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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Single incision laparoscopic surgery (SILS) for primary surgery in medically refectory ulcerative colitis: a case series(Wiely-Blackwell, 2016) Chandrasinghe, P.C.; Leo, C.A.; Samaranayake, S.F.; Santorelliei, C.; Strouhal, R.; Warusavitarne, J.INTRODUCTION: Medically refractive ulcerative colitis (UC) requires surgical intervention. Due to the ongoing inflammation in the colon this patient group is considered as high risk. Primary surgery includes subtotal colectomy (STC) as the first step of a staged restorative procedure, restorative proctocolectomy (RPC) or panproctocolectomy (PPC) with end ileostomy. Single incision surgery is gaining popularity in this group of patients. METHOD: Patients who underwent single incision surgery for medically refractory UC from 2013 January to 2015 December were prospectively followed up. Demographics, hospital stay and early complications were analyzed. Mann-Whitney U test was used to compare the medians. RESULTS: A total of 34 patients (male – 24, median age – 41.5 years; range 17–69 years) were included. There were 21 STCs, 9 PPCs and 4 RPCs done as primary surgery for medically refractory UC. The median hospital stay was 7 days (4–41 days). Four out of 34 patients had a complication with Clavien-Dindo score above 3; (2-re-operation for obstruction (5%), 2 required intensive care for sepsis (5%). Two procedures (5.8%) had to be converted strategically to open. Three patients had cancer in the resected specimen. The median age of those who had PPC was significantly higher compared to those who had restorative procedures (48 years: range 17–69 Vs 38 years: range 34–64; P < 0.005). CONCLUSION: Single incision surgery for medically refractory UC is safe with an acceptable complication profile in this group of medically unwell patients. The quality of life implications of this procedure require further evaluation.Item Single incision laparoscopic surgery (SILS) for primary surgery in medically refectory ulcerative colitis: a case series(Wiely-Blackwell, 2016) Chandrasinghe, P.C.; Leo, C.A.; Samaranayake, S.F.; Santorelli, C.; Strouhal, R.; Warusavitarne, J.AIM:Medically refractive ulcerative colitis (UC) requires surgical intervention. Primary surgery includes subtotal colectomy (STC), restorative proctocolectomy (RPC) or panproctocolectomy (PPC) with end ileostomy. Single incision surgery is gaining popularity in this group of patients. METHOD: Patients who underwent single incision surgery for medically refractory UC from 2013 January to 2015 December were prospectively followed up. Demographics, hospital stay and early complications were analysed. RESULTS: A total of 34 patients were included. There were 21 STCs, 9 PPCs and 4 RPCs done as primary surgery for medically refractory UC. The median hospital stay was 7 days (range: 4–41 days). Four out of 34 patients had a complication with Clavien-Dindo score above 3; (2-re-operation for obstruction (5%), 2 required intensive care for sepsis (5%). Two procedures (5.8%) had to be converted strategically to open. Three patients had cancer in the resected specimen. The median age of those who had PPC was significantly higher compared to those who had restorative procedures (48 years: range 17–69 vs 38 years: range 34–64; P < 0.005). CONCLUSION: Single incision surgery for medically refractory UC is safe with an acceptable complication profile. The quality of life implications of this procedure require further evaluation.Item Long-term function after transanal versus transabdominal ileal pouch-anal anastomosis for ulcerative colitis: a multicenter cohort study(Wiely-Blackwell, 2019) Chandrasinghe, P.; Carvello, M.; Wasmann, K.; Tanis, P.; Warusavitarne, J.; Spinelli, A.; Bemelman, W.AIM:The novel transanal approach to ileal pouch-anal anastomosis (ta-IPAA) provides better exposure with lower short-term morbidity in ulcerative colitis (UC). The aim of this study was to assess the long-term outcomes after ta-IPAA versus abdominal IPAA (abd-IPAA) in UC. METHOD:This is a multicentre cohort analysis between March 2002 