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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Characteristics and survival of advanced untreated hepatocellular carcinoma of non-viral etiology(Indian Society of Gastroenterology, 2024) Ekanayaka, S.P.N.; Luke, N.; Thilakarathne, S.B.; Dassanayake, A.; Gunetilleke, M.B.; Niriella, M.A.; Siriwardana, R.C.INTRODUCTION AND OBJECTIVES Hepatocellular carcinoma (HCC) is an aggressive tumor and presents late. The underlying etiology of HCC is changing rapidly. HCC in Sri Lanka is unique due to its predominant non-viral etiology (nvHCC) but lacks survival data.METHOD Data was collected from patients who presented with HCC from 2011 to 2018. There were 560/568 (98.6%) nvHCC. The patients who were not candidates for tumor-specific treatment (149/560 [26.7%]) were selected. Population characteristics, demographic data, tumor characteristics, survival and factors affecting survival were analyzed.RESULTS The median age was 64 years (range 30-88) and 86% (n = 129) were males. As many as 124 (83%) were cirrhotic. The overall performance score was 80%. Nearly 21/124 tumors were detected in cirrhotic screening. Tumors were single nodular in 32 (21%), up to three nodules in 28 (18%), more than three nodules in 33 (22%) and diffusely infiltrating in 56 (37%). The major venous invasions were present in 78 (52.3%). Extra-hepatic tumor spread was seen in 19 (12.7%) (lungs 13 [72.2%], bones 2 [11.1%]). The median survival of patients receiving palliative care was three months (1-43 months). Tumor size and cirrhotic status were significant predictors in univariate analysis.CONCLUSION A quarter of nvHCCs were not amenable to treatment at presentation as they had dismal survival.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 A Case of persistent portal hypertension following ligation of a large porto - systemic shunt during cadaveric donor liver transplantation(Sri Lanka Medical Association., 2020) Siriwardana, R.C.; Shanthanayagam, N.; Gunetilleke, M.B.; Weerasuriya, A.P.; Niriella, M.A.; Dassanayake, A.S.; Dissanayake, R.No abstract availableItem Perioperative outcome following establishment of deceased donor liver transplantation: A single center experience in Ragama, Sri Lanka(Sri Lanka Medical Association, 2018) Withanachchi, A.D.; Thalagala, T.A.E.S.; Liyanage, I.K.; Dassanayake, A.S.; de Silva, A.P.; Gunetilleke, M.B.; Siriwardana, R.C.; Niriella, M.A.INTRODUCTION AND OBJECTIVES: Liver transplant (LT) perioperative mortality is a good performance indicator among transplant centres. Colombo North Teaching Hospital (CNTH) is the first LT program in Sri Lanka. We aimed to evaluate the perioperative (30 day) outcomes and complications of patients who underwent deceased donor liver transplantation (DOLT) at CNTH between the first 9 DDLTs that were carried out before 2016 (Tl) and the last 10 DDLTs after 2016 (T2). METHODS: Retrospective analysis of pre-operative records, operation notes, discharge and follow up notes were carried out on all patients who underwent DOLT at CNTH. RESULTS: A total of 19-DDLTs were performed during this period. Mean age of the recipients was 50.3 (Tl :52.9, T2:47.9) years: Indications (n) for DDLT were: advanced cirrhosis with high MELD (12), other complications of cirrhosis (3),."cirrhosis with hepatocellular carcinoma (3) and acute liver failure (1 ). Aetiology of cirrhosis (n) were: cryptogenic (13), alcohol (3), autoimmune hepatitis (1), other (1). Pre transplant MELD was 16 in Tl and 18 in T2. Average hospital stay was 11.1 days (7.4 days in the intensive care). Perioperative mortality was 4/9 (44%) in Tl and 2/10 (20%) in T2. Mortality was due to PNF (3), sepsis (2) and post-operative reperfusion syndrome (1). Other post-operative complications (in Tl and T2) were: hepatic artery thrombosis (0,0), cholestasis (0, 1 ), acute cellular rejection (0,2), hydrothorax (0,3), clinically significant tacrolimus toxicity (1,o) and acute renal failure (4,2). CONCLUSION: Perioperative mortality has reduced and outcomes improved in the second half indicating success of the CNTH LT program.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 Local infiltration versus laparoscopic-guided transverse abdominis plane block in laparoscopic cholecystectomy: double-blinded randomized control trial(Springer, 2019) Siriwardana, R.C.; Kumarage, S.K.; Gunetilleke, M.B.; Thilakarathne, S.B.; Wijesinghe, J.S.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 3-5 ml of 0.25% bupivacaine. The test group received additional laparoscopic-guided TAP block with 20 ml of 0.25% bupivacaine subcostally, 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 6 h (P = 0.043) and opioid requirement at 6 h (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 using plain bupivacaine does not give an additional pain relief or other favorable outcomes. It can worsen the pain scores.Item 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.