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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 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 Hilar cholangiocarcionoma; Is aggressively answered(College of Surgeons of Sri Lanka, 2015) Bandara, L.M.P.M.; Jayarathne, V.S.; Siriwardana, R.C.; Nawarathna, N.M.M.; Liyanage, C.A.H.INTRODUCTION: Cholangiocarcinoma (CCA) is a malignant disease involving the billiary system with majority occurring in the hilar region. CCA demands prompt management because of its aggressive nature. MATERIALS AND METHODS: Patients who presented to Gastroenterology and hepatobiliary unit at NHSL and the Professorial Surgical Unit of NCTH from January 2011 to June 2015 were included in this study. Diagnosis was made by CT imaging, MRCP and ERCP. RESULTS: Total of 120 patients were diagnosed with CCA. The median age of presentation was 64 years (31-85) with 51.2% being males. Majority of 63 patients (52.1%) of CCA occurred in the hilar region with rest involving the common bile duct. Out of 63 hilar CCA 44 were classified according to the bismuth classification. 13/44 were type I, 7/44 were type II, 9/44 were of type III and 15/44 were of type IV. While 5 patients (7.9%) underwent hepatic resection, Majority of 40 patients (63.5 %) were stented with 9 (14.2%) being treated with Radiofrequency ablation (RFA). Survival was significant following surgery (P=0.027). Four patients who underwent surgery are currently followed up at NCTH. CONCLUSIONS: Surgery appears to be the effective treatment for CCA. Aggressive palliation with stenting seems beneficial.Item Bile reflux and quality of life after modified retrocolic posterior gastric gastrojejunostomy in whipple procedure(College of Surgeons of Sri Lanka, 2015) Rajapaksha, R.W.M.A.L.; Liyanage, C.A.H.; Hewavisenthi, S.J.D.S.; Liyanage, S.K.; Bandara, L.M.P.M.; Siriwardana, R.C.INTRODUCTION: Perioperative outcome of Whipple surgery has greatly improved. Quality of life has become an important issue in long-term survivors. Delayed gastric emptying and bile reflux are common concerns. Modified retrocolic posterior gastric gastrojejunostomy with mesocolic stich has been unit's standard practice. Study was designed to assess macro and microscopic bile reflux and dyspepsia related quality of life in long-term survivors. MATERIAL AND METHODS: Out of 42 patients operated from June 2012, twenty long-term survivors were selected after excluding once with recurrence and ones who had chemotherapy during last six months. All underwent gastroscopy. Macroscopic bile reflux was grouped in to four categories. Six gastric biopsies were taken from standard sites. Microscopic bile reflux index (BRI) was calculated in stained specimens. BRI score of more than 14 was considered significant. Validated Nepean dyspepsia index-short form (NDI-SF) was used to assess the severity of dyspepsia related quality of life and compared with age and gender matched control. RESULTS: The median age was 48.5 years (21- 69). Median survival of the group was 37 months (6-40). Endoscopically, 18/20 (90%) had macroscopic bile reflux (83.3% yellowish bile lake, 16.7% greenish bile lakes). None had stomal ulcers or macroscopic inflammation. Mean Bile reflux index score was 13.22 (SD: 9.46). Mean dyspepsia score of Whipple group was 23.1 (SD 8.88). In controls, mean dyspepsia score was 20 (SD 8.2), showing no significant difference (p =0.245). CONCLUSION: Though there was macroscopic bile reflux, clinical symptoms and microscopic changes were minimal. Modified technique had good long-term results.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 Long- term glycemic control after pancreatectomy- prospective study(College of Surgeons of Sri Lanka, 2015) Ekanayake, C.S.; Bandara, L.M.P.M.; Liyanage, C.A.H.; Siriwardena, R.C.INTRODUCTION: Pancreatic resection leads to loss of functional pancreatic tissue. The study evaluates the glycemic control and factors affecting the glycemic control in long-term survivors after pancreatic resection. MATERIAL AND METHODS: Patients who survived for three months or more after pancreatectomy were selected. Baseline parameters were collected with an interviewer administered questionnaire. All patients had a fasting blood sugar (FBS) and HbA1C. Previous non diabetics had oral glucose tolerance test (OGTT) at one and two hours. There were 49 Whipple procedures and 6 distal pancreatectomies. 