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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 World Bank prescription for health(Ceylon Medical Association, 1996) Fonseka, C.No abstract availableItem Should Sri Lanka reconsider its rubella immunisation strategy?(Ceylon Medical Association, 1997) Gunasekara, P.C.; Gunasekara, D.P.No abstract availableItem Suicide by suffocation with a plastic bag(Ceylon Medical Association, 1998) Tennakoon, U.A.; Jayawardena, H.Death by suffocation using a plastic bag has not been recorded in Sri Lanka. We report such a case here. Findings at the scene, the history, and autopsy and laboratory investigations assisted in arriving at the conclusion of suicide.Item The treatment of ulcerative colitis: from cure to a new disease(Ceylon Medical Association, 1994) de Silva, H.J.No abstract availableItem Hemoglobin E-beta-thalassemia: Progress report from the international study group(Blackwell Publishing, 2005) Premawardhena, A.; de Silver, S.; Arambepola, M.; Olivieri, N.F.; Vichinsky, E.P.; Merson, L.; Muraco, G.; Allen, A.; Fisher, C.; Peto, T.; Weatherall, D.J.A long-term observational study of Hb E-beta-thalassemia in Sri Lanka is beginning to define some of the genetic and environmental factors that are responsible for its remarkable phenotypic variability. In this population there is a very small difference between the steady-state hemoglobin levels between the mild and severe phenotypes, and it has been possible to stop transfusion in many of those who have been on long-term treatment of this kind. These preliminary observations, made over the last 7 years, provide directions for future research into this increasingly important disease.Item Hepatocellular carcinoma in Sri Lanka: Where do we stand?(Sri Lanka Medical Association, 2013) Siriwardana, R.C.; Liyanage, C.A.H.L.; Jayatunge, D.S.P.; Dassanayaka, A.; Gunetileke, M.G.; Niriella, M.A.; Sirigampola, C.; Upasena, A.; de Silva, H.J.INTRODUCTION AND OBJECTIVES:Hepato-cellular carcinoma (HCC) is the sixth commonest cancer worldwide. We studied 105 consecutive patients with HCC in a single tertiary care centre. METHODS: North Colombo Liver Unit maintains a prospective database of HCC since September 2011. There were 105 entries by February 2013. Decision on the best form of treatment was taken at a multidisciplinary meeting. RESULTS: The median age at presentation was 63 years (range 12-79). Patients were predominantly male 93 (87%). Alcohol consumption above the safe limit was reported in 47 (45%). Hepatitis B surface antigen or C antibody was not detected in any of the patients. Background liver cirrhosis was evident in 59 (79%). Forty two (46%) patients had single nodular tumours while in 20 (21%) it was diffusely infiltrating. Portal vein invasion was seen in 22 (20 %). Median alpha-feto protein (AFP) level was 57.25 mg/ml (1.16- 94120 ng/ml; n=72). Twenty four (33%) patients had AFP level > 400u/l. Surgery was performed in 20 (19%), liver transplant in 2 (1.9%), radio frequency ablation or alcohol ablation in 8 (7.6%), trans arterial chemo embolization (TACE) in 44 (41.9%) and sorafmib was prescribed in four patients. Overall mean survival was 15 months. In the ‘no treatment’ group, mean survival was 4 months. Surgery group had a mean survival of 20 months. CONCLUSION: Hepatitis B is not a risk factor for HCC in Sri Lankans. Median survival without treatment is 4 months.Item Chracterisation of beta giobin mutations in Sri Lankan patients with betathalassaemia intermedia(Sri Lanka Medical Association, 2013) Perera, S.; Silva, D.P.S.I.; Hapugoda, M.; Wickramarathne, M.N.; Wijesirwardhena, I.; Efremove, D.G.; Fisher, C.A.; Weatherall, D.J.; Premawardhena, A.P.INTRODUCTION AND OBJECTIVES: Patients with beta thalassaemia intermedia account for a third of patients attending thalassaemia clinics in Sri Lanka. They show immense phenotypic diversity, the genetic basis for which has not been identified so far. Objective were to characterise beta globin gene mutations in Sri Lankan thalassaemia intermedia patients and to determine how it to influences disease severity. METHODS: We identified 64 thalassaemia intermedia patients from the five main thalassaemia centers; Anuradhapura (n= 6), Kuruncgala (n= 4), Ragama (n= 42), Badulla (n=7) and Chilaw (n=5). Their beta globin DNA