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SUBJECTS: Fifty-eight patients with cancer of the oesophagus were studied from July 2002 to November 2005. Thirty-seven patients presented with strictures and 21 presented with tracheo-oesophageal fistula (TOF). METHODS: There were 35 males and 23 females. Mean age was 57 years. Stents were positioned under fluoroscopic guidance, in the majority of cases under conscious sedation. A contrast study was done on day 1 to assess stent expansion and sealing of the TOF. Data were analysed using Stata Statistcal Software, Release 8.0. Survival was calculated using Kaplan-Meier methodology and log-rank tests were used to assess differences. A p-value < 0.05 was considered to be statistically significant. RESULTS: Stenting was successful in 57 of the 58 patients; 1 perforation occurred at the time of insertion. In total, 68 stents were inserted in 58 patients. Re-stenting was necessary in 10 patients, because of tumour overgrowth (N = 5), stent migration (N = 3) and recurrent fistula (N = 2). Dysphagia improved from a mean score of 2.98 to 1.08. All lesions were squamous cell carcinoma. The positions of the fistulas were proximal (N = 4), middle (N = 14) and distal (N = 3). Over half of the patients in the TOF group had concomitant pneumonia at presentation with decreased survival (p = 0.010) and a hazard ratio of 10.86. Two patients died, on days 4 and 7 respectively. Median survival was 91 days (range 0-273 days) for the stricture group and 62 days (range 3-413 days) for the TOF group, but these differences were not significant (p = 0.945). CONCLUSION: Covered self-expandable metallic stents provide an acceptable option for the palliation of TOF due to cancer of the oesophagus.

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OBJECTIVE: To evaluate the outcome of treatment of patients with sigmoid volvulus in the Polokwane-Mankweng Hospital and to identify the best management options for these patients. METHODS: A retrospective study was undertaken of 85 patients with sigmoid volvulus treated in Polokwane-Mankweng Hospital during the period July 1997-May 2004. RESULTS: In total, 85 patients were evaluated (77 males and 8 females, male/female ratio 9:1). The age range was 7-80 years (mean 42 years). Sigmoidoscopic derotation was attempted in 17 patients, and was successful in 10 patients. Laparotomy was done in 84 patients, viz. 75 emergencies and 9 electives. During laparotomy, gangrenous sigmoid colon was found in 30 patients and viable sigmoid in 54 patients. Resection with primary anastomosis was done in 44 patients. Hartmann's procedure was performed in 33 patients. Sigmoidopexy was done in 7 patients. Total hospital mortality was 6% (5 deaths). Mortality in the 84 operated cases was 5% (4 deaths). CONCLUSIONS: There was no mortality in patients undergoing elective resection and primary anastomosis after successful preoperative deflation and in patients with viable sigmoid volvulus who underwent an emergency Hartmann's procedure. There was low mortality in those patients with resection and primary anastomosis on viable sigmoid (3%, 1:39). The highest mortality (1:5) occurred in cases of resection and primary anastomosis of gangrenous sigmoid colon.

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UNLABELLED: Between September 1992 and April 2003, 96 patients in chronic renal failure had 134 potential related living donors. The aim of this study was to determine the factors that influence living related kidney transplantation among black South Africans. METHODS: Potential recipients and donors were screened for suitability to donate or receive kidneys. The relationship of the donor to the recipient was documented. RESULTS: Ninety-six potential recipients of median age 32 years (range, 7 to 53) and a female to male ratio of 1:1.6 had potential related donation from 47 sisters, 33 brothers, 27 mothers, 8 fathers, and 11 children. Eight potential donors were from cousins, spouses, stepbrothers, and friends. One, two, or three potential donors per recipient were counted among 54, 19, and 10 recipients, respectively. Contraindications to transplantation in 45 potential donors were ABO incompatibility (n = 19); hypertension (n = 11); HIV positivity (n = 10); and one each for nephrotic syndrome, gastric cancer, Hepatitis B, withdrawal, and a single functioning kidney. Thirty-five patients were transplanted from relatives. Although HLA-A, B, and DR antigens were studied in transplanted patients using both serologic and polymerase chain reaction-sequence-specific oligonucleotide methods, HLA matching was not used for donor selection. Only two living related pairs were HLA identical. Actual 1-year graft survival after transplantation was 95%. In conclusion, the concept of related living donation is acceptable among black South Africans and the number of donors per recipient suggests that HLA matching can be improved.

