Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Obstructing Colorectal Cancer Treated by Endoscopic Stenting as a Bridge to Surgery.

PURPOSE: Neutrophil-to-lymphocyte ratio (NLR) has been reported to predict adverse survival outcomes among patients with colorectal cancer (CRC). This study evaluates the prognostic value of NLR among patients with obstructing CRC who successfully underwent stenting before curative surgery. METHODS: We retrospectively reviewed patients who underwent stenting before surgery. Patient demographics, tumor characteristics, perioperative outcomes, recurrence-free survival (RFS), and overall survival (OS) were analyzed. NLR was calculated from the differential white blood cell counts at least 4 days after successful stenting, before elective surgery. Optimal cutoff to dichotomize NLR was obtained by maximizing log-rank test statistic with recursive partitioning of KaplanMeier RFS and OS curves. The optimal cutoff for high NLR was ≥ 5 at presentation before stenting, and ≥ 4 after stenting. RESULTS: Fifty-seven patients with localized obstructing CRC underwent successful endoscopic stenting before curative surgery. High NLR was associated with lymphovascular invasion (P = 0.006) and apical lymph node involvement (P = 0.034). Major perioperative complication(s) (hazard ratio [HR], 11.34; 95% confidence interval [CI], 2.49 to 51.56; P < 0.01) and high NLR (HR, 3.69; 95% CI, 1.46 to 9.35; P < 0.01) negatively impacted OS on univariate and multivariate analyses. High NLR negatively impacted RFS on univariate analysis (HR, 2.91; 95% CI, 1.29 to 6.60; P = 0.01). CONCLUSION: NLR of ≥ 4 after stenting is an independent prognostic factor among patients with obstructing localized CRC who are successfully decompressed by endoscopic stenting before curative surgery.

Infected femoral pseudoaneurysms in intravenous drug abusers: a decade of experience from a Singapore tertiary centre.

INTRODUCTION: A pseudoaneurysm (or false aneurysm) is a haematoma that communicates with an artery through a disruption in the arterial wall. The femoral artery is the most common injection site among drug users, and infected femoral pseudoaneurysms are the most common vascular complications. METHODS: A retrospective review of medical records of intravenous drug abusers (IVDAs) who presented with infected femoral pseudoaneurysms from January 2006 to December 2016 was carried out. Patients who had pseudoaneurysms due to other aetiologies or trauma were excluded. RESULTS: A total of 27 patients with infected femoral pseudoaneurysms were identified. The majority were male (92.6%) and of Malay ethnicity (55.6%). Median age was 50 (range 31-62) years. Commonly abused drugs were buprenorphine (or Subutex; 59.3%) and midazolam (or Dormicum; 51.9%). Groin pain and swelling (100.0%), fever (66.7%) and presence of a pulsatile mass (51.9%) were the most common presenting symptoms. Diagnosis was confirmed via computed tomography angiography in all patients. 25 patients underwent upfront arterial ligation with debridement, among whom three patients required concurrent surgical revascularisation. Only two patients underwent ultrasonography-guided thrombin injection - one eventually required surgery and the other was lost to follow-up. Postoperative complications included wound infection (42.3%), bleeding (11.5%) and necrotising fasciitis eventually resulting in limb loss (3.8%). There were no associated mortalities. CONCLUSION: Infected pseudoaneurysms in IVDAs pose a unique challenge to vascular surgeons. We found that simple ligation and debridement was a safe and effective option for such patients.

The direct extravascular calcium interruption arterial procedure technique for heavily calcified vessels.

Severely calcified lesions continue to plague endovascular interventions by negatively affecting the acute and long-term results. A new technique was developed to allow balloon crossing or to treat persistent recoil. In the direct extravascular calcium interruption arterial procedure technique, an artery forceps is percutaneously introduced to modify the plaque after conventional techniques have failed. In this initial experience, the direct extravascular calcium interruption arterial procedure technique was successful as a bailout option in patients in whom balloon crossing was impossible or recoil was untreatable even with high-pressure balloons.

