Search PubMed⌕ Search

Biomedical subjects

J Terblanche

Publications and source records attributed to J Terblanche.

At least 37 records · Page 2Linked to original sources
PubMed1997

The treatment of oesophageal varices: a debate and a discussion.

At the Biennial Meeting of the International Association for the Study of the Liver, in Cape Town, South Africa, 20-24 February 1996, the treatment of oesophageal varices was selected as a subject for the discussion of controversies in portal hypertension. This review gives a summary of that discussion. Dr Didier LeBrec gave a broad overview of the medical management of oesophageal varices by presenting a list of 52 pharmacological agents that reduce portal venous pressure and presented the advantages and disadvantages of each. He emphasized that recent randomized clinical trials (RCT) have demonstrated that propranolol delays and decreases the occurrence of haemorrhage from varices in patients who have not previously suffered such complications. He also reported that isosorbidemononitrate is equally effective and further enhances the effect of propranolol. He also reported that the effects of propranolol plus endoscopic sclerotherapy (EST) were more effective than EST alone in preventing haemorrhage, but not in improving survival. Finally he noted that propranolol in high dosage did not prevent the development of large varices in cirrhotic patients with small or undetectable varices. Dr John Terblanche compared the efficacy of EST and endoscopic ligation of varices (ELV) and reported that all four RCTs found ELV to be superior. He discussed portacaval anastomosis (PCA) and concluded that only emergency PCA as reported by Orloff, is thought to be truly beneficial, and suggested that EST, plus ELV may be the treatment of choice. Dr Harold O. Conn, who served as the moderator of this session summarized the presentations and pointed out that liver transplantation is the most effective form of therapy of all, albeit extremely complex and expensive. He discussed transjugular intrahepatic portosystemic shunts (TIPS), the newest form of therapy, and emphasized its virtues (immediate reduction of portal venous pressure) and its limitations (frequent portosystemic encephalopathy and frequent spontaneous stenoses). He presented a brief discussion of the prevention of the development of the varices themselves, currently termed "pre-primary prophylaxis', a hope for the future. He ended with "Predictions' which if proven correct will give a preview of portal hypertension in the 21st century.

Esophageal and Gastric Varices↗
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↗
PubMed1997

The management of biliary complications following orthotopic liver transplantation.

OBJECTIVE: Review of the biliary complications following orthotopic liver transplantation (OLT) at our institution, and their management and outcome. DESIGN: Retrospective study of medical records of 63 patients who underwent 68 transplant operations. SETTING: The Liver Transplant Unit, Groote Schuur Hospital and Red Cross War Memorial Children's Hospital, Cape Town PATIENTS: Six patients treated for 9 biliary complications. INTERVENTIONS: Reoperation with biliary reconstruction, or non-operative measures by either endoscopic retrograde pancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). OUTCOME MEASURES: Clinical outcome and survival following treatment for biliary complications. RESULTS: Biliary complications occurred in 8.8% of patients who underwent transplantation at our institution. These consisted of strictures in 4 patients (with leak in 2), bile leak in 1 patient, and unsuspected primary sclerosing cholangitis (PSC) of the recipient duct in 1 patient. The mean time interval of biliary complications following OLT was 8 weeks (range 3-16). Biliary reconstruction was required in 4 patients while 2 patients were treated by endoscopic stenting. After a mean follow-up period of 30 months (range 1-64), 4 patients remained stable, 1 patient developed progressive stricturing of the intrahepatic ducts requiring repeated PTC dilatations, and 1 patient experienced stent blockages requiring endoscopic stent changes (died of unrelated causes). CONCLUSIONS: The rate of biliary complications following OLT at our institution compares favourably with literature reports. While biliary reconstruction is usually needed, endoscopic stenting appears effective in selected cases of biliary stricture and leak. PSC should be excluded prior to transplantation in young patients with cryptogenic cirrhosis.

Adolescent↗
PubMed1997

Endoscopic management of pancreatic pseudocysts.

