RÉSUMÉ
BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic gallstone disease. The procedure has a steep learning curve and may result in significant postoperative morbidity and mortality. LC carries a morbidity of 1.6-5.3%, a mortality of 0.05-0.14% and readmission rates of 3.3% (0-11.7%). We aimed to evaluate the 30-day outcomes of LC across four metropole hospitals in the Western Cape (WC) including mortality, length of stay, readmissions and complications according to the Clavien-Dindo classification system. METHODS: A retrospective review of a prospective database was performed. Data were collected between September 2019 and July 2022. Relative clinical, operative findings and postoperative outcomes were analysed. RESULTS: There were 1 000 consecutive LCs included in this study. The mean postoperative length of stay was 1.92 days. Forty surgical complications were noted of which the most common were a bile leak (n = 14) and intra-abdominal collections (n = 11). Seven patients with bile leaks required reintervention. Four (0.4%) bile duct injuries (BDI) were reported in our series. Twenty-five percent of postoperative complications were graded as Clavien-Dindo IIIa and 28% were graded as Clavien-Dindo IIIb. The 30-day readmission rate was 3.8% (n = 38). Thirty-five patients were readmitted with surgical complications. There were three reported deaths (0.3%). CONCLUSION: Laparoscopic cholecystectomy is considered the standard of treatment for gallstone disease but a small percentage may have serious complications. The outcomes reported in this series are similar to that of other reported studies.
Sujet(s)
Cholécystectomie laparoscopique , Calculs biliaires , Hôpitaux publics , Durée du séjour , Réadmission du patient , Complications postopératoires , Humains , Cholécystectomie laparoscopique/effets indésirables , Cholécystectomie laparoscopique/méthodes , Mâle , Femelle , République d'Afrique du Sud , Études rétrospectives , Adulte d'âge moyen , Complications postopératoires/épidémiologie , Adulte , Durée du séjour/statistiques et données numériques , Réadmission du patient/statistiques et données numériques , Calculs biliaires/chirurgie , Sujet âgé , Résultat thérapeutique , Sujet âgé de 80 ans ou plusRÉSUMÉ
BACKGROUND: The value of the textbook outcome in pancreatic surgery (TOPS) score, a composite measure of surgical performance for quality assurance, was evaluated in a South African tertiary hospital cohort of pancreaticoduodenectomies (PD) performed for adenocarcinoma of the ampulla of Vater (AAV). METHODS: A review of all patients undergoing a PD for AAV at a single centre between January 1999 and December 2023 was performed. Demographic, operative, pathological and postoperative variables were recorded. Ten clinical and histological variables were used to construct a TOPS score. These included an R0 resection, no postoperative pancreatic fistula (POPF), no bile leak, no post-pancreatectomy haemorrhage, no delayed gastric emptying, no major postoperative complications (< Gr 3 Clavien-Dindo), no readmission to ICU, length of stay ≤ 10 days, no 30-day readmission or intervention and no 30-day mortality. A textbook outcome (TO) was defined as the fulfilment of all 10 variables. In patients in whom TO was not achieved, the reasons for failure were identified. In addition, the number of patients who had major complications and died were categorised as failure to rescue (FTR). RESULTS: A positive TOPS score was achieved in 27 of 79 (34.2%) patients undergoing a PD. Overall five-year survival after PD was 33.9%. TOPS conferred a significant 1-year survival benefit, 88.9% vs 66.7% (OR 4.12, 95% CI 1.08-15.67, p = 0.038). There was no significant difference in 5-year survival between TOPS and non-TOPS patients, 40.0% vs 32.4% (OR 1.39, 95% CI 0.48-3.99, p = 0.54). A POPF occurred in 31.6% patients, resulting in a significantly longer hospital admission, 17 vs 10 days (95% CI 2.66-11.34, p = 0.0019). Twenty-one (26.6%) patients developed a major complication, five of whom died (FTR = 6.3%). CONCLUSION: This study confirmed the value of TOPS as a useful measurement to assess hospital quality metrics and short-term survival after PD for AAV. One quarter of patients developed a major complication with a 6.3% FTR.
