Biomedical subjects
J Terblanche
Publications and source records attributed to J Terblanche.
Christian (Chris) Neethling Barnard, 1922-2001.
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Variceal rebleeding and recurrence after endoscopic injection sclerotherapy: a prospective evaluation in 204 patients.
HYPOTHESIS: Eradication of esophageal varices by repeated injection sclerotherapy and maintenance of eradication using continued surveillance endoscopy may reduce recurrent variceal bleeding and death from esophageal varices. DESIGN: A prospective study of consecutive adult patients with endoscopically proved esophageal variceal bleeding. SETTING: A tertiary care university hospital in a metropolitan area. PATIENTS: Two hundred four patients (127 men and 77 women; mean age, 50.1 years; age range, 16-82 years) underwent 993 emergency and elective variceal endoscopic injection treatments with 5% ethanolamine oleate during 1992 endoscopy sessions. Most (166 [81.4%]) had cirrhosis, mainly due to alcohol abuse (131 [78. 9%]). The number of patients with each modified Pugh-Child risk grade was as follows: A, 30; B, 91; and C, 83. (The modified Pugh-Child classification comprises ascites, encephalopathy, serum albumin and bilirubin levels, and prothrombin time. Each variable is given a value of 1 to 3 with increasing impairment of liver function. Addition of the values leads to the Pugh-Child risk grades for each patient, with 5 and 6 giving grade A; 7 through 9, grade B; and 10 through 15, grade C, respectively.) RESULTS: Ninety-five patients (46.6%) rebled at a median of 17 days (range, 0-2583 days). Seventy-four patients (36.3%) had a total of 112 further bleeding episodes before eradication of varices. Varices were eradicated in 99 (87.6%) of 113 patients who survived longer than 3 months after a median of 5 injections and remained eradicated in 43 (mean follow-up after eradication, 38 months; range, 4-125 months). Rebleeding was markedly reduced after eradication of varices. Varices recurred in 56 patients, of whom only 10 rebled from recurrent esophageal varices. Cumulative survival by life table analysis was 55%, 41%, and 30% at 1, 3, and 5 years, respectively. One hundred thirty-seven patients (67.2%) died during follow-up. Liver failure was the most common cause of death. Minor complications (mucosal ulceration) occurred in 105 patients. Major complications, including a localized injection site leak (n = 9), esophageal stenosis (n = 25), and esophageal perforation (n = 5), occurred in 39 patients. CONCLUSIONS: Repeated injection sclerotherapy eradicated esophageal varices in most long-term patients. Complications related to injection sclerotherapy were mostly minor. Complete eradication of varices reduced rebleeding and death from esophageal varices.
Analysis of 153 gunshot wounds of the liver.
BACKGROUND: Gunshot wounds of the liver may result in substantial morbidity and death, and optimal management of complex injuries is controversial. METHODS: One hundred and fifty-three patients with civilian gunshot liver injuries were treated during the 10-year period 1986-1995. Demographic, clinical and operative data were recorded. Factors influencing postoperative complications and death were analysed. RESULTS: One hundred and forty-two patients (93 per cent) had single missile injuries and 11 (7 per cent) had shotgun injuries. Three patients were treated non-operatively and 150 patients underwent operation. In 105 patients (70 per cent) the injuries to the liver were minor and required either no treatment (93) or simple suture of bleeding vessels (12). Forty-five patients (30 per cent) had major injuries which were either packed only (26) or required more complex surgical intervention (19). This included resectional debridement (ten), major venous repair (eight) and hepatotomy (one); eight of these patients required packing combined with the procedure. Associated intra-abdominal injuries occurred in 115 patients (77 per cent). The overall mortality rate was 17 per cent (26 patients). Death was directly attributable to the liver injury in 13 patients (8 per cent), 12 of whom died from uncontrolled bleeding. Complications occurred in 63 (51 per cent) of 124 survivors, and correlated with the type and severity of the liver injury and the number of associated injuries. CONCLUSION: Most gunshot liver injuries can be managed by simple surgical techniques. In complex injuries control of major haemorrhage is vital and perihepatic packing may be life saving before undertaking definitive repair of the injury under controlled conditions.
