Guideline for the diagnosis and treatment of chronic pancreatitis

BACKGROUND: Chronic pancreatitis (CP) is defined as a continuing inflammatory disease of the pancreas characterised by irreversible morphological changes, often associated with pain and with the loss of exocrine and/or endocrine function that may be clinically relevant. Alcohol is the predominant cause of CP in the western world and is particularly prevalent in South Africa, especially in the indigent patient. CP ranks high among intractable diseases of the gastrointestinal tract. The tendency for substance abuse in the alcohol-induced group poses major psychological and socioeconomic problems. OBJECTIVE: CP is a disease with significant clinical and pathological heterogeneity. Level 1 evidence to support definitive guidelines for diagnosis, medical management and interventional therapy is lacking. Despite this paucity of robust scientific evidence, it is important to provide some assistance based on the best available evidence as to the current standard of care for CP in the South African context; this will aid all involved in the management of the disease, and includes clinicians, health care managers and funders. Scope. The guidelines were developed as recommendations addressing the diagnosis, medical management and interventions, both endoscopic and surgical, for the management of a very complex and heterogeneous disease of the pancreas. The recommendations are particularly relevant in the South African context where the predominant patho-aetiological agents are alcohol-associated with smoking. RECOMMENDATIONS: The guidelines provide clear recommendations regarding the diagnostic modalities available, both imaging (which includes MRI and endoscopic ultrasound (EUS)) and pancreatic function tests. The section on medical management makes recommendations on the use of analgesics, enzyme replacement and other therapeutic options in the non-interventional management of the majority of patients with CP. The section on interventional procedures identifies the indications and options available for the interventional management of both uncomplicated and complicated CP. The role of endoscopic and surgical modalities is defined, but it is in this context especially that the best available evidence, combined with the experience of the group, influenced the recommendations put forward. Owing to the lack of evidence and the complexity of the disease, it is recommended that, where possible, CP is managed in the context of a multidisciplinary team. Validation. The guidelines are based on best practice principles determined by the available evidence and the opinions of the group, which comprised 7 medical and surgical gastroenterologists with significant experience in dealing with patients with chronic pancreatitis in the South African context. The group convened between May 2009 and August 2010 under the auspices of the Hepato-Pancreatico-Biliary Association of South Africa (HPBASA) and the South African Gastroenterology Society (SAGES), and the guidelines are the result of broad consensus within this group. The draft was presented to other experts in this field of endeavour to ensure broader participation and consensus. Plans for guideline revision. HPBASA and SAGES will publish a revised modification of the recommendations when new levels 1 and 2 evidence data are published

A survey of South African endoscopic surgical practice

To coincide with the first annual meeting of the South African Society of Endoscopic Surgeons (SASES), a postal survey of the endoscopic surgical practices of 98 registered specialist surgeons was undertaken. A response rate of 73.5% was achieved, and 94.5% of respondents had personally performed endoscopic surgical procedures. Cholecystectomy (4 557) was the most commonly performed endoscopic surgical procedure and was associated with a postoperative mortality rate of 0.13% and morbidity of 3.5%. Twelve bile duct injuries were reported (0,26%). In descending order of frequency, other procedures reported were diagnostic laparoscopy (1 404), dorsal sympathectomy (412), appendicectomy (396), inguinal hernia repair (146), anti-reflux procedures (83) and diagnostic thoracoscopy (51). No postoperative deaths were recorded and complication rates varied from zero for diagnostic thoracoscopy to 4.8% for inguinal hernia repair and anti-reflux procedures. The selected sample of South African surgeons canvassed appears to have adopted endoscopic surgical techniques with enthusiasm and with complication rates that compare favourably with those reported elsewhere.Articl

Evaluation of the Grassi Test for the Completeness of Vagotomy

This article describes our experience with the Grassi test in the experimental laboratory, using dogs. We found the reliability of this test questionable for completeness of vagotomy

