HPBASA from inception to maturity

The seed to create a Hepato-Pancreato-Biliary (HPB) group in South Africa was planted at the 2005 European HPB Association (EHPBA) biennial congress in Heidelberg, Germany. Professor Philipp Bornman and Martin Smith had a pivotal conversation with the EHPBA committee regarding the integration of the South African HPB community into the broader regional and international HPB societal structures. Professor Bornman, a council member of the EHPBA at the time, and Professor Smith identified a significant opportunity for South Africa to contribute meaningfully to the field, noting that much of the scientific discourse at the congress was well within South Africa’s capabilities. From this discussion emerged two primary objectives: the establishment of a national HPB chapter in South Africa and the submission of a bid to be adjudicated at the 2006 World Congress in Edinburgh to host the 2012 International HPB Association (IHPBA) World Congress in South Africa.

New horizons in liver transplantation for hepatocellular carcinoma

As the third most common cause of death due to cancer worldwide in 2020, primary liver cancer continues to be a major contributor to mortality across the globe. It has been estimated that by the year 2025, more than 1 million people will develop liver cancer annually. As the predominant type, hepatocellular carcinoma (HCC) accounts for up to 90% of all liver cancers. The aetiology and incidence of HCC vary widely across geographic regions. Viral aetiologies predominate, specifically the Hepatitis B virus (HBV) across most of Asia, Africa and South America, and the Hepatitis C virus (HCV) across North America, Western Europe and Japan. Alcohol intake remains the main contributor in Central and Eastern Europe. It is important to note that the incidence of non-alcoholic steatohepatitis (NASH) is on the rise and is predicted to soon become the leading cause of HCC, particularly in high-income regions.

Liver resection for hepatocellular and fibrolamellar carcinoma in a South African tertiary referral centre – an observational cohort analysis

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy in adults and is the fifth most common solid tumour worldwide with a variable prevalence based on underlying risk factors and geography. The incidence has risen over the past several decades and HCC is now the third leading cause of cancer-related deaths globally, after lung and stomach cancers, with a 5-year survival rate less than 20% and recurrence rates as high as 88%. More than 80% of global HCCs occur in sub-Saharan Africa (SSA) and Eastern Asia where the incidence ranges from 4.8 to 8.3 per 100 000 per year in different regions of SSA with the highest incidence in western and central Africa compared to less than 3 per 100 000 in Western countries. HCC has become a significant public health concern in SSA and is now the second leading cancer in men and the third for women, occurring in particular in young adults.3,6 Unfortunately only a small proportion of patients in SSA with HCC are treated with curative intent. Data are scarce, but studies consistently report that curative-intended treatment is pursued in less than 1% of patients in SSA with HCC. Fibrolamellar carcinoma (FLC) was until recently regarded as a variant of HCC occurring in young patients with a relatively good prognosis but is now recognised as a distinct clinical entity with consistent chimeric fusion protein (DNAJB1-PRKACA) expression by FLC tumours.

Outcomes of jaundice in advanced hepatocellular carcinoma – a sub-Saharan perspective

The global incidence of hepatocellular carcinoma (HCC) is rising and by 2040, HCC will account for an estimated 1.3 million deaths annually.1 Eighty per cent of all new HCC originate from low- and middle-income countries (LMICs), most of which are in South-East Asia and sub-Saharan Africa (SSA).2-7 In SSA, HCC is typically a fatal disease of the young. The age at presentation is between 28 and 54 years, and 84% present with advanced disease. Most patients receive best supportive care (BSC) as the sole modality of care, and only six per cent are alive at one year. Chronic hepatitis B virus (HBV) infection is the main aetiology of HCC on the African sub-continent. Over the last thirty years, many studies have attributed the HCC disease profile in young SSA patients (large tumours in non-cirrhotic livers, high metastatic burden and frequent tumour-related complications) to the hepatocarcinogenic potential of HBV. The high prevalence of vascular invasion and extrahepatic metastases also support the impact of this HBV carcinogenic pathway.

Inflammatory myofibroblastic tumours of the liver – a systematic review

Inflammatory myofibroblastic tumour (IMT) is an uncommon condition characterised by the proliferation of myofibroblastic spindle cells with concomitant inflammatory cell infiltration. Although IMT is the recommended terminology for the condition, other terms such as inflammatory pseudotumour, inflammatory fibrosarcoma, plasma cell granuloma, post-inflammatory tumour, xanthomatous pseudotumour, and sclerosing pseudotumour have been used interchangeably in the medical literature. Inflammatory myofibroblastic tumours tend to occur in the lungs where they typically have an indolent course. They may also occur in the genitourinary tract (bladder, uterus), gastrointestinal tract (liver, stomach, spleen), and upper respiratory tract (larynx, trachea) where a risk of malignant transformation exists.

Isolated Roux-en-Y versus single loop pancreaticojejunal reconstruction after pancreaticoduodenectomy – a systematic review and meta-analysis of randomised controlled trials

Pancreaticoduodenectomy (PD) is the surgical procedure of choice for the treatment of periampullary neoplasms (cancers of the ampulla, distal common bile duct, head of the pancreas, and periampullary duodenum). The initial perioperative mortality after PD was reported at around 25–39% in the 1970s. However, with advances in operative and anaesthetic techniques, establishment of high volume centres, implementation of standardised pathway for recovery and a better understanding and management of common complications, the perioperative mortality has reduced significantly to less than 5% especially in high volume centres. Despite the reduction in perioperative mortality, perioperative morbidity remains high with most centres reporting complication rates of 30–50%.

