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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Transanal minimally invasive proctectomy with ileal pouch anal anastomosis (Ta-IPAA) in patients with ulcerative colitis: a cohort study from the TaTME international database(Oxford University Press, 2018) Pellino, G.; Sahnan, K.; Penna, M.; Adegbola, S.; Chandrasinghe, P.C.; Spinelli, A.; Hompes, R.; Warusavitarne, J.; International TaTME Registry CollaborativeBACKGROUND:Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) can achieve excellent outcomes in terms of function and quality of life, for patients refractory to medical therapy for ulcerative colitis (UC). Minimally invasive approaches are gaining momentum and evolution of the transanal approach to rectal surgery has led to broadening its use, from total mesenteric excision (TME) in cancer, to include IPAA in ulcerative colitis. In this study, we analysed the short-term outcomes of transanal minimally invasive IPAA (Ta-IPAA) within the International TaTME registry.METHODS:The TaTME registry, a secure online database was interrogated from 2014 to 2017 for benign conditions. Data were collected across 11 international centres submitted for patients who received Ta-IPAA, with or without TME, for UC. RESULTS:Sixty-nine patients with a median age of 38.6 ± 12.2 years were entered into the database. The majority of patients were male (75.4%; 52/69) and had a median BMI of 24.4 ± 4 kg/m2. There were no smokers in our cohort. Over half of the patients (53.6; 37/69) had active IBD at the time of surgery and 12 patients were on steroids at the time of the surgery. A proctectomy in the TME plane was the most common approach (75.4%; 52/69), a close rectal dissection was chosen in 13 patients and in four patients the plane was not specified. A simultaneous abdominal/TaTME approach was performed in over two-thirds of cases (69.6%; 48/69) and most surgeons either used an SILS approach (46.4%; 32/69) or a laparoscopic approach (40.6%; 28/69). A pursestring was used by the majority (87%; 60/69) at a median height of 4 ± 1.6 cm. The majority of pouches were created using a stapler (85.1%; 57/69) at a median distance of 2.9 ± 1.5 cm from the anal verge. Median operative time was 311 ± 126 min. Under a quarter of abdominal operations were converted (24.6%; 14/57) compared with four cases (5.8%) in the perineal phase. The median length of postoperative stay was 10 ± 6 days and three patients had a re-operation. There were no mortalities. Three patients (4.3%) had an anastomotic leak and two patients (2.9%) had collections. Late morbidity (>1 month) was available in 31 patients and of these seven patients (22.6%) had a stricture. CONCLUSIONS: Transanal minimally invasive proctectomy with ileal pouch anal anastomosis is feasible and safe in patients with UC. It is also associated with relatively low rates of re-operation and anastomotic leakage.Item Single Incision Laparoscopic Surgery (SILS) as surgical option in Crohn's disease: our experience(Oxford University Press, 2018) Leo, C.A.; Samaranayake, S.F.; Hodgkinson, J.D.; Santorelli, C.; Chandrasinghe, P.C.; Warusavitarne, J.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 Detection of incidental thyroid carcinoma is significantly higher in goiters with background thyroiditis(College of Surgeons of Sri Lanka, 2015) Pradeep, I.H.D.S.; Chandrasinghe, P.C.; Wijewardana, B.D.A.N.; Dissanayaka, D.M.C.D.; Fernando, F.R.; Buddika, U.A.; Kannangara., K.R.INTRODUCTION: Incidence of 'incidental thyroid carcinoma' (ITC) is reported to be 3 % to 16% in operatively treated benign thyroid diseases. This study analyses the results of a single surgeon performing total thyroidectomy for benign diseases and is the continuation of the study preliminary published in 2009. MATERIAL AND METHODS: All patients, who underwent total thyroidectomy for benign diseases at the unit from January 2003 to October 2014 were included. All patients had preoperative ultrasonography and fine needle aspiration cytology (FNAC). Diagnosis of ITC was based on post op histopathological reporting. Test of proportions with a P value of 0.05 was considered significant. RESULTS: Total thyroidectomy specimens of 449 (Median age- 37 years; range: 25 - 65 years, female – 74.07 %) patients were analyzed. ITC was detected in 6.01% (n=27) of patients. Papillary carcinoma was the commonest (62.96%) subtype. There were 8 (29.62%) follicular and 2 (7.4 %) medullary cancers. Males had a significantly higher proportion of ITC (Male: ITC/benign = 15% Vs Female: ITC/ benign = 5%; P= 0.02). Specimens with ITC reported a significantly higher rate of background thyroiditis (ITC = 33% Vs benign = 15 %; P= 0.02). ITC was not significantly associated with a family history (P= 0.7887). Postoperative transient hoarseness was observed in 3.56%and hypocalcaemia in 10.69%. CONCLUSIONS: A significant proportion of 'benign' goiters may harbor ITC, especially with background thyroiditis. With