Sujet(s)
Adénocarcinome , Ampoule hépatopancréatique , Tumeurs du cholédoque , Duodénopancréatectomie , Humains , Ampoule hépatopancréatique/chirurgie , Mâle , Femelle , Tumeurs du cholédoque/chirurgie , Tumeurs du cholédoque/mortalité , Tumeurs du cholédoque/anatomopathologie , Adulte d'âge moyen , Adénocarcinome/chirurgie , Adénocarcinome/mortalité , Adénocarcinome/anatomopathologie , Sujet âgé , Études rétrospectives , Pronostic , Complications postopératoires , République d'Afrique du Sud , Adulte , Résultat thérapeutiqueRÉSUMÉ
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.
Sujet(s)
Varices oesophagiennes et gastriques , Hémorragie gastro-intestinale , Anastomose portosystémique intrahépatique par voie transjugulaire , Humains , Mâle , Femelle , Adulte d'âge moyen , Hémorragie gastro-intestinale/chirurgie , Hémorragie gastro-intestinale/mortalité , Hémorragie gastro-intestinale/étiologie , Varices oesophagiennes et gastriques/chirurgie , Varices oesophagiennes et gastriques/mortalité , Varices oesophagiennes et gastriques/complications , Pronostic , Anastomose portosystémique intrahépatique par voie transjugulaire/méthodes , Thérapie de rattrapage/méthodes , Études rétrospectives , Adulte , Taux de survie , Indice de gravité de la maladie , Indice APACHERÉSUMÉ
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.
Sujet(s)
Cholangiopancréatographie par résonance magnétique , Humains , Mâle , Adulte , Femelle , Conduits biliaires/traumatismes , Conduits biliaires/imagerie diagnostique , Adulte d'âge moyenRÉSUMÉ
BACKGROUND: Endoscopic therapy is the first-line treatment of choice for control of acute variceal bleeding (AVB). In high-risk patients with persistent AVB despite pharmacological treatment and endoscopic intervention, percutaneous transjugular intrahepatic portosystemic shunting (TIPS) provides a minimally invasive salvage method to reduce portal pressure and control bleeding. OBJECTIVES: To evaluate factors influencing in-hospital mortality after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding despite medical treatment and endoscopic intervention. METHODS: Clinical and laboratory data were analysed in all patients treated with sTIPS following failed endoscopic therapy for AVB between August 1991 and November 2020. Factors associated with and predictors of death were determined using bivariate analysis and univariate logistic regression analysis. RESULTS: Thirty-four patients (29 men, 5 women), mean age 52 years (range 31 - 80), received sTIPS for uncontrolled (n=11) or refractory (n=23) AVB. The causes of portal hypertension were alcohol-related (n=24) and non-alcohol-related cirrhosis. Salvage TIPS controlled bleeding in 32 patients, with recurrence in 1. Ten patients died in hospital (mean 4.8 days, range 1 - 10) of liver failure (n=4), multiorgan failure (n=3), alcoholic cardiomyopathy (n=2) and uncontrolled gastric variceal bleeding (n=1). On bivariate analysis, factors associated with death were Child-Pugh (C-P) score ≥10 (p=0.006), sodium Model for End-stage Liver Disease (MELD-Na) score ≥22 (p<0.001), ≥8 units of blood transfused (p<0.001), Sengstaken-Blakemore balloon tube placement (p<0.001), endotracheal intubation (p<0.001), inotropic support (p<0.001) and endoscopically uncontrolled bleeding (p<0.001). Univariate logistic regression analysis showed that the most significant predictors of mortality were inotrope dependency (odds ratio (OR) 134; p<0.001), endotracheal intubation (OR 99; p<0.001), endoscopically uncontrolled bleeding (OR 28; p=0.001), grade 3 ascites (OR 20.9; p=0.012) and C-P grade C (OR 8.8; p=0.011). CONCLUSION: Salvage TIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy with 29% in-hospital mortality. The most significant predictors of mortality were C-P grade C, grade 3 ascites, inotrope requirement, endotracheal intubation and endoscopically uncontrolled bleeding.
