Browsing by Author "Chinnery, Galya"

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    A retrospective review of risk factors for recalcitrant peptic structures
    (2025) Ndlebe, Babalwa; Chinnery, Galya; Scriba, Thomas
    Introduction: Peptic strictures (PS) are a common benign cause of dysphagia, but a scarcity of local data is available as regards identifying risk factors associated with recalcitrancy. Methods: Single centre retrospective audit of PS undergoing endoscopic management between 1st March 2018 and 1st March 2022, aiming to identify recalcitrancy risk factors. Results: Of 69 patients (37 male, 53.4%) with PS, 27 (39.1%) were diagnosed with recalcitrant strictures. Most strictures were positioned distally (53; 76.8%) with an associated hiatus hernia in 52 (75.4%). While comorbidities were not associated with recalcitrancy, younger age was a risk factor (recalcitrant stricture group median age 51 (IQR 38.5-61.0 years) versus non-recalcitrant group median age 62.5 (IQR 48.5-70.8 years); p=0.044). Although HIV status did not affect recalcitrancy risk, taking oral antiretrovirals (ARVs) was significantly associated with PS recalcitrancy (p=0.032; OR 4.55). Presenting degree of dysphagia (p<0.001; OR 16), requiring more than 3 dilatations (p<0.001), and smaller index residual oesophageal lumen (p<0.001) were all significantly associated with stricture recalcitrancy. Fourteen patients were temporarily stented (having a total of 24 stents placed). Thirteen patients had post endoscopic complications with most of these complications occurring amongst the recalcitrant group (n=11). Four complications occurred during endoscopy, two partial thickness tears managed endoscopically, a gastric perforation requiring an over-the-scope-clip closure and one sedation related hypoxia requiring a short period of bag-mask-valve ventilation and sedation-reversal. Two deaths occurred in the cohort; one from a suspected aspiration pneumonia five days after last dilatation and one from a suspected missed oesophageal perforation (2.3% immediate endoscopic intervention complication rate for 265 dilatations performed). Conclusion: Locally pill oesophagitis related to ARVs has been identified as a potential cause of recalcitrancy; identifying at-risk patients early may allow for management adjustments to improve outcomes.
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    A Retrospective Review of the Technical Success of Endoscopic Stenting for Malignant Gastric Outlet Obstruction
    (2022) Tait, Déan; Chinnery, Galya
    Introduction: Palliation of patients with advanced and irresectable malignancies causing gastric outlet obstruction (GOO) with the endoscopic placement of a self-expanding metal stent (SEMS) has become standard. Internationally, technical success rates are high. This study reviewed endoscopic stent placement for malignant GOO compared to other international high-volume endoscopy units, looking into local success rates, pathology, and patient demographics. Methods: A retrospective review of patients presenting to the Groote Schuur Hospital Upper Gastrointestinal Unit with irresectable malignant GOO between 1 March 2018 and 31 August 2021 was performed, evaluating demographics, technical success, pathology, and immediate and late stent complications. Results: One hundred and fourteen patients, 44 (38.6%) female and 70 (61.4%) male, were referred for palliative stenting of malignant GOO; distal obstructive gastric cancer (74.6%) and obstructing pancreatic malignancies (14.9%) being the two most frequent indications. Median age was 63.5years (IQR: 53.25-70) with 48.2% having at least one comorbidity and 48.3% performance scores of 3 or 4. The majority (96; 85.7%) required only one stent, 15 patients (13.4%) had a second stent placed, and one patient required four stents. In total, 132 stent insertion attempts were undertaken. With primary placement, three technical failures were experienced. One stent was initially incorrectly placed but immediately correctly repositioned, while two failed insertions were referred for surgical gastrojejunostomy, equating to a technical success rate of 97.4%.Four immediate stent insertion related complications occurred (3.1%), two related to sedation, one stent placed too distally requiring repositioning and an oesophagogastric junction perforation with procedural death. Fifteen late-stent complications occurred with thirteen stent blockages due to tumour in-growth (10%), one stent fracture and one stent with poor radial expansion. The stent blockages occurred between 3 to 548 days after placement (median 107 days, IQR: 80 – 275 days). Salvage stenting was 100% successful in the 14 cases with late stent complications that required re-stenting. Conclusion: Technical insertion success rates of primary and salvage duodenal stenting for malignant GOO are on par with international high-volume units. The leading pathology locally is gastric adenocarcinoma, with palliative stenting remaining a feasible and accessible option.
