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 management of complex pancreatic injuries

Major injuries of the pancreas are uncommon, but may result in considerable morbidity and mortality because of the magnitude of associated vascular and duodenal injuries or underestimation of the extent of the pancreatic injury. Prognosis is influenced by the cause and complexity of the pancreatic injury, the amount of blood lost, duration of shock, speed of resuscitation and quality and nature of surgical intervention. Early mortality usually results from uncontrolled or massive bleeding due to associated vascular and adjacent organ injuries. Late mortality is a consequence of infection or multiple organ failure. Neglect of major pancreatic duct injury may lead to life-threatening complications including pseudocysts, fistulas, pancreatitis, sepsis and secondary haemorrhage. Careful operative assessment to determine the extent of gland damage and the likelihood of duct injury is usually sufficient to allow planning of further management. This strategy provides a simple approach to the management of pancreatic injuries regardless of the cause. Four situations are defined by the extent and site of injury: (i) minor lacerations, stabs or gunshot wounds of the superior or inferior border of the body or tail of the pancreas (i.e. remote from the main pancreatic duct), without visible duct involvement, are best managed by external drainage; (ii) major lacerations or gunshot or stab wounds in the body or tail with visible duct involvement or transection of more than half the width of the pancreas are treated by distal pancreatectomy; (iii) stab wounds, gunshot wounds and contusions of the head of the pancreas without devitalisation of pancreatic tissue are managed by external drainage, provided that any associated duodenal injury is amenable to simple repair; and (iv) non-reconstructable injuries with disruption of the ampullary-biliary-pancreatic union or major devitalising injuries of the pancreatic head and duodenum in stable patients are best treated by pancreatoduodenectomy. Internal drainage or complex defunctioning procedures are not useful in the emergency management of pancreatic injuries, and can be avoided without increasing morbidity. Unstable patients may require initial damage control before later definitive surgery. Successful treatment of complex injuries of the head of the pancreas depends largely on initial correct assessment and appropriate treatment. The management of these severe proximal pancreatic injuries remains one of the most difficult challenges in abdominal trauma surgery, and optimal results are most likely to be obtained by an experienced multidisciplinary team