Medicine
Permanent URI for this communityhttp://repository.kln.ac.lk/handle/123456789/12
This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
Browse
36 results
Search Results
Item Translation, cross-cultural adaptation, and validation of the duke activity status index (DASI) to Sinhala language(BioMed Central, 2024) Ranasinghe, C.; Kariyawasam, K.; Liyanage, J.; Walpita, Y.; Rajasinghe, U.; Abayadeera, A.; Chandrasinghe, P.; Gunasekara, M.; Kumarage, S.; De Silva, M.; Ranathunga, K.; Deen, K.; Ismail, H.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.Item North Colombo diverticular disease snap shot audit (VISTA study): a collaborative research initiative(The College of Surgeons of Sri Lanka, 2023) Chandrasinghe, P.; Ediriweera, E.P.D.S.; Niriella, M.; Ranwaka, C.; Fernando, A.; Gunawardena, H.; Kumarage, S.INTRODUCTION Diverticulosis and diverticular disease (DD) is a common occurrence in clinical practice in the local setting with a lack of documented literature. A snapshot audit was conducted at North Colombo Teaching Hospital (NCTH) to ascertain the disease burden in clinical practice as a pilot study to assess feasibility and response rate for a nation wide snapshot audit. METHODOLOGY All surgical and gastroenterology units at NCTH were requested to enter the data between 1st January 2022 to 30th of June 2022 on all patients presenting with DD or those detected with diverticulosis during screening colonoscopy. Prospective data collection was done using RedCap© data capturing platform. RESULTS Out of the 8 units invited (general surgery – 5, GI surgery – 1, gastroenterology – 2), 5 units participated (general surgery – 2, GI surgery – 1, gastroenterology – 2); response rate is 62%. A total of 46 patient records (median age- 68 years; range 29- 86; female 51%) were received within 6 months. Of the total 54.3% had symptomatic uncomplicated diverticular disease (SUDD) while 33% were detected with diverticulosis at screening. Only 13% (n=6) required inward care (bleeding – 3, diverticulitis – 2, perforation – 1) and detected using colonoscopy in 4 and CT scan in 2. In the DD group, 20% (6/31) had complicated DD while 80% had Symptomatic Uncomplicated Diverticular Disease (SUDD). CONCLUSION In this pilot study, a majority of the patients with DD presented with SUDD while around 20% came with complicated DD. The response rate from collaborators was satisfactory. The secure online database usage is feasible and will be used for a national level study in the future to assess the disease burden in the healthcare setting in Sri Lanka.Item Development of a model of 3D imaging for the pre-operative planning of TaTME(Oxford University Press, 2018) Sahnan, K.; Pellino, G.; Adegbola, S.O.; Tozer, P.J.; Chandrasinghe, P.; Misovik, D.; Hompes, R.; Hart, A.L.; Warusavitarne, J.; Lung, R.F.BACKGROUND:Transanal TME (TaTME) is a new addition to the approaches in rectal surgery. TaTME requires advanced technical skills and, more importantly, knowledge of the pelvic structures, planes, and spaces as they are encountered moving cephalad from the perineum. We have developed a technique for producing 3D reconstructions of the anorectum and associated anatomy, to aid peri-operative planning and understanding of the anatomy crucial to TaTME surgery. METHODS: A patient was scheduled for single incision laparoscopy surgery (SILS) TaTME completion proctectomy and ileoanal pouch formation for ulcerative colitis. Standard axial T2-weighted Spectral Attenuated Inversion Recovery (SPAIR) and sagittal T2-weighted MRI sequences were obtained and digital imaging and communications in medicine (DICOM) images were imported into a validated open-source segmentation software.1 A specialist consultant gastrointestinal radiologist manually segmented the following structures: sphincter complex; rectosigmoid colon; levator plate, bladder, ureters, urethra and prostate. Each mesh was imported into another open-source system, MeshLab V1.3.3.1 as Stereolithography (STL) files for mesh smoothing to be applied. Individual labels were applied to each anatomical structure. RESULTS: Segmentation took approximately 15 min and an additional 10 min was required for smoothing and applying colour and transparency of the anatomical structures to emphasise surgically relevant anatomy. In Figure (A) provides an overview of the anatomy showing a relatively straight and posterior direction of the rectum as it descends into the pelvis; (B) provides insight into the relation between internal