Gastroesophageal reflux disease in Sri Lanka: An island-wide epidemiological survey assessing the prevalence and associated factors.

Gastroesophageal reflux disease (GERD) is commonly encountered in clinical practice in Sri Lanka. However, its prevalence in Sri Lanka is unknown. Our objective was to study the island-wide prevalence of GERD symptoms in Sri Lanka and its associated factors. A total of 1200 individuals aged 18-70 years (male: female 1: 1.16, mean age 42.7 years [SD 14.4 years]). were recruited from all 25 districts of the country, using stratified random sampling. An interviewer-administered, country-validated questionnaire was used to assess the GERD symptom prevalence and associated factors. Weight, height, waist, and hip circumference were measured. Heartburn and/or regurgitation at least once a week, an internationally used criterion for probable GERD was used to diagnose GERD. In this study, GERD symptom prevalence was 25.3% (male 42.1% and female 57.9%). Factors independently associated with GERD were inadequate sleep, snacking at midnight, sleeping within two hours of consuming a meal, skipping breakfast, increased mental stress, and certain medications used such as statins, and antihypertensive medications (p<0.001, univariate and logistic regression analysis). 38.4% of the study population have been using medication for heartburn and regurgitation in the past 3 months and 19.8% were on proton pump inhibitors. To conclude, the prevalence of GERD symptoms in Sri Lanka (25.3%) is higher than its estimated global prevalence of 13.8%. Several meal-related lifestyle habits, mental stress, and the use of some medications are significantly associated with GERD, indicating the importance of lifestyle modification and stress reduction in its management.

Incidence and Patterns of Liver Cancers in Sri Lanka from 2001 to 2010: Analysis of National Cancer Registry Data.

Sanjeewa SeneviratneObjectives Varying trends in the incidence of liver cancer have been observed in many Asian countries. We conducted this study to examine trends in liver cancer incidence and histological patterns in Sri Lanka. Materials and Methods All newly diagnosed patients with liver cancer included in Sri Lanka National Cancer Registry during 2001 to 2010 were analyzed. Statistical Analysis Joinpoint regression analysis was performed. A p -value of less than 0.05 was considered statistically significant. Results Overall, 1,482 (male:female = 2.7:1; mean age = 57.5 years) liver cancers were analyzed. Majority were hepatocellular carcinomas ( n = 1,169; 78.9%), followed by intrahepatic cholangiocarcinomas ( n = 100; 6.75%). Highest incidence of liver cancer was observed in 70-74-year age group (5.1/100,000). Overall, the World Health Organization age-standardized rate (ASR) has increased during 2001 to 2004, from 0.6/100,000 (95% confidence interval [CI] = 0.48-0.72) to 1.0/100,000 (95% CI = 0.85-1.15), with an estimated annual percentage change (EAPC) of 17.8 (95% CI = 5.0-46.2); p > 0.05. From 2004 to 2010, a gradual decline in the incidence was observed. ASR in 2010 was 0.96 (95% CI = 0.81-1.1), with an EAPC of -0.9 (95% CI = -6.7 to 5.4); p > 0.05. Similar patterns of incidence change were observed in both genders. Conclusions Overall, the incidence of liver cancer appears to be steadily declining in Sri Lanka. Similar patterns of incidence change were observed in both genders. The actual decline is likely to be greater as it is likely that diagnostic scrutiny and reporting would have improved during the study period.

The Worldwide Epidemiology of Acute Appendicitis: An Analysis of the Global Health Data Exchange Dataset.

BACKGROUND: This study aims to describe the worldwide epidemiology and changing disease trends of acute appendicitis (AA). METHODS: Epidemiological data on the incidence of AA and deaths were collected from the Global Health Data Exchange repository from 1990 to 2019. Data were stratified by age, sex and Socio-Demographic Index (SDI). RESULTS: In 2019, there were an estimated 17.7 million cases (incidence 228/100,000) with over 33,400 deaths (0.43/100,000). Both the absolute number and the incidence had increased from 1990 to 2019 (+ 38.8% and + 11.4%, respectively). The number of deaths and deaths per 100,000 declined during this period (- 21.8% and - 46.2%, respectively). These trends were largely similar in all 5 SDI groups. There was a significant difference in the incidence of AA between the SDI groups, with low SDI group having the lowest and high SDI group having the highest. The high SDI group had the lowest mortality rate (Kruskall-Wallis test, p < 0.001). The peak incidence was in the 15-19-year age group. The mortality rate increased exponentially from the third decade of life. CONCLUSIONS: The mortality rate of AA is declining worldwide, while the incidence is increasing. The peak incidence is in the 15-19-year group.

