Conference Presentations by Dumind Niwunhella
Annual Research Composium - University of Kelaniya, 2014
The Journal of the College of Ophthalmologists of Sri Lanka , 2014
The dimensions of the orbit are of importance in the management of orbital pathologies. The avera... more The dimensions of the orbit are of importance in the management of orbital pathologies. The average height and width of the orbital cavity as given in literature are respectively 35mm and 40mm1. However numerous studies have shown that orbital dimensions change according to race and ethnicity2. 24 dry adult Sri Lankan skulls were used for this study. Orbital height and width were directly measured using the Vernier Caliper. The mean orbital height for the left and right orbit was respectively 33.39mm and 32.86mm. The mean orbital width of the left and right orbit was respectively 38.45mm and 37.84mm. The mean orbital index (orbital height/ orbital width) was 87. Therefore the study population belongs to the mesoseme (intermediate) category. This study will be of service not only to ophthalmologists but also for craniofacial surgeons, forensic experts, anthropologists and anatomists
50th Annual Academic Sessions - The College f Surgeons of Sri Lanka, 2021
Introduction: Esophageal carcinoma is a well prevalent cause of cancer in Sri Lanka, being the 3r... more Introduction: Esophageal carcinoma is a well prevalent cause of cancer in Sri Lanka, being the 3rd commonest cancer in males & 4th commonest cancer in females (1). Whilst the open surgery for esophageal cancers are being practised, laparoscopic esophagectomy are now known to minimize overall post operative patient morbidity (2). Laparoscopic three stage (McKeown) esophagectomy with cervical anastomosis is a well known and established technique for minimally invasive surgery for esophageal carcinoma.
Methods: Study in cooperated consecutive 21 patients who underwent laparoscopic McKeown surgery from May 2017 to May 2021 at General Hospital Hambanthota to study surgical sequel of patients with esophageal carcinoma who underwent three stage (McKeown) esophagectomy. Following discharge, post operative patients were followed up weekly for one month, monthly for 3 months and every 3 monthly thereafter up to 3 years.
Results: 5 patients in 2017, 7 in 2018, 5 in 2019, 2 in 2020 & 2 in 2021 have been operated. Males were predominant in presentation [n = 13(62%)] . Mean age of presentation was 61.6 years for males, 63.2 years for females. Anatomical location of cancer depicted 23.8% (n=5) mid esophageal & 76.2% (n = 16) lower esophageal/ gastro esophageal junction (GOJ) tumors. sole GOJ tumors comprised of 42.8% (n = 9) where I mid esophageal lesion comprised a synchronous upper esophageal lesion (4.7%). Squamous cell carcinoma prevalence was 66.6% (n = 14) 71.4% had T3 staging and 33.3% showed positive nodes before neoadjuvant therapy with no reduction has been observed in post neoadjuvant CT. 66.6% (n = 14) were given neo adjuvant radiotherapy & 7 patients (50%) showed T3 to T2 down-staging as per post neo adjuvant CT findings. Pathological staging was compatible with post neo adjuvant radiological staging in 13 cases (62%); 24% were down staged from T3 to T2 or T1 than CT & 14% were upstaged From T2 to T3 than CT findings. Mean operating time was 210 minutes. Conversion to open surgery rate was zero. Mean LN harvest was rate 16 (4-26). Intra operative blood loss ranged 150-600cc. Post operative mean ICU stay was 4 days. 57% (n = 12) had uncomplicated post operative recovery. Four out of them expired within first 30 days post operative period. One patient out of them underwent re exploration due to refeeding syndrome with duodenal perforation and expired on post op day 15. No deaths were reported after day 30 as a complication of esophagectomy. 24% (n=5) had post operative pneumonia, 14% * (n = 3) had unilateral vocal cord palsy and 9.5% (n=2) had cervical anastomosis leak which were conservatively managed and recovered. Mean hospital stay was 17 (11-43) days. Strictures at anastomosis sites were not reported.
Discussion: Laparoscopic three stage McKeown esophagectomy with cervical anastomosis depicted up to 80.95% overall survival, 27% uneventful post op recovery and 0% mortality following post op 30 days period and 0% mortality following post op 30 days period & 0% conversion rate to open surgery, upon the current follow up data and involves minimal blood loss which are positive factors to depict as a safe procedure to offer for patients up to T4 esophageal carcinoma. Neo adjuvant radiotherapy provides a significant down staging to further benefit the patients. The main morbidity factors noted in the surgery were pneumonia and unilateral vocal cord palsy.
45th Annual Academic Sessions - The College of Surgeons of Sri Lanka, 2016
Introduction
The vermiform appendix may occupy several positions. The commonest position seen in ... more Introduction
The vermiform appendix may occupy several positions. The commonest position seen in clinical practice is retrocaecal. Other positions, including retrocolic, pelvic, subcaecal and pre or postilial, are occasionally seen. This anatomical variation is a challenge during open appendectomy because it may require an extension of the skin incision or additional muscle splitting or muscle cutting. It may increase the morbidity of the surgery.
Methods
We have assessed the position of the appendix in all patients undergo open and laparoscopic appendicectomy for acute appendicitis in surgical wards In General Hospital Trincomalee from August 2015 to January 2016. The percentages of different positions of appendix were calculated.
Results
22 male and 17 female patients (total 39) with acute appendicitis were included to the study, with age range of 6 years to 71 years; Mean- 27.6 years (SD-17.5 years). Retrocaecal 53.8%, Retro colic 12.8%, Pelvic 23.1%, Postileal 7.7%, Sub caecal 2.6%
Conclusion
Our study indicates that retrocaecal is the commonest position while the pelvic appendix is the second commonest. Although there is ethnic variation of position of appendix, our study results do not deviate from international values. In western literature retrocaecal and retrocolic appendix together account for 65% of incidence and it can present in the iliac fossa in 31%.
