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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Cost evaluation, quality of life and pelvic organ function of three approaches to hysterectomy for benign uterine conditions: study protocol for a randomized controlled trial(BioMed Central, 2017) Ekanayake, C.; Pathmeswaran, A.; Kularatna, S.; Herath, R.; Wijesinghe, P.BACKGROUND: Hysterectomy is the commonest major gynaecological surgery. Although there are many approaches to hysterectomy, which depend on clinical criteria, certain patients may be eligible to be operated in any of the several available approaches. However, most comparative studies on hysterectomy are between two approaches. There is also a relative absence of data on long-term outcomes on quality of life and pelvic organ function. There is no single study which has considered quality of life, pelvic organ function and cost-effectiveness for the three main types of hysterectomy. Therefore, the objective of this study is to provide evidence on the optimal route of hysterectomy in terms of cost-effectiveness by way of a three-armed randomized control study between non-descent vaginal hysterectomy, total laparoscopic hysterectomy and total abdominal hysterectomy. METHODS: A multicentre three-armed randomized control trial is being conducted at the professorial gynaecology unit of the North Colombo Teaching Hospital, Ragama, Sri Lanka and gynaecology unit of the District General Hospital, Mannar, Sri Lanka. The study population is women needing hysterectomy for non-malignant uterine causes. Patients with a uterus > 14 weeks, previous pelvic surgery, those requiring incontinence surgery or pelvic floor surgery, any medical illness which caution/contraindicate laparoscopic surgery and who cannot read and write will be excluded. The main exposure variable is non-descent vaginal hysterectomy and total laparoscopic hysterectomy. The control group will be patients undergoing total abdominal hysterectomy. The primary outcome is time to recover following surgery, which is the earliest time to resume all of the usual activities done prior to surgery. In total, 147 patients (49 per arm) are needed to have 80% power at α-0.01 considering a loss to follow-up of 20% to detect a 7-day difference between the three routes; TLH versus TAH versus NDVH. The economic evaluation will take a societal perspective and will include direct costs in relation to allocation of healthcare resources and indirect costs which are borne by the patient. A micro-costing approach will be adopted to calculate direct costs from the time of presentation to the gynaecology clinic up to 6 months after surgery. Incremental cost-effectiveness ratios (ICER) will be obtained by calculating the incremental costs divided by the incremental effects (time to recover and QALYs gained) for the intervention groups (NDVH and TLH) over the standard care (TAH) group. DISCUSSION: The cost of the procedure, quality of life and pelvic organ function following the three main routes of hysterectomy are important to clinicians and healthcare providers, both in developed and developing countries.Item Experience on endoscopic management of Iatrogenic bile duct injuries following laparoscopic cholecystectomy(Quest Journals Inc., 2016) Hasan, R.; Abeysuriya, V.; Navarathne, N.M.M; Wijesinghe, J.A.A.S.INTRODUCTION: Clinically significant bile leaks due to iatrogenic bile duct injuries following laparoscopic cholecystectomy is not infrequent. Endoscopic procedures have become the treatment of choice for the management of biliary leakage following iatrogenic bile duct injuries. GENERAL OBJECTIVE: To assess the therapeutic outcome of endoscopic therapy of the patients who had iatrogenic biliary injury and biliary leakage following laparoscopic cholecystectomy. METHODS: Prospective descriptive study was performed on32 patients who underwent therapeutic endoscopic procedures for iatrogenic injuries following laparoscopic cholecystectomy for symptomatic gall stone disease in the National Hospital of Sri Lanka. Bile leaks were diagnosed by the presence of persistent abdominal pain, jaundice with cholangitis, abdominal distension and persistent bile flow to the skin surface through and around the existing drains. All the patients underwent abdominal ultra-sonography or CT scan. The presences of bile leaks were confirmed by ERCP. RESULTS: Patients who had bile leaks were diagnosed by, persistent abdominal pain 30 % (9/30), jaundice with cholangitis 6.6% (2/30), abdominal distension 16.6% (5/30), and