Ten years of liver transplantation at Groote Schuur Hospital.
INTRODUCTION: Liver transplantation has evolved from an experimental procedure to being the treatment of choice for many patients with end-stage liver disease, and is performed on a routine basis in most major centres throughout the world. However, certain situations peculiar to developing countries have a major impact on liver transplant programmes in these countries. We present the results of the liver transplant programme in Cape Town. PATIENTS AND METHODS: All patients undergoing orthotopic liver transplantation at Groote Schuur Hospital and Red Cross War Memorial Children's Hospital were included in this report. Standard surgical techniques were used for procuring the donor liver, the recipient hepatectomy and the subsequent implantation of the liver. All patients received standardised peri-operative management; in particular, the immunosuppressive protocol consisted of cyclosporin, steroids and azathioprine. Since October 1988, 83 patients have undergone 89 orthotopic liver transplants. There were 44 adults and 39 children, the age range being from 6 months to 56 years. The commonest indications for hepatic transplantation in adults included cryptogenic cirrhosis, auto-immune hepatitis and primary sclerosing cholangitis. In children biliary atresia was the commonest cause of liver failure. RESULTS: Of the 81 patients transplanted, 50 are alive and well with follow-up ranging from 2 months to 9.5 years. The cumulative graft survival rate was 72% at 1 year and 61% at 5 years. Six patients have undergone re-transplantation and 4 patients have had combined liver/kidney transplants. De novo hepatitis due to hepatitis B virus (HBV) has occurred in 8 patients following transplantation. Subsequent investigation has shown that 5 of the donors of these livers were hepatitis B core antibody (HBcAb)-positive, while information on the remaining 3 was not available. Tuberculosis (TB) has been a significant problem in 4 patients, with 2 deaths precipitated by anti-TB drug-induced hepatitis. Post-transplant lymphoproliferative disorder was also responsible for significant postoperative morbidity. CONCLUSION: Orthotopic liver transplantation has been established at Groote Schuur Hospital as the treatment of choice for selected patients with chronic end-stage liver disease. However, hepatitis B and TB appear to present a problem. The particularly high prevalence of HBV carrier status in our donor population may necessitate the use of living donors in the future.
Endoscopic band ligation of oesophageal varices.
BACKGROUND: For 25 years the optimal management of bleeding oesophageal varices has included endoscopic injection sclerotherapy (EIS) both to arrest bleeding and to prevent rebleeding. However, the recent innovation of endoscopic variceal ligation (EVL) may be a more effective treatment; this paper reviews its efficacy. METHODS: All Medline (National Library of Medicine, Washington DC, USA) articles containing the text words 'oesophageal varices', 'sclerotherapy' or 'band ligation' were reviewed. Prospective randomized studies comparing sclerotherapy with band ligation, or combinations thereof, were included. RESULTS: After an acute variceal bleed EVL is as effective as EIS for control and eradication of oesophageal varices. Initial control of bleeding is similar, but eradication is achieved in fewer sessions with EVL. EVL is associated with lower rebleeding rates and fewer procedure-related complications; it is also more effective for control of active bleeding at initial endoscopy. Combination therapy (EIS plus EVL) confers no advantage over EVL alone. CONCLUSION: EVL is similar to EIS for control of bleeding varices, but the former has less associated morbidity, lower rebleeding rates and achieves more rapid variceal eradication. EVL should be considered the endoscopic treatment of choice in the management of variceal haemorrhage.
Proximal bile duct cancer: high resectability rate and 5-year survival.