College of Surgeons Sri Lanka, 2021
Introduction: Exposure through close interpersonal interactions is the main modality of transmiss... more Introduction: Exposure through close interpersonal interactions is the main modality of transmission in SARS CoV-2. Hospitals being such main interaction points, usage of personal protective equipments, hand washing, surface sanitization are the common measures taken for exposure prevention. In line with the evolving trend for telemedicine, this study elaborates the practical feasibility of managing surgical out patients in a tertiary care centre, by direct communication between the doctor & patients using freely available smart phone applications. Methods: This study in cooperated a single doctor coordinating 1635 consecutive patients over 15 months through 'Whatsapp' platform, who were seen at first clinic visits or discharged following inward care. Multiple call log data was analyzed using 'Callyzer' - call analyzing application. An online questionnaire distributed through whatsapp was used to assess patient feedback. 'TimeTree' application was used to schedule surgeries and procedures to prevent inter-HCW spread due to use of a common book entry. Results: Average total call time spent was 33 minutes per day. This method prevented 686 physical visits to hospital without having any undue morbidity/ mortality, out of 57% feedbacks received, and TimeTree application completely avoided using a common book entries and therefore prevented more than 1908 times of handling a common diary. Discussion: Provided this method is carefully handled by multiple doctors in surgical unit, it is a practical, feasible and a safe way to distantly manage patients and an effective way to prevent SARS CoV-2 exposure in the community specially between patients and health care workers.
35th Annual Scientific Sessions 2021 - Sri Jayawardenepura Teaching Hospital, 2021
Background: Cholecysto-colonic fistula (CCF) is the second most common cholecysto-enteric fistula... more Background: Cholecysto-colonic fistula (CCF) is the second most common cholecysto-enteric fistula and is often discovered intra-operatively. The current case depicts a rare variety; cholecysto-duodenal (D2)- appendiceal fistula of a 55 years old female patient with a history of
cholecystitis and endometriosis. Cholecysto-colonic fistulae are mostly found in women in their 6th to 7th decade and is rarely diagnosed preoperatively. Yet we report that the current case was evident during CECT abdomen as cholecysto-colonic fistula but intra-operatively precisely found to be dual fistula consisting of 1.) Cholecysto-duodenal (D2) fistula with a stone impacted in between the fistula tract without perforation to peritoneal cavity, & amp; 2.) cholecysto-appendiceal
fistula with appendix fused to gall bladder forming a tract and also adhered from serosal layer to the duodenum. The rare positioning of high located appendix along with recurrent cholecystitis must have may have caused the tip of the appendix to fistulate with the inflamed gallbladder.
Method: Open cholecystectomy, D2 repair and appendicectomy was performed in this patient was unremarkably recovered without subsequent peritonitis or ileus. CCF presents as an acute onset disease entity mostly with biliary ileus; yet this patient presented with typical signs and symptoms of cholecystitis without loose stools or ileus. In 1/4th of such patients with CCF, a second hepatobiliary abnormality is found including gall bladder cancer in 2% cases, but none found with regard to current patient.
Conclusion: CCF presentation may vary from typical cholecystitis presentation to gall stone ileus. Pre operative CECT plays a good role in identifying yet intraoperative findings may be more precise than imaging study conclusions.
Annual Scientfic Sessions 2019, Sri Jayawardenepura Teaching Hospital, 2019
Introduction : To assess a surgical case with oesophageal carcinoma caused late liver metastasis ... more Introduction : To assess a surgical case with oesophageal carcinoma caused late liver metastasis following complete and timely resection of tumor.
Case: Patient was managed in surgical ward and clinics at SJGH - 65 years old female (BMI-17.5kg/m2) with a history of total thyroidectomy for invasive follicular carcinoma 6 months prior to this presentation, presented with progressive worsening of dysphagia for solids for two months. UGIE picked a malignant oesophageal growth at 25cm-35cm. Histology revealed squamous cell carcinoma. CECT staging- T3N1M0 with extension into gastric cardia without local invasion. Neo-adjuvant chemo-radiation given for 6 weeks. PET scan and CECT followed by chemo-radiation revealed same staging with comparative reduction of tumor size. Repeat UGIE revealed regression of intraluminal mass. Laperoscopic oesophagectomy done and recovery was uneventful with regard to anastomosis. Histology of the resected segment revealed squamous cell carcinoma with lympho-vascular embolism. Clearance was adequate and 1/3rd of the resected lymph nodes were positive for tumor deposits with extra nodal extensions. On follow up, the patient defaulted after 2 weeks on follow up, later found to have liver metastasis after 4 months from the oesophagectomy, in another hospital.
Discussion/ Conclusions: Neo-adjuvant chemo radiation & surgical technique used are complying with current standard research findings. Although, despite neoadjuvant chemo-radiation followed by eosophagectomy with adequate surgical resection margins, OSCC metastasized due to involved regional lymph node status - therefore acted as a poor prognostic factor.
