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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Immediate outcome of microwave ablation for liver tumours in a single cohort of patients in Sri Lanka.(The College of Surgeons of Sri Lanka, 2022) Appuhamy, C.; Ganewatte, E.; Ranaweera, L.; Dassanayake, A.S.; Gunetilleke, M.B.; Tillakaratne, S.; Gunawardena,H.P.; Niriella,M.A.; Siriwardana,R.C.Introduction and Objectives Microwave ablation (MWA) is an emerging treatment modality for hepatocellular carcinoma (HCC) and other liver tumours. We aimed to assess the immediate success and complications of MWA in a cohort of patients. Method Patients were assessed retrospectively, using an intervieweradministered questionnaire and a follow-up CECT/MRI at, 6-week.Result 55 patients underwent MWA from October 2021-May 2022, at Colombo-North Teaching Hospital, Ragama, Sri Lanka, and selected private hospitals( Durdans Hospital, Colombo, Nawaloka Hospital, Colombo, Lanka Hospital, Colombo).The median age was 64 (40-82) years, with a male preponderance (n=45, 81.1%). The indication was HCC in 54 (98.1%) and metastatic tumour in one (1.8%). The median tumour size was 28 (10-80) mm. Segment VII was the commonest site to be involved (n=18, 34.6%). The majority (n=40, 72.7%) was a single lesion. No participant underwent the procedure twice. The mean post-procedural hospital stay was 12 hours (95%CI=11.4-12.5, SD=2.0).In the 6-week follow-up, 2 recurrences (3.6%) and single death (1.8%) with no relation to the procedure, were reported. Another 2 (3.6%) denied the follow-up. Complete ablation was reported in 46 patients (83.7%), comparable to the rates in literature (95-97%), with only 7 patients (12.7%) having residual tumours. No major complications were reported. 9 patients (16.4%) developed 'Post ablation syndrome', not as common as in literature (34%). They presented with abdominal pain (7.3%), vomiting (7.3%), and fever (3.6%).Conclusion MWA is a successful and safe treatment option for primary liver tumours in Sri Lanka, with ablation rates comparable to the western world.Item Local infiltration versus Laparoscopic e guided transverse abdominis plane block in laparoscopic cholecystectomy e double blinded randomized control trial(Elsevier, 2018) Siriwardana, R.C.; Kumarage, S.K.; Gunetilleke, M.B.; Thilakarathne, S.B.BACKGROUND: Transverse abdominal plane block (TAP) is a new technique of regional block described to reduce postoperative pain in laparoscopic cholecystectomy (LC). Recent reports describe an easy technique to deliver local anesthetic agent under laparoscopic guidance. METHODS: This randomized control trial was designed to compare the effectiveness of additional laparoscopic guided TAP block against the standard full thickness port site infiltration. 45 patients were randomized in to each arm after excluding emergency LC, conversions, ones with coagulopathy, pregnancy and allergy to local anesthetics. All cases were four ports LC. Interventions - Both groups received standard port site infiltration with 3-5ml of 0.25% bupivacaine. The test group received additional laparoscopic guided TAP block with 20ml of 0.25% bupivacaine subcostaly, between the anterior axillary and mid clavicular lines. As outcome measures the pain score, opioid requirement, episodes of nausea and vomiting and time to mobilize was measured at 6 hourly intervals. RESULTS: The two groups were comparable in the age, gender, body mass index, indication for cholecystectomy difficulty index and surgery duration. The pain score at six hours (P = 0.043) and opioid requirement at six hours (P =0.026) was higher in the TAP group. These were similar in subsequent assessments. Other secondary outcomes were similar in the two groups. CONCLUSION: Laparoscopic-guided transverses abdominis plane block does not give an additional pain relief or other favorable outcomes. It can worsen the pain scoresItem First paediatric live donor liver transplant in Sri Lanka with 1 year outcome : challenges for the future(The College of Surgeons of Sri Lanka, 2021) Siriwardana, R.; Thilakarathne, S.; Fernando, M.; Gunetilleke, M.B.; Weerasooriya, A.; Appuhamy, C.INTRODUCTION: Liver transplantation in the paediatric age group is demanding due to smaller body proportions and physiology. This paper describes the first successful paediatric liver transplant in Sri Lanka along with its one-year outcome. Describing the challenges faced during the process, we highlight the factors that need to be considered for a sustainable programme in the future. METHODOLOGY: A 9-year-old girl who had progressive familial intra hepatic cholestasis type 3 was referred to us with features of end stage liver disease. She was