Browsing by Author "Jonas, Eduard"

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    Open Access
    A prospective, longitudinal, observational study to assess the health-related quality of life of patients with pancreatic ductal adenocarcinoma in the South African context
    (2022) Kotze, Urda Karin; Jonas, Eduard; Krige, Jake
    Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive visceral malignancy originating from pancreatic duct cells. Despite advances in detection, diagnostic procedures and surgical and oncologic treatment, the overall prognosis remains dismal. GLOBOCAN 2020 ranks PDAC as the 7 th leading cause of all cancer deaths. There are no reliable statistics on the incidence of PDAC in South Africa. The National Cancer Registry South Africa of 2017 reports that PDAC accounts for 0.53% and 0.58% of all cancers in females and males respectively. However, this low incidence may be due to underreporting, as the diagnoses are based on positive histology which are performed on only a small proportion of PDAC patients reported by the National Health Laboratory Service (NHLS), only one of several laboratories in South Africa. The overall 5-year survival rate for all PDAC patients is reported to be less than 5%, and the overall median survival is 4-7 months from the time of diagnosis. Surgical resection offers the only chance of cure, but as few as 10% of patients are treated with curative intent with 5-year survival rates of 15-25%. A median survival of 2.8-5.7 months has been reported for patients with metastatic disease. Early symptoms of PDAC such as loss of appetite, weight loss and fatigue are vague and non-specific, which often leads to a delay in the diagnosis. Approximately 80% of patients who have PDAC involving the head of the pancreas present with painless jaundice. In those with advanced disease other digestive symptoms such as loss of weight, nausea and vomiting, bloating, altered bowel habits and backache are prominent. Because of the severity of symptoms, the small proportion of patients who are eligible for curative treatment, and the dismal overall survival, palliative treatment is an important component of the overall treatment of PDAC. In this respect information provided by health-related quality of life (HRQOL) assessments, which refer to the subjective experiences and perceptions of patients regarding their health, illness, and medical interventions, and how these affect their everyday life and functioning, are invaluable for planning and assessing the effect of palliative treatment. HRQOL assessment quantifies not only the actual symptoms but also the effect of the disease on a person in his or her totality. Many studies that report on HRQOL in PDAC are conducted in sponsored clinical trials and are guided by regulatory requirements. These studies typically include highly selected cohorts defined by strict inclusion and exclusion criteria, and results do not reflect HRQOL in the larger unselected patient population. Several nonclinical trial PDAC HRQOL studies have been done both in patients who underwent an operation and those who received palliative treatment. The prognostic value of HRQOL parameters have also been investigated. Very little data are available on the HRQOL of PDAC patients in low- and middle-income countries (LMICs), and to our knowledge no data have been published on the HRQOL of PDAC patients in South Africa. The aim of this research was to assess HRQOL in a South African PDAC patient cohort presenting at a major hepato-pancreato-biliary (HPB) academic referral centre, and to determine the possible clinical applications of HRQOL outcomes in the management of these patients, treated with either curative or palliative intent. The European Organisation for Research and Treatment of Cancer (EORTC)-QLQ-C30 and EORTC-QLQ-PAN26 instruments were used in a longitudinal design study to allow for comparisons with baseline (BL) reports at regular intervals, thereby identifying statistically significant and clinically meaningful changes that may have occurred over time. As in previous publications, a high mortality and decreasing compliance over time in both the curative intended and palliative cohorts were noted. In contrast to patients who underwent an operation in whom the functional and symptom scales and scores fluctuated notably between time points, the same remained relatively stable in the patients who received palliative treatment. Some interesting observations regarding the possible prognostic value of HRQOL outcomes in the respective treatment groups need to be further investigated in larger patient cohorts. Some of the lessons learnt in this study from a LMIC, may be of value in planning subsequent tumour-related HRQOL studies in LMICs, regardless of tumour type.