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    A retrospective single centre audit on gastric gastrointestinal stromal tumours over a period of fifteen years
    (2022) Kuhn, Suzanne; Chinnery, Galya
    Introduction: Gastrointestinal stromal tumours (GIST) are the commonest tumour of mesenchymal origin; favour the stomach, and account for a very small percentage of gastrointestinal tract tumours. Methods: In this retrospective audit of GISTs presenting to the Groote Schuur Hospital surgical and oncological multidisciplinary team (MDT) between 2004 – 2019, gastric GISTs were evaluated as regards presentation, gastric anatomical position, histological subtype with risk stratification, management and outcomes. Results: Of 126 GIST tumours presenting to this MDT, 82 originated in the stomach. Complete histopathological records could be obtained for 64. With an average of 59 years (50 male: 32 female), 18 (28%) presented with a herald bleed. Other common presentations included anaemia, epigastric mass and pain. The tumours were predominantly found in the body and fundus (64%), with a spindle cell subtype predominance (41%). The association between cancer cell subtype and gastric position was not significantly different (p=0.728). Cystic degeneration was found on 11 (17%) analyzed and cell necrosis on 12 (18%). These findings were not related to larger tumor size or prognosis. Five required downstaging with Imatinib prior to surgery. Thirty-seven patients underwent a surgical procedure: 24 wedge resections and 12 anatomical resections. Risk stratification was performed with the modified National Institutes of Health (NIH/Fletcher) score. Twenty-eight cases had inaccurate mitotic counts and couldn't be scored, 17 scored high risk, 9 intermediate risk, 9 low risk and 1 very low risk. Ten patients died of metastatic disease, 34 were discharged with no disease progression after 3 years, 1 patient with disease progression currently remains on Imatinib, and 19 were lost to follow up. Conclusion: Gastric GISTs appear to have a predilection for the proximal stomach; it is unsure whether this is purely due the greater surface area. The spindle cell subtype dominated in the proximal gastric GISTs. Cystic degeneration and cell necrosis did not seem to be related to larger tumours or outcomes.
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    A review of the incidence and management of complications following malignant oesophageal stenting
    (2024) Teyangesikayi, Gilbert; Chinnery, Galya; Jonas, Eduard
    Background Stenting provides effective palliation of malignant dysphagia for irresectable tumours due to either local invasion, metastatic disease, or poor performance status. Immediate technical success rates are very high, with clinical improvement approaching 90% in most reported series. Complications specific to oesophageal stenting include perforation, pain, aspiration, volume reflux, bleeding, migration, tumour overgrowth and ingrowth. Methods This retrospective audit of palliative oesophageal stenting over a three-year period (March 2018 - March 2021), with review of technical and clinical outcomes, aimed to determine local incidence and management of complications. Results The majority (73.4%) of palliative stents were placed for squamous cell carcinoma (SCC) with a total of 354 stent insertion attempts undertaken in 297 patients (49 requiring multiple stents). Three unsuccessful insertions and six incorrectly placed stents, all immediately addressed, equated to an immediate technicalsuccess rate of 97.5%. Most (346; 98.6%) were fully covered stents; only two partially covered and three uncovered stents were inserted. Seventeen stents (4.8%) were placed for a confirmed trachea-oesophageal fistula. Twenty-one (6.0%) immediate insertion-related complications occurred, including two oesophageal perforations. Five patients required removal of proximal stents on the same day due to significant globus sensation or chest pain. There was no mortality due to immediate stent insertion related complications. Dysphagia improvement was registered in all (100% clinical success rate) successful stent insertions. Late complications occurred in 73 (20.8%). The most frequent indication requiring reintervention was tumour overgrowth (30; 10.1%) occurring at a median 63.5 days(IQR 41.0 - 103.3 days). Stent migration occurred in 18 patients (6.1%) at a median 28.0 days(IQR 10.0 - 52.8 days). Of the total 354 placed stents, 264 (75.2%) had no documented complications for the lifetime of that stent. When comparing the rate of stent migration and tumour overgrowth by tumour position, distal tumours (>30cm from the incisors) were 8.93 times (p<0.0001) more likely to migrate than proximal tumours (>30cm from the incisors) were 8.93 times (p<0.0001) more likely to migrate than proximal tumours (<30cm). Tumour overgrowth was more likely in proximal tumours, but this did not reach statistical significance. Conclusion: Oesophageal stenting is an effective and safe palliation of malignant dysphagia. Outcomes reported by this cohort from a low/middle income setting compare favorably to high volume international units.
