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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Idiopathic pancreatitis: Is it a consequence of an altering spectrum of bile nucleation time?.(BMJ Publishing Group, 2009) Abeysuriya, V.; Deen, K.I.; Navaratne, N.M.M.; Kumarage, S.K.INTRODUCTION: The pathogenesis of idiopathic pancreatitis (IP) remains poorly understood. Our hypothesis is that IP is a sequel of the microcrystallisation of hepatic bile. AIMS AND METHODS: A prospective case-control study compared 55 patients (symptomatic cholelithiasis, 30: 14 men, 16 women, median age 36 years, body mass index (BMI) 25.1 +/- 0.33 kg/m2; gallstone pancreatitis, nine: six women, three men, median age 35 years, BMI 24.86 +/- 0.23 kg/m2; and idiopathic pancreatitis, 16: seven women, nine men, median age 34 years, BMI 23.34 +/- 0.2 kg/m2) with 30 controls (15 men, 15 women, median age 38 years, BMI 24.5 +/- 0.23 kg/m2, undergoing laparotomy and who had normal gallbladder and no demonstrable stones on ultrasonography). Ultrafiltered bile from the common hepatic duct in patients and controls was anaerobically incubated and examined by polarised light microscopy, for nucleation time (NT). Ethical approval was obtained. RESULT(S): Patients were similar to controls. Mean NT in all groups of patients was significantly shorter than controls (established gallstones cumulative mean NT, 1.73 +/- 0.2 vs controls, 12.74 +/- 0.4 days vs, p = 0.001, t test and IP patients mean NT, 3.1 +/- 0.24 days vs controls, 12.74 +/- 0.4 days, p = 0.001, t test). However, NT in those with IP was significantly longer compared with those with established gallstones (mean NT in IP, 3.1 +/- 0.24 SEM days, vs cumulative mean in patients with established symptomatic gallstones, 1.73 +/- 0.2 days, p = 0.002, t test). CONCLUSION(S): NT in bile in patients with IP is abnormal and is intermediate in NT of lithogenic and non-lithogenic bile.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 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 A new on-table colonic irrigation device- results of a pilot study(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Sabaratnam, V.Y.; Deen, K.I.; Kim, J.H.INTRODUCTION: Management of left colon obstruction either by primary anastomosis or by diversion almost always requires decompression and lavage of the colon. This will facilitate colonic mobilization primary anastomosis, delivery of stoma without contamination and tension free abdominal wound closure. Objective: To examine the results of a new devise that enables on-table he ability to perform concomitant colonoscopy. METHODS: 8 patients (5 males, median age 44 years; range 23 to 78 years) underwent resection of left colon cancer (I), recto-sigmoid cancer (3), and rectal cancer (4). Four were obstructing tumours, while in the remaining 4, full bowel preparation with polyethylene glycol was deemed risky hence requiring intraoperative preparation. The device consisted of a screw-on plastic tube (diameter- 35mm), with an inlet valve and a single outlet for faecal effluent. Following complete irrigation. on table colonoscopy was possible through the inlet. Features assessed were extra intestinal faecal leakage, bowel perforation, irrigation time, volume infused and total time taken. RESULTS: There was no technical problem with introduction and securing the device to the bowel wall. Leakage of faeces was not encountered in a single case. Total time taken for irrigation was (median. range) 20 minutes (8-20), colonoscopy time was 8 and 10 minutes respectively in 2 patients who underwent colonoscopy. 5 underwent primary anastomosis whilst 2 underwent Hartmann operation and I had a Paul-Mickulicz procedure. No anastomotic leakages were detected clinically. No faecal contamination was encountered. All were commenced on oral fluids on day 1 after operation, median time to pass flatus was 2 days (1-3) and discharge from the hospital was (median. range) 8 days (6-12). CONCLUSION: This disposable irrigation device guarantees a complete bowel seal during on-table lavage and ensures complete decompression with bowel cleansing, enabling safe anastomosisItem Accuracy of histopathology reporting in colorectalcancer (crc): we need a proforma(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Siriwardana, P.N.; Rathnayaka, G.; Deen, K.I.INTRODUCTION: The quality of a histopathology report in CRC will determine prognosis and the need for adjuvant therapy. OBJECTIVE: To evaluate the completeness of pathology reports in colorectal cancer.METHODS: In 82 consecutive patients (rectal cancer 47, colon cancer 35) based on the minimum data set by the Royal College of Pathologists, UK. Pathology reports were reviewed by a single person who looked for 17 pathology data sets for colon cancer and 15 for rectal cancer. Completeness of reporting(%) was classified as 40 - 50%, 60 - 70% or 80 - I 00%. RESULTS: 47 of rectal cancer group, 5 (11%) reports were 40-59% complete and 23 (49%) and 19 (40%) were 60-79% and 80-100% complete respectively. In the colon cancer group 04 ( 11.5%), 13.