BACKGROUND: Pancreatic pseudocysts may produce pain, or biliary or duodenal obstruction. Those over 6 cm in diameter or associated with chronic pancreatitis are unlikely to resolve and usually require intervention. There are a number of treatment modalities available and this paper reviews the role of endoscopic drainage. METHODS: All articles and case reports quoted on Medline (National Library of Medicine, Washington DC, USA) containing the text words 'endoscopy' and 'pseudocyst', and citations from these references were reviewed. RESULTS: Endoscopic drainage is technically feasible in around 50 per cent of pancreatic pseudocysts associated with chronic pancreatitis. Successful drainage occurred in 82-89 percent. The major complication is bleeding which required surgery for control in 5 per cent of procedures. One death attributable to the procedure has been reported. Recurrence rates range from 6 to 18 per cent with up to 4 years' follow-up. As in open surgery, recurrence is highest with drainage via the stomach. CONCLUSION: Endoscopic drainage provides a minimally invasive approach to pseudocyst management, with success and recurrence rates similar to those of open surgery but with lower morbidity and mortality rates. It should be considered the treatment of choice for pseudocysts less than 1 cm thick which bulge into the stomach or duodenum, or for those which communicate with the main pancreatic duct.

Drainage↗
PubMed1996

Surgery in South Africa.

The practice of surgery in South Africa ranges from full-time service in state-funded and academic hospitals serving a largely indigent population to a private sector for medically insured patients. Surgical training occurs at eight medical schools, and specialist registration is obtained after 4 to 5 years with either a university-conferred degree or a fellowship from the College of Surgeons of South Africa. The wide spectrum of First- to Third-World diseases and the high incidence of trauma provide comprehensive experience for practical training. Surgical standards are uniformly high, matching and sometimes pioneering the very best of Western medicine. The health care system is undergoing radical change to correct the imbalances of the apartheid era. Academic institutions are under pressure, and with incipient major financial cutbacks, there is concern that the proud record of service, teaching, and research excellence may be compromised. To facilitate the mission of broadening health care services, diploma training in surgery for rural practitioners is being developed. Outreach programs and closer liaisons with surgical societies in sub-Saharan African countries have also been initiated.

Academic Medical Centers↗
PubMed1996

Operative strategies in pancreatic trauma.

Pancreatic injuries are relatively uncommon and the choice of an appropriate operative procedure can be difficult. Operations for pancreatic trauma from January 1990 to June 1993 have been reviewed. Fifty-one patients were studied; 13 had blunt trauma, 17 gunshot wounds and 21 stab wounds. The distribution of injuries was: pancreatic head (17), body (15) and tail (19). Most patients had associated injuries of surrounding organs. Operations performed included pancreatoduodenectomy (seven), distal pancreatectomy (seven) and external drainage (35). Five patients (10 per cent) died: two from haemorrhage, one from an acute subdural haematoma and two from multiple organ failure. Ten patients (20 per cent) developed a pancreatic fistula, four following blunt trauma, four after gunshot wounds and two with stab wounds; all but one had undergone drainage procedures. Stab wounds were associated with a low incidence of duct injury and external drainage was usually satisfactory. After blunt trauma and gunshot wounds, duct injuries were common and easily missed; careful exploration by an experienced surgeon is essential. In appropriately selected patients, pancreatic resection can be performed with good result.

Adolescent↗
PubMed1995

Choledochal cysts in adults.

Fourteen adults who presented with choledochal cysts were studied. Symptoms in most cases were non-specific, which resulted in delayed diagnosis. Associated extracystic hepatobiliary disease occurred in 11 patients, including two with cholangiocarcinoma. Nine patients underwent total cyst excision (eight Todani classification type I and one type II), while four with type IVa cysts had excision of the extrahepatic cyst component. There were no surgical deaths. One patient with metastases was treated conservatively. Median follow-up was 6.5 years. Two of three patients who developed anastomotic strictures underwent successful revision surgery, while one with secondary sclerosing cholangitis developed biliary cirrhosis and died from hepatic failure after 8 years. Both patients with cholangiocarcinoma have died. Ten survivors are well and one patient was lost to follow-up. This study highlights the complexity of choledochal cysts in adults and emphasizes the need for earlier diagnosis and treatment. Cyst excision should be performed where possible, with reconstruction modified to deal with the cyst type as well as associated hepatobiliary pathology.