Short- and Long-Term Outcomes of Overlap Anal Sphincter Repair for Fecal Incontinence Following Sphincter Injury / Resultados em curto e longo prazos do reparo por sobreposição do esfíncter anal para incontinência fecal após lesão esfincteriana

Abstract Objective Several techniques are used to repair the anal sphincter following injury. The aim of the present study is to comprehensively analyze the short- and long-term outcomes of overlap repair following anal sphincter injury. Methods A search was conducted in the PubMed, Medline, Embase, Scopus and Google Scholar databases between January 2000 and January 2020. Studies that described the outcomes that are specific to overlap sphincter repair for fecal incontinence with a minimum follow-up period of one year were selected. Results A total of 22 studies described the outcomes of overlap sphincter repair. However, 14 studies included other surgical techniques in addition to overlap repair, and were excluded from the analysis. Finally, data from 8 studies including 429 repairs were analyzed. All studies used at least one objective instrument; however, there was significant heterogeneity among them. Most patients were female (n=407; 94.87%) and the mean age of the included individuals was 44.6 years. The majority of the procedures were performed due to obstetric injuries (n=384; 89.51%). The eight included studies described long-term outcomes, and seven of them demonstrated statistically significant improvements regarding the continence; one study described poor outcomes in terms of overall continence. The long-term scores were significantly better compared with the preoperative scores. However, compared with the shortterm scores, a statistically significant deterioration was noted in the long-term. Conclusion The majority of the studies described good long-term outcomes in terms of anal continence after overlap sphincter repair. However, further studies are needed

Resumo Objetivo Diversas técnicas são usadas no reparo do esfíncter anal após lesões. O objetivo deste estudo é fazer uma análise completa dos desfechos nos curto e longo prazos do reparo por sobreposição após lesão do esfíncter anal. Métodos Realizou-se uma busca nas bases de dados PubMed, Medline, Embase, Scopus e Google Scholar entre janeiro de 2000 e janeiro de 2020. Estudos que descreviam desfechos específicos do reparo de esfíncter por sobreposição para incontinência fecal, com um mínimo de 1 ano de seguimento, foram selecionados. Resultados No total, 22 estudos descreviam os desfechos do reparo de esfíncter por sobreposição. No entanto, 14 estudos incluíam outras técnicas cirúrgicas além do reparo por sobreposição, e foram excluídos da análise. Por fim, dados de 8 estudos que incluíam 429 reparos foram analisados. Todos os estudos usaram pelo menos um instrumento objetivo, mas havia uma heterogeneidade significativa entre eles. A maioria dos pacientes era do sexo feminino (n=407; 94,87%), e a idade média dos indivíduos incluídos foi de 44,6 anos. A maioria das cirurgias foi realizada devido a lesões obstétricas (n=384; 89,51%). Os oito estudos incluídos descreveram os desfechos no longo prazo, e sete deles demonstraram melhoras estatisticamente significativas com relação à continência; um estudo descreveu resultados ruins em termos gerais com relação à continência. As pontuações no longo prazo foram significativamente melhores em comparação com as pontuações no pré-operatório. No entanto, em comparação com as pontuações no curto prazo, percebeu-se uma piora estatisticamente significativa no longo prazo. Conclusão A maioria dos estudos descrevia bons resultados no longo prazo em termos de continência anal depois do reparo do esfíncter por sobreposição. Entretanto mais estudos são necessários para que se identifiquem os fatores associados aos desfechos ruins para auxiliar na seleção de pacientes para o reparo por sobreposição.

Clinical Outcomes and Effectiveness of Laser Treatment for Hemorrhoids: A Systematic Review.

