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THE SRI LANKA
JOURNAL OF SURGERY
April 2015 Volume 33, No.1 ISSN 1391-491X
In this issue
 Stoma care training for nurses in Sri Lanka
 Hand Injuries
 Symposium on gastro-oesophageal reflux disease
 Botox in pelvic floor dyssynergia
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April 2015 Volume 33, No.1 - Quarterly. ISSN 1391-491X
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Mission: “To reach the highest standard of scientific surgical practice by dissemination of high quality scientific
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April 2015 Volume 33, No.1
Contents
Editorial
The surgeon should assume a prominent role in the diagnosis and treatment of
gastro-oesophageal reflux disease
William C. Dengler
1
Scientific articles
Establishment of a stoma care training program for nurses in Sri Lanka and evaluation of its
effectiveness
D.P. Wickramasinghe, A.M.P. Samarasekera, S. Senaratne, C.S. Perera, A. Tissera, D.N. Samarasekera
4
Continuing medical education
Management of the injured hand - basic principles of care
K. Karunadasa
9
Symposium on GORD
Diagnosis and management of gastro-oesophageal reflux disease
14
N.P. Dinamithra, N.M.M. Nawarathne
Oesophageal manometry and pH-impedance studies in gastro-oesophageal reflux disease
S.U.B. Dassanayake, A.N.R. Fernandopulle
20
Nissen fundoplication: how I do it
C.A.H Liyanage, S. Kumarage
24
Technical note
Botulinum toxin injection to the puborectalis in the management of pelvic floor dyssynergia
H.D.S Pradeep, P.C Chandrasinghe, S.A.S.R Siriwardana, S.K Kumarage
27
Case reports
A Sri Lankan family with cerebellar hemangioblastoma due to a heterozygous nonsense
mutation in the von Hippel-Lindau tumor suppressor, E3 ubiquitin protein ligase (VHL) gene
P.K.D.C.T. Somadasa, N.D. Sirisena, V.H.W. Dissanayake
30
Laparoscopic resection with minilaparotomy anastomosis for pancreatico-duodenectomy
K.B. Galketiya, V. Pinto, R. Rohankumar, B.G. Jayawickrama, A. Herath
33
Axial torsion and gangrene of a giant Meckel's diverticulum causing small bowel obstruction
S.N. Deshmukh, S.P. Jadhav, A.G. Asole
35
Incisional hernia after ventriculoperitoneal shunt
M. Jayant, R. Kaushik
37
Epidermal splenic cyst
G.H.M. Pinsara, N. Liyanage, P.G.K. Anuradha, P.M. Lambiyas, H. Gamage
41
Selected abstracts
45
EDITORIAL
The surgeon should assume a prominent role in the diagnosis and treatment of gastro-oesophageal
reflux disease
A few months ago, in February, I had the privilege of participating in a panel discussion in front of members of the
College of Surgeons of Sri Lanka as well as pathologists where questions regarding the diagnosis and management of
gastro-oesophageal reflux disease (GORD) were discussed. It was quite apparent from the questions presented, that a
great deal of thought and insight existed on the part of College members about the important issues in caring for the
GORD patient. Central to the discussion was the question, “What is the role of the general surgeon in the management
of this disease?”
In the United States, we are taught that GORD is a disease of the western world, primarily seen in the US and Europe due
to diet, the epidemic of obesity and other factors. It is the most common gastrointestinal disorder seen by both primary
care physicians and gastroenterologists. We are also taught that reflux disease is rarely seen in Asia and other eastern
countries such as Sri Lanka. However, it became quite apparent that GORD is seen with increasing frequency in
Sri Lanka and the same problematic questions regarding efficient diagnosis and management that we struggle with in
the US, also exist in this nation.