Choledochoduodenostomie en Sfinkteroplastiek

From experience derived from a series of 322 gall bladder removals, in 35,6% of which exploration of the common bile duct was performed, and 10% of which were drained either by choledochoduodenostomy (19 cases) or sphincteroplasty (13 cases), a plea is made that operative cholangiography is essential; that the indications for drainage must be correct and that the correct procedure must be used. The two operations of sphincteroplasty and choledochoduodenostomy are described

Primary sclerosing cholangitis associated with inflammatory bowel disease in Cape Town, 1975 -1981

Patients with inflammatory bowel disease and serum akaline phosphatase persistently raised to more than twice the normal level were investigated to assess the frequency of primary sclerosing cholangitis (PSC) in the Gastro-intestinal Clinic from 1975 to 1981. Twelve patients had a persistently raised alkaline phosphatase level of hepatic origin, 9 out of 250 with ulcerative colitis and 3 out of 164 with Crohn's disease. PSC was demonstrated in 8 (3%) of the patients with ulcerative colitis, and carcinoma of the pancreas in the remaining 1. Three of the patients with PSC also had gallstones. The colitis antedated the biliary symptoms and signs in all but 1 patient. There was no correlation between the duration, extent and activity of the colitis and the development and outcome of the liver involvement. Investigations in the 3 patients with Crohn"s disease revealed the presence of PSC in 2 (1,2%) and chronic active hepatitis in the 3rd. Of the 2 with PSC, one had cholelithiasis and has had recurrent episodes of cholangitis. The other has had only mild symptpms

Book Reviews

Book Review 1Book Title: From academe to the bushveld. Hope Beyond the ShadowsBook Author: Ian SpencerPp. 238. Westville, RSA: Forest Publishers. 1992.Book Review 2Book Title: Healthy running. Lore of RunningBook Author: T. Noakespp. xiv + 734. Illustrated. Cape Town: Oxford University Press. 1992.Book Review 3Book Title: Claims for compensation. Compensation Claims: Insurance, Legal and Medical AspectsBook Author: M. Simpp. 250. Victoria: Emmess. 1992.Book Review 4Book Title: Endoscopy. Techniques in Therapeutic EndoscopyBook Authors: J. E. Geenen, D. E. Fleischer & J. D. Waye (Ed.)2nd Ed. Pp. 250. Illustrated. London: Gower Medical. 1992.Book Review 5Book Title: GIT motility disorders Motility Disorders of the Gastrointestinal Tract: Principles and PracticeBook Author: Sinn AnurasPp. xii + 465. Illustrated. New York: Raven Press. 1992Book Review 6Book Title: CT in urology. Computed Tomography in UrologyBook Authors: H.H. Schild, F.J. Schweden & E.K. LangPp. xviii + 381. Illustrated. Stuttgart. Georg Thieme Verlag. 1992.Book Review 7Book Title: Ear and temporary bone surgery Surgery of the Ear and Temporal BoneBook Authors: J.B. Nadol jun. &  H.F. Schuknecht (Ed.)Pp. xi + 480. illustrated, New York: Raven Press. 1992Book Review 8Book Title: Anti-epileptic drug prescribing. A Practitioner's Guide to Optimum Use of Antiepileptic DrugsBook Authors: R Miller & M.L. McFadyenPp. v + 90. Randburg: Medical Education Services on behalf of the Medicine Group (sponsored by Parke-Davis). 1992.Book Review 9Book Title: Neurology. Neurologic Differential DiagnosisBook Author: M. Mumenthaler2nd Ed. Illustrated. Pp. ix + 178. Stuttgart: Georg Thieme Verlag. 1992.Book Review 10Book Title: Temporal bone surgery Anson-Donaldson: Surgical Anatomy of the Temporal BoneBook Authors: I.A. Donaldson, L.G. Duckert, P.M. Lambert & E.W. Rubel4th ed. Pp. xv + 546. Illustrated. New York: Raven Press. 199