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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 analysis of prognostic, endoscopic and transjugular intrahepatic portosystemic salvage shunting factors influencing rebleeding and death in portal hypertensive patients with life-threatening variceal bleeding
    (2025) Krige, Jacobus; Jonas, Eduard; Beningfield, Steve
    The management of refractory variceal bleeding constitutes one of the most difficult and complex life-threatening emergencies in surgical gastroenterology. Over the past four decades the treatment of variceal bleeding has evolved and improved with the consequence that mortality has decreased substantially to current rates of 15 to 20% at six weeks after the index variceal bleed. Significant advances have included new vasoactive drug combinations, improved endoscopic techniques with refinements in variceal ligation equipment using multi-band devices and the selective use of radiologically inserted transjugular intrahepatic portosystemic shunts (TIPS). While medical and endoscopic technical advances in treatment have reduced overall mortality, uncontrolled, recurrent and persistent refractory bleeding from recalcitrant varices and the consequences of progressive liver failure remain the leading causes of early death in portal hypertensive patients. Despite progress in overall management, specific limitations in treatment and deficiencies in existing knowledge remain and represent areas where further research, analysis and clinical improvements are necessary. These investigations relate to the need for more accurate prognostic scoring in complex variceal bleeding, the lack of comparative efficacy outcome data for injection sclerotherapy and endoscopic ligation when treating active variceal bleeding, the long-term limitations of endoscopic ligation in eradicating varices, preventing variceal recurrence and rebleeding and crucially, improving the safety profile of variceal interventional endoscopy. In addition, there is a dearth of clinical and laboratory risk factors predicting in-hospital mortality and intermediate and long-term survival after salvage transjugular intrahepatic portosystemic shunting when used as a rescue method in patients who have endoscopically uncontrolled variceal bleeding. These major clinical issues and deficiencies are addressed in this thesis which comprises a literature review and six clinical investigations. A. The literature review component focusses on three main variceal bleeding themes. These include: 1. Prognostic predictors of mortality in acute variceal bleeding including a comparative evaluation of existing Child-Pugh and MELD scores, the pathophysiology of variceal bleeding and the implications of altered oesophageal venous anatomy on endoscopic treatment of varices. 2. Endoscopic methods used in acute variceal bleeding including a historical perspective and the evolution of endoscopic variceal intervention, injection sclerotherapy and variceal ligation endoscopic techniques, and comparative studies evaluating the relative efficacies of endoscopic variceal intervention in the treatment of acute variceal bleeding and an analysis of oesophageal, regional and systemic adverse events after endoscopic variceal ligation for oesophageal varices. 3. A review of salvage transjugular intrahepatic portosystemic shunts (sTIPS) for uncontrolled oesophageal variceal bleeding, including a historical background, the evolution and development of sTIPS, indications and insertion technique, contra-indications and complications of TIPS insertion, and the results of sTIPS. B. An assessment of the major unresolved clinical variceal bleeding-related issues indicated above are addressed in six clinical investigations which constitute the research component of this thesis. 1. Improvement of prognostic scoring: While the ideal prognostic score should be accurate, objective, functional on a continuous scale, validated worldwide, be able to guide treatment and easy to calculate, the currently available Child-Pugh and MELD scores are flawed when used to assess severity of liver dysfunction and predict patient risk for in-hospital rebleeding and death. Neither score is ideal, and both have intrinsic limitations related to their development and inclusion of biochemical and clinical components. Study 1 in this thesis addresses these issues and proposes and validates a new 4-category recalibrated C-P score. 2. Endoscopic control of acute variceal bleeding. Immediate and durable endoscopic control of acute variceal bleeding is the objective of intervention and is crucial to survival. Study 2 in this thesis evaluated the relative efficacies of endoscopic ligation and injection sclerotherapy in arresting acute variceal bleeding in a matched controlled cohort study. 3. Determining the benefits and limitations of endoscopic banding in variceal bleeding. Although the utility of endoscopic therapy in controlling acute variceal bleeding has been widely reported, the long-term efficacy and safety of banding in a high-risk cohort of patients with active variceal bleeding is poorly defined and documented. Study 3 in this thesis assessed acute bleeding control, rebleeding, variceal eradication and recurrence after endoscopic banding in a prospective longitudinal observational study. 4. Identifying factors influencing in-hospital mortality for salvage TIPS in cirrhotic patients with recalcitrant variceal bleeding after failed endoscopic intervention. TIPS is now established as the preferred rescue or salvage procedure for patients who have either uncontrolled or severe recurrent variceal bleeding unresponsive to medical and endoscopic treatment. Study 4 in this thesis investigated the outcome of sTIPS in patients who had life-threatening variceal bleeding resistant to standard treatments in order to identify clinical and laboratory risk factors that would predict in-hospital death during the index admission. 