The evolution of GORD management in the United States has unfortunately led to an undesirable “status quo”. A
patient presents, usually to the primary care physician with symptoms such as heartburn, regurgitation or any other
foregut complaint. The physician concludes that the symptom source is possibly reflux disease and the patient is placed
on empiric proton pump inhibitor therapy (PPIs) and sent on his way. If symptoms resolve, patients are left on their
PPIs, often indefinitely. Persistent symptoms are often further investigated by a gastroenterologist with an endoscopy,
which usually is without significant findings. Patients are typically continued on PPIs and returned to the care of the
primary care physician without resolution of their problem. This method of management has led to runaway PPI costs,
exceeding 10 billion dollars annually. We have continued this approach and watched the incidence of reflux-induced
oesophageal adenocarcinoma increase more then 600% in the past 40 years [1] and millions continue to suffer under
medical therapy often augmenting their PPIs with antacids and H2 blockers without relief. The present approach is
failing and based on the medical literature, that should be of no surprise.
Making the diagnosis of GORD based on patient symptoms alone is fraught with hazard. Some 30-40% of patients,
including those presenting with typical symptoms of heartburn and regurgitation, are found not to have reflux disease
after undergoing pH testing. Furthermore, while upper endoscopy is necessary to rule out other disorders, it is a terrible
test for the presence or absence of GORD with objective findings of reflux (erosive oesophagitis, stricture or Barrett's
oesophagus) present in only 20% of patients [2]. Symptomatic response to PPI therapy also incorrectly predicts the
presence or absence of reflux disease in as many as 50% of patients [3]. Yet these are the “tools” typically used in the
diagnosis of reflux that have led to the unsatisfactory management we observe today. The availability in recent years of
over the counter PPIs, allowing patients to self medicate has made this problem even greater.
From a therapeutic standpoint, more problems are seen. Upon their introduction, PPIs were thought to be the panacea
due to their powerful acid suppressive effects. However, we now understand that approximately 40% of GORD patients
continue to have breakthrough symptoms on PPIs [4]. Continued symptomatic complaints are frequently ignored by
medical physicians or addressed by escalating the dose of these medications, often without benefit. The immense
experience with PPIs over the years, has unmasked disturbing side effects. These include an increased risk of hip
fractures and increased risk of C. difficile colitis, both of which have prompted Food and Drug Administration alerts in
the US. Hypomagnesemia, increases in community acquired pneumonias and other side effects are of concern. Many
patients are also never told that this medical therapy is usually necessary for life and other options such as surgery are
never discussed or offered. One must question the desirability of a therapy that requires daily medications for life, is
extremely costly, has significant side effects and resolves a patient's symptoms only about 60% of the time. Certainly,
The Sri Lanka Journal of Surgery 2015; 33(1): 1-3
1
specific efforts in developing an approach where other therapeutic choices, including surgery, could provide great
patient benefit.
The endemic use of PPIs may also be playing a role in the dramatic and disturbing rise in the incidence adenocarcinoma
of the oesophagus. Even the American Gastroenterological Association in its 2011 Guidelines on the management of
Barrett's oesophagus acknowledged the possibility that PPI-induced gastric pH changes could possibly be adversely
altering the chemistry of the refluxate and contribute to the rise in reflux-induced cancer [5]. This should be an alarming
concept, yet it is infrequently discussed and has not significantly affected PPI use. In that same publication, the
possibility that anti-reflux surgery may protect against development of cancer by stopping the reflux was also
discussed.
Despite the above considerations, the present empiric medical approach seems entrenched in the United States and
significant change will be very difficult. However, as more and more GORD is seen in Sri Lanka, a different course,
recognizing these problematic issues could be taken. Involvement of the surgeon in both the diagnostic and therapeutic
aspects of GORD would allow a more effective approach to this disease that would greatly benefit patients. The
surgeon, however, must position himself not as an individual interested in only performing an operation, but as
someone with a true understanding of reflux and oesophageal disease, capable of proper diagnostic evaluations, patient
education and familiarity with all potential therapies. Only the surgeon can offer all options and tailor such offerings to
each specific patient.
