A symptom-specific quality of life questionnaire for dysphagia.

M. Med. Sc. University of KwaZulu-Natal, Durban 2014.Dysphagia is a common clinical problem. It is a distressing symptom which impacts negatively on the quality of life (QOL) of patients. There is increasing recognition that assessing QOL gives a broader perspective when deciding on and assessing the effect of treatment of our patients. An abstract concept, QOL is perceived by many clinicians in South Africa as difficult to measure and hence they are reluctant use it to help with therapeutic decision making. There is a dearth of QOL information from third-world countries and there is no locally developed or validated tool to measure it. If we are to provide more holistic health care to our patients this situation needs to be rectified and an appropriate tool developed. Aim: To develop a quality of life questionnaire specific for dysphagia relevant to our local population and validated it against established international questionnaires. The newly developed questionnaire needs to be comprehensive enough to measure general QOL as well as specific enough to be able to detect differences in QOL before and after treatment. Furthermore it needs to be brief and simple so as to be clearly understood and completed by our patient population with varied literacy competencies. Methods: We formulated a questionnaire related to dysphagia and other symptoms commonly associated with it and named it the Greys Dysphagia Quality of Life (GREYS DQOL) questionnaire. The questionnaire contained questions pertaining to generic QOL issues as well as to dysphagia-related QOL issues. We administered the questionnaire to a sample of patients together with two other internationally used questionnaires. One of the international questionnaires, the Short Form 36 (SF-36) quality of life questionnaire is a fully validated generic quality of life questionnaire which is extensively used world-wide and in South Africa. The other, the Dysphagia Score (DS), is a dysphagia-specific questionnaire used internationally to assess patients with conditions presenting with dysphagia. We compared the results of the three questionnaires as well as the compliance of patients in answering the three questionnaires. Demographic data collected included age, gender and level of education. Results: One hundred patients were entered into the study. The majority were males in their sixth and seventh decade of life. Most patients had no established diagnosis at the time of the study, but of those who did have a diagnosis, the most common cause of the dysphagia was malignant obstruction of the oesophagus. The literacy level amongst our patients was found to be low. Twenty three patients received no formal schooling and only 11 patients completed school to matriculation level. The quality of life of our sample population was poor according to all three questionnaires. The mean score for patients on the SADQOL questionnaire was 61 where a score of 0 indicates the best quality of life possible and a score of 100 indicates the worst quality of life possible. The mean score for patients on the SF-36 was 30, where 0 indicates the worst possible quality of life and 100 the best possible quality of life. The mean score for patients on the dysphagia score was 7, where 0 is the best score and 10 the worst. The results of the new questionnaire correlated well with that of the international questionnaires, confirming test-validity. The compliance of patients in answering questions in the GREYS DQOL questionnaire was superior to that of the internationally used questionnaires. The level of education influenced the scores of the SF-36 but not those of the GREYS DQOL and DS. This makes the GREYS DQOL more appropriate for use in our patient population. Conclusion: The GREYS DQOL questionnaire is simpler to comply with and correlates well with established international tools. We therefore consider it to be a good tool for assessing quality of life of patients presenting with dysphagia in South Africa. It can be used to assess QOL in our patients at initial presentation and after treatment is administered and is understood well by our patient population

Oesophageal cancer in South Africa: The long timeline from onset of symptoms to definitive management

