Departments of surgery in South Africa - legacies of the past, challenges for the future

Among the most important constituencies of the South African Journal of Surgery are its readership and contributing authors. The needs and interests of our readers are being addressed in several ways. A new feature in this and the following issues of the Journal is a review highlighting one of the academic departments of general surgery in South Africa. Each of the eight heads of department has been invited to introduce and record the achievements and talents of his department in a remit that includes a synoptic background and biographical detail of previous opinion leaders and staff who have made seminal contributions to clinical surgery, teaching and research in South Africa. Within the brief are current research directions, registrar development, the thrust of undergraduate teaching and future prospects and challenges for surgery in that environment. Professor Brian Warren is the first to take up the gauntlet

Endoscopic injection sclerotherapy in the treatment of bleeding oesophageal varices in patients with portal hypertension due to alcohol-induced cirrhosis : an assessment of acute control of bleeding, prevention of recurrent bleeding and prognostic factors predicting early variceal rebleeding and death

The ideal treatment of portal hypertension and bleeding varices should be universally effective, safe, easy to administer and inexpensive. Currently no such treatment exists and the surgeon or physician is obliged to select the most appropriate intervention from a menu of currently available therapeutic options, none of which is ideal or applicable to all patients. The rational treatment of oesophageal varices depends on a clear understanding of the risks of rebleeding and the response to each specific intervention. The selection of the correct and appropriate intervention is critical and requires a comprehensive understanding of the relative efficacy and safety of each treatment compared to other competing options. In addition, the chosen intervention requires detailed knowledge of the criteria underpinning the correct selection of patients for treatment in order to maximize the therapeutic benefits of the appropriate choice while minimising the side effects of the treatment. The optimal management of bleeding oesophageal varices therefore requires a full appreciation of portal, gastric and oesophageal venous collateral anatomy, the pathogenesis and haemodynamic consequences of variceal bleeding and the utility of each available therapy at specific stages in the natural history of portal hypertension (Henderson 1998)

Taking the tension out of portal hypertension

Bleeding from oesophageal varices is the most serious complication of portal hypertension and accounts for most cirrhosis-related deaths. A quarter of high-risk cirrhotic patients with liver decompensation who present with a first major variceal bleed die as a consequence of the bleed. After control of the index bleed, there is a 70% chance of rebleeding with a similar mortality if further effective treatment is not given. Mortality is related to several factors, including failure of rapid control of initial bleeding, early rebleeding, presence and severity of underlying liver disease and functional hepatic reserve. Optimal emergency management requires an efficient and organised team to provide accurate initial assessment of the patient, effective resuscitation, rapid endoscopic diagnosis, successful intervention with control of bleeding, and prevention of early rebleeding as well as the anticipated complications of liver decompensation including spontaneous bacterial peritonitis, progressive liver and renal failure and hepatic encephalopathy. The modern management of acute, persistent variceal bleeding is therefore best accomplished by a skilled, knowledgeable and well-equipped team that can offer the full spectrum of treatment options

Taking the tension out of portal hypertension

Bleeding from oesophageal varices is the most serious complication of portal hypertension and accounts for most cirrhosis-related deaths. A quarter of high-risk cirrhotic patients with liver decompensation who present with a first major variceal bleed die as a consequence of the bleed. After control of the index bleed, there is a 70% chance of rebleeding with a similar mortality if further effective treatment is not given. Mortality is related to several factors, including failure of rapid control of initial bleeding, early rebleeding, presence and severity of underlying liver disease and functional hepatic reserve. Optimal emergency management requires an efficient and organised team to provide accurate initial assessment of the patient, effective resuscitation, rapid endoscopic diagnosis, successful intervention with control of bleeding, and prevention of early rebleeding as well as the anticipated complications of liver decompensation including spontaneous bacterial peritonitis, progressive liver and renal failure and hepatic encephalopathy. The modern management of acute, persistent variceal bleeding is therefore best accomplished by a skilled, knowledgeable and well-equipped team that can offer the full spectrum of treatment options