Sri Lanka Journal of Surgery, 2021
ERCP is the main modality of interventional treatment for biliary & pancreatic diseases. Purpose ... more ERCP is the main modality of interventional treatment for biliary & pancreatic diseases. Purpose of this study was to evaluate the outcomes & safety upon our experience of ERCP over the past 2 years. Methods: All patients (n=32) underwent ERCPP from 2019 January to 2020 December were selected. Intra-procedure & post procedure details with special focus on duration of cannulation (including stenting) versus pancreatitis were assessed. All patients were followed up to at least 6 months post-procedure. Results: Males =9 & females =23 with mean ages 52.7 and 60.5 years respectively; all ERCPs were done for therapeutic purposes; most common presentation was bile duct stones (75%, n=24); stone extraction rate was 62.5%; stent insertion rate (71.8%, n=23); 22% (n=7)cases managed only with a sphincterotomy 6.2% managed with a precut papillotomy; mean total procedure time - 37.5min (15-75min); mean cannulation duration -24.2min (10-40min) mean number of ampullary cannulation attempts was 1.78 for all cases; 12.5% (n=4) pancreatic duct stenting done with mean cannulation duration of 16.5min; one patient (25%) had post procedure acute pancreatitis with maximum Ranson's score of 5 and recovered with 4 day post procedure hospital stay; mean hospital stay - 2.1days; No iatrogenic cholangitis/ bile duct or pancreatic duct strictures or morality reported so far. Discussion: ERCP depicts high clinical success rate in acute set ups. Cannulation durations less than 40 minutes show successful recovery rates without significant morbidity. Conclusions: ERCP is a safe, life-saving procedure with less frequency of morbidity & mortality
KDU International Conference - Medicine (2014), 2014
Introduction: The jugular foramen has a wide ethnic variation in the anatomy and is a well known ... more Introduction: The jugular foramen has a wide ethnic variation in the anatomy and is a well known area for pathological lesions such as glomus tumors, Schwannomas etc, where such lesions are approached by drilling the bone around the jugular foramen. The authors intended to describe the morphometry and anatomical variations of the jugular foramen and the possible dimensional distinction between the jugular foramen and the jugular fossa. Methods: A descriptive study of 24 skulls was done regardless of the gender, to describe the mophometry of jugular foramen and jugular fossa along with scaled photographs. Comparisons between the right & left jugular foramen/ jugular fossa and comparison of jugular foramen & jugular fossa on the same side were done using the student t-test. Results: We found that the jugular foramen was present bilaterally in all the skulls studied. The mean ML diameter of the jugular foramen was larger in the right 16.02(±2.46) mm than in the left 15.46(±2.68) mm, which is compatible with previous studies; the mean AP diameters of jugular foramen were 8.28(±1.70) mm on left side and 6.84(±1.76) mm on right side. Conclusion: Therefore the jugular foramen is mophometrically different from jugular fossa at least from the AP diameter (t<0.05 bilaterally) and should be considered as two distinct anatomical structures rather than fossa as a section of foramen. The rest of the variations are possibly due to constitutional, racial, gender related or genetic factors and supports previous established data on Jugular foramen.
Papers by Dumind Niwunhella
Appendicitis is the most common abdominal emergency and accounts for nearly or more than 40,000 h... more Appendicitis is the most common abdominal emergency and accounts for nearly or more than 40,000 hospital admissions in England each year(1,2,3). Since 1940s the incidence of hospital admission for acute appendicitis has been falling, but the reason for this decline is not clear (1). An USA study says that appendicitis is most common between the ages of 10 and 20 years; sex, race and geography play a role in incidence (4). A male preponderance exists, with a male to female ratio of 1.4:1; the overall lifetime risk is 8.6% for males and 6.7% for females in the United States. The lifetime risk of appendectomy is 12.0% for males and 23.1% for females.(4)
The diagnosis of acute appendicitis is predominantly a clinical one; many patients present with a typical history and examination findings(1).The diagnostic sequence of colicky central abdominal pain followed by vomiting with migration of the pain to the right iliac fossa may only be present in 50% of patients.(1) Profuse vomiting may indicate development of generalized peritonitis after perforation but is rarely a major feature in simple appendicitis(1,5) . A meta-analysis of the symptoms and signs of acute appendicitis could not demonstrate a single diagnostic feature although it showed that migration of pain was associated with acute appendicitis.(6)
In the Sri Lankan setting, mean age of presentation for appendicitis was 22 years where it was 27 years in GH Trincomalee. More patients underwent open appendicectomy in the SL studies. Laparoscopic approach was used less commonly in a study at Faculty of Medicine, University of Kelaniya Vs GH - Trincomalee (11.9% Vs 11%),however it was utilized more often in the western population (50.5%)(7).Post-operative complications were similarly represented in both UK and comparative Sri Lankan (SL) study, but significantly lesser in our study. More Readmissions were observed in our study (2.5%) than in the comparative SL study (0%) (7). Histologically confirmed appendicitis was seen in a significant greater proportion of SL patients - SL study Vs GH - Trincomalee(93.1%vs. 87.1%).
Clinical history and examination with haematological investigations & ultrasound scanning play the main roles in managing acute appendicitis in SL preoperative setup. CT is used more commonly in western population(7). Appendicectomy is the treatment of choice and is increasingly carried out as a laparoscopic procedure.(1,8,9).
This article reviews the presentation, investigation, diagnostic accuracy, treatment, and complications of acute appendicitis and appendicectomy.
Workload Audit in General Surgical Unit, General Hospital -Trincomalee, Sri Lanka in 2015, 2016
BACKGROUND & SUMMARY: THE POWER OF SURGICAL AUDIT
LIES IN ITS ABILITY TO CLEARLY RECORD COMPLICAT... more BACKGROUND & SUMMARY: THE POWER OF SURGICAL AUDIT
LIES IN ITS ABILITY TO CLEARLY RECORD COMPLICATIONS AND TO
COMPARE CASE MIX FROM YEAR TO YEAR AND BETWEEN
CENTRES IN ORDER TO COMPARE RESULTS. AUDIT IS ALSO VITAL
FOR RESOURCE ALLOCATION, IMPROVING EXISTING SERVICES
AND THE DEVELOPMENT OF NEW SERVICES. THIS PAPER
FOCUSES WORKLOAD IN GH- TRINCOMALEE WITH RESPECT TO
GENERAL SURGERY IN SRI LANKA.
PATIENTS AND METHODS: ALL GENERAL SURGICAL ACTIVITY IN
THE SURGICAL UNIT, GH-TRINCOMALEE UNDER THE
SUPERVISION OF THE AUTHOR, FROM 1ST JANUARY 2015 TO
31ST DECEMBER2015 WAS PROSPECTIVELY DOCUMENTED.
THE SURGICAL PROCEDURES WERE CLASSIFIED ACCORDING TO
THE ROYAL AUSTRALIAN COLLEGE OF SURGEONS' MORBIDITY
AUDIT & LOG BOOK TOOL. THE CASELOAD DETAILS WERE USED
TO DRIVE THE WORKLOAD USING THE INTERMEDIATE
EQUIVALENT (IEV) SYSTEM OF JONES AND COLLINS AND THE
SERVICE EQUIVALENT VALUE (SEV) AS A MEASURE OF
EFFECTIVE CONTRIBUTION OF SURGICAL TRAINEES TO PATIENT
CARE. THE WORKLOAD WAS COMPARED WITH THE
RECOMMENDATIONS OF THE UNITED KINGDOM - COLLINS CD
ET AL.
