Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Survival following curative surgery for colorectal cancer (CRC) in the middle-aged population: data from a South Asian cohort(Springer, 2021) Vishwajith, P.; Chandrasinghe, P.; Gunasekare, K.; Gajasinghe, S.; Kumarage, S.BACKGROUND/AIM : Colorectal cancer (CRC) is the fourth commonest cancer in Sri Lanka. Disease burden and survival among the middleaged population (50–70 years) with CRC is less studied. With the aging global population, this cohort has a high economic and a social impact. This study aims to analyse the survival pattern and contributing factors in a middle-aged patient cohort with CRC. METHODS: CRC patients managed with a curative intent between 1997 and 2020 at a specialised tertiary care unit were analysed. Demographic data, tumour characteristics and survival of the patients aged between 50 and 70 years was analyzed. Overall survival was compared with the younger (\50 years) and older ([70 years) populations with CRC using Kaplan–Meire curves. Individual variable analysis was performed to sought for significant association of survival with age, sex, tumour stage and tumour site. Multifactorial analysis was performed using Cox-proportional hazard model. RESULTS: A total of 411 patients between 50 and 70 years age group with CRC were analysed (mean 60.07 years; range—50–70 years, male—47.45%). Overall survival of the middle-aged population was significantly better (mean— 133 months, SE 6.84) compared to the elderly population (mean—58 month, SE = 7.74) but worse compare to the younger population (mean—167 month, SE = 10.81). Majority of the tumours (60.5%) in the middle-aged group were locally advanced on presentation ([T3). Tumor site and age at presentation were significant factors that influence survival in this age group. CONCLUSION: Middle-aged patients have a better mean overall survival than their older counterparts but fare worse compared to the younger age group. Tumor stage and age were the only factor that significantly influenced survivalItem Quality of life following curative surgery for colorectal cancer in a Sri Lankan cohort; North Colombo experience(Springer, 2021) Godahewa, S.; Gunasekare, K.; Gajasinghe, S.; Kumarage, S.; Chandrasinghe, P.BACKGROUND/AIM: Colorectal cancer (CRC) is the 4th commonest cancer in Sri Lanka. It is increasingly approached with a curative intent due to the advancements in the surgical and medical management. This has resulted in a large cohort of cancer survivors that needs to be managed. Quality of life (QOL) and patient reported outcomes in CRC survivors assist in identifying and managing unique issues in this population. This study aims to describe objectively measured quality of life after surgery for colorectal cancer in a South Asian population. METHODS: Patients who underwent surgery for CRC and are currently disease free were included. QOL was assessed using the translated and validated SF36 questionnaire (Sinhala) along with patient complaints. SF36 components were aggregated into physical component summery (PCS) and mental component summery (MCS). Patient reported symptoms were categorized in to organ function, life style, and psycho-sexual. RESULTS: A Total of 100 patients completed the survey (median age—61 years; range 25–86, female—56%). Of the total 65% were rectal cancers while 35% were colon cancers. QOL assessment reported a PCS of 0.64 and a MCS of 0.67 (Max- 1.0). There was no difference in QOL between rectal and colon cancers (PCS: rectal—0.64 vs colon—0.63, P = 0.9; MCS: rectal— 0.65 vs colon—0.66) or based on follow-up period (\5 years vs[ 5 years; P = 0.3 and 0.9). Organ function related problems were reported by 69% and increased frequency was the main complaint (27%). CONCLUSION: The QOL of a Sri Lankan cohort of CRC survivors is described. QOL did not differ between rectal and colon cancers. Neither PCS nor MCS had significantly improved over time following surgery.Item Survival pattern and clinicopathological data from a South Asian cohort of young colorectal cancers treated with curative intent(Springer, 2021) Gunasekare, K.; Godahewa, S.; Vishwajith, P.; Gajasinghe, S.; Ekanayake, M.; Kumarage, S.; Chandrasinghe, P.BACKGROUND/AIM :Colorectal cancer (CRC) has the fourth highest incidence among cancers in Sri Lanka. Although CRC is considered as a disease of the elderly, currently there is a shift towards an increasing incidence of young cancers globally. Despite the increasing incidence there is a scarcity of data from the South Asian region. This study