sequences were analyzed using ABI PRISM 313lx genetic analyser. RESULTS: Of sixteen patients identified to be homozygous for beta mutations, eleven carried mild beta alleles, IVSI 5 G_C (n= 10) and a rare homozygous promoter mutation - 90 C_T (N=l). Other five were shown to have different types of severe iputations in homozygous state. Nearly half the sample (n=39) was heterozygous for beta mutations. Of them 33 showed mild to severe mutation in one of the alleles IVSI-5 G_C (n=12), IVSI-1 G_A (n= 11) were the commonest. Two patients who were hetcrozygones for beta mutation had a highly unstable Hb variant haemoglobin Mizuho causing severe haemolytic anacma. Hb variants Hb G-Szuhu and Hb G-Coushatta were identified in two patients. CONCLUSIONS: We identified types of beta mutations in some patients with thalassaemia intermedia, which account for the clinical severity.Item Paraspinal extramcduallry erythropoiesis- a rare cause of spinal cord compression: two case reports(Sri Lanka Medical Association, 2004) Arambepola, M.; Premawardhena, A.P.; de Silva, S.; Olivieri, N.; Weatherall, D.J.INTRODUCTION: Extrameduallry erythropoiesis (EME) is characterized by the appearance of haemopoietic tissue outside the bone marrow. When EME occurs, albeit rarely, outside the liver and spleen problems may occur. We describe two patients with haemoglobin E- [β thalassaemia who had spinal cord compression, due to EME masses which was reversed with treatment with hydroxyurea and hypertransfusion. PATIENT A: Was a 27year old with HbE -(β thalassaemia. His mean pre transfusion haemoglobin level was 5.5 g/dl. He presented with a six-month history of progressive numbness of his legs. On examination he was found to be paraparetic. The magnetic resonance scan (MRI) showed external compression of the spinal cord between the 4th and 8th thoracic vertebrae. Patient was put on a hypertransfusion regimen and hydroxyurea and made a complete recovery within 4 weeks. Patient B: Was a 9 year old boy with a diagnosis of Haemoglobin E [β thalassaemia who presented with paraplegia which had developed over 3 months. His spinal MRI showed two masses one in the upper thoracic vertebrae and the other at the 1st lumbar level. He was commenced on hydroxyurea and hypertransfusiion to maintain pre-transfusion haemoglobin at >9.5g/dl) and his neurological recover was remarkable. Six months later he had no neurological deficit. DISCUSSION: The above cases highlight the potentially dangerous complications of EME when it involves the spinal cord. They also highlight that even lesions which are sufficiently large to cause complete paraplegia are potentially reversible. Hypertransfusion, hydroxyurea, surgery and previously been used with varying success. The problem remains in deciding the optimal method of management.Item Development of a model of 3D imaging for the pre-operative planning of TaTME(Oxford University Press, 2018) Sahnan, K.; Pellino, G.; Adegbola, S.O.; Tozer, P.J.; Chandrasinghe, P.; Misovik, D.; Hompes, R.; Hart, A.L.; Warusavitarne, J.; Lung, R.F.BACKGROUND:Transanal TME (TaTME) is a new addition to the approaches in rectal surgery. TaTME requires advanced technical skills and, more importantly, knowledge of the pelvic structures, planes, and spaces as they are encountered moving cephalad from the perineum. We have developed a technique for producing 3D reconstructions of the anorectum and associated anatomy, to aid peri-operative planning and understanding of the anatomy crucial to TaTME surgery. METHODS: A patient was scheduled for single incision laparoscopy surgery (SILS) TaTME completion proctectomy and ileoanal pouch formation for ulcerative colitis. Standard axial T2-weighted Spectral Attenuated Inversion Recovery (SPAIR) and sagittal T2-weighted MRI sequences were obtained and digital imaging and communications in medicine (DICOM) images were imported into a validated open-source segmentation software.1 A specialist consultant gastrointestinal radiologist manually segmented the following structures: sphincter complex; rectosigmoid colon; levator plate, bladder, ureters, urethra and prostate. Each mesh was imported into another open-source system, MeshLab V1.3.3.1 as Stereolithography (STL) files for mesh smoothing to be applied. Individual labels were applied to each anatomical structure. RESULTS: Segmentation took approximately 15 min and an additional 10 min was required for smoothing and applying colour and transparency of the anatomical structures to emphasise surgically relevant anatomy. In Figure (A) provides an overview of the anatomy showing a relatively straight and posterior direction of the rectum as it descends into the pelvis; (B) provides insight into the relation between internal sphincter/rectum and the prostate/urethra. Distance between structures and relative proximity can be easily understood. Figure (C) shows the clearance between low rectum and both ureters, whilst (D) shows an anterior oblique view of the sphincter complex and the urethra. Conclusions :Surgeons currently use a combination of MRI scans, reports and discussion with radiologists to better understand anatomy. The use of these reconstructions in the MDT, in clinic and in the operating theatre could be useful to better communicate complex rectal anatomy, identify areas of difficulty and aid surgical planning. Our reconstructions present a present a cost-neutral solution to better visualise the anatomy they represent the first step towards innovation in TaTME surgery.Item Transanal minimally invasive proctectomy (TaMIP) in patients with Crohn’s disease: A cohort study from the TaTME international database(Oxford University Press, 2018) Pellino, G.; Sahnan, K.; Penna, M.; Adegbola, S.; Chandrasinghe, P.; Hompes, R.; Spinelli, A.; Warusavitarne, J.; International TaTME Registry CollaborativeBACKGROUND :Perianal Crohn’s disease (pCD) is a debilitating condition and despite the advances of medical and surgical treatment, a proportion of patients eventually require proctectomy for severe and/or refractory pCD. TaTME has several advantages, particularly in patients with low rectal cancer, narrow pelvis, previous radiation and bulky prostate. Aim of this study is to assess the feasibility of transanal minimally invasive proctectomy (TaMIP) within the International TaTME registry. METHODS:The TaTME registry was interrogated from 2014 to 2017 for benign conditions. Data were collected across 11 international centres submitted for patients who received TaMIP, with or without TME, for pCD. RESULTS:Forty patients (mean age 42.6 ± 13.8 years) underwent TaMIP for pCD with a median total operative time of 202 ± 102 min for the abdominal phase and 126 ± 58 min for the perineal phase. The majority of patients were female (67.5%; 27 of 40), 80.0% had active IBD at the time of surgery and average duration of follow-up was 4.4 ± 5.8 months. The commonest approach to proctectomy was an intersphincteric APE (30.0%; 12 of 40), with over half of cases (52.5%; 21 of 40) undergoing total intersphincteric dissection. The median height of the pursestring was 4.4 ± 2.4 cm and the most common extraction site was transanal (37.5%; 15 of 40). Intact specimens were found in 21% (8 of 38 TME) and major defects in four cases. During the abdominal phase, 29% (9 of 31) cases were converted-to-open procedure (all strategic) and 20% (8 of 40) during the perineal phase. Peri-operative complications during perineal dissection were: bleeding (12.5%, 5 of 40), incorrect plane (15%, 6 of 40), issues with smoke extraction (12.5%; 5 of 40) and maintaining pneumopelvis (10.0%; 4 of 40). Rectal perforations occurred in two cases at a median of 4 ± 2.8 cm from the anal verge. There were no urethral injuries and blood loss was < 100 ml in 45.4% (15.33) in our cohort. The average length of stay was 6 ± 5 days with no post-operative mortalities. The majority of patients (75.0%; 30 of 40) had no complications. Two-thirds of patients had Clavien-Dindo grade II complications (60.0%; 6 of 40) and one patient had a grade III complication. Late morbidity (>1 month) was available for 23 patients and perineal wound complications were identified in over half of patients (56.5%). CONCLUSIONS: pCD causes perineal fibrosis and chronic sepsis, which can make proctectomy an extremely complex operation (particularly when associated with proctitis), thereby increasing the risk of complications. TaMIP offers a safe and feasible minimally invasive approach to this subset of patients. Outcomes from TaMIP need to be compared with current techniques in order to discern the future role and training requirements for this promising new technique.