RESULT: THE MINIMUM TOTAL SURGICAL WORKLOAD WAS
2124IEVS, WHICH IS 3.4TIMES HIGHER THAN THE
RECOMMENDED VALUE. THE MINIMUM SEV IS 896.2 WHICH IS
3.4 TIMES HIGHER THAN THE RECOMMENDED VALUE. THE
MAJOR, COMPLEX MAJOR OPERATIONS IN GH- TRINCOMALLEE
COMPRISED26.7% OF THE GENERAL SURGICAL
WORKLOAD.38% OF THE GENERAL SURGICAL WORK WAS
EMERGENCIES. 84% OF THE EMERGENCY WORKLOAD WAS
MAJOR OR MORE IN TERMS OF COMPLEXITY. UNPLANNED
READMISSIONS RATE WITHIN 30 DAYS OF DISCHARGE WAS24
(0.4% OF ALL ADMISSIONS) 0.86% PATIENTS HAD UNPLANNED
RETURN TO THE THEATRE. TOTAL DEATH RATE WAS 23
INCLUDING 9 DEATHS ON ADMISSION (0.39% OF TOTAL
ADMISSIONS).
CONCLUSIONS: THE GENERAL SURGICAL ACTIVITY IN THE
GENERAL SURGICAL UNIT, GH TRINCOMALEE, IS MORE THAN
WHAT IS RECOMMENDED FOR A DEDICATED GENERAL SURGICAL
UNIT. THIS SHOULD BE THE BASIS FOR ALLOCATION OF
ADEQUATE AND APPROPRIATE RESOURCES FOR A GENERAL
SURGICAL FACILITY.
International Journal of Biological, Biomolecular, Agricultural, Food and Biotechnological Engineering , 2014
Male factor infertility due to endocrine disturbances such as abnormalities in prolactin levels a... more Male factor infertility due to endocrine disturbances such as abnormalities in prolactin levels are encountered in a significant proportion. This case control study was carried out to determine the effects of prolactin on the male reproductive tract, using 200 male white rats. The rats were maintained as the control group (G1), hypoprolactinaemic group (G2), 3 hyperprolactinaemic groups induced using oral largactil (G3), low dose fluphenazine (G4) and high dose fluphenazine (G5). After 100 days, rats were subjected to serum prolactin (PRL) level measurements and for basic seminal fluid analysis (BSA). The difference between serum PRL concentrations of rats in G2, G3, G4 and G5 as compared to the control group were highly significant by Student’s t-test (p<0.001). There were statistically significant differences in seminal fluid characteristics of rats with induced prolactin abnormalities when compared with those of control group (p value <0.05), effects were more marked as the PRL levels rise.
Sri Lanka Journal of Obstetrics and Gynaecology , 2018
Background: Sexually Transmitted Infections (STIs) are a major global public health issue leading... more Background: Sexually Transmitted Infections (STIs) are a major global public health issue leading to many physical, psychological and social consequences. Sri Lanka has a low prevalence of HIV and needs to target key population (KPs) at higher risk of infection. This study examines the district wise STI incidences and KPs in Sri Lanka to evaluate the trends and relationships of STIs and to provide recommendations for further investigations. Methods: Data were extracted from the National STD/AIDS Control Programme (NSACP) report for the year 2015 in Sri Lanka. Canonical Correspondence Analysis (CCA) was carried out to identify how STIs correlate with male/female sex workers within districts using PC-ORD 4 software. Results: Colombo district was at high risk for all tested STIs. The relationship of STIs among districts was examined by CCA and three distinguishable clusters were identified. The first group included seven districts and four STIs. The second group included five districts associated with genital herpes. Third group comprised of two districts correlated with late syphilis and gonorrhoea. Most districts with high STI incidences correlated well with districts with densely clustered KPs. Districts where KPs are clustered
Thesis Chapters by Dumind Niwunhella
Drafts by Dumind Niwunhella
Oman - Workload audit in General practice and Emergency medicine setting, 2022
There has been a growing realization that good resource planning requires effective measurement o... more There has been a growing realization that good resource planning requires effective measurement of medical and surgical workload by good audit. This paper examines the general practitioner and associated emergency room workload at Mahoot Health Centre, Al Wosta Governorate, Sultanate of Oman, utilizing the details extracted from the built in patient data entry system
(1) The power of a medical/ surgical audit lies in its ability to clearly record patient presentations/ complications and to compare case mix from year to year and for a single health care worker/ doctor or in larger scale - between health provider centers in order to compare results. Audit is also vital for resource allocation, improving existing services and the development of new services
(2) This is an audit that covers all the workload carried by the author in the mentioned health centre within the duration he engaged working, where there are General Practitioner duties admixed with Emergency patient management, with 5 days - 7 hours shifts plus 2 to 3 night on-call days comprising of 7 - 10 hours emergency on-call duties were carried out throughout the study duration. Basically, 2 days per week is considered as off days.
A contribution of 12.15% for General Practitioner consultations among 9 doctors and 1 dentist; 35.89% contribution towards emergency patient management had been provided by author. In addition, multiple surgical procedures has been carried out successfully and has been successfully played as a team member during patient management to minimize patient morbidity and mortality.
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Conference Presentations by Dumind Niwunhella
Methods: Study in cooperated consecutive 21 patients who underwent laparoscopic McKeown surgery from May 2017 to May 2021 at General Hospital Hambanthota to study surgical sequel of patients with esophageal carcinoma who underwent three stage (McKeown) esophagectomy. Following discharge, post operative patients were followed up weekly for one month, monthly for 3 months and every 3 monthly thereafter up to 3 years.