Adolescent↗
PubMed1995

Choledochal cyst in pregnancy: a therapeutic dilemma.

BACKGROUND: Choledochal cysts occurring in pregnant women represent a diagnostic and therapeutic challenge to a broad spectrum of the medical profession. Not only is the association rare, but the clinical signs and symptoms are obscured by physiological changes that occur during pregnancy. As a result, diagnosis is often delayed until patients present with life-threatening complications. STUDY DESIGN: This report describes three cases of choledochal cysts occurring during pregnancy. RESULTS: Although the diagnosis was initially missed in two patients, delayed treatment was not associated with an adverse outcome. In a third patient, conservative management was complicated by rupture of the cyst which resulted in fetal loss and a protracted hospital course. Definitive cyst surgery resulted in a good long-term result in all three patients. CONCLUSIONS: Although choledochal cysts rarely occur in pregnancy, clinicians need to be aware of the condition, as delayed or inappropriate therapy may be catastrophic for both mother and child. Once the diagnosis is established, patients should be referred to specialized centers where treatment can be carefully planned, bearing in mind maternal and fetal well-being, as well as the likelihood of cyst-related complications both in the short- and long-term period. Excision with reconstruction is the procedure of choice to treat this type of cyst in nonpregnant patients. In pregnancy, however, a more conservative approach may have to be adopted until the second trimester or after delivery, when the surgical risk is lowest. Elective cesarean section should be undertaken in patients in whom the cyst has not been decompressed so as to avoid the complication of cystic rupture postpartum.

Abortion, Spontaneous↗
PubMed1994

Endoscopic drainage of traumatic pancreatic pseudocyst.

Pancreatic pseudocyst following trauma is usually caused by a major duct injury and may present late. The outcome of endoscopic treatment in five patients with post-traumatic pseudocyst is described. Diagnosis was made from 3 weeks to 1 year after injury by ultrasonography and computed tomography. A distinct bulge was visible in the stomach or duodenum using endoscopic retrograde cholangio-pancreatography, and a cyst enterostomy was established with a knife or standard papillotome. Successful drainage was achieved without complications. One patient developed a recurrence, which was redrained endoscopically, but surgical intervention was required for persistent pain. Early results suggest that endoscopic drainage for selected pancreatic pseudocysts is feasible and safe.

Adult↗
PubMed1994

A 15-year experience of injection sclerotherapy in adult patients with extrahepatic portal venous obstruction.

OBJECTIVE: The authors report a 15-year experience with injection sclerotherapy in the management of adult and teenage patients with esophageal varices due to extrahepatic portal venous obstruction (EHPVO). SUMMARY BACKGROUND DATA: Extrahepatic portal venous obstruction is an uncommon cause of esophageal varices and is associated with normal liver function. Effective control of variceal bleeding is the major factor influencing survival. The results of surgery have been unsatisfactory, and therefore, more conservative management policies have been adopted. METHODS: Fifty-five patients with proven EHPVO underwent repeated injection sclerotherapy via either a modified rigid esophagoscope under general anaesthesia or a fiber-optic endoscope under light sedation, using ethanolamine oleate as the sclerosant. RESULTS: Esophageal varices were eradicated in 44 patients after a median number 6 injections (range 1-17) over a mean of 12.5 months (range 1-48). The mean follow-up was 6.8 years (range 1.1-14.6 years). Eleven patients were admitted on eighteen occasions with bleeding from esophageal varices before eradication and there were seven bleeding episodes in six patients from recurrent varices after initial eradication. Complications related to sclerotherapy included injection site leak (6), stenosis (11) and mucosal ulceration (32) during 362 injection sclerotherapy episodes. Four patients died during the study period. CONCLUSIONS: Injection scelotherapy is the treatment of choice in most patients with EHPVO.

Adult↗
PubMed1994

Liver transplantation for severe Lepiota helveola poisoning.

Orthotopic liver transplantation in patients with fulminant hepatic failure secondary to Lepiota helveola poisoning has not, to our knowledge, been reported. Our recent experience with liver transplantation in a 27-year-old woman with acute hepatic failure secondary to this poisoning is described. The indications for orthotopic liver transplantation are discussed.

Adult↗