Predicting gallstone pancreatitis in HIV infected patients.

BACKGROUND: Human immunodeficiency virus (HIV) infection, low cluster of differentiation (CD)4 counts and antiretroviral therapy can cause cholestasis and raised transaminases. In acute pancreatitis, this may render biochemical predictors of a gallstone aetiology inaccurate. METHODS: In a prospective observational study, acute pancreatitis was diagnosed by standard criteria. Cholecystolithiasis and bile duct diameter were diagnosed by ultrasound. Cholestasis was defined as two of the following: bilirubin ≥ 21 umol/l, γ glutamyl transferase ≥ 78 U/l, alkaline phosphatase ≥ 121 U/l. Cholangitis was defined as cholestasis and any two sepsis criteria: (temperature > 38˚C, WCC > 12.6 ×109/L, pulse > 90 beats/min). Cholangitis, cholestasis, and bile duct diameter greater that 1 cm were indications for endoscopic retrograde cholangiopancreatography (ERCP). These parameters' ability to predict gallstone pancreatitis (GSP) and choledocholithiasis were compared in HIV+ve and HIV-ve patients. RESULTS: Sixty-two (26%) of 216 patients had GSP. Twenty four were HIV+ve patients. More HIV+ve patients had cholestasis (p = 0.059) and ERCP (p = 0.004). In HIV+ve patients alanine aminotransferase (ALT) > 100 U/L, gamma glutamyl transferase (GGT) > 2 upper limit of normal and cholestasis had a negative predictive value of 92%, 96.7% and 95.2% respectively. In HIV-ve patients, negative predictive value (NPV) was 84%, 83.8% and 84.6% respectively. Bile duct stones were demonstrated at ERCP in 6 (25%) and 3 (8%) of HIV+ve and HIV-ve patients respectively (p = 0.077). Five of 14 ERCP patients had no bile duct stones. HIV+ve and HIV-ve groups had two deaths each. CONCLUSION: Absence at presentation of the abnormal parameters analysed were good predictors of a non-gallstone aetiology particularly in HIV+ve patients. Prior, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) would reduce the number of non-therapeutic ERCPs.

Association between chronic pancreatitis and pancreatic cancer at a central hospital in KwaZulu-Natal, South Africa.

BACKGROUND: The frequency of histological chronic pancreatitis (CP) evidence in the resident pancreas of resected periampullary cancers (PACs) has never been studied in Africa. This study aims to describe the spectrum of pathology and outcomes of pancreatic surgeries and address this deficit from a South African central hospital cohort. METHODS: A retrospective audit of patients undergoing pancreatic surgery at Inkosi Albert Luthuli Central Hospital (IALCH) between 2003 and 2023 was conducted. The patient demographics, human immunodeficiency virus (HIV) status, histological subtypes, type and extent of surgery, and 30-day and overall mortality were captured from medical records. The presence of CP in the resident pancreas of patients resected for pancreatic and PAC was obtained from the pathology reports. RESULTS: Of the cohort, 72% were Africans, presenting at an earlier average age than other races. Surgery was performed on 126 (107 for cancer, 19 for CP) patients. Of these, 77 were pancreaticoduodenectomy (PD), of which 34 were for pancreatic ductal adenocarcinoma (PDAC). The prevalence of CP in the resident pancreas was 29.9%, and 55.9% in PDAC. Age was the only factor significantly associated with 30-day mortality, as well as long-term survival amongst patients with pancreatic and PAC. The overall median survival for patients with PAC was seven months; 11 patients are alive. CONCLUSION: In a predominantly African cohort undergoing pancreatic surgery, PDAC presents at a younger age. The high perioperative mortality and low overall survival (OS) in the setting of high CP prevalence in the resident pancreas requires further investigation of its role in the aetiopathogenesis and prognosis in PDAC.

HIV associated malignancies presenting as acute pancreatitis: a case series.

