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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Colonoscopic ultrasound is associated with a learning phenomenon despite previous rigid probe experience(Springer India, 2009) Siriwardana, P.N.; Hewavisenthi, S.J.de S.; Pathmeswaran, A.; Deen, K.I.Colonoscopic ultrasound (CUS) enables total colonoscopic examination combined with staging of tumor. Rigid probe transrectal ultrasound (TRUS) is reliable in assessing rectal cancer. Both the modalities are associated with an initial learning curve. We evaluated the predictability CUS in preoperative staging of rectal cancer during the learning curve, despite experience with TRUS. Forty-four patients with non-obstructing rectal cancer were assessed by colonoscopy and colonic ultrasound using a 7.5 MHz rotating transducer. Accuracy of ultrasound staging was compared with pathological staging. Tumor staging and nodal staging at pathology and ultrasound were named pT, pN and uT, uN, respectively. The pathological staging was pT1 in two (4.5%), pT2 in 16 (36%), pT3 in 21 (48%) and pT4 in five (11.5%) rectal cancer specimens. CUS understaged the tumor in 11 cases and overstaged it in 10 cases. Overall, the positive predictive value was 61%, negative predictive value 73%, sensitivity 61%, and specificity 73%. Lymph nodes were not visualized in 14. The overall un-weighted kappa of CUS staging of RC was 0.18 (poor). The predictive value in tumor staging of CUS is suboptimal in the learning phase, despite previous experience with TRUS.Item Effect of audio and visual distraction on patients undergoing colonoscopy: a randomized controlled study(Stuttgart : Georg Thieme Verlag KG, 2016) de Silva, A.P.; Niriella, M.A.; Nandamuni, Y.; Nanayakkara, S.D.; Perera, K.R.P.; Kodisinghe, S.K.; Subasinghe, K.C.E.; Pathmeswaran, A.; de Silva, H.J.BACKGROUND AND STUDY AIMS : Colonoscopy can cause anxiety and discomfort in patients. Sedation and analgesia as premedication can lead to complications in the elderly and those with comorbidities. This has led to an interest in the use of audio-visual distraction during the colonoscopy. We compared the effects of audio (AD) versus visual distraction (VD) in reducing discomfort and the need for sedation during colonoscopy. PATIENTS AND METHODS: Consecutive patients undergoing colonoscopy were randomized into three groups: one group was allowed to listen to the music of their choice (AD), the second group was allowed to watch a movie of their choice (VD), and the third group was not allowed either distraction during colonoscopy and acted as a control (C). Patient controlled analgesia and sedation were administered to all three groups. We used 25 mg of pethidine in 5-mg aliquots and 2.5 mg of midazolam in 0.5-mg aliquots. All patients were assessed for perceived pain and willingness to repeat the procedure. Number of "top-ups" of sedation and total dose of pethidine and midazolam were noted. Patient cooperation and ease of procedure were assessed by the colonoscopist. RESULTS: In total, 200 patients were recruited [AD, n = 66 (32 males, median age 57 years); VD, n = 67 (43 males, median age 58 years); C, n = 67 (35 males, median age 59 years)]. The AD group had significantly less pain (P = 0.001), better patient cooperation (P = 0.001) and willingness to undergo a repeat procedure (P = 0.024) compared with VD and C groups. CONCLUSIONS: AD reduces pain and discomfort, improves patient cooperation and willingness to undergo a repeat procedure, and seems a useful, simple adjunct to low dose sedation during colonoscopy.Item Usefulness of Ileoscopy during Colonoscopy(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2011) Wijewantha, H.; de Silva, A.P.; Wijesinghe, N.T.; Kumarasena, R.S.; Dassanayake, A.S.; Hewavisenthi, S.J.; de Silva, H.J.INTRODUCTION: Ileoscopy during colonoscopy adds only three minutes to total procedure time and has no added complications. However, available evidence for recommending the procedure is contradictory. There are few studies adressing this issue in South Asian populations. Aims: To investigate the usefulness of terminal ileoscopy during colonoscopy in a cohort of Sri Lankan patients attending a tertiary care centre. METHODOLOGY: From January 2007, our unit policy was to perform ileoscopy in all patients undergoing colonoscopy. A retrospective analysis of all patients who underwent colonoscopy in the unit from January 2007 to September 2010 was performed. Data were obtained from endoscopy unit and patient records. We compared usefulness of ileoscopy in patients considered to have specific clinical indications for ileoscopy - right iliac fossa pain, diarrhea, anemia, inflammatory bowel disease and raised inflammatory markers (group A) with those that did not (group B). RESULTS: 789 colonoscopies were performed during the study period, and the terminal ileum was successfully intubated in 638 (80.9%). Reasons for not intubating the ileum were technical difficulty and/or severe patient discomfort. Overall, 108/ 638 (16.9%) patients had macroscopic or microscopic abnormalities of the ileum. 51/638 (8%) of these were considered to be significant ileal pathology: Crohn’s disease (34), tuberculosis (5), ileitis-resolving infection (8) or drug induced (4). The other abnormalities, of doubtful clinical importance and which did not alter management, were backwash ileitis in ulcerative colitis (12), and non-specific ileitis (37). 35 patients with ileal abnormalities (Crohn’s disease 6, non-specific ileitis 29) had no abnormalities in the colon. 