Charles F M Saint – South Africa’s original surgical pioneer

Charles F M Saint, a 33-year-old graduate from the University of Durham, Newcastle upon Tyne, was appointed to establish the first department of surgery in South Africa (SA) at the University of Cape Town (UCT) in 1920. A mentee of the celebrated British surgeon, Prof. James Rutherford Morison, Saint’s distinguished surgical pedigree and exceptional academic and clinical achievements underpinned his astute leadership and legendary ability to inspire, essential qualities necessary for the founding professor of SA surgery. Saint’s imprimatur gave primacy to teaching and a priority to skilled, rigorous and fundamental undergraduate instruction, expounding the Morison-Saint philosophy, which made the department the seedbed of SA surgery. He was the first to introduce basic research programmes in clinical departments. During his tenure, Saint received wide international recognition and honours and when he retired in 1946, he had taught more than 1 300 students, trained 7 professors of surgery and over 40 specialist surgeons, instilling his distinctive brand of disciplined, caring surgery. In his 26 years at UCT and Groote Schur Hospital, Saint laid the foundations and built a department of surgery with a global reach and an enduring legacy at the southern tip of Africa

The new DEAL - a novel technique using a double-entry access loop to facilitate bilateral intrahepatic biliary access for complex intrahepatic stones

The management of patients with primary intrahepatic stones may be complex as the natural history is frequently complicated by further episodes of cholangitis after initial treatment because of residual or recurrent intrahepatic stones or strictures.1 Curative segmental or lobar hepatic resection of atrophic segments and diseased ducts is possible in only the 20% of patients with localised stones or strictures.2 Complete stone removal by resection is therefore not feasible in the majority of patients with bilateral lobar stones and strictures. Patients who subsequently develop cholangitis pose a major operative risk if secondary biliary cirrhosis, portal hypertension or the atrophy-hypertrophy complex has occurred.3 Treatment of recurrent stones and strictures via the percutaneous transhepatic biliary route is successful in only 70% of patients.3 In order to avoid these hazards, to reduce the incidence of incomplete operative stone removal and to facilitate extraction of recurrent intrahepatic stones, we have used a multidisciplinary approach in complex hepatolithiasis, combining resection of atrophic liver segments with a modified hepaticojejunostomy incorporating permanent access for interventional radiological procedures via a jejunal access loop

Fibrolamellar hepatocellular carcinoma at a tertiary centre in South Africa

Background: Fibrolamellar carcinoma (FLC) is an uncommon malignant tumour of hepatocyte origin that differs from hepatocellular carcinoma (HCC) in aetiology, demographics, condition of the affected liver, and tumour markers. Controversy exists whether FLC demonstrates a more favourable prognosis than typical HCC. A review of existing literature reveals a dearth of FLC data from the African continent. Methods: We utilised the prospective liver resection database at Groote Schuur Hospital to identify all patients who underwent surgery for FLC between 1990 and 2008. Results: Seven patients (median age 21 years, range 19 - 42, 5 men, 2 women) underwent surgery for FLC. No patient had underlying liver disease or an elevated alpha fetoprotein (AFP) at either initial presentation or recurrence. Six patients had a solitary tumour at diagnosis (mean largest diameter = 12cm), and underwent left hepatectomy (N=2), right hepatectomy (N=1), extended right hepatectomy (N=1), and segmentectomies (N=2). Three patients underwent a portal lymphadenectomy for regional lymphatic tumour involvement. One patient with advanced extrahepatic portal nodal metastasis was unresectable. No peri-operative deaths occurred. Recurrence occurred post resection in all 6 patients. Median overall survival was 60 months, and overall 5-year survival was 4 out of 7 (57%). Post-resection survival (N=6) was 61 months, with a 5-year survival rate of 4 out of 6 (67%). The patient with unresectable disease survived 38 months after tumour embolisation with Lipiodol. Conclusion: Our series suggests that despite (i) a high resection rate of solitary lesions with clear tumour resection margins, and (ii) absence of underlying liver disease, FLC has a high recurrence rate with an ultimately poor clinical outcome. These findings concur with recent international experience of FLC