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BACKGROUND: There is often a delay of more than 12 h in transferring patients with penetrating colonic injury from outlying hospitals to a regional referral centre. The aim of this prospective study was to determine whether primary suture of a penetrating colonic injury in the presence of delayed presentation, shock, peritoneal contamination or associated injuries leads to increased morbidity and mortality rates. METHODS: Patients with penetrating colonic injuries were randomized to primary closure or colostomy. Patients were compared with regard to interval from injury to operation, associated injuries, duration of operation, postoperative complications and hospital stay. RESULTS: Two hundred and forty patients were seen over a 69-month period. The interval from injury to operation ranged from 3 to 56 h, and was similar in the two treatment groups. Postoperative complications were similar in the two groups but there were significant differences in operation time (mean(s.d.) 127.1(45.8) min for primary repair and 142.3(43.0) min for colostomy; P = 0.009) and length of hospital stay (mean (range) 9 (6-56) versus 26 (13-64) days respectively; P < 0.001). CONCLUSION: Delay from time of penetrating colonic injury is not a contraindication to primary repair. :

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BACKGROUND: Most thyroid centers use fine-needle aspiration (FNA) and technetium-99m pertechnetate for the preoperative assessment of thyroid nodules. This approach is sufficient in most cases other than follicular neoplasm, and follicular carcinoma is more common than papillary carcinoma in developing countries such as in our center. Technetium 99m-methoxyisobutylisonitrile (MIBI) proposed for myocardial perfusion was also found to be taken up by a variety of tumors including thyroid cancer. METHODS: We evaluated MIBI uptake of nodular thyroid disease and compared it with pertechnetate scan, FNA, and histologic findings for the differentiation of malignant thyroid nodules from benign lesions. Seventy-one patients were included in the study. Three-phase pertechnetate scintigraphy was completed after a single injection of 150 MBq. Perfusion/uptake mismatch (uniform perfusion with cold uptake) was regarded as positive for malignancy, whereas perfusion/uptake match (cold perfusion with cold uptake) was regarded as negative. After 1 week, 400 MBq of MIBI was injected, images were obtained at 20 minutes and 2 hours, and evaluated semiquantitatively by use of a 4-point (0-3) scoring system. MIBI scans were considered positive if there was uptake superior to normal thyroid tissue on early and delayed images (score = 3). In the following days and weeks, all patients underwent FNA followed by surgery. RESULTS: Histopathologic diagnosis revealed a total of 23 thyroid carcinomas, 21 (91%) and 19 (83%) were positive on MIBI and pertechnetate, respectively. Of the 48 patients with benign nodules, 11 (23%) and 29 (60%) were positive on MIBI and pertechnetate, respectively. The specificity of MIBI, pertechnetate, and FNA is 77%, 40%, and 90%, respectively. CONCLUSIONS: In combination with FNA and three-phase pertechnetate scan, MIBI could be helpful in preoperative assessment of thyroid nodules. Intense MIBI activity increases the probability of thyroid cancer, whereas reduced activity drastically decreases the probability of malignancy.

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OBJECTIVE: To assess the possible impact of HIV infection on the management of general surgical patients at the Ga-Rankuwa Hospital. DESIGN: A prospective study. SETTING: Ga-Rankuwa Hospital/Medical University of Southern Africa (MEDUNSA) Academic Complex, Pretoria, South Africa. SUBJECTS: Nine hundred and forty one patients admitted to general surgical wards. MAIN OUTCOME MEASURES: HIV infection and CD4 counts. RESULTS: Nine hundred and forty one patients admitted to general surgical wards from January 1966 to December 1997 were tested for HIV infection. Twelve per cent tested positive. HIV positive patients were significantly younger [33 +/- 10 versus 41 +/- 7 (men +/- SD) years, Chi-square = 51, p < 0.0001]. There was no correlation of HIV positivity to the patient's sex (p = 0.7). In forty three HIV positive patients treated surgically, mortality was attributed to HIV/AIDS in only one patient with a CD4 count of 47/ul who died following laparotomy for peritonitis. CD4 counts done during follow up in thirty one HIV positive patients revealed a count of < 500/ul in eleven patients. CONCLUSION: It is predicted that an increasing number of patients with HIV/AIDS will be admitted to general surgery wards of the Ga-Rankuwa Hospital. Surgeons are advised to take universal precautions to prevent HIV infection.