Book Reviews

Book Review 1Book Title: Gastroenterological procedures: Manual of Gastroenterologic ProceduresBook Author: D.A. Drossman (Ed,)3rd ed. Pp. xv + 288. illustrated. New York: Raven Press. 1992.Book Review 2Book Title: Safety in diagnostic ultrasound: Exposure Criteria for Medical Diagnostic Ultrasound: I. Criteria Based on Thennal MechanismsBook Author: NCRP Report No. 113Pp. xv + 278. Illustrated. Bethesda MD: NCRP. 1992.Book Review 3Book Title: Knee arthroplasty: Total Knee ArthroplastyBook Author: James A. Rand (Ed.)pp. xiv + 464. illustrated. New York: Raven Press. 1992.Book Review 4Book Title: Drug-induced skin changes: Cutaneous Drug Reactions. An Integral Synopsis of Today's Systemic DrugsBook Authors: K. Zürcher & A. Krebs (Eds.)2nd Ed. pp. viii +570. Basel: Karger. 1992Book Review 5Book Title: Rabies WHO Expert Couunittee on Rabies: 8th ReportBook Author: WHOTechnical Report Series No. 824. Pp. vii + 84. Geneva: WHO. 1992.Book Review 6Book Title: Entomology and malaria. Entomological Field Techniques for Malaria ControlBook Author: WHOpp. 77. Geneva: WHO. 1992.Book Review 7Book Title: Handbook of PCVC. Handbook of Percutaneous Central Venous CatheterisationBook Authors: M. Rosen, P. Lano & S. Nig (Eds.)2nd Ed. pp. viii + 249. illustrated. Kent: Harcourt Brace and Jovanovich. 1992Book Review 8Book Title: HIV/AIDS resource directory: Resource Directory for HIV and AIDSBook Authors: Stewart Harris & Geoffrey Taylor (Eds.)83 + iv. 1992.Book Review 9Book Title: Laparoscopic surgery: Atlas of Laparoscopic SurgeryBook Authors:  E. J. Reddick, with W. B. Say & J. D. Corbitt (Eds.)Pp. ix + 116. illustrated. New York: Raven Press. 1992Book Review 10Book Title: Medical history. The illustrated History of MedicineBook Author:  Jean-Charles SourniaPp. 585. Illustrated. London: Harold Starke. 1992. (Distributed by Medical Association of South Africa, Private Bag XI, Pinelands 7430).Book Review 11Book Title: Plants in Cardiology. Plants in Cardiology Book Author: A. HollmanPp. vii + 40. Illustrated. London: BMJ. 1992.Book Review 12Book Title: Fraud in medical research. Fraud and Misconduct in Medical ResearchBook Authors: Stephen Lock & Frank Wells (Eds.)Pp. xi + 202. London: BMJ. 1993.Book Review 13Book Title: Anaesthesiology in emergencies Bailliere's Clinical Anaesthesiology: Emergency Medicine and the AnaesthetistBook Authors: H.H. Delooz (Ed.)Pp. xi + 212. Illustrated.London: Bailliere Tindall. 1992.Book Review 14Book Title: BMJ literary extracts. Soundings from BMJ ColunmistsBook Author: Ruth Holland (Ed.)Pp. xi + 89. London: BMJ 1992.Book Review 15Book Title: Chest imaging. Atlas of Chest Imaging: Correlated Anatomy with MRI and CTBook Authors: Marvin Wagner & Thomas L. Lawson (Eds.)Pp. ix + 134. lllustrated. New York: Raven Press. 1992.Book Review 16Book Title: Knee Meniscus: Basic and Clinical FoundationsBook Authors: Van C. Mow, Steven P. Amoczky & Douglas W. Jackson (Eds.)Pp. xi + 190. Illustrated. New York: Raven Press. 1992Book Review 17Book Title: Cryptorchidism. Descent of the TestisBook Authors: John M. Hutson & Spencer W. BeasleyPp. 187. Price: Illustrated. London: Edward Arnold. 1992.Book Review 18Book Title: Radiosurgery: Baseline and TrendsBook Authors: L. SteinerPp. xiv + 302. Illustrated. New York: Raven Press. 1992