BACKGROUND: Laser treatment is increasingly used in the treatment of symptomatic hemorrhoids, and several studies have attempted to describe its clinical outcomes. In this systematic review, we aimed to comprehensively analyze the clinical outcomes and effectiveness of laser treatment. METHODS: We performed a systematic review of currently available data on laser treatment for hemorrhoids. We searched MEDLINE and Google Scholar between January 2009 and May 2020. Studies that described the clinical outcomes and effectiveness of laser treatment were selected based on pre-specified inclusion criteria with a minimum follow-up period of 3 months. Qualitative synthesis of the clinical outcomes, effectiveness and complications was performed. RESULTS: Nineteen studies including 1937 patients were analyzed. The majority were males (n = 1239) and included grade 2 and 3 hemorrhoids. In the majority (n = 1750, 90.34%), the 980 nm wave length diode laser was used as the energy source. Doppler-guided localization was performed in six studies (n = 579, 29.89%). All studies (n = 1937) reported low postoperative pain scores and nine studies (n = 1131) showed significantly lower pain compared to open technique. Furthermore, six studies (n = 1023) showed significantly less intra- and postoperative bleeding compared to open technique. Seven studies (n = 1052) reported long-term follow-up results and were found to be satisfactory in terms of symptom relief and recurrence. This study was limited by heterogeneity of outcomes precluding a meta-analysis. CONCLUSION: Laser treatment had acceptable clinical outcomes for grade 2 and 3 hemorrhoids with lower rates of postoperative pain and bleeding with satisfactory long-term outcomes.

The incidence and patterns of gastric cancers in Sri Lanka from 2001 to 2012: Analysis of National Cancer Registry Data.

OBJECTIVES: Varying patterns in incidence of gastric cancer (GC) have been reported globally. We aimed to examine the trends of GC incidence in Sri Lanka. METHODS: All newly diagnosed patients with GC in Sri Lanka during 2001-2012 included in the National Cancer Registry were analyzed. Joinpoint regression analysis was used to determine the trends in incidence by age and gender. The minimum number of joinpoints were added to the model and statistical significance was checked using the Monte-Carlo permutation method. RESULTS: Overall, 3353 (male : female = 2.7:1, mean age: 59.5 years) GCs were included in the analysis. Histology findings were available in 2835 patients. Of those, 14.3% (n = 404) were classified as nonspecified neoplasm/carcinoma. Of the remaining 2431 patients, majority (84.1%, n = 2044) were adenocarcinoma/its variants and 9.4% (n = 228) were squamous cell carcinoma. The WHO age-standardized incidence of GC was found to have significantly increased from 1.06 in 2001 (95% CI = 0.9-1.21) to 2.41/100 000 population in 2012 (95% CI = 2.2-2.61); with an estimated annual percentage change (EAPC) of 7.7 (95% CI = 6.1-9.4). Highest incidence of GC was seen in 65-69 year age group (8.2/100 000). The proportional rise in incidence was higher for females (from 0.5 to 1.36, EAPC: 9.0 [95% CI = 6.4-11.8], P < .05 for trend) compared with males (from 1.71 to 3.66, EAPC: 7.5 [95% CI = 5.5-9.6], P < .05 for trend). CONCLUSIONS: A rise in the incidence of GC was noted in Sri Lanka during the period 2001-2012, which was predominately observed in females. A combination of true increase in incidence and improved reporting may have contributed to this increase. Future studies analyzing tumor characteristics and mortality would enable better understand the burden of GC and potential underlying reasons.

Correlation between immunity from BCG and the morbidity and mortality of COVID-19.

BACKGROUND: To investigate the association between parameters indicating immunity from BCG at country level (presence of BCG vaccination policy, BCG coverage, age-specific incidence of tuberculosis (TB)) and the morbidity and mortality of COVID-19. METHODS: Country-specific data for COVID-19 cases and deaths, demographic details, BCG coverage and policy, age-specific TB incidence and income level were obtained. The crude COVID-19 cases and deaths per 100,000 population were calculated and assessed against the parameters indicating immunity from BCG using linear regression analysis. RESULTS: Univariate analysis identified higher income level of a country to be significantly associated with COVID-19 cases (p < 0.0001) and deaths (p < 0.0001) but not with its case fatality rate. The association between COVID-19 and TB was strongest for TB incidence in patients > 65-years (Cases (rs = - 0.785,p = 0.0001)) and deaths (rs = - 0.647,p = 0.0001).Multivariate analysis identified the higher income level of a country and not having a universal BCG vaccination policy to affect the COVID-19 cases. The deaths were inversely affected by the presence of BCG vaccination policy and coverage; and positively by the TB incidence in patients > 65-years. CONCLUSION: Significant inverse correlations observed between cases and deaths of COVID-19 and BCG related parameters highlights immunity from BCG as a likely explanation for the variation in COVID-19 across countries.