(37%) and 18 (51.5%) were in the categories of 40-59%, 60-79% and 80-100% respectively. The presence or absence of tumour at the resection margin was reported in 91.5%. Information on the distance of tumour to distal resection margin was present in 68% of reports. Apical node involvement was commented in 33%. CONCLUSION: There is a wide variation in the quality of pathology reports in colorectal cancer. We have found a lack of vital data in up to two thirds of the reports.Item Abdominal suture rectopexy without large bowel resection for rectal prolapse does not result in constipation: data from prospective bowel function evaluation, anorectal physiology and transit studies(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Sabaratnam, V. Y.; Rathnayake, G.; Deen, K.I.INTRODUCTION: Traditionally, suture rectopexy has been combined with sigmoid resection for rectal prolapse to prevent postoperative constipation. Furthermore, preservation of lateral ligaments will not result in constipation. Suture rectopexy alone without resection, is being popularised. OBJECTIVE: To study the influence of suture rectopexy without resection on colonic transit and postoperative constipation. PATIENTS AND METHODS: Forty-six patients (median (range) age 32(19-82) years) with rectal prolapse underwent suture rectopexy alone without division of lateral ligaments from March 1999. Prospectively, bowel function and anorectal physiology (ARP) were evaluated before and after surgery in a subset of 15 patients. Follow up (median, range) has been 12 (1-42) months. RESULTS: Follow up was complete in 36 patients. Recurrent prolapse was seen in 5 (full thickness 3 (8.3%); mucosa! prolapse 2 (5.5%)). Physiological data in a subset of 15 patients revealed no significant difference in anorectal physiology before and 3 months after the operation (table). Similarly there was no significant difference in the rate of evacuation of transit markers on day 3 and 5. Maximum resting pressure (median and range) was 25(7-50) mmHg and 33.2(7- 80, P value 0.026) before and after surgery. The median (range) maximum squeeze pressure were 67.5(19-i30) and 90(28 - 157, P 0.!64) before and after surgery. The maximum tolerable volume (ml) was 230 ( ! 80 -340) before surgery and 200 (50-290) after surgery (P. 0.139). Transit (as an excretion percentage) was 100% before and after surgery (P = 0. 197). CONCLUSION: Abdominal suture rectopexy without resection for rectal prolapse improves constipation and does not result in significant change in colonic transit. We recommend this procedure either by open operation or by laparoscopy.Item Detection of micrometastasis in LYMPH nodes using reverse transcription polymerase chain reaction (RT-PCR) for Cytokeratin 20 (CK-20): are we under staging rectal cancer(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Wijesuriya, S.R.E.; Kuruppuarachchi, K.O.R.; Deen, K.I.; Weerasinghe, A.; Ramesh, R.; Hewavisenthi, J.INTRODUCTION: Postoperative adjuvant chemotherapy in rectal cancer is determined by the presence of metastases in lymph nodes. Detection of LYMPH node metastases is routinely performed by light microscopy. Conventional histology may not detect all metastases especially following neoadjuvant therapy (NAT). CK-20 is a cytokeratin known to be specific to colonic epithelium which may help detection of rectal cancer metastases in lymph nodes. OBJECTIVE: To detect micro metastases in lymph nodes in patients with rectal cancer. staged node negative by routine histology. METHODS: Mesenteric lymph nodes from patients who have undergone NAT for rectal cancer were harvested during surgery. Nodes were bisected and one half sent for Haernatoxylin and eosin (H&E) staining and evaluated by a single pathologist, while the other half was examined for CK 20 by RT-PCR. The technique was validated by testing lymph nodes with known metastases and nodes from patients without cancer. 21 lymph nodes from 6 patients (median age 46 years, range 25-55) which were negative for tumour deposits by H&E stain were assessed for micro metastases. RESULTS: All 2 l nodes which were histologically negative for metastases were positive for micro metastases (positive predictive value l 00%) whilst 2 nodes with known metastases were positive for CK-20, 3 nodes from non-cancer patients were negative for CK-20. CONCLUSION: Detection of CK-20 is accurate in identification of micro metastases of rectal cancer to lymph nodes. Assessment of nodes by H&E histology risks under staging lymph node micro metastases in rectal cancer.Item The prevalence of urinary and sexual dysfunction following rectal excision(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Perera, M.T.P.R.; Ratnayake, G.; de Silva, G.S.; Deen, K.I.INTRODUCTION: With improved survival following rectal excision for cancer and focus on nerve sparing operation, recent interest has centered on urinary and sexual dysfunction. OBJECTIVE: To identify the prevalence of urinary and sexual dysfunction in patients after rectal excision.METHODS: 43 patients (17 male, median age 55 years, range 24 to 74) underwent anterior resection (23), restorative proctocolectomy (13), abdomino-perineal excision (04), and rectal excision as part of subtotal colectomy (03). Structured interview was performed at least 03 months after stoma closure. Data were compared with age and gender matched controls. Statistical