emerging evidence to support total thyroidectomy with low morbidity it may be prudent to offer total thyroidectomy for benign goiters with background thyroiditis.Item Risk factors for locally advanced cancer associated with ulcerative colitis: Results of a retrospective multicentric study in the era of biologics(Elsevier, 2020) Rottoli, M.; Tanzanu, M.; Di Candido, F.; Colombo, F.; Frontali, A.; Chandrasinghe, P.C.; Pellino, G.; Frasson, M.; Warusavitarne, J.; Panis, Y.; Sampietro, G.M.; Spinelli, A.; Poggioli, G.BACKGROUND: Patients affected by ulcerative colitis (UC) are more likely to develop colorectal cancer, and are often diagnosed with lymph node involvement (N+) at surgery. AIM: To identify the risk factors for N+ cancer in UC patients. METHODS: Patients undergoing surgery from 2001 to 2018 in six European tertiary centres were included. N+ patients were compared to the control group (N-) for clinical variables. The evaluation of risk factors for N+ was assessed using univariate and multivariable logistic regression analyses. RESULTS: A total of 130 patients were included. Median duration of disease was 21 years (1-52). Forty patients (30.8%) were N+ at surgery. Eighteen (13.8%) developed cancer within 10 years from the onset of UC. Younger age at surgery (Odds ratio -OR- 0.96, p = 0.042), left colon location (OR 2.44, p = 0.045) and the presence of stricture (OR 5.07, p = 0.002) were associated with N+. CONCLUSION: Location in the left colon, presence of strictures and younger age strongly correlated with a higher risk of N+ cancer, which could develop before the starting point of surveillance. Duration, extension and severity of disease were not associated with N+. These results should be considered in the evaluation of risk of advanced cancer in UC patients. KEYWORDS: Cancer; Lymph nodes; Ulcerative colitis.Item Hypocalcemia and hoarseness following total thyroidectomy for benign disease: Relationship of incidence to the size of the gland(Jaypee Brothers Medical Publishers (P) Ltd, 2011) Fernando, R.; Chandrasinghe, P.C.; Bandara, M.; Renuka, M.B.S.; Athulugama, N.S.INTRODUCTION: Total thyroidectomy is considered as the standard surgical procedure for most malignancies and benign disease involving both lobes of the thyroid gland. Postoperative complications are likely to be commoner when the thyroid gland is large in size due to the alteration of structural anatomy. METHODS: Postoperative complications of 102 patients who underwent total thyroidectomy for benign disease, by the same surgeon, were analyzed. Patients were prospectively followed up and presence of hoarseness and hypocalcemia, both transient and temporary, were compared with the weight of the gland. RESULTS: Fourteen patients developed hypocalcemia of which 12 (11.7%) had transient and 2 (1.96%) had permanent deficiencies. Eight patients developed hoarseness following surgery of which seven (6.86%) had transient and only one (0.98%) had permanent hoarseness. A mean thyroid weight of 91.78 gm was observed in the uncomplicated group. Those who developed postoperative hypocalcemia and transient hoarseness had a mean thyroid weight over 100 gm. One patient, who had a thyroid weighing 195 gm developed permanent hoarseness due to RLN injury. CONCLUSION: There is no statistically significant difference in the incidence of transient RLN and transient or permanent hypocalcemia. With increased size of the thyroid gland increased rate of complications was observed with a mean thyroid weight above 100 gm. There may be a significant risk of permanent RLN injury when the thyroid gland is enlarged over 10 times (closer to 200 gm) its normal size. © Jaypee Brothers Medical Publishers (P) Ltd. AUTHOR KEYWORDS: Complications; Size of the gland; Thyroidectomy. INDEX KEYWORDS: adult; aged; article; controlled study; female; goiter; hoarseness; human; hypocalcemia; incidence; major clinical study; male; nerve injury; postoperative complication; recurrent laryngeal nerve injury; risk assessment; thyroid weight; thyroidectomyItem Incidental thyroid carcinoma in benign thyroid disease: A Cohort study(World Journal of Endocrine Surgery., 2018) Pinto, D.; Munasinghe, N.; Chandrasinghe, P.C.; Fernando, R.ABSTRACT: AIM: An incidental thyroid carcinoma (ITC) is a thyroid malignancy that is not clinically or cytologically detected preoperatively. The incidence of ITC is between 10% to 20% in the literature. A study was undertaken to assess the incidence of ITC in patients undergoing total thyroidectomy for benign disease of the thyroid to University Surgical Unit, North Colombo Teaching Hospital (NCTH), Sri Lanka. MATERIALS AND METHODS: Prospective cohort study was undertaken from November, 2002 to October, 2015. Patients with palpable thyroid nodules were assessed with fine needle aspiration cytology (FNAC) and ultrasound scan (USS) to ascertain benign thyroid disease (BTD). Hormone assays were conducted to detect thyroid status. All patients with BTD who underwent total