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BACKGROUND AND PURPOSE: Hepaticojejunostomy is the reconstructive procedure performed for iatrogenic bile duct injuries. Anastomotic site stricture is the most significant complication of this operation. Revision surgery is associated with a significant morbidity and mortality. Creation of access to the anastomotic site facilitates the management of such strictures by minimal access techniques and reduces the need for revision surgery. This retrospective study aims to investigate the technical accessibility, usefulness, morbidity related to and the outcome of hepaticojejunostomy with gastric access loops performed as the treatment for iatrogenic bile duct injuries. METHODOLOGY: Twenty-seven consecutive patients who have undergone hepaticojejunostomy (including three revision surgeries and a re-revision surgery) with gastric access loops from July 2005 to October 2009 were followed up for clinical, biochemical, radiological and endoscopic evidence of anastomotic site occlusion and the need for intervention. Morbidity related to gastric access loops was assessed by dyspepsia disability score. RESULTS: Mean follow up was 35.4 (range 6-61) months. Three patients developed anastomotic strictures at 4, 22 and 5 months after hepaticojejunostomy and had successful endotherapy via the gastric access loop. They remain well at 33rd, 31st and 3rd months, respectively, following intervention. Based on the dyspepsia disability score none of the patients had symptomatic dyspepsia affecting daily activities. CONCLUSIONS: Gastric access loop is accessible and useful for stricture dilation and other endotherapeutic procedures. In the absence of significant symptoms related to bile reflux, gastric access loop could be considered as a useful and safe adjunct in the management of hepaticojejunostomy by surgeons especially in settings with limited facilities and expertise for radiological manipulations. [ABSTRACT FROM AUTHOR]

Introduction: A significant proportion of patients are being treated at hospitals in the government sector in Sri Lanka. Informal caregivers play a major role in taking care of hospitalized surgical patients while facing physical, social, and psychological challenges., Objective: To describe the socio-economic effects on informal caregivers of long-term hospitalized adult patients., Methods: A cross-sectional descriptive study was conducted among 202 informal caregivers of long-term hospitalized patients in a tertiary care hospital in Sri Lanka, using an interviewer-administered questionnaire. Sociodemographic assessment of both caregiver and care recipient, the health status of the care recipient, effects on social life, and economic aspect of informal caregiver were assessed., Results: Most of the caregivers were married (n=164, 81.2%), first degree relative of the care receiver (n=139, 68.8%), employed (n=115, 56.9%) and sole caregivers (n=130, 64.4%). Four out of 5 caregivers (n=181, 89.6%) showed moderate to severe socio-economic maladaptation. Increasing age (p=0.00), marital status (p=0.00) and sole caregiving (p=0.01) are significantly associated with the level of maladaptation., Conclusion: Moderate to severe levels of maladaptation is present among a substantial number of informal caregivers of long-term hospitalized patients. Sole caregiving is one of the contributing factors and can be addressed by adequate formal caregivers appointed by health care authorities or from voluntary services to minimize informal caregiver burnout.

Pancreatic cancer has a high mortality and morbidity and its incidence has increased over the years. Our objective was to analyze the demographic and clinical data among pancreatic adenocarcinoma patients who presented to the University Surgical Unit, CSTH from 2018 to 2021. Of the 103 patients included, majority were males above the age of 60. The commonest presentation was epigastric pain (54%). 46% were resectable at the time of diagnosis but 50% of the study population were lost to follow up due to a multitude of reasons.

