Changing Therapy for Gastrinoma

Objective: The author analyzed potential survival determinants in gastrinoma to characterize a possible uniform staging system and to determine whether complete surgical resection improves expected survival

A 10-Year Prospective Evaluation of Balloon Tube Tamponade and Emergency Injection Sclerotherapy for Actively Bleeding Oesophageal Varices

During a 10 year study period 234 patients were admitted on 371 occasions with a total of 566 acute variceal bleeding episodes. Of these, 173 patients had 343 variceal bleeds which required balloon tamponade to achieve initial control of bleeding during 229 admissions and were then referred for emergency injection sclerotherapy. Sixty-eight percent of these patients had alcoholic cirrhosis and 42% were poor risk Grade C patients. Injection sclerotherapy was performed initially using the rigid Negus oesophagoscope under general anaesthesia and later using the fibreoptic endoscope under light sedation. Definitive control of variceal bleeding was achieved with sclerotherapy during 197 hospital admissions (92%). Of the 17 failures of emergency sclerotherapy, 4 patients died from uncontrolled bleeding and 13 patients underwent major surgical intervention. Definitive control of variceal bleeding was achieved with a single injection treatment in 138 hospital admissions (70%). Complications were mostly of a minor nature and occurred at a rate of 6% per injection treatment. The overall hospital admission mortality was 36%. The majority of patients died due to liver failure. The mortality in patients who required 4 injection treatments to control variceal bleeding was 71%. Injection sclerotherapy is proposed as the emergency treatment of choice for patients whose variceal bleeding continues or recurs after initial conservative management. Patients whose variceal bleeding is not controlled by 2 injection treatments require more major emergency surgery

Long-Term Management After Variceal Bleed — The Current Role of Sclerotherapy

While injection sclerotherapy has been accepted as the treatment of choice for acute variceal bleeding, its role as a definitive long-term treatment modality has not yet been clearly defined. This paper will critically analyse the current status of this technique, now widely used, and a comparison will be made with conventional medical management. The review will be based on the 10 years' Cape Town experience and the published series on this subject. A long-term management strategy will also be discussed

Pancreatic pseudocysts

Improvements in imaging studies and a better understanding of the natural history of pancreatic fluid collections (PFCs) have allowed the different types to be clarified. Stratification of PFCs into subgroups should help in selecting from the increasing current available treatment options, which include percutaneous, endoscopic and surgical drainage. Percutaneous catheter drainage is safe and effective and should be the treatment of choice in poor-risk patients, and for infected pseudocysts related to acute pancreatitis. Endoscopic drainage should be the first management option in suitable pseudocysts related to chronic pancreatitis, if the necessary expertise is available. The high success rate and current low morbidity of elective open surgery mean that it is still the standard of management in this disease. Laparoscopic approaches are gaining favour, predominantly in drainage of collections in the lesser sac, and long-term data are awaited. The precise application of this modality will need to be critically compared with the low morbidity of mini-laparotomy, which is the current standard after non-operative treatment fails in these patients. It is essential to clearly stratify the different types of pancreatic pseudocysts, in particular with relation to acute or chronic pancreatitis, and perform a valid comparison of the different treatment modalities within groups. In this capacity a precise and transparent classification may provide valuable answers, in particular relating to optimal management according to pseudocyst type

Surgical resection for hepatocellular carcinoma in Cape Town - A clinical and histopathological study

Objective. Review of surgical resections performed for hepatocellular carcinoma (BCC) at our institution between 1990 and 1996, histology of resected specimens, and clinical outcome. Design, Retrospective and prospective study of 14 patients who underwent resection for HCC.Setting. The Hepatobiliary Unit and Liver Clinic, Groote Schuur Hospital, Cape Town.Patients. Fourteen patients who underwent liver resections for HCC.Interventions. Hepatic resections using prolonged vascular inflow occlusion.Outcome measures. Clinical outcome and disease-free survival following resection.Results. Fourteen patients (5.6% of the total number presenting with HCC) underwent liver resection for HCC at our institution between 1990 and 1996. There were 7 men, median age 40 years (range 18 - 74 years). Only 2 patients were black, and only 1 of these patients had evidence of hepatitis B virus (HBY) infection in the liver. Extensive liver resections were often required. The mean (SD) ischaemic time was 81 (26) minutes and mean estimated blood loss was 938 (649) ml. During hospital admission, 1 patient developed a minor bile leak that settled spontaneously, and 1 patient suffered a stroke and died. The mean hospital stay following operation was 12 days (range 7 - 21 days). Disease-free patient survival at 1, 2 and 3 years was 85%, 75%, and 62%, respectively. Histopathology of the resected specimens showed that 10 of 14 tumours had arisen in non-cirrhotic livers. Mean tumour size was 10.6 (4.6) cm. Only 1 specimen showed the fibrolamellar variant of HCC.Conclusions. Only a small proportion of patients with HCC seen at Groote Schuur Hospital were eligible for resection, and only a minority of these had HBV-associated 'African' HCC. The results of hepatic resection at our institution compare favourably with literature reports, despite the relatively large size of the tumours. It is of interest that most tumours arose in non-cirrhotic livers. There was no evidence of proliferation of 'oval-like' cells in non-neoplastic liver tissue

