Medicine
Permanent URI for this communityhttp://repository.kln.ac.lk/handle/123456789/12
This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
Browse
33 results
Search Results
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 Hepatocellular carcinoma in Sri Lanka: Where do we stand?(Sri Lanka Medical Association, 2013) Siriwardana, R.C.; Liyanage, C.A.H.L.; Jayatunge, D.S.P.; Dassanayaka, A.; Gunetileke, M.G.; Niriella, M.A.; Sirigampola, C.; Upasena, A.; de Silva, H.J.INTRODUCTION AND OBJECTIVES:Hepato-cellular carcinoma (HCC) is the sixth commonest cancer worldwide. We studied 105 consecutive patients with HCC in a single tertiary care centre. METHODS: North Colombo Liver Unit maintains a prospective database of HCC since September 2011. There were 105 entries by February 2013. Decision on the best form of treatment was taken at a multidisciplinary meeting. RESULTS: The median age at presentation was 63 years (range 12-79). Patients were predominantly male 93 (87%). Alcohol consumption above the safe limit was reported in 47 (45%). Hepatitis B surface antigen or C antibody was not detected in any of the patients. Background liver cirrhosis was evident in 59 (79%). Forty two (46%) patients had single nodular tumours while in 20 (21%) it was diffusely infiltrating. Portal vein invasion was seen in 22 (20 %). Median alpha-feto protein (AFP) level was 57.25 mg/ml (1.16- 94120 ng/ml; n=72). Twenty four (33%) patients had AFP level > 400u/l. Surgery was performed in 20 (19%), liver transplant in 2 (1.9%), radio frequency ablation or alcohol ablation in 8 (7.6%), trans arterial chemo embolization (TACE) in 44 (41.9%) and sorafmib was prescribed in four patients. Overall mean survival was 15 months. In the ‘no treatment’ group, mean survival was 4 months. Surgery group had a mean survival of 20 months. CONCLUSION: Hepatitis B is not a risk factor for HCC in Sri Lankans. Median survival without treatment is 4 months.Item Hilar cholangiocarcionoma; Is aggressively answered(College of Surgeons of Sri Lanka, 2015) Bandara, L.M.P.M.; Jayarathne, V.S.; Siriwardana, R.C.; Nawarathna, N.M.M.; Liyanage, C.A.H.INTRODUCTION: Cholangiocarcinoma (CCA) is a malignant disease involving the billiary system with majority occurring in the hilar region. CCA demands prompt management because of its aggressive nature. MATERIALS AND METHODS: Patients who presented to Gastroenterology and hepatobiliary unit at NHSL and the Professorial Surgical Unit of NCTH from January 2011 to June 2015 were included in this study. Diagnosis was made by CT imaging, MRCP and ERCP. RESULTS: Total of 120 patients were diagnosed with CCA. The median age of presentation was 64 years (31-85) with 51.2% being males. Majority of 63 patients (52.1%) of CCA occurred in the hilar region with rest involving the common bile duct. Out of 63 hilar CCA 44 were classified according to the bismuth classification. 13/44 were type I, 7/44 were type II, 9/44 were of type III and 15/44 were of type IV. While 5 patients (7.9%) underwent hepatic resection, Majority of 40 patients (63.5 %) were stented with 9 (14.2%) being treated with Radiofrequency ablation (RFA). Survival was significant following surgery (P=0.027). Four patients who underwent surgery are currently followed up at NCTH. CONCLUSIONS: Surgery appears to be the effective treatment for CCA. Aggressive palliation with stenting seems beneficial.Item Bile reflux and quality of life after modified retrocolic posterior gastric gastrojejunostomy in whipple procedure(College of Surgeons of Sri Lanka, 2015) Rajapaksha, R.W.M.A.L.; Liyanage, C.A.H.; Hewavisenthi, S.J.D.S.; Liyanage, S.K.; Bandara, L.M.P.M.; Siriwardana, R.C.INTRODUCTION: Perioperative outcome of Whipple surgery has greatly improved. Quality of life has become an important issue in long-term survivors. Delayed gastric emptying and bile reflux are common concerns. Modified retrocolic posterior gastric gastrojejunostomy with mesocolic stich has been unit's standard practice. Study was designed to assess macro and microscopic bile reflux and dyspepsia related quality of life in long-term survivors. MATERIAL AND METHODS: Out of 42 patients operated from June 2012, twenty long-term survivors were selected after excluding once with recurrence and ones who had chemotherapy during last six months. All underwent gastroscopy. Macroscopic bile reflux was grouped in to four categories. Six gastric biopsies were taken from standard sites. Microscopic bile reflux index (BRI) was calculated in stained specimens. BRI score of more than 14 was considered significant. Validated Nepean dyspepsia index-short form (NDI-SF) was used to assess the severity of dyspepsia related quality of life and compared with age and gender matched control. RESULTS: The median age was 48.5 years (21- 69). Median survival of the group was 37 months (6-40). Endoscopically, 18/20 (90%) had macroscopic bile reflux (83.3% yellowish bile lake, 16.7% greenish bile lakes). None had stomal ulcers or macroscopic inflammation. Mean Bile reflux index score was 13.22 (SD: 9.46). Mean dyspepsia score of Whipple group was 23.1 (SD 8.88). In controls, mean dyspepsia score was 20 (SD 8.2), showing no significant difference (p =0.245). CONCLUSION: Though there was macroscopic bile reflux, clinical symptoms and microscopic changes were minimal. Modified technique had good long-term results.Item Factors affecting Post- Embolization fever and liver failure after Trans- Arterial Chemo-Embolization in a cohort without background infective hepatitis- A prospective analysis.