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Biomedical subjects

J E Krige

Publications and source records attributed to J E Krige.

At least 37 records · Page 2Linked to original sources
PubMed1999

Pancreaticoduodenectomy of ampullary carcinoma.

Thirty-two consecutive patients with adenocarcinoma of the ampulla of Vater who had curative resection by pancreaticoduodenectomy were analyzed to determine the accuracy of preoperative investigations and factors that influenced survival. Obstructive jaundice was present in 31 patients, and most patients had pain and weight loss. Ultrasound was more useful than CT in identifying biliary obstruction, whereas CT was more accurate in demonstrating pancreatic duct dilatation and an ampullary mass. Endoscopic retrograde cholangiopancreatography with biopsy and brush cytology was the most accurate investigation and proved or was suspicious of carcinoma in all patients. Nineteen patients had postoperative complications, three of whom died (9.4%)-two of sepsis and one from aspiration following hematemesis. Actuarial 5-year survival was 46 per cent. Stage of disease was the strongest predictor of survival. All patients with T1 lesions are alive more than 5 years after resection. Patients with lymph node metastases had a significantly shorter survival than node-negative patients (P = 0.00087). Pancreaticoduodenectomy is advocated for ampullary carcinoma in good-risk patients, with the anticipation of prolonged survival in those with early (T1) lesions and node-negative disease.

Adult↗
PubMed1998

Pancreatic carcinoma. Diagnostic and prognostic implications of a normal pancreatogram.

BACKGROUND: The aim of this study was to establish the implications of a normal pancreatogram in patients with pancreatic cancer. METHODS: We reviewed all ERCP done at our institution for the period 1983-92 and studied 62 of 727 patients who had a diagnosis of pancreatic (n = 416) or biliary (n = 311) cancer but a normal pancreatic duct. RESULTS: Thirty of the 62 patients had pancreatic cancer. In 15 cases, the ERCP diagnosis was incorrect, and in 19 cases, Santorini's duct was not visualized. Other imaging revealed a pancreatic head mass in 25 patients (2.5->7 cm). Only three patients had resectable tumors; another eight underwent laparotomy. Five had bypass surgery, 10 required biliary stenting, and nine had no treatment. Four patients died in hospital, and eight were lost to follow-up. In the remaining 18 patients, median survival was 7 months (range, 1-30 months). CONCLUSION: A normal pancreatogram does not exclude the diagnosis of pancreatic cancer, nor does it confer a better prognosis.

Adult↗
PubMed1998

Operative management of papillary cystic neoplasms of the pancreas.

BACKGROUND: Papillary cystic neoplasm (PCN) is a rare malignant tumor of the pancreas that typically occurs in young females and has an excellent prognosis. STUDY DESIGN: We report a retrospective review of 12 patients treated during a 16-year period. Pre-, intra-, and postoperative data were evaluated in all patients to determine optimal management with specific reference to surgical strategy. RESULTS: All 12 tumors occurred in young women (mean age 22 years, range 14-36 years). Six patients presented with an epigastric mass, and three with severe abdominal pain. The correct diagnosis was made preoperatively in only five patients. Incorrect diagnoses included hepatoma, pancreatic pseudocyst, and hydatid cyst. The PCNs had a mean diameter of 12.5 cm (range 8-20 cm), and occurred in the head (four), neck (three), body (three), and tail (two) of the pancreas. All were resected. Operations performed were pylorus-preserving pancreaticoduodenectomy (three), central pancreatectomy with pancreaticogastrostomy (three), distal pancreatectomy (three), and local resection (three). In one patient two liver metastases were resected in addition to the pancreatic primary. One patient presented with tumor rupture and a major bleed into the lesser sac and died of multiple organ failure after resection. Postoperative complications included a stricture at the hepaticojejunostomy after pancreaticoduodenectomy, which resolved after temporary stenting, and a pancreatic duct fistula after local tumor resection, which required a distal pancreatectomy. Eleven patients are well at followup (mean 6.6 years; range 6 months to 15 years). CONCLUSIONS: PCN should be considered in the differential diagnosis of large pancreatic masses, especially in young females. Conservative resection, where technically feasible, is safe and effective and represents the therapy of choice.

Adult↗
PubMed1998

Malignant melanoma in Cape Town, South Africa.

There is a world-wide increase in the incidence of cutaneous malignant melanoma among white people. Absence of accurate population-based data on the incidence of melanoma in South Africa prompted a study to determine the incidence, anatomical sites and pathological details of melanoma in Cape Town. In a prospective study from 1 January 1990 to 31 December 1995, all the histopathology reports of melanoma presenting in a geographically defined area of Cape Town, were actively retrieved from every pathologist practising in this area. The data evaluated included information on age, sex, ethnic group and location of residence. Details of melanoma comprised body site, Clark level of invasion, Breslow thickness in millimetres and histogenetic type. The histology slides were reviewed by a panel in those cases where the recorded information was ambiguous or incomplete. A final number of 595 reports of primary invasive cutaneous melanomas in white people was analysed. Of these 50.3% were men and 49.7% women. The overall age-standardized incidence rate was 24.4 per 100,000 per annum (27.5 for men and 22.2 for women). There was no change in the incidence rate over the study period. Most melanomas in both sexes (74% of women and 71% of men) were < 1.5 mm Breslow thickness. Results of this study indicate a high incidence rate of melanoma in white South Africans, comparable with that in Australia, which demands urgent preventive health measures.