Stenting as a bridge to surgery for obstructed stage IV colorectal cancers - long-term outcomes of a 10-year study.

INTRODUCTION: Successful stenting of an obstructing colorectal tumor can avert upfront emergency surgery in malnourished obstructed patients with metastatic disease and poor physiological condition. This study aims to evaluate the outcomes of stenting followed by primary colorectal tumor resection among patients with obstructed stage IV colorectal cancer at presentation, over a 10-year period. METHODS: From 2007 to 2016, a cohort comprising 25 consecutive patients were retrospectively reviewed from a prospectively collected database. The durability of palliation of bowel obstruction, oncological outcomes and factors influencing overall survival were analyzed. RESULTS: No re-interventions were required for bowel obstruction during the study period. The overall perioperative morbidity rate was 16%, with no postoperative 90-day mortality. Laparoscopic resection rate was 52% and stoma formation rate was 8%. The median overall survival was 24 months for the entire cohort, and the 1-, 3- and 5-year survival rates were 80%, 35% and 23.33% respectively. More than one site of distant metastases, peritoneal involvement, and elevated carcinoembryonic antigen levels were significantly associated with poorer survival outcomes. Patients with peritoneal-only metastasis had worse outcomes, with a median survival of 7 months and no patients surviving beyond 18 months. CONCLUSION: Stenting followed by resection of the primary obstructing colorectal cancer provides durable palliation among patients with stage IV disease, with low perioperative morbidity and stoma formation rates. Superior survival was observed among patients with single-site, non-peritoneal distant metastases.

Novel Use of Capturex Device and Reliant Balloon for Inferior Vena Cava Tumor Thrombectomy: A Case Report and Review of Literature.

INTRODUCTION: Most common tumor extending into the inferior vena cava (IVC) are renal carcinomas, such extension have been noted in nearly one-fifth of tumors. Tumor thrombectomy improves the prognosis of patients including those with extension of tumor as far as supra hepatic vena cava. In contrast, if radical nephrectomy is performed as the sole procedure, the prognosis is reduced drastically. CASE PRESENTATION: We present a case of a 42-year-old male who presented to us with renal cell carcinoma with tumor thrombus extending to IVC. We performed a hybrid endovascular and open procedure using novel surgical techniques to obtain proximal vena caval control and to remove the tumor thrombus-Capturex filter which was placed endovascularly 1 cm above the thrombus via the right internal jugular vein and reliant balloon was placed above the capturex below the hepatic veins. At this position, when the reliant balloon was inflated, it acted as a retro hepatic IVC control. Following vascular control, we proceeded to tumor thrombectomy and radical nephrectomy using transperitoneal approach. Patient made an uneventful recovery and was subsequently referred for medical oncology service for consideration of targeted therapy. Detailed description of the procedure is followed by the discussion of the literature.

Percutaneous deep venous arterialization in patients with critical limb ischemia.

BACKGROUND: Critical limb ischemia (CLI) is the presentation of end stage peripheral arterial disease and typically presents with rest pain, ulceration and gangrene. The outcome of conservative treatment is poor and often leads to amputations. Arterial revascularization plays an important role in amputation prevention. Unfortunately, a significant percentage of CLI patients cannot be revascularized and subsequently end up with a palliative amputation. This has led to the need and exploration of new treatment options in this no option subgroup of CLI. Deep venous arterialization (DVA) is one of them and has been reported as a save and feasible novel and promising alternative to amputation. The goal of DVA is to provide arterialized blood in significant volumes and pressure to the plantar venous arch and ischemic tissue to enable wound healing. Selecting the right patients is critical for successful DVA and requires that extra attention is paid to the wounds as well as arterial and venous vascular status. METHODS: The procedure was previously described in our initial experience in the first-in-man study performed on 7 patients with NOP-CLI. The angiographic goal of the procedure is to deliver arterialized blood to the plantar venous arch in significant volumes and pressure, circumventing the numerous valves in the process. The clinical goal is to achieve wound healing. RESULTS: Technical success was achieved in all patients. Flow in the plantar arch was achieved in 5 of the 7 patients. One patient with chronic rest pain became pain free within 48 hours after the procedure. Complete wound healing was achieved at 12 months in 5 of the 7 patients. Reinterventions were performed in 5 of 7 patients to maintain patency. Of the 7 study patients, five underwent minor amputation of one or more toes, and two underwent major amputations within 12 months (limb salvage, 71%). CONCLUSIONS: The LimFlow system is currently the only registered device a total percutaneous DVA can be performed with. In addition to the percutaneous creation of an arteriovenous fistula (AVF), it also allows disruption of the veins with a dedicated valvulotome.