Results: 5 patients in 2017, 7 in 2018, 5 in 2019, 2 in 2020 & 2 in 2021 have been operated. Males were predominant in presentation [n = 13(62%)] . Mean age of presentation was 61.6 years for males, 63.2 years for females. Anatomical location of cancer depicted 23.8% (n=5) mid esophageal & 76.2% (n = 16) lower esophageal/ gastro esophageal junction (GOJ) tumors. sole GOJ tumors comprised of 42.8% (n = 9) where I mid esophageal lesion comprised a synchronous upper esophageal lesion (4.7%). Squamous cell carcinoma prevalence was 66.6% (n = 14) 71.4% had T3 staging and 33.3% showed positive nodes before neoadjuvant therapy with no reduction has been observed in post neoadjuvant CT. 66.6% (n = 14) were given neo adjuvant radiotherapy & 7 patients (50%) showed T3 to T2 down-staging as per post neo adjuvant CT findings. Pathological staging was compatible with post neo adjuvant radiological staging in 13 cases (62%); 24% were down staged from T3 to T2 or T1 than CT & 14% were upstaged From T2 to T3 than CT findings. Mean operating time was 210 minutes. Conversion to open surgery rate was zero. Mean LN harvest was rate 16 (4-26). Intra operative blood loss ranged 150-600cc. Post operative mean ICU stay was 4 days. 57% (n = 12) had uncomplicated post operative recovery. Four out of them expired within first 30 days post operative period. One patient out of them underwent re exploration due to refeeding syndrome with duodenal perforation and expired on post op day 15. No deaths were reported after day 30 as a complication of esophagectomy. 24% (n=5) had post operative pneumonia, 14% * (n = 3) had unilateral vocal cord palsy and 9.5% (n=2) had cervical anastomosis leak which were conservatively managed and recovered. Mean hospital stay was 17 (11-43) days. Strictures at anastomosis sites were not reported.
Discussion: Laparoscopic three stage McKeown esophagectomy with cervical anastomosis depicted up to 80.95% overall survival, 27% uneventful post op recovery and 0% mortality following post op 30 days period and 0% mortality following post op 30 days period & 0% conversion rate to open surgery, upon the current follow up data and involves minimal blood loss which are positive factors to depict as a safe procedure to offer for patients up to T4 esophageal carcinoma. Neo adjuvant radiotherapy provides a significant down staging to further benefit the patients. The main morbidity factors noted in the surgery were pneumonia and unilateral vocal cord palsy.
The vermiform appendix may occupy several positions. The commonest position seen in clinical practice is retrocaecal. Other positions, including retrocolic, pelvic, subcaecal and pre or postilial, are occasionally seen. This anatomical variation is a challenge during open appendectomy because it may require an extension of the skin incision or additional muscle splitting or muscle cutting. It may increase the morbidity of the surgery.
Methods
We have assessed the position of the appendix in all patients undergo open and laparoscopic appendicectomy for acute appendicitis in surgical wards In General Hospital Trincomalee from August 2015 to January 2016. The percentages of different positions of appendix were calculated.
Results
22 male and 17 female patients (total 39) with acute appendicitis were included to the study, with age range of 6 years to 71 years; Mean- 27.6 years (SD-17.5 years). Retrocaecal 53.8%, Retro colic 12.8%, Pelvic 23.1%, Postileal 7.7%, Sub caecal 2.6%
Conclusion
Our study indicates that retrocaecal is the commonest position while the pelvic appendix is the second commonest. Although there is ethnic variation of position of appendix, our study results do not deviate from international values. In western literature retrocaecal and retrocolic appendix together account for 65% of incidence and it can present in the iliac fossa in 31%.
cholecystitis and endometriosis. Cholecysto-colonic fistulae are mostly found in women in their 6th to 7th decade and is rarely diagnosed preoperatively. Yet we report that the current case was evident during CECT abdomen as cholecysto-colonic fistula but intra-operatively precisely found to be dual fistula consisting of 1.) Cholecysto-duodenal (D2) fistula with a stone impacted in between the fistula tract without perforation to peritoneal cavity, & amp; 2.) cholecysto-appendiceal
fistula with appendix fused to gall bladder forming a tract and also adhered from serosal layer to the duodenum. The rare positioning of high located appendix along with recurrent cholecystitis must have may have caused the tip of the appendix to fistulate with the inflamed gallbladder.
Method: Open cholecystectomy, D2 repair and appendicectomy was performed in this patient was unremarkably recovered without subsequent peritonitis or ileus. CCF presents as an acute onset disease entity mostly with biliary ileus; yet this patient presented with typical signs and symptoms of cholecystitis without loose stools or ileus. In 1/4th of such patients with CCF, a second hepatobiliary abnormality is found including gall bladder cancer in 2% cases, but none found with regard to current patient.
Conclusion: CCF presentation may vary from typical cholecystitis presentation to gall stone ileus. Pre operative CECT plays a good role in identifying yet intraoperative findings may be more precise than imaging study conclusions.
Case: Patient was managed in surgical ward and clinics at SJGH - 65 years old female (BMI-17.5kg/m2) with a history of total thyroidectomy for invasive follicular carcinoma 6 months prior to this presentation, presented with progressive worsening of dysphagia for solids for two months. UGIE picked a malignant oesophageal growth at 25cm-35cm. Histology revealed squamous cell carcinoma. CECT staging- T3N1M0 with extension into gastric cardia without local invasion. Neo-adjuvant chemo-radiation given for 6 weeks. PET scan and CECT followed by chemo-radiation revealed same staging with comparative reduction of tumor size. Repeat UGIE revealed regression of intraluminal mass. Laperoscopic oesophagectomy done and recovery was uneventful with regard to anastomosis. Histology of the resected segment revealed squamous cell carcinoma with lympho-vascular embolism. Clearance was adequate and 1/3rd of the resected lymph nodes were positive for tumor deposits with extra nodal extensions. On follow up, the patient defaulted after 2 weeks on follow up, later found to have liver metastasis after 4 months from the oesophagectomy, in another hospital.
Discussion/ Conclusions: Neo-adjuvant chemo radiation & surgical technique used are complying with current standard research findings. Although, despite neoadjuvant chemo-radiation followed by eosophagectomy with adequate surgical resection margins, OSCC metastasized due to involved regional lymph node status - therefore acted as a poor prognostic factor.