BACKGROUND: Acute pancreatitis (AP) may be the presenting symptom in a small percentage of patients harbouring pancreatic or extra pancreatic tumours. This case series aims to describe the pathological spectrum of tumours detected in two AP cohorts from a high HIV-endemic region. METHODS: Prospectively collected databases of patients admitted with AP over two periods 2001 to 2010 and 2013 to 2015, were retrospectively evaluated to detect those with pancreatic and extra-pancreatic tumours. The diagnosis of AP was by standard criteria. HIV infection and CD4 counts were routinely tested for in the latter period and only tested on clinical grounds in the initial period. CT scan was performed when there was diagnostic doubt, predicted severe disease, and failure to improve clinically after one week. Demographic, clinical, investigative, and pathology details were collected and presented. RESULTS: HIV-positive patients admitted with AP were 106 (17%) of 628 in the first period and 90 (38%) of 238 of the second period. No tumours were diagnosed in the HIV-negative patients. Seven of the HIV-positive patients had tumours diagnosed at endoscopy, CT scan, and endoscopic retrograde cholangiography. Of the seven HIV-positive patients with tumours, two patients had a CD4 count above 200. There were four patients with lymphoma involving the pancreatic head, three having associated cholestasis, and three patients with Kaposi's Sarcoma. One Kaposi's sarcoma patient died three months after presentation. One patient with lymphoma died on day 14 and another two months after initial presentation, and the remaining four patients were referred to oncology. CONCLUSION: Despite their rarity (< 4%), when HIV-positive patients with low CD4 count and cholestasis present with AP, tumours should be suspected and evaluated by cross sectional imaging and endoscopic ultrasound.

Development and internal validation of the survival time risk score in patients treated for oesophageal cancer with palliative intent in South Africa.

BACKGROUND: Most patients who present to South African state hospitals with advanced stage oesophageal squamous cell cancer (OSCC) disease receive palliative treatment. This study aimed to assess the factors that influence survival in patients with OSCC who received palliative management and to develop a prognostic score to aid clinicians in decisionmaking. METHODS: Analysis of a prospectively collected database assessed factors influencing survival of patients diagnosed with OSCC receiving palliative treatment. Factors assessed included patient demographics, clinical and laboratory data and tumour factors. A multivariable logistic regression model was used to assess for significant factors associated with survival time and a prognostic score was developed and internally validated based on these factors. RESULTS: There were 384 patients with a male-to-female ratio of 1.3:1. The median survival of the cohort was 3.7 months. Factors that influenced survival on multivariate analysis included area of residence (aOR 1.82, 95% CI 1.02-3.24), performance status (aOR 2.56, 95% CI 1.50-4.35), body mass index (aOR 1.87, 95% CI 1.14-3.06) and serum albumin (aOR 3.06, 95% CI 1.46-6.42). The final prognostic score contained three of the four independent variables based on the regression coefficient for each variable. After internal validation, the risk score maintained fair discrimination and good calibration. CONCLUSION: The prognostic scoring system based on patient performance status, body mass index and serum albumin, if validated on an independent cohort, would allow more objective decisions on whether to stage or not prior to embarking on palliative treatment, streamlining care and improving quality of life.

HIV associated malignancies presenting as acute pancreatitis: a case series.

BACKGROUND: Acute pancreatitis (AP) may be the presenting symptom in a small percentage of patients harbouring pancreatic or extra pancreatic tumours. This case series aims to describe the pathological spectrum of tumours detected in two AP cohorts from a high HIV-endemic region. METHODS: Prospectively collected databases of patients admitted with AP over two periods 2001 to 2010 and 2013 to 2015, were retrospectively evaluated to detect those with pancreatic and extra-pancreatic tumours. The diagnosis of AP was by standard criteria. HIV infection and CD4 counts were routinely tested for in the latter period and only tested on clinical grounds in the initial period. CT scan was performed when there was diagnostic doubt, predicted severe disease, and failure to improve clinically after one week. Demographic, clinical, investigative, and pathology details were collected and presented. RESULTS: HIV-positive patients admitted with AP were 106 (17%) of 628 in the first period and 90 (38%) of 238 of the second period. No tumours were diagnosed in the HIV-negative patients. Seven of the HIV-positive patients had tumours diagnosed at endoscopy, CT scan, and endoscopic retrograde cholangiography. Of the seven HIV-positive patients with tumours, two patients had a CD4 count above 200. There were four patients with lymphoma involving the pancreatic head, three having associated cholestasis, and three patients with Kaposi's Sarcoma. One Kaposi's sarcoma patient died three months after presentation. One patient with lymphoma died on day 14 and another two months after initial presentation, and the remaining four patients were referred to oncology. CONCLUSION: Despite their rarity (< 4%), when HIV-positive patients with low CD4 count and cholestasis present with AP,tumours should be suspected and evaluated by cross sectional imaging and endoscopic ultrasound.