Spontaneous intracranial hypotension presenting as thunderclap headache: a case report.

BACKGROUND: Spontaneous intracranial hypotension is a rare but treatable cause of a disabling headache syndrome. It is characterized by positional orthostatic headache, pachymeningeal enhancement and low cerebrospinal fluid pressure. However, the spectrum of clinical and radiographic manifestations is varied and misdiagnosis is common even in the modern era of magnetic resonance imaging. Spontaneous intracranial hypotension presenting as thunderclap headache is recognized but rare. CASE PRESENTATION: A 41-year-old Sri Lankan female presented with thunderclap headache associated with nausea and vomiting, but the headache was characterized by positional variation with aggravation in the upright posture and relief in the supine posture. Gadolinium-enhanced cranial magnetic resonance imaging demonstrated generalized meningeal enhancement and normal magnetic resonance angiography while lumbar puncture revealed a cerebrospinal fluid opening pressure of less than 30 millimetres of water. Magnetic resonance myelography failed to identify the site of cerebrospinal fluid leak. The patient was managed conservatively with bed-rest, intravenous hydration, analgesics and an increased intake of oral coffee which led to a gradual relief of headaches in the upright posture. CONCLUSIONS: Spontaneous intracranial hypotension can rarely present as thunderclap headache. Awareness of its varied spectrum of presentations would avoid inappropriate investigations, misinterpretation of imaging results and ineffective treatment.

Why do doctors emigrate from Sri Lanka? A survey of medical undergraduates and new graduates.

BACKGROUND: Migration of medical professionals is a long recognized problem in Sri Lanka, but it has not been studied in depth. Undergraduate and postgraduate medical education in Sri Lanka is state sponsored, and loss of trained personnel is a loss of investment. This study assessed the intention to migrate among medical students and newly passed out graduates from the largest medical school in Sri Lanka. METHODS: A cross sectional descriptive study was conducted in the Faculty of Medicine, University of Colombo in September 2013 with the participation of first and fourth year medical students and pre-intern medical graduates. Data was collected using a self administered, pre-tested questionnaire that collected data on socio-demographic details, intention to migrate and factors influencing a decision for or against migration. RESULTS: There were 374 respondents, 162 from first year (females; 104, 64.2%), 159 from fourth year (females; 85, 53.5%) and 53 pre interns (females; 22, 41.5%). Of the entire sample, 89 (23.8%) had already decided to migrate while another 121 (32.3%) were not sure of their decision. The most cited reasons for migration were a perceived better quality of life, better earnings and more training opportunities in the host country. There were no socio-demographic characteristics that had a significant association with the intention to migrate, indicating that it is a highly individualized decision. CONCLUSIONS: The rate of intention to migrate in this sample is low when compared to international studies from Africa and South Asia, but is still significant. The core reasons which prompt doctors to migrate should be addressed by a multipronged approach to prevent brain drain.

Unusual case of recurrent thigh lump in a girl: a case report.