Anti-reflux surgery has been proven to be an effective long-term therapy for GORD [6]. In expert hands, it provides
symptomatic relief, eliminates the need for acid suppressive medications and may decrease the likelihood of a patient
developing of oesophageal adenocarcinoma. It is the only approach that actually stops the reflux and this had been
confirmed with postoperative pH study normalization in 80-90% of patients. Although there are known side effects,
these are minimal in the majority of patients if a proper pre-operative evaluation is performed. Persistent dysphagia
should be seen in no more than 2-5%. Surgery tends to be offered to the most severely symptomatic patients and even in
this group, satisfaction is high with symptom resolution in over 80% [7]. This exceeds efficacy and satisfaction with the
entire group of PPI patients, many of whom have relatively minimal symptoms. Conceptually, the surgical approach
makes sense as it directly addresses the cause of the disease by re-establishing the integrity of the lower oesophageal
sphincter (LOS) and stopping the reflux. Medical therapy with PPIs does absolutely nothing for the LOS and the reflux
is not reduced. Only the composition of the refluxate is changed and for many patients this is not sufficient. As noted
above, it could possibly be quite harmful.
The efficacy of laparoscopic Nissen fundoplication has been proven and the concept of a therapy that directly restores
the function of the LOS has prompted the development of a host of endoscopic approaches over recent years. Most have
come and gone due to lack of efficacy. The Stretta procedure and transoral intraluminal fundoplication (TIF) remain
available, but their efficacy is debated and neither has demonstrated predictable improvement in distal oesophageal
acid exposure. They do not predictably decrease reflux and therefore their efficacy in positively influencing a
dysfunctional LOS is questioned.
LINX (Torax Medical, Minneapolis, MN, USA) is a relatively new procedure that has been available for several years.
A small ring of titanium magnetic beads is placed around the LOS using a laparoscopic procedure that takes
approximately 30 minutes and requires minimal dissection. The procedure can be done as an outpatient. The ring does
not compress the LOS. It is placed loosely and “augments” the LOS. The beads separate when a food bolus is passed
into the stomach and then the magnets return to their resting state providing augmentation to the damaged LOS thereby
preventing reflux. Over 3000 LINX procedures have been performed worldwide and follow up of greater than 5 years is
available. LINX provides predictable symptom resolution in >80% without the side effects seen with Nissen
fundoplication. Normalization of pH is seen in the majority of patients confirming the desired result [8]. Sphincter
augmentation with LINX results in restoration of the barrier to reflux. Medications can usually be completely
discontinued. Exclusion criteria include hiatus hernia >3cm.
The Sri Lanka Journal of Surgery 2015; 33(1): 1-3
2
Only the surgeon can offer all of the treatment options. To do so effectively, he must understand and apply knowledge of
all aspects of GORD. This includes a meticulous evaluation of patients and incorporation of pH testing and high
resolution oesophageal manometry. Understanding the utilization and interpretation of these diagnostics are essential
in the logical management of GORD. This requires quite a commitment on the part of the surgeon but will translate into
optimal patient care with proper utilization of both medical and surgical therapy.
To achieve this end, I propose the establishment of a “Reflux Center” for the evaluation and treatment of GORD and
oesophageal disease. This entity should be overseen by the general surgeon or collaboratively with gastroenterologists
who want to advance beyond the “scope and a pill, one size fits all” approach. Symptomatic patients would undergo
complete evaluation including endoscopy, biopsies, pH testing and high resolution manometry, providing an objective
diagnosis for each. For many, GORD will be ruled out. Some will be found to have a primary oesophageal motility
disorder such as achalasia or nutcracker oesophagus. GORD patients failing medical therapy or desiring an alternative
will be educated and offered a surgical approach.
The incidence of GORD in Sri Lanka is likely to increase and for the benefit of your patients a logical, programmatic
approach is encouraged with the general surgeon taking a lead role.
William C. Dengler, MD, FACS
wdengler@legatomedical.com
References:
1.
2.
3.
4.
5.
6.
7.
8.
