Translation, cross-cultural adaptation, and validation of the Duke Activity Status Index (DASI) to Sinhala language.

BACKGROUND: Duke Activity Status Index (DASI) is a widely used tool to assess functional capacity among patients, but there is no Sinhala version validated for patients in Sri Lanka. This study aimed to cross-culturally adapt and test the validity and reliability of the Sinhala version of DASI (DASI-S). METHODS: The translation and cross-cultural adaptation of the DASI questionnaire were conducted following the standard guidelines. It was pre-tested on ten pre-operative patients and further modified. The construct validity and reliability of DASI-S were evaluated by administering the modified final DASI-S, which comprised 12 items, along with the physical functioning sub-scale of the 36-item short-form health survey (SF-36), consisting of 10 items to eighty-one patients who were awaiting non-cardiac surgeries at university surgical wards, National Hospital of Sri Lanka (NHSL), and Colombo North Teaching Hospital (CNTH), Sri Lanka. Reliability was assessed through Cronbach alpha, while the validity was evaluated using factor analysis and Spearman's correlation. The ethical approval was obtained from the Ethics Review Committee, Faculty of Medicine, University of Colombo, Sri Lanka. RESULTS: The mean age of the participants was 46.2 (± 16.6) years and the majority were females (54.3%). The mean height, weight, and body mass index of the sample were 160.5 (± 9.6) cm, 60.3 (± 11.9) kg, and 23.4 (± 4.5) kgm-2 respectively. The Cronbach's alpha coefficient for the internal consistency of DASI-S was 0.861. The concurrent validity of DASI-S was substantiated by positively correlating (p < 0.01, rs = 0.466) with the physical sub-scale of SF-36. There was a significant difference (p < 0.01) in the total score of DASI-S between the two age groups. CONCLUSIONS: Sinhala version of the DASI appears to be a valid, reliable and easy-to-administer tool to assess functional capacity among patients who are awaiting non-cardiac surgeries.

A novel structure for online surgical undergraduate teaching during the COVID-19 pandemic.

BACKGROUND: The Covid-19 pandemic necessitated the delivery of online higher education. Online learning is a novel experience for medical education in Sri Lanka. A novel approach to undergraduate surgical learning was taken up in an attempt to improve the interest amongst the students in clinical practice while maximizing the limited contact time. METHOD: Online learning activity was designed involving medical students from all stages and multi consultant panel discussions. The discussions were designed to cover each topic from basic sciences to high-level clinical management in an attempt to stimulate the student interest in clinical medicine. Online meeting platform with free to use basic plan and a social media platform were used in combination to communicate with the students. The student feedback was periodically assessed for individual topics as well as for general outcome. Lickert scales and numeric scales were used to acquire student agreement on the desired learning outcomes. RESULTS: A total of 1047 student responses for 7 questionnaires were analysed. During a 6-week period, 24 surgical topics were discussed with 51 contact hours. Eighty-seven per cent definitely agreed (highest agreement) with the statement 'students benefitted from the discussions'. Over 95% have either participated for all or most sessions. A majority of the respondents (83.4%) 'definitely agreed' that the discussions helped to improve their clinical sense. Of the total respondents, 79.3% definitely agreed that the discussions helped to build an interest in clinical medicine. Around 90% agreed that both exam-oriented and clinical practice-oriented topics were highly important and relevant. Most widely raised concerns were the poor Internet connectivity and limitation of access to the meeting platform. CONCLUSION: Online teaching with a novel structure is feasible and effective in a resource-limited setting. Students agree that it could improve clinical interest while meeting the expected learning outcomes.

Colorectal cancer burden and trends in a South Asian cohort: experience from a regional tertiary care center in Sri Lanka.

OBJECTIVE: Colorectal cancer (CRC) burden is increasing in the south Asian region due to the changing socio-economic landscape and population demographics. There is a lack of robust high quality data from this region in order to evaluate the disease pattern and comparison. Using generalized linear models assuming Poisson distribution and model fitting, authors describe the variation in the landscape of CRC burden along time since 1997 at a regional tertiary care center in Sri Lanka. RESULTS: Analyzing 679 patients, it is observed that both colon and rectal cancers have significantly increased over time (pre 2000-61, 2000 to 2004-178, 2005 to 2009-190, 2010 to 2014-250; P < 0.05). Majority of the cancers were left sided (82%) while 77% were rectosigmoid. Over 25% of all CRC were diagnosed in patients less than 50 years and the median age at diagnosis is < 62 years. Increasing trend is seen in the stage at presentation while 33% of the rectal cancers received neoadjuvant chemoradiation. Left sided preponderance, younger age at presentation and advanced stage at presentation was observed. CRC disease pattern in the South Asian population may vary from that observed in the western population which has implications on disease surveillance and treatment.