Recurrence after Delorme's procedure in a single and multi-surgeon setting.

BACKGROUND: Delorme's procedure (DP) is a perineal repair reserved for full-thickness rectal prolapse (FTRP) in elderly/comorbid patients due to its low perioperative morbidity. Reported recurrence rates are higher than for abdominal approaches. This study reports the long-term clinical outcomes of recurrence and postoperative bowel function after DP. METHODS: A retrospective cohort study including all patients who underwent a DP for FTRP between February 2001 and March 2014 at two primary study sites: Groote Schuur Hospital (multi-surgeon) and Kingsbury Hospital (singlesurgeon). Primary outcome was the absence of recurrence of FTRP after DP. Secondary outcomes were 30-day mortality and morbidity, postoperative bowel function and length of hospital stay. RESULTS: 70 patients underwent DP: 37 were operated on by the single surgeon and 33 by multiple surgeons. The median age was 76 years (IQR 20 years). Median length of follow-up was 46 months (IQR 55 months). 16 recurrences occurred: 7 in the single-surgeon cohort and 9 in the multi-surgeon cohort (p = 0.4). Median time to recurrence was 23 months (IQR 36 months): 48 months in the single-surgeon cohort and 15 months in the multi-surgeon cohort (p = 0.6). Six patients each had minor and major complications. Three patients died postoperatively. 8 patients required reoperation. Median postoperative hospital stay was three days (IQR 2 days). There were no significant differences between the multi-surgeon and single-surgeon cohorts. CONCLUSION: Long-term follow-up demonstrates a recurrence rate of 23% after DP, with no difference between an experienced colorectal specialist and supervised trainee surgeons.

Do upper GI bleed guidelines reach patient care: effect of a quality improvement initiative.

BACKGROUND: Adherence is variable in clinical practice to consensus guidelines on the management of upper gastrointestinal bleeding. We aimed to assess the effect of a quality improvement program (QIP) on guideline adherence. METHODS: A QIP was undertaken over a two-month period. Data were collected retrospectively, for the one-year pre QIP and prospectively for one-year post QIP. The QIP goals were adherence to criteria for the timing of oesophagogastroduodenoscopy (OGD), achievement of dual endotherapy and blood transfusion triggers. RESULTS: Fifty-one patients were pre QIP and 58 post QIP. The two groups' baseline data were comparable. Over 80% had their OGD within 24 hours (pre QIP 82.3%, post QIP 81.0%). The overall and high-risk groups (variceal and MBS > 10) had an insignificantly longer time to OGD (mean 19.2 and 17.8 hours respectively) in the post QIP cohort (mean 14.2 and 15.2 hours).The practice of dual endotherapy improved post QIP (p = 0.02) for non-variceal bleeding. The Hb g/dL (mean + SD) in stable patients who were transfused was significantly different pre QIP (6.3 + 2) and post QIP (5.7 + 1.69) (p = 0.04). Twelve patients (23.5%) were transfused for Hb above 7 g/dl pre QIP and six (10.3%) post QIP (p = 0.047). Thirty-day mortality rate was 9.8% (pre QIP) and 10.3% (post QIP). Univariate analysis showed that Grade III shock was the only significant factor in determining 30-day mortality. CONCLUSION: This QIP had no effect on time to OGD adherence which compares favorably to similar audits. Adherence to transfusion triggers and the ability to deliver dual endotherapy routinely were positive QIP outcomes.

Prevalence and characteristics of incidental colorectal polyps in patients undergoing colonoscopy at a South African tertiary institution.