Does the textbook outcome in pancreatic surgery score after pancreaticoduodenectomy for ampullary carcinoma have prognostic value?

Adenocarcinoma of the ampulla of Vater (AAV) is an uncommon histologically and molecularly heterogeneous tumour, accounting for 7% of periampullary and distal biliary malignancies and 0.2% of all gastrointestinal tumours. True ampullary carcinomas have a more favourable prognosis than other periampullary malignancies with reported 5-year survival rates of 30–50% after pancreaticoduodenectomy (PD). Although PD offers the best chance of cure, the longterm benefits should be balanced against the perioperative morbidity and mortality rates of a major pancreatic resection (PR). Postoperative mortality has decreased over the past decades to around 5% but postoperative morbidity remains substantial. Assessment of the quality and outcome of specific operations has traditionally used discrete clinical and pathological indicators which have included postoperative morbidity, surgical margin status, and mortality. Evaluating each of these quality metrics in isolation does not, however, accurately reflect the total quality of a specific surgical operation and without standardised, clinically relevant and universally applied endpoints, the evaluation of surgical interventions remains ill-defined and inconsistent.

Pancreaticoduodenectomy for distal cholangiocarcinoma at a South African centre

Constituting 13–23% of all extrahepatic biliary cancers, dCCA is defined as a tumour originating in the mucosa of the common bile duct below the confluence with the cystic duct and above the ampulla of Vater. Despite the advent of multimodal treatment strategies, such as chemotherapy and, more recently, immunotherapy, surgical resection of dCCA offers patients the only chance for cure and long-term OS.2-5,8-30 Surgical strategies for dCCA include pylorus preserving pancreaticoduodenectomy (PPPD) and the Whipple procedure (PD).

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

Pancreatic cancer (PC) is the seventh most lethal cancer in the world, with a mortality-to-incidence ratio of 98% and a five-year OS rate of only 9%. This lethality, also observed in the most common subtype of adenocarcinoma, is mainly due to the retroperitoneal location of the pancreas and non-specific clinical signs of PC, resulting in late diagnosis when it is locally advanced and amenable, in the main, to palliative therapy. There is a lack of data on the burden of PC in South Africa (SA). In 2020, the SA National Cancer Registry reported PC rates of 0.62% to 0.64% of all cancers. In Africa, the age-standardised rate of PC was reported to be 2.2 per 100 000 compared to 7.7 per 100 000 in Europe. A study in the Free State province found a discordantly higher incidence of PC when contrasted with the national registry reports, possibly reflecting underdiagnosis or under reporting nationally.

Predicting gallstone pancreatitis in HIV infected patients

Biochemical markers in acute pancreatitis may aid in the prediction of a biliary aetiology and indicate the need for early interventions. In some patients with pancreatitis and cholangitis, endoscopic retrograde cholangiopancreatography (ERCP) may be indicated. In those with cholecystolithiasis and cholestasis, evaluation for ductal stones is by abdominal ultrasound, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) or intraoperative cholangiography. In previous studies a number of biochemical markers including total bilirubin (TBIL), alkaline phosphatase (ALP), gamma glutamyl transferase (GGT) alanine aminotransferase (ALT) and aspartate aminotransaminase (AST) have been investigated as markers of a biliary aetiology.

Intermediate and long-term survival prediction using prognostic scores in patients undergoing salvage TIPS for uncontrolled variceal bleeding

Acute variceal bleeding (AVB) remains a serious complication in patients with portal hypertension and hepatic decompensation. Achieving survival in this high-risk group requires astute multidisciplinary management with urgent control of variceal bleeding, prevention of subsequent rebleeding and support of deteriorating liver function. Standard of care treatment including fluid and blood resuscitation, vasoactive drugs, prophylactic antibiotics, and endoscopic intervention is effective in controlling bleeding in over 90% of patients. However, despite optimal management, up to 10% of patients fail initial endoscopic control and over 20% rebleed within six weeks after control of the initial bleed.

The role of endoscopic retrograde cholangiopancreatography in the treatment of hepatic cystic Echinococcus in a high HIV prevalence population: a retrospective cohort study

CE is caused by the cestode Echinococcus granulosus (EG), which normally follows a sheep-dog host cycle but may accidentally infect humans who are dead-end hosts. Incubatory cysts may lodge in various organs in the body, most notably the liver, causing HCE. HCE has a long latency period, is frequently asymptomatic, and potentially self-limiting. However, in a third of patients, it may progress and become symptomatic or complicated with secondary infection or rupture into the peritoneal cavity or the biliary system.

Effect of preoperative biliary drainage on intraoperative biliary cultures and surgical outcomes after pancreatic resection

Obstructive jaundice (OJ) is a common presenting symptom in patients with periampullary tumours who may need surgical resection, which is the only curative-intended treatment for patients with periampullary cancers. Unrelieved and prolonged OJ is associated with malnutrition, coagulopathy, impaired immune and renal function and poor wound healing. Infective complications occur in up to 38% of patients after pancreaticoduodenectomy and are associated with increased length of hospital stay, increased cost of treatment, need for additional invasive procedures, postpancreatectomy bleeding, delay in commencing adjuvant chemotherapy and diminished disease-free survival. Endoscopic or percutaneous preoperative biliary drainage (POBD) will correct the physiological abnormalities associated with OJ. Endoscopic stenting with placement of self-expanding metal stents (SEMS) is favoured. Routine POBD, however is associated with an increase in postoperative infective complications and has generally been reserved for patients with cholangitis, malnutrition, very high bilirubin levels and those requiring neo-adjuvant therapy.

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South African Journal of Surgery - Vol 62 no 2 - 2024