Introduction: The relationship between pancreatitis and dyslipidaemia is unclear and has never been studied in a South African context. Patients and methods: A prospective evaluation of all admissions with acute pancreatitis to a regional hospital general surgical service was performed to ascertain its relationship to dyslipidaemia. Aetiology was determined by history and ultrasound assessment. Disease severity was assessed using a modified Imrie score and an organ failure score. Body mass index was calculated. A lipid profile was obtained. Abnormal profiles were repeated. Secondary causes of dyslipidaemia were noted. A comparison of the demographic profile, aetiology, disease severity scores, complications and deaths were made in relationship to the lipid profiles. Results: From June 2001 to May 2005, there were 230 admissions, of whom 31% were women and 69% men. The median age was 38 years(range 13- 73). The pancreatitis was associated with alcohol in 146(63%), gallstones in 42(19%) and idiopathic in 27(12%). The amylase was significantly higher with a gallstone aetiology (p / Thesis (MMedSc)-University of KwaZulu-Natal, 2006.

Renal failure in patients undergoing Aortic surgery is associated with a poor outcome. The shortcomings of serum creatinine for measuring renal function are well documented. We examined the value of alternative markers in diagnosing and predicting renal damage in patients undergoing abdominal aortic surgery and those exposed to intravascular contrast media. Cystatin C lacks some of the reservations associated with serum creatinine when used as a marker of glomerular filtration rate. The protease inhibitor alpha-glutathione Stransferase (a-GST) is recovered in urine after injury to proximal tubular cells. Urine microalbumin is a marker of glomerular permeability. Together we used all four assays to detect and characterize the nature of renal injury after surgery and contrast exposure. Cystatin C had a marginally better sensitivity than serum creatinine at detecting baseline renal impairment. It also showed earlier changes in individual patients whose renal dysfunction deteriorated over time. The urinary markers showed an earlier significant rise after the onset of surgery when compared to serum markers, but only a-GST rose significantly after contrast exposure. Patients undergoing a supra-renal cross-clamp showed significantly higher a-GST levels (and not the other three markers) when compared to the infra-renal group. Cystatin C appears to have better sensitivity and specificity for predicting the need for dialysis in patients undergoing surgery. Peak serum creatinine and cystatin C after contrast exposure show good correlation with peak values after surgery. Cystatin C is equivalent to and may be better than serum creatinine in detecting preexisting and deteriorating renal impairment. Although the urinary assays are earlier markers of renal injury, their clinical significance needs to be determined. Elevation in creatinine and cystatin C after contrast exposure parallel those after surgical intervention and may be helpful in selecting out high-risk patients prior to surgery. / Thesis (M.Med.Sc.)-University of Natal, 2003.

Objective. To assess the influence of diabetes mellitus on early morbidity and mortality following open vascular surgical interventions. Methods. Clinical data on patients subjected to open vascular surgical procedures over a 5 year period at the Durban Metropolitan Vascular Service was culled from a prospectively maintained computerized database. They were divided according to the type of surgical procedure performed. These were open abdominal aortic surgery, peripheral bypass surgery, lower extremity major amputation and carotid endarterectomy. They were further subdivided into 2 groups, diabetic and non-diabetic. Results. 1104 charts were analysed. There were no significant differences in demographics and risk factors between the two groups. 273 patients had open abdominal aortic surgery. 217 (79%) were non-diabetic. diabetic patients had significantly higher incidence of myocardial infarction (p=0.00001) (6 of 6 patients), graft sepsis (p=0.000001) (7 of 7 patients) and mortality rate (p=0.0335) (5 of 10 patients). 337 patients had peripheral bypass procedures. 204 (60%) of these were non-diabetic. There was a high prevalence of smokers among non-diabetics and of hypertension among diabetics. Diabetic patients had a preponderance of graft infection (p=0.0015) (15 of 20 patients) and cardiovascular complications (p=0.0072) (7 of 8 patients). 230 patients had lower extremity major amputations, 81 (35%) were diabetic and 149 (65%) non-diabetic. Myocardial infarction and death (6 of 8 patients each) were significantly higher among diabetics (p =0.04). 264 patients had carotid endarterectomy, 170 (64%) being non-diabetic. The surgical outcome was similar between the two groups. Conclusions. This is retrospective study and as such it has some its limitations. Not all patients might have been included in the study and some of the information might have been lost. The numbers in this study are large and these limitations would appear not to have influenced the outcome of this study. This study has shown that diabetes mellitus had diverse influence on the early outcome following different vascular surgical procedures. Diabetes mellitus significantly increased the incidence of graft sepsis among those who had aorto-bifemoral bypass and peripheral bypass procedures. The incidence of peri-operative cardiovascular morbidity was significantly increased among diabetics who had peripheral bypass procedures, open abdominal aortic surgery and lower extremity major amputations. Diabetes mellitus had no influence on the surgical outcome following carotid endarterectomy. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2012.

