South African Journal of Surgery最新文献

Background: Jaundice is a marker of advanced disease and poor outcomes in hepatocellular carcinoma (HCC). The aim of this study was to describe and analyse the management and outcomes of jaundiced HCC patients at a large academic referral centre in sub-Saharan Africa (SSA).

Methods: Treatment-naïve adult HCC patients who presented with jaundice between 1990 and 2023 were analysed.

Results: During the inclusion period, 676 HCC patients were treated at Groote Schuur Hospital. The mean age of the 126 (18.6%) who were jaundiced was 48.8 (± 13.2) years. Eighty-nine (70.6%) were male. Ninety-four (74.6%) patients with jaundice secondary to diffuse tumour infiltration had best supportive care (BSC) only. Thirty-two had obstructive jaundice (OJ); four were excluded because of missing hospital records. In 28 of these patients, 16 underwent biliary drainage (BD) and 12 received BSC only. The mean overall survival (OS) of the 126 patients was 100.5 (± 242.3) days. The patients with diffuse tumour infiltration had an OS of 105.9 (± 273.3) days. The patients with OJ survived 86.5 (± 135.0) days. There was no significant difference in OS between the three patient groups (p = 0.941). In the OJ group, patients who underwent BD survived longer than the BSC group (117.9 ± 166.4 vs. 29.2 ± 34.7 days, p = 0.015).

Conclusion:

Background: This study investigated the value of prognostic scores to predict 90-day, 1-, 3- and 5-year survival after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding who failed endoscopic intervention.

Methods: The Model for End-Stage Liver Disease (MELD), Model for End-Stage Liver Disease Sodium (MELDNa), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Child-Pugh (C-P) grades and scores were calculated using Kaplan-Meier curves and Cox proportional hazards models in sTIPS patients treated between August 1991 and November 2020.

Results: Thirty-four patients (29 men, 5 women), mean age 52 years, SD ± 11.6 underwent sTIPS which controlled bleeding in 32 (94%) patients. Ten (29.4%) patients died in hospital at a median of 4.8 (range 1-10) days. On bivariate analysis, C-P score ≥ 10 (p = 0.017), high C-P grade (p = 0.048), MELD ≥ 15 (p = 0.010), MELD-Na score ≥ 22 (p < 0.001) and APACHE II score ≥ 15 (p < 0.001) predicted 90-day mortality. Individual clinical characteristics associated with 90-day mortality were grade 3 ascites (p = 0.029), > 10 units of blood transfused (p = 0.004), balloon tube placement (p < 0.001), endotracheal intubation (< 0.001) and inotrope support (p < 0.001). The overall 90-day, 1-, 3- and 5-year survival rates were 67.6%, 55.9%, 26.5% and 20.6% respectively. Nine patients (26.5%) were alive at a median of two years (range 1-18 years) post-TIPS. Patients with C-P grade A, C-P score < 10, MELD score < 15, MELD-Na score < 22 and APACHE II score < 15 had significantly better 90-day, 1-, 3- and 5-year survival rates.

Conclusion: Although sTIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy, in-hospital mortality was 29% and less than one quarter were alive after five years. The selected cut-off values for the nominated scoring systems accurately predicted 90-day mortality and long-term survival.

Background: The frequency of histological chronic pancreatitis (CP) evidence in the resident pancreas of resected periampullary cancers (PACs) has never been studied in Africa. This study aims to describe the spectrum of pathology and outcomes of pancreatic surgeries and address this deficit from a South African central hospital cohort.

Methods: A retrospective audit of patients undergoing pancreatic surgery at Inkosi Albert Luthuli Central Hospital (IALCH) between 2003 and 2023 was conducted. The patient demographics, human immunodeficiency virus (HIV) status, histological subtypes, type and extent of surgery, and 30-day and overall mortality were captured from medical records. The presence of CP in the resident pancreas of patients resected for pancreatic and PAC was obtained from the pathology reports.

Results: Of the cohort, 72% were Africans, presenting at an earlier average age than other races. Surgery was performed on 126 (107 for cancer, 19 for CP) patients. Of these, 77 were pancreaticoduodenectomy (PD), of which 34 were for pancreatic ductal adenocarcinoma (PDAC). The prevalence of CP in the resident pancreas was 29.9%, and 55.9% in PDAC. Age was the only factor significantly associated with 30-day mortality, as well as long-term survival amongst patients with pancreatic and PAC. The overall median survival for patients with PAC was seven months; 11 patients are alive.

Conclusion: In a predominantly African cohort undergoing pancreatic surgery, PDAC presents at a younger age. The high perioperative mortality and low overall survival (OS) in the setting of high CP prevalence in the resident pancreas requires further investigation of its role in the aetiopathogenesis and prognosis in PDAC.

Background: Magnetic resonance imaging (MRI) is widely regarded as the gold standard for assessment of the bile ducts in patients with bile duct injuries (BDIs). This case series aims to highlight the shortcomings of this imaging modality and demonstrate how it may overestimate the injury severity.

Methods: Three patients treated at Groote Schuur Hospital and the University of Cape Town in whom MRI/magnetic resonance cholangiopancreatography (MRCP) overestimated the severity of BDI were included in the study. Demographic characteristics, clinical presentation, blood results and imaging findings are presented.

Results: All patients had an MRI/MRCP done which assessed the BDIs as major complete cut-off of the proximal common hepatic duct with substance loss. Subsequent direct cholangiography showed minor injuries and all three patients were successfully managed with endoscopic stenting.

Conclusion: Major BDIs are complex, and assessment of severity is intricate and may be overestimated. These patients are best managed in high-volume multidisciplinary team settings.