Sujet(s)
Maladie du foie en phase terminale , Varices oesophagiennes et gastriques , Anastomose portosystémique intrahépatique par voie transjugulaire , Mâle , Humains , Femelle , Adulte , Adulte d'âge moyen , Sujet âgé , Sujet âgé de 80 ans ou plus , Varices oesophagiennes et gastriques/chirurgie , Varices oesophagiennes et gastriques/complications , Hémorragie gastro-intestinale/étiologie , Hémorragie gastro-intestinale/chirurgie , Ascites/complications , Ascites/chirurgie , Mortalité hospitalière , Maladie du foie en phase terminale/étiologie , Anastomose portosystémique intrahépatique par voie transjugulaire/effets indésirables , Indice de gravité de la maladie , République d'Afrique du Sud , Cirrhose du foie/complications , Résultat thérapeutiqueRÉSUMÉ
BACKGROUND: The Hernia Interest Group (HIG) of South Africa (SA), following the publication of their inguinal and ventral hernia guidelines (in 2015 and 2016 respectively), developed a hernia registry, the HIG(SA) hernia registry. METHODS: A retrospective analysis of the prospectively maintained HIG(SA) hernia registry from 1 February 2019 to 29 February 2020. Compliance to six recommendations made in the HIG(SA) ventral hernia guidelines were assessed in both the public and private healthcare systems. RESULTS: Three hundred and fifty-three ventral hernia repair cases were included in the study. Fifty-four per cent were private and 46% were public sector cases. Laparoscopic repair for patients with a BMI > 35 kg/m2 occurred in 38% of eligible cases and a minimum 5 cm of mesh overlap was achieved in 50% of cases. Overall, 80% of elective cases occurred in non-smokers; 97% of the intraperitoneal on-lay mesh (IPOM) repairs used composite mesh; 96% of ventral hernias with defects of larger than 2 cm and 95% of incisional hernias were repaired with mesh. Non-smokers undergoing repair numbered 72% in public and 85% in private practice, p = 0.01. CONCLUSION: Ventral hernia repair practices in SA facilities overall had good compliance to four out of the six HIG(SA) ventral hernia guidelines highlighted for the purposes of this study. The two guidelines that had poor compliance overall were 'laparoscopic repair for patients with a BMI of > 35 kg/m2' and 'ensuring a mesh overlap of 5 cm'. The public sector had higher rates of current smokers undergoing elective ventral hernia repair.
Sujet(s)
Hernie ventrale , Laparoscopie , Hernie ventrale/chirurgie , Herniorraphie , Humains , Opinion publique , Récidive , Enregistrements , Études rétrospectives , République d'Afrique du Sud , Filet chirurgicalRÉSUMÉ
PURPOSE: The purpose of this paper was to introduce a new registry in a developing country by describing the demographics, management and 30-day outcomes of patients undergoing ventral hernia repair in the public and private healthcare sectors of South Africa. METHODS: This study was a retrospective review of a prospectively maintained hernia registry from the 1st of February 2019 to 29th of February 2020. RESULTS: 353 ventral hernia repair cases were recorded of which 47% were incisional hernias and the remainder were primary hernias. The median age was 54 years with even distribution of males and females. Half of the patients were obese with a median BMI of 31 kg/m2. The private sector performed 190 cases (54%) and the public sector 163 cases (46%). The public sector had more current smokers undergoing elective repairs, 28% vs 15%, p = 0.01 and performed more emergency repair cases, 21% vs 8%, p < 0.01. The majority (89%) of hernias were repaired with mesh and one-third were repaired laparoscopically. 30 day follow up was obtained in 30% of cases, the private sector had better follow up rates (42% vs 14%). CONCLUSION: Participation in the HIG (SA) registry was low with poor follow up over the first year. Ongoing prospective data capture on the HIG (SA) hernia registry will continue to provide further insights into hernia repair practices in South Africa.