5. Intermediate and long-term outcomes after salvage TIPS for uncontrolled variceal bleeding. The reported long-term survival data after salvage TIPS placement are widely divergent due to differing inclusion criteria, population selection, timing of TIPS, severity of underlying liver disease and the experience of the faculty and the facility in the management of critically ill patients with end-stage liver disease. Accurate patient selection is an important consideration in the TIPS procedure. Study 5 in this thesis assessed intermediate and long-term survival after sTIPS to identify possible prognostic factors influencing prolonged survival. 6. Development of a novel CABIN prognostic score to predict in-hospital mortality After salvage TIPS and testing the efficacy of the new score against other established prognostic models. Several prognostic and risk scores have been developed to identify patients at risk for a poor clinical outcome after sTIPS insertion. Although these individual models have been correlated with TIPS outcome, their relative performances have not been assessed in a detailed analysis. Study 6 in this thesis assessed the accuracy of a newly developed and novel CABIN score and compared the CABIN score to existing established risk scores to predict in-hospital mortality after sTIPS placement. The studies reported in this thesis are original, relevant and important and make a substantial contribution to the existing body of knowledge. As the six studies are clinically based and involve portal hypertensive patients with acute and life-threatening variceal bleeding which has a substantial mortality rate, any improvement in outcome will have a beneficial impact on existing patient care. The newly proposed 4-category recalibrated Child-Pugh score is easy to calculate at the bedside and can assist in guiding treatment and predicting the risk of in-hospital variceal rebleeding and death. In the matched controlled cohort study, endoscopic ligation has been shown to be the optimal method of controlling acute variceal bleeding, while the long-term study defined the benefits and exposed the limitations of variceal ligation. The three salvage TIPS studies identified factors influencing in-hospital mortality in cirrhotic patients with recalcitrant variceal bleeding after failed endoscopic intervention, as well as intermediate and long-term outcomes and predictive risk factors. The development of a novel CABIN prognostic score designed to predict in-hospital mortality after salvage TIPS was shown to be an improvement over other established prognostic models and should be beneficial in future accurate patient selection for salvage TIPS. In making recommendations for future research, new prognostic scoring systems incorporating artificial intelligence, machine learning algorithms and neural network models will need to be assessed and included as part of essential variceal bleeding clinical algorithms. Because published results are variable and conflicting with small sample sizes, referral bias, dissimilar study endpoints, differences in patient selection, methods and techniques of endoscopic intervention and the precise definition of rebleeding, specific and uniformly defined study end-points are required. Unexplored research areas of quality of life and cost-effective issues are increasingly important concepts to consider in future trial design. As endoscopic failure to control variceal bleeding is encountered by even the most experienced endoscopists, the clear definition and early recognition of endoscopic failures and the implementation of local control methods including self-expanding oesophageal metal stents and improved quality PTFE-coated TIPS stenting are anticipated to improve bleeding control and survival in this high-risk cohort. Several important and unresolved issues relating to the specific role of sTIPS in the management of patients with actively bleeding uncontrolled oesophageal varices remain. Published results are variable and conflicting and an important future goal will be to define and identify the specific target population who would benefit or not from sTIPS. Another objective which requires further investigative research is accurately identifying stable but recurrent variceal bleeders who would benefit from pre-emptive or early-TIPS. The literature review in this thesis has shown considerable variation in the quality of randomised trials evaluated, especially regarding generation of allocation sequences and allocation concealment adversely affecting patient selection, assessment and attrition bias. Despite the number of concluded studies, there remain unresolved questions. Understanding the problems inherent in the design, execution and interpretation of clinical trials in portal hypertension is critical to eliminating quality variations by addressing these deficiencies and answering these questions when planning future studies. In addition, the statistical power of trials remains a major problem in portal hypertension trials, where modest survival advantages are unlikely to be detected unless large-scale, multicentre randomised trials are undertaken incorporating sufficient patient numbers. A further limitation is that only a modest number of published trials have performed blinded outcome assessment. The implications for future research into variceal bleeding are that adequately powered, meticulously conducted, properly reported multicentre trials need to continue to address unresolved issues. As patient recruitment becomes an increasing impediment, future studies require internationally accepted standard protocols to facilitate aggregated analyses and future meta-analyses. In addition, the increasing demand for medical fiscal discipline and logistic efficiency require the issue of cost to be adequately addressed in prospective studies, as illustrated by concerns raised at the recent Baveno Consensus Conferences on future improvements and research requirements in portal hypertension (de Franchis, 2024).