sphincter/rectum and the prostate/urethra. Distance between structures and relative proximity can be easily understood. Figure (C) shows the clearance between low rectum and both ureters, whilst (D) shows an anterior oblique view of the sphincter complex and the urethra. Conclusions :Surgeons currently use a combination of MRI scans, reports and discussion with radiologists to better understand anatomy. The use of these reconstructions in the MDT, in clinic and in the operating theatre could be useful to better communicate complex rectal anatomy, identify areas of difficulty and aid surgical planning. Our reconstructions present a present a cost-neutral solution to better visualise the anatomy they represent the first step towards innovation in TaTME surgery.Item Transanal minimally invasive proctectomy (TaMIP) in patients with Crohn’s disease: A cohort study from the TaTME international database(Oxford University Press, 2018) Pellino, G.; Sahnan, K.; Penna, M.; Adegbola, S.; Chandrasinghe, P.; Hompes, R.; Spinelli, A.; Warusavitarne, J.; International TaTME Registry CollaborativeBACKGROUND :Perianal Crohn’s disease (pCD) is a debilitating condition and despite the advances of medical and surgical treatment, a proportion of patients eventually require proctectomy for severe and/or refractory pCD. TaTME has several advantages, particularly in patients with low rectal cancer, narrow pelvis, previous radiation and bulky prostate. Aim of this study is to assess the feasibility of transanal minimally invasive proctectomy (TaMIP) within the International TaTME registry. METHODS:The TaTME registry was interrogated from 2014 to 2017 for benign conditions. Data were collected across 11 international centres submitted for patients who received TaMIP, with or without TME, for pCD. RESULTS:Forty patients (mean age 42.6 ± 13.8 years) underwent TaMIP for pCD with a median total operative time of 202 ± 102 min for the abdominal phase and 126 ± 58 min for the perineal phase. The majority of patients were female (67.5%; 27 of 40), 80.0% had active IBD at the time of surgery and average duration of follow-up was 4.4 ± 5.8 months. The commonest approach to proctectomy was an intersphincteric APE (30.0%; 12 of 40), with over half of cases (52.5%; 21 of 40) undergoing total intersphincteric dissection. The median height of the pursestring was 4.4 ± 2.4 cm and the most common extraction site was transanal (37.5%; 15 of 40). Intact specimens were found in 21% (8 of 38 TME) and major defects in four cases. During the abdominal phase, 29% (9 of 31) cases were converted-to-open procedure (all strategic) and 20% (8 of 40) during the perineal phase. Peri-operative complications during perineal dissection were: bleeding (12.5%, 5 of 40), incorrect plane (15%, 6 of 40), issues with smoke extraction (12.5%; 5 of 40) and maintaining pneumopelvis (10.0%; 4 of 40). Rectal perforations occurred in two cases at a median of 4 ± 2.8 cm from the anal verge. There were no urethral injuries and blood loss was < 100 ml in 45.4% (15.33) in our cohort. The average length of stay was 6 ± 5 days with no post-operative mortalities. The majority of patients (75.0%; 30 of 40) had no complications. Two-thirds of patients had Clavien-Dindo grade II complications (60.0%; 6 of 40) and one patient had a grade III complication. Late morbidity (>1 month) was available for 23 patients and perineal wound complications were identified in over half of patients (56.5%). CONCLUSIONS: pCD causes perineal fibrosis and chronic sepsis, which can make proctectomy an extremely complex operation (particularly when associated with proctitis), thereby increasing the risk of complications. TaMIP offers a safe and feasible minimally invasive approach to this subset of patients. Outcomes from TaMIP need to be compared with current techniques in order to discern the future role and training requirements for this promising new technique.Item Transanal minimally invasive proctectomy (TaMIP) in patients with inflammatory bowel diseases (IBD) within the TaTME international database(Oxford University Press, 2018) Pellino, G.; Sahnan, K.; Penna, M.; Adegbola, S.; Chandrasinghe, P.; Spinelli, A.; Hompes, R.; Warusavitarne, J.; International TaTME Registry CollaborativeBACKGROUND : The necessity of proctectomy in IBD often represents refractory disease, with severe active/chronic inflammation, frequently in the context of immunosuppression. Minimally invasive techniques are currently being used as an option in the often challenging operations