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 Standard local infiltration vs. additional laparoscopic-guided transverse abdominis plane block in laparoscopic cholecystectomy: interim analysis of double blinded randomized control study(Sri Lanka Medical Association, 2017) Tillakaratne, M.S.B.; Gunetilleke, B.; Kumarage, S.; Siriwardana, R.C.INTRODUCTION & OBJECTIVES: Transverse abdominal plane block (TAP) is a new technique used in perioperative analgesia. It has shown a clear benefit in long laparoscopic procedures. Current trial evaluates its efficacy in uncomplicated laparoscopic cholecystectomy. METHODS: A single centre double blinded randomized control trial was designed with 45 patients to each group based on 80% power at a p<0.01. Patients who underwent elective uncomplicated laparoscopic cholecystectomy were randomized in to local port site infiltration of bupivacaine and additional TAP block groups. Primary efficacy variables were postoperative pain score and requirement for opioids measured every six hourly. Duration of immobilization and hospital stay were some of the secondary variables. An interim analysis was done at 8 months. RESULTS: Thirty eight patients were randomized to two groups. Twenty-two (58%) were given TAP blocks. The male:female ratio (p=0.24), age (p=0.4), indication for surgery (p=0.34), ASA (p=0.45) and BMI (p=0.58) were similar in the two groups. There was no difference in operating time (p=0.28), intraoperative findings (p=0.4) and the difficulty index (p=0.26). Six hourly pain scores till the time of discharge, total and six hourly opioid dose, number of vomiting episodes, total hospital stay (p=0.98) and time to mobilize out of the bed (p=0.63) were similar in the two groups. CONCLUSION: TAP block does not have an added advantage over standard port site infiltration in uncomplicated laparoscopic cholecystectomy.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 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 Prospective analysis of serum ferritin in a cohort of NAFLD related hepatocellular carcinoma(Sri Lanka Medical Association, 2016) Siriwardana, R.C.; Niriella, M.A.; Dassanayake, A.S.; Ediriweera, D.S.; Gunetilleke, B.; Liyanage, C.A.H.; Siwasundaram, T.; de Silva, H.J.INTRODUCTION: Non-alcoholic fatty liver disease (NAFLD) is a leading cause for hepatocellular carcinoma (HCC) in Sri Lanka. In these patients diabetes mellitus, alcohol abuse and liver inflammation are known to increase the risk of HCC. OBJECTIVES: The present study evaluates serum ferritin levels in a cohort of patients with non-viral hepatitis-HCC (nvHCC). METHOD: Consecutive patients with nvHCC, presenting to the Colombo North Liver transplant Service, Ragama, from Jan 2012 to Aug 2015 were investigated. All were negative for Hepatitis B and C. At registration, 5ml of serum was separated into plain tubes, stored at-800 C and analysed for ferritin using an enzyme-linked immunosorbent assay. Correlation between the serum ferritin and patient risk factors, liver status and tumour characteristics were analysed. RESULTS: There were 93 patients with nvHCC [median age65(12-82) years; 82(88.2%) males]. The median ferritin level was 246.2 mcg/L,and 38(40.86%) patients had elevated ferritin. Non-diabetics (median=363.5mg/L, p= 0.003), alcohol abusers (median=261.2mg/L, p= 0.018) and patients with advanced Child class (Child A=207.8mg/L, Child B=208.6mg/L, Child C 635mg/L, p= 0.045) had higher ferritin levels. On multivariate analysis being non-diabetic and an advanced Child class were significantly associated with high serum ferritin. No association was found between serum ferritin and body mass index, tumour stage, size and morphology, number of nodules and alpha fetoprotein. CONCLUSIONS: In patients with nvHCC, serum ferritin levels are higher in non-diabetics and advanced cirrhosis.