Jake E. Krige

Biliary tract obstruction in chronic pancreatitis

Bile duct strictures are a common complication in patients with advanced chronic pancreatitis and have a variable clinical presentation ranging from an incidental finding to overt jaundice and cholangitis. The diagnosis is mostly made during investigations for abdominal pain but jaundice may be the initial clinical presentation. The jaundice is typically transient but may be recurrent with a small risk of secondary biliary cirrhosis in longstanding cases. The management of a bile duct stricture is conservative in patients in whom it is an incidental finding as the risk of secondary biliary cirrhosis is negligible. Initial conservative treatment is advised in patients who present with jaundice as most will resolve once the acute on chronic attack has subsided. A surgical biliary drainage is indicated when there is persistent jaundice for more than one month or if complicated by secondary gallstones or cholangitis. The biliary drainage procedure of choice is a choledocho-jejunostomy which may be combined with a pancreaticojejunostomy in patients who have associated pain. Since many patients with chronic pancreatitis have an inflammatory mass in the head of the pancreas, a Frey procedure is indicated but a resection should be performed when there is concern about a malignancy. Temporary endoscopic stenting is reserved for cholangitis while an expandable metal stent may be indicated in patients with severe co-morbid disease.

Selective nonoperative management of liver gunshot injuries.

Objective:Nonoperative management (NOM) of liver gunshot injuries is yet to gain general acceptance. The aim of this study was to assess the feasibility and safety of selective NOM of liver gunshot injuries. Patients and Methods:A prospective, protocol-driven study, which included all liver gunshot injuries admitted to a level I trauma center, was conducted over a 4-year period. Patients with right-sided thoracoabdominal, and right upper quadrant gunshot wounds with or without localized right upper quadrant tenderness underwent contrasted abdominal computed tomography scan evaluation to detect the presence of a liver injury. Patients with confirmed liver injuries were observed with serial clinical examinations. Outcome parameters included need for delayed laparotomy, complications, length of hospital stay, and survival. Results:During the study period, 63 patients with liver gunshot injuries were selected for NOM. The mean injury severity score was 19.6 (range, 4–34). Simple liver injuries (grades I and II) occurred in 26 (41.3%) patients and complex liver injuries (grades III, IV, and V) occurred in 37 (58.7%) patients. Associated injuries included 14 (22.2%) kidney, 44 (69.8%) diaphragm, 43 (68.3%) lung contusion, 42 (66.7%) hemothorax and/or pneuomothorax, and 21 (33.3%) rib fractures. Five patients required delayed laparotomy resulting in successful NOM rate of 92%. Complications included liver abscess (3), biliary fistula (3), retained hemothorax (4), and nosocomial pneumonia (5). The mean hospital stay was 6.1 (range, 3–23 days). There was no mortality. Conclusion:The NOM of appropriately selected patients with liver gunshot injuries is feasible, safe, and effective, regardless of the liver injury severity.

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.

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.

Variceal Recurrence, Rebleeding, and Survival After Endoscopic Injection Sclerotherapy in 287 Alcoholic Cirrhotic Patients With Bleeding Esophageal Varices

Objective:This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis. Summary Background Data:Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy. Methods:Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24–87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded. Results:Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1–174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3–198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death. Conclusion:Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients.

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.

Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum

BACKGROUND This single-centre study evaluated the outcome of a pancreatoduodenectomy for Grade 5 injuries of the pancreas and duodenum. METHODS Prospectively recorded data of patients who underwent a pancreatoduodenectomy for trauma at a Level I Trauma Centre during a 22-year period were analysed. RESULTS Nineteen (17 men and 2 women, median age 28 years, range 14-53 years) out of 426 patients with pancreatic injuries underwent a pancreatoduodenectomy (gunshot n = 12, blunt trauma n = 6 and stab wound n = 1). Nine patients had associated inferior vena cava (IVC) or portal vein (PV) injuries. Five patients had initial damage control procedures and underwent a definitive operation at a median of 15 h (range 11-92) later. Twelve had a pylorus-preserving pancreatoduodenectomy (PPPD) and 7 a standard Whipple. Three patients with APACHE II scores of 15, 18, 18 died post-operatively of multi-organ failure. All 16 survivors had Dindo-Clavien grade I (n = 1), grade II (n = 7), grade IIIa (n = 2), grade IVa (n = 6) post-operative complications. Factors complicating surgery were shock on admission, number of associated injuries, coagulopathy, hypothermia, gross bowel oedema and traumatic pancreatitis. CONCLUSIONS A pancreatoduodenectomy is a life-saving procedure in a small cohort of stable patients with non-reconstructable pancreatic head injuries. Damage control before a pancreatoduodenectomy will salvage a proportion of the most severely injured patients who have multiple injuries.

The expression of MUC mucin in cholangiocarcinoma

Cholangiocarcinoma (CC) is a highly malignant epithelial cancer of the biliary tract, the cellular and molecular pathogenesis of which remains unclear. Malignant transformation of glandular epithelial cells is associated with the altered expression of mucin. We investigated the type of mucins expressed in CC. Twenty-six patients with histologically confirmed CC were included in this study. The expression of mucin was studied by immunohistochemistry using antibodies to MUC1, MUC1 core, MUC2, MUC3, MUC4, MUC5AC, and MUC6. There was extensive (>50%) expression of mucin, mainly MUC1 in 11/25 and MUC5AC in 12/26 cases. In the case of MUC3, 6/26 cases expressed mucin extensively, whilst only 1/26 had MUC2, MUC4, and MUC6 expression. Well-differentiated tumors significantly expressed MUC3 extensively compared to poor or moderately differentiated tumors (p=0.003). Fifteen of 25 cases had metastatic disease. MUC1 was extensively expressed in 9/15 cases with metastatic disease. In contrast, MUC1 expression was present in 2/10 cases where metastases were absent. Hilar lesions were less likely to express MUC1, but this was not statistically significant. Fifteen of 25 cases had metastatic disease. Extensive MUC3 expression was significantly associated with well-differentiated tumors, whilst there was an approaching significance between the extensive expression of MUC1 and metastasis in cholangiocarcinoma.

Hydatid Cyst in the Head of the Pancreas with Obstructive Jaundice

We report a rare case of obstructive jaundice caused by an intrapancreatic hydatid cyst in a 17-year-old black girl. Ultrasonography and computed tomography demonstrated the obstructing cyst in the head of the pancreas. Cyst aspiration produced clear fluid with a low amylase content and no hydatid hooklets or protoscolices. Pancreaticoduodenectomy was performed for a presumed cystic neoplasm of the pancreas, but histology showed the true diagnosis. Pancreatic hydatidosis should be considered in the differential diagnosis of obstructing pancreatic cysts in the appropriate epidemiological setting.

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

ObjectiveThe 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 DataExtrahepatic 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. MethodsFifty-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. ResultsEsophageal 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. ConclusionsInjection scelotherapy is the treatment of choice in most patients with EHPVO.