Background: In rural South Africa, most patients with oesophageal cancer have delayed presentations with debilitating symptoms and inoperable disease. This study was undertaken to quantify the delay between onset of symptoms and definitive treatment in a cohort of patients in rural South Africa, presenting to a state hospital in KwaZulu-Natal. The study also sought to establish reasons for delays in seeking medical attention and identify ways to encourage earlier presentation. Methods: It was a two-armed study of patients with oesophageal cancer seen at Greys Hospital in Pietermaritzburg. One was a retrospective chart review establishing a timeline. The second part was a prospective study between June and November 2012 where data were collected by means of patient interviews. Results: One hundred and thirteen charts were reviewed. The time from first symptoms to definitive management ranged from 2 to 14 months (average 7 months). Forty-six patients were interviewed. All experienced dysphagia but 83% were only prompted to seek help after weight loss. The duration of symptoms prior to first clinic or hospital attendance was 0–12 months (average 3 months). The reasons for the delay included the following: 41% of patients did not consider dysphagia a significant symptom, 24% had no money, 19% sought the help of traditional healers first and 15% said the hospital was too far away. Conclusion: There are long delays in the management of oesophageal cancer in our setting. The delays are prehospital as well as within the health care system. Lack of knowledge about oesophageal cancer symptoms and limited access to health care contributed to delays in management. Targeted quality improvement interventions are necessary. Patient education and improved referral systems are vital in encouraging earlier presentation

Self-expanding metal stent placement for oesophageal cancer without fluoroscopy is safe and effective

Background. Self-expanding metal stents (SEMS) are widely used to palliate patients with oesophageal cancer. Placement is usually done under endoscopic and fluoroscopic guidance. We have developed an exclusively endoscopic technique to deploy these stents. This article documents the technique and periprocedural experience.Patients and methods. All patients who had SEMS placement for oesophageal cancer at Grey’s Hospital, Pietermaritzburg, South Africa, over a 5-year period (2007 - 2011) were reviewed. Stenting was performed without radiological guidance using the technique documented in this article. At endoscopy, the oesophageal lesion was identified, dilated over a guidewire if necessary, and a partially covered stent was passed over the wire and positioned and deployed under direct vision. Data were captured from completed procedure forms and included demographics, tumour length, the presence of fistulas, stent size and immediate complications.Results. A total of 480 SEMS were inserted, involving 453 patients, of whom 43 required repeat stenting. There were 185 female patients (40.8%) and 268 male patients (59.2%). The mean age was 60 years (range 38 - 101). There were 432 black patients (95.4%), 15 white patients (3.3%) and 6 Indian patients (1.3%). The reasons for palliative stenting were distributed as follows: age >70 years n=95 patients, tumour >8 cm n=142, tracheo-oesophageal fistula (TOF) n=29, and unspecified n=170. One patient refused surgery, and one stent was placed for a post-oesophagectomy leak. Repeat stenting was for stent migration (n=15), tumour overgrowth (n=26) and a blocked stent and a stricture (n=1 each). Complications were recorded in six cases (1.3%): iatrogenic TOF (n=2), false tracts (n=3) and perforation (n=1). All six were nevertheless successfully stented. There was no periprocedural mortality.Conclusion. The endoscopic placement technique described is a viable and safe option with a low periprocedural complication rate. It is of particular use in situations of restricted access to fluoroscopic guidance

Developing a novel laparoscopic training model during the Covid-19 pandemic in a resource-limited setting

Background: This paper describes the development and implementation of a unique laparoscopic suturing course in a resource-constrained setting and reviews the initial experience with the program. Methods: This study describes the development of Grey's laparoscopic suturing course (GLSC) and reviews the questionnaires and feedback over the past year. Results: The GLSC has been run for over a year and has enrolled 47 participants. Most participants were registrars, followed by consultants and medical officers, and most participants had limited minimal access surgery (MAS) experience. Only three had previously undertaken a formal course or observership. The mean result for the pre-course test was 50%, and for the post-course test, 88%. During the skills laboratory session, every participant competently performed intra-corporeal suturing. The entire group unanimously agreed that the GLSC should be recommended for all surgical trainees in the evaluation form. All participants expressed interest in an advanced MAS course. Conclusion: We have demonstrated that developing a local MAS suturing course with limited resources and industry support during the Covid 19 pandemic is possible. It has benefited a large group of trainees thus far and hopefully will become part of the curriculum of surgical trainees in South Africa