Conference Papers
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This collection contains abstracts of conference papers, presented at local and international conferences by the staff of the Faculty of Medicine
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Item Post hepatectomy adjuvant trans-arterial chemotherapy- A pilot study(College of Surgeons of Sri Lanka, 2015) Ekanayake, C.S.; Bandara, L.M.P.M.; Liyanage, C.A.H.; Niriella, M.A.; Dassanayake, A.S.; Siriwardena, R.C.INTRODUCTION: Hepatic micro metastases lead to early recurrence after surgery for hepatocellular carcinoma (HCC). Trans arterial therapy (TAT) without selective embolization may be an effective treatment that induces tumour necrosis. This potential has not been investigated before. This study looks in to the tolerability of TAT in patients after major hepatectomy. MATERIAL AND METHODS: Consented patients were offered trans arterial chemotherapy after normalization of liver functions following surgery. Through the femoral artery, right and left hepatic arteries were selectively cannulated. Doxorubicin 50mg was mixed with 10ml of Lipidol and injected. Post procedure biochemistry and complications were assessed at day 3, 7 and 14 intervals. RESULTS: 11 Patients consented (81% males, median age 61y [range 47y-76y]. There were 7(63.6%) cirrhotics. Four (36.3%) were extended right or left hepatectomies while others were bisegmentectomies. The median time period from surgery to chemotherapy was 25 weeks (range 4-60weeks). Post procedure, 1 (9%) had right hypochondrial pain, 2 (18.1%) had fever, 4(36.3%) had nausea, 2(18.1%) had vomiting within 48 hours. All were discharged at 48 hours. One patient developed a transient bradycardia during procedure. There was no clinical evidence of liver failure. Two patients had three-FOLD rise in transaminase levels at day3 and 7. All recovered by day 14. None of the patients had significant rise in prothrombin time or bilirubin levels. CONCLUSIONS: Post hepatectomy adjuvant trans –arterial chemotherapy is a well-tolerated procedure in the view of short term complications.Item Factors affecting Post- Embolization fever and liver failure after Trans- Arterial Chemo-Embolization in a cohort without background infective hepatitis- A prospective analysis.(College of Surgeons of Sri Lanka, 2015) Bandara, L.M.P.M.; Siriwardana, R.C.; Niriella, M.A.; Dassanayake, A.S.; Liyanage, C.A.H.; Sirigampala, C.; Upasena, A.; de Silva, H.J.INTRODUCTION: Transarterial-chemo-embolization (TACE) is used for palliation of unresectable hepatocellular carcinoma (HCC). We studied the tolerability of TACE in a cohort of patients with NASH and alcoholic cirrhosis related HCC. MATERIAL AND METHODS: Of 290 patients with HCC(July 2011 - December 2014), 84 underwent TACE. They were monitored for post-TACE complications: post embolization fever(PEF), nausea and vomiting (NV), abdominal pain, infection, acute hepatic decompensation (AHD) and acute kidney injury (AKI). RESULTS: 84 patients [90.5% males, 89.2% cirrhotics, 89.2% nodular HCC, median age 63(34-84) years] underwent 111 TACE sessions. All were Child class A [69.4% sessions(n=77)] or B; ascites and portal vein invasion was present in 18(16.2%) and 15(13.6%), respectively. 42 (38.2%) TACE procedures resulted in complications [PEF 28(25.2 %), NV 4(3.6%), abdominal pain 9(8.1%), infection 7(6.3%), AHD 13(11.7%), AKI 3(2.7%)]. There were no immediate post-TACE deaths. On univariate analysis elevated serum bilirubin (p=0.046) and low serum albumin (p=0.035) predicted PEF while low serum albumin (p=0.021) and low platelet counts (p=0.041) predicted AHD. In the multivariate model, factors with p 5 cm (p=0.049,OR=2.410)and elevated serum bilirubin (p=0.036,OR=1.517) predicted AHD. CONCLUSIONS: In NASH and alcoholic cirrhosis related HCC patients pre- procedure serum