identified; 1 patient presented with two sites of intussusception. There were 16 males and 6 females. The average age of presentation was 53. A pre-operative diagnosis was made in 8 of the 22, CT scan diagnosed 6, and the remaining 2 were diagnosed at colonoscopy and ultrasound respectively. The rest were diagnosed intraoperatively. The lead points were adenocarcinoma (4), amoebic colitis (2), gastro-intestinal stromal tumour (2), lymphoma (1), lipoma (1), Peutz Jeghers (1), inflammatory myofibroblastic tumour (1). No lead point could be identified in 2 cases and the lead points in the remaining 6 could not be determined due to necrosis. The anatomical descriptions of the intussusceptions were jejuno-jejunal (3), ileo-ileal (10), and ileocolic (9) and colo-colic (1). Resection was performed in 20, 2 early postoperative intussusceptions with no palpable lead point being reduced intra operatively. The Peutz Jeghers patient had resection of the lead point via an enterotomy.
CONCLUSION: Adult intussusception is rare and is usually secondary to a lead point. One-third present with subacute symptoms and a CT scan is the preferred diagnostic modality. Resectional surgery is the mainstay of treatment.



Outcome analysis of pancreaticoduo-denectomies at Groote Schuur Hospital -an interim analysis



Troskie C; Bornman PC; Essel H; Krige JEJ

Department of Surgery, University of Cape Town and Groote Schuur Hospital



AIM: To review the outcome of non-trauma-related pancreaticoduodenectomies performed at Groote Schuur Hospital between 1980 and 2007, with a sub analysis of survival between 2000 and 2007.
METHODS: Retrospective analysis was performed. The pathology, postoperative complications and mortality were reviewed. A sub-analysis compared the survival and stages of patients between 2000 and 2007.
RESULTS: The male:female ratio was 135:96 with a median age of 57 years. Of the 221 patients, 159 had a pylorus-preserving pancreaticoduodenectomy and 62 a standard Whipple procedure. Pathology (n=223): adenocarcinoma n=62 (28%), ampullary tumour n=70 (31%), chronic pancreatitis n=28 (13%), cholangiocarcinoma n=18 (8%), cystic neoplasm n=14 (6%), duodenal carcinoma n=5 (2%), other n=15 (7%). The in-hospital mortality was 5.5% (n=12).The causes of death were bleeding (n=4), liver necrosis (n=1), multi-organ failure (n=6), and DVT/PE (n=1). The complications were: pancreatic fistula n=31(14%), bile leak n=20 (9%), delayed gastric emptying n=25 (11%), bleeding n=16 (7%). Re-operation was required in 7% for bleeding. Survival of 11% at 5 years were documented.
CONCLUSION: Pancreaticoduodenectomy remains a major physiological insult with significant morbidity and mortality, and an acceptable survival benefit.




(in alphabetical order according to presenting author)



CT scan in the assessment of acute pancreatitis in a regional hospital setting


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