persistent bile flow to the skin surface through and around the existing drains, 46.6%(14/30). The median duration between initial surgery and detection of bile leak was 3 days (range 0-12 days). Twenty-three patients 76.6% had high-grade bile leaks and 7(23.4%) had low-grade leaks. The iatrogenic bile duct injuries were; cystic duct injuries 10(33.3%) (3 high grade: 7 low grade bile leaks), the common bile duct injuries 16(53.3%) and the right hepatic duct injuries 4(13.3%). All patients were subjected to therapeutic procedures, which consisted of Sphincterotomy with stone extraction followed by biliary stenting (10 patients), Sphincterotomy with biliary stenting (15 patients) and Sphincterotomy alone (5 patients). Bile leaks stopped in all patients at a median of 4 days (range 2-14 days) after endoscopic interventions. Drains were removed at a median duration of time of 6 days (range 5-16 days) after endoscopic procedures. Stents were removed at a 6-8 weeks’ interval. Three (3/6) who had low-grade cystic duct bile leaks, who underwent Sphincterotomy alone, had mean 3.6±0.88SEM days for complete cessation of bile leakage from the drains. Other three patients (3/6) who underwent Sphincterotomy and stent placement had mean of 3.0±0.57SEM days cessation of bile leakage (P=0.52, t-test). All high-grade bile leak (3/10) patients were offered Sphincterotomy and stent placement and had mean 6.8±0.5SEM days for complete cessation of bile leakage from the drains. CONCLUSIONS: Iatrogenic bile duct injuries occur commonly in the common bile duct. Residual stones are found in one-third of cases. No significant difference in healing was seen between the patients who had low-grade bile leaks due to cystic duct injuries and whom were offered either Sphincterotomy alone and Sphincterotomy and stenting.Item Postoperative adhesions and small bowel obstruction - New insights(College of Surgeons of Sri Lanka, 2000) Deen, K.I.Patients having surgical procedures below the level of the transverse colon are at risk of adhesion formation. Small bowel obstruction is the commonest presenting feature of adhesions, is estimated that up to 10 percent of patients undergoing laparotomy will require re-operation for adhesions in a life time. Economic implications, the nature of adhesions formation and its aetiology to formulate methods of prevention is discussed in the articleItem Closed loop small bowel obstruction caused by a retained faecolith complicating acute appendicular perforation(College of Surgeons of Sri Lanka, 1999) Gunawardena, P.A.H.A.; Deen, K.I.Case report of an 11 year old boy presented with a 36 hour history of central abdominal pain which localized in the right iliac fossa, vomiting and fever. A diagnosis of appendicitis was made. He developed abdominal distension and vomitting on the third post-operative day. The primary cause of the complication was the retained faecolith which was not found at the time of apendicectomy, despite extension.Item Prospective clinical and functional audit of emergency and elective haemorrhoidectomy(College of Surgeons of Sri Lanka, 1999) Deen, K.I.; Paris, M.A.S.; Ariyaratne, M.H.J.; Samarasekera, D.N.Background Traditionally, prolapsed thrombosed haemorrhoids have been treated conservatively because of the popular belief that the incidence of complications are greater after emergency operation compared with elective operation for haemorrhoids. An audit comparing emergency operation for prolapsed thrombosed haemorrhoids with elective operation for third and fourth degree haemorrhoids is presented. Patients and methods 104 patients (82 male, median age 47 years, range -18 to 80 years) undergoing emer- gency (65) or elective haemorrhoidectomy (39) were evaluated for complications after operation, hospital stay and postoperative bowel function which was assessed at 3 months by mailed questionnaire. Results Trainees performed as many operations as consultants (trainee 48 (46 percent) vs. consultant 56 (54 percent) although consultants performed more emergency operations (trainee-20, consultant-45). Postoperative complications were seen in 13 (12percent) ; emergency-9 versus elective-4 (p=0.69). There was no difference in complications after trainee performed operation (8) compared with operation by consultant (5). Median (range) duration of hospital stay after emergency operation was 2 days (1-17) compared with elective operation -2 days (1-10). A subset of 41 patients responded to a questionnaire on bowel function at 3 months: 5 of twenty five (20 percent) after emergency