Comparison of hazard of death following surgery for colon versus rectal cancer.

INTORDUCTION: Prognosis in cancer is usually assessed by use of Kaplan-Meier survival function estimate curves, which reflect survival, or the proportion of patients that will remain alive after a particular event at a given time. By contrast, hazard function represents the proportion expected to be deceased among those surviving at a given time after an event. Objectives To evaluate survival and hazard of death, in patients with colon cancer (CC) and rectal cancer (RC), as indices of prognosis. METHODS: Colon and rectal cancer patients who underwent surgical resection with curative intent from 1996 to 2011 were studied. The hazard of death and survival patterns were assessed with Weibull Hazard models and Kaplan- Meier survival function estimate curves. RESULTS: There were 119 CC and 250 RC patients included in the study. Median (Inter-quartile range: IQR) age of both groups was 58 (49 - 66.5) years. The median (IQR) followup time was 30 (12 - 72) months for CC and 30 (13 - 70) months for RC. Both groups were similar in comparison with regard to age (p=0.96), gender (p=0.56), tumour stage (p=0.33), vascular invasion (p=0.69), lymphatic invasion (p=0.33), perineural invasion (p=0.94), degree of tumour differentiation (p=0.38) and preoperative carcinoembryonic antigen levels (p=0.77). CC showed better overall survival compared to RC (p=0.03) with a 5-year survival rate of 72% versus 60% respectively. After curative resection, CC showed a 6% decrease in hazard of death with time compared with RC which showed a 1% increase in the hazard of death with time. CONCLUSIONS: Among patients who underwent resectional surgery, CC had a better prognosis than RC.

Uses of a familial adenomatous polyposis registry.

OBJECTIVES: To improve the prognosis of patients with familial adenomatous polyposis (FAP) by early diagnosis and prophylactic treatment through a coordinated FAP register. DESIGN: The establishment and descriptive analysis of the prospective database of the FAP registry. SETTING: University surgical unit, Colombo North Teaching Hospital Ragama, Sri Lanka. PATIENTS: Probands were identified by tracing all diagnosed FAP patients from 1996 to 2010 and their family members at risk. INTERVENTIONS: The establishment of a polyposis register included the following stages: ascertainment of probands (first contact symptomatic FAP patients), construction of pedigrees, counselling relatives and prophylactic screening of family members at risk, treatment and follow up. RESULTS: Twenty seven enrolled probands (12 male and 15 female, age 11-52 years, median age 34 years) were investigated. Pedigree analyses showed 206 relatives at risk. Twenty four family members at risk were screened of a total of 51 registered individuals. The rate of spontaneous mutations was 41%. Thirty five were diagnosed with FAP. Eight were screen detected (median age - 32 years) and 27 symptomatic (median age - 34 years). Concomitant colorectal cancer was detected in 17 (63%) symptomatic individuals and in 1 (13%) screen detected individual. Colectomy was performed in 27 (77%) patients while 8 (23%) are on chemoprophylaxis. Congenital hypertrophic retinal pigment epithelium was detected in 15. Desmoids tumours (6%) and other extraintestinal manifestations including osteomas, sebacious cysts and dental abnormalities (34%) were also detected. A thyroid gland malignancy was screen detected while retinoblastoma, hepatoblastoma and cerebral tumours were seen in pedigrees. CONCLUSIONS: A polyposis register may improve prognosis of FAP by early detection. It will help coordinate, optimise and streamline clinical management of patients with FAP and their relatives at risk.

Young patients with colorectal cancer have poor survival in the first twenty months after operation and predictable survival in the medium and long-term: analysis of survival and prognostic markers.