identified as a suitable candidate for liver transplantation. Her 38-year-old mother was selected as the donor, who was evaluated for suitability of a left lateral segment donation. RESULTS: The first paediatric liver transplantation was performed in July 2020. The child's mother donated the left lateral segment weighing 325g. During the postoperative period the child developed outflow tract obstruction at the hepatic venous anastomosis. This was managed with a percutaneously placed stent. Six months after transplant, she developed an acute rejection that required steroids. Treatment of rejection was complicated with multiple liver abscesses caused byAspergillus. The infection was treated with systemic antifungals and drainage. At one-year post transplant, the recipient had recovered from the trauma of surgery and had normal liver biochemistry, a patent hepatic venous stented anastomosis and complete resolution of the abscesses. We faced dual challenges in dealing with a live liver transplant donor and a young child who was the recipient. Our success, on this occasion, was underscored by the multidisciplinary contribution from specialists scattered across the island combined with state-public partnership. CONCLUSION: To offer a sustainable live donor liver transplant service for the future, many other aspects, beyond surgery itself, need to be addressed.Item Clinical characteristics and outcomes of hepatocellular carcinoma: results from prospective study, from a tertiary referral center in Sri Lanka(Sri Lanka Medical Association, 2018) Bulathsinhala, B.K.S.; Siriwardana, R.C.; Gunetilleke, M.B.; Niriella, M.A.; Dassanayake, A.S.INTRODUCTION:Hepatocellular carcinoma is increasing globally. Compared to global patterns, hepatitis B and C are rare in Sri Lanka whilst non-alcoholic fatty liver disease (NAFLD) and alcohol are the commonest causes of hepatocellular carcinoma.OBJECTIVE:To determine the characteristics of a cohort of Sri Lankan patients with hepatocellular carcinoma of non-viral aetiology.METHODS:Details of 550 consecutive patients with hepatocellular carcinoma referred from 2012 to 2017 were collected prospectively. Demographic data, clinical and biochemical details, aetiology, comorbidities, tumor characteristics and type of treatment offered were retrospectively analyzed.RESULTS:Median age was 62.9 years (range 12 - 88) with male preponderance (n = 473; 86%). Overall median BMI was 35.8 kgm-2. Majority (n=309; 56 %) had NAFLD induced cirrhosis, second commonest cause was alcohol (n=203;36.9 %). Tumour was single nodular 233(42.4%) and diffusely infiltrating 92(16.7%). Diagnostic rise in serum alpha-fetoprotein (over 200 micrograms) was seen in 30.2%. Venous invasion was present in 28.5% [portal vein 136 (24.7%), hepatic vein 9 (1.6%) and cava 12(2.2%)]. Extra hepatic tumor spread was seen in 6.9% [lungs 20(3.6%), bones 4(0.7%), peritoneal 6 (1.1%) and metastases at other sites 8 (1.45%)]. Curative surgery was offered in 78(14.2%). Tumour embolization was done in 192(34.9%), radio frequency ablation 34(6.2%), alcohol injection 42(7.6%) and 204(37.1%) patients were offered palliative care. Overall median survival was 20.6 months.CONCLUSION:In a large Sri Lankan cohort, most hepatocellular carcinomas were due to cryptogenic cirrhosis and it was aggressive at presentation. Screening of high-risk NAFLD patients needs to be considered and further palliative care needs to be improved.Item Outcome of hepatic resection: First five-year experience in elderly and younger patients(Sri Lanka Medical Association, 2018) Bulathsinhala, B.K.S.; Thillekaratne, M.S.B.; Gunetilleke, M.B.; Niriella, M.A.; Wijegunawardena, D.G.A.; Siriwardana, R.C.No Abstract AvailableItem Pancreatico-duodenectomy with long segment portal vein resection and reconstruction with left renal vein autologous graft(College of Surgeons of Sri Lanka, 2017) Bulathsinhala, B.K.S.; Tillakaratne, M.S.B.; Gunetilleke, M.B.; Siriwardana, R.C.Item Pre-treatment alphafeto protein in hepatocellular carcinoma with non-viral aetiology - a prospective study(BioMed Central, 2017) Siriwardana, R.C.; Thilakarathne, S.; Niriella, M.A.; Dassanayake, A.S.; Gunetilleke, M.B.; Habarakada, L.C.A.; de Silva, H.J.BACKGROUND: Alpha-fetoprotein (AFP) is a biomarker for hepatocellular carcinoma (HCC). The significance of pre-treatment AFP (pt-AFP) in non-viral HCC (nvHCC) is not clear. METHODS: Patients with nvHCC, referred to a Hepatobiliary Clinic from September 2011-2015 were screened. HCC was diagnosed using American Association for the Study of Liver Disease guidelines, and TNM staged. nvHCC was diagnosed when HBsAg and anti-HCVAb was negative. Child-Turcotte-Pugh (CTP) and Model for End-stage Liver Disease (MELD) scores were calculated. AFP level was evaluated against patient characteristics, tumour characteristics and survival. RESULTS: Three hundred eighty-nine patients with nvHCC [age 64(12-88) years; 344(88.4%) males] were screened. Median AFP was 25.46 ng/ml (1.16-100,000). 