Sujet(s)
Hernie ventrale , Laparoscopie , Femelle , Secteur des soins de santé , Hernie ventrale/épidémiologie , Hernie ventrale/chirurgie , Herniorraphie , Humains , Mâle , Adulte d'âge moyen , Complications postopératoires , Études prospectives , Récidive , Enregistrements , Études rétrospectives , République d'Afrique du Sud/épidémiologie , Filet chirurgicalRÉSUMÉ
BACKGROUND: Hospital-acquired infections (HAIs) are a major cause of morbidity and mortality. Surgical site infection (SSI) rates are reported to range from 2.5% to 41%. HAI increases the risk of death by 2 - 11%, and three-quarters of these deaths are directly attributable to SSIs. OBJECTIVES: To determine the incidence of HAI and to identify risk factors amenable to modification with a resultant reduction in infection rates. METHODS: An analysis of HAIs was performed between January and April 2018 in the trauma centre surgical wards at Groote Schuur Hospital, Cape Town, South Africa. RESULTS: There were 769 admissions during the study period. Twenty-two patients (0.03%) developed an HAI. The majority were men, and the mean age was 32 years (range 18 - 57). The mean length of hospital stay (LoS) was 9 days, higher than the mean LoS for the hospital of 6 days. Fourteen patients underwent emergency surgery, 3 patients underwent abbreviated damage control surgery, and 9 patients were admitted to the critical care unit. Most patients with nosocomial sepsis were treated with appropriate culture-based antibiotics (82%). Four patients were treated with amoxicillin/clavulanic acid presumptively prior to culture and sensitivity results, after which antibiotic therapy was tailored. All but 1 patient received antibiotics. CONCLUSIONS: A combination of measures is required to prevent trauma-related infections. By determining the incidence of nosocomial infections in our trauma patients, uniform policies to reduce infection rates further could be determined. Our low incidence of infection may be explained by established preventive care bundles already in place.
Sujet(s)
Antibactériens/administration et posologie , Infection croisée/épidémiologie , Sepsie/épidémiologie , Infection de plaie opératoire/épidémiologie , Adolescent , Adulte , Infection croisée/prévention et contrôle , Femelle , Humains , Incidence , Durée du séjour , Mâle , Adulte d'âge moyen , Études prospectives , Facteurs de risque , Sepsie/traitement médicamenteux , République d'Afrique du Sud/épidémiologie , Centres de traumatologie , Services de santé en milieu urbain , Jeune adulteRÉSUMÉ
BACKGROUND: Various inguinal hernia repair techniques exist, without one 'single best' option. Hernia society guidelines recommend laparoscopic repair as one of its mainstays, provided surgeons are adequately trained. The current practice for hernia repair in South Africa as well as the surgical registrar exposure to laparoscopic repair training is unknown. OBJECTIVES: To quantify the current practice of inguinal hernia surgery in hospitals affiliated to the University of Cape Town (UCT) and to assess trainee exposure to laparoscopic repair. METHODS: Adult patients who underwent inguinal hernia repair during the 12-month study period, at the four UCT affiliated hospitals were included. Collected data parameters included age, gender, primary or recurrent, uni- or bilateral hernia, primary surgeon consultant or non-consultant, operative time, and open or laparoscopic technique used. RESULTS: Three hundred and seventy-seven patients were included. Eighty-eight (23.2%) repairs were performed laparoscopically, of which five (5.7%) were converted to open. Non-consultants were present at 70/88 (79.5%) cases performed laparoscopically and were the primary surgeon at only 15 (17%). Laparoscopic repair was performed for 63.6% of bilateral versus 19.5% of unilateral hernias, 39.4% of recurrent hernias and 45% of hernias in females. Two of the four hospitals in this study performed 81.8% of all laparoscopic repairs. CONCLUSIONS: Inguinal hernias in our setting are predominantly repaired by open surgery. The likelihood of laparoscopic repair varies significantly depending on which hospital the patient is referred to. Non-consultants have limited exposure to performing laparoscopic hernia repairs as the primary surgeon.
