Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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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 Incidence, prevalence and trends in IBD(CRC Press, 2018) Chandrasinghe, P.; Spinelli, A.; Warusavitarne, J.The inflammatory bowel diseases (IBD), Crohn’s disease and ulcerative colitis, are inflammatory conditions of unknown aetiology that affect the gastrointestinal tract. In Saudi Arabia, an increasing incidence of IBD has been registered, and a comparable disease progression has been recognised. Disease location is a significant factor associated with the long-term outcome in IBD. Extra-intestinal manifestations are pathologically and clinically important entities in IBD. Mortality due to IBD may be caused by complications of acute flares of the disease, long-term complication of the disease or surgical complications. Surgery is required in patients with IBD mainly for intestinal complications. The natural history of IBD is difficult to assess in today’s context, as a majority patients with symptoms will be undergoing some form of treatment. The downward trend may have been the result of more comprehensive surveillance programmes established in many high-volume IBD centres. IBDs are common chronic conditions, which place a significant burden on the individual and community.Item The Association between new generation oral contraceptive pill and the development of inflammatory bowel diseases(Korean Association for the Study of Intestinal Diseases, 2018) Sanagapalli, S.; Ko, Y.; Kariyawasam, V.; Ng, S.C.; Tang, W.; de Silva, H.J.; Chen, M.; Wu, K.; Aniwan, S.; Ng, K.K.; Ong, D.; Ouyang, Q.; Hilmi, I.; Simadibrata, M.; Pisespongsa, P.; Gopikrishna, S.; Leong, R.W.; IBD Sydney Organization and the asia-Pacific Crohn's Epidemiology Study (ACCESS) GroupBACKGROUND/AIMS: To examine the association between use of oral contraceptive pills (OCPs) and the risk of developing inflammatory bowel diseases (IBD), in a modern cohort. METHODS: A prospective nested case-control study across sites in the Asia-Pacific region was conducted; involving female IBD cases and asymptomatic controls. Subjects completed a questionnaire addressing questions related to OCP use. Primary outcome was the risk of development of IBD of those exposed to OCP versus non-exposure. Secondary outcomes were development of Crohn's disease (CD) versus ulcerative colitis (UC), and whether age of first use of OCP use may be associated with risk of IBD. RESULTS: Three hundred and forty-eight female IBD cases (41% CD, median age: 43 years) and 590 female age-matched controls were recruited. No significant association was found between OCP use and the risk of IBD (odds ratio [OR], 1.65; 95% confidence interval, 0.77-3.13; P=0.22), CD (OR, 1.55) or UC (OR, 1.01). The lack of association persisted when results were adjusted for age and smoking. IBD cases commenced OCP use at a younger age than controls (18 years vs. 20 years, P=0.049). CONCLUSIONS: In this large cohort of subjects from the Asia-Pacific region, we found a modest but not significantly increased risk of developing IBD amongst OCP users.Item Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents.(Springer-Verlag, 2018) Zaghiyan, K.; Warusavitarne, J.; Spinelli, A.; Chandrasinghe, P.; Di Candido, F.; Fleshner, P.PURPOSE: Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents. METHODS: Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated. RESULTS: Sixty-two patients (median age 38 years; range 16-68 years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n = 55 (89%)]. Median surgical time was 266 min (range 180-576 min) and blood loss 100 ml (range 10-500 ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers. CONCLUSIONS: This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.Item Early clinical course of IBD in Sri Lanka(Sri Lanka Medical Association, 2016) Niriella, M.A.; Kodisinghe, S.K.; Dinamithra, N.P.; Rajapakshe, N.; Nanayakkara, S.D.; Luke, H.P.D.P.; Silva, K.T.M.; Dassanayake, A.S.; de Silva, A.P.; Navarathne, N.M.M.; de Silva, H.J.INTRODUCTION: There is very limited data on the early clinical course of IBD from Sri Lanka. METHOD: Patients with histologically proven IBD [ulcerative