Diagnostic Pitfalls and Therapeutic Strategies in the Treatment of Pancreatic Duct Haemorrhage

Haemorrhage via the pancreatic duct, a rare cause of upper gastrointestinal bleeding (GIB), often poses a diagnostic dilemma. We analysed our experience with 10 patients (8 men, 2 women; mean age 44 years, range 34 – 62) treated during a 12 year period. All had a history of alcohol abuse and presented with major upper GIB requiring a median of 8 units (range 2 – 40) blood, transfusion. Nine had upper abdominal pain at the time of admission and nine had a history of pancreatitis. Upper gastroduodenal endoscopy (median 4; range 1 – 9), was diagnostic in only one. Side-viewing endoscopy showed bleeding from the pancreatic duct in 7 of 8 patients. Visceral aneurysms were demonstrated in 7 of 9 patients in whom coeliac angiography was carried out: (splenic artery 4, gastroduodenal artery 2, and pancreaticoduodenal artery 1). Two of 4 selective embolisations were successful. Six patients underwent distal pancreatectomy, 1 had gastroduodenal artery ligation and 1 died of coagulopathy following a total pancreatectomy. Pancreatic duct haemorrhage should be considered in patients with unexplained recurrent upper GIB, alcohol abuse and epigastric pain, particularly in those with established chronic pancreatitis. Selective angiography is essential for diagnosis and management. For bleeding sites in the head of the pancreas, embolisation should be attempted to avoid major resection. Distal pancreatectomy is preferred for splenic artery lesions

Primary hydatid cysts of the pancreas

Pancreatic involvement by hydatid disease is uncommon. Establishing a precise diagnosis may be difficult because the presenting symptoms and findings of investigations may be similar to other more commonly encountered cystic lesions of the pancreas. We report 4 patients with primary hydatid cysts in the head of the pancreas. The records of all patients treated for hydatid disease from 1980 to 2000 were reviewed. During the study period a total of 280 patients were treated, 4 of whom had hydatid disease involving only the pancreas. The 4 patients (3 women, 1 man) ranged in age from 17 to 60 years. Three patients presented with jaundice, abdominal pain and weight loss, 2 with hepatomegaly and 1 with an epigastric mass. All 4 lesions involved the head of the pancreas and ranged in size from 3 to 10 cm in diameter. In 2 patients the investigations incorrectly suggested a cystic tumour and both underwent pancreaticoduodenectomy. In 2 patients the correct diagnosis allowed local excision to be performed. Hydatid cyst is a rare cause of a cystic mass in the head of the pancreas, but should be included in the differential diagnosis of cystic lesions of the pancreas, especially in endemic areas

A multidisciplinary study of a small, temporarily open/closed South African estuary, with particular emphasis on the influence of mouth state on the ecology of the system

In 2005/2006 a multidisciplinary research programme that included studies on the hydrodynamics, sediment dynamics, macronutrients, microalgae, macrophytes, zoobenthos, hyperbenthos, zooplankton, ichthyoplankton, fish and birds of the temporarily open/closed East Kleinemonde Estuary was conducted. Particular attention was given to the responses of the different ecosystem components to the opening and closing of the estuary mouth and how this is driven by both riverine and marine events. Using a complementary dataset of daily estuary mouth conditions spanning a 14-year period, five distinct phases of the estuary were identified, including closed (average = 90% of the days), outflow (<1%), tidal (9%) and semi-closed (<1%). The open-mouth phase is critical for the movements of a number of estuary-associated fish (e.g. Rhabdosargus holubi) and invertebrates (e.g. Scylla serrata) between the estuary and sea. The timing of this open phase has a direct influence on the ability of certain estuaryassociated fish (e.g. Lithognathus lithognathus) and invertebrates (e.g. Palaemon peringueyi) to successfully recruit into the system, with a spring opening (October/November) being regarded as optimal for most species. The type of mouth-breaching event and outflow phase is also important in terms of the subsequent salinity regime once the berm barrier forms. A deep mouth breaching following a large river flood tends to result in major tidal inputs of marine water prior to mouth closure and therefore higher salinities (15–25). Conversely, a shallow mouth breaching with reduced tidal exchange during the open phase often leads to a much lower salinity regime at the time of mouth closure (5–15). The biota, especially the submerged macrophytes, respond very differently to the above two scenarios, with Ruppia cirrhosa benefiting from the former and Potamogeton pectinatus from the latter. River flooding and the associated outflow of large volumes of water through the estuary can result in major declines in zooplankton, zoobenthos, hyperbenthos and fish populations during this phase. However, this resetting of the estuary is necessary because certain marine invertebrate and fish species are dependent on the opening of the estuary mouth in order to facilitate recruitment of larvae and post-larvae into the system from the sea. Slight increases in the numbers of certain piscivorous and resident wading bird species were recorded when the estuary mouth opened, possibly linked to increased feeding opportunities during that phase