bilirubin, ascites, tumour size and female gender predicted PEF post-TACE. Tumours larger 5cm with elevated bilirubin predicted AHD post-TACE.Item Incidence and predictors of Diabetes Mellitus: A 7- year community cohort follow-up of urban, adult Sri Lankans(Sri Lanka Medical Association., 2019) de Silva, S.T.; Ediriweera, D.; Beddage, T.; Kasturiratne, A.; Niriella, M.A.; de Silva, A.P.; Dassanayake, A.S.; Pathmeswaran, A.; Kato, N.; Wickremasinghe, A.R.INTRODUCTION & OBJECTIVES: There is limited data on incidence of type 2 diabetes mellitus (T2DM) from South Asia. We investigated incidence and predictors ofT2DM in an urban, adult population after seven-years of follow-up. METHODS: The study population (42-71 year-olds in 2014, selected by age-stratified random sampling from the Ragama MOH area) was initially screened in 2007 and re-evaluated in 2014 with informed written consent. On both occasions they were assessed by structured interview, anthropometric measurements, liver ultrasound, biochemical and serological tests. RESULTS: Of the 2986 enrolled in 2007, 737 had established T2DM giving a baseline prevalence of 24.7% (95% CI: 23.1%-26.2%). 2148/2984 (71.6%) of the original cohort attended follow-up [1237 (57.5%) women; median (IQR) 60 (54-66) years]. 1650 participants who did not have T2DM in 2007 presented for follow up; 436 (27.6%) of them had developed new T2DM by 2014, giving an annual incidence of 3.9% (95% CI: 3.0%-4.9%). Of 525 participants with pre-diabetes (HbA1c 5.7-6.4%) in 2007, 364 attended follow up and 201/364 (55.1%) had developed T2DM by 2014, giving an annual conversion rate of pre-diabetes to T2DM of 7.9%. On logistic regression, pre-diabetes (OR:4.4;95%CI:3.3%-6.0%), central obesity (OR: 1.8;95%CI: 1.3%-2.4%), dyslipidemia (OR: l.5;95%CI: 1.1 %-2.1 %) and non-alcoholic fatty liver disease (NAFLD) (OR:1.5;95%CI: 1.1 %-2.1%) showed significant association with incident T2DM. CONCLUSION: In this urban cohort, the annual incidence of T2DM was 3.9% and the annual conversion rate of pre-diabetes to T2DM was 7.9%. Our findings emphasize the need for targeted and intensive lifestyle interventions for individuals with high metabolic risk to prevent T2DM.Item Perioperative outcome following establishment of deceased donor liver transplantation: A single center experience in Ragama, Sri Lanka(Sri Lanka Medical Association, 2018) Withanachchi, A.D.; Thalagala, T.A.E.S.; Liyanage, I.K.; Dassanayake, A.S.; de Silva, A.P.; Gunetilleke, M.B.; Siriwardana, R.C.; Niriella, M.A.INTRODUCTION AND OBJECTIVES: Liver transplant (LT) perioperative mortality is a good performance indicator among transplant centres. Colombo North Teaching Hospital (CNTH) is the first LT program in Sri Lanka. We aimed to evaluate the perioperative (30 day) outcomes and complications of patients who underwent deceased donor liver transplantation (DOLT) at CNTH between the first 9 DDLTs that were carried out before 2016 (Tl) and the last 10 DDLTs after 2016 (T2). METHODS: Retrospective analysis of pre-operative records, operation notes, discharge and follow up notes were carried out on all patients who underwent DOLT at CNTH. RESULTS: A total of 19-DDLTs were performed during this period. Mean age of the recipients was 50.3 (Tl :52.9, T2:47.9) years: Indications (n) for DDLT were: advanced cirrhosis with high MELD (12), other complications of cirrhosis (3),."cirrhosis with hepatocellular carcinoma (3) and acute liver failure (1 ). Aetiology of cirrhosis (n) were: cryptogenic (13), alcohol (3), autoimmune hepatitis (1), other (1). Pre transplant MELD was 16 in Tl and 18 in T2. Average hospital stay was 11.1 days (7.4 days in the intensive care). Perioperative mortality was 4/9 (44%) in Tl and 2/10 (20%) in T2. Mortality was due to PNF (3), sepsis (2) and post-operative reperfusion syndrome (1). Other post-operative complications (in