and September 2017. Patient characteristics, surgical details and postoperative outcomes were compared. The primary end-point was CGQL (Cleveland Global Quality of Life) score at 12 months. RESULTS:374 patients (100 ta-IPAA vs 274 abd-IPAA) were included. Mean CGQL scores were comparable between the two groups (0.75 ± 0.11 vs 0.71 ± 0.14; respectively, P = 0.1). Quality of life (7.71 ± 1.17 vs 7.30 ± 1.46; P = 0.04) and energy level (7.16 ± 1.52 vs 6.66 ± 1.68; P = 0.03) were significantly better after ta-IPAA, while the quality of health item was comparable (7.68 ± 1.26 vs 7.64 ± 1.44; P = 0.9655). Stool frequencies (> 10/24 h:22% vs 21%; P = 1.0) and major incontinence rates (27% vs 26%; P = 0.89) were similar. Thirty-day morbidity rates (33% vs 41%; P = 0.2) and anastomotic leak rates were comparable (6% vs 13%; P = 0.09). CONCLUSION: This study, for the first time, provides evidence of comparable long-term functional outcome of ta-IPAA vs abd-IPAA for UC.Item Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents.(Springer-Verlag, 2018) Zaghiyan, K.; Warusavitarne, J.; Spinelli, A.; Chandrasinghe, P.; Di Candido, F.; Fleshner, P.PURPOSE: Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents. METHODS: Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated. RESULTS: Sixty-two patients (median age 38 years; range 16-68 years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n = 55 (89%)]. Median surgical time was 266 min (range 180-576 min) and blood loss 100 ml (range 10-500 ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers. CONCLUSIONS: This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.Item Randomised trial to determine the optimum level of pouch-anal anastomosis in stapled restoractive proctocolectomy(Lippincott Williams and Wilkins, 1995) Deen, K.I.; Williams, J.G.; Grant, E.A.; Billingham, C.; Keighley, M.R.B.PURPOSE:This study was undertaken to identify the optimum level of stapled ileal pouch-anal anastomosis. METHOD: A prospective, randomized trial was completed to compare double-stapled ileoanal anastomosis placed at the top of anal columns (high, n = 26) with anastomosis at the dentate line (low, n = 21). RESULTS: There was no significant difference in the overall complication rate between operations (high, n = 7, vs. low, n = 8; P < 0.21). Pouch-anal functional score (scale 0-12; 0 = excellent, 12 = poor) was significantly better in the high anastomosis group (median (range): 2 (1-9) vs. 5.5 (1-12); P < 0.05). Incontinence occurred in only two patients randomized to high anastomosis compared with six in the low anastomosis group. Nocturnal soiling was reported in three patients after high anastomosis and in six patients after dentate line anastomosis. Both operations caused a significant but comparable reduction of maximum and resting pressure (31 percent after high anastomosis (P < 0.05); 23 percent after low anastomosis (P < 0.05)). However, a significant fall in functional length of the anal canal was only seen after a low pouch-anal anastomosis (P < 0.05). CONCLUSION: Stapled pouch-anal anastomosis at the top of anal columns gives better functional results compared with a stapled anastomosis at the dentate line.Item Histological assessment of the distal 'doughnut' in patients undergoing stapled restorative proctocolectomy with high or low anal transection(1994) Deen, K.I.; Hubscher, S.; Bain, I.; Patel, R.; Keighley, M.R.A non-randomized prospective study of 38 patients, 32 with ulcerative colitis and six with familial adenomatous polyposis (FAP), who underwent high or low anal transection during stapled restorative proctocolectomy was undertaken. The median (range) height of the staple line 6 months after operation was 5.2 (3.2-6.0) cm after high transection compared with 2.9 (1.8-3.6) cm after low transection. Nineteen of 20 patients after high anal transection had columnar epithelium in the distal 'doughnut' versus 16 of 18 after low transection. Active colitis was present in 12 of 19 'doughnuts' in patients with high anal transection and columnar mucosa and in seven of 16 after low transection. Nine patients (high transection two, low transection