Objective: Published literature so far has supported the fact that patients who underwent endoscopic retrograde cholangio-pancreatography and sphincterotomy (ERCPS) had a difficult perioperative course after subsequent laparoscopic cholecystectomy. Through a retrospective study, this original report mentions statistics in a Southeast Asian population comparing the effect on conversion to open surgery in patients undergoing laparoscopic cholecystectomy after ERCPS in a university hospital in Sri Lanka., Methods: The results of 205 patients who underwent laparoscopic cholecystectomy and 85 patients who were converted to open surgery between 2016 and 2018 were analyzed to find out whether ERCPS is a risk factor for conversion or subsequent perioperative morbidity., Results: Demographics like age, gender and previous abdominal surgeries were comparable between the two groups. Cholecysto-choledocholithiasis and undergoing ERCPS for it were significant factors associated with conversion to open cholecystectomy., Conclusion: Performing laparoscopic cholecystectomy after ERCPS for cholecysto-choledocholithiasis is a significant challenge and preferably should be often handled by a more experienced surgeon., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Sachintha Nandasena et al.)

Objective: Ultrasonography remains the initial imaging modality in the management of biliary disease. This study is designed to evaluate the accuracy of transabdominal ultrasonography in diagnosing biliary pathology in patients with choledocholithiasis., Methods: This was a retrospective study of a continuous sample of patients over a period of 3 years ending in January 2016; these patients were referred for endoscopic management of choledocholithiasis to a tertiary care hospital in Colombo, Sri Lanka. Ultrasound reporting was carried out by different consultant radiologists at both the index and the referring hospitals. The findings of endoscopic retrograde cholangiograms were compared with the ultrasound scan (USS) results., Results: A total of 247 patients were included in the study. USS was 97.4% accurate in detecting intrahepatic duct dilatation (IHDD). Stone counts and the location of stone(s) in the USSs correlated strongly with the number of stones delivered during endoscopic removal and their location in cholangiograms ( P < 0.001). The difference in mean diameter of the common bile duct (CBD) of patients with choledochal cysts (CCs) (18.57 mm) and of patients without them (12.39 mm) is statistically significant ( P < 0.001). At 14.5 mm, the negative predictive value for a CC is 99.02%., Conclusion: Ultrasonography is a reliable tool in predicting IHDD, stone count, and the location of stones in the biliary tree, particularly in a resource-poor setting. A CBD diameter of 14.5 mm in transabdominal ultrasound scan can be used as a cutoff for predicting extrahepatic CC., Competing Interests: There are no conflicts of interest.

Backgrounds/aims: Published data on choledocholithiasis in Sri Lanka is scarce. This study was conducted to determine epidemiological, clinical and endoscopic characteristics of choledocholithiasis in Sri Lanka., Methods: This was a retrospective study of consecutive patients for a period of three years until April 2016. The sample included patients from many parts of the island. Patients were selected from the endoscopy database of the unit and the data were collected from the records of the patients., Results: A total of 253 patients were included in the study. The mean age of the patients was 53.6 years. Patients presented with obstructive jaundice (58.5%), cholangitis (25.3%), biliary colic or upper abdominal pain (14.2%) and acute biliary pancreatitis (1.8%). There were 26 (10.3%) post cholecystectomy patients. Concomitant gallbladder stones were found in 173 patients (68.4%). Juxta-papillary diverticula were found in 36 patients (14.2%). Twenty-one (8.3%) and nine patients (3.6%) were found to have choledochal cysts and common bile duct strictures, respectively. Stones were commonly found in the distal common bile duct (68.4%). A majority of the patients had a single stone (47.8%). In 209 patients (79.6%), the size of the largest stones measured between 0.5-1.5 cm., Conclusions: Choledocholithiasis is a disease affecting middle-aged population with predominance among females in Sri Lanka. Patients with symptomatic choledocholithiasis commonly present with obstructive jaundice. In the present study, most of the stones were formed in anatomically normal biliary systems. Stones were predominantly distal, single and measured 0.5-1.5 cm in size. The observed features were favorable features for successful endoscopic clearance. None of the patients included in the study had primary CBD stones according to the available criteria.

