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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Proximal and distal rectal cancers differ in curative resectability and local recurrence(Baishideng Publishing Group, 2011) Wijenayake, W.; Perera, M.; Balawardena, J.; Deen, R.; Wijesuriya, S.R.; Kumarage, S.K.; Deen, K.I.AIM: To evaluate patients with proximal rectal cancer (PRC) (> 6 cm up to 12 cm) and distal rectal cancer (DRC) (0 to 6 cm from the anal verge). METHODS: Two hundred and eighteen patients (120 male, 98 female, median age 58 years, range 19- 88 years) comprised 100 with PRC and 118 with DRC. The proportion of T1, T2 vs T3, T4 stage cancers was similar in both groups (PRC: T1+T2 = 29%; T3+T4 = 71% and DRC: T1+T2 = -31%; T3+T4 = 69%). All patients had cancer confined to the rectum - those with synchronous distant metastasis were excluded. Surgical resection was with curative intent with or without preoperative chemoradiation (c-RT). Follow-up was for a median of 35 mo (range: 12 to 126 mo). End points were: 30 d mortality, complications of operation, microscopic tumour- free margins, resection with a tumourfree circumferential margin (CRM) of 1 to 2 mm and > 2 mm, local recurrence, survival and the permanent stoma rate. RESULTS: Overall 30-d mortality was 6% (12): PRC 7 % and DRC 4%. Postoperative complications occurred in 14% with PRC compared with 21.5% with DRC, urinary retention was the complication most frequently reported (PRC 2% vs DRC 9%, P = 0.04). Twelve percent with PRC compared with 37% with DRC were subjected to preoperative c-RT (P = 0.03). A tumour-free CRM of 1 to 2 mm and > 2 mm was reported in 93% and 82% with PRC and 88% and 75% with DRC respectively (PRC vs DRC, P > 0.05). However, local recurrence was 5% for PRC vs 11% for DRC (P < 0.001). Three and five years survival was 65.6% and 60.2% for PRC vs 67% and 64.3% for DRC respectively. No patient with PRC and 23 (20%) with DRC received an abdomino-perineal resection. CONCLUSION: PRC and DRC differ in the rate of abdomino-perineal resection, post-operative urinary retention and local recurrence. Survival in both groups was similar.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 Young patients with colorectal cancer have poor survival in the first twenty months after operation and predictable survival in the medium and long-term: analysis of survival and prognostic markers(BioMed Central, 2010) Chan, K.K.; Dassanayake, B.; Deen, R.; Wickramarachchi, R.E.; Kumarage, S.K.; Samita, S.; Deen, K.I.OBJECTIVES: This study compares clinico-pathological features in young (<40 years) and older patients (>50 years) with colorectal cancer, survival in the young and the influence of pre-operative clinical and histological factors on survival. MATERIALS AND METHODS: A twelve-year prospective database of colorectal cancer was analysed. Fifty-three young patients were compared with forty-seven consecutive older patients over fifty years old. An analysis of survival was undertaken in young patients using Kaplan Meier graphs, non-parametric methods, Cox's Proportional Hazard Ratios and Weibull Hazard models. RESULTS: Young patients comprised 13.4 percent of 397 with colorectal cancer. Duration of symptoms and presentation in the young was similar to older patients (median, range; young patients; 6 months, 2 weeks to 2 years, older patients; 4 months, 4 weeks to 3 years, p > 0.05). In both groups, the majority presented without bowel obstruction (young--81%, older--94%). Cancer proximal to the splenic flexure was present more in young than in older patients. Synchronous cancers were found exclusively in the young. Mucinous tumours were seen in 16% of young and 4% of older patients (p < 0.05). Ninety-four percent of young cancer deaths were within 20 months of operation. At median follow up of 50 months in the young, overall survival was 70% and disease free survival 66%. American Joint Committee on Cancer (AJCC) stage 4 and use of pre-operative chemoradiation in rectal cancer was associated with poor survival in the young. CONCLUSION: If patients, who are less than 40 years old with colorectal cancer, survive twenty months after operation, the prognosis improves and their survival becomes predictable.Item Complete migration of a composite mesh into small bowel incidentally found during laparotomy for colectomy in an asymptomatic patient: a case report(BioMed Central, 2020) Chandrasinghe, P.; de Silva, A.; Welivita, A.; Deen, K.I.BACKGROUND: Composite meshes are used for incisional hernia repair because they enable intraperitoneal mesh placement due to their dorsal surface, which is made of inert material. We report, for the first time, to our knowledge, a case of composite mesh migration detected incidentally during a laparotomy for colon cancer in an asymptomatic patient. CASE PRESENTATION: Our patient was a 71-year-old South Asian man who underwent ventral mesh repair following a postoperative complication after right hemicolectomy for colon cancer. The patient was diagnosed with a metachronous sigmoid cancer 5 years later, for which he underwent laparotomy. During laparotomy, a migrated mesh was incidentally found and extracted from his proximal ileum without any evidence of abscess or fistula formation. CONCLUSION: To our knowledge, this is the first report of an incidentally found migrated composite mesh from a bowel lumen in an asymptomatic patient. KEYWORDS: Case report; Composite mesh; Mesh complications; Mesh migration.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.