required. We aim to assess the feasibility and short-term outcomes of a transanal minimally invasive approach to proctectomy (TaMIP) in patients undergoing surgery for IBD within the TaTME registry. METHODS: The TaTME registry (secure online database), was interrogated from 2014 to 2017 for benign conditions. Data were collected across 11 international centres submitted for IBD patients. Patients with ulcerative colitis (UC) received proctectomy with or without Ta-IPAA, and patients with Crohn’s disease (CD) received TaMIP, with or without total mesorectal excision (TME), for perianal CD (pCD).RESULTS: In total, 174 patients with a median BMI of 25.6 ± 4.7 kg/m2 were entered into the database. The majority of patients (77%; 134 of 174) had UC and 79.9% (111 of 174) had a simultaneous laparoscopic or single-incision laparoscopic (SILS) approach to the abdomen. Active IBD featured in 63.8% (111 of 174) which was more prominent in the CD patients (80% vs. 59%, p = 0.015) and 19% (33 of 174) were on steroids at the time of surgery. The median total operative time was 249 ± 113 min (abdominal phase 206 ± 112 and perineal phase 133 ± 60 min). An incorrect plane was the most common problem encountered intra-operatively (10.3%; 18 of 174) followed by bleeding (9.2%; 16 of 174). There was an inadvertent rectal perforation rate of 5.6% (6 of 107). Over a fifth of abdominal procedures were converted (21.6%; 30 of 139) compared with 17 (9.8%) in the perineal phase. There were more perineal conversions in CD patients (20% vs. 6.7%, p = 0.028). A purse-string was used in 51.1% (81 of 174) at a median height of 3.8 ± 2 cm. Most anastomoses were created using a stapler (85.1%; 57 of 67) at median distance of 2.9 ± 1.5 cm from the anal verge. The median length of postoperative stay was 9 ± 6.5 days, which was longer in the UC patients (9 ± 7 days vs. 6 ± 5 days, p = 0.0079). There were no mortalities. Forty-four patients (25.3%) had a complication and seven (15.9%) of these (i.e. 4% of total cohort) had a grade III Clavien-Dindo complication (re-operation). Data on late morbidity (>1 month) were available in 92 patients and 15 of these patients (16.3%) had a wound breakdown. Two of these had a VAC dressing and three had re-operations. There was a trend towards more wound sinuses in CD (19% vs. 4.8%, p = 0.062). CONCLUSIONS:Our results demonstrate that the application of a transanal minimally invasive approach to proctectomy is a feasible option in IBD patients with a relatively low complication rate.Item Improving quality of life after pouch surgery with a dedicated nurse led follow up programme(Wiely-Blackwell, 2016) Chandrasinghe, P.; Leo, A.; Alison, L.; Perry-Woodford, Z.; Warusavitarne, J.AIM:Bowel function after ileal pouch affects the quality of life (QOL). The aim of the study was to assess if objective evaluation and specialised supportive care improves QOL after pouch surgery.METHOD: Consecutive patients who had an ileoanal pouch were invited to participate in a systematic follow-up regime led by specialised pouch nurse practitioners. The Cleveland global Quality of Life (CGQOL) and specific pouch related symptoms were documented at 6, 12, 24 and 52 weeks after ileostomy reversal. Pearson's Rho coefficient was used to assess the correlation between symptoms and CGQOL. RESULTS: Thirty-nine consecutive patients who had ileoanal pouch surgery were evaluated. Thirty-four had more than two visits and improvement in CGQOL (mean-1.36 ± 0.95) was seen in 27 (79%). There was reduction in CGQOL in 5 patients (15%) and no change in 2 (6%). Daytime frequency (DTF) significantly correlated with mean CGQOL (R = −0.7, P < 0.01). Twenty (59%) of 34 had reduced DTF after intervention. Nocturnal frequency only showed correlation with CGQOL up to 3 months. Incontinence had no impact on the QOL in this cohort. CONCLUSION: DTF has the highest impact on QOL in this cohort. Regular systematic specialised pouch care follow up may achieve better QOL.Item Long-term function after transanal vs. transabdominal ileal pouch-anal anastomosis for ulcerative colitis: a multi-centre cohort study(Oxford University Press, 2019) Chandrasinghe, P.; Carvello, M.; Wasmann, K.; Tanis, P.; Warusavitarne, J.; Spinelli, A.; Bemelman, W.BACKGROUND:The transanal approach has been introduced in ileal pouch-anal (IPAA) surgery to gain better exposure for the rectal dissection. It has been shown to be safe with lower morbidity than the trans-abdominal approach. The aim of this study was to compare