colitis(UC), Crohn disease(CD)] of less than 3 years duration, were included from Colombo North Teaching Hospital and National Hospital of Sri Lanka (two main referral centers). Complicated disease behaviour (stricturing or penetrating CD, extensive or pancolitis for UC), treatment refractory disease (frequently relapsing, steroid dependent, steroid refractory, need for biologics) and complications (perforation, bleeding, colectomy and malignancy) were analysed. RESULTS: 177 patients were eligible for inclusion [UC-97(54.8%), 46(47.4%) males, median follow up (IQR) 17.0(5.5-28) months; CD 80(45.2%), 39(48.8%) males, median follow up (IQR) 7(2-21.5) months]. Admissions with severe episodes of extensive or pancolitis for UC were 26(26.8%) and 20(21.1%) respectively. Admissions with severe episodes, stricturing(B2), penetrating(B3) or perianal disease(P) for CD were 7(8.8%), 9(11.5%) and 16(20%) respectively. Treatment refractoriness (steroid dependency, steroid refractory or frequently relapsing) was 6(9.6%) for UC and 6(8.4%) for CD. Immunomodulator use was 35 (37.2%) and 56(72.7%), and Anti-TNF agent use 2(2.1%) and 2(2.6%) respectively for UC and CD. Few had complications [UC-bleeding 5(5.2%), malignancy 1(1%), surgery 2(2.1%); CD-stricture 3(3.8%), perforation 3(3.8%), malignancy 1(1.3%), surgery 3(3.8%)]. CONCLUSIONS: In the early clinical course of this cohort of IBD patients, admissions with complicated disease were common for UC but not CD. Few patients were treatment refractory. Immunomodulator use was more common for CD, but need for biologics was rare for both. Few IBD patients developed complications. This indicates a relatively benign early disease course.Item Changing phenotype of IBD in Sri Lanka(Sri Lanka Medical Association, 2016) Niriella, M.A.; Kodisinghe, S.K.; Dinamithra, N.P.; Rajapakshe, N.; Nanayakkara, S.D.; Luke, H.P.D.P.; Silva, K.T.M.; Dassanayake, A.S.; de Silva, A.P.; Navarathne, N.M.M.; de Silva, H.J.INTRODUCTION: Inflammatory bowel disease (IBD) is increasing in Asia Pacific, with recent changes in phenotype reported from some countries. METHOD: Patients with histologically proven IBD [ulcerative colitis(UC), Crohn’s disease(CD), unclassified(U)], diagnosed between January 2006-December 2010 (Group 1) and January 2011-December 2015 (Group 2), who had regular follow up, were included from Colombo North Teaching Hospital and National Hospital of Sri Lanka (two main referral centers). The two groups were compared with regard to phenotype of IBD (subgroups, severity, age at diagnosis, duration of symptoms, extra-intestinal manifestations (EIM) at diagnosis, cigarette smoking, family history, and highest therapy during follow up). RESULTS: 304 patients were included [Group 1: UC-72(74.2%), CD-25(25.8%); Group 2: UC-113(54.6%), CD-90(43.5%), U-4(1.9%)]. There were more females in Group 2 for UC and CD. Median age at diagnosis was similar for UC but higher for CD in Group 2 compared to Group 1.The median duration of symptoms to diagnosis was not different for UC and CD in the two groups. In both groups, left sided colitis (E2) predominated for UC and Ileo-colonic disease (L3) and non-stricturing, non-penetrating (B1) disease predominated for CD. There was no difference in degree of severity, rate of complications, pattern of EIM, smoking history at presentation, family history or highest therapy during follow up for either disease in the two groups (Table 1). CONCLUSIONS: During the 10 years, there seems to be a recent increase in the proportion of CD among IBD patients. However, there were no major changes in disease phenotype for UC or CD.Item Asia Pacific Consensus Statements on Crohn's Disease Part 1: definition, diagnosis and epidemiology (Asia Pacific Crohn’s Disease Consensus Part 1)(Wiley-Blackwell, 2016) Ooi, C.J.; Hilmi, I.; Makharia, G.K.; Gibson, P.R.; Fock, K.M.; Ahuja, V.; Ling, K.L.; Lim, W.C.; Thia, K.T.; Wei, S.C.; Leung, W.K.; Koh, P.K.; Gearry, R.B.; Goh, K.L.; Ouyang, Q.; Sollano, J.; Manatsathit, S.; de Silva, H.J.; Rerknimitr, R.; Pisespongsa, P.; Abu Hassan, M.R.; Sung, J.; Hibi, T.; Boey, C.C.; Moran, N.; Leong, R. W.; Asia Pacific Association of Gastroenterology (APAGE) Working Group on Inflammatory Bowel DiseaseInflammatory bowel disease (IBD) was previously thought to be rare in Asia, but emerging data indicate rising incidence and prevalence of IBD in the region. The Asia Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, at the Asia Pacific Digestive Week conference in 2006 under the auspices of the Asian Pacific Association of Gastroenterology (APAGE) with the goal of developing best management practices, coordinating research and raising awareness of IBD in the region. The consensus group previously published recommendations for the diagnosis and management of ulcerative colitis (UC) with specific relevance to the Asia-Pacific region.1 The present consensus statements were developed following a similar process to address the epidemiology, diagnosis and management of Crohn's disease (CD). The goals of these statements are to pool the pertinent literature specifically highlighting relevant data and conditions in the Asia-Pacific region relating to the economy, health systems, background infectious diseases, differential diagnoses and treatment availability. It does not intend to be all-comprehensive and future revisions are likely to be required in this ever-changing field. This article is protected by copyright. All rights reserved.Item The Asia Pacific Consensus Statements on Crohn's Disease Part 2: Management(Wiley-Blackwell, 2016) Ooi, C.J.; Hilmi, I.; Makharia, G.K.; Gibson, P.R.; Fock, K.M.; Ahuja, V.; Ling, K.L.; Lim, W.C.; Thia, K.T.; Wei, S.C.; Leung, W.K.; Koh, P.K.; Gearry, R.B.; Goh, K.L.; Ouyang, Q.; Sollano, J.; Manatsathit, S.; de Silva, H.J.; Rerknimitr, R.; Pisespongsa, P.; Abu Hassan, M.R.; Sung, J.; Hibi, T.; Boey, C.C.; Moran, N.; Leong, R.W.; Asia Pacific Association of Gastroenterology (APAGE) Working Group on Inflammatory Bowel DiseaseInflammatory bowel disease (IBD) was previously thought to be rare in Asia, but emerging data indicate rising incidence and prevalence of IBD in the region. The Asia Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, at the Asia Pacific Digestive Week conference in 2006 under the auspices of the Asian Pacific Association of Gastroenterology (APAGE) with the goal of developing best management practices, coordinating research and raising awareness of IBD in the region. The consensus group previously published recommendations for the diagnosis and management of ulcerative colitis (UC) with specific relevance to the Asia-Pacific region.1 The present consensus statements were developed following a similar process to address the epidemiology, diagnosis and management of Crohn's disease (CD). The goals of these statements are to pool the pertinent literature specifically highlighting relevant data and conditions in the Asia-Pacific region relating to the economy, health systems, background infectious diseases, differential diagnoses and treatment availability. It does not intend to be all-comprehensive and future revisions are likely to be required in this ever-changing field. This article is protected by copyright. All rights reserved.Item Incidence and phenotype of Inflammatory Bowel Disease from 2012-2013 across 9 countries in Asia: results from the 2012 access inception cohort(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2015) Ng, S.C.; Zeng, Z.; Chen, M.; Tang, W.; de Silva, H.J.; Niriella, M.A.; Senanayake, Y.U.; Yang, hong; Qian, J.M.; Yu, H.H.; Li, M.F.; Zhang, J.; Ng, K.K.; Ong, D.E.; Ling, K-L; Goh, K.L.; Hilmi, I.; Pisespongsa, P.; Aniwan, S.; Limsrivilai, J.; Manatsathit, S.; Abdullah, M.; Simadibrata, M.; Gunawan, J.A.; Chong, V.H.; Tsang, S.; Chan, K.H.; Lo, F.H.; Hui, A.J.; Chow, C.M.; Kamm, M.A.; Hu, P.; Ching, J.; Chan, F.K.L.; Sung, J.J.Y.BACKGROUND: The incidence of inflammatory bowel disease (IBD) in Asia was first reported in the 2011 ACCESS inception cohort. This study aims to validate the incidence reported in 2011 by including a second independent cohort from 8 of the participating countries in 2011 and Brunei to investigate the incidence of IBD in Asia in 2012. METHODS: Incident IBD cases diagnosed between April 1, 2012 and March 31, 2013 from 18 centres, 11 cities and 9 countries in Asia were enrolled. Data including demographics and disease phenotype were entered into a Web-based database (http://www.access-apibd.com/access/index.html). Disease