INTRODUCTION: Lipofibromatosis is a rare fibro-fatty tumour with a predilection to involve distal extremities. It has only recently been described as a distinctive clinicopathologic entity, and subsequently only a few cases have been published in the literature. To address the clinicopathologic significance of this rare entity, we here describe a case of lipofibromatosis occurring on the left thigh of a Sri Lankan girl who developed a recurrence following excision. CASE PRESENTATION: A 15-year-old previously healthy girl of Sri Lankan ethnicity presented with a painless progressively enlarging mass in her left thigh. Magnetic resonance imaging of her thigh lump, revealed a septated mass arising from subcutaneous tissue of anterolateral and medial aspects of her thigh. Histological assessment revealed evidence of lipofibromatosis, and the lesion was excised followed by split-skin grafting. She presented again with a local recurrence at the same site. CONCLUSIONS: Adequate surgical excision leads to complete cure of this benign lesion, but recurrences are common following incomplete excision. Therefore awareness among clinicians of this rare entity is vital in offering the best possible care to the patients.

Anatomical landmarks for safer carpal tunnel decompression: an experimental cadaveric study.

BACKGROUND: Carpal tunnel syndrome is a common presentation to surgical outpatient clinics. Treatment of carpal tunnel syndrome involves surgical division of the flexor retinaculum. Palmar and recurrent branches of the median nerve as well as the superficial palmar arch are at risk of damage. METHODOLOGY: Thirteen cadavers of Sri Lankan nationality were selected. Cadavers with deformed or damaged hands were excluded. All selected cadavers were preserved with the conventional arterial method using formalin as the main preservative. Both hands of the cadavers were placed in the anatomical position and dissected carefully. We took pre- determined measurements using a vernier caliper. We hypothesized that the structures at risk during carpal tunnel decompression such as recurrent branch of the median nerve and superficial palmar arch can be protected if simple anatomical landmarks are identified. We also hypothesized that an avascular area exists in the flexor retinaculum, identification of which facilitates safe dissection with minimal intra operative bleeding. Therefore we attempted to characterize the anatomical extent of such an avascular area as well as anatomical landmarks for a safer carpal tunnel decompression.Ethical clearance was obtained for the study. RESULTS: In a majority of specimens the recurrent branch was a single trunk (n =20, 76.9%). Similarly 84.6% (n = 22) were extra ligamentous in location. Mean distance from the distal border of the TCL to the recurrent branch was 7.75 mm. Mean distance from the distal border of TCL to the superficial palmar arch was 11.48 mm. Mean length of the flexor retinaculum, as measured along the incision, was 27.00 mm. Mean proximal and distal width of the avascular area on TCL was 11.10 mm and 7.09 mm respectively. CONCLUSION: We recommend incision along the radial border of the extended ring finger for carpal tunnel decompression. Extending the incision more than 8.16 mm proximally and 7.75 mm distally from the corresponding borders of the TCL should be avoided. Incision should be kept to a mean length of 27.0 mm, which corresponds to the length of TCL along the above axis. We also propose an avascular area along the TCL, identification of which minimizes blood loss.

Kidney disease in the elderly: a Sri Lankan perspective.

Renal disease in the elderly in Sri Lanka is a largely neglected area in the literature with hardly any publications. We carried out a hospital-based survey of elderly patients (elderly is defined in this article as patients aged 65 years or above) with renal disease. This prospective study included all patients aged 65 years or above admitted to the University Medical Unit, National Hospital of Sri Lanka, over a period of 1 year with a primary renal-related illness as the reason for hospitalization. This hospital-based survey is the first of its kind to look into the nephrological disease profile of elderly patients in Sri Lanka. Based on our findings, we have made several pertinent recommendations regarding the care of the elderly with renal disease in Sri Lanka that may be relevant to other developing nations as well.

Electrocardiographic and echocardiographic manifestations of cardiac involvement in leptospirosis.

BACKGROUND: Cardiac involvement is known to occur in leptospirosis, however, data on the significance of electrocardiographic and echocardiographic findings is very limited. METHODS: Electrocardiographic and echocardiographic changes were studied in serologically confirmed patients with leptospirosis. RESULTS: Of 22 patients, 45% (10) had cardiac symptoms; 59% (13) had abnormalities on the ECG; 90% (9/10) of patients with cardiac symptoms had at least one electrocardiographic abnormality. Echocardiographic abnormalities were seen in 41% (9). Clinical and echocardiographic evidence of myocarditis was seen in two patients, but left ventricular function was preserved. CONCLUSIONS: Echocardiographic changes may be useful in identifying patients with myocarditis in leptospirosis, especially in symptomatic patients.