In clinical anatomy, the renal venous system is relatively understudied compared to the arterial system. This investigation aims to clarify and update the variable patterns of the renal venous vasculature using cadaveric human (adult and foetal) and Chacma baboon (Papio ursinus) kidneys and to reflect on its clinical application, particularly in surgery and radiology. The study employed gross anatomical dissection and detailed morphometric and statistical analyses on resin cast and plastinated kidneys harvested from 211 adult, 20 foetal and 10 baboon cadavers. Radiological techniques were used to study intrarenal flow, renal veins and collateral pathways and renal vein valves. The gross anatomical description of the renal veins and its relations were confirmed and updated. Additional renal veins were observed much more frequently on the right side (31 %) than previously documented (15.4%). A practical classification system for the renal veins based on the number of primary tributaries, additional renal veins and anomalies is proposed. Detailed morphometric analyses of the various parameters of the renal veins corroborated and augmented previous anatomical studies. Contrary to standard anatomical textbooks, it was noted that the left renal vein is 2.5 times the length of its counterpart and that there are variable levels of entry of the renal veins into the IVC. Justification for the distal segment of the left renal vein to be termed the surgical trunk, and the proximal segment to be the homologue of the right renal vein is presented. Radiological investigations demonstrated a non-segmental and non-lobar intrarenal venous architecture, an absence of renal vein valves and extensive venous collaterals centering on the left renal vein. These collateral channels, present in the foetus, and persisting in the adult, may be operative and of clinical significance in pathological states. No sex differences and no race differences of note were recorded in this study. The Chacma baboon displayed similar intra-renal venous anatomy. The applied clinical anatomy of these findings with particular regard to renal surgery and uro-radiology is emphasised. / Thesis (M.D.)-University of Natal, 1993.