BACKGROUND: There is a lack of data on the frequency and pattern of colorectal adenomas in sub-Saharan Africa to guide diagnostic and preventive strategies for colorectal cancer (CRC) in the region. OBJECTIVES: To describe polyp characteristics and adenoma frequency in patients at average risk of CRC, who are undergoing colonoscopy for bowel symptoms at a tertiary hospital in South Africa (SA). METHODS: Colonoscopy records from the prospective endoscopy database at Groote Schuur Hospital, Cape Town, SA, from August 2014 to February 2017, were retrieved. The presence of polyps, and their morphology, size, site and number in relation to ethnicity, symptoms and colonoscopy quality indicators were analysed. The histological type and grade were obtained from laboratory records and analysed. The primary endpoint was the adenoma detection rate (ADR). Age, gender, ethnicity, symptoms, bowel preparation and caecal intubation rates were also compared between patients with adenomas and those without. RESULTS: Of 1 334 colonoscopies, 342 were performed in patients at increased risk of premalignant lesions; these were excluded from the analysis. Polyps were identified in 172 of the remaining 992 patients (17.3%), whose self-declared ethnicity was mixed race (76%), white (12%), black African (11%) or Asian (1%). The quality of bowel preparation and caecal intubation rate were similar between patients with polyps and those without. Patients with polyps were older than those without polyps (mean age 61.5 (standard deviation 12.9) v. 56.3 (17.4) years; p<0.002). On histological examination of these polyps, 119 were adenomas, 26 were hyperplastic and 27 were normal. The majority of the adenomas were tubular (80%), and there were only 6% with high-grade dysplasia. Half (51%) of the adenomas were in the proximal colon, and the overall ADR was 12%. The ADR (prevalence) was highest in white and Asian South Africans (18% each), followed by that in persons of mixed race (13%), but much lower in black Africans (5%). CONCLUSIONS: This study provides a benchmark ADR for our catchment population and potentially across Africa. There is evidence of a continuing differential colorectal neoplasia risk according to ethnicity, with fewer adenomas being detected in black South Africans.

Oesophageal cancer in Area 2 of Kwazulu-Natal: predictors of late presentation.

BACKGROUND: There are limited prospective data sets on clinical characteristics, stage of presentation and treatment of patients with Oesophageal Squamous Cell Carcinoma (OSCC) in South Africa. This study aimed to assess the frequency and severity of clinical characteristics associated with late presentation of patients with OSCC presenting to a cancer referral centre in KwaZulu-Natal, South Africa. METHODS: A prospective consecutive series of patients presenting with confirmed OSCC treated at Greys Hospital in 2016/2017 were enrolled. Data collected included: age, gender, home language, referral centre, clinical and laboratory characteristics: dysphagia score, Eastern Cooperative Oncology Group (ECOG) performance status, body mass index (BMI), serum albumin, tumour pathology and treatment administered. RESULTS: One hundred patients were analysed. Ninety four percent spoke isiZulu. The mean age was 61 with a male to female ratio of 1.5:1 Ninety percent had palliative treatment as their overall assessment precluded curative treatment. Five patients underwent curative treatment. The age standardised incidence (ASR) was 25.2 per 100 000. The factors associated with late presentation and their frequency were: advanced dysphagia grade (

Resection of biliary mucinous cystic neoplasms of the liver: a prospective cohort series of 13 consecutive patients.