Learning styles and approaches to learning among medical undergraduates and postgraduates.

BACKGROUND: The challenge of imparting a large amount of knowledge within a limited time period in a way it is retained, remembered and effectively interpreted by a student is considerable. This has resulted in crucial changes in the field of medical education, with a shift from didactic teacher centered and subject based teaching to the use of interactive, problem based, student centered learning. This study tested the hypothesis that learning styles (visual, auditory, read/write and kinesthetic) and approaches to learning (deep, strategic and superficial) differ among first and final year undergraduate medical students, and postgraduates medical trainees. METHODS: We used self administered VARK and ASSIST questionnaires to assess the differences in learning styles and approaches to learning among medical undergraduates of the University of Colombo and postgraduate trainees of the Postgraduate Institute of Medicine, Colombo. RESULTS: A total of 147 participated: 73 (49.7%) first year students, 40 (27.2%) final year students and 34(23.1%) postgraduate students. The majority (69.9%) of first year students had multimodal learning styles. Among final year students, the majority (67.5%) had multimodal learning styles, and among postgraduates, the majority were unimodal (52.9%) learners.Among all three groups, the predominant approach to learning was strategic. Postgraduates had significant higher mean scores for deep and strategic approaches than first years or final years (p < 0.05). Mean scores for the superficial approach did not differ significantly between groups. CONCLUSIONS: The learning approaches suggest a positive shift towards deep and strategic learning in postgraduate students. However a similar difference was not observed in undergraduate students from first year to final year, suggesting that their curriculum may not have influenced learning methodology over a five year period.

Prevalence of chromosomal abnormalities in Sri Lankan women with primary amenorrhea.

AIM: Chromosomal abnormalities are implicated in the etiology of primary amenorrhea. The underlying chromosomal aberrations are varied and regional differences have been reported. The objective of this study is to describe the prevalence of various types of chromosomal abnormalities in Sri Lankan women with primary amenorrhea. MATERIAL AND METHODS: Medical records of all patients diagnosed with primary amenorrhea referred for cytogenetic analysis to two genetic centers in Sri Lanka from January 2005 to December 2011 were reviewed. Chromosome culture and karyotyping was performed on peripheral blood samples obtained from each patient. Data were analyzed using standard descriptive statistics. RESULTS: Altogether 338 patients with primary amenorrhea were karyotyped and mean age at testing was 20.5 years. Numerical and structural chromosomal abnormalities were noted in 115 (34.0%) patients which included 45,X Turner syndrome (10.7%), Turner syndrome variants (13.9%), XY females (6.5%), 45,X/46,XY (0.9%), 46,XX/46,XY (0.6%), 47,XXX (0.3%), 47,XX,+ mar (0.3%), 46,X,i(X)(p10) (0.3%), 46,XX with SRY gene translocation on X chromosome (0.3%) and 46,XX,inv(7)(p10;q11.2) (0.3%). Short stature, absent secondary sexual characteristics, neck webbing, cubitus valgus and broad chest with widely spaced nipples were commonly seen in patients with Turner syndrome and variant forms. Neck webbing and absent secondary sexual characteristics were significantly associated with classical Turner syndrome than variant forms. CONCLUSION: A considerable proportion of women with primary amenorrhea had chromosomal abnormalities. Mean age at testing was late suggesting delay in referral for karyotyping. Early referral for cytogenetic evaluation is recommended for the identification of underlying chromosomal aberrations in women with primary amenorrhea.

Giant presacral schwannoma presenting with constipation: a case report.