Papers by Dumind Niwunhella
The diagnosis of acute appendicitis is predominantly a clinical one; many patients present with a typical history and examination findings(1).The diagnostic sequence of colicky central abdominal pain followed by vomiting with migration of the pain to the right iliac fossa may only be present in 50% of patients.(1) Profuse vomiting may indicate development of generalized peritonitis after perforation but is rarely a major feature in simple appendicitis(1,5) . A meta-analysis of the symptoms and signs of acute appendicitis could not demonstrate a single diagnostic feature although it showed that migration of pain was associated with acute appendicitis.(6)
In the Sri Lankan setting, mean age of presentation for appendicitis was 22 years where it was 27 years in GH Trincomalee. More patients underwent open appendicectomy in the SL studies. Laparoscopic approach was used less commonly in a study at Faculty of Medicine, University of Kelaniya Vs GH - Trincomalee (11.9% Vs 11%),however it was utilized more often in the western population (50.5%)(7).Post-operative complications were similarly represented in both UK and comparative Sri Lankan (SL) study, but significantly lesser in our study. More Readmissions were observed in our study (2.5%) than in the comparative SL study (0%) (7). Histologically confirmed appendicitis was seen in a significant greater proportion of SL patients - SL study Vs GH - Trincomalee(93.1%vs. 87.1%).
Clinical history and examination with haematological investigations & ultrasound scanning play the main roles in managing acute appendicitis in SL preoperative setup. CT is used more commonly in western population(7). Appendicectomy is the treatment of choice and is increasingly carried out as a laparoscopic procedure.(1,8,9).
This article reviews the presentation, investigation, diagnostic accuracy, treatment, and complications of acute appendicitis and appendicectomy.
LIES IN ITS ABILITY TO CLEARLY RECORD COMPLICATIONS AND TO
COMPARE CASE MIX FROM YEAR TO YEAR AND BETWEEN
CENTRES IN ORDER TO COMPARE RESULTS. AUDIT IS ALSO VITAL
FOR RESOURCE ALLOCATION, IMPROVING EXISTING SERVICES
AND THE DEVELOPMENT OF NEW SERVICES. THIS PAPER
FOCUSES WORKLOAD IN GH- TRINCOMALEE WITH RESPECT TO
GENERAL SURGERY IN SRI LANKA.
PATIENTS AND METHODS: ALL GENERAL SURGICAL ACTIVITY IN
THE SURGICAL UNIT, GH-TRINCOMALEE UNDER THE
SUPERVISION OF THE AUTHOR, FROM 1ST JANUARY 2015 TO
31ST DECEMBER2015 WAS PROSPECTIVELY DOCUMENTED.
THE SURGICAL PROCEDURES WERE CLASSIFIED ACCORDING TO
THE ROYAL AUSTRALIAN COLLEGE OF SURGEONS' MORBIDITY
AUDIT & LOG BOOK TOOL. THE CASELOAD DETAILS WERE USED
TO DRIVE THE WORKLOAD USING THE INTERMEDIATE
EQUIVALENT (IEV) SYSTEM OF JONES AND COLLINS AND THE
SERVICE EQUIVALENT VALUE (SEV) AS A MEASURE OF
EFFECTIVE CONTRIBUTION OF SURGICAL TRAINEES TO PATIENT
CARE. THE WORKLOAD WAS COMPARED WITH THE
RECOMMENDATIONS OF THE UNITED KINGDOM - COLLINS CD
ET AL.
RESULT: THE MINIMUM TOTAL SURGICAL WORKLOAD WAS
2124IEVS, WHICH IS 3.4TIMES HIGHER THAN THE
RECOMMENDED VALUE. THE MINIMUM SEV IS 896.2 WHICH IS
3.4 TIMES HIGHER THAN THE RECOMMENDED VALUE. THE
MAJOR, COMPLEX MAJOR OPERATIONS IN GH- TRINCOMALLEE
COMPRISED26.7% OF THE GENERAL SURGICAL
WORKLOAD.38% OF THE GENERAL SURGICAL WORK WAS
EMERGENCIES. 84% OF THE EMERGENCY WORKLOAD WAS
MAJOR OR MORE IN TERMS OF COMPLEXITY. UNPLANNED
READMISSIONS RATE WITHIN 30 DAYS OF DISCHARGE WAS24
(0.4% OF ALL ADMISSIONS) 0.86% PATIENTS HAD UNPLANNED
RETURN TO THE THEATRE. TOTAL DEATH RATE WAS 23
INCLUDING 9 DEATHS ON ADMISSION (0.39% OF TOTAL
ADMISSIONS).
CONCLUSIONS: THE GENERAL SURGICAL ACTIVITY IN THE
GENERAL SURGICAL UNIT, GH TRINCOMALEE, IS MORE THAN
WHAT IS RECOMMENDED FOR A DEDICATED GENERAL SURGICAL
UNIT. THIS SHOULD BE THE BASIS FOR ALLOCATION OF
ADEQUATE AND APPROPRIATE RESOURCES FOR A GENERAL
SURGICAL FACILITY.
Thesis Chapters by Dumind Niwunhella
Drafts by Dumind Niwunhella
(1) The power of a medical/ surgical audit lies in its ability to clearly record patient presentations/ complications and to compare case mix from year to year and for a single health care worker/ doctor or in larger scale - between health provider centers in order to compare results. Audit is also vital for resource allocation, improving existing services and the development of new services
(2) This is an audit that covers all the workload carried by the author in the mentioned health centre within the duration he engaged working, where there are General Practitioner duties admixed with Emergency patient management, with 5 days - 7 hours shifts plus 2 to 3 night on-call days comprising of 7 - 10 hours emergency on-call duties were carried out throughout the study duration. Basically, 2 days per week is considered as off days.
A contribution of 12.15% for General Practitioner consultations among 9 doctors and 1 dentist; 35.89% contribution towards emergency patient management had been provided by author. In addition, multiple surgical procedures has been carried out successfully and has been successfully played as a team member during patient management to minimize patient morbidity and mortality.
Methods: Study in cooperated consecutive 21 patients who underwent laparoscopic McKeown surgery from May 2017 to May 2021 at General Hospital Hambanthota to study surgical sequel of patients with esophageal carcinoma who underwent three stage (McKeown) esophagectomy. Following discharge, post operative patients were followed up weekly for one month, monthly for 3 months and every 3 monthly thereafter up to 3 years.