BACKGROUND: Biliary mucinous cystic neoplasms (BMCNs) are uncommon neoplastic septated intrahepatic cysts which are often incorrectly diagnosed and have the potential for malignant transformation. OBJECTIVE: To assess the outcome of surgical resection of BMCNs. METHOD: A prospective liver surgery database was used to identify patients who underwent surgery at Groote Schuur Hospital Complex for BMCN from 1999 to 2015. Demographic variables including age and gender were documented as well as detailed preoperative imaging, location and size, operative treatment, extent of resection, histology, postoperative complications and outcome. RESULTS: Thirteen female patients (median age 45 years) had surgery. Eleven were diagnosed by imaging for symptoms. Two were jaundiced. One cyst was found during an elective cholecystectomy. Five cysts were located centrally in the liver. Before referral three cysts were treated with percutaneous drainage and two were treated with operative deroofing. Six patients had anatomical liver resections and seven patients had non anatomical liver resections of which two needed ablation of residual cyst wall. One patient needed a biliary-enteric reconstruction to treat a fistula. Median operative time was 183 minutes (range: 130-375). No invasive carcinoma was found. There was no operative mortality. One surgical site infection and one intra-abdominal collection were treated. Two patients developed recurrent BMCN after 24 months. CONCLUSION: BMCNs should be considered in middle aged women who have well encapsulated multilocular liver cysts. Treatment of large central BMCNs adjacent to vascular and biliary structures may require technically complex liver resections and are best managed in a specialised hepato-pancreatico-biliary unit.

Resection of biliary mucinous cystic neoplasms of the liver: a prospective cohort series of 13 consecutive patients

Background: Biliary mucinous cystic neoplasms (BMCNs) are uncommon neoplastic septated intrahepatic cysts which are often incorrectly diagnosed and have the potential for malignant transformation.Objectives:To assess the outcome of surgical resection of BMCNs.Methods:A prospective liver surgery database was used to identify patients who underwent surgery at Groote Schuur Hospital Complex for BMCN from 1999 to 2015. Demographic variables including age and gender were documented as well as detailed preoperative imaging, location and size, operative treatment, extent of resection, histology, postoperative complications and outcome.Results:Thirteen female patients (median age 45 years) had surgery. Eleven were diagnosed by imaging for symptoms. Two were jaundiced. One cyst was found during an elective cholecystectomy. Five cysts were located centrally in the liver. Before referral three cysts were treated with percutaneous drainage and two were treated with operative deroofing. Six patients had anatomical liver resections and seven patients had non anatomical liver resections of which two needed ablation of residual cyst wall. One patient needed a biliary-enteric reconstruction to treat a fistula. Median operative time was 183 minutes (range: 130­375). No invasive carcinoma was found. There was no operative mortality. One surgical site infection and one intra-abdominal collection were treated. Two patients developed recurrent BMCN after 24 months.Conclusion:BMCNs should be considered in middle aged women who have well encapsulated multilocular liver cysts. Treatment of large central BMCNs adjacent to vascular and biliary structures may require technically complex liver resections and are best managed in a specialised hepato-pancreatico-biliary unit

Auditing surgical service provision at a South African tertiary institution: Implications for the development of district services.

BACKGROUND: The optimal management of resources within South African state hospitals has been hampered by a paucity of data due to a lack of robust auditing information systems. This study reviews the use of a Hybrid Electronic Medical Record (HEMR) system to capture and aggregate data pertaining to the inpatient service demands on a South African tertiary surgical service. This dataset was used to analyse the appropriateness of tertiary surgical resource utilisation. METHOD: The HEMR system was implemented at Greys Hospital, in the city of Pietermaritzburg, Kwa-Zulu Natal, South Africa on 1 January 2013. Inpatient data pertaining to surgical admissions and operative interventions were captured prospectively. Following an 18-month study period, the data were extracted, aggregated and analysed. The district referral hospitals were mapped, and district surgical procedures performed within the tertiary center were identified and quantified. Results: 7314 patients were admitted and managed by the tertiary surgical service during the study period. The median patient age was 33 years (IQR 6.5-42.4 years). 59.7% were male and 40.3% were female. General, trauma and paediatric surgical admissions constituted 54.8%, 28.6% and 16.6% respectively. Emergency admissions constituted 62.4% and elective admissions 37.6%. Referral sources were captured for 6653 (91%) of the cohort. 4338 (65.2%) patients were referred from district hospitals. The district hospital (Northdale) closest to Greys Hospital was responsible for 1675 (25.2%) of surgical referrals. 4174 operative procedures were performed during the study period, 54.7% performed as an emergency, 34.1% electively and 11.2% semi-electively. The median waiting time for emergency operative intervention was 535 minutes (IQR 130-663). A total of 1272 (30.5%) operative procedures performed were assessed as district-level operations. The time intervals of 07:00-07:59 and 17:00-17:59 were identified as the time periods during which the least number of emergency procedures were performed in the operating theatres. CONCLUSION: The HEMR system enabled the Pietermaritzburg Metropolitan Department of Surgery to quantify the burden of surgical disease and map district referral patterns. Thirty percent of operative procedures performed were assessed as district-level operations. Potentially correctable deficits identified within the tertiary center were lengthy delays to emergency surgery and non-optimal theatre utilisation periods.