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OBJECTIVES: To review our experience and assess the role of TC99m MIBI thyroid scintigraphy in patients with well-differentiated thyroid carcinoma. DESIGN: Cross sectional descriptive study comparing the results of TC99m MIBI and TC99m pertechnetate scintigraphy with histology. SETTING: Ga-Rankuwa Hospital, a tertiary referral centre, MEDUNSA, South Africa. SUBJECTS: Between October 1998 and January 2000, 63 patients presenting with a single thyroid nodule were included in this study. INTERVENTION: All patients included in the study were subjected to fine needle aspiration, thyroid function tests, TC99m pertechnetate and TC99m MIBI scintigraphy. Following surgery all specimens were sent for pathological examination. MAIN OUTCOME MEASURES: The outcome of the study was measured comparing the results of pre-operative TC99m MIBI and TC99m pertechnetate scintigraphy with final histology. RESULTS: 41 of these 63 patients were found to have benign disease and 22 patients had malignant disease. In the malignant group there were 17 females and five males. The age of the patients ranged from 28 years to 85 years in the carcinoma group. Thirteen patients had follicular carcinoma, six patients had papillary carcinoma, two patients had Hurthle cell carcinoma and one patient had medullary carcinoma. TC99m MIBI correctly predicted malignancy in 21/22 patients in contrast with TC99m pertechnetate scintigraphy which diagnosed malignancy in 17/22 patients. The sensitivity of MIBI was 95% and its specificity was found to be 63%. The sensitivity and specificity of TC99m pertechnetate, however, was 77% and 29% respectively. CONCLUSION: TC99m MIBI scintigraphy can be used in association with Fine Needle Aspiration (FNA) in the pre-operative evaluation of thyroid carcinoma.

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OBJECTIVE: To determine feasibility and outcome of laparoscopic cholecystectomy for Black patients in Ga-Rankuwa Hospital and to analyse the type of stones harvested. DESIGN: Cross sectional description study. SETTING: Ga-Rankuwa Hospital/Medunsa, South Africa. SUBJECTS: 79 patients who presented with cholelithiasis over a six year period. MAIN OUTCOME MEASURES: Successful performance of laparoscopic cholecystectomy on the subjects. RESULTS: 39 laparoscopic cholecystectomies were performed with seven conversions (18% conversion rate). Forty open cholecystectomies were also performed. Post operative stay after laparoscopic cholecystectomy averaged 3.5 days and that of the open converted group 6.9 days (p < 0.001). Two patients returned with persistence of symptoms following laparoscopic cholecystectomy. Twenty gall stones were analysed; 17 were of the cholesterol type and three of the black pigment type. CONCLUSIONS: Laparoscopic cholecystectomy is feasible in the Black populace of Ga-Rankuwa Hospital. The majority of gallstones are of the cholesterol type.

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The availability of donor organs was analyzed following the placement of a transplant coordinator in Ga-Rankuwa Hospital's kidney transplant program. From February 1, 1992, to January 6, 1994, 44 brain-dead potential donors were identified. In 20 of those cases, relatives could not be reached to acquire consent for donation of cadaveric organs. In the remaining 24 cases, an intensive care resident together with a transplant coordinator obtained consent for 9 potential donors. Over the same period, 119 (80%) of living-related potential donors who had been approached stated that they were willing to donate a kidney. This outcome suggests that among blacks, altruism is a positive factor for acquiring consent for organ donation. Public education is required to correct ignorance, misconception, and cultural beliefs regarding cadaveric donation.

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The effect of HLA-DR3 gene expression was studied in black cadaveric renal allograft recipients of organs from the same donor race. From January 1984 to June 1992, 70 patients received cadaveric renal allografts at the Medical University of Southern Africa (MEDUNSA). The average age and F:M ratio was 30 years and 1: 1.2 respectively. HLA-A, B and DR matching was zero to one in 80%. Actuarial graft survival at yearly intervals in 22 HLA-DR3 gene expressors was 62, 55, 38, 30 and 24% as compared to 82, 78, 70, 64 and 58% in 48 non-HLA DR3 gene expressors (Breslow p = 0.01 and Mantel-Cox p = 0.05). There was no statistical differences in creatinine values associated with HLA-DR3 gene expression during the 1st year after transplantation. Renal allografts were lost from rejection in 9 out of 16 HLA-DR3 gene expressors as compared to 19 out of 29 non-HLA DR3 gene expressors (Fisher's exact test p = 0.8). HLA-DR3 gene expression is a risk factor for earlier graft loss in black South Africans.