Chandrasoma PT, DeMeester TR. GERD: From Reflux to Adenocarcinoma. 1st ed. Burlington MA, USA: Academic
Press 2006
Richter JE, Pandolfino JE, Vela MF, Kahrials PJ, Lacy BE, Ganz R, Dengler W, Oelschlager BK, Peters J, DeVault KR,
Fass R,GyawaliCP, Conklin J, DeMeester T. Utilization of wireless pH monitoring technologies:a summary of the
proceedingsfrom the Esophageal Diagnostic Working Group. Dis Esophagus 2013;26(8):755-765.
Bytzer P, Jones R, Vakil N, Junghard O, Lind T, Wernersson B, Dent J. Limited ability of the proton-pump inhibitor test to
identify patients with gastroesophagealreflux disease. ClinGastroenterolHepatol 2012;10 (12):1360-1366.
AGA Institute: GERD patient study: patients and their medications. Harris Interactive 2008
Spechler SJ, Souza RF, Inadomi JA, Shaheen N, Allen JI, Brill J, Pruitt RE, Kahrilas PJ, Peters J, Nix K, Montgomery EA,
MitchellDB, Yao J. American Gastroenterological Association medical position statement and technical review on the
management of Barrett's Esophagus. Gastro 2011; 140 (3): 1084-1091.
Katz PO, Gerson LB, Vela MF. Guide lines for the diagnosis and management of gastroesophagealreflux disease.
Am J Gastroenterol 2013; 108 (3): 308-28.
Oelschlager BK, Ma KC, Soares RV, Montenovo MI, Munoz Oca JE, Pellegrini CA. A broad assessment of clinical
outcomes after laparoscopic anti-reflux surgery. Ann Surg 2012;256 (1):87-94.
Bonavina L, Saino G, Bona D, Sironi A, Lazzari V. One hundred consecutive patients treated with magnetic sphincter
augmentation for gastroesophageal reflux disease: 6 years of clinical experience from a single center. J AmColl Surg
2013; 217 (4): 577-85.
The Sri Lanka Journal of Surgery 2015; 33(1): 1-3
3
SCIENTIFIC ARTICLES
Establishment of a stoma care training program for nurses in Sri Lanka
and evaluation of its effectiveness
D.P. Wickramasinghe1, A.M.P. Samarasekera1, S. Senaratne1, C.S. Perera2, A. Tissera3, D.N. Samarasekera1
1 Department of Surgery, Faculty of Medicine, University of Colombo, Sri Lanka
2 Faculty of Medicine, Sir John Kotelawala Defence University, Sri Lanka
3 Education, Training and Research Unit, Ministry of Health, Sri Lanka
Key words: Stoma care nurse; training; developing
country; effectiveness
Abstract
Introduction
In June 2012, the Ministry of Health with the
Department of Surgery of the Faculty of Medicine,
University of Colombo conducted the first certificate
course in stoma therapy for nurses in Sri Lanka.
We aim to evaluate the success of the course in
enhancing the knowledge and skills of the participants.
Methods
We evaluated 15 domains of patient care in the 61
participants using a self-administered validated
questionnaire administered before the onset and after
completion of the course. Data were analysed using
Wilcoxon signed-rank test.
Results
Of the 61, 37 (60.6%) were females. The mean age was
31.5 (SD±5.5) years. All 15 domains of patient care had
improved at the end of the program. The biggest
increase was seen in staff confidence category. The 3
domains that had the biggest improvement were;
confidence to select different appliances to suit different
conditions (90% improvement in score), having
material for proper patient teaching (88.6%) and
confidence in educating patients (77.6%). There were
no statistically significant correlation between age,
gender or years in nursing and the improvement in any
of the measured domains.
Correspondence: D.N. Samarasekera
E-mail: samarasekera58@yahoo.co.uk
The Sri Lanka Journal of Surgery 2015; 33(1): 4-8
Conclusion
The program was successful in allowing the participants
to function independently. It was conducted with local
resource personnel and minimal cost.