Predictors of emergency colectomy in patients admitted with acute severe ulcerative colitis.

BACKGROUND: Acute Severe Ulcerative Colitis (ASUC) is a life-threatening condition which requires urgent and aggressive medical therapy to reduce mortality, morbidity and avoid surgery. To facilitate this process, it is essential to identify patients at high risk of poor outcomes and emergency colectomy. Numerous such risk factors have been described in Western literature, however there is no local data addressing this issue. As such it is unclear if these predictors are applicable in our setting. The aim of this study is thus to identify risk factors for emergency colectomy in patients admitted to Groote Schuur Hospital with ASUC. METHOD: A retrospective cohort study of 98 patients admitted with ASUC between January 2003 and January 2013 was performed. Clinical, demographic, laboratory and endoscopic factors on admission and 3 days thereafter were analysed as predictors of colectomy by univariate and multivariate analysis. RESULTS: Twenty-five percent of the cohort underwent emergency colectomy. On univariate analysis, factors predicting colectomy on admission were exposure to oral corticosteroids (p=0.01), megacolon (p=0.049) or mucosal islands (p=0.04) on abdominal X-ray, and a short duration from UC diagnosis until presentation with ASUC (p=0.04). The only variable that was significantly associated with colectomy on day 3 was serum albumin (p=0.01). This was also the only variable to remain significant on multivariate analysis (OR 0.79, 95% CI 0.65-0.97, p=0.01). CONCLUSION: ASUC is a medical emergency and predicting colectomy risk aids in therapeutic management. The only variable significantly associated with the need for surgery in our study was hypoalbuminaemia on day 3. Given the small study numbers a larger prospective study would be of value.

Incidence and management of postoperative bile leaks: A prospective cohort analysis of 467 liver resections.

BACKGROUND: Bile leaks from the parenchymal transection margin are a major cause of morbidity following major liver resections. The aim of this study was to benchmark the incidence and identify the risk factors for postoperative bile leakage after hepatic resection. PATIENTS AND METHODS: A prospective database of 467 consecutive liver resections performed by the University of Cape Town HPB surgical unit between January 1990 and January 2016 was analysed. The relationship of demographic, clinical and perioperative factors to the development of bile leakage was determined. Bile leak and postoperative complications severity were graded using the International Study Group of Liver Surgery and Accordion classifications. RESULTS: Overall morbidity was 24% (n = 112), with bile leaks occurring in 25 (5.4%) patients. Significantly more bile leaks occurred in patients who had major resections (≥ 3 segments) and longer total operative times (p < 0.05). There were 5 Grade A bile leaks which stopped spontaneously. Seventeen Grade B leaks required a combination of percutaneous drainage (n = 15), endoscopic biliary stenting (n = 8) and percutaneous transhepatic biliary drainage (n = 3). All 3 Grade C leaks required laparotomy for definitive drainage. Median hospital stay in the 442 patients without a bile leak was 8 days (IQR 1-98) compared with 12 days (IQR 6-30) for the 25 with bile leaks (p < 0.05) with no mortality. Major resections (≥ 3 segments) and total operative time (> 180mins) were significantly associated with bile leaks. CONCLUSION: The incidence of bile leakage was 5.4% and occurred after major liver resections with longer operative times and resulted in significantly extended hospitalisation. Most were effectively treated nonoperatively by percutaneous drainage of the collection and/or endoscopic or percutaneous biliary drainage without mortality.

Primary seromucinous cystadenocarcinoma of the mesentery.