20 Whipple procedure patients and 5 distal pancreatectomy patients consented. Sixteen (64%) participants were females. Median age was 47 (15-70) years. Eleven (44%) were previously known diabetic patients. The median Body Mass Index (BMI) was 18.28 kg/m3 (11.36-30.07). The median time since surgery was 16 (3-37) months. There was one (4%) newly diagnosed diabetic patient. Out of non-diabetics, one had more than 200 mg/dl OGTT at 2 hours. Nine diabetics had HbA1c elevation more than 7%. Mean post-surgical FBS in diabetic patients (136.9 mg/dl) were significantly (p<0.05) higher than pre-surgical FBS (109.4 mg/dl). BMI (p=0.006), waist to hip ratio (p=0.039) and percentage of pancreas removed (p=0.002) showed a significant correlation to worsening of post-surgical sugar control. CONCLUSIONS: Pancreatectomy leads to worsening of blood sugar control in known diabetics. New onset diabetes is rare. Close follow-up and strict control is needed in known diabetics with high BMI and high waist to hip ratio.Item Surgical handover in a Sri Lankan setting: problems, pitfalls and prevention of error(The College of Surgeons of Sri Lanka, 2011) Keragala, T.S.; Deen, K.I.; Liyanage, C.A.H.INTRODUCTION:Effective clinical handover ensures continuity of patient care. There is little evidence regarding clinical handovers in the Sri Lankan setting assesses the effect of standardised pro-forma on clinical data transfer among team members during a surgical casualty. MATERIAL AND METHODS: We collected data handed over from admission during a surgical causality,for a period of 12 weeks to the university surgical unit of Colombo North Teaching Hospital(CNTH), where clinical handovers are consultant-led, conference-based and carried out with an educational focus. Initial stage, clinical handovers were carried out using a verbal method. A standardised pro-forma was trialled according to the recommendations in literature. After revaluation the sheet was revised and implemented. A re-audit of handover data, was then undertaken using the revised standardised pro-forma during the last 6 weeks. RESULTS: Total of 223 patients handed over verbally and 256 using standardized pro-forma. The only incident of delay in treatment attributed to handover process occurred during verbal handover (p=0.94648967). Incidents causing investigation delays occurred once during pro-forma based over and thrice during verbal handover (p=0.83231572). Two incidents of prolongation of hospital stay occurred during verbal method compared to one during pro-forma based method (p=0.88203094). DISCUSSION AND CONCLUSIONS: Though' the results are not statistically significant, we feel the use of standardised pro-forma could be valuable as a sentinel tool to avoid catastrophic events. The standardised pro-forma is now an accepted and important part of patient management in the university surgical unit of CNTH.Item Diffuse-Type Hepatoma: A grave prognostic marker(Karger Medical and Scientific Publishers, 2017) Siriwardana, R.C.; Liyanage, C.A.H.; Gunetilleke, B.; Niriella, M.A.; de Silva, H.J.; Dassanayake, A.S.; Jayatunga, S.P.BACKGROUND: Data on diffuse-type hepatocellular carcinoma (HCC) are rare. HCC in Sri Lanka is rising, and the majority is related to nonalcoholic fatty liver disease. This study was planned to compare nodular- and diffuse-type HCC in this cohort. METHODS: CT scans of 227 patients with HCC negative for infective hepatitis were analyzed and grouped as nodular and diffuse from July 2011 to July 2014. Diffuse-type cancer was defined as a tumor without convex/distinct margin, diffusely infiltrating the hepatic parenchyma. There were 45 (20%) cases. The baseline liver