Background: Pancreaticoduodenectomy is a complex intra-abdominal operation used for the treatment of benign and malignant disease of the pancreatic head or periampullary region. Despite developments in surgical techniques, pancreaticoduodenectomy is still associated with high rate of postoperative complications. We performed this systematic review and meta-analysis to compare the surgical outcomes of isolated Roux-en-Y pancreaticojejunostomy (IRYPJ), and conventional pancreaticojejunostomy(CPJ).

Methods: We performed a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. We searched the following electronic databases - PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Clinical-Trials.gov. Published trials comparing the efficacy and safety of IRYPJ and CPJ after pancreaticoduodenectomy were evaluated. The search terms were "pancreaticoduodenectomy," "Whipple," "pylorus-preserving pancreaticoduodenectomy," "pancreaticojejunostomy," "Roux-en-Y," and "isolated Roux loop pancreaticojejunostomy." Only randomised controlled trials comparing outcome of IRYPJ and CPJ after pancreaticoduodenectomy were included. The analysed outcome measures were postoperative pancreatic fistula (POPF), clinically relevant POPF (CR-POPF), bile leak and delayed gastric emptying (DGE).

Results: The initial search yielded 342 results but only four randomised control trials fulfilled the inclusion criteria and were included for data synthesis and meta-analysis. Meta-analysis of POPF revealed that IRYPJ is associated with less POPF compared to CPJ but the difference was not statistically significant (risk ratio = 0.58, p = 0.56). A similar finding was also observed with CR-POPF (risk ratio = 0.17, p = 0.87) and DGE (risk ratio = 0.74, p = 0.46).

Conclusion: Isolated Roux-en-Y pancreaticojejunostomy is not associated with a superior outcome when compared to CPJ.

Primary liver cancer was the third most common cause of death due to cancer worldwide in 2020. As the predominant type, hepatocellular carcinoma (HCC) represents the overwhelming majority of newly diagnosed primary liver tumours. Liver transplantation remains the treatment of choice for a cure in otherwise unresectable HCC. For nearly thirty years, the Milan and Barcelona Clinic Liver Cancer (BCLC) criteria have guided physicians' clinical decision-making for selection of liver transplant candidates in the treatment of HCC. More recently, studies have demonstrated survival benefit for patients transplanted beyond Milan criteria. This remains an area of active research and includes advancements in local-regional therapies and their role in downstaging tumours to within transplant criteria as a bridge to transplant. Other advancements on the horizon include the identification of tumour biomarkers that may lead to earlier diagnosis and more accurate prediction of prognosis and risk of recurrence, as well as new neoadjuvant therapies and post-transplant immunosuppression regimens that may allow for further expansion of transplant eligibility criteria. Additionally, several recent studies have investigated the potential survival benefit of combination therapy using local-regional intervention with systemic immunotherapy to downstage otherwise unresectable disease that is beyond Milan criteria. Liver transplantation will continue to play an important role in the treatment of HCC for the foreseeable future and based on currently available evidence, both local-regional therapies and immunomodulation in combination are poised to change the landscape of liver transplantation for HCC as we currently know it.

Summary: The influence of human immunodeficiency virus (HIV) on the severity of hepatic cystic echinococcosis (CE) is uncertain. HIV-modulated immune suppression may increase the risk of contracting CE with less self-limiting disease, more rapid progression, and a higher likelihood of complications. A 30-year-old male with concurrent, untreated HIV underwent surgery for two large, complicated hepatic CE cysts, which were replacing the right hemiliver, and innumerable peritoneal daughter cysts. At operation, 30 kg of cystic material was removed from the liver and peritoneal cavity. Despite postoperative complications, including cardiac arrest, respiratory failure, and a bile leak, the patient made a full recovery.

Background: Human immunodeficiency virus (HIV) infection, low cluster of differentiation (CD)4 counts and antiretroviral therapy can cause cholestasis and raised transaminases. In acute pancreatitis, this may render biochemical predictors of a gallstone aetiology inaccurate.

Methods: In a prospective observational study, acute pancreatitis was diagnosed by standard criteria. Cholecystolithiasis and bile duct diameter were diagnosed by ultrasound. Cholestasis was defined as two of the following: bilirubin ≥ 21 umol/l, γ glutamyl transferase ≥ 78 U/l, alkaline phosphatase ≥ 121 U/l. Cholangitis was defined as cholestasis and any two sepsis criteria: (temperature > 38˚C, WCC > 12.6 ×10⁹/L, pulse > 90 beats/min). Cholangitis, cholestasis, and bile duct diameter greater that 1 cm were indications for endoscopic retrograde cholangiopancreatography (ERCP). These parameters' ability to predict gallstone pancreatitis (GSP) and choledocholithiasis were compared in HIV+ve and HIV-ve patients.

Results: Sixty-two (26%) of 216 patients had GSP. Twenty four were HIV+ve patients. More HIV+ve patients had cholestasis (p = 0.059) and ERCP (p = 0.004). In HIV+ve patients alanine aminotransferase (ALT) > 100 U/L, gamma glutamyl transferase (GGT) > 2 upper limit of normal and cholestasis had a negative predictive value of 92%, 96.7% and 95.2% respectively. In HIV-ve patients, negative predictive value (NPV) was 84%, 83.8% and 84.6% respectively. Bile duct stones were demonstrated at ERCP in 6 (25%) and 3 (8%) of HIV+ve and HIV-ve patients respectively (p = 0.077). Five of 14 ERCP patients had no bile duct stones. HIV+ve and HIV-ve groups had two deaths each.

Conclusion: Absence at presentation of the abnormal parameters analysed were good predictors of a non-gallstone aetiology particularly in HIV+ve patients. Prior, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) would reduce the number of non-therapeutic ERCPs.