Background: Only a limited number of multiple synchronous primary malignancies of the pancreas have been reported in the medical literature. We report a case of two solid malignant tumors of the pancreas diagnosed preoperatively., Case Presentation: We describe a 65-year-old Sri Lankan woman who presented with progressive obstructive jaundice. Initial contrast-enhanced computed tomography imaging detected a malignant tumor at the tail of her pancreas. A second tumor of the pancreatic head was detected with integrated imaging using multidetector computed tomography and multimodal magnetic resonance imaging. She underwent total pancreaticoduodenectomy and splenectomy. Gross examination of the specimen confirmed the presence of two separate tumors. Histology of the ampullary tumor showed pancreatic-type adenocarcinoma and the tumor in the tail of her pancreas showed a colloid-type adenocarcinoma., Conclusion: The possibility of multiple primary malignant solid tumors of different types with malignant potential has to be considered even without background pathology when managing multiple tumors in the pancreas.

Cystic lymphangioma of the small bowel mesentery is a rare clinical entity, especially after childhood. Medical literature reveals a limited number of such cases presenting as acute abdomen due to bowel obstruction, small bowel volvulus and bleeding into the tumour. We present the management experience of an 18-year-old woman who presented with rapid onset diffuse peritonism and raised inflammatory markers. Computed tomography showed a mass in the small bowel mesentery with suspicion of segmental bowel ischaemia. Emergency laparotomy revealed a mass in the mid-jejunal mesentery close to the bowel wall with no bowel ischaemia. The patient made an uncomplicated recovery after segmental bowel resection and end-to-end anastomosis. Histology confirmed the mass as a cystic lymphangioma involving the jejunal mesentery and two small jejunal polyps. Lymphangioma could be considered in the differential diagnosis of an acute abdomen in a young adult when the presentation is atypical.

Objective: To assess appetite and gut hormone levels in patients following partial (PR) or total resection (TR) of the large bowel., Methods: A comparative cross sectional study was carried out with healthy controls (n = 99) and patients who had undergone PR (n = 64) or TR (n = 12) of the large bowel. Participants consumed a standard (720 kcal) breakfast meal at 0830 (t = 0) h followed by lactulose (15 g) and a buffet lunch (t = 210 min). Participants rated the subjective feelings of hunger at t = -30, 0, 30, 60, 120, and 180 min. Breath hydrogen (BH) concentrations were also evaluated. In a matched subset (11 controls, 11 PR and 9 TR patients) PYY and GLP-1 concentrations were measured following breakfast. The primary outcome measure was appetite, as measured using visual analogue scales and the buffet lunch. The secondary outcome was BH concentrations following a test meal., Results: PR and TR participants had lower hunger and energy intake at the buffet lunch meal compared to controls. PR subjects had higher BH concentrations compared to controls and TR subjects. BH levels correlated with circulating GLP-1 levels at specific time points., Conclusions: PR or TR of the large bowel reduced feelings of hunger and energy intake, and PR increased gastrointestinal fermentation., (© 2016 The Obesity Society.)

Background: Duodenal Peutz-Jeghers polyp is a rare cause of duodenal or biliary obstruction. However, a sporadic Peutz-Jeghers polyp leading to simultaneous biliary and duodenal obstruction has not been reported., Case Presentation: We report a case of a 25-year-old Sri Lankan woman presenting with features of recurrent upper small intestinal obstruction and biliary obstruction. She had clinical as well as biochemical evidence of intermittent biliary obstruction. Evidence of duodenal intussusception was found in a computed tomography enterogram and a duodenal polyp was noted as the lead point. Marked elongation and distortion of her lower common bile duct with intrahepatic duct dilatation was also noted and the ampulla was found to be on the left side of the midline pulled toward the intussusceptum. Open polypectomy and reduction of intussusception were done and she became fully asymptomatic following surgery. Histology of the resected specimen was reported as a typical "Peutz-Jeghers polyp". As there was not enough evidence to diagnose Peutz-Jeghers syndrome this was considered to be a sporadic Peutz-Jeghers polyp., Conclusion: Rare benign causes such as a duodenal polyp should be considered and looked for in initial imaging, when the cause for concurrent biliary and intestinal obstruction is uncertain, particularly in young individuals.