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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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    Open Access
    Colorectal cancer liver metastases – a population-based study on incidence, management and survival
    (BioMed Central, 2018-01-15) Engstrand, Jennie; Nilsson, Henrik; Strömberg, Cecilia; Jonas, Eduard; Freedman, Jacob
    Background: Colorectal cancer (CRC) is a leading cause of cancer-associated deaths with liver metastases developing in 25–30% of those affected. Previous data suggest a survival difference between right- and left-sided liver metastatic CRC, even though left-sided cancer has a higher incidence of liver metastases. The aim of the study was to describe the liver metastatic patterns and survival as a function of the characteristics of the primary tumour and different combinations of metastatic disease. Methods: A retrospective population-based study was performed on a cohort of patients diagnosed with CRC in the region of Stockholm, Sweden during 2008. Patients were identified through the Swedish National Quality Registry for Colorectal Cancer Treatment (SCRCR) and additional information on intra- and extra-hepatic metastatic pattern and treatment were retrieved from electronic patient records. Patients were followed for 5 years or until death. Factors influencing overall survival (OS) were investigated by means of Cox regression. OS was compared using Kaplan-Meier estimations and the log-rank test. Results: Liver metastases were diagnosed in 272/1026 (26.5%) patients within five years of diagnosis of the primary. Liver and lung metastases were more often diagnosed in left-sided colon cancer compared to right-sided cancer (28.4% versus 22.1%, p = 0.029 and 19.7% versus 13.2%, p = 0.010, respectively) but the extent of liver metastases were more extensive for right-sided cancer as compared to left-sided (p = 0.001). Liver metastatic left-sided cancer, including rectal cancer, was associated with a 44% decreased mortality risk compared to right-sided cancer (HR = 0.56, 95% CI: 0. 39–0.79) with a 5-year OS of 16.6% versus 4.3% (p < 0.001). In liver metastatic CRC, the presence of lung metastases did not significantly influence OS as assessed by multivariate analysis (HR = 1.11, 95% CI: 0.80–1.53). Conclusion: The worse survival in liver metastatic right-sided colon cancer could possibly be explained by the higher number of metastases, as well as more extensive segmental involvement compared with left-sided colon and rectal cancer, even though the latter had a higher incidence of liver metastases. Detailed population-based data on the metastatic pattern of CRC and survival could assist in more structured and individualized guidelines for follow-up of patients with CRC.
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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.
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    Liver resection for hepatocellular and fibrolamellar carcinoma in a South African tertiary referral centre
    (2025) Ziaei, Yalda; Jej, Krige; Jonas, Eduard
    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 the western central Africa compared to less than 3 per 100 000 in Western countries. Hepatocellular carcinoma 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. 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 recognized as a distinct clinical entity with consistent chimeric fusion protein (DNAJB1-PRKACA) expression by FLC tumours. The optimal treatment of HCC and FLC is influenced by the stage of the disease, the degree of liver impairment, and patient performance status. Currently, the therapeutic strategy is based on international guidelines and the Barcelona Clinic Liver Cancer (BCLC) staging system in which potentially curative treatment for early-stage HCC includes resection, transplantation and ablation. Surgical resection is the treatment of choice in patients without cirrhosis and in those with cirrhosis and well-preserved hepatic function. Despite advances in surgical techniques and perioperative care, hepatectomy remains a high-risk surgical procedure with complications occurring in up to 40% of resections. This adds a significant burden to individual patients by adversely affecting quality of life and increasing length of hospital stay, readmission rates, and healthcare costs. Recurrence despite curative-intent treatment is as high as 88% and is due to tumour multifocality, size ≥5 cm, macroscopic vascular or microscopic lymphovascular invasion, elevated alfa-fetoprotein (AFP) levels and impaired liver function. Previous publications from our unit have reported earlier data on resection for HCC and FLC. The aim of this research was to assess the peri-operative outcome and survival of patients with HCC and FLC following curative liver resection at a tertiary referral centre in South Africa. In this study a retrospective analysis was done of all liver resections for HCC and FLC at Groote Schuur Hospital and the University of Cape Town Private Academic Hospital between January 1990 and December 2021. Three resection groups were compared, (i) HCC occurring in normal livers, (ii) HCC occurring in cirrhotic livers, and (iii) fibrolamellar carcinoma. Post-operative complications were classified according to the expanded Accordion severity grading system. Median overall survival (OS) and 95% confidence intervals (CI) were calculated. Forty-eight patients were included in the study, 25 with HCC in non-cirrhotic livers, 15 in cirrhotic livers and eight for FLC. Thirty-six patients (75%) underwent a major resection. No mortality occurred but 16 patients (33%) developed grade 1 to 4 complications. Thirty-three patients (68%) developed recurrence of HCC following their initial resection of whom 29 (60%) ultimately died. Median OS was 64.2m, 95% CI [29.7-84.6], 61.9m, [28.1-95.6] and 31.7months, [1.5-61.8] for patients with HCC in non-cirrhotic livers, FLC and HCC in cirrhotic livers respectively. Liver resection for HCC and FLC was a safe procedure with no mortality, but one-third of patients had associated post-operative morbidity. The high long-term recurrence rate remains a major obstacle in achieving better survival results after resection.