OBJECTIVES: This study compares clinico-pathological features in young (<40 years) and older patients (>50 years) with colorectal cancer, survival in the young and the influence of pre-operative clinical and histological factors on survival. MATERIALS AND METHODS: A twelve year prospective database of colorectal cancer was analysed. Fifty-three young patients were compared with forty seven consecutive older patients over fifty years old. An analysis of survival was undertaken in young patients using Kaplan Meier graphs, non parametric methods, Cox's Proportional Hazard Ratios and Weibull Hazard models. RESULTS: Young patients comprised 13.4 percent of 397 with colorectal cancer. Duration of symptoms and presentation in the young was similar to older patients (median, range; young patients; 6 months, 2 weeks to 2 years, older patients; 4 months, 4 weeks to 3 years, p > 0.05). In both groups, the majority presented without bowel obstruction (young--81%, older--94%). Cancer proximal to the splenic flexure was present more in young than in older patients. Synchronous cancers were found exclusively in the young. Mucinous tumours were seen in 16% of young and 4% of older patients (p < 0.05). Ninety four percent of young cancer deaths were within 20 months of operation. At median follow up of 50 months in the young, overall survival was 70% and disease free survival 66%. American Joint Committee on Cancer (AJCC) stage 4 and use of pre-operative chemoradiation in rectal cancer was associated with poor survival in the young. CONCLUSION: If patients, who are less than 40 years old with colorectal cancer, survive twenty months after operation, the prognosis improves and their survival becomes predictable.

Sexual and urinary dysfunction following rectal dissection compared with segmental colectomy.

INTRODUCTION: The aim of this study was to assess the impact of nerve sparing surgery and major abdominal surgery on sexual and urinary function in men and women with colorectal cancer undergoing rectal dissection and segmental colectomy. METHOD: Forty-eight patients (group A: 22 males, 26 females; median age 55 years) undergoing rectal dissection were compared with 24 having segmental colectomy (group B: 12 male, 12 female; median age 55 years). Preoperative data were also compared with age- and gender-matched controls (group C). RESULTS: More patients after rectal dissection vs segmental colectomy had urinary tract infections [15 (31%) vs 3 (17.5%), P = 0.04]. At 37 months, urinary dysfunction after rectal excision was seen in 29 (60%; 20 men) vs nine (37.5%; eight men) after segmental colectomy. Postoperative urinary symptoms were significant in group A, but not in group B (pre: vs post; groups A and B: poor stream--13%vs 38%, P = 0.001 and 21%vs 21%, P = NS; incontinence--4.2%vs 17%, P = 0.008 and 8%vs 8%, P = NS; hesitancy--13%vs 35%, P = 0.034 and 17%vs 21%, P = NS). Sexual health was worse after rectal excision compared with segmental colectomy (men--62.5%, women--25%vs 44% of men) respectively. Erectile dysfunction was the chief cause (rectal excision--50%vs segmental colectomy - 33%). After rectal excision, 6% of women had dyspareunia and 19% reported reduced orgasm but none after segmental colectomy. Conclusion More men than women had urinary and sexual impairment after rectal excision than after segmental colectomy. Its aetiology is multifactorial.

Complications of loop ileostomy and ileostomy closure and their implications for extended enterostomal therapy: a prospective clinical study.

INTRODUCTION: Patients who have a temporary loop ileostomy have impaired quality of life. Complications associated with a loop ileostomy or ileostomy closure will impair patients' quality of life further and require extended enterostomal therapy. We performed a prospective audit of loop ileostomy to ascertain the nature of the workload that may be created with ileostomy-related complications. PATIENTS AND METHODS: One hundred and forty patients (67 males, 73 females, median age 50 years, range 5-90 years) who received a temporary loop ileostomy were analysed after completion of proformas on a prospective basis between 1999 and 2006. RESULTS: Operation was performed for rectal cancer 100 (71%), familial adenomatous polyposis 14 (10%), ulcerative colitis 21 (15%) and for trauma or Hirchsprung's disease 5 (3%). Complications of loop ileostomy were: retraction 1 (0.7%), ileostomy flux 11 (8%), stomal prolapse 1 (0.7%), parastomal hernia 1 (0.7%), paraileostomy abscess 4 (3%) and severe skin excoriation 9 (6%). The loop ileostomy was reversed in 117 (83%) at a median (range) of 13 weeks (1-60). Ileostomy closure-related complications were: small bowel fistula 1 (0.9%), small bowel obstruction 5 (4.3%) and a stitch sinus in 1 (0.9%). Five women developed recto-vaginal fistula (n=3; 2.6%), pouch-vaginal fistula (n=1; 0.9%) and pouch-anal fistula (n=1; 0.9%) that required extended enterostomal therapy, after loop ileostomy reversal. CONCLUSION: Nineteen percent of patients following creation of a loop ileostomy and 10.5% of patients after reversal of the ileostomy required extended enterostomal care by a specialized enterostomal therapist, which supported resumption of a normal life.