aims to analyze the clinicopathological features and long term survival of young CRC from a South Asian cohort of patients. METHODS: All patients treated for CRC at a tertiary care center from 1997 to 2017 were prospectively followed up. Demographics, tumour characteristics and survival data were recorded. Age less than 45 years at diagnosis was considered as a young cancer. Overall survival among the populations was compared using Kaplan-Mire survival curves. A P value of\0.05 was considered significant. Results: A total of 113 (16.5%) young cancers (Mean age 36.35; range 17–45; female 53.1%) were operated during the period. Rectum (60.2%) was the commonest site followed by the right colon (24.8%) and left colonic (15%) tumors. Adenocarcinomas of moderately differentiated variety (72.4%) was the commonest histological type. Seventy percent of cases had locally advanced disease (T3/T4) with 53.2% having positive nodal status. Of the total 27% received neoadjuvant treatment and 66.7% received adjuvant treatment. Young CRC patients had a significantly better overall survival compared to their older counterparts (P = 0.008). CONCLUSION Young cancers accounts for a significant proportion of the colorectal cancers in this cohort. Over 75% of the cancers were on the left colon and the majority was locally advanced disease. Overall survival of the young CRCs were better compared to the older population in this cohort.Item First series of laparoscopic sleeve gastrectomy in Sri Lanka-technical feasibility and outcome in a resource poor setting in asia.(New York; Springer, 2014) Wijeratne, T.K.; Bulugahapitiya, U.; Kumarage, S.; Rajaratnam, H.INTRODUCTION: Morbid obesity and metabolic syndrome are emerging as a major health issues in developing South Asian countries. Laparoscopic Sleeve Gastrectomy (LSG) has been introduced to this region with excellent out comes in controlling morbid obesity and metabolic syndrome. OBJECTIVE(S): Assess the technical feasibility and outcome of LSG as a surgical procedure in a resource poor country in south Asia where Bariatric surgery is still a novel concept. METHOD(S): Prospective Analytical study of the first 15 patients who underwent LSG in a tertiary care hospital in Sri Lanka over 2 years. All data on pre operative, surgical and post operative follow up were recorded in a pre-designed research Performa and all patients were followed up for a minimum period of 6 months by Surgical and Endocrine team. All Surgeries were performed by the same surgeon and the surgical team using total Laparoscopic technique using a 40 F Gastric bougie to standardize the Sleeved stomach. There were 14 females and one male in the study group. Weight range was from 83 to 167 kg with a mean weight of 106.2 kg. Average BMI 45 kg/m2 Results: There were no major complications. The percentage excess weight loss during first 3 months was 28.8 % and at 6 months 42.3 %. Resolution of comorbidities especially Diabetes and Metabolic Syndrome was excellent and one out of two patients who had surgery for subfertility conceived during study period. CONCLUSION(S): LSG can be performed safely in a resource poor setting in south Asia and is effective as a Bariatric surgical procedure for Sri Lankan population.Item Elective cholecystectomy is associated with increased morbidity and mortality in patients with severe Thalassemia: A retrospective case control study.(Ferrata Storti Foundation, 2015) Premawardhena, A.; Fernando, R.; Kumarage, S.; Nishad, N.; de Silva, I.BACKGROUND: Haemoglobin disorders including thalassemia and sickle cell disease are often complicated with gall stone formation. The co-existence of Gilbert's syndrome together with these diseases further increases the risk of gall bladder disease. Some of these patients develop symptomatic disease which necessitates surgical intervention. At present the timing of cholecystectomy for thalassemia is no different from that of the general population with the exception of removal of the gall bladder at the time of splenectomy. This is no longer the case in sickle cell disease where, laparoscopic cholecystectomy is recommended even in asymptomatic patients. This practice however has not been extended to other types of haemoglobin disorders. AIM(S): 1.To assess the perioperative complications of patients with thalassaemia during cholecytetomy and to compare it with non thalassaemics who undergo the procedure. 