INTRODUCTION: Schwannoma, otherwise known as a neurilemmoma, is a tumor arising from peripheral nerve sheaths. Although commonly noted in association with the eighth cranial nerve as intracranial acoustic neuroma, cases of schwannoma arising in other locations have been reported in the literature. These tumors usually cause symptoms as a result of their mass effect and, since they are benign, encapsulated and non-invasive tumors, complete surgical excision is considered curative. CASE PRESENTATION: We report the case of a 46-year-old Sri Lankan man who presented to our facility with recent onset of difficulty evacuating his bowels. He was noted to have a giant presacral schwannoma on magnetic resonance imaging scan. The mass was surgically excised with improvement of our patient's symptoms. A subsequent histopathological examination confirmed the presence of a benign schwannoma. CONCLUSIONS: Although schwannomas commonly occur in the extremities, a rare case of occurrence in the pelvis is reported here. Due to the limited space in the pelvis, the local mass effect may be the presenting feature of such a lesion and surgical excision is curative.

Fanconi anaemia with bilateral diffuse pulmonary arterio venous fistulae: a case report.

BACKGROUND: We report a patient with cytogenetically confirmed Fanconi anaemia with associated diffuse bilateral pulmonary arterio-venous fistulae. This is only the second reported case of diffuse pulmonary arterio-venous fistulae with Fanconi anaemia. CASE PRESENTATION: A 16 year old Sri Lankan boy, with a cytogenetically confirmed Fanconi anaemia was admitted to University Medical Unit, National Hospital of Sri Lanka for further assessment and treatment. Both central and peripheral cyanosis plus clubbing were noted on examination. The peripheral saturation was persistently low on room air and did not improve with supplementary Oxygen. Contrast echocardiography failed to demonstrate an intra cardiac shunt but showed early crossover of contrast, suggesting the possibility of pulmonary arterio-venous fistulae. Computed tomography pulmonary angiogram was inconclusive. Subsequent right heart catheterisation revealed bilateral diffuse arterio-venous fistulae not amenable for device closure or surgical intervention. CONCLUSION: To our knowledge, this is the second reported patient with diffuse pulmonary arterio-venous fistulae associated with Fanconi anaemia. We report this case to create awareness among clinicians regarding this elusive association. We recommend screening patients with Fanconi anaemia using contrast echocardiography at the time of assessment with transthoracic echocardiogram. Though universal screening may be impossible given the cost constraints, such screening should at least be performed in patients with clinical evidence of desaturation or when a therapeutic option such as haematopoietic stem cell transplantation is considered. Treatment of pulmonary arteriovenous fistulae would improve patient outcome as desaturation by shunting worsens the anaemic symptoms by reducing the oxygen carrying capacity of blood.

Anatomical relations of the superficial sensory branches of the radial nerve: a cadaveric study with clinical implications.

BACKGROUND: Anatomically, it is difficult to give a systematic description of the superficial branch of the radial nerve (SBRN). Our aim was to describe the exact relationship of the SBRN to fixed bony points of radial styloid and Lister's tubercle, and to the cephalic vein. We also compared our data with other international studies. METHODS: The study was a descriptive anatomical study. Twenty-five forearms were dissected. Measurements were made from predefined fixed reference points. RESULTS: The mean distance to the point of emergence of the nerve from the radial styloid was 8.54 cm (SD = 1.32). The nerve branched at a mean distance of 5.57 cm (SD = 1.43) from the radial styloid. The mean distance to the point where the most medial and most lateral branches of the nerve crossing the wrist joint, measured from the Lister's tubercle were 2.51 cm (SD = 0.53) and 3.90 cm (SD = 0.64). In 17 specimens(68%) cephalic vein crossed the SBRN superficially once. Mean distance from the radial styloid to the most distal point where the vein crossed the nerve was 5.10 cm. Diffefrence between mean distance to the point of emergence and branching point, when compared with other international studies were not statistically significant. (P value > 0.05) CONCLUSIONS: We recommend avoiding transverse incisions in the snuffbox region between 2.51 cm and 3.90 cm from the Listers tubercle. We also recommend avoiding cannulation of the cephalic vein in the distal forearm.