Atypical Presentation of Severe Dengue in a Patient following a Major Abdominal Surgery.

Severe dengue infections in a postoperative patient may lead to significant derangement in the body's homeostasis resulting in morbidity and sometimes even mortality. Reports on presentation and clinical manifestations of dengue in patients following major surgical procedures are scarce and restricted to few case reports. We describe a 26-year-old male with atypical presentation and late detection of dengue haemorrhagic fever following a major abdominal surgery. On postoperative day 6, he developed spontaneous bleeding from the drain site and moderate-to-massive bilateral pleural effusion with respiratory distress. His dengue IgM and IgG were positive. Therefore, a diagnosis of dengue haemorrhagic fever with bilateral lower zone pneumonia was made. A right-sided intercostal tube was inserted. Intensive care was given and was managed with intravenous antibiotics, targeted fluid therapy, and supportive care. He recovered from the infection and was discharged uneventfully. This case is unique because during the postoperative period, he went into critical phase with significant fluid leakage and developed bleeding manifestations without a clear febrile phase and deterioration in the haemodynamic parameters. High degree of suspicion and early detection are necessary to guide the fluid therapy and provide organ support in such patients.

The incidence and patterns of colorectal cancers in Sri Lanka from 2001 to 2010: Analysis of national cancer registry data.

OBJECTIVES: The incidence of colorectal cancer (CRC) has been increasing in many Asian countries. This study aims to analyse trends in CRC incidence and histological patterns in Sri Lanka. METHODS: All newly diagnosed patients with CRC in Sri Lanka during 2001-2010 included in the National Cancer Registry were analysed for trends in incidence using Joinpoint regression software. RESULTS: A total of 7,694 CRC (male:female = 1.02:1, mean age = 58.7 years) were analysed. The incidence of CRC in Sri Lanka has increased from a WHO age-standardised rate of 2.9/100,000 in 2001 (95%-confidence interval [95%-CI]: 2.64-3.16) to 6.08/100,000 in 2010 (95%-CI: 5.71-6.44). This is an estimated annual percentage change (EAPC) of 8.9 (95%-CI: 7.5-10.4). The proportional increase in incidence was observed to be greater for females (2.8 to 5.6, EAPC: 9.4 (95%-CI: 7.7-11.2), p < .05) than males (3.02 to 6.62, EAPC: 8.5 (95%-CI: 6.9-10.2), p < .05). CONCLUSIONS: Similar to other Asian countries, a significant increase in the incidence of CRC was observed in Sri Lanka. Rate of the increase may have been artificially inflated due to better case reporting and diagnostic scrutiny. Future studies focussing on trends in tumour stage and fatality will help shed light on changing patterns in the burden of CRC in Sri Lanka.

Translation and Validation of the Sinhala Version of the EORTC-QLQ-CR29 Questionnaire.

PURPOSE: To validate the Sinhalese version of the EORTC QLQ-CR29 quality of life questionnaire for colorectal cancer. METHOD: We translated and pilot-tested (n=10) the questionnaire in Sri Lanka. We then assessed the reliability, factor structure and construct validity according to the EORTC guidelines. The testing was done in two tertiary care hospitals in Sri Lanka. RESULTS: Of 110 participants, 103 (93%) returned the questionnaire, and 15 out of 20 (75%) returned the repeat-test questionnaire within a period of two weeks. Out of the original four scales three had better reliability than the original scales: urinary frequency (Cronbach α - 0.82), blood and mucus in stools (α-0.85), defaecation problems (α-0.76). The body image scale showed low reliability (α - 0.33).  However, when one of the 3 items in the scale was omitted, it showed sufficient reliability (α - 0.74). Factor analysis showed good reliability for overall assessment of the two item scale for stool frequency (α - 0.82) and six item scale for defaecation problems (α - 0.76). Correlations between the subscales of CR29 and C30 questionnaires were below 0.40, except for body image, which correlated moderately (r-0.44) with emotional functioning. This confirmed satisfactory overall construct validity  Conclusion: The scales for urinary frequency, blood and mucus in stools and defaecation problems which were reliable and had good validity. Body image scale failed to show sufficient reliability with the three-item scale and we suggest omitting one of the items to improve the overall reliability of the questionnaire. Construct validity was comparable to published data.

The incidence and histological patterns of oesophageal cancer in Sri Lanka from 2001 to 2010: Analysis of national cancer registry data.