Prediction of thyroid malignancy with fine needle aspiration cytology or individual ultrasound characteristics has several limitations. This study evaluates the usefulness of a combination of ultrasound characteristics in predicting malignancy in patients with thyroid nodules. We assessed 189 thyroid nodules using ultrasonography and histology. Each nodule was assigned a score based on ultrasonographic characteristics. This score was compared with histology to identify ability to predict malignancy. There were 28 malignant nodules. The scoring system was appropriate for clinical use, obtaining an area under ROC curve of 0.822 [p< 0.0001] 95% confidence. FNAC of nodules with a score of more than 4 can be recommended (100% sensitivity). Nodules with a score less than 8 can be offered total thyroidectomy when FNAC is inconclusive (97.5% sensitivity). A combination of ultrasonographic criteria increase the accuracy of predicting malignancy in thyroid nodules.

Objective: Antiseptics are widely used in wound management to prevent or treat wound infections due to their proven wound healing properties regardless of their cytotoxicity. The objective of this study was to determine the bactericidal effects of three antiseptics on pathogens known to cause wound infections., Method: The study was carried out at a tertiary care hospital and a university microbiology laboratory in Sri Lanka in 2013. The three acids (acetic acid, ascorbic acid and boric acid) in increasing concentration (0.5%, 0.75% and 1%) were tested against bacterial suspensions equivalent to 0.5 McFarland standard. The Bacteria isolates used were isolated from wound and standard strains of Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa., Results: There were 33 (68.8%) Coliforms, 10 (20.8%) Pseudomonas species, and 5 (10.4%) strains of Staphylococcus aureus. Acetic acid at concentration of 0.5% inhibited growth of 37 (77%) and 42 (87.5%) of tested isolates when exposed for 30 and 60 minutes, respectively. However 100% inhibition was achieved at four hours. At a concentration of 0.75%, 40 (83.3%) and 44 (91.7%) were inhibited when exposed for 30 and 60 minutes, respectively, with 100% inhibition at 4 hours. At concentration of 1%, 46 (95.8%) inhibition was seen at 30 minutes and 100% inhibition at 60 minutes. Ascorbic acid, at 0.5% and 0.75 % concentrations, inhibited growth of 45(93.7%) and 47(97.9%) of isolates respectively when exposed for 30 minutes. At these two concentrations, 100% inhibition was achieved when exposed for one hour. At 1% concentration, 100% inhibition was achieved at 30 minutes. Boric acid did not show bactericidal effect at concentrations of 0.5%, 0.75 % and 1%. Pseudomonas species were inhibited at 30 minutes by 0.5% acetic acid. Bactericidal effect against all the standard strains was seen with three acids at each concentration tested from 30 minutes onwards, Conclusion: Ascorbic acid was bactericidal for all organisms tested within the shortest exposure time at the lowest concentration compared to other two acids. Despite promising bactericidal effects, further studies warrant, as ongoing debates on toxicity of acids on tissue epithelialisation. Application of antiseptics for a shorter duration could overcome this problem without losing bactericidal activity., Declaration of Interest: The authors have no conflict of interest and no funding was received for this study.

A retrospective comparative study was done to compare the outcome of intermittent Pringle manoeuvre (IPM) and selective hepatic vascular exclusion (SHVE) in 19 major hepatectomies in non-cirrhotic patients that were done from October 2003 to June 2009. Intra-operative blood loss (IBL), total operative time (TOT) and immediate outcome were assessed in the two groups. Thirteen underwent IPM and the others underwent SHVE. The mean age was 50 years (SHVE) and 39.2 years (IPM). Mean IBL was 641 ml and 802 ml in the SHVE and IPM groups respectively (p > .05). TOT was 4.7 hours in both groups. There was one mortality from myocardial infarction in the IPM group and no morbidities in both groups. The results obtained from this study shows that IPM is equivalent to SHVE, with regards to IBL, TOT and immediate outcome in major hepatectomies in non-cirrhotic patients.