Transcutaneous oxygen pressure measurement (TCp02) using a miniaturised Clarke electrode and a heating thermistor was developed independently by Huch et al and Eberhardt et al in 1972. After its initial use to non invasively monitor arterial partial pressure (Pa02) in neonates it was proposed as a useful test of skin blood flow and possibly amputation wound healing level selection in patients with peripheral vascular disease. Unfortunately a wide range of predictive values emerged with some authors reporting amputations healing when the TCp02 value was 0 mmHg. The investigation, while still considered useful, has not gained widespread support. This study investigates the use of TCp02, establishes a value for the use of the TCp02 Index to predict amputation wound healing potential and examines the hypothesis that the use of the TcpO Index to select amputation level can reduce patient morbidity and mortality. The literature is reviewed and a series of studies evaluating TCp02 use, undertaken in the Durban Metropolitan Vascular Service Non-Invasive Laboratories, are presented. TCp02 measurements were performed in a standardised manner with the subject supine breathing room air. Measurements were taken at fixed sites, on the mid dorsum of the foot (Foot), 10 cm distal to the tibial tuberosity and 2 cm lateral to the anterior tibial margin (BKA), 10 cm proximal to the patella in the midline (AKA) and on the chest in the mid-clavicular line. A TCp02 Index, the limb to chest ratio was defined. TCp02 data derived from control subjects asymptomatic of peripheral vascular disease were shown to be similar to age matched pooled data derived from the literature. In patients with peripheral vascular disease, absolute TCp02 and the TCp02 Index were shown to fall from proximal to distal sites and again were no different to pooled data derived from the literature. Based on presenting symptoms, the fall in TCp02 and the TCp02 Index was significant from proximal to distal sites. The reduction in absolute TCp02 and the TCp02 was also related to the most distal pulse present. TCp02 values were found to be no different in patients with peripheral vascular disease with or without diabetes. When comparing TCp02 and the TCp02 Index with Doppler pressure measurements at the Popliteal artery and at the foot, and the Doppler ankle brachial index (ABI), Doppler derived data were significantly higher in diabetic patients than in non-diabetic patients. No differences were noted in TCp02 data. TCp02 was compared with the 133Xe radio-isotope skin washout test. The best correlation was (r = 0.46) was obtained with a logarithmic curve y = 10.862Ln(x) + 38.751. TCp02 was compared with antibiotic concentrations (Cefoxitin) in muscle obtained from the site of amputation and the Cefoxitin Index, the ratio of muscle antibiotic concentration to plasma concentration, as an indication of the relationship of skin TCp02 to muscle blood flow. A significant correlation was shown between the Cefoxitin Index and TCp02 (r = 0.67, p = 0.035) and the TCp02 Index (r = 0.64, P = 0.045), suggesting that skin oxygen delivery may reflect muscle antibiotic delivery and hence blood flow. TCp02 and the TCp02 Index were compared with heated and unheated laser Doppler fluxmetry (LDF) in 35 patients undergoing amputation wound healing assessment. Significant correlations were shown between heated LDF, heated LDF Index and the TCp02 Index (r = 0.63 and r = 0.69, P < 0.0001). TCp02 Index values of 0.5 and 0.55 showed an accuracy of 96.2 % in predicting amputation outcome while LDF values of 3, 4 and 5 arbitrary units gave an accuracy of 88.5 %. Using receiver operator curves, a TCp02 Index of 0.55 was shown to be the best test. Over the years 1987 and 1988, TCp02 data were gathered on 193 patients undergoing lower limb amputation for peripheral vascular disease. Information on the outcome of the amputation was available for 152 amputations. Circumstances which might result in a reduced pre-operative TCp02 reading were identified and criteria were set for the use of TCp02 to predict amputation wound healing potential. 122 amputations which met the defined entry criteria were available for evaluation. A TCp02 Index of 0.50 gave a definitive predictive value below which no amputation healed. Similarly no amputation with an absolute TCp02 of less than 27 mmHg healed. Receiver operator characteristic curves showed the TCp02 Index to be a better test than absolute TCp02. A TCp02 Index of 0.55 was shown to have the best sensitivity of96.7 %, with a specificity of79.8 % and an accuracy of 90.2 %. When introduced to clinical practice, correct use of the TCp02 Index of 0.55 resulted in a reduction in amputation revision rate from 40.3 % in 1987, to 8.2 % in 1990. Initially some surgeons felt that the TCp02 Index predicted amputation wound failure at distal sites at which healing could be expected on clinical criteria, and chose amputate at sites with a TCp02 Index value less than 0.55. These amputations failed to heal. As surgeons gained confidence in the test, they chose to follow the TCp02 data more often and the percentage of amputations performed at sites predicted by the TCp02 Index to fail , fell from 35.5 % in 1987 to 6.6 % in 1990. Over a 15 year period at King Edward VIII Hospital, the amputation revision rate has fallen from an average of 32.7 % in the first five years when Tcp02 data were not available to the surgeon, to 21.4 % and 22.9 % in the two subsequent 5 year periods when Tcp02 data were available. The mortality rates were unchanged. The decline in revision rates was less than expected and relates to the fact that approximately only 42 % of patients requiring amputation undergo the test. This is because it is time consuming and available only during weekday office hours. These studies have confirmed the usefulness of Tcp02 measurement in the non-invasive vascular laboratory. The index is shown to be superior to absolute Tcp02 as a predictive test of amputation wound healing. The introduction of several criteria to define when Tcp02 use is appropriate has refined the investigation and made it clinically useful in our setting. A Tcp02 Index of 0.55 in the appropriate patient is a useful test to predict amputation wound healing and its use has resulted in reduced patient morbidity and mortality, confirming the hypothesis tested. / Thesis (M.D.)-University of Natal, 2001.

Thesis (M.Med.)--University of Natal, Durban, 1997.

The pattern of mucosal blood flow in normal human stomachs, and benign gastric ulcers was assesed with laser Doppler flowmetry and the relationship between a single determination of ulcer blood flow and the systemic level of growth factors was investigated. A significant ascending gradient in mucosal blood flow from the antrum to fundus was demonstrated. Different levels of cellular activity in the regions of the stomach may explain this gradient. In the gastric ulcers that healed on standard medical therapy mucosal blood flow was significantly increased in comparison to normal stomachs. In the ulcers that were refractory to standard medical therapy mucosal blood flow was significantly lower than in normal stomachs and healing ulcers. Higher systemic levels of the growth factor bFGF were demonstrated in healing ulcers compared to non-healing ulcers. Gastric mucosal blood flow can increase in response to the increased metabolic demands of healing, however impairment of this response may be an important factor preventing healing of benign gastric ulcers. It would appear that non-healing of gastric ulcers can be predicted at initial diagnosis by reduced peri-ulcer gastric mucosal blood flow and low blood levels of bFGF. / Thesis (M.Med.Sc.)-University of Natal, Durban, 1999.