(College of Surgeons of Sri Lanka, 2015) Bandara, L.M.P.M.; Siriwardana, R.C.; Niriella, M.A.; Dassanayake, A.S.; Liyanage, C.A.H.; Sirigampala, C.; Upasena, A.; de Silva, H.J.INTRODUCTION: 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. MATERIAL AND METHODS: Of 290 patients with HCC(July 2011 - December 2014), 84 underwent TACE. They were monitored for post-TACE complications: post embolization fever(PEF), nausea and vomiting (NV), abdominal pain, infection, acute hepatic decompensation (AHD) and acute kidney injury (AKI). 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%), AKI 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 5 cm (p=0.049,OR=2.410)and elevated serum bilirubin (p=0.036,OR=1.517) predicted AHD. CONCLUSIONS: In NASH and alcoholic cirrhosis related HCC patients pre- procedure serum bilirubin, ascites, tumour size and female gender predicted PEF post-TACE. Tumours larger 5cm with elevated bilirubin predicted AHD post-TACE.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 Computed tomography-based evaluation of segmental variation of liver density and Its implications.(Indian Society of Gastroenterology, 2020) Siriwardana, R.C.; Sivasundaram, T.; Paranaheva, L.; Ediriweera, D.S.BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) has become a major health concern. Focal fat deposition frequently seems to involve segment IV b. This indicates a consistent pattern of fat deposition in the liver. The present study evaluates the pattern of fat distribution in the liver using computed tomogram (CT) attenuation index. METHODS: Two radiologists evaluated 517 non-contrast CT scan images of the abdomen and pelvis. Two 40-mm2 regions of interest (ROIs) were selected from each segment. The hepatic segmental densities (HSDs) were obtained by calculating the mean densities of areas of corresponding liver segments. The mean hepatic attenuation (MHA) was quantified by obtaining the mean segmental densities. Densities were compared between the segments and with the MHA. RESULTS: The mean age (SD) of the patients was 55.5 year (15.6), and 276 (53.4%) were males. The overall mean hepatic density was 53.05 (95% CI, 52.95-53.15) Hounsfield units (HU). The lowest mean HSD was observed in segment IV b and the highest mean HSD was observed in segment V. Segments I, IV a and IV b showed significantly lower mean HSDs and segments V, VI and VIII showed significantly higher mean HSDs compared with the overall mean MHA/mean hepatic density (MHD), whereas mean HSDs of segments II, III and VII were not significantly different from the overall mean MHA/MHD. CONCLUSIONS: Segment IV b seems to be the most vulnerable site for fat deposition; focal lesions here should be carefully evaluated. Segments II, III and VII seem to closely represent MHD. KEYWORDS: Cirrhosis; Diagnostic imaging; Fatty liver; Non-alcholic fatty liver disease.Item 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 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 Diffuse-Type Hepatoma: A grave prognostic marker(Karger Medical and Scientific Publishers, 2017) Siriwardana, R.C.; Liyanage, C.A.H.; Gunetilleke, B.; Niriella, M.A.; de Silva, H.J.; Dassanayake, A.S.; Jayatunga, S.P.BACKGROUND: Data on diffuse-type hepatocellular carcinoma (HCC) are rare. HCC in Sri Lanka is rising, and the majority is related to nonalcoholic fatty liver disease. This study was planned to compare nodular- and diffuse-type HCC in this cohort. METHODS: CT scans of 227 patients with HCC negative for infective hepatitis were analyzed and grouped as nodular and diffuse from July 2011 to July 2014. Diffuse-type cancer was defined as a tumor without convex/distinct margin, diffusely infiltrating the hepatic parenchyma. There were 45 (20%) cases. The baseline liver functions, etiology, treatment, and the outcome were compared with nodular-type cancers. Stage III diffuse cancers were matched with 2 stage III nodular cancers looking at the T stage and background liver. RESULTS: There was no difference in the age (63 vs. 62 years, p = 0.937) and gender. Diffuse cancers had a low BMI (24 vs. 22, p = 0.009), a higher alpha fetoprotein (AFP) level (p < 0.001), a higher incidence of major vascular invasion (14 vs. 80%, p < 0.001), and a history of significant alcohol consumption (39 vs. 67%, p = 0.001). The baseline liver functions were similar in diffuse and nodular cancers. A large proportion (27 vs.77%, p < 0.001) of diffuse cancers were not candidates for active treatment. Overall survival was poor in the diffuse type(4.7 vs. 25 months, p < 0.001). Diffuse-type stage III cancers had a poor survival compared to matched nodular cancers (2.5 vs. 15.8 months, p = 0.001). CONCLUSION: HCC without a background of infective hepatitis were common in our cohort. These tumors are associated with high AFP levels, major vascular invasion, and a poor prognosis.