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    Resection of biliary mucinous cystic neoplasms: Study of a single institutional cohort and a literature review
    (2017) Kloppers, Jacobus Christoffel; Krige, Jake E J; Jonas, Eduard
    Background: Biliary mucinous cystic neoplasms (BMCNs) are uncommon neoplastic septated intrahepatic cysts which are often incorrectly diagnosed and have the potential for malignant transformation. Aim: The aim of this study was to assess the outcome of surgical resection of BMCNs. Methods: Data from a departmental and faculty registered prospective liver surgery database was used to identify patients who underwent surgery at Groote Schuur and the University of Cape Town Private Academic Hospitals for BMCN from 1999 to 2015. Standard demographic variables including age and gender were documented as well as detailed preoperative imaging, location and size, operative treatment, extent of resection, histology, post-operative complications using the Clavien-Dindo classification and long-term outcome. Results: Thirteen female patients (median age 45 years) had surgery. Eleven were diagnosed by computer tomography scan after investigation of abdominal pain or a palpable mass. Two were jaundiced. One cyst was found incidentally during an elective cholecystectomy. Five cysts were located centrally in the liver. Before referral three cysts were treated inappropriately with percutaneous aspiration or drainage and two were treated with operative deroofing. Six patients had anatomical liver resections and seven patients had non anatomical liver resections of which two needed ablation of residual cyst wall. One patient needed a biliary-enteric reconstruction to treat a fistula of the left hepatic duct. Median operative time was 183 minutes (range: 130-375). No invasive carcinoma was found on histology. There was no operative mortality. One surgical site infection was treated and one patient developed an intra-abdominal collection one month post-operatively. Two patients developed recurrent BMCN after 24 months. Conclusion: BMCNs should be considered in middle aged women who have well encapsulated multilocular liver cysts. Treatment of large central BMCNs adjacent to vascular and biliary structures in particular may require technically complex liver resections and are best managed in a specialized hepato-pancreatico-biliary unit.
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    Synchronous and metachronous liver metastases in patients with colorectal cancer—towards a clinically relevant definition
    (2019-12-26) Engstrand, Jennie; Strömberg, Cecilia; Nilsson, Henrik; Freedman, Jacob; Jonas, Eduard
    Abstract Background Approximately 25% of patients with colorectal cancer (CRC) will have liver metastases classified as synchronous or metachronous. There is no consensus on the defining time point for synchronous/metachronous, and the prognostic implications thereof remain unclear. The aim of the study was to assess the prognostic value of differential detection at various defining time points in a population-based patient cohort and conduct a literature review of the topic. Methods All patients diagnosed with CRC in the counties of Stockholm and Gotland, Sweden, during 2008 were included in the study and followed for 5 years or until death to identify patients diagnosed with liver metastases. Patients with liver metastases were followed from time of diagnosis of liver metastases for at least 5 years or until death. Different time points defining synchronous/metachronous detection, as reported in the literature and identified in a literature search of databases (PubMed, Embase, Cochrane library), were applied to the cohort, and overall survival was calculated using Kaplan-Meier curves and compared with log-rank test. The influence of synchronously or metachronously detected liver metastases on disease-free and overall survival as reported in articles forthcoming from the literature search was also assessed. Results Liver metastases were diagnosed in 272/1026 patients with CRC (26.5%). No statistically significant difference in overall survival for synchronous vs. metachronous detection at any of the defining time points (CRC diagnosis/surgery and 3, 6 and 12 months post-diagnosis/surgery) was demonstrated for operated or non-operated patients. In the literature search, 41 publications met the inclusion criteria. No clear pattern emerged regarding the prognostic significance of synchronous vs. metachronous detection. Conclusion Synchronous vs. metachronous detection of CRC liver metastases lacks prognostic value. Using primary tumour diagnosis/operation as standardized cut-off point to define synchronous/metachronous detection is semantically correct. In synchronous detection, it defines a clinically relevant group of patients where individualized multimodality treatment protocols will apply.