functional outcome of transanal ileal pouch-anal anastomosis (ta-IPAA) with transabdominal (abd-IPAA) approach for ulcerative colitis (UC) using the Cleveland Global Quality of Life (CGQL). METHODS: This is a multi-centre cohort of consecutive patients undergoing abd-IPAA or ta-IPAA for UC prospectively registered in the databases of three tertiary referral institutions between March 2002 to September 2017. Patient characteristics, surgical details and postoperative outcomes were retrieved. The primary end-point was pouch function determined by CGQL score. The questionnaire was administered to all patients with a functioning pouch for 12 months. RESULTS: Ninety-nine patients with ta-IPAA were compared with 274 patients with abd-IPAA. A defunctioning stoma was created at the time of pouch construction in 46 (46%) patients undergoing ta-IPAA and in 130 (47%) patients with abd-IPAA (p = 0.90). Thirty-day postoperative complications according to Clavien-Dindo classification (p = 0.22) as well as anastomotic leak rates (13% vs. 6%), abd-IPAA and ta-IPAA, respectively, were comparable (p = 0.09). Time to stoma closure did not differ between the two groups (abd-IPAA- 6 ± 7 vs. ta-IPAA- 5 ± 4 months; p = 0.72). Twelve months CGQL score was obtained for 251 patients in the abd-IPAA group and for 97 in ta-IPAA cohort. The CGQL index was comparable between the two groups (0.72 ± 0.15 vs. 0.75 ± 0.12; p = 0.07). Quality of health and energy level components were statistically higher for ta-IPAA (7.30 ± 1.53 vs. 7.73 ± 1.19, p = 0.01; 6.68 ± 1.74 vs. 7.17 ± 1.54, p = 0.01) while no difference was found for quality of life item (7.63 ± 1.52 vs. 7.62 ± 1.30, p = 0.73). Pouch failure (including defunction and excision) was reported in 40 of 298 (12%) patients undergoing abd-IPAA and in 1 patient (1%) having ta-IPAA during the follow-up period. CONCLUSIONS: ta-IPAA produces functional result comparable to transabdominal approach at 12 months after surgery.Item SMAD7 shows a biphasic expression pattern during progression of ulcerative colitis-associated colorectal cancer(Oxford University Press, 2019) Chandrasinghe, P.; Cereser, B.; Moorghen, M.; Spaggiari, P.; Maroli, A.; Del Bel Belluz, L.; Hart, A.; Spinelli, A.; Stebbing, J.; Warusavitarne, J.BACKGROUND: Ulcerative colitis (UC) is an idiopathic inflammation of the intestine with an increased risk of developing colitis-associated cancer (CAC). Currently, clinical trials are underway aiming to inhibit SMAD7 to ameliorate inflammation. While the direct effect of depleting SMAD7, an inhibitory molecule in the transforming growth factor-β1 (TGFβ1) pathway, may be therapeutic in UC, its indirect effect on CAC development is largely unknown. TGFβ1 is known to enhance late stages of sporadic colorectal cancers (CRC), where SMAD7 is also elevated. Therefore, we hypothesise that removing inhibition of this pathway by depleting SMAD7 may also be detrimental for CAC. We therefore evaluated the expression of SMAD7 in the colonic epithelium during the inflammation associated neoplastic process to determine a possible role of SMAD7 in CAC. METHODS: The expression of SMAD7 protein and mRNA in colonic epithelia was assessed by immunohistochemistry (IHC) and in situ hybridisation (ISH),, respectively, in a cohort of 53 archival colon samples (17 CAC, 12 dysplastic, 12 inflammed, 12 non-neoplastic/non-inflammed) from patients who have undergone colectomies for UC and CAC. The expression within the epithelial cells was evaluated by both digital quantification and validated by blind scoring by a pathologist. Significant differences were tested with one-way ANOVA and Mann–Whitney U test. RESULTS: Cytoplasmic expression of SMAD7 protein is significantly higher in the inflammed epithelium compared with non-inflamed epithelium (p < 0.0001). Interestingly, a significant decrease of the same was detected in dysplasia (p = 0.01), although this group is characterised by a higher variability. SMAD7 levels are elevated in cancer compared with dysplasia, suggesting a biphasic expression (p = 0.009), which could be in part due to the different genetic composition. SMAD7 mRNA expression was not significantly different across different stages of CAC (p = 0.49). We hypothesise that the lack of correlation between mRNA and protein levels could be attributed to yet unknown post-transcriptional or post-translational regulations. CONCLUSIONS:In our cohort of UC affected colon tissues, SMAD7 demonstrated a biphasic expression pattern along the different stages