Background: Surgical disease related to HIV is scantily documented with a paucity of data detailing the manifestations of HIV in surgery especially in resource-poor, high prevalence settings such as in South Africa. This review provides an update on the topical issues surrounding HIV and surgery. Objectives: The objective of the study was to determine the incidence, pathogenesis, clinical presentation, aspects of diagnosis and management of: HIV- associated salivary gland disease in particular parotid gland enlargement; Kaposi’s sarcoma (KS) and lower limb lymphoedema; AIDS- related abdominal malignancies due to KS and lymphoma; Acalculous cholecystitis and HIV- cholangiopathy and HIV- associated vasculopathy. Methods: A collective review of the literature was performed and data sourced from a search of relevant electronic medical databases for literature from the period 2000 to the present date. Studies under each section were selected based on inclusion and exclusion criteria. Content analysis was used to analyse data. Results: The HIV pandemic has resulted in an increased frequency of benign lymphoepithelial cysts making it the commonest cause of parotidomegaly in most surgical practices. KS should be considered in the differential diagnosis of a patient with chronic lymphoedema. Lymphoedema may be present without cutaneous lesions, making clinical diagnosis of KS difficult. The gastrointestinal tract is the commonest site of extra- cutaneous KS. Surgical management of the lymphoma patient is restricted nowadays to determining the diagnosis and in some cases to evaluate disease stage. Highly active antiretroviral therapy (HAART) is an important part of the management of biliary tract conditions in addition to relevant surgical procedures. HIV- vasculopathy represents a distinct clinico- pathological entity characterized by a vasculitis with probable immune- mediated or direct HIV- related injury to the vessel wall. Conclusion: The rising incidence of HIV in South Africa and other developing countries has been associated with new and unusual disease manifestations requiring surgical management for diagnostic, palliative or curative intent. It is crucial that surgeons remain abreast of new developments related to the challenging spectrum of HIV and its protean manifestations. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2012.

This study investigates the clinical and major risk factor profiles in Whites, Indians and Blacks with atherosclerotic peripheral vascular disease at the Vascular Service in Durban; and compares them to that for coronary artery disease in the same race groups. The clinical profile for chronic peripheral vascular disease was established in a retrospective study of 2175 patients seen at the Vascular Service during 1981-1986. Atherosclerosis was confirmed in 1974 patients (92,3%) on the basis of clinical, doppler, angiographic and histological evidence. The disease predominantly affected the aorta and distal peripheral vessels. Extracranial cerebrovascular disease occurred less commonly in Blacks than in Whites and Indians. Occlusive disease was the most common pathological type in all race groups. Aneurysmal disease occurred mainly in the aorta with peripheral aneurysms being most common in Blacks. The disease manifested in Blacks at an . earlier age and more aggressively than in Whites and Indians. The risk factor profile for atherosclerotic peripheral vascular disease was established in a prospective study of 302 male patients consisting of 100 Whites, 97 Indians and 105 Blacks on the basis of historical, clinical and haematological data. The sample was randomly selected, and not strictly representative of the clinical pattern in the retrospective study. All patients were confirmed to have atherosclerosis on the basis of the previously mentioned criteria. Smoking was the single most common risk factor in all race groups. Hypertension occurred more commonly in Whites and Indians than in Blacks, while diabetes was commonest in Indians. Insulin resistance did not occur in Blacks, but was possibly present in Whites and Indians. Total cholesterol, LDL cholesterol and triglycerides were raised in Whites and Indians, but not in Blacks. HDL cholesterol was reduced in all 3 race groups. These findings suggest that contrary to the established view, atherosclerotic peripheral vascular disease is an established entity in Blacks seen at the Vascular Service in Durban without a concomitant increase in coronary and extracranial cerebrovascular disease. In Whites and Indians atherosclerosis occurred in all of the vascular beds. This could support the contention that in a socially developing society atherosclerosis affects the aorta and distal peripheral vessels before the coronary vascular bed. Since this occurs in the presence of normal levels of total cholesterol, LDL cholesterol and triglycerides, it does not support the contention that hypercholesterolaemic states are essential for atherosclerotic lesions to develop. On this basis it is postulated that with social transition there is a differential atherosclerotic involvement of the vascular beds due to a differential vascular susceptibility. Smoking is an important socio-environmental risk factor, while at the biochemical level a reduced HDL cholesterol and not a raised total cholesterol, LDL cholesterol or triglyceride could trigger the 'lipid pathway' in atherogenesis. It is further postulated that the differential vascular susceptibility does not exist in a fully developed society once lipid aberrations include a raised total cholesterol, LDL cholesterol and triglycerides. Insulin resistance/hyperinsulinaemia may play a role in the evolution of the disease within the coronary vascular bed. / Thesis (M.D.)-University of Natal, Durban, 1996.