Sujet(s)
Hernie inguinale , Laparoscopie , Adulte , Femelle , Hernie inguinale/chirurgie , Herniorraphie , Hôpitaux , Humains , Études rétrospectivesRÉSUMÉ
BACKGROUND: Combined multimodal treatment (CMT) is the preferred treatment for anal squamous carcinoma with radical surgery reserved for treatment failure. Some patients require a defunctioning stoma prior to CMT. Successful closure of such a stoma is unlikely. Abdominoperineal excision (APE) may be suitable as primary treatment in these patients. METHOD: A retrospective review of all patients with anal squamous carcinoma was undertaken. Patients who required defunctioning colostomies prior to CMT were analysed for potential resectability of tumour prior to CMT and rate of permanent stoma. OBJECTIVE: To evaluate organ preservation in the treatment of anal squamous cancer and the closure rate of pre-treatment, temporary diverting colostomy, thereby assessing whether APE could be offered as primary treatment in those requiring a pre-treatment colostomy. RESULTS: One hundred and twenty-five patients were included of which 58 were males. The mean age was 56 years. 107 were treated with curative intent. Six received primary APE and 12 salvage APE. Thirty (22 males) required pretreatment diverting colostomies. Three (10%) stomas were successfully reversed. Forty-eight (38%) of the 125 completed treatment with a permanent colostomy. Six patients who needed a stoma prior to CMT were deemed resectable. CONCLUSION: Organ preservation was not possible in about a third of patients. Defunctioning stomas prior to CMT were likely to be permanent. We propose that APE could be considered as an alternative in selective cases where the tumour is resectable with low morbidity and a stoma is indicated.
Sujet(s)
Tumeurs de l'anus/chirurgie , Carcinome épidermoïde/chirurgie , Colostomie/méthodes , Traitements préservant les organes , Proctectomie/méthodes , Adulte , Facteurs âges , Sujet âgé , Anastomose chirurgicale , Tumeurs de l'anus/mortalité , Tumeurs de l'anus/anatomopathologie , Carcinome épidermoïde/mortalité , Carcinome épidermoïde/anatomopathologie , Études de cohortes , Association thérapeutique/méthodes , Pays en voie de développement , Femelle , Études de suivi , Humains , Mâle , Adulte d'âge moyen , Qualité de vie , Études rétrospectives , Appréciation des risques , Facteurs sexuels , République d'Afrique du Sud , Centres de soins tertiaires , Résultat thérapeutiqueRÉSUMÉ
BACKGROUND: Biliary mucinous cystic neoplasms (BMCNs) are uncommon neoplastic septated intrahepatic cysts which are often incorrectly diagnosed and have the potential for malignant transformation. OBJECTIVE: To assess the outcome of surgical resection of BMCNs. METHOD: A prospective liver surgery database was used to identify patients who underwent surgery at Groote Schuur Hospital Complex for BMCN from 1999 to 2015. Demographic variables including age and gender were documented as well as detailed preoperative imaging, location and size, operative treatment, extent of resection, histology, postoperative complications and outcome. RESULTS: Thirteen female patients (median age 45 years) had surgery. Eleven were diagnosed by imaging for symptoms. Two were jaundiced. One cyst was found during an elective cholecystectomy. Five cysts were located centrally in the liver. Before referral three cysts were treated with percutaneous drainage and two were treated with operative deroofing. Six patients had anatomical liver resections and seven patients had non anatomical liver resections of which two needed ablation of residual cyst wall. One patient needed a biliary-enteric reconstruction to treat a fistula. Median operative time was 183 minutes (range: 130-375). No invasive carcinoma was found. There was no operative mortality. One surgical site infection and one intra-abdominal collection were treated. Two patients developed recurrent BMCN after 24 months. CONCLUSION: BMCNs should be considered in middle aged women who have well encapsulated multilocular liver cysts. Treatment of large central BMCNs adjacent to vascular and biliary structures may require technically complex liver resections and are best managed in a specialised hepato-pancreatico-biliary unit.
