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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Intraoperative visualization of biliary anatomy using Indocyanine green (ICG) fluorescence in a Sri Lankan patient cohort(The College of Surgeons of Sri Lanka, 2024) Kumarage, S.K.; Lakshani, D.H.J.P.U.; Pinto, M.D.P.; Chandrasinghe, P.C.INTRODUCTION: Bile duct injury (BDI) is a complication with high morbidity, associated with laparoscopic cholecystectomy (LC). The risk of BDI can be reduced by accurate visualization of the biliary tree with the use of indocyanine green fluorescence (ICG). This study describes the use of this non-invasive technique in a cohort of Sri Lankan patients to visualize the biliary anatomy intraoperatively. METHOD: A total of 121 consecutive patients undergoing LC were included. All received 5 mg of ICG intravenously, 30 minutes prior to induction of anesthesia. The Stryker 1588 laparoscope was used to visualize the anatomical landmarks, both pre and post-dissection of the Calot's triangle, using visible light and near-infrared imaging (NIR). RESULT: In 121 patients (female - 64.5%, median age - 42 years; range of 18-82) included in the study, biliary colic was the commonest indication (70%) for LC. ICG fluorescence resulted in significantly better visualization of the extrahepatic biliary tract (p=<0.001), both pre-dissection (95%CI = 91.7% [85.3%-96.0%]) and post-dissection (95% CI=71.1% [62.1%-79.0%]) of the Calot's triangle. Furthermore, the hepatic ducts were only visualized with ICG. Visualization of the Cystic duct common bile duct junction (CDCBDJ) improved from 6% to 88% (P<0.001) predissection with ICG. Fluorescence enabled the visualization of CDCBDJ post-dissection in all cases compared to 54% without it (P<0.001). ICG enhanced visualization of the Common bile duct (CBD) from 34% to 88% (P<0.001) predissection and 100% visibility post-dissection compared to 62% under visible light (P<0.001). No adverse effects of ICG or bile duct injuries were reported during the study. CONCLUSION: The use of ICG during LC significantly enhanced the identification of biliary landmarks in this cohort. Identification of anatomy can help reduce inadvertent BDI. This safe and effective modality may be considered a routine step in LC.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 Neoadjuvant chemoradiation for rectal cancer achieves satisfactory tumour regression and local recurrence - result of a dedicated multi-disciplinary approach from a South Asian Centre(BioMed Central, 2023) Deen, R.; Ediriweera, D.S.; Thillakaratne, S.; Hewavissenthi, J.; Kumarage, S.K.; Chandrasinghe, P.C.BACKGROUND: Pre-operative long-course chemoradiotherapy (CRT) for rectal cancer has resulted in improvement in rates of restorative rectal resection and local recurrence by inducing tumour downstaging and downsizing. Total mesorectal excision (TME) is a standardised surgical technique of low anterior resection aimed at the prevention of local tumour recurrence. The purpose of this study was to evaluate tumour response following CRT in a standardised group of patients with rectal cancer. METHODS: One hundred and thirty-one patients (79 male; 52 female, median age 57; interquartile range 47-62 years) of 153 with rectal cancer who underwent pre-operative long-course CRT were treated by standardised open low anterior resection at a median of 10 weeks post-CRT. Sixteen of 131 (12%) were 70 years or older. Median follow-up at the time of analysis was 15 months (interquartile range 6-45 months). Pathology reports were analysed based on AJCC-UICC classification using the TNM system. Data recorded were overall/subgrades of tumour regression; good, moderate or poor, lymph node harvest, local recurrence, disease-free and overall survival using standard statistical methods. RESULTS: 78% showed tumour regression post-CRT; 43% displayed good tumour regression/response while 22% had poor tumour regression/response. All patients had a pre-operative T-stage of either T3 or T4. Post-operation, good responders had a median T stage of T2 vs. T3 in poor responders (P = 0.0002). Overall, the median lymph node harvest was < 12. There was no difference in the number of nodes harvested in good vs. poor responders (Good/moderate-6 nodes vs. Poor- 8; P = 0.31). Good responders tended to have a lesser number of malignant nodes vs. poor responders (P = 0.31). Overall, local recurrence was 6.8% and the anal sphincter preservation rate was 89%. Predicted 5-year disease-free and overall survival were similar between good and poor responders. CONCLUSION: Long-course CRT resulted in satisfactory tumour regression and enabled consideration for safe, sphincter-saving resection in rectal cancer. A dedicated multi-disciplinary team approach achieved a global benchmark for local recurrence in a resource-limited setting.Item Heterotopic salivary gland tissue in the gastro-oesophageal junction: a rare entity(College of Pathologists of Sri Lanka, 2021) Dharani, K.; Medagoda, K.; Kumarage, S.K.; Mahendra, B.A.G.G.Introduction: Gastric and pancreatic heterotopia are the two most common types of heterotopias seen in the gastrointestinal tract (GIT). These are the two most common types of heterotopias seen in the oesophagus as well. The occurrence of heterotopic salivary gland tissue (HSGT) in the GIT is rare, and most reported