2. To see if there is enough evidence to recommend elective cholecystectomy for thalassaemics. METHOD(S): We retrospectively studied case notes of thalassemia patients who had cholecystectomy (cases) in two of the biggest thalassaemia centres in Sri Lanka and also of 62 non-thalassaemics (controls) with gall bladder disease who had been scheduled to have gall bladder surgery in the same hospitals and looked at their peri-operative complications. RESULT(S): 98 out of 540 (18%) thalassaemics in the two centres had gall stones. Mean age of cases was 26.8 (SD 10.9) years and of controls 47.5 (SD 19.7) years. 19 (19%) thalassaemics with gall stones had undergone cholecystectomy. Ten patients had cholecystectomy simultaneously with splenectomy. The majority of non-thalassaemic "controls" had laparoscopic cholecystectomy 53/55 (96.3%) whilst the patients with thalassaemia were mostly operated with laparotomy 13/19 (68%). There was a significant excess complications occurring in both early (42.11 vs. 18.1%) and late (31.5 vs. 12.7%) phases in the thalassaemic patients compared with the controls. Among the early complications, sepsis (10.5% vs. 1.8%) and liver abscess formation (5.2 vs. 0%) was significantly different in the groups, adversely affecting the thalassaemics. Recurrent abdominal pain was more common among the thalassaemics as a late complication (P<0.05). Six thalassaemic patients with gall stone disease died during this study, 5(5%) while awaiting surgery and 1(1%) after surgery. There were no deaths among the controls. Out of the deaths, 3 (50%) were directly attributable to gallstone disease. In all three septicemia precipitated heart failure. We found a significant increase of both early and late post-surgical complications in the thalassemia group and also increased mortality most of which was related to severe sepsis. Higher perioperative mortality and morbidity were seen among symptomatic thalassaemic patients with gall stone disease undergoing cholecystectomy. This seems to suggest a strong case for supporting elective cholecystectomy in thalassemics before they develop symptoms. SUMMARY AND CONCLUSION(S): We suggest that laparoscopic elective cholecystectomy be considered for non-sickle, thalassemia patients too who have asymptomatic gall bladder disease, in an attempt to reduce this morbidity and mortality.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 The total number of lymph nodes harvested is associated with better survival in stages II and III colorectal cancer(Springer India, 2014) Chandrasinghe, P.C.; Ediriweera, D.S.; Hewavisenthi, J.; Kumarage, S.; Deen, K.I.BACKGROUND: Lymph node status is important in staging colorectal cancer (CRC). Presence of metastatic nodes differentiates stage IIIfrom stage II. The role of adjuvant therapy is still unclear in stage II CRC. Inadequate node sampling may result in inaccurate staging. METHOD: Records of 131 patients with stages II and III CRC who underwent curative resection, having five or more lymph nodes harvestedfrom the specimen, were prospectively followed up and analyzed. The Kaplan-Meier method was used to analyze survival, based on groups of serially ascending values of lymph nodes harvested. Regression analysis was performed by Cox proportional hazards ratio model with right-censored CRC survival data at a 10 % significance level. The effect of nodal harvest on survival was adjusted for age, sex, preoperative carcinoembryonic antigen (CEA) level, neoadjuvant chemoradiation, pathological tumor stage, histological type, differentiation, margin positivity, angioinvasion, perineural invasion, and lymphovascular infiltration. RESULTS: The total population showed improved survival with 14 or more nodes harvested (p= 0.005). For both rectal (n= 83; p= 0.03) and colon cancers (n= 46; p= 0.08), most significant survival benefits were seen with over 14 nodes harvested, irrespective of the stage. With multiple regression analysis, advanced age (p= 0.003), male sex (p= 0.017), lymphovascular infiltration (p= 0.015), and preoperative CEA levels (p= 0.096) were found to be other significant factors. The lymph node effect remained significant (HR = 0.19, p= 0.004) after adjusting for the above factors. CONCLUSION: A lymph node harvest of 14 or more resulted in better survival outcome from CRC in this population. Staging of the disease could be accurate with increased nodal harvestingItem Idiopathic pancreatitis is a consequence of an altering spectrum of bile nucleation time(Biomed Central, 2011) Abeysuriya, V.; Deen, K.I.; Dassanayake, B.; Kumarage, S.; Navarathne, N.; Pathirana, A.BACKGROUND: The pathogenesis of idiopathic pancreatitis (IP) remains poorly understood. Our hypothesis