Sujet(s)
Cystadénocarcinome mucineux/anatomopathologie , Cystadénocarcinome mucineux/chirurgie , Hépatectomie/méthodes , Tumeurs du foie/anatomopathologie , Tumeurs du foie/chirurgie , Adulte , Sujet âgé , Ponction-biopsie à l'aiguille , Études de cohortes , Cystadénocarcinome mucineux/imagerie diagnostique , Cystadénocarcinome mucineux/mortalité , Bases de données factuelles , Pays en voie de développement , Femelle , Humains , Immunohistochimie , Tumeurs du foie/imagerie diagnostique , Adulte d'âge moyen , Invasion tumorale/anatomopathologie , Stadification tumorale , Pronostic , Études prospectives , Enregistrements , Appréciation des risques , Études par échantillonnage , République d'Afrique du Sud , Taux de survie , Tomodensitométrie/méthodes , Résultat thérapeutiqueRÉSUMÉ
BACKGROUND: The aim of this study was to determine the safety and clinical effectiveness of 10Fr plastic biliary stents compared to uncovered self-expanding metal stents (SEMS) for palliative treatment of patients with inoperable extra-hepatic malignant biliary obstruction in a public hospital in South Africa. METHOD: From January 2009 to December 2013, 40 patients who were admitted to a tertiary academic centre because of distal malignant biliary obstruction were enrolled in a prospective randomized study. Patients were randomly assigned to receive an uncovered SEMS or a plastic stent deployed through the biliary stricture during endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Patient survival time in the two groups did not differ significantly (median: SEMS - 114 days; plastic - 107 days). Stent failure was more common in the plastic stent group (7/19 vs. 1/21). The results became significant after 6 months of follow-up. There was no significant difference between the two groups in the incidence of serious adverse events. CONCLUSION: SEMS had a longer duration of patency than plastic stents, which recommends their use in the palliative treatment of patients with biliary obstruction due to distal malignant biliary obstruction.
Sujet(s)
Tumeurs des canaux biliaires/anatomopathologie , Cholestase/thérapie , Ictère rétentionnel/thérapie , Soins palliatifs , Tumeurs du pancréas/anatomopathologie , Endoprothèses métalliques auto-expansibles , Sujet âgé , Sujet âgé de 80 ans ou plus , Tumeurs des canaux biliaires/mortalité , Cholangiopancréatographie rétrograde endoscopique , Cholestase/étiologie , Cholestase/mortalité , Femelle , Humains , Ictère rétentionnel/étiologie , Ictère rétentionnel/mortalité , Mâle , Adulte d'âge moyen , Tumeurs du pancréas/mortalité , Matières plastiques , Études prospectives , Conception de prothèse , Défaillance de prothèse , Taux de survieRÉSUMÉ
Background: The aim of this study was to determine the safety and clinical effectiveness of 10Fr plastic biliary stents compared to uncovered self-expanding metal stents (SEMS) for palliative treatment of patients with inoperable extra-hepatic malignant biliary obstruction in a public hospital in South Africa.Methods: From January 2009 to December 2013, 40 patients who were admitted to a tertiary academic centre because of distal malignant biliary obstruction were enrolled in a prospective randomized study. Patients were randomly assigned to receive an uncovered SEMS or a plastic stent deployed through the biliary stricture during endoscopic retrograde cholangiopancreatography (ERCP).Results: Patient survival time in the two groups did not differ significantly (median: SEMS 114 days; plastic 107 days). Stent failure was more common in the plastic stent group (7/19 vs. 1/21). The results became significant after 6 months of follow-up. There was no significant difference between the two groups in the incidence of serious adverse events.Conclusions: SEMS had a longer duration of patency than plastic stents, which recommends their use in the palliative treatment of patients with biliary obstruction due to distal malignant biliary obstruction
Sujet(s)
Cirrhose biliaire , Patients , République d'Afrique du SudRÉSUMÉ