Introduction
Sri Lanka with a population of nearly 21 million [1] is
one of the few developing countries in the world which
still maintains a government sponsored free health care
service. The health services expenditure was 2.9% of the
GDP in 2010 [1] which is comparable with other
countries in the region like India, Bangladesh and
Singapore. There are approximately 60,000 beds for
inpatient care (3 per 1000 persons) and 19,000 nurses in
the free health service in Sri Lanka [2]. Though the
traditional role of the in-ward nurse has largely persisted
in Sri Lanka, the new trend towards specialized nurses is
slowly emerging.
Stoma care is a specialized area in nursing, and a trained
stoma care nurse is an important member in the
colorectal surgical team [3-5]. Their role in patient
rehabilitation is multi fold; from pre-operative services
to post-operative and community care [6-8]. The
National Health Service (NHS) in the United Kingdom
has identified the importance of the involvement of
nurses in the management of patients with colorectal
cancer and has made several recommendations about
their role in the diagnosis, treatment and support of
patients [9]. In Sri Lanka there were only 3 trained stoma
care nurses available in the state health care service.
There were 447 documented cases of patients with anorectal cancer referred to the National Cancer Institute in
2005 [10]. In addition the prevalence of Inflammatory
Bowel Disease such as ulcerative colitis and Crohn's
disease which may need ostomies are also increasing in
Sri Lanka (incidence 5.3/100,000 and 1.2/100,000
respectively [11]. Hence, the need for specialized stoma
4
therapy nurses was promptly identified by the Ministry
of Health. The authors were invited to plan and
supervise the training program. The aim was to provide
at least one trained stoma care nurse to each teaching
and general hospital.
Material and methods
Outline of the course
The course was designed to cover the important aspects
of stomas created in the gastro intestinal and genito
urinary systems. Tracheostomy was not included in the
course due to the different management strategies
involved. It was designed as a 4 week full time
certificate course. Key competencies recognized by
previous authors [12] including stoma assessment,
pouch fitting, pouch emptying, access to resources and
supplies, and basic problem-solving skills as well as
other content considered necessary by the local resource
personnel were included in the curriculum.
The course involved lectures and discussions by the
experts in the respective fields in the country. The
anatomical and physiological aspects, disease
processes, medical and surgical management and
clinical decision making components were taught by
clinicians. The nursing component was taught by the
second author. Formal teaching-learning activities
included lectures, discussions, ward visits and clinic
duties. In addition, the participants were asked to select
a stoma patient and follow them up for the duration of
the course. They were instructed to identify health and
non-health problems of the patient and potential
interventions were suggested. The end of course
assessment included a report and a case presentation by
each group. A panel of experts reviewed their reports
and gave a feedback on changes and improvements.
The entire program, except interaction with patients,
was conducted in English.
Ethical clearance for the study was obtained from the
Ethics Review Committee of the National Hospital of
Sri Lanka (NHSL).
Participation
The participants were selected from teaching and
general hospitals from the entire country. From nearly
300 applicants, 61 participants were selected. They
The Sri Lanka Journal of Surgery 2015; 33(1): 4-8
were subsequently grouped into groups of 10 for ward
and clinic rotations. The feedback received indicated
that participants engaged actively in the teachinglearning activities.
After 6 months, the trainees participated in a 1-day
sequel in which their knowledge, skills and patient
records were assessed. They also presented short case
scenarios of their patients with management dilemmas
which were then discussed by the content experts.
Analysis of effectiveness
Participants completed a validated questionnaire [13]
which evaluated basic demographic details and some
aspects of patient care (staff confidence, staff resources
and patient preparedness for discharge). The questions
were derived from the “Survey of Ostomy Care
questionnaire” which was a self-administered
questionnaire used in a previous publication by Gemmil
et al [13]. It contained a 15-item Likert scale (1-Strongly
disagree, 5-Strongly agree) addressing confidence of
the staff nurse and attitudes about the ability to care for
patients with an ostomy. The questionnaire was
administered on the first day of the program and at the
completion. All surveys were anonymous and did not
include identifying information. Continuous data were
analysed using the mean, median and standard
deviation. Repeated measure data were analysed using
the Wilcoxon Signed Rank test. Correlations were
identified using the Spearman correlation.