OBJECTIVES: An increase in global incidence of oesophageal cancer has been reported in the last few decades. We conducted this study to examine trends in oesophageal cancer in Sri Lanka. METHODS: A retrospective cohort evaluation of newly diagnosed patients with oesophageal cancer during 2001-2010 was performed using population-based data published by the Sri Lanka National Cancer Control Programme. RESULTS: A total of 10,626 (male: female = 1:1.06, mean age: 62 years) oesophageal cancers were analysed. Of those, 1,553(14.6%) were classified as non-specific carcinoma. Of the remaining, 88% (n = 7,986) were squamous cell carcinoma (SCC) and 10.5% (n = 956) were adenocarcinoma. The WHO age-standardised incidence was observed to have increased from 5.78 per 100,000 in 2001 (95% CI = 5.41-6.16) to 6.23 per 100,000 in 2010 (95%CI = 5.86-6.60). WHO age-standardised incidence of SCC has increased from 4.09 to 4.97 per 100,000 from 2001 to 2010 (p < .05 for trend, estimated annual percentage change (EAPC) = 3.6, 95% CI = 0.9-6.3) while incidence of adenocarcinoma showed a greater proportional increase from 0.33 to 0.7 per 100,000 from 2001 to 2010 (p < .05 for trend, EAPC = 7.1, 95% CI = 2.1-12.4). CONCLUSIONS: A statistically significant increase in the incidence of oesophageal cancer in Sri Lanka was noted, with greater proportional increases of adenocarcinomas and cancers in men. Further studies including tumour stage and mortality may help better understand changing patterns of disease burden.

A Rare Occurrence of Three Primary Malignancies of the Rectum, Breast, and Kidney in the Same Patient: A Case Report and Review of the Literature.

An increasing number of patients with multiple primary cancers are encountered due to improved cancer detection, widespread cancer screening, and better cancer treatment. Here, we report such a patient without a family history of malignancies or a known genetic predisposition developing three primary malignancies of the rectum, breast, and kidney. A 63-year-old female who underwent an anterior resection for rectal cancer was detected to have an elevated carcinoembryonic antigen (CEA) level during a routine follow-up, 8 years after the initial surgery. Clinical examination revealed a left breast lump which was confirmed as invasive ductal carcinoma (pT3 pN0 cM0). Imaging and colonoscopy excluded a local recurrence. However, a right renal lesion suggestive of a renal cell carcinoma was detected (pT1a). She underwent left mastectomy with a sentinel lymph node biopsy and a right partial nephrectomy with a curative intent. Postoperatively, CEA levels declined to normal limits. Management of multiple primary malignancies poses a major challenge. A multidisciplinary approach and tailored decision-making for the individual patient help with the optimum outcome.

Treatment of fistula in-ano with fistula plug: experience of a tertiary care centre in South Asia and comparison of results with the West.

OBJECTIVES: Surgery for fistula in ano is associated with anal incontinence. The biologic anal fistula plug (AFP) can minimize this. This is a retrospective analysis of patients with cryptoglandular anorectal fistulae, who underwent a surgical procedure using AFP. Patient's demographics and characteristics of the fistulae were obtained from a prospective database. Each primary opening was occluded by using an AFP. Success was defined by the closure of the external opening and absent drainage. RESULTS: Fifty-one patients were treated with AFP (male:female: 37:14), mean age 42 years (SD ± 14.86, range 26-70). Ten patients defaulted follow-up. Forty-seven procedures were analysed. Twenty-three (56.1%) patients had complete healing while 18 (43.9%) patients failed the fistula plug procedure during the follow up period of 12 months. Logistical regression failed to identify any statistical significant association with demographic or disease factors and healing. Healing was 1.5 times less likely for every failed procedure prior to AFP insertion. Contrary to other published studies, placement of fistula plug was associated with much lower overall rates of fistula healing. Highest success rates were seen in simple fistulae when compared to the complex type. Repeat plug placement may be successful in selected patients.

A cross-sectional study of quality of life in a cohort of enteral ostomy patients presenting to a tertiary care hospital in a developing country in South Asia.

