ObjectivesThis 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 methodsA 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.ResultsYoung 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.ConclusionIf patients, who are less than 40 years old with colorectal cancer, survive twenty months after operation, the prognosis improves and their survival becomes predictable.

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.

BackgroundSerum albumin is a marker of nutrition and inflammation. It has recently emerged as a predictor of outcome after surgery for rectal cancer. Our aim was to evaluate if pre-operative serum albumin would predict survival after resection for rectal cancer.Method226 Patients with rectal cancer of all stages undergoing resection with curative intent were studied. Kaplan-Meier curves analysed survival based on a pre-operative albumin level of <35 g/L vs. >35 g/L. We sought for significant associations of survival with age, sex, stage, tumour site, use of neoadjuvant chemoradiation, microscopic positive resection margins, differentiation, angio, peri-neural, and lymphovascular invasion using individual variable analysis. Multifactorial analysis was performed using type III analysis with Weibull hazard model and Cox-proportional hazard model. Significance was assigned to a P value <0.05.ResultsOf 226 patients (median age- 59 years; range 19 – 88, Male - 54%), forty five (20%) had an albumin level < 35 g/L and was associated with a poor overall survival (P = 0.02). Mean survival in months for <35 g/L vs. >35 g/L was 64.7 (SE - 9.3) vs. 95.8 (SE – 7.0) and 5 year overall survival rates were 49% and 69%. Individual variable analysis revealed age, circumferential margin, stage, perineural, lympho-vascular and angio invasion to be also significant. With multifactorial analysis hypoalbuminaemia (HR = 0.58; 95% CI: 0.35 - 0.95, P = 0.03), advanced stage (HR = 2.0; 95% CI: 1.26 - 3.23, P < 0.01) and positive circumferential margin (HR = 2.2; 95% CI: 1.26 - 3.89, P < 0.01) remained significant.ConclusionPreoperative hypoalbuminaemia is an independent risk factor for poor overall survival in rectal cancer. Advanced tumour stage and circumferential margin positivity were the other associations with poor survival.

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.

ObjectiveColorectal 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.ResultsAnalyzing 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.