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    An overview of adult corrosive ingestion injuries in a sub-Saharan African setting
    (2025) Scriba, Matthias Frank; Jonas, Eduard; Chinnery, Galya
    BACKGROUND Corrosive ingestion remains an important global pathology with high associated morbidity and mortality. Data on the acute management of adult corrosive injuries from sub-Saharan Africa (SSA) is scarce, with international investigative algorithms, relying heavily on computerised tomography (CT), having limited availability in this setting. AIM To investigate the corrosive injury spectrum in a low-resource setting and the applicability of parameters for predicting full-thickness (FT) necrosis and mortality. METHODS A retrospective analysis of a prospective corrosive injury registry (1st March 2017 – 31st October 2023) was performed to include all adult patients with acute corrosive ingestion managed at a single, academic referral centre in Cape Town, South Africa. Patient demographics, corrosive ingestion details, initial investigations, management, and short-term outcomes were described using simple descriptive statistics while univariate analyses with receiver operator characteristic area under the curve (ROC AUC) were used to identify factors predictive of FT necrosis and short-term mortality on admission. CT (grade III corrosive CT grading), endoscopy (Zargar IIIB), and blood gas findings were specifically analysed for FT necrosis prediction performance. RESULTS A total of 100 patients were included, with a mean age of 32 years (SD: 11.2 years) and a male predominance (65.0%). The majority (73.0%) were intentional suicide attempts. Endoscopy on admission was the most frequent initial investigation performed (95 patients), while only 17 were assessed with CT. A chest X-ray (CXR) was performed in 82 patients and only one patient was initially assessed using a contrast swallow examination. Neither CXR nor early contrast swallow findings directly influenced the management in any of these cases. Twenty patients required acute surgery with 17 having full thickness necrosis at surgery, of which eleven underwent emergency resection and six were palliated. Five patients underwent oesophagogastrectomy and five total gastrectomy, with two requiring extended resections (pancreas-preserving duodenectomy and proximal jejunal resection). Thirty-day mortality was 14,0% and morbidity 27,0%. Patients with full thickness necrosis at surgery and those with an established perforation had a 30-day mortality of 58.8% and 91,0%, respectively. Full thickness necrosis was associated with a cumulative survival of 17.6% at 2 years. Univariate analyses with ROC AUC showed admission endoscopy findings, CT findings, and blood gas findings, specifically pH, base excess, and lactate, to all have significant predictive value for full thickness necrosis, with endoscopy proving to have the best predictive value (AUC 0.850). CT and endoscopy findings were the only factors predictive of early mortality, with CT performing better than endoscopy (AUC 0.798 vs 0.759). CONCLUSION Intentional corrosive injuries result in devastating morbidity and mortality. Locally, early endoscopy remains the mainstay of severity assessment, but referral for CT imaging should be considered especially when blood gas findings are abnormal.
