Philippus Christoffel Bornman

Solid pseudopapillary epithelial neoplasms (SPENs) of the pancreas are rare but curable tumours that have a low-grade malignant potential and occur almost exclusively in young women, with an excellent prognosis after complete resection. This study examines the clinicopathological characteristics of these tumours and evaluates the role of surgery in relation to their size and location. We reviewed the pre-, intra- and postoperative data on 21 patients with SPENs who underwent resection during a 30-year period. Data including demographic information, presenting symptoms and signs, extent of operation, histology, tumour markers and postoperative complications were evaluated to establish the optimal surgical management. All 21 tumours occurred in women (mean age 24.6 years, range 13-51 years). Sixteen patients presented with nonspecific abdominal complaints and a palpable abdominal mass, in 1 patient the tumour was found during emergency laparotomy for a complicated ovarian cyst, 1 patient presented with severe abdominal pain and shock due to a ruptured tumour, and in 3 patients the tumour was detected incidentally during imaging. The correct pre-operative diagnosis of SPEN was made in 10 patients. Incorrect preoperative diagnoses included hydatid cyst (3 patients), mesenteric cyst (2), pancreatic cystadenoma (2), ovarian cysts (1), islet cell tumour of the pancreas (1), and cavernous haemangioma of the liver (1). The mean diameter of the tumours was 12.5 cm (range 8 - 20 cm), and they occurred in the head (8), neck (5), body (2), and tail (6) of the pancreas. All SPENs were resected. Five patients had a pylorus-preserving pancreaticoduodenectomy, 4 a central pancreatectomy with distal pancreaticogastrostomy, 8 a distal pancreatectomy, 3 a local resection and one a total pancreatectomy and portal vein graft. In 1 patient, 2 liver metastases were resected in addition to the pancreatic primary tumour. The patient who presented in shock with tumour rupture and bleeding into the lesser sac later died of multiple organ failure after successful resection. Postoperative complications included a stricture at the hepaticojejunostomy after pancreaticoduodenectomy, which resolved after stenting, and a pancreatic duct fistula after local tumour resection, which required a distal pancreatectomy. Other complications were bleeding (2 patients) requiring re-operation and intraabdominal fluid collections requiring percutaneous drainage (3) or operation (1). Mean postoperative hospital stay was 16 days (range 6 - 40 days). Twenty patients are alive and well without recurrence, including the patient with metastases, with a mean follow-up of 6.6 years (range 6 months-15 years). This study demonstrated that SPENs of the pancreas are uncommon, but should be considered in the differential diagnosis of a cystic mass of the pancreas in a young woman. Despite the indolent biological behaviour of SPENs, most patients required major pancreatic resection. Surgery is curative regardless of the size or location of the tumour. Metastases are rare, as is recurrence after complete surgical resection.

Background. Chronic pancreatitis (CP) is defined as a continuing inflammatory disease of the pancreas characterised by irreversible morphological changes, often associated with pain and with the loss of exocrine and/or endocrine function that may be clinically relevant. Alcohol is the predominant cause of CP in the western world and is particularly prevalent in South Africa, especially in the indigent patient. CP ranks high among intractable diseases of the gastrointestinal tract. The tendency for substance abuse in the alcohol-induced group poses major psychological and socio-economic problems. Objective. CP is a disease with significant clinical and pathological heterogeneity. Level 1 evidence to support definitive guidelines for diagnosis, medical management and interventional therapy is lacking. Despite this paucity of robust scientific evidence, it is important to provide some assistance based on the best available evidence as to the current standard of care for CP in the South African context; this will aid all involved in the management of the disease, and includes clinicians, health care managers and funders. Scope. The guidelines were developed as recommendations addressing the diagnosis, medical management and interventions, both endoscopic and surgical, for the management of a very complex and heterogeneous disease of the pancreas. The recommendations are particularly relevant in the South African context where the predominant patho-aetiological agents are alcohol-associated with smoking. Recommendations. The guidelines provide clear recommendations regarding the diagnostic modalities available, both imaging (which includes MRI and endoscopic ultrasound (EUS)) and pancreatic function tests. The section on medical management makes recommendations on the use of analgesics, enzyme replacement and other therapeutic options in the non-interventional management of the majority of patients with CP. The section on interventional procedures identifies the indications and options available for the interventional management of both uncomplicated and complicated CP. The role of endoscopic and surgical modalities is defined, but it is in this context especially that the best available evidence, combined with the experience of the group, influenced the recommendations put forward. Owing to the lack of evidence and the complexity of the disease, it is recommended that, where possible, CP is managed in the context of a multidisciplinary team. Validation. The guidelines are based on best practice principles determined by the available evidence and the opinions of the group, which comprised 7 medical and surgical gastroenterologists with significant experience in dealing with patients with chronic pancreatitis in the South African context. The group convened between May 2009 and August 2010 under the auspices of the Hepato-Pancreatico-Biliary Association of South Africa (HPBASA) and the South African Gastroenterology Society (SAGES), and the guidelines are the result of broad consensus within this group. The draft was presented to other experts in this field of endeavour to ensure broader participation and consensus. Plans for guideline revision. HPBASA and SAGES will publish a revised modification of the recommendations when new levels 1 and 2 evidence data are published.