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Distal splenorenal shunt (DSRS) is a once-only form of treatment. It is suitable for many black South Africans with non-cirrhotic variceal bleeding who cannot attend repeated follow-up sclerotherapy sessions. However, persistent hyperbilirubinaemia and encephalopathy may occur following DSRS in schistosomiasis. Forty-one consecutive patients with DSRS have been treated over a 7-year period. The causes of portal hypertension were schistosomiasis (32), portal vein thrombosis (8) and diffuse nodular hyperplasia (1). Operative mortality was 6%. Encephalopathy was observed in 1 patient. Galactose elimination capacity (GEC) and technetium-diethylenetriamine penta-acetic acid hepatic perfusion index (HPI) were used to assess liver function and hepatic perfusion pre- and postoperatively, respectively, in schistosomiasis. GEC was 348 +/- 37 (M +/- SD) before, compared with 343 +/- 67 postoperatively (P = 0.78). HPI showed long-term preservation of hepatopetal portal venous flow following DSRS. Morbidity and mortality were observed only in patients with schistosomiasis associated with hepatitis B chronic active hepatitis. DSRS is ideal treatment in selected patients with non-cirrhotic variceal bleeding.

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HLA histocompatibility antigens form part of the basis of immune reactions in transplant immunology. However, controversy surrounds their use in renal allograft organ sharing. Selected HLA-related studies in the transplant programmes of Northwestern Memorial Hospital (NWMH), Chicago, USA, and the Medical University of Southern Africa (MEDUNSA), Pretoria, are presented. In the Northwestern Memorial Hospital experience with 27 recipients of O-mismatches, 48% were mixed leucocyte culture (MLC) compatible (% relative response < 25). Actuarial graft survival rates at yearly intervals up to 5 years were 100%, 100%, 85%, 75%, 75%, compared with 75%, 65%, 65%, 55% and 55% in compatible and incompatible groups, respectively (Breslow P = 0.05 and Mantel-Cox P = 0.11). Creatinine values at yearly intervals up to 5 years were significantly better in the MLC-compatible group (Mann-Whitney U-test P < 0.05). In the MEDUNSA experience with 85 black recipients of poorly HLA-matched renal allografts of the same donor race, actuarial graft survival at yearly intervals up to 5 years was 73%, 68%, 61%, 61% and 57%. The commonest HLA-A, B and DR antigens at MEDUNSA are A30, A9, A2, A10, A28; B17, B12, B42, B8; DR3, DR5 and DR4 (in this order of frequency). The NWMH experience illustrates that HLA-matching improves renal allograft survival in O-mismatches. At MEDUNSA, however, satisfactory results are obtained using kidneys harvested from black donors.

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Between July 1987 and February 1990, 42 patients with pancreatic pseudocysts were treated. In 83% the pseudocyst was related to alcohol. Patients were managed by observation (7), surgical external drainage (7), and internal drainage (12). Fifteen patients were treated by ultrasound guided percutaneous catheter drainage (UGPCD) with apparent success in 67%. In 5 of these UGPCD was abandoned because of either prolonged drainage or infection of the pseudocyst. In patients with recurrent pseudocysts or in those with failed UGPCD, the cystic collections were successfully drained internally in 16 out of 17 patients (94%). Internal drainage appears to be acceptable treatment for mature pseudocysts, recurrent pseudocysts or for failed UGPCD, provided there is no downstream pancreatic duct obstruction or duct dilatation. If either exist, resection or direct ductal drainage will be required.

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Four patients with extremely large lateral neck swellings are described. In the discussion the controversy about using radiotherapy: (i) to make an 'inoperable tumour operable', and (ii) to 'sterilise the operative field' is considered. It is concluded that modern radiotherapeutic techniques probably satisfy these requirements.

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