is that IP is a sequel of micro-crystallization of hepatic bile. METHODS: A prospective case control study compared 55 patients; symptomatic cholelithiasis - 30 (14 male, median age 36 years; mean BMI - 25.1 kg/m2), gallstone pancreatitis - 9 (3 male, median age 35 years; mean BMI - 24.86 kg/m2 ) and IP - 16 (9 male, median age 34 years; mean BMI -23.34 kg/m2) with 30 controls (15 male, median age 38 years; mean BMI = 24.5 kg/m2) undergoing laparotomy for conditions not related to the gall bladder and bile duct. Ultrafiltered bile from the common hepatic duct in patients and controls was incubated in anaerobic conditions and examined by polarized light microscopy to assess bile nucleation time (NT). In the analysis, the mean NT of patients with gallstones and gallstone pancreatitis was taken as a cumulative mean NT for those with established gallstone disease (EGD). RESULTS: Patients were similar to controls. Mean NT in all groups of patients was significantly shorter than controls (EGD cumulative mean NT, 1.73 +/- 0.2 days vs. controls, 12.74 +/- 0.4 days, P = 0.001 and IP patients mean NT, 3.1 +/- 0.24 days vs. controls, 12.74 +/- 0.4 days, P = 0.001). However, NT in those with IP was longer compared with those with EGD (mean NT in IP, 3.1 +/- 0.24 days vs. cumulative mean in EGD: 1.73 +/- 0.2 days, P = 0.002). CONCLUSION: Nucleation time of bile in patients with IP is abnormal and is intermediate to nucleation time of lithogenic bile at one end of the spectrum of lithogenicity and non-lithogenic bile, at the other endItem Laparoscopy as a diagnostic and therapeutic option in evaluating chronic unexplained right iliac fossa pain(Springer International, 2010) Siriwardana, R.C.; Renuka, S.; Kumarage, S.BACKGROUND: Management of chronic right iliac fossa (CRIF) pain is poorly documented in literature. No guidelines are available on the best therapeutic approach. METHOD: Patients presenting from October 2007 to August 2009 with pain persisting or recurring in right lower abdomen over a period of 6 weeks or more were assessed. Severity of CRIF pain was documented using a ten-point visual analogue scale. Initial history and examination were followed by urine analysis, blood counts, X-ray and ultrasound scan of the abdomen. Full colonoscopy was performed in all negative cases. Diagnostic or therapeutic laparoscopy was offered to patients with normal initial investigations. The normal-looking appendix was removed in the absence of other positive laparoscopic findings. Patient's immediate complications, pain score at 8 weeks and histology of appendix were assessed. RESULTS: Nineteen patients with median age of 43 years (range 32-52 years) underwent laparoscopy. All were female. Median pain score was 5 (range 4-6). During surgery, 12 (64%) had positive findings. Of these, 6 (30%) had adhesions, which were separated. Three patients with congested appendices were removed. One caecal perforation, tubal mass and ovarian cyst were treated laparoscopically. Seven (36%) patients who had macroscopically normal appendices underwent appendicectomy. There were no immediate postoperative complications. Significant improvement was seen in overall pain score after surgery (median 5, range 4-6 versus median 0, range 0-6; p = 0.001). However, only 57% of patients with normal appendix had improved pain scores (median 5, range 4-6 versus median 1, range 0-6; p = 0.12). All patients with positive laparoscopic findings improved after surgery. CONCLUSION: Laparoscopy seems effective in evaluation and treatment of CRIF pain. The role of appendicectomy with normal-looking appendix needs further evaluationItem Duodenum-preserving local excision of a gastrointestinal stromal tumor(Elsevier, 2008) Liyanage, C.A.H.; Abeygunawardhana, S.; Kumarage, S.; Deen, K.I.BACKGROUND: Duodenal gastrointestinal stromal tumors (GISTs) are rare. Because of the complex anatomy of the duodenum, the methods of resection of these tumors are controversial and diverse. METHODS: We report a case of a duodenal GIST in the anterolateral wall of the second part of the duodenum, which was successfully managed by local excision. The surgery was facilitated by preoperative mapping with Indian ink and navigation by endoscopy to assess the adequacy of resection and to avoid injury to the ampulla. RESULT: Reconstruction was successful with a duodenojejunostomy and protected by a nasoduodenal drain. CONCLUSION: The patient had no postoperative complications and the tumor was confirmed to be a GIST of the duodenum successful with an adequate resection margin