Results: 5 patients in 2017, 7 in 2018, 5 in 2019, 2 in 2020 & 2 in 2021 have been operated. Males were predominant in presentation [n = 13(62%)] . Mean age of presentation was 61.6 years for males, 63.2 years for females. Anatomical location of cancer depicted 23.8% (n=5) mid esophageal & 76.2% (n = 16) lower esophageal/ gastro esophageal junction (GOJ) tumors. sole GOJ tumors comprised of 42.8% (n = 9) where I mid esophageal lesion comprised a synchronous upper esophageal lesion (4.7%). Squamous cell carcinoma prevalence was 66.6% (n = 14) 71.4% had T3 staging and 33.3% showed positive nodes before neoadjuvant therapy with no reduction has been observed in post neoadjuvant CT. 66.6% (n = 14) were given neo adjuvant radiotherapy & 7 patients (50%) showed T3 to T2 down-staging as per post neo adjuvant CT findings. Pathological staging was compatible with post neo adjuvant radiological staging in 13 cases (62%); 24% were down staged from T3 to T2 or T1 than CT & 14% were upstaged From T2 to T3 than CT findings. Mean operating time was 210 minutes. Conversion to open surgery rate was zero. Mean LN harvest was rate 16 (4-26). Intra operative blood loss ranged 150-600cc. Post operative mean ICU stay was 4 days. 57% (n = 12) had uncomplicated post operative recovery. Four out of them expired within first 30 days post operative period. One patient out of them underwent re exploration due to refeeding syndrome with duodenal perforation and expired on post op day 15. No deaths were reported after day 30 as a complication of esophagectomy. 24% (n=5) had post operative pneumonia, 14% * (n = 3) had unilateral vocal cord palsy and 9.5% (n=2) had cervical anastomosis leak which were conservatively managed and recovered. Mean hospital stay was 17 (11-43) days. Strictures at anastomosis sites were not reported.
Discussion: Laparoscopic three stage McKeown esophagectomy with cervical anastomosis depicted up to 80.95% overall survival, 27% uneventful post op recovery and 0% mortality following post op 30 days period and 0% mortality following post op 30 days period & 0% conversion rate to open surgery, upon the current follow up data and involves minimal blood loss which are positive factors to depict as a safe procedure to offer for patients up to T4 esophageal carcinoma. Neo adjuvant radiotherapy provides a significant down staging to further benefit the patients. The main morbidity factors noted in the surgery were pneumonia and unilateral vocal cord palsy.
The vermiform appendix may occupy several positions. The commonest position seen in clinical practice is retrocaecal. Other positions, including retrocolic, pelvic, subcaecal and pre or postilial, are occasionally seen. This anatomical variation is a challenge during open appendectomy because it may require an extension of the skin incision or additional muscle splitting or muscle cutting. It may increase the morbidity of the surgery.
Methods
We have assessed the position of the appendix in all patients undergo open and laparoscopic appendicectomy for acute appendicitis in surgical wards In General Hospital Trincomalee from August 2015 to January 2016. The percentages of different positions of appendix were calculated.
Results
22 male and 17 female patients (total 39) with acute appendicitis were included to the study, with age range of 6 years to 71 years; Mean- 27.6 years (SD-17.5 years). Retrocaecal 53.8%, Retro colic 12.8%, Pelvic 23.1%, Postileal 7.7%, Sub caecal 2.6%
Conclusion
Our study indicates that retrocaecal is the commonest position while the pelvic appendix is the second commonest. Although there is ethnic variation of position of appendix, our study results do not deviate from international values. In western literature retrocaecal and retrocolic appendix together account for 65% of incidence and it can present in the iliac fossa in 31%.
cholecystitis and endometriosis. Cholecysto-colonic fistulae are mostly found in women in their 6th to 7th decade and is rarely diagnosed preoperatively. Yet we report that the current case was evident during CECT abdomen as cholecysto-colonic fistula but intra-operatively precisely found to be dual fistula consisting of 1.) Cholecysto-duodenal (D2) fistula with a stone impacted in between the fistula tract without perforation to peritoneal cavity, & amp; 2.) cholecysto-appendiceal
fistula with appendix fused to gall bladder forming a tract and also adhered from serosal layer to the duodenum. The rare positioning of high located appendix along with recurrent cholecystitis must have may have caused the tip of the appendix to fistulate with the inflamed gallbladder.
Method: Open cholecystectomy, D2 repair and appendicectomy was performed in this patient was unremarkably recovered without subsequent peritonitis or ileus. CCF presents as an acute onset disease entity mostly with biliary ileus; yet this patient presented with typical signs and symptoms of cholecystitis without loose stools or ileus. In 1/4th of such patients with CCF, a second hepatobiliary abnormality is found including gall bladder cancer in 2% cases, but none found with regard to current patient.
Conclusion: CCF presentation may vary from typical cholecystitis presentation to gall stone ileus. Pre operative CECT plays a good role in identifying yet intraoperative findings may be more precise than imaging study conclusions.
Case: Patient was managed in surgical ward and clinics at SJGH - 65 years old female (BMI-17.5kg/m2) with a history of total thyroidectomy for invasive follicular carcinoma 6 months prior to this presentation, presented with progressive worsening of dysphagia for solids for two months. UGIE picked a malignant oesophageal growth at 25cm-35cm. Histology revealed squamous cell carcinoma. CECT staging- T3N1M0 with extension into gastric cardia without local invasion. Neo-adjuvant chemo-radiation given for 6 weeks. PET scan and CECT followed by chemo-radiation revealed same staging with comparative reduction of tumor size. Repeat UGIE revealed regression of intraluminal mass. Laperoscopic oesophagectomy done and recovery was uneventful with regard to anastomosis. Histology of the resected segment revealed squamous cell carcinoma with lympho-vascular embolism. Clearance was adequate and 1/3rd of the resected lymph nodes were positive for tumor deposits with extra nodal extensions. On follow up, the patient defaulted after 2 weeks on follow up, later found to have liver metastasis after 4 months from the oesophagectomy, in another hospital.