evaluation was by the McNemar test and test of proportions. Significance was assigned to a P value <0.05. RESULTS: Median (range) duration after operation was 28 months (8 - 84). Preoperatively, urinary function was similar in patients and controls. After operation, a significant number of patients had transient urinary dysfunction [urinary symptoms, pre vs post; 07 (16%) vs. 28 (65%) p< 0.05]. Long-term prevalence of poor stream and urinary hesitancy after operation were significant [poor stream; pre vs. post- 6 vs. 16: P=0.006 and hesitancy; pre vs. post - 6 vs. 18: P=0.004]. Sexual function was also significantly reduced in patients after operation [sexually active; pre vs. post- 29 vs. 17: P=0.004]. Fourteen (9 male,5 female) of 29 (48%) reported transient abstinence from sexual activity 6 months after operation whilst eight of 29 (27 .5%) reported more permanent abstinence (lack of interest-6, dyspareunia-1, erectile failure/ retrograde ejaculation - 7). CONCLUSION: Counseling regarding sexual and urinary function should be an integral part of the pre-operative work-up in patients having rectal excisionItem Result of trans-anal inter-sphincteric resection(taisr) combined with total mesorectal excision (ime) and colo- anal anastomosis for distal rectal cancer(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Deen, K.I.; Rajendra, S.; Hewavisenthi, J.; Perera, M.T.P.R.; Satheesan, B.INTRODUCTION: The treatment of distal rectal cancer is controversial. Most prefer abdomino-perineal excision because of the potential for wide local clearance. Staplers have limitations in restorative resection for distal rectal cancer. OBJECTIVE: To audit the results ofcombinning TAISR with TME and handsewn colo-anal anastomosis for distal rectal cancer. METHODS: I 08 Patients (45 male, median age 59 years, range -22-87) with rectal cancer underwent abdomino-perineal resection -15 ( 14%), Hartmann's procedure - 7 (6.5%), anterior resection -39 (36%) and anterior resection or total colectomy with TAISR and colo-anal anastomosis -47 (43.5%). TAISR was undertaken for tumours between O and 7 ems from the anal verge for rectal cancer with familial polyposis. Data sought were; overall survival, local clearance (RO- clear margins; R l-at least one involved margin) and local recurrence at 24 month median follow up (range- 5 -89 months). Data in the TAISR group were compared with the rest by the test for proportions. Significance was assigned to p<0.05. RESULTS: For the entire group, operative 30-day mortality was 4.6%. Overall disease related mortality at 24 months was 18%. For the entire group, curative resection (RO) was achieved in 93(86%) { TAISR- 39 of 47 (83%) vs. resection without TAJSR- 54 of61(88.5%)- P>0.05}. Overall, local recurrence was seen in 8 (7.4%) {TAISR - 4 of 47 (8.5%) vs. resection without TAISR- 4 of 61 (6.5%). CONCLUSION: There was no significant difference in achievement of free resection margins and local recurrence, in the-short-term, employin anal inter-sphincteric resection with TME for distal rectal cancer co with resection for proximal rectai cancer. Trans-anal inter-sphincteric r with TME for distal rectal cancer is safe in trained hands and should preferred choice in surgical management of distal rectal cancer.Item Training in laparoscopic cholecystectomy: lessons from a structured training programme(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Sabaratnam, V.Y.; Deen, K.I.INTRODUCTION: Data have shown that structured training in Laparoscopic cho!ecystectomy (LC) reduces morbidity and mortality related to the learning curve. OBJECTIVE: This study was performed to evaluate morbidity, mortality and to provide insight into steps in operation that requires trainees assistance in LC. METHODS: Five higher surgical trainees with no previous laparoscopic experience were evaluated from July 2000. Each trainee should have held a camera during operation, learnt the skills of Veress needle insertion and acquired hand-eye coordination on a laparoscopic trainer. The operation was divided into 4 steps; I. Creation of pneumoperitoneum 2. Port insertion and laparoscopic survey 3. Dissection in Calot's triangle and application of clips 4. Dissection and delivery of the gall bladder. We audited total time taken, complications and the requirement for assistance. RESULTS: 29 LC's were performed. One (3%) was converted to open cholecystectomy to establish biliary drainage from a duct of Luschka. One (3%) death resulted from pulmonary embolism. There was no significant postoperative morbidity. Overall trainer assistance was required on 18 occasions in 8 (26%) patients (step I - 2; step 2 - 4; step 3 - 8; step 4 - 4). Detailed stepwise evaluation revealed frequent requirement for trainer assistance in insertion of the umbilical port (in step 2), delineation of the junction of the cystic duct with infundibulum and common bile duct and application of clips (in step 3 and 4) and the delivery of the gall bladder. Total time taken was (median& range) 2.08 ( 1.5-3 .18) hours. Median number of LC performed by a trainee was 5 (range 3- 7).CONCLUSION: It is possible to undertake structured training in LC safely. Dissection in Calot's triangle required most trainer assistance