OBJECTIVE: To review and update the authors' experience with resectional surgery for proximal bile duct carcinoma (Klatskin tumor) and assess the role of liver resection over the past 25 years. BACKGROUND: Until recently, resection of proximal bile duct carcinoma was uncommon, with most patients undergoing palliative procedures. The authors adopted a radical surgical approach aimed at definitive cure in 1974. Recent reports suggest that resection improves outcome. METHODS: The records of 40 of 94 patients (23 men, 17 women, age range 34-81 years) diagnosed with proximal bile duct carcinoma who underwent resection between 1968 and 1993 were reviewed. According to the Bismuth classification, there were five type I, four type II, 25 type III, and six type IV lesions; 11 patients underwent tumor resection alone, and 25 patients had combined tumor and liver resection (seven of these also underwent an associated regional vascular resection). In 3 patients, venous allografts were harvested from cadaveric donors and used to reconstruct the portal vein. Four patients underwent liver transplantation; in two, organ cluster-type resections including the liver with porta hepatitis and pancreas were performed. RESULTS: The resectability rate in the more recent period of the study was 49.4%. Most type I, three (of four) type II, T in situ, T1a, T1b, and all stage 0 tumors were resected without hepatectomy. In the other subgroups of tumors, the main surgical procedure was hepatectomy. Thirty-day mortality was 12.5%. After tumor resection alone, survival at 1, 3, and 5 years was 81.8%, 45.5%, and 27.3%, respectively. After tumor resection and hepatectomy without vascular resection, 1-, 3-, and 5-year survival was 66.7%, 16.7%, and 6%, respectively. With vascular resection, survival rates were similar: 64%, 20%, and 4%, respectively. CONCLUSION: The type of surgery required to achieve cure is closely related to tumor location, TNM classification, and staging. Increasing resectability through the use of hepatectomy improves survival and offers a chance of cure in patients with more advanced disease.
Long term outcome of endoscopic drainage of pancreatic pseudocysts.
OBJECTIVE: Nonoperative drainage either by the percutaneous or endoscopic route has become a viable alternative to surgical drainage of pancreatic pseudocysts. Endoscopic drainage has been reported in a few small series with encouraging short term results. The aim of this study was to determine the indications, suitability, and long term outcome of transmural endoscopic drainage procedures. METHODS: All patients presenting over a 2-yr period to a tertiary referral hepatobiliary unit with pancreatic pseudocysts were studied. Endoscopic drainage was performed in patients with pseudocysts bulging into the stomach or duodenal lumen. Outcome measures were successful drainage of the pseudocyst, complications, and recurrence rates. RESULTS: Of 66 patients presenting with pseudocysts, 34 were considered suitable for endoscopic drainage. Twenty-four (71%) were successfully drained. Failures were associated with thick walled pseudocysts (> 1 cm), location in the tail of the pancreas, and pseudocysts associated with acute necrotizing pancreatitis. There were three recurrences (7%), two of which were successfully redrained endoscopically. The long term success rate (median follow-up, 46 months) of the initial procedure was 62%. CONCLUSION: Transmural endoscopic drainage is a safe procedure with minimal complications. It should be the procedure of choice for pseudocysts associated with chronic pancreatitis or trauma, with a wall thickness of < 1 cm and a visible bulge into the gastrointestinal lumen. Forty percent of pseudocysts fulfilled these criteria in our study.
Ductal dilatation and stenting for residual hepatolithiasis.
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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.
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.
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.
Blood supply of the right and left hepatic ducts.
BACKGROUND: Increasing precision of liver resection and use of reduced liver grafts stimulated this study of the blood supply of the intrahepatic bile ducts. METHOD: Corrosion casts of human liver were dissected to study the blood supply of the right and left hepatic ducts. RESULTS: The dissected casts showed that the ducts are surrounded by a vascular plexus supplied from the main right and left hepatic arteries, segmental arteries, gastroduodenal artery and accessory hepatic arteries. This plexus is closely associated with the arteries supplying the caudate lobe. They arise from both right and left in two general patterns. This plexus links the arterial supplies of the right and left livers. Segment i.v. and the central portion of the left hepatic duct are often supplied by the right arterial system. CONCLUSION: This study provides further insights into bile duct blood supply. The caudate lobe and biliary plexus provide collateral connections between the right and left livers.
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.
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.
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.
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.