location and behavior were classified according to the Montreal classification. RESULTS: A total of 325 IBD patients were identified including 189 (58%) ulcerative colitis (UC), 119 (37%) Crohn’s disease (CD), and 17 (5%) indeterminate colitis (IC). The crude overall annual incidence per 100,000 of IBD was 1.61 (95% confidence interval, CI, 1.44-1.79) in 2012 compared with 1.15 (95% CI, 1.25-1.51) in 2011. The highest incidence in Asia was in Guangzhou (3.86 per 100,000), Hong Kong (2.91 per 100,000) followed by Macau (2.60 per 100,000). Overall ratio of UC to CD in 2012 was similar to that of 2011 (1.57 vs. 1.69; p=0.211). There were more male than female patients in both years (59% vs 60%; p=0.773). Mean age of diagnosis was 40 years (±15.96) in 2011 and 42 years (±16.30; p=0.084) in 2012. Median time from symptom onset to diagnosis was 6 months (IQR 3-24) and 7 months (IQR 2-16), respectively, in 2011 and 2012 (p=0.958). Disease behavior (B1: 72.0%, B2: 9.9%, B3: 4.4%, perianal: 13.2%), location for CD (L1: 25.3%, L2: 25.3%, L3: 49.5%) and UC (E1: 30.9%, E2: 40.1%, E3: 28.9%) did not differ from previous year. Most CD patients were non-smokers (80.3%) whereas 9.9% were current smokers and 9.9% were ex-smokers. CONCLUSION: The incidence of IBD, UC to CD ratio and age of disease onset in the ACCESS 2012 cohort was not significantly different from that reported in the 2011 cohort. Disease phenotype was also similar over 2 years. The ACCESS inception cohort reflects the true incidence of IBD in Asia.Item Incidence and phenotype of inflammatory bowel disease based on results from the Asia-pacific Crohn's and colitis epidemiology study(Elsevier-W.B. Saunders, 2013) Ng, S.C.; Tang, W.; Ching, J.Y.; Wong, M.; Chow, C.M.; Hui, A.J.; Wong, T.C.; Leung, V.K.; Tsang, S.W.; Yu, H.H.; Li, M.F.; Ng, K.K.; Kamm, M.A.; Studd, C.; Bell, S.; Leong, R.; de Silva, H.J.; Kasturiratne, A.; Mufeena, M.N.; Ling, K.L.; Ooi, C.J.; Tan, P.S.; Ong, D.; Goh, K.L.; Hilmi, I.; Pisespongsa, P.; Manatsathit, S.; Rerknimitr, R.; Aniwan, S.; Wang, Y.F.; Ouyang, Q.; Zeng, Z.; Zhu, Z.; Chen, M.H.; Hu, P.J.; Wu, K.; Wang, X.; Simadibrata, M.; Abdullah, M.; Wu, J.C.; Sung, J.J.; Chan, F.K.; Asia-Pacific Crohn's and Colitis Epidemiologic Study (ACCESS) Study GroupBACKGROUND & AIMS: Inflammatory bowel diseases (IBD) are becoming more common in Asia, but epidemiologic data are lacking. The Asia Pacific Crohn's and Colitis Epidemiology Study aimed to determine the incidence and phenotype of IBD in 8 countries across Asia and in Australia. METHODS: We performed a prospective, population-based study of IBD incidence in predefined catchment areas, collecting data for 1 year, starting on April 1, 2011. New cases were ascertained from multiple overlapping sources and entered into a Web-based database. Cases were confirmed using standard criteria. Local endoscopy, pathology, and pharmacy records were searched to ensure completeness of case capture. RESULTS: We identified 419 new cases of IBD (232 of ulcerative colitis [UC], 166 of Crohn's disease [CD], and 21 IBD-undetermined). The crude annual overall incidence values per 100,000 individuals were 1.37 for IBD in Asia (95% confidence interval: 1.25-1.51; 0.76 for UC, 0.54 for CD, and 0.07 for IBD-undetermined) and 23.67 in Australia (95% confidence interval: 18.46-29.85; 7.33 for UC, 14.00 for CD, and 2.33 for IBD-undetermined). China had the highest incidence of IBD in Asia (3.44 per 100,000 individuals). The ratios of UC to CD were 2.0 in Asia and 0.5 in Australia. Median time from symptom onset to diagnosis was 5.5 months (interquartile range, 1.4-15 months). Complicated CD (stricturing, penetrating, or perianal disease) was more common in Asia than Australia (52% vs 24%; P = .001), and a family history of IBD was less common in Asia (3% vs 17%; P < .001). CONCLUSIONS: We performed a large-scale population-based study and found that although the incidence of IBD varies throughout Asia, it is still lower than in the West. IBD can be as severe or more severe in Asia than in the West. The emergence of IBD in Asia will result in the need for specific health care resources, and offers a unique opportunity to study etiologic factors in developing nations.