haemorrhoidectomy and 2 of sixteen (12.5 percent) after elective haemorrhoidectomy reported transient incontinence to gas or stool up to 3 weeks after operations but none were incontinent at 3 months. After emergency haemorrhoidectomy, 9 (36 percent) reported a sense of anal narrowing compared with 2 (12.5 percent) after elective haemorrhoidectomy (p=0.13). None required corrective surgery for anal stenosis. Conclusion There were no significant differences in complications, hospital stay and postoperative bowel function in patients after emergency and elective haemorrhoidectomy. Emergency haemorrhoidectomy is likely to result in low morbidity when undertaken by trained persons.Item Histological assessment of the distal 'doughnut' in patients undergoing stapled restorative proctocolectomy with high or low anal transection(1994) Deen, K.I.; Hubscher, S.; Bain, I.; Patel, R.; Keighley, M.R.A non-randomized prospective study of 38 patients, 32 with ulcerative colitis and six with familial adenomatous polyposis (FAP), who underwent high or low anal transection during stapled restorative proctocolectomy was undertaken. The median (range) height of the staple line 6 months after operation was 5.2 (3.2-6.0) cm after high transection compared with 2.9 (1.8-3.6) cm after low transection. Nineteen of 20 patients after high anal transection had columnar epithelium in the distal 'doughnut' versus 16 of 18 after low transection. Active colitis was present in 12 of 19 'doughnuts' in patients with high anal transection and columnar mucosa and in seven of 16 after low transection. Nine patients (high transection two, low transection seven; P < 0.05) had striated muscle in the stapled distal 'doughnut'. Dysplasia was found in the resected colon in one patient with ulcerative colitis and adenocarcinoma in two colectomy specimens (ulcerative colitis, one; FAP, one). No dysplasia or carcinoma was seen in any of the 'doughnuts' from patients with ulcerative colitis. Four patients with FAP (high transection, two; low transection, two) had microadenoma in the distal 'doughnut'. Despite attempts to place a stapled pouch-anal anastomosis below the anal transition zone, it was not possible to remove columnar mucosa completely from the remaining anal canal in most patients (16 of 18). High anal transection and pouch-anal anastomosis should be the preferred option in restorative proctocolectomy, as a dentate-line anastomosis may not fully eliminate columnar epithelium and may involve resection of some of the external sphincter.Item Effects of the faecal stream and stasis on the ileal pouch mucosa(British Medical Assosiation, 1991) de Silva, H.J.; Millard, P.R.; Soper, N.; Kettlewell, M.; Mortensen, N.; Jewell, D.P.This study aimed to investigate the effects of the faecal stream and stasis on the mucosa of ileal pouches. Nine patients were followed up. Two pouch biopsy specimens were obtained from each at the time of pouch formation, ileostomy closure, and three, six, and 12 months after operation. None developed pouchitis. Two pouch biopsy specimens each were also obtained from 20 patients (six with pouchitis), whose pouches had been functioning for at least a year and in whom pouch evacuation was assessed by radioisotope labelled artificial stool. Biopsy specimens were assessed for the degree of acute and chronic inflammation, mucin type (high iron diamine-alcian blue stain), a morphometric index of villous atrophy (villous height:total mucosal thickness), and crypt cell proliferation (using the monoclonal antibody Ki67). Mean values from the two biopsy specimens were obtained for each parameter. After three months of pouch function, the scores for acute and chronic inflammation, the degree of sulphomucin, and crypt cell proliferation were significantly higher, and the index of villous atrophy was significantly lower (indicating a greater degree of villous atrophy), than at pouch formation or at ileostomy closure. The values at pouch formation and ileostomy closure were similar. For all parameters, the changes seen at six and 12 months were not significantly different from those at three months. There was no significant correlation between the efficiency of pouch evacuation and any of the mucosal changes. It is concluded that exposure to the faecal stream is necessary for changes to take place in the pouch mucosa, although the amount of stasis, as measured by radioisotopic evacuation studies, seems to be irrelevant. The mucosal changes occur soon after ileostomy closure and then remain stable for at least one year.