Tl and T2) were: hepatic artery thrombosis (0,0), cholestasis (0, 1 ), acute cellular rejection (0,2), hydrothorax (0,3), clinically significant tacrolimus toxicity (1,o) and acute renal failure (4,2). CONCLUSION: Perioperative mortality has reduced and outcomes improved in the second half indicating success of the CNTH LT program.Item Patterns of alcohol use and occurrence of alcoholic fatty liver disease: a prospective, community cohort, 7-year follow-up study(Sri Lanka Medical Association, 2017) Niriella, M.A.; de Silva, S.T.; Kasturiratne, A.; Perera, K.R.; Subasinghe, S.K.C.E.; Kodisinghe, S.K.; Piyaratna, T.A.C.L.; Vithiya, K.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.INTRODUCTION & OBJECTIVES: Data is limited on alcoholic fatty liver disease (AFLD). We investigated patterns of alcohol use and AFLD, among urban, adult, Sri Lankans. METHODS: Study population (selected by age-stratified random sampling from Ragama MOH-area) was screened initially in 2007 (35-64 years) and re-evaluated in 2014. On both occasions they were assessed by structured-interview, anthropometric measurements, liver ultrasound, biochemical and serological tests. AFLD was diagnosed on ultrasound criteria, unsafe alcohol consumption (Asian standards: males>14units, females>7units per week) and absence of hepatitis B/C markers. Controls were individuals with unsafe alcohol consumption, but had no ultrasound criteria of AFLD. Case-control genetic-association for PNPLA3 (rs738409) polymorphism for AFLD was performed. RESULTS: A total of 2983/3012 (99%) had complete data. 272/2983(9.1%) were unsafe-drinkers [males- 70; mean-age 51.9 (SD-8.0) years]. 86/2983 (2.9%) of the cohort and 86/272 (31.6%) of unsafe-drinkers had AFLD [males-85; mean-age 50.2 (SD-8.6) years]. Males [p<0.001], increased waist circumference (WC) [p=0.001], BMI>23kg/m2 [p<0.001], raised triglycerides (TG) [p<0.001], low education level (LEL-not completed secondary-education) [p<0.01] and low monthly household-income (23kg/m2 [p<0.001], raised TG [p<0.001] and LEL [p<0.05] independently predicted incident-AFLD. The genetic association study [133-cases (combined 2007-2014), 97-controls] showed no association with AFLD at PNPLA3 (rs738409). CONCLUSION: The prevalence of AFLD was 2.9% in 2007 and annual incidence among heavy drinkers, after 7-year follow-up was 5.7%. Incident-AFLD was associated with males, obesity, raised TG and LEL.Item Clinical predictors of poor outcomes in hepatocellular carcinoma of nonviral aetiology(Sri Lanka Medical Association, 2017) Siriwardana, H.D.R.C.; Niriella, M.A.; Dassanayake, A.S.; de Silva, A.P.; Gunetilleke, B.; Pathmeswaran, A.; de Silva, H.J.INTRODUCTION & OBJECTIVES: Clinical predictors for prognosis of NASH and alcohol related (non-viral) hepatocellular carcinoma (nvHCC) is poorly described. METHODS: Patients with nvHCC, from a tertiary referral hepatobiliary clinic were prospectively screened. Clinical evaluation, liver biochemistry, pre-treatment AFP (pt-AFP) and contrast enhanced CT abdomen were performed. HCC was diagnosed using American Association for the Study of Liver Disease guidelines, and TNM staged. nvHCC was diagnosed in HCC negative for HBsAg, anti-HCVantibody, autoimmune and metabolic screening. Child-Turcotte-Pugh (CTP) and Model for End-stage Liver Disease (MELD) scores were calculated. Cox regression analysis was used to identify the factors associated with mortality. RESULTS: A total of 472 patients with nvHCC [age-64 (12-88) years; males-417 (88.3%)] were screened [261 (61.1%) had diabetes; 212 (48.8%) were regular, 85 (19.6%) social, 137 (31.6%) nonconsumers of alcohol]. 358 (83.4%) had cirrhosis [Child A (58.3%), B (32.8%), C (8.9%); median CTP 6 (1-14), MELD 11 (5-40)]. 170 (42.2%) HCCs were TNM stage 3, with median diameter 6cm (0.9-26.5). 