Biomedical subjects
Publications and source records attributed to A A Haffejee.
We describe the case of a 32-year-old patient with gallbladder agenesis encountered at laparoscopy. Diagnostic confirmation was made by endoscopic retrograde cholangiopancreatography and computerized scanning. Formal laparotomy was avoided. A review of the literature is presented.
Whilst colonic amoebiasis and its complications are well-documented, ileal amoebiasis has not been described in the literature. We report the cases of two patients with ileal amoebiasis and outline their management and outcome. It is important that surgeons working in areas endemic for amoebiasis be mindful of this entity.
Advances in optics, illumination and video-technology together with refinements in operative technique have made endoscopic transthoracoscopic sympathectomy (ETS) the method of choice for upper thoracic sympathectomy. Palmar hyperhidrosis is by far the main indication for ETS. The procedure is technically easy and well tolerated by patients, and complications are few and minor.
Gastric tuberculosis is an uncommon clinical entity. Great difficulty is encountered in making the pre-operative diagnosis. Other chronic granulomatous conditions (Crohn's disease, sarcoidosis and isolated granulomatous gastritis) should always be considered. Surgery, with postoperative antituberculosis treatment, remains the main modality for accurate diagnosis and treatment.
OBJECTIVE: To see if it is possible to predict mortality in isolated post-traumatic acute renal failure. DESIGN: Retrospective study 1984-1990 inclusive. SETTING: Teaching hospital, South Africa. SUBJECTS: Thirty-nine patients who developed isolated post-traumatic acute renal failure out of 106526 admissions for trauma. INTERVENTIONS: Standard aggressive management of traumatic injury and acute renal failure. MAIN OUTCOME MEASURE: Death. RESULTS: Fifteen of the 39 patients who developed post-traumatic acute renal failure died (39%). Blunt trauma from assaults was a major cause of acute renal failure (16/39, 41%). Hypotension and hyperkalaemia were the two main predictors of death having a mortality of 63% and 52%, respectively. CONCLUSION: Clinicians should be aware of the risks of hypotension and hyperkalaemia in injured patients. Preventive measures such as aggressive resuscitation and timely correction of serum electrolyte concentrations are essential in such patients.
Laparoscopic retrieval of an intra-abdominal foreign body is described. This novel use of the laparoscope has not been described before.
Oesophageal tuberculosis is a rare entity often pre-disposed to by caseating tuberculous mediastinal lymphadenopathy (TML). Although widely reported in children, TML is an under appreciated entity in adults; in this article dysphagia in an adult patient caused by TML is described.
A prospective analysis of 20 patients with external pancreatic fistulas was undertaken over a 5-year period to evaluate the response of pancreatic fistulas to non-operative management. In 90% of patients fistula followed external trauma to the pancreas. There were 18 males and 2 females and the average age was 30.3 years. Fifteen patients were given enteral nutrition alone and 5 received total parenteral nutrition; 2 of these received somatostatin as well. All the fistulas healed spontaneously within 7-80 days, with no deaths. We conclude that if the patient's condition is stable external pancreatic fistulas can be managed safely and effectively by non-operative means. Nutritional support, especially via the enteral route if possible, is beneficial.
A 58-year-old black woman was admitted to hospital with abdominal pain and gross ascites and was found on examination to have a tumour in the pouch of Douglas and subsequently to have squamous carcinoma of the oesophagus. The patient was treated non-operatively by repeated ascitic taps and intubation of the oesophagus.
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This study was undertaken to determine the incidence and clinical features of avascular necrosis of bone in 69 transplant recipients all of whom had a functioning allograft for at least 12 months. An attempt was also made to identify any potential predisposing factors. The patients were assessed by an orthopaedic surgeon. The diagnosis of avascular necrosis was made on the basis of radiographs and isotope bone scans. Fourteen patients (20.2%) developed avascular necrosis with a mean onset of 19 months post-transplantation. The hip joint was most commonly affected. The isotope bone scan was the most sensitive diagnostic tool; abnormalities were detected before the onset of symptoms in 4 patients. Avascular necrosis was more common in Indian transplant recipients and was also associated with: (i) cadaver transplants; (ii) more frequent bouts of acute rejection (P < 0.05); and (iii) a greater incidence of other steroid-associated side-effects (P < 0.05). Alcohol consumption and radiological evidence of osteoporosis were more prevalent in the avascular necrosis group (42.8% v. 29.0% and 28.5% v. 7.2% respectively). Avascular necrosis did not correlate with age, sex, renal function at 1 year or severe secondary hyperparathyroidism. This study suggests that corticosteroid therapy plays an important role in the pathogenesis of avascular necrosis. Excessive alcohol consumption and osteoporosis also appear to be risk factors.