seven; P < 0.05) had striated muscle in the stapled distal 'doughnut'. Dysplasia was found in the resected colon in one patient with ulcerative colitis and adenocarcinoma in two colectomy specimens (ulcerative colitis, one; FAP, one). No dysplasia or carcinoma was seen in any of the 'doughnuts' from patients with ulcerative colitis. Four patients with FAP (high transection, two; low transection, two) had microadenoma in the distal 'doughnut'. Despite attempts to place a stapled pouch-anal anastomosis below the anal transition zone, it was not possible to remove columnar mucosa completely from the remaining anal canal in most patients (16 of 18). High anal transection and pouch-anal anastomosis should be the preferred option in restorative proctocolectomy, as a dentate-line anastomosis may not fully eliminate columnar epithelium and may involve resection of some of the external sphincter.Item The Traeatment of ulcerative colitis : from cure to a new disease(Sri Lanka Medical Association, 1994) de Silva, H.J.Item Persistent ileitis after ileal salvage from a failed Kock pouch(Blackwell Scientific Publications, 1992) de Silva, H.J.; Mortensen, N.J. Mc. C.A case of persistent ileitis following the refashioning of a Kock ileal pouch into a Brooke ileostomy for severe pouchitis is reported. Preserving the terminal ileum by a salvage procedure may not be a safe alternative to pouch excision with the formation of a new end ileostomy in the surgical management of pouchitis refractory to medical treatment.Item Mucosal characteristics of pelvic ileal pouches(British Medical Assosiation, 1991) de Silva, H.J.; Millard, P.R.; Kettlewell, M.; Mortensen, N.J.; Prince, C.; Jewell, D.P.This study aimed to investigate the degree of colonic metaplasia in ileo - anal pouches. Biopsy specimens from 25 patients with functioning pouches, eight of whom had pouchitis, were studied using routine histology, mucosal morphometry, mucin histochemistry, and immunoperoxidase staining with monoclonal antibodies directed towards a 40kD colonic protein and a small bowel specific disaccharidase-sucrase isomaltase. Thirteen patients (including all eight with pouchitis) had subtotal or total villous atrophy and crypt hyperplasia. In this group, nine had colorectal type sulphomucin and the 40kD colonic protein was detected in two. These changes were not observed in patients with less severe villous abnormalities. Sucrase-isomaltase activity was, however, present in all 25 pouch specimens. We conclude that although some ileal pouches acquire certain colonic characteristics, complete colonic metaplasia does not occur.Item Crypt cell proliferation and HLA-DR expression in pelvic ileal pouches(BMJ Publishing Group, 1990) de Silva, H.J.; Gatter, K.C.; Millard, P.R.; Kettlewell, M.; Mortensen, N.J.; Jewell, D.P.To investigate the nature of the morphological changes that occur in ileal pouches, 26 biopsy specimens from patients with functioning ileo-anal pouches (eight with pouchitis) were studied. Normal ileum (n = 10) was used as a control. Mucosal morphometry (using linear measurements), crypt cell proliferation (CCP) (using the monoclonal antibody Ki67), and epithelial HLA-DR expression (monoclonal antibody CR3/43) were assessed. CCP (expressed as the percentage of Ki67 positive nuclei for each crypt) was significantly higher in pouches with pouchitis, compared with those without, and in pouches without pouchitis compared with normal ileum. CCP values in some pouches without pouchitis approached values found in those with pouchitis. CCP was related inversely to villous height and an index of villous atrophy (VH/TMT), and directly to crypt depth. In the presence of pouchitis there was intense epithelial HLA-DR expression that extended into the crypts. In some pouches with high CCP values, but without clinically important inflammation, surface epithelial HLA-DR expression was weak and patchy. It is concluded that villous atrophy and crypt hyperplasia in ileal pouches are associated with high CCP values. These may be increased even in the absence of active inflammation, and this increase may occur as a response to the new luminal environment.