Background: Biliary mucinous cystic neoplasms (BMCNs) are uncommon neoplastic septated intrahepatic cysts which are often incorrectly diagnosed and have the potential for malignant transformation.Objectives:To assess the outcome of surgical resection of BMCNs.Methods:A prospective liver surgery database was used to identify patients who underwent surgery at Groote Schuur Hospital Complex for BMCN from 1999 to 2015. Demographic variables including age and gender were documented as well as detailed preoperative imaging, location and size, operative treatment, extent of resection, histology, postoperative complications and outcome.Results:Thirteen female patients (median age 45 years) had surgery. Eleven were diagnosed by imaging for symptoms. Two were jaundiced. One cyst was found during an elective cholecystectomy. Five cysts were located centrally in the liver. Before referral three cysts were treated with percutaneous drainage and two were treated with operative deroofing. Six patients had anatomical liver resections and seven patients had non anatomical liver resections of which two needed ablation of residual cyst wall. One patient needed a biliary-enteric reconstruction to treat a fistula. Median operative time was 183 minutes (range: 130375). No invasive carcinoma was found. There was no operative mortality. One surgical site infection and one intra-abdominal collection were treated. Two patients developed recurrent BMCN after 24 months.Conclusion:BMCNs should be considered in middle aged women who have well encapsulated multilocular liver cysts. Treatment of large central BMCNs adjacent to vascular and biliary structures may require technically complex liver resections and are best managed in a specialised hepato-pancreatico-biliary unit
Sujet(s)
Tumeurs kystiques, mucineuses et séreuses , Patients , République d'Afrique du Sud , FemmesRÉSUMÉ
Background: Combined multimodal treatment (CMT) is the preferred treatment for anal squamous carcinoma with radical surgery reserved for treatment failure. Some patients require a defunctioning stoma prior to CMT. Successful closure of such a stoma is unlikely. Abdominoperineal excision (APE) may be suitable as primary treatment in these patients.Objectives: To evaluate organ preservation in the treatment of anal squamous cancer and the closure rate of pre-treatment, temporary diverting colostomy, thereby assessing whether APE could be offered as primary treatment in those requiring a pre-treatment colostomy.Methods: A retrospective review of all patients with anal squamous carcinoma was undertaken. Patients who required defunctioning colostomies prior to CMT were analysed for potential resectability of tumour prior to CMT and rate of permanent stoma.Results: One hundred and twenty-five patients were included of which 58 were males. The mean age was 56 years. 107 were treated with curative intent. Six received primary APE and 12 salvage APE. Thirty (22 males) required pre-treatment diverting colostomies. Three (10%) stomas were successfully reversed. Forty-eight (38%) of the 125 completed treatment with a permanent colostomy. Six patients who needed a stoma prior to CMT were deemed resectable.Conclusion: Organ preservation was not possible in about a third of patients. Defunctioning stomas prior to CMT were likely to be permanent. We propose that APE could be considered as an alternative in selective cases where the tumour is resectable with low morbidity and a stoma is indicated
Sujet(s)
Association thérapeutique , Patients , Proctectomie , République d'Afrique du Sud , Stomies chirurgicalesRÉSUMÉ
BACKGROUND: The need for an acute care and general surgical unit (ACGSU) to provide care for patients previously managed on an ad hoc basis by subspecialist units was recognised by the provincial government of the Western Cape Province, South Africa, the management of Groote Schuur Hospital (GSH) and the Department of Surgery. OBJECTIVE: To describe the resulting ACGSU and its functioning. METHODS: Data available from administrative records, patient files and operating room forms were collected in spreadsheet form for the period July 2013 - November 2016 inclusive. RESULTS: The ACGSU comprised a medical care team of four consultants and four to five trainees. A total of 7 571 patients were seen during the study period, the majority (66.1%) referred from the GSH Emergency Centre. Skin and soft-tissue infections formed the major disease complex. A total of 3 144 operative records were available. The most common procedures were wound debridement and inguinal hernia repairs. Trainees acted as primary surgeon in most cases. Complications (Clavien-Dindo grades I - V) were noted in 25.0% of patients. CONCLUSIONS: The ACGSU provides patient management that would otherwise complicate care in the subspecialist surgical units. It serves as a training ground for registrars and stands as a model for other institutions. Further research into the effect on patient care is planned.