thyroidectomy were included in the study. Histopathological assessments were made by a panel of pathologists. Patients with autoimmune thyroiditis (AIT) were excluded due to the known association with malignancy of the thyroid. Post-thyroidectomy histopathological diagnoses were collected prospectively and patients with ITC were identified. Statistical analysis was done using statistical package for the social sciences (SPSS) software, version 20. RESULTS: Hundred and sixty seven patients (n = 167) who fulfilled the inclusion criteria were analysed (Male–20, female–147, median age = 40.25 year, range 28 year–62 year). ITC was found in 19 patients with an incidence of 11.38%. No significant association was noted with morphology, biochemical status of the thyroid or gender. CONCLUSION: Incidence of ITC is 11.38% in this cohort. Incidence of ITC being approximately 1:10 emphasizes the need to consider total thyroidectomy in the management of BTD.Item Pre-operative hypoalbunaemia is associated with poor overall survival in rectal cancer.(The College of Surgeons of Sri Lanka, 2012) Chandrasinghe, P.C.; Ediriweera, E.P.D.S.; Kumarage, S.K.; Deen, K.I.INTRODUCTION: Serum albumin is a marker of nutrition and inflammation. It has recently emerged as a predictor of outcome after surgery for rectal cancer. Our aim was to evaluate if pre-operative serum albumin would predict survival after resection for rectal cancer. METHOD: 226 Patients with rectal cancer of all stages undergoing resection with curative intent were studied. Kaplan-Meier curves analysed survival based on a pre-operative albumin level of <35g/L vs. >35g/L. We sought for significant associations of survival with age, sex, stage, tumour site, use of neoadjuvant chemoradiation, microscopic positive resection margins (R1 ), differentiation, angio, peri-neural, and lymphovascular invasion using individual variable analysis. Multifactorial analysis was performed using type III analysis with Weibull hazard model and Cox-proportional hazard model. Significance was assigned to a P value <0.05. RESULTS: Of 226 patients (median age- 59 years; range 19 - 88, Male - 54%), forty five (20%) had an albumin level < 35g/L and was associated with a poor overall survival (P=0.01). Mean survival in months for <35g/ s. >35g/L was 64.7 (SE - 9.3) vs. 95.8 (SE - 7.0). Individual variable anaysis revealed age, circumferential margin, stage,, perineural, lymphovascular and angio invasion to be also significant. With multifactorial analysis hypo-albunaemia (HR= 0.58, P=0.03), advanced stage (HR= 2.0, P < 0.01 ) and R1 circumferential margin (HR= 2.2, P < 0.01) remained significant. CONCLUSION: Preoperative hypoalbunaemia is an independent risk factor for poor overall survival in rectal cancer. Advanced tumour stage and R1 circumferential margin were the other associations with poor survival.Item Lateral approach to thyroid(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2016) Dissanayake, D.M.C.D.; Kumarasinghe, K.A.P.R.; Pinto, M.D.P.; Amaraweera, P.C.; Munasinghe, B.N.L.; Chandrasinghe, P.C.; Fernando, R.BACKGROUND: Thyroidectomy is the commonest endocrine surgical procedure, undertaken throughout the world. Re-do thyroidectomies are challenging procedures with a higher morbidity rate. Lateral approach to thyroid (LATT) is a good alternative to the standard midline exploration. The key to the technique is the development of the natural tissue plane between the strap muscle and the ipsilateral sternocledomastoid muscle to explore the thyroid bed. OBJECTIVE: This study was done to assess the efficacy, safety and complications of LATT. METHODS: Data on patients undergoing LATT in Professorial Surgical Unit, Colombo North Teaching Hospital, Ragama from 2008 to 2015 was collected prospectively and analyzed. All procedures were done by a single surgeon. RESULTS: A total 36 LATTs were done. Data from 32 people were collected as 4 patients were lost to follow up. 29 (90.6%) were females and 3 (9.4%) were males. Age ranged between 28 and 61 (Median 43.37) years. Three (9.4%) LATTs were for parathyroid explorations and out of which one (3.1%) was for redo parathyroid explorations. Nine (28.1%) were redo thyroidectomies and 18 (56.2%) were mini incision thyroidectomies with lateral approach. Hemi thyroidectomies were performed for 28 (87.5%). Bilateral explorations done for 3(9.4%) patients and 4(12.5%) lateral approaches done for completion thyroidectomies were for follicular malignant lesions. Transient clinical hypocalcaemia was noticed in 4 (12.5%) patients and 1 (3.1%) developed hoarseness of voice which was temporary. None of them had complications such as haematoma or post-surgery stridor. CONCLUSIONS: LATT is a safe alternative to the standard approach, for re-explorative thyroid surgery.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 Clopidogrel and surgical intervention: A point to ponder(College of Surgeons of Sri Lanka, 2011) Chandrasinghe, P.C.; Liyanage, C.A.H.No Abstract Available