Background: Biliary tract injuries are mostly iatrogenic. Related data are limited in developing countries. There are lessons to be learned by revisiting the clinical profiles, management issues and outcome of patients referred to a tertiary care center in Sri Lanka, compared with the previous data from the same center published in 2006. Such a review is particularly relevant at a time of changing global perceptions of iatrogenic biliary injuries. This study aimed to analyze and compare the changes in the injury pattern, management and outcome following biliary tract injury in a Sri Lankan study population treated at a tertiary care center., Methods: A retrospective analysis was made of 67 patients treated between May 2002 and February 2011. The profiles of the last 38 patients treated from October 2006 to February 2011 were compared with those of the first 29 patients treated from May 2002 to September 2006. Definitive management options included endoscopic biliary stenting, reconstructive hepaticojejunostomy with creation of gastric access loops, and biliary stricture dilation. Post-treatment jaundice, cholangitis and abdominal pain needing intervention were considered as treatment failures., Results: In the 67 patients, 55 were women and 12 men. Their mean age was 40.6 (range 19-80) years. Five patients had traumatic injuries. Thirty-seven injuries (23 during the second study period) were due to laparoscopic cholecystectomy and 25 (10 during the second study period) to open cholecystectomy. The identification rate of intra-operative injury was 19% in the laparoscopic group and 8% in the open group. Bismuth type I, II, III and IV injuries were seen in 18, 18, 15 and 12 patients, respectively. Endoscopic stenting was the definitive treatment in 20 patients. In 35 patients who had hepaticojejunostomy, 33 underwent creation of the gastric access loop. Twenty-two reconstructions were performed during the second study period. A gastric access loop was used for endotherapy in three patients with anastomotic occlusion at the site of hepaticojejunostomy. The overall outcome was satisfactory in the majority of patients. There were four injury-related deaths., Conclusions: Biliary tract injuries associated with laparoscopic cholecystectomy have become the most frequent cause of biliary injury management at our center. Although endotherapy was useful in selected patients, in the majority, surgical reconstruction with hepaticojejunostomy was required as the definitive treatment. Creation of the gastric access loop was found to be a useful adjunct in the management of hepaticojejunostomy strictures.

Background: The standard treatment used to control the symptoms of carcinoid syndrome (CS) involves subcutaneous injections of the somatostatin analogue octreotide. This is expensive (US $8000--16,000 per year), and treatment may be for many years. The aim of this study was to evaluate the efficacy and cost-effectiveness of our experience over the last 5 years with 1-131-labelled metaiodobenzylguanidine (MIBG) radionuclide therapy in the palliation of patients with CS., Methods: A consecutive series of 20 symptomatic patients (referred between 1994 and 1999) with CS were evaluated. Fifteen of them underwent(123)I-MIBG scanning. Of the 13 patients with significant tracer uptake in metastatic deposits compared to background, 12 underwent a course of therapeutic(131)I-MIBG (one patient refused). Symptoms, biochemical markers, CT scans, follow-up(123)I-MIBG scans, and the requirement for octreotide were used to assess outcome of treatment. Costs of(131)I-MIBG and octreotide treatments were compared., Results: MIBG treatment was well tolerated in all with only transient side-effects. Ten patients showed a measurable clinical improvement. Seven had a complete clinical response. The mean duration of response was 15.4 months. Octreotide was not required or was reduced in eight patients. Treatment with(131)I-MIBG resulted in a saving of US $1000 per patient, with effective symptom control, when compared to octreotide., Conclusion: 1-131 MIBG therapy is a safe and cost-effective therapeutic option to successfully control symptoms in patients with carcinoid syndrome., (Copyright Harcourt Publishers Limited.)