41.2% (n = 160) Of patients had normal AFP level. 22.9% (n = 89) had AFP over 400 ng/ml. Female gender (P < 0.05), vascular invasion (P < 0.001), tumours over 5 cm (P < 0.05), late TNM stage (P < 0.001) and non-surgical candidates had higher AFP levels. Diffuse type (P < 0.001), macro vascular invasion (P < 0.001) and late stage tumours (P < 0.001) had AFP over 400 ng/ml. Having AFP below 400 ng/ml was associated with longer survival (16 vs. 7 months, P < 0.001). CONCLUSION: Pre treatment AFP has a limited value In diagnosing nvHCC, Having a AFP value over 400 ng/ml was associated with aggressive tumour behaviour and poor prognosis.Item Short and medium term glycaemic control after pancreaticoduodenectomy(College of Surgeons of Sri Lanka, 2016) Siriwardana, R.C.; Bandara, L.M.P.M.; Atulugama, N.; Gunetilleke, M.B.; Ekanayake, C.S.Introduction: Perioperative outcomes of pancreaticoduodenectomy (PD) have improved over the years. Glycaemic control in longterm survivors is a matter of concern. Materials and methods: 48 surviving patients of 66 patients who underwent Whipple surgery from 2011 to 2015 were evaluated. Patients with recurrences, who had chemotherapy within three months and patients who had not completed a minimum six months follow-up were excluded. 25 patients were selected. Patients' demographic data, HbA1c level, fasting blood sugar level, physical activity index and waist to hip ratio were calculated. Volume of the pancreatic specimen was calculated. Non diabetics underwent oral glucose tolerance test (OGTT). Results: There were 6 (24%) pre-existing diabetics, 3 new onset diabetics and two patients with impaired glucose tolerance (20%). Median preoperative BMI, body fat distribution, calculated median pancreatic volumes resected or underlying pancreatic pathology did not differ in diabetic and non-diabetic groups. In non-diabetics, HbA1c level or two hour OGTT did not associate with age, preoperative BMI, waist to hip ratio and resected pancreatic volumes. Conclusion: Significant proportion of patients develop diabetes immediately after PD. Reliable prediction of this group pre-operatively is difficult due to many interacting, confounding factors. They need close monitoring in immediate perioperative period.Item Factors affecting the clinical outcome of transarteriai chemo treatment for hepatocellular carcinoma in Sri Lankan patients(Sri lanka Medical Association, 2015) Jayatunge, D.S.P.; Siriwardana, H.D.R.C.; Niriella, M.A.; Dassanayake, A.S.; Liyanage, C.A.H.; Gunetilleke, M.B.; Upasena, A.; Sirigampola, C.; de Silva, A.P.; de Silva, H.J.INTRODUCTION AND OBJECTIVES: Transarterial-chemo-embolization (TACE) is used for palliation of unresectable hepatocellular carcinoma (HCC). We studied the tolerability of TACE in a cohort of patients with NASH and alcoholic cirrhosis related HCC. METHOD: Of 290 patients with HCC (July 2011 -December 2014), 84 underwent TACE. They were monitored for post-TACE complications: postembolization fever (PEF), nausea and vomiting (NV), abdominal pain, infection, acute hepatic decompensation (AHD) and acute kidney injury (AK1). RESULTS: 84 patients [90.5% males, 89.2% cirrhotics, 89.2% nodular HCC, median age 63(34-84) years] underwent 111 TACE sessions. All were Child class A [69.4% sessions (n=77)] or B; ascites and portal vein invasion was present in 18 (16.2%) and 15 (13.6%), respectively. 42 (38.2%) TACE procedures resulted in complications [PEF 28 (25.2 %), NV 4 (3.6%), abdominal pain 9 (8.1%), infection 7 (6.3%), AHD 13 (11.7%), AKl 3 (2.7%)]. There were no immediate post-TACE deaths. On univariate analysis elevated serum bilirubin (p=0.046) and low serum albumin (p=0.035) predicted PEF while low serum albumin (p=0.021) and low platelet counts (p=0.041) predicted AHD. In the multivariate model, factors with p<0.200 on univariate analysis and factors derived from the previous literature were considered covariates. Female gender (p=0.029, OR=1.412), ascites (p=0.030, OR = 1.212), elevated serum bilirubin (p=0.007, OR= 4.357) and large tumour size (p=O.Q36, OR=3.603) were independent risk factors for PEF. Tumour diameter >5cm (p=0.049, OR=2.410) and elevated serum bilirubin (p=0.036, OR=1.517) predicted AHD. CONCLUSION: In NASH and alcoholic cirrhosis related HCC patients pre-procedure serum bilirubin, ascites, tumour size and female gender predicted PEF post-TACE, Tumours>5cm with elevated bilirubin predicted AHD post-TACE.