A 72-year-old woman presented with a slow growing mass on the left side of the abdomen, which was found to originate from the mesentery of the descending colon. Histopathology revealed a seromucinous cystadenocarcinoma of the mesentery, a rare clinical entity occurring most often in females. There are only 20 cases reported in the literature. It is postulated that these tumours develop as a result of serous or mucinous metaplasia of pre-existing coelomic mesothelium. Surgical excision remains the mainstay of successful management.

Granulomas at initial diagnosis of Crohn's disease signal a poor outcome.

BACKGROUND: Over time, most patients with Crohn's disease (CD) develop strictures or fistulas, resulting in hospitalisations and surgery. Timely therapy with immunomodulators and biologicals may alter this natural history, but carries a significant risk of side-effects. OBJECTIVE: To identify factors to predict poor-outcome severe CD at diagnosis, and thus patients who would benefit most from early, aggressive medical therapies. METHODS: CD patients (n=101) with uncomplicated non-stricturing, non-penetrating disease at diagnosis, and with follow-up >5 years, were retrospectively analysed using a predefined definition of severe CD (SCD) over the disease course. Clinical, demographic, laboratory and histological factors at diagnosis associated with SCD and poor outcome were evaluated by univariate and multivariate analysis. RESULTS: Overall 33.7% of the cohort developed SCD, and on multivariate Cox proportional hazard analysis the presence of granulomas on endoscopic biopsy at diagnosis was independently associated with development of SCD (hazard ratio (HR) 2.3; 95% confidence interval (CI) 1.15 - 4.64; p=0.02). Simple perianal disease was also associated with this outcome (HR 2.49; 95% CI 1.14 - 5.41; p=0.02). The presence of these variables had a specificity of 99% and a positive predictive value of 88%. CONCLUSION: At diagnosis, factors predictive of SCD in our referral centre were endoscopic biopsy granulomas and perianal disease. Patients with these risk factors should be considered for early, aggressive medical therapy, as benefit will probably outweigh risk. To our knowledge, this is the first study to show that endoscopic biopsy granulomas in patients with uncomplicated (non-stricturing, non-penetrating) CD predict the subsequent development of SCD.

Lessons from emergency laparotomy for abdominal tuberculosis in the HIV/AIDS era.

BACKGROUND: The rising incidence of HIV/AIDS has resulted in a resurgence of abdominal tuberculosis (TB) in HIV-positive patients in South Africa. These often debilitated patients frequently present with acute complications requiring surgery. METHODS: A prospective audit of all patients with abdominal TB undergoing emergency laparotomy was conducted. From January 2008 to June 2010, 49 patients had emergency laparotomy and specimens obtained from them were diagnostic of TB. Twenty-five were males and 24 females, with a median age of 32 years (range 2 - 62). Thirty-nine patients were HIV-positive (79.6%). RESULTS: Intra-operative findings were bowel perforations in 13 cases, small-bowel obstruction in seven, a frozen abdomen in ten, and enlarged lymph nodes and an ileocaecal mass in 19. Eleven patients (22.4%) underwent small-bowel resection and eight (16.3%) right hemicolectomy. Eighteen patients (36.7%) ended up with stomas, 14 (28.6%) had re-laparotomies, and 18 (36.7%) were admitted to the intensive care unit. Twenty-three patients (46.9%) required blood transfusion and 15 (30.6%) total parenteral nutrition. Three patients (6.1%) developed an enterocutaneous fistula and 19 (38.8%) died. Pre-operative illness severity indices of acidosis, anaemia and hypo-albuminaemia were significant predictors of death, but mode of presentation and surgical interventions were not. CONCLUSION: Laparotomy as currently practised for the 'acute abdomen' in patients with suspected HIV and abdominal TB is associated with very high morbidity and mortality, which is related to pre-operative severity indices. More liberal use of imaging may define cases in which a more conservative approach could improve outcome.

A prospective audit of the use of diagnostic laparoscopy to establish the diagnosis of abdominal tuberculosis.