239 (71.6%) had no vascular or visceral invasion. Median pt-AFP was 26.6ng/ml (1.16-100,000) [pt-AFP>200ng/ml: n=90 (31.4%) pt-AFP>400ng/ml: n=68 (23.8%)]. Gender, alcohol use (consumer/not), diabetes (present/absent), cirrhosis (present/absent), Child-class (A or B/C), total diameter (<5cm or ≥5cm), nodularity (single/multiple), vascular invasion (present/absent), TNM stage (early/late) and pt-AFP level (<200 or ≥200ng/ml) were assessed as predictors of mortality. On bivariate analysis, Child B/C class (p<0.05), vascular invasion (p<0.001), TNM stage 3 and 4 (p<0.05) and pt- AFP≥200ng/ml (<0.05) were predictive of death. On multivariate analysis, TNM stage ¾ (p<0.05, HR=2.07 and 4.07 respectively) and pt-AFP level≥200ng/ml (p<0.05, HR=1.71) remained independently predictive of death. CONCLUSION: Among patients with nvHCC, TNM stage 3/4 and pt-AFP≥200ng/ml independently predicts death.Item Incidence, prevalence and demographic and life style risk factors for obesity among urban, adult Sri Lankans: a community cohort follow-up study(Sri Lanka Medical Association, 2017) Niriella, M.A.; de Silva, S.T.; Kasturiratne, A.; Kottachchi, D.; Ranasinghe, R.M.A.G.; Dassanayake, A.S.; de Silva, A.P.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.INTRODUCTION & OBJECTIVES: Obesity is a global problem. Data from the South Asian region is limited. METHODS: In a cohort follow-up study we investigated obesity among urban, adult, Sri Lankans (35-64y; selected by age-stratified random sampling from Ragama-MOH area; initial screening 2007; re-evaluation 2014). On both occasions structured interview, anthropometry, liver ultrasound, biochemical and serological tests were performed. Total body fat (TBF) and visceral fat percentage (VFP) were assessed by impedance in 2014. General-obesity (GO) was BMI>25kg/m2. Central-obesity (CO) was waist circumference (WC)>90cm males and WC>80cm females. Multinomial logistic regression was fitted to assess associations. RESULTS: In 2007 (n=2967), 614 (20.7%) were overweight [51.9%-women], 1161(39.1%) had GO [65.9%-women] and 1584(53.4%) had CO [71%-women]. Females (p<0.001), raised-TG (p<0.001), low-HDL (p<0.001), diabetes (p<0.001), hypertension (p<0.001), NAFLD (p<0.001), and low household income (p<0.001) were significantly associated with prevalent GO and CO respectively. Additionally, increased-age (p=0.05), low-educational level (p<0.001) and unhealthy eating (p<0.001) were associated with prevalent CO. Inadequate physical activity was not associated with either. 2137 (72%) attended follow-up in 2014. Of those who were initially non-obese who attended follow-up, 189/1270 (14.9%) [64% women] had developed GO (annual-incidence 2.13%) and 206/947 (21.9%) [56.3% women] had developed CO (annual incidence 3.12%) after 7 years. TBF and VFP significantly correlated with incident GO and CO (p<0.001). Female gender (OR-1.78, p<0.001; 2.81, p<0.001) and NAFLD (OR-2.93, p<0.001; OR-2.27, p<0.001) independently predicted incident GO and CO respectively. CONCLUSION: The prevalence and incidence of GO and CO were high in this cohort. Both incident GO and CO were strongly associated with female gender and NAFLD.Item Significance of pre-treatment serum alpha-fetoprotein in hepatocellular carcinoma of non-viral aetiology(Sri Lanka Medical Association, 2016) Siriwardana, R.C.; Niriella, M.A.; Dassanayake, A.S.; de Silva, A.P.; Gunetilleke, B.; de Silva, H.J.INTRODUCTION: Alpha-fetoprotein (AFP) is a biomarker for hepatocellular carcinoma (HCC). The significance of pre-treatment AFP (pt-AFP) in non-viral HCC (nvHCC) is not clear. METHOD: Patients with nvHCC, referred to a Hepatobiliary Clinic from September 2011-2015 were screened. Clinical evaluation, liver biochemistry, pt-AFP and contrast enhanced CT abdomen were performed. HCC was diagnosed using American Association for the Study of Liver Disease guidelines and TNM staged. nvHCC was diagnosed in