Discussion/ Conclusions: Neo-adjuvant chemo radiation & surgical technique used are complying with current standard research findings. Although, despite neoadjuvant chemo-radiation followed by eosophagectomy with adequate surgical resection margins, OSCC metastasized due to involved regional lymph node status - therefore acted as a poor prognostic factor.
The diagnosis of acute appendicitis is predominantly a clinical one; many patients present with a typical history and examination findings(1).The diagnostic sequence of colicky central abdominal pain followed by vomiting with migration of the pain to the right iliac fossa may only be present in 50% of patients.(1) Profuse vomiting may indicate development of generalized peritonitis after perforation but is rarely a major feature in simple appendicitis(1,5) . A meta-analysis of the symptoms and signs of acute appendicitis could not demonstrate a single diagnostic feature although it showed that migration of pain was associated with acute appendicitis.(6)
In the Sri Lankan setting, mean age of presentation for appendicitis was 22 years where it was 27 years in GH Trincomalee. More patients underwent open appendicectomy in the SL studies. Laparoscopic approach was used less commonly in a study at Faculty of Medicine, University of Kelaniya Vs GH - Trincomalee (11.9% Vs 11%),however it was utilized more often in the western population (50.5%)(7).Post-operative complications were similarly represented in both UK and comparative Sri Lankan (SL) study, but significantly lesser in our study. More Readmissions were observed in our study (2.5%) than in the comparative SL study (0%) (7). Histologically confirmed appendicitis was seen in a significant greater proportion of SL patients - SL study Vs GH - Trincomalee(93.1%vs. 87.1%).
Clinical history and examination with haematological investigations & ultrasound scanning play the main roles in managing acute appendicitis in SL preoperative setup. CT is used more commonly in western population(7). Appendicectomy is the treatment of choice and is increasingly carried out as a laparoscopic procedure.(1,8,9).
This article reviews the presentation, investigation, diagnostic accuracy, treatment, and complications of acute appendicitis and appendicectomy.
LIES IN ITS ABILITY TO CLEARLY RECORD COMPLICATIONS AND TO
COMPARE CASE MIX FROM YEAR TO YEAR AND BETWEEN
CENTRES IN ORDER TO COMPARE RESULTS. AUDIT IS ALSO VITAL
FOR RESOURCE ALLOCATION, IMPROVING EXISTING SERVICES
AND THE DEVELOPMENT OF NEW SERVICES. THIS PAPER
FOCUSES WORKLOAD IN GH- TRINCOMALEE WITH RESPECT TO
GENERAL SURGERY IN SRI LANKA.
PATIENTS AND METHODS: ALL GENERAL SURGICAL ACTIVITY IN
THE SURGICAL UNIT, GH-TRINCOMALEE UNDER THE
SUPERVISION OF THE AUTHOR, FROM 1ST JANUARY 2015 TO
31ST DECEMBER2015 WAS PROSPECTIVELY DOCUMENTED.
THE SURGICAL PROCEDURES WERE CLASSIFIED ACCORDING TO
THE ROYAL AUSTRALIAN COLLEGE OF SURGEONS' MORBIDITY
AUDIT & LOG BOOK TOOL. THE CASELOAD DETAILS WERE USED
TO DRIVE THE WORKLOAD USING THE INTERMEDIATE
EQUIVALENT (IEV) SYSTEM OF JONES AND COLLINS AND THE
SERVICE EQUIVALENT VALUE (SEV) AS A MEASURE OF
EFFECTIVE CONTRIBUTION OF SURGICAL TRAINEES TO PATIENT
CARE. THE WORKLOAD WAS COMPARED WITH THE
RECOMMENDATIONS OF THE UNITED KINGDOM - COLLINS CD
ET AL.
RESULT: THE MINIMUM TOTAL SURGICAL WORKLOAD WAS
2124IEVS, WHICH IS 3.4TIMES HIGHER THAN THE
RECOMMENDED VALUE. THE MINIMUM SEV IS 896.2 WHICH IS
3.4 TIMES HIGHER THAN THE RECOMMENDED VALUE. THE
MAJOR, COMPLEX MAJOR OPERATIONS IN GH- TRINCOMALLEE
COMPRISED26.7% OF THE GENERAL SURGICAL
WORKLOAD.38% OF THE GENERAL SURGICAL WORK WAS
EMERGENCIES. 84% OF THE EMERGENCY WORKLOAD WAS
MAJOR OR MORE IN TERMS OF COMPLEXITY. UNPLANNED
READMISSIONS RATE WITHIN 30 DAYS OF DISCHARGE WAS24
(0.4% OF ALL ADMISSIONS) 0.86% PATIENTS HAD UNPLANNED
RETURN TO THE THEATRE. TOTAL DEATH RATE WAS 23
INCLUDING 9 DEATHS ON ADMISSION (0.39% OF TOTAL
ADMISSIONS).
CONCLUSIONS: THE GENERAL SURGICAL ACTIVITY IN THE
GENERAL SURGICAL UNIT, GH TRINCOMALEE, IS MORE THAN
WHAT IS RECOMMENDED FOR A DEDICATED GENERAL SURGICAL
UNIT. THIS SHOULD BE THE BASIS FOR ALLOCATION OF
ADEQUATE AND APPROPRIATE RESOURCES FOR A GENERAL
SURGICAL FACILITY.
(1) The power of a medical/ surgical audit lies in its ability to clearly record patient presentations/ complications and to compare case mix from year to year and for a single health care worker/ doctor or in larger scale - between health provider centers in order to compare results. Audit is also vital for resource allocation, improving existing services and the development of new services
(2) This is an audit that covers all the workload carried by the author in the mentioned health centre within the duration he engaged working, where there are General Practitioner duties admixed with Emergency patient management, with 5 days - 7 hours shifts plus 2 to 3 night on-call days comprising of 7 - 10 hours emergency on-call duties were carried out throughout the study duration. Basically, 2 days per week is considered as off days.
A contribution of 12.15% for General Practitioner consultations among 9 doctors and 1 dentist; 35.89% contribution towards emergency patient management had been provided by author. In addition, multiple surgical procedures has been carried out successfully and has been successfully played as a team member during patient management to minimize patient morbidity and mortality.