This study evaluated the incidence of rebleeding and death at 6 weeks after a first episode of acute variceal haemorrhage (AVH) treated by emergency endoscopic sclerotherapy in a large cohort of alcoholic cirrhotic patients. From January 1984 to December 2006, 310 alcoholic cirrhotic patients (242 men, 68 women; mean age 51.7 years) with AVH underwent 786 endoscopic variceal injection treatments (342 emergency, 444 elective) during 919 endoscopy sessions in the first 6 weeks after the first variceal bleed. Endoscopic control of initial bleeding, variceal rebleeding and survival at 6 weeks were recorded. Endoscopic intervention controlled AVH in 304 of 310 patients (98.1%). Seventy-five patients (24.2%) rebled, 38 (12.3%) within 5 days and 37 (11.9%) within 6 weeks. No patient scored as Child-Pugh A died. Seventy-seven (24.8%) Child-Pugh B and C patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days. Mortality increased exponentially as the Child-Pugh score increased, reaching 80% when the score exceeded 13. Despite initial control of variceal haemorrhage, 1 in 4 patients (24.2%) rebled within 6 weeks. Survival at 6 weeks was 75.2% and was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients.

The incidence of common bile duct stricture (CBDS) in chronic pancreatitis (CP) varies widely depending on the precise definition, diagnostic vigor, and demographics of any given series. The wide variation in the reported incidence, which ranges from 3% to 46%[ 1 x [1] Yadegar, J., Williams, R., and Passaro, E. Common duct stricture from chronic pancreatitis. Arch Surg. 1980; 115: 582–586 Crossref | PubMed | Scopus (57) | Google Scholar See all References , 2 x [2] Stabile, B., Wilson, S., and Passaro, E. Stricture of the common bile duct from chronic pancreatitis. Surg Gynaecol Obstet. 1987; 165: 121–126 Google Scholar See all References , 3 x [3] Huizinga, W. and Thompson, S.R. Chronic pancreatitis with biliary obstruction. Ann Roy Coll Surg Engl. 1992; 74: 119–125 PubMed | Google Scholar See all References , 4 x [4] Petrozza, J. and Dutta, S. The variable appearance of distal common bile duct stenosis in chronic pancreatitis. J Clin Gastroenterol. 1985; 7: 447–450 Crossref | PubMed | Scopus (15) | Google Scholar See all References , 5 x [5] Aranha, G., Prinz, R., and Freeark, R. The spectrum of biliary tract obstruction from chronic pancreatitis. Arch Surg. 1984; 119: 600 Google Scholar See all References , 6 x [6] Afroudakis, A. and Kaplowitz, N. Liver histopathology in chronic bile duct stenosis due to chronic alcohol pancreatitis. Hepatology. 1981; 1: 65–72 Crossref | PubMed | Scopus (65) | Google Scholar See all References , 7 x [7] Wisloff, F., Jakobsen, J., and Osnes, M. Stenosis of the common bile duct in chronic pancreatitis. Br J Surg. 1982; 69: 52–54 Crossref | PubMed | Scopus (54) | Google Scholar See all References , 8 x [8] Sand, J. and Nordbank, I. Management of cholestasis in patients with pancreatitis: evaluation of a treatment protocol. Eur J Surg. 1995; 161: 587–592 PubMed | Google Scholar See all References ] (Table I Table I ), occurs because not all patients with biliary obstruction in CP present with jaundice. The jaundice may frequently be transient [ 9 x [9] Scott, J., Summerfield, J.A., and Elias, E. Chronic pancreatitis: a cause of cholestasis. Gut. 1977; 18: 196–201 Crossref | PubMed | Scopus (67) | Google Scholar See all References ] [9] , and in an appreciable number of patients the bile duct stricture is discovered incidentally [ 10 x [10] Sarles, H. and Sahel, J. Cholestasis and lesions of the biliary tract in chronic pancreatitis. Gut. 1978; 19: 851–857 Crossref | PubMed | Scopus (60) | Google Scholar See all References , 11 x [11] Littenberg, G., Afroudakis, A., and Kaplowitz, N. Common bile duct stenosis from chronic pancreatitis: a clinical and pathologic spectrum. Medicine. 1979; 58: 385–412 Crossref | PubMed | Scopus (66) | Google Scholar See all References , 12 x [12] Gregg, J., Carr-Locke, D., and Gallagher, M. Importance of common bile duct strictures associated with chronic pancreatitis. Am J Surg. 1981; 141: 199–203 Abstract | Full Text PDF | PubMed | Scopus (24) | Google Scholar See all References , 13 x [13] Kalvaria, I., Bornman, P., and Marks, I. The spectrum and natural history of common bile duct stenosis in chronic alcohol induced pancreatitis. Ann Surg. 1989; 210: 608–613 Crossref | PubMed | Scopus (38) | Google Scholar See all References , 14 x [14] Stahl, T., Allen, M., and Ansell, H. Partial biliary obstruction caused by chronic pancreatitis. Ann Surg. 1988; 207: 26–32 Crossref | PubMed | Scopus (60) | Google Scholar See all References ].