of CAC with peaks during active inflammation and cancer. The increase in SMAD7 expression during neoplastic transformation, comparable to sporadic CRC, may be a protective response of the epithelium to inhibit the effect of TGFβ1. Although inhibiting SMAD7 as a therapy for UC may remit inflammation, we hypothesise it may exacerbate CAC due to further enhancement in TGFβ1 signalling. We envisage further mechanistic studies in vitro, in particular in organoids, could help in understanding the TGFβ superfamily pathway in CAC.Item Transanal minimal invasive proctectomy (TaMIP) for perineal Crohn’s disease; a multi-centre prospective cohort study(Oxford University Press, 2019) Chandrasinghe, P.; Di Candido, F.; Warusavitarne, J.; Spinelli, A.BACKGROUND: Transanal minimally invasive proctectomy (TaMIP) has some advantages particularly in relation to access to the deep pelvis. Key challenges faced with the TaMIP approach for proctectomy in Crohn’s disease are the diseased pelvis and inflamed, bulky mesorectum causing difficult planes. This study aims to assess the short-term outcomes and perineal wound complications following TaMIP for Crohn’s disease. METHODS: All patients undergoing TaMIP proctectomy between 2014 and 2018, at 2 tertiary care referral centres were prospectively evaluated. Thirty-day morbidity, operative details and perineal wound complications were analysed. RESULTS:A total of 33 patients (M 42%, age 38.5 years; range 26 to 77) have undergone TaMIP for Crohn’s disease. Surgeries were performed as double single port procedures with either complete mesorectal excision or close rectal dissection. The mean operative time was 120 min (range: 60–240) for the perineal procedure and 234 min (range: 140–279) for the total procedure. One case (3%) had to be converted to an open procedure due to difficult dissection and haemorrhage. Ninety per cent of the patients were ASA II and 54.5% underwent completion proctectomy while 45.5% had a panproctocolectomy as a single procedure. Four patients (12%; II 2, III 2) had complications which were Clavien-Dindo II and above. One patient had re-intervention for a pelvic collection while another patient had a ureteric injury. Vacuum dressing was used for primary wound closure in one patient. Major perineal wound dehiscence was seen in 6% (2 of 33) of the patients while one needed vacuum therapy. In long-term follow-up one patient developed an enterocutaneous fistula at the abdominal wound while 7 (21%) chronic perineal sinuses were reported. CONCLUSIONS:Perineal Crohn’s disease poses a challenge for transanal minimally invasive surgery due to the chronic inflammation and perineal sepsis. Transanal approach offers a safe and feasible option for perineal Crohn’s disease. The commonest complication following TaMIP is the development of a chronic perineal sinus and evaluation with laparoscopic and open techniques would be useful to ascertain if this rate is different.Item Long-term function after transanal versus transabdominal ileal pouch-anal anastomosis for ulcerative colitis: a multicenter cohort study(Wiely-Blackwell, 2019) Chandrasinghe, P.; Carvello, M.; Wasmann, K.; Tanis, P.; Warusavitarne, J.; Spinelli, A.; Bemelman, W.AIM:The novel transanal approach to ileal pouch-anal anastomosis (ta-IPAA) provides better exposure with lower short-term morbidity in ulcerative colitis (UC). The aim of this study was to assess the long-term outcomes after ta-IPAA versus abdominal IPAA (abd-IPAA) in UC. METHOD:This is a multicentre cohort analysis between March 2002 and September 2017. Patient characteristics, surgical details and postoperative outcomes were compared. The primary end-point was CGQL (Cleveland Global Quality of Life) score at 12 months. RESULTS:374 patients (100 ta-IPAA vs 274 abd-IPAA) were included. Mean CGQL scores were comparable between the two groups (0.75 ± 0.11 vs 0.71 ± 0.14; respectively, P = 0.1). Quality of life (7.71 ± 1.17 vs 7.30 ± 1.46; P = 0.04) and energy level (7.16 ± 1.52 vs 6.66 ± 1.68; P = 0.03) were significantly better after ta-IPAA, while the quality of health item was comparable (7.68 ± 1.26 vs 7.64 ± 1.44; P = 0.9655). Stool frequencies (> 10/24 h:22% vs 21%; P = 1.0) and major incontinence rates (27% vs 26%; P = 0.89) were similar. Thirty-day morbidity rates (33% vs 41%; P = 0.2) and anastomotic leak rates were comparable (6% vs 13%; P = 0.09). CONCLUSION: This study, for the first time, provides evidence of comparable long-term functional outcome of ta-IPAA vs abd-IPAA for UC.