BACKGROUND: The incidence of abdominal tuberculosis is much higher in an HIV-positive cohort. The use of laparoscopy in the diagnostic work-up of suspected abdominal tuberculosis is underutilized and its use and efficacy in the context of HIV co-infection has never been examined. METHODS: A prospective clinical audit of the use of diagnostic laparoscopy was conducted in patients with clinically suspected abdominal tuberculosis but histologically or microbiologically unconfirmed tuberculosis at any site. RESULTS: From January 2008 to June 2010, 81 patients underwent diagnostic laparoscopy; 34 were male and 47 were female, with a mean age of 33 years, and 77 % were HIV-positive. Fifty-five patients (68 %) had positive histology or culture for tuberculosis. In 15 patients (19 %), histology revealed non-specific inflammation, no pathology was found in one patient, and no specimen was taken from one patient. Eighty percent of peritoneal deposits and 77 % of lymph nodes were positive for tuberculosis, whereas 35 % of ascitic fluid cultures were positive. In nine patients (11 %) an alternative diagnosis was found; nine patients (11 %) had conversion to laparotomy. There was no procedure-related death. Nine patients (11 %) died during the 2-month follow-up period. CONCLUSIONS: Diagnostic laparoscopy avoids the morbidity and mortality of laparotomy in chronically ill patients, and reduces the rate of misdiagnosis of other abdominal conditions and unnecessary long-term therapy. Diagnostic laparoscopy and tissue sampling is a viable and reliable strategy in patients with suspected abdominal tuberculosis.

Assessing the gap between the acute trauma workload and the capacity of a single rural health district in South Africa. What are the implications for systems planning?

INTRODUCTION: This study focuses on a single rural health district in South Africa, and attempts to establish the burden of disease and to review the capacity of the district hospitals to deal with this load. METHODS: Ethical approval to undertake this study was obtained from both the University of Kwa-Zulu Natal and the Department of Health. The audit was performed over a 6-month period in the four district hospitals of rural Sisonke District. There were four components to this audit. 1. Information on the hospital incidence of acute trauma in Sisonke was also sourced from the epidemiology unit of the Department of Health in Pietermaritzburg 2. Each of the district hospitals was visited and the medical manager was interviewed. The medical manager was asked to complete the World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. (SAT). 3. The operative registers were reviewed to determine the number of index cases for trauma. This information was used to determine the unmet need of acute trauma in the district. 4. Each hospital was classified according to the Trauma Society of South Africa (TSSA) guidelines for levels of trauma care. RESULTS: The annual incidence of trauma in the Sisonke District is estimated to be 1,590 per 100,000 population. Although there appeared to be adequate infrastructure in the district hospitals, the SAT revealed significant deficits in terms of capacity of staff to adequately treat and triage acute trauma patients. There is a significant unmet need for trauma care in Sisonke. The four district hospitals can best be classified as Level IV centers of trauma care. CONCLUSION: There is a significant burden of trauma in the Sisonke District, yet the capacity to deal with this burden is inadequate. Although the physical infrastructure is adequate, the deficits relate to human resources. The strategic choices are between enhancing the district hospitals' capacity to deal with acute trauma, or deciding to bypass them completely and deliver all acute trauma patients to large regional trauma centers. If the first option is chosen, urgent intervention is required to build up the human resource capacity of district hospitals.

Laparoscopic splenectomy for immune thrombocytopenic purpura.

BACKGROUND: Laparoscopic splenectomy has become the preferred method of splenectomy for refractory immune thrombocytopenic purpura (ITP). We present our experience with the introduction of laparoscopic splenectomy for ITP. METHODS: Over a 2-year period, retrospective and prospective data were collected on all patients undergoing laparoscopic splenectomy for ITP at our institution. We analysed demographic data, peri-operative courses, platelet count responses and complications. RESULTS: Twenty laparoscopic splenectomies were performed. There were 2 conversions to an open procedure. The average operating time was 100 minutes (range 30 - 170 minutes), and mean blood loss was 106 ml (range 50 - 200 ml). There were no deaths or major complications. The mean follow-up period was 7 months. Ninety-five per cent of patients had a complete or partial response to splenectomy. CONCLUSION: Laparoscopic splenectomy can be introduced safely with an acceptable conversion rate, and is an effective treatment for ITP on short-term follow-up.