BACKGROUND: Enteral ostomy creation affects the quality of life (QOL) of stoma patients significantly. Studying the QOL and its determinants is important as it may help in the early identification of those with poor QOL leading to appropriate intervention. This study was aimed to assess the possible contributory factors of QOL of stoma patients. METHODS: A cross sectional study was conducted among 43 ostomy patients who presented for follow up at a surgical clinic of a tertiary care hospital in Sri Lanka over a period of 1 year. Relevant demographic and ostomy related data were collected using an interviewer administered questionnaire. Stoma quality of life scale (Stoma-QOL) and stoma care self-efficacy scale (SCSE) which are validated questionnaires were used to assess QOL and self-efficacy in managing stoma respectively. Associations were established using independent samples t test and Spearman's correlation. RESULTS: The median age of the study participants was 47.5 years (range 18-83). The median follow up duration was 38 months (range 6-183). The mean overall QOL score was 53.07 ± SD 12.68. Approximately 70% of the study participants scored less than 60. Higher QOL was associated with female sex, colostomies, comfortable income and satisfactory sexual activity. Significantly lower overall QOL was found in those who reported a significant change in the style of dressing (p < 0.05), those who felt depressed (p < 0.05), and those who had thoughts of self-harm soon after surgery (p < 0.05). There was a significant positive correlation between QOL and self-efficacy (p < 0.01). Those who took longer time to learn to take care of the stoma had lower QOL (p < 0.05). CONCLUSIONS: The overall QOL score was considerably low in our study. The QOL was significantly associated with self-efficacy which indicates the importance of patient education and training during follow up visits to maintain a higher QOL. Furthermore integrating with other non-surgical specialities to address multi-dimensional problems including psychosocial and sexual aspects may be helpful to achieve a better QOL.

Incidence of esophageal cancer in Sri Lanka: Analysis of cancer registry data and comparison with other South Asian populations.

INTRODUCTION: The objectives of this study were to report the incidence of Carcinoma of Esophagus (CaE) in Sri Lanka and to compare these values with other cancer registry data of the region and with migrant populations. MATERIALS AND METHODS: We compared the data published by the National Cancer Control Program over the last two decades with data from the National Cancer Registry Programme of the Indian Council of Medical Research and Karachi Cancer Registry. SEERstat was used to analyze the surveillance, epidemiology and end results database to analyze data on Indian migrant population. RESULTS: CaE was the fourth most common cancer overall and among females and third most common cancer among males. The incidence of CaE rises with age in both sexes, with a peak in the 70-74 year age group. There was a disproportionately higher number of CaE in the Tamil population (chi-square test, P < 0.00001). The commonest type of CaE in Sri Lanka was squamous cell carcinoma, Not otherwise specified (NOS) (n = 750, 70.5%), followed by adenocarcinoma, NOS (n = 83, 7.8%). India, Pakistan and Sri Lanka have comparable age-adjusted incidence and age distribution of CaE. All migrant populations had lower incidence of CaE than original population or population in their present country. Both cigarette smoking and alcohol consumption are more prevalent in Sri Lankan males than females. DISCUSSION AND CONCLUSIONS: The incidence of CaE and its distribution among age groups in Sri Lanka was comparable to other countries of the region. Persons of Tamil ethnicity have a higher risk of developing CaE.

A study of long-term complications associated with enteral ostomy and their contributory factors.

BACKGROUND: Complications of ostomy significantly affect the quality of life of ostomates. There is little evidence on the rate of long-term complications in ostomates, especially from the developing countries which include Sri Lanka. This study was aimed to describe the long-term complications of enteral ostomies and their contributory factors. METHODS: A retrospective analysis was carried out on 192 patients who underwent ostomy creation over a period of 5 years. Data on type of complications, age, sex, type of ostomy, type of surgery and perioperative care by enteric stoma therapist were gathered. Associations were established using Chi square test and multiple logistic regression. RESULTS: Out of 192 patients, only 146 patients presented regularly for follow up. The mean follow up duration was 28 months (range: 3-183). Around 34.2% developed surgical long-term complications related to the ostomy. Common complications were prolapse (n = 24, 16.4%), skin excoriation (n = 22, 15.1%) and parastomal hernia (n = 14, 9.6%). Overall complication rate was significantly less in loop ostomies (p < 0.05) and defunctioning ostomies (p < 0.05). Skin excoriation was significantly high in males (p < 0.05) and in ileostomies (p < 0.001). Parastomal hernia was commoner in end ostomies (p < 0.05). Perioperative care by enteric stoma therapist reduced the overall and specific complications (p < 0.001). CONCLUSION: The overall complication rate in our cohort of patients was 34.2%. The perioperative care of a stoma therapist may be very effective in preventing complications particularly in a setting with limited resources.