Adolescent↗
PubMed1998

Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis.

BACKGROUND: The open subtotal cholecystectomy technique has simplified removal of the difficult gallbladder. Increasing laparoscopic experience has made laparoscopic subtotal cholecystectomy (LSC) a feasible option in patients with complicated acute or chronic cholecystitis. METHODS: LSC was performed in 29 patients with severe inflammation or fibrosis of the gallbladder associated with gallstone disease over a 23-month period. These 29 patients (mean age 53 years; 22 women) constituted 8.5 per cent of the total number of laparoscopic cholecystectomies performed (n = 340) and 15.6 per cent of 186 patients with acute cholecystitis. Eighteen patients in the latter group underwent conversion to open cholecystectomy. The indications for LSC were acute cholecystitis/empyema (n = 23) and severe fibrosis (n = 6). RESULTS: The cystic duct was either clipped before division (n = 15), sutured (n = 2) or ligated using an Endoloop (n = 10). In two patients the gallbladder bed was drained without isolating the cystic duct. The posterior wall of the gallbladder was left intact to avoid excessive bleeding or damage to bile ducts in the gallbladder bed. A suction drain was inserted in 14 cases. Median operating time was 73 (range 45-130) min. One patient died after operation from a myocardial infarction. Six patients had local complications (two haematomas, three bile leaks, one minor wound sepsis) and nine developed respiratory infections. Median hospital stay was 5 (range 2-28) days. CONCLUSION: LSC is a safe, relatively simple and definitive procedure allowing removal of a difficult gallbladder and reducing the need for open conversion or cholecystostomy in the majority of patients.

Acute Disease↗
PubMed1998

Management of hepatobiliary and pancreatic Ascaris infestation in adults after failed medical treatment.

BACKGROUND: The roles of endoscopy and surgery in the management of Ascaris lumbricoides affecting the hepatobiliary and pancreatic system in adults were determined. METHODS: All patients undergoing endoscopic retrograde pancreatography for ascariasis of the biliary or pancreatic system unresponsive to standard medical therapy were analysed. Worms were extracted using snare, Dormia basket or biopsy forceps. Success was defined as clearance of worms and eradication of symptoms. RESULTS: Endoscopic extraction was performed in 25 patients with success in 19. Failures occurred in one patient with Ascaris in the gallbladder, and in five with associated strictures or stones. All six patients were treated successfully by surgery. CONCLUSION: Endoscopy was successful in the treatment of Ascaris infestation resistant to medical therapy in 19 of 25 patients. Surgery remains important in the management of infestations complicated by biliary or pancreatic strictures and stones, or worms in the gallbladder.

Adolescent↗
PubMed1998

Subparietal hepaticojejunal access loop for the long-term management of intrahepatic stones.

BACKGROUND: The subparietal hepaticojejunal biliary access loop is a recognized technique for the long-term management of primary intrahepatic stone disease. This paper assesses the results of this approach in a series of South African patients. METHODS: Between 1985 and 1997, 21 patients, of mean age 34 (range 24-66) years, underwent surgical extraction of intrahepatic stones and formation of an hepaticojejunal access loop. The access loop was subsequently used for further stone removal and stricture dilatation. Patients were followed prospectively (median 47 months) and details of the number and type of procedures performed, stone clearance rates, morbidity and subsequent outcome were recorded. RESULTS: The distribution of intrahepatic stones was left lobe in 13 of 21 patients, right lobe in one and bilateral in seven. Six patients underwent additional left lobectomy at the initial operation because of associated atrophy of the left lobe. Following operation, stone removal and/or stricture dilatation was performed on 97 occasions (median 4 (range 0-24) procedures per patient). Complete stone clearance was achieved in 17 of 21 patients with partial clearance in the remaining four. There were no major complications and no deaths associated with the procedures. CONCLUSION: The subparietal access loop permits long-term access to the intrahepatic ducts allowing removal of stones and dilatation of strictures with minimal patient discomfort and low morbidity.

Adult↗
PubMed1998

Melanoma of the face: the safety of narrow excision margins.

Recent studies have shown that narrower excision margins may be safe, but the optimal or minimum margin for melanoma is unknown. Wide margins of excision are possible on the trunk and limbs, but functional and cosmetic constraints often limit the extent of excision on the face. A collaborative study from two continents (Cape Town, South Africa and Northwood, England) investigated the outcome of different excision margins of 106 patients with stage I melanoma of the face. The margin of excision was measured from the records of the pathological specimen. Thirty patients had margins of less than 1 cm, 64 had margins of between 1 and 2 cm, and 12 had margins greater than 2 cm. Primary apposition or flap closure was possible in 85 patients. Seven patients developed local recurrences and these were not influenced by the excision margin. This study supports the contention that the primary treatment of cutaneous melanoma on the face should be histologically confirmed complete excision, and that this can be achieved with margins of excision less than 1 cm. Local recurrence is not related to the margin of excision or to tumour thickness.