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    The introduction of workplace-based assessment for general surgery training at a South African university
    (2025) Nel, Daniel; Jonas, Eduard; Burch, Vanessa; Caincross, Lydia
    Assessment in postgraduate training in South Africa has traditionally focused solely on knowledge objectives. There is currently a movement to introduce Workplace-Based Assessment (WBA) to evaluate trainee clinical competence. However, concerns have been raised regarding the feasibility of this approach in a South African context. Similar concerns about feasibility and other issues with WBA implementation have been identified in General surgery in different settings. The aim of this study was to determine if it was possible to introduce WBA and to identify the characteristics of a WBA strategy that would ensure successful implementation at a South African university. Methods: The design-based research methodology was used to define the educational problem, generate guiding principles for a solution, test the solution through cycles of implementation and refinement, and finally reflect on the implementation process to derive a final set of design principles. The study was conducted in the Division of General Surgery at the University of Cape Town from 2022 to 2023. The planning of the design and the interpretation of the findings were considered in the context of socio-cultural learning theory. Results: Fifteen guiding principles, underpinned by theory, were used to design the WBA strategy. Three cycles of testing and refinement showed relatively high perceived feasibility, acceptability, and appropriateness among trainees and supervisors. The lessons learned from each cycle enabled the solution and design principles to be modified, in consultation with a stakeholder team, to further enhance participant perceptions and implementation. This process resulted in 15 final design principles, of which six were substantive and nine were procedural. The substantive principles related to the selection of EPAs, assessment tools, the supervisor base, and the digital platform. The procedural principles related to the pace of introduction, team development, managing the formative-summative tension, and change management approach. Conclusion: WBA can be introduced for postgraduate General surgery training at a South African university. Design principles have been identified to ensure a feasible introduction in this context. These principles may assist others in implementing new or refining existing WBA strategies.
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    The profile and outcomes of patients with Hepatocellular Carcinoma treated with curative intent at Groote Schuur Hospital, a Tertiary Referral Centre in South Africa
    (2022) Chilton, Gareth Harvey; Bernon, Marc; Jonas, Eduard
    Introduction: HCC is a common cause of cancer-related death in sub-Saharan Africa (SSA). Whereas several papers have reported on HCC in the South African context, very few studies have evaluated treatment options and subsequent survival data. Objective: To identify the clinical characteristics of patients with HCC presenting to Groote Schuur Hospital and present survival data on patients treated with curative intent. Methodology: All patients who presented with HCC from 1 July 2015 to 30 June 2020 were included in the study. Data was extracted from a faculty approved, prospectively maintained registry. Information collected included demographics, clinical characteristics, grading of liver dysfunction according to the Child-Pugh Score (CPS) and Model for end stage liver disease (MELD) score, disease stage according to the Barcelona Clinic Liver Cancer (BCLC) grading system and treatment received. Variables were assessed for the total patient cohort as well as for the palliative and curative intended patient groups. Survival data was collected for the curative intended treatment group up to 31st of August 2021. Results: A total of 152 patients were included in the study. Chronic hepatitis B infection (60.5 %) was the most common aetiological factor. Twenty-one patients (13.8%) were treated with curative intent. The median survival of the entire curative intended cohort was 45.5 months (range 0.1-72.5). The median survival for the transplantation, resection and local ablation groups were 54.3, 23.0 and 45.5 months respectively. Conclusion: Only 13.8% of patients were treated with curative intent. Survival data in the patients treated with curative intent is comparable to other reported series. The findings highlight the need for improved screening of high risk patients and appropriate referral of patients for curative intended treatment.