Improvements in imaging studies and a better understanding of the natural history of pancreatic fluid collections (PFCs) have allowed the different types to be clarified. Stratification of PFCs into subgroups should help in selecting from the increasing current available treatment options, which include percutaneous, endoscopic and surgical drainage. Percutaneous catheter drainage is safe and effective and should be the treatment of choice in poor-risk patients, and for infected pseudocysts related to acute pancreatitis. Endoscopic drainage should be the first management option in suitable pseudocysts related to chronic pancreatitis, if the necessary expertise is available. The high success rate and current low morbidity of elective open surgery mean that it is still the standard of management in this disease. Laparoscopic approaches are gaining favour, predominantly in drainage of collections in the lesser sac, and long-term data are awaited. The precise application of this modality will need to be critically compared with the low morbidity of mini-laparotomy, which is the current standard after non-operative treatment fails in these patients. It is essential to clearly stratify the different types of pancreatic pseudocysts, in particular with relation to acute or chronic pancreatitis, and perform a valid comparison of the different treatment modalities within groups. In this capacity a precise and transparent classification may provide valuable answers, in particular relating to optimal management according to pseudocyst type.

Echinococcus granulosus remains a clinical problem in sheep and subsistence farming communities in South Africa. The most commonly affected organs are the liver and the lung. Most cysts remain clinically silent and are diagnosed incidentally or when complications occur. Clinical examination is unreliable in making the diagnosis. Serological testing has a broad range of sensitivity and specificity and is dependent on the purity of the antigens utilised. Ultrasound examination of the abdomen is gens utilised. Ultrasound examination of the abdomen is both sensitive and cost effective. Computed tomography and endoscopic retrograde cholangiopancreatography (ERCP) are reserved for complicated cases. The differential diagnosis includes any cystic lesion of the liver. Liver hydatid cysts can be treated by medical or minimally invasive (laparoscopic and percutaneous) means or by conventional open surgery. The most effective chemotherapeutic agents against the parasite are the benzimidazole carbamates, albendazole and mebendazole. Albendazole is more efficacious, but recommended treatment regimens differ widely in terms of timing, length of treatment and dose. Medical treatment alone is not an effective and durable treatment option. PAIR (puncture, aspiration, injection, reaspiration) is the newest and most widely practised minimally invasive technique with encouraging results, but it requires considerable expertise. Open surgery remains the most accessible and widely practised method of treatment in South Africa. The options are either radical (pericystectomy and hepatic resection) or conservative (deroofing and management of the residual cavity). Various scolicidal agents are used intraoperatively (Eusol, hypertonic saline and others), although none have been tested in a formal randomised controlled trial. Laparoscopic surgery trials are small and unconvincing at present and should be limited to centres with expertise. Complicated cysts (intrabiliary rupture and secondary infection) may require ERCP to obtain biliary clearance before surgery, and referral to a specialist centre may be indicated.

Annular pancreas is an uncommon developmental abnormality of the ventral pancreas. Half of all patients present in adulthood. Abdominal pain and duodenal obstruction are the commonest presenting features. Despite newer imaging modalities, the diagnosis is mostly made at surgery. We report on two patients and review the embryology, presentation, diagnosis and the current surgical management options of annular pancreas.