Adult↗
PubMed1998

Plantar melanoma: results of treatment in three population groups.

BACKGROUND: The frequency of plantar melanoma varies widely in different population groups. The plantar surface is an infrequent site in white persons but is common in the black population. The effect of ethnicity on melanoma of the plantar surface has not previously been well defined. The aim of this study was to analyze the results of a standard protocol of treatment of melanoma of the sole in 3 homogeneous population groups treated during a 15-year period at a university referral hospital. METHODS: A retrospective analysis of 1403 consecutive patients with melanoma treated between 1977 and 1991 was performed. Eighty-five patients (35 black, 25 white, and 16 of mixed ancestry) had primary cutaneous melanoma involving the sole of the foot. RESULTS: Acral lentiginous melanoma was the most common histogenetic type and occurred in 49 patients. Significantly more black patients (20 of 35) had metastatic disease compared with white patients or groups with mixed ancestry (P < .05). The Breslow depth was significantly more advanced in black patients (7.1 mm) with stage I disease than in white patients (3.3 mm) or those of mixed ancestry (3.6 mm) (P < .05). The 5-year survival rate was 60% for white patients, 26% for black patients, and 24% for those of mixed ancestry. CONCLUSIONS: Black patients were seen more frequently with advanced local disease, and nearly half had disseminated disease. Those of mixed ancestry had a histogenetic type resembling that of black patients, but the Breslow depth of penetration was similar to that of white patients. Education programs to heighten awareness of both patient and physician are required to enable earlier diagnosis and improve outcome.

Adult↗
PubMed1998

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

OBJECTIVE: Review of surgical resections performed for hepatocellular carcinoma (HCC) 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 (HBV) 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.

Adolescent↗
PubMed1997

Severe necrotizing pancreatitis caused by organophosphate poisoning.

Pancreatitis secondary to organophosphate insecticide toxicity is rare and is believed to follow a subclinical and uneventful course. We report two cases of severe acute pancreatitis complicated by pancreatic necrosis and retroperitoneal sepsis in which the diagnosis was obscured by the systemic effects of organophosphate toxicity. Awareness of this complication should prompt earlier investigation because early diagnosis coupled with timely therapeutic measures may improve patient prognosis.

Adult↗
PubMed1997

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.

Adult↗
PubMed1997

Liver trauma in 446 patients.

A total of 446 patients with liver trauma were treated over a 10-year period: 295 (66%) had penetrating injuries (204 stab wounds, 91 gunshot wounds) and 151 (34%) blunt trauma. Seventeen patients died during resuscitation before laparotomy. In 344 (80%) of the 429 patients who underwent laparotomy, injuries were managed by simple methods such as temporary packing, diathermy, sutures or vessel ligation. Eighty-five patients (18%) had complex injuries and underwent one or more of the following procedures to control bleeding: hepatotomy and intrahepatic vessel suture (28), resectional debridement (31), lobar resection (17), perihepatic packing and relaparotomy (25), total hepatic isolation (4) or atriocaval shunt (1). Overall mortality was 54 (12.1%) and was greatest after blunt injury (27%) compared with gunshot (11%) and stab wounds (2%). Mortality was directly attributable to the abdominal injury in 39 patients, 22 of whom died from uncontrolled haemorrhage. Complications occurred in 151 of 392 survivors (38.5%) and correlated with type and severity of the liver injury (31% in stab wounds, 43% in gunshot wounds, 57% in blunt injuries) and the number of associated injuries. As many as 80% of liver injuries can be managed by simple surgical techniques. In major liver injuries perihepatic packing may be life-saving, allowing control of bleeding before a logical sequential strategy is instituted to isolate and repair the injury.

Female↗
PubMed1997

The current treatment of oesophageal varices.

The wide range of management options available today are evaluated in this article. The advised management policy for acute variceal bleeding includes admission to a hospital with an interest in portal hypertension, resuscitation, the possible use of pharmacological agents to lower portal pressure, and definitive endoscopic therapy (either sclerotherapy or banding). More major surgical procedures (i.e. shunts or transection operations or TIPS) should be reserved for patients in whom endoscopic therapy falls. Long-term management to prevent recurrent variceal bleeding is somewhat more controversial. The options for the majority of patients are pharmacological therapy with beta-blockers, or repeated endoscopic therapy to eradicate varices, or a major surgical procedure, preferably a partial shunt. All patients should be considered for liver transplantation although few will ultimately end up as liver transplant candidates. Prophylactic therapy prior to a variceal bleed, other than beta-blockade in selected patients, is unjustified today because of the difficulty in identifying high-risk patients.

Esophageal and Gastric Varices↗