66 patients with a macroscopically normal terminal ileum had abnormal microscopy: Crohn’s disease (21), ileitis - resolving infection (3) or drug induced (2), backwash ileitis in ulcerative colitis (4), non-specific ileitis (36). In group A [n=511; mean (SD) age 47.7 (16) years; 53.4% males] 47/511 (9.2%) had significant ileal pathology compared to 4/ 127 (3.15%) in group B [n=127; mean (SD) age 53.2 (16) years; 50.4% males] (x2 4.270, df=1, p=0.038). CONCLUSION: Ileoscopy and biopsy during colonoscopy is a useful investigation which detects significant pathology, in some instances where the rest of the colon is normal and sometimes even when the ileum appears macroscopically normal. The procedure should be recommended, especially for patients with right iliac fossa pain, diarrhea, anemia, inflammatory bowel disease and raised inflammatory markers.Item The Prone 12 o'clock position reduces iIleal intubation time during colonoscopy compared to the left lateral 6 o'clock (standard) position(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2010) de Silva, A.P.; Kumarasena, R.S.; Keragala, S.P.; Udayapushpa, K.V.; Niriella, M.A.; Dassanayake, A.S.; Pathmeswaran, A.; de Silva, H.J.INTRODUCTION Ileal intubation is the gold standard for evidence of a complete colonoscopy. However, despite evidence of clinical benefit, ileoscopy is not always attempted due to perceived technical difficulty. Although several studies have previously reported on the time taken for ileal intubation, such timings have not been standardized. Aim To compare time taken for ileal intubation using a new position - the prone 12 o’clock position (PP) - with the standard method (left lateral 6 o’clock position-LLP). METHODS We first performed a pilot study using fluoroscopy to determine the best patient position for the most direct (end-on) approach to the ileo-caecal valve. The prone 12 o’clock position appeared to be the best position. We then randomized consecutive patients having colonoscopy, aged 18-80 years and who were not pregnant, to undergo ileoscopy in the standard position or the prone 12 o’clock position. After the ileo-caecal valve was identified during colonoscopy, ileal intubation time was standardized and defined as the time taken for the tip of the colonoscope to be maneuvered from the mid-point of the caecum to entering the terminal ileum. RESULTS Colonoscopy was performed on 150 patients [82 females, mean (SD) age 53 (16) years]. 75 patients were randomized for ileal intubation in the PP and 75 patients in the LLP. Overall, the ileum was successfully intubated in 145 (96%) patients [74 (98.7%) in the PP and71 (94.7%) in the LLP]. The mean (SD) ileal intubation time was 26.4 (63) seconds in the PP and 96.9 (112) seconds in the LLP (p0.0001; Student t-test). The ileum was abnormal in 11 (7.5%) patients: 6 in the PP group and 5 in the LLP group. CONCLUSIONS During colonoscopy, the prone 12 o’clock position gives a more direct approach to the ileo-caecal valve and significantly reduces ileal intubation time when compared to the standard left lateral 6 o’clock positionItem A Randomized control study of audio versus visual distraction to reduce patient discomfort during colonoscopy(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2015) de Silva, A.P.; Nandamuni, Y.; Nanayakkara, S.; Perera, K.R.; Kodisinghe, S.K.; Subasinghe, S.K.C.; Niriella, M.A.; Dassanayake, A.S.; Pathmeswaran, A.; de Silva, H.J.INTRODUCTION : Colonoscopy can cause anxiety and discomfort in patients who undergo this procedure. Heavy sedation and analgesia as premedication can lead to complications in the elderly and those with co-morbidities. This has led to an interest in use of audio-visual distraction during the colonoscopy as an adjunct. Our aim was to compare effects of audio (AD) versus visual distraction (VD) in reducing discomfort and need for sedation during colonoscopy. METHODS : Consecutive consenting patients who were undergoing colonoscopy were randomized into three groups: one group was allowed to listen to the music of their choice (AD), the second group was allowed to watch a film of their choice (VD) (using SONY head mounted display:HMZ-T3W-H) and the third group with neither during colonoscopy acted as a control (C). Patient controlled sedation (PCS) was administered to all three groups. We used 25 mg pethidine in 5 mg aliquots and 2.5 mg midazolam in 0.5 mg aliquots. All patients were assessed for pain, number of ‘top-ups’ of sedation, total dose of pethidine and midazolam, patient cooperation and willingness to repeat the procedure. RESULTS :There were 77 patients [AD, n=25 (16 males, median age 57 years); VD, n=26, (18 males, median age 58 years); C, n=26 (10 males, median age 59 years)]. The AD group had significantly less pain (p=0.048), number of ‘top-ups’ of sedation (p=0.03), total doses of pethidine (p=0.03) and midazolam (p=0.032), and better patient cooperation (p=0.001) compared with controls. There was no difference between the AD (72%) and VD (73%) groups in willingness to undergo a repeat procedure. Conclusions AD reduces pain and discomfort and the requirement for sedation and seems a useful and simple adjunct to low dose sedation use during colonoscopy.Item Relief of large bowel obstruction with a self-expanding metal stent(College of Surgeons of Sri Lanka, 2000) Malalasekera, A.P.; Deen, K.I.A 58 year old woman presented with progressive abdominal distension of 6 months duration associated with constipation is reported here.