Sujet(s)
Prestations des soins de santé , Interventions chirurgicales non urgentes/statistiques et données numériques , Service hospitalier d'urgences/statistiques et données numériques , Procédures de chirurgie opératoire , Prestations des soins de santé/méthodes , Prestations des soins de santé/organisation et administration , Prestations des soins de santé/statistiques et données numériques , Femelle , Humains , Mâle , Adulte d'âge moyen , Études rétrospectives , République d'Afrique du Sud/épidémiologie , Département hospitalier de chirurgie/statistiques et données numériques , Procédures de chirurgie opératoire/effets indésirables , Procédures de chirurgie opératoire/classification , Procédures de chirurgie opératoire/mortalité , Centres de soins tertiaires/statistiques et données numériquesRÉSUMÉ
A 72-year-old woman presented with a slow growing mass on the left side of the abdomen, which was found to originate from the mesentery of the descending colon. Histopathology revealed a seromucinous cystadenocarcinoma of the mesentery, a rare clinical entity occurring most often in females. There are only 20 cases reported in the literature. It is postulated that these tumours develop as a result of serous or mucinous metaplasia of pre-existing coelomic mesothelium. Surgical excision remains the mainstay of successful management.
RÉSUMÉ
BACKGROUND: Bleeding after a major pancreatic resection, although uncommon, has serious implications and substantial mortality rates. AIM: To analyse our experience with severe post-pancreatoduodenectomy haemorrhage (PPH) over the last 7 years to establish the incidence, causes, intervention required and outcome. METHOD: All patients who underwent a pancreatoduodenectomy (PD) between January 2008 and December 2015 were identified from a prospectively maintained database. Data analysed included demographic information, operative details, anastomotic technique, histology, postoperative complications including pancreatic fistula and PPH, length of hospital stay, need for blood products and special investigations. Pancreatic fistula was classified according to the International Study Group of Pancreatic Surgery (ISGPS) classification. A modified ISGPS classification was used for PPH. RESULTS: One hundred and eighteen patients underwent PD during the study period of whom 6 (5.0%) died perioperatively. Twenty patients (16.9%) developed a pancreatic fistula and 11 patients (9.3%) had a severe PPH of whom one (9.1%) died. No patients had a severe bleed during the first 24 hours postoperatively. Four patients bled within the first 5 days and the remaining 7 after five days. Six patients bled from the gastroduodenal artery and were all preceded by a pancreatic fistula. Three of the 7 patients who bled late presented with extraluminal bleeding, 3 presented with intraluminal bleeding and 1 with a combination of both. Patients presenting in the first 5 days were all successfully managed either endoscopically or surgically. Five patients who presented beyond 5 days postoperatively were managed primarily with interventional angiography, either with coiling or deployment of a covered stent. Three patients who had radiological intervention developed a liver abscess or necrosis. CONCLUSION: Severe PPH is associated with substantial morbidity. Clinical factors including the onset of the bleeding, presentation with either extra and/or intraluminal haemorrhage, and the presence of a pancreatic fistula give an indication of the likely aetiology of the bleeding. A management algorithm based on these factors is presented.