cases are colorectal and anal lesions with only a few cases involving the oesophagus. Case report: A 69-year-old man presented with a seven-month history of gastro-oesophageal reflux disease (GORD). The upper gastrointestinal endoscopy showed a moderate hiatus hernia with a pale pink mucosal patch close to the gastro-oesophageal junction. The biopsy showed oesophageal tissue with morphological changes of mild reflux oesophagitis. The submucosal tissue contained organized glandular structures with mucinous glands and intercalated ducts resembling mature salivary gland tissue. There was no evidence of Barrett oesophagus, dysplasia or neoplasm. Discussion and conclusion: HSGT is most commonly seen in the head and neck region of the body, and its occurrence in the GIT is rare. Occurrence of oesophageal HSGT is extremely rare and most cases have presented with symptoms of GORD. Although HSGT is usually benign and a rare phenomenon, clinicians and pathologists need to be aware of this condition to prevent a delay in diagnosis and inappropriate management.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 Hardware interface for haptic feedback in laparoscopic surgery simulators(Institute of Electronics and Electrical Engineers(IEEE), 2014) Kannangara, S.M.; Ranasinghe, S.C.; Kumarage, S.K.; Nanayakkara, N.D.Minimally Invasive Surgeries (MIS) such as laparoscopic procedures are increasingly preferred over conventional surgeries due to many different advantages. Laparoscopic surgical procedures are very complex compared to open surgeries and require high level of experience and expertise. Hybrid surgery simulators available for training using physical phantoms are expensive and not readily available in majority of health care facilities around the world. Therefore, computer simulation or Virtual Reality (VR) is a better way to obtain skills for MIS. A VR simulator incorporated with haptic feedback provides a comprehensive training closer to real world experience. In this paper, we present a novel approach to incorporate force feedback to VR laparoscopic surgery training. The proposed interface incorporates force feedback in all three axes to provide three levels of force feedback. Computational models of abdomen organs were generated using the cryosection data of Visible Human Project of the National Library of Medicine, USA. The organ models were developed with three basic force categories: soft, mild and hard. A hardware interface is developed to provide the force feedback for the interaction of virtual tools with the said organ models while generating the tool navigation information for the VR simulator. © 2014 IEEE.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 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 Adapting surgical services at a tertiary care unit amidst the COVID19 pandemic: a Sri Lankan perspective(College of Surgeons of Sri Lanka, 2020) Chandrasinghe, P.C.; Siriwardana, R.C.; Kumarage, S.K.; Gunetilleke, B.; Weerasuriya, A.; Munasinghe, N.M.; Thilakarathne, S.T.; Pinto, D.; Fernando, R.F.No Abstract available.Item A Novel structure for online surgical undergraduate teaching during the COVID-19 pandemic(BioMed Central., 2020) Chandrasinghe, P.C.; Siriwardana, R.C.; Kumarage, S.K.; Munasinghe, B.N.L.; Weerasuriya, A.; Tillakaratne, S.; Pinto, D.; Gunetilleke, B.; Fernando, F.R.BACKGROUND: The Covid-19 pandemic necessitated the delivery of online higher education. Online learning is a novel experience for medical education in Sri Lanka. A novel approach to undergraduate surgical learning was taken up in an attempt to improve the interest amongst the students in clinical practice while maximizing the limited contact time. METHOD: Online learning activity was designed involving medical students from all stages and multi consultant panel discussions. The discussions were designed to cover each topic from basic sciences to high-level clinical management in an attempt to stimulate the student interest in clinical medicine. Online meeting platform with free to use basic plan and a social media platform were used in combination to communicate with the students. The student feedback was periodically assessed for individual topics as well as for general outcome. Lickert scales and numeric scales were used to acquire student agreement on the desired learning outcomes. RESULTS: A total of 1047 student responses for 7 questionnaires were analysed. During a 6-week period, 24 surgical topics were discussed with 51 contact hours. Eighty-seven per cent definitely agreed (highest agreement) with the statement 'students benefitted from the discussions'. Over 95% have either participated for all or most sessions. A majority of the respondents (83.4%) 'definitely agreed' that the discussions helped to improve their clinical sense. Of the total respondents, 79.3% definitely agreed that the discussions helped to build an interest in clinical medicine. Around 90% agreed that both exam-oriented and clinical practice-oriented topics were highly important and relevant. Most widely raised concerns were the poor Internet connectivity and limitation of access to the meeting platform. CONCLUSION: Online teaching with a novel structure is feasible and effective in a resource-limited setting. Students agree that it could improve clinical interest while meeting the expected learning outcomes.