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    The role of serial lactate and liver enzyme dynamics in predicting post hepatectomy liver failure
    (2022) Soldati, Vuyolwethu Sonwabile; Bernon, Marc; Jonas, Eduard
    Background: Post-hepatectomy liver failure (PHLF) is an important cause of morbidity and mortality following liver resection. Current prognostic models only allow for the detection of PHLF on post-operative day 5. Earlier detection and intervention may improve outcomes. To date, no studies have evaluated serial post-operative lactate and liver function tests (LFT) to predict PHLF. Aim: This study evaluated the prognostic utility of serial lactate concentrations and LFTs to predict PHLF following hepatectomy. Methods: All major liver resections (≥ 3 Couinaud segments) undertaken at Groote Schuur Hospital and UCT Private Academic Hospital from May 2018 to April 2021 were included. Lactate levels were measured 4-hourly for the first 24 hours post hepatectomy and daily LFTs for the first 5 days. Associations between baseline patient characteristics and lactate dynamics in PHLF as well as the predictive value of lactate, INR and bilirubin were determined. Results: Forty-seven patients, mean age 56.5 (±13.2) years, of whom 24 were males were assessed. Five (10.6%) patients had PHLF and were older (67.4 ± 12.2) and were predominantly men (80%)...
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    The surgical management and prevention of laparoscopic cholecystectomy associated bile duct injuries
    (2020) Lindemann, Jessica Danielle; Jonas, Eduard; Strasberg Steven
    Laparoscopic cholecystectomy (LC) is considered the gold standard in the surgical management of gallstone disease and is one of the most commonly performed general surgery operations worldwide. Bile duct injury (BDI) in LC remains a feared complication as it is associated with significant morbidity, prolonged hospital stay, increased costs, and reduced quality of life for patients, as well as the risk of litigation for the injuring surgeon. The initial incidence of BDI after the introduction of LC was reported to be between 0.4 and 0.8%, which was higher than the estimated 0.2% reported during the open cholecystectomy era. However, recent reports from the United States and Europe suggest a return to open cholecystectomy rates. Despite being a frequently performed operation in both the private and public health sectors in South Africa, there is a paucity of data on the incidence of BDI. In the only study to date reporting the frequency of BDI in South Africa, a single centre incidence of 1.2% was documented over an 18-month period, which is significantly higher than previous reports. No data have been published on the implications of BDI for patients treated within the South African healthcare system. This thesis describes the surgical management of BDI at an academic referral centre over a thirty-year period. Potential factors influencing treatment and patient outcome after BDI are investigated. These include the influence of geographic distance from referral centre on the timing of referral and repair, and subsequent long-term patient outcomes. The influence of dual healthcare sectors (public vs. private) on access to diagnostic and interventional modalities, and eventual outcome is also investigated, and the evolution in the management of BDIs over the three studied decades is documented. Factors associated with loss of patency following surgical repair of LC-BDIs are also determined. Based on the findings of this detailed review of the management and outcomes of LC-BDIs, a treatment algorithm for management in resource-constrained environments is proposed. Establishing the optimal management of LC-BDIs in a developing country healthcare setting is important but does not address the source of the problem. In an effort to make LC-BDI a near-never event, a standardized method of performing, documenting and monitoring the quality of LC was developed and implemented for all LCs performed in the Cape Metro West health district. Prospective data collection is scheduled to continue to the end of 2020; however, an interim analysis is presented. A previously published scoring system for assessing quality of the critical view of safety achieved during LC, a critical component of a safe LC, is applied and validated in a large cohort of LC patients. A prospective database was created for data capture along with a Standard Operating Procedure, both designed with the goal of expanding the intervention and database nationally. The studies reported in this thesis make a substantial contribution to the literature and will have a beneficial impact on patient care in two important ways. Firstly, the management of BDI in South Africa is described and a treatment algorithm for resource-constrained environments is proposed, based on local experience. Secondly, a change of practice was implemented and a LC database was established with the possibility of expanding the effort to the national level. Locally, the change in practice has thus far resulted in identification of areas of improvement to limit BDI and increased knowledge about the appropriate steps to take to avoid causing a LC-BDI.