From 1984 to 1989 the clinicopathological aspects of 21 patients with smooth muscle tumours of the stomach were reviewed. Ten patients had leiomyomas: 7 males, 3 females, average age 53 +/- 8 years. Four out of seven leiomyomas presenting with haematemesis were diagnosed correctly by an endoscopist but biopsy was positive in only two patients. Three leiomyomas were found incidently at laparotomy, and a total of nine leiomyomas were resected with a cuff of normal stomach. Their size ranged from 2 to 20 cm. All patients who underwent local resection are alive. Eight patients had leiomyosarcomata: 3 males, 5 females, average age 62 +/- 9 years. Six of these patients had an epigastric mass and four had haematemesis or melaena. The remaining patient in this group presented with dysphagia. Seven of these patients, who had no evidence of metastatic disease, underwent exploratory laparotomy. In four, palliative resections of the stomach and distal oesophagus were performed. In two, exogastric lesions involving colon and liver respectively were resected en bloc with a cuff of stomach. In one, biopsy alone was carried out. Two patients in this group are alive 1 and 2 years following surgery. Adjuvant treatment was not given to any of our patients. The remaining three tumours comprised a smooth muscle tumour of undetermined malignant potential whose clinical behaviour was unpredictable, and two leiomyoblastomas which mimicked malignant tumours in their presentation.
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Pre-operative investigations, although providing useful information, were unreliable in predicting resectability in patients with malignant oesophageal lesions. Chest radiographs excluded metastasis and active tuberculosis. The barium swallow examination determined the length of the lesion and displayed various displacements, none of which excluded resectability. Tumour infiltration of the airways was the only change visible at bronchoscopy that contraindicated resection. Computed axial tomography was unreliable in excluding extra-oesophageal tumour extension and operability. As all these pre-operative investigations have their limitations in assessing operability, exploration of the lesion is essential to determine resectability for squamous carcinoma of the oesophagus, provided there is prior histological confirmation of a malignant oesophageal lesion.
Catheter-related sepsis still remains one of the most frequent and serious complication of total parenteral nutrition. Strategies for preventing contamination of central venous lines have focused on decreasing the number of micro-organisms around the exit site and inhibiting their entry into the catheter wound. This prospective study compares a new occlusive hydrocolloid dressing (Visiband; Convatec Squibb) with that of a polyurethane film dressing for nutritional catheters. Dressings were changed either on day 3 or day 5 after application. Swab smears of the catheter exit site at each dressing change were stained by Gram's method before inoculation onto a blood agar plate, a chocolate agar plate and a MacConkey agar plate. Significantly less colonisation occurred under the former dressing at day 3 and day 5 dressing changes. In addition, the polyurethane film dressing was associated with a significant increase in skin colonisation (P = 0.04) and the number of positive Gram-stain microbes if left unchanged for 5 days (P = 0.0018). Staphylococcus aureus catheter-related sepsis occurred in 1 patient on day 18 in the polyurethane film dressing group. In addition, Candida albicans colonisation was confined to patients with the polyurethane film dressing. While the type of dressing applied to the catheter exit site may influence the incidence of catheter colonisation and infection, it must be emphasised that strict adherence to aseptic technique during catheter insertion and manipulation of the dressing is vital in the prevention of catheter-related sepsis during total parenteral nutrition.
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This study analysed clinical features and laboratory investigations in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy at this hospital between 1984 and 1988. Tuberculous peritonitis was found in 2% of all patients with tuberculosis and in 59.8% of all those with abdominal tuberculosis admitted to the hospital during the study period. Tuberculous peritonitis was more common in women than men (1.4:1) and was most frequently encountered in the third and fourth decades of life. The commonest presenting symptoms were abdominal swelling (73.1%), fever and night sweats (53.8%), anorexia (46.9%), weight loss (44.1%), and abdominal pain (35.9%). The mean duration of symptoms was 1.5 months. Ascites was the commonest (95.2%) physical sign. Tuberculin skin testing was positive in 57.6% of patients (n = 118). The mean erythrocyte sedimentation rate was 75 mm/1st hour (n = 58). Chest radiography on 98 patients showed pleuropulmonary pathology in 40 patients (40.8%). Sputum examination confirmed active pulmonary tuberculosis in 26 patients. The ascitic fluid was an exudate in 96.4% and a transudate in 3.6% of patients, with 91.3% showing a straw coloured ascites. Cirrhosis, detected by biopsy specimen, was a finding in 6.2% of patients.
A 54-year-old black man presented to hospital with diarrhoea containing blood and mucus and marked loss of weight over a 1-year period. Barium enema examination revealed cobblestoning and rose-thorn ulceration with possible stricture formation of the terminal ileum. A right hemicolectomy was performed to remove inflamed sections of small and large bowel. Histological examination of the resected specimen demonstrated features of ileal diverticular disease. This is the first documented case of this disease occurring in a black patient.