Gastric fundal heterotopic pancreas mimicking a gastrointestinal stromal tumour (GIST): a case report and a brief review.

BACKGROUND: Heterotopic pancreas is a rare congenital condition characterised by pancreatic tissue lacking vascular or anatomic communication with the normal pancreas. Most cases of ectopic pancreas are asymptomatic. The preoperative diagnosis of this condition is difficult. CASE PRESENTATION: A 50-year-old woman presented with dyspeptic symptoms of 4 years duration. Contrast enhanced CT (computed tomography) scan of abdomen suggested a gastrointestinal stromal tumour in the fundus of the stomach. The patient underwent laparoscopy assisted resection and subsequent histology revealed ectopic pancreatic tissue. CONCLUSION: Although heterotopic pancreas is a rare lesion diagnosed on histology, it should be considered in the differential diagnosis of gastric mass lesions and in patients presenting with vague upper gastrointestinal symptoms.

Jejunal obstruction due to a variant of transmesocolic hernia: a rare presentation of an acute abdomen.

BACKGROUND: Internal hernias include paraduodenal, pericecal, through foramen of Winslow, intersigmoid and retroanastomotic hernias. These hernias could be either congenital or acquired after abdominal surgery. They account for approximately 0.5-5 % of all cases of intestinal obstruction. CASE PRESENTATION: A 48-year-old female was admitted to casualty with a history of abdominal distension and vomiting of 3 days duration. An abdominal X-ray supine film showed multiple small bowel loops with air fluid levels. On surgery she was found to have a transmesocolic hernia. The defect in the transverse mesocolon was repaired. CONCLUSION: The clinical signs and symptoms of lesser sac hernia are non-specific. These rare lesser sac hernias can be lethal. Therefore, immediate diagnosis and surgery is essential. Although a rare entity, they account for significant mortality form intestinal obstruction. We report an extremely rare case of an internal abdominal hernia through the transverse mesocolon, in a young woman.

Structured endoscopic ultrasonography (EUS) training program improved knowledge and skills of trainees: Results from the Asian EUS Group.

BACKGROUND AND AIM: A major reason impeding the growth of endoscopic ultrasound (EUS) in Asia is the lack of training availability. We aimed to prospectively evaluate the effectiveness of a short-term structured EUS training program in improving the knowledge and skill of EUS among trainees. METHODS: The study was conducted in six workshops in six countries including Sri Lanka, Pakistan, Thailand, Vietnam, Singapore and Philippines, within a year. Trainees were evaluated using written and skill tests before and after completion of the training. RESULTS: Pre- and post-workshop written tests from a total of 62 trainees were analyzed. Compared with pre-training, the trainees improved significantly in the overall mean (± SD) scores after the training (66.0 ± 0.3% to 77.5 ± 0.2%, P < 0.0001). Thirty-one trainees were randomly selected to undergo a skill test before and after the course. Compared with pre-training, the proportions of trainees who succeeded in locating each structure post-training were: celiac axis (36-80.5%), pancreatic body (51.5-80.5%), pancreatic body and tail (42-77.5%), splenic vein and artery (48.5-84%), left kidney (60-83%), and spleen (47-83%). Overall, there was a significant improvement in the proportion of trainees' successful localization of structures post-training compared to before training (P < 0.0001). CONCLUSION: Following a structured training program, trainees' knowledge and skills in EUS improved significantly. Structured training courses appear to be an effective way of imparting EUS knowledge and skills to aspiring endosonographers in the Asian region.

Neurofibroma invading into urinary bladder presenting with symptoms of obstructed defecation and a large perineal hernia.

BACKGROUND: Pelvic floor hernias pose a diagnostic and a treatment challange. Neurofibromatosis is a rare systemic disease, and urinary tract involvement is rare. CASE PRESENTATION: Here we report a case of a 54-year-old female with multiple neurofibromatosis who presented with features of obstructed defecation and was found to have a large perineal hernia. At surgery, we found an unusual herniation of a large neuropathic bladder and rectum through a perineal defect. She underwent reduction cystoplasty and repair of the pelvic floor using a prolene mesh. Subsequent histopathological examination confirmed a large neurofibroma infiltrating the urinary bladder. CONCLUSION: Neurofibromatosis of the bladder is rare it should be considered as a differential diagnosis in patients presenting with symptoms of obstructed defecation.