HCC, negative for HBsAg and anti-HCVAb. Child-Turcotte-Pugh (CTP) and Model for End-stage Liver Disease (MELD) scores were calculated. All values are presented as median (range). Differences between groups were tested using Pearson’s Chi-square, Mann Whitney U and Kruskal-Wallis tests. Cumulative survival and recurrence rates were calculated by the Kaplan-Meier method. Difference between survival was evaluated by the log-rank test. A p<0.05 was considered significant. RESULTS: Three hundred and eighty nine patients with nvHCC [age 64 (12-88) years; 344 (88.4%) males] were screened. Two hundred and thirty three (59.9%) had diabetes; 187 (48.1%) were regular, 79 (20.3%) social, 123 (31.6%) non-consumers of alcohol]. Three hundred and twenty nine (84.6%) had cirrhosis [Child A (57.3%), B (32.4%), C (10.3%); median CTP 6 (1-14), MELD 11(5-28)]. One hundred and seventy seven (45.5%) HCCs were TNM stage 3, with median diameter 6cm (0.9-26.5). Two hundred and thirty three (59.9%) had no vascular or visceral invasion. Median AFP was 25.46ng/ml (1.16-100,000) [AFP<10ng/ml: n=160(41.2%), AFP>400ng/ml: n=89(22.9%)]. Females (p<0.05), vascular invasion (p<0.001), diameter>5cm (p<0.05), late TNM stage (p<0.001) and non-surgical candidates had higher AFP levels. Diffuse (p<0.001), invasive (p<0.001) and late stage tumours (p<0.001) had AFP>400ng/ml. AFP<400ng/ml was associated with longer survival compared to AFP>400ng/ml (16 vs. 7 months, p<0.001). CONCLUSIONS: Although pt-AFP was not helpful for diagnosis of nvHCC, AFP>400ng/ml was associated with aggressive tumour behaviour and poor prognosis.Item Comparison of cryptogenic and hepatitis B related hepatocellular carcinoma(Sri Lanka Medical Association, 2016) Siriwardana, R.C.; Niriella, M.A.; Dassanayake, A.S.; de Silva, A.P.; Gunetilleke, B.; Chok, K.S.H.; Lo, C.M.; Chan, S.C.; Fan, S.T.; de Silva, S.T.INTRODUCTION AND OBJECTIVES: Viral hepatitis is the leading cause for hepatocellular carcinoma (HCC) globally. Cryptogenic or non-alcoholic fatty liver related HCC is increasing and is predominant in Sri Lanka (SL). Few studies have compared cryptogenic (cHCC) and hepatitis B (bHCC) HCC. Objective of the study was to compare cryptogenic and hepatitis B related hepatocellular carcinoma. METHOD: Patients with HCC were screened at two centres, in Hong Kong (HK) and SL, from 2012-2014. HCC was diagnosed on typical CT/MRI appearance. Biopsy was performed when uncertain. Those with safe alcohol intake, no hepatotoxic exposure, and not having viral, autoimmune or inherited aetiology were considered cHCC. Demography, baseline liver status, tumour characteristics and treatment were compared between groups. A p<0.05 was considered significant. RESULTS: There were 891 patients (350-SL,541-HK). All HK patients were HBsAg positive. Two HBsAg positive SL patients, and 363 with unsafe alcohol intake were excluded. There were no hepatitis C patients. cHCC=234 and bHCC=292 were compared. There was no difference in gender, presenting age, symptoms, transaminases, platelet counts, median tumour diameter, morphology and tumour stage at presentation between groups. Significantly more cHCC had diabetes [133 vs. 67], while more bHCC were cirrhotics [269 vs.175]. At presentation, serum bilirubin was significantly higher in bHCC (1.2 vs. 0.7), while INR (1.23vs1.1) and AFP (51u/lvs.26u/l) were significantly higher in cHCC. bHCC had significantly more surgical candidates [113 vs. 50], while significantly more cHCC were transarterial- chemo-embolization (TACE) candidates [74 vs. 53]. More cHCC were unsuitable for active treatment despite similar tumour stage at presentation. CONCLUSIONS: More cHCC had diabetes and occurred in non-cirrhotic livers. Compared to bHCC, fewer cHCC were candidates for surgery or active treatment at presentation.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.