functions, etiology, treatment, and the outcome were compared with nodular-type cancers. Stage III diffuse cancers were matched with 2 stage III nodular cancers looking at the T stage and background liver. RESULTS: There was no difference in the age (63 vs. 62 years, p = 0.937) and gender. Diffuse cancers had a low BMI (24 vs. 22, p = 0.009), a higher alpha fetoprotein (AFP) level (p < 0.001), a higher incidence of major vascular invasion (14 vs. 80%, p < 0.001), and a history of significant alcohol consumption (39 vs. 67%, p = 0.001). The baseline liver functions were similar in diffuse and nodular cancers. A large proportion (27 vs.77%, p < 0.001) of diffuse cancers were not candidates for active treatment. Overall survival was poor in the diffuse type(4.7 vs. 25 months, p < 0.001). Diffuse-type stage III cancers had a poor survival compared to matched nodular cancers (2.5 vs. 15.8 months, p = 0.001). CONCLUSION: HCC without a background of infective hepatitis were common in our cohort. These tumors are associated with high AFP levels, major vascular invasion, and a poor prognosis.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.Item Recurrence of graft steatosis after liver transplantation for cryptogenic cirrhosis in recently commenced liver transplant program(Springer India, 2016) Siriwardana, R.C.; Niriella, M.A.; Dassanayake, A.S.; Liyanage, C.A.H.; Gunetilleke, B.; de Silva, H.J.Non-alcoholic fatty liver disease (NAFLD) seems to recur in at least one third of patients transplanted for non-alcoholic steatohepatitis (NASH)-related cirrhosis. While, NASH recurrence does not seem to affect overall graft and patient survival up to 10 years, cardiovascular and infection-related morbidity and mortality seem to be increased in these patients. This report looks at the graft histology in patients who were transplanted for NASH-related cirrhosis after short-term follow up. We report a high prevalence of recurrent NAFLD in liver grafts post-transplant among five patients. The degree of steatosis noted among the recipients is alarming.Item Liver transplantation - initial experience at Colombo North Liver Transplantation Service(Sri Lanka Medical Assosiation, 2012) Bogamuwa, M.M.M.P.; Siriwardana, R.C.; Niriella, M.A.; Dassanayake, A.S.; Wijesuriya, S.R.E.; Liyanage, C.A.H.; Gunetilleke, M.B.; de Silva, H.J.INTRODUCTION: Liver transplantation (LT) is the treatment of choice for end stage liver diseases. LT is still in its infancy in Sri Lanka. AIMS: To describe the initial experience of the Colombo North Liver Transplantation Service (CNLTS) METHODS: The study population included all patients referred for LT to CNLTS. All cases were evaluated for the indication and medical, social and psychological suitability for LT. Decision to list patients for LT was reached by a multidisciplinary team consisting of surgeons, physicians and anaesthetists. All data were collected prospectively. RESULTS: 52 patients were referred for LT over a period of 7 months. 48/52[92.3%) were males. The median age at referral was 52(range 13-66) years. The median Child-Turcotte-Pugh(CTP) score at referral was 9/15(range 5-13/15). Median Model for End Stage Liver Disease (MELD) score at referral was 17(range 9-26). 3/52(5.8%) had hepatocellular carcinoma and 9/52(17.3%) had a low MELD score (<14) but with life threatening complications of cirrhosis as indication. 4/9(44.4%) of those being upper gastrointestinal bleeds from varices. 28/52(53.8%) of the referrals had cryptogenic cirrhosis (CC), 18/52(34.6%) had alcoholic cirrhosis, 2/52(3.8%) each had metabolic, congenital and other causes for cirrhosis. 7/52(13.5%) transplants were performed [3 Live Donor LTs(LDLT) and 4 Deceased Donor LTs(DDLT)]. 5/7(71.4%)[2 - LDLT, 3 -DDLT] had a successful LT outcome. 11/45(24.4%) patients died while on the LT waiting list. CONCLUSIONS: High MELD CC was the commonest reason for referral for LT in our group. There was a high waiting list mortality highlighting the need for an efficient DDLT service.
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