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    ETD: Symptoms and Intraoperative findings in patients undergoing revision fundoplication
    (2025) Etalleb, Mohamed; Chinnery, Galya
    Approximately 20% of patients who undergo anti-reflux surgery will report a recurrence of reflux symptoms or develop new symptoms, with 5% ultimately requiring revision fundoplication. The aim of this study is to document symptoms at representation, pre-operative work-up and intraoperative findings of patients presenting for revision fundoplication (RF). Methods: This is a single center descriptive retrospective review of 37 patients who required revision of a previous fundoplication for significant recurrent symptoms between January 2015 and December 2017 at Groote Schuur Hospital and UCT Private Academic Hospital. Patient data included demographics, body mass index (BMI), patient reported symptoms prompting initial fundoplication, interval to symptom recurrence and RF, technique of the first and subsequent revision surgery and perioperative morbidity. Recurrent symptoms at representation, results of pre-operative investigations and actual intraoperative assessment during RF were reviewed. Results: During the two-year study period 37 patients underwent RF. The mean age was 52.9 years (range 22 – 77 years, SD =13.3), with 25 (67.6%) females and 12 (32.4%) males included in the cohort. The most frequent patient-reported indication for index fundoplication was gastro- oesophageal reflux (GOR) (65%). Symptoms at representation prior to RF included dysphagia (51.4%) and heartburn (51.4%) equally, epigastric pain (48.6%), volume reflux (43.2%), atypical chest pain (24.3%), bloating (16.2%), nausea (13.5%) and early satiety (10.8%). The most observed endoscopic finding (available in 35 patients) was a recurrent sliding hiatus hernia (42.9%). All had a contrast swallow with evidence of delayed transit into the stomach present in 45.9%, recurrent sliding hernia and dilated distal oesophagus in 35.1% equally. The RF was performed at a median of 24 months (IQR 2.5 - 66 months) following prior fundoplication. Technique of RF included 17 (45.9%) conversions from full Nissen to partial anterior fundoplication (Dor), 10 (27.0%) re-do Nissen's, two (5.4%) conversions from full Nissen to partial posterior fundoplication's (Toupet), three (8.1%) complete reversal of fundoplication with oesophagogastric junction adhesiolysis, two (5.4%) Heller's myotomies with anterior fundoplication, two (5.4%) crural repairs only (intact wraps) and one (2.7%) opening of tight crura closure. The majority (83.8%) of revisions were completed laparoscopically. The most frequent intraoperative findings included significant oesophagogastric adhesions with wrap distortion (75.7%), recurrent crural defect (51.4%), slipped wrap (45.9%), distal oesophageal/crural fibrosis (37.8%), recurrent sliding hernia (35.1%), a tight crural inlet (24.3%), mixed herniation (10.8%) and three (8.1%) para-oesophageal hernias. Conclusion: This single-center review on revision fundoplication conforms with much of what is written in other studies. Dysphagia is the predominant symptom prompting repeat surgery and most patients present two years after their initial operation. Despite revision anti-reflux surgery remaining technically challenging, the vast majority of operations were completed laparoscopically with low associated morbidity. Larger, multi-center studies would allow for a bigger picture of revision anti-reflux surgery in the greater South African context.
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    Is psoas muscle area as determined by cross-sectional measurement an accurate predictor of peri-operative outcomes in adenocarcinoma of the upper gastrointestinal tract?
    (2022) Divey, Mark; Chinnery, Galya; Jonas, Eduard
    Background Radiologically measured psoas muscle area has been associated with poorer surgical outcomes. Our hypothesis is that patients with gastric cancer and lower psoas muscle area have poorer short-term surgical outcomes. Methods Individuals with gastric cancer were assessed and total psoas muscle area (TPA) in mm2 was measured at the level of the third lumbar vertebra on staging CT, using Phillips IntelloSpace PACS Enterprise version 4.4.553.50. The psoas muscle area was normalised for height (TPA mm2 /m2 ), creating the psoas muscle index (PMI). All individuals proceeding to surgery were compared in terms of PMI with correlation to short-term complications (Accordion), length of stay and mortality. In addition, PMI and tumour staging was evaluated. Results One hundred and seventy-seven individuals (115 males, 62 females, mean age of 60.8 ± 0.9) were evaluated of which sixty-eight underwent surgery (56 resections, 12 palliative bypasses). The surgical complication rate was 40% (27/68), major complications being Accordion 3 or higher at a rate of 16% (11/68) and mortality rate of 10% (7/68). The average length of stay was 10 ± 0.7 days. There was no statistically significant difference in PMI for males or females in respect to all complications, major complications, length of stay or mortality. PMI and tumour staging did not correlate. Males with gastric outlet obstruction had a statistically significant lower PMI (p <0.03) Conclusions Although low psoas muscle area has been shown to correlate with poorer surgical outcomes, we did not show this is our population undergoing surgery for gastric cancer.