Results
Of the total 61 participants, 37 (60.6%) were females.
The mean age was 34.5 (±5.5) years. The mean years in
nursing profession was 9.5 (±5.5) years. All 15 domains
of patient care that were measured had improved at the
end of the program (Table 1). The biggest increase was
seen in staff confidence category (average increase in
score 63.5%) followed by staff resource (55.1%) and
patient preparedness for discharge (43.8%). The 5
domains that had the biggest improvement in
descending order are; the confidence to select different
appliances to suit different conditions (P<0.0001),
having material for proper patient teaching (P<0.001),
confidence in educating patients ( P<0.001), confidence
in having adequate knowledge (P<0.001) and
confidence in assessing the stoma (P<0.001).
5
There were no statistically significant correlation
between age, gender or years in nursing and the
improvement in any of the measured domains.
Score before
participation
Score after
participation
Improvement
Sign ificance
(%)
Staff confidence
1.
I feel confident that I can assess my patient’s ostomy
well enough to care for my patient with an ostomy at
this time.
I feel confident that I have the skills to size, fit, and
apply an ostomy appliance at this time.
2.8
4.57
63.2
<0.005
3.1
4.69
51.2
<0.005
I feel confident that I can advise my patients on
community resources for supplies, education, and
support well enough at this time.
2.5
4.44
77.6
<0.005
I feel confident that I have the background, knowledge,
and experience in ostomy care to sufficiently care for
my patients at this time.
2.7
4.41
63.3
<0.005
5.
I feel confident that I can teach my patients well enough
to care for themselves at home at this time.
3
4.57
52.3
<0.005
6.
I feel confident that I know enough about the different
types of appliances for the various ostomies and
patients’ conditions to adequately select the proper ones
for my patient at this time.
2 .3 3
4.43
90.1
<0.005
I care for ostomy patients often enough to keep up my
skills in ostomy car e.
2 .9 5
4.34
47.1
<0.005
2.
3.
4.
7.
Staff resources
8.
I know who to call for answers about ostomy care
should I encounter a problem.
2 .6 7
4.25
59.1
<0.005
9.
I have the proper patient teaching materials (booklets,
pamphlets, videos, etc.) to teach my patients/family
about ostomy care.
1 .9 3
3.64
88.6
<0.005
10. If I am unsure about any aspect of ostomy care, there is
someone available who can answer my questions.
3 .0 3
4.02
32.6
<0.005
11. I have enough time during my shift to teach ostomy
care to my patient/family.
2 .6 6
3.52
32.3
<0.005
2 .3 3
3.79
62.6
<0.005
13. Patients are well infor med about what to expect
regarding their condition, expected changes, and care at
home at the time they leave the hospital.
2.8
4.1
46.4
<0.005
14. I feel that patients will get adequate follow-up care and
teaching after they leave the hospital.
2 .8 9
3.98
37.7
<0.005
15. Patients are well prepared to care for themselves at
home at the time they leave the hospital.
2 .7 9
4.11
47.3
<0.005
12. There is adequate staff education or in-service
opportunities to keep my knowledge up-to-date on
ostomy care.
Patient preparedness for discharge
Table 1. Improvements in different domains
The Sri Lanka Journal of Surgery 2015; 33(1): 4-8
6
Discussion
Stoma care nurses fulfil a variety of needs in patients
with stomas; from pre-operative services such as
counselling regarding the surgical procedure, the impact
of an ostomy, ostomy management, sexual counselling
and stoma site selection to postoperative services such
as advising the family in ostomy care, diet, provide
long-term follow-up and on-going counselling,
education, surveillance for complications and
community care [6]. Thus, their knowledge and skills
directly affect the care and education of the patients [13]
and patient satisfaction [14,15]. Nurses who perceive
themselves to have high competence and a favourable
perception of the ostomy patient were found to have had
significantly more education [15]. Given the diversity
of these requirements, their training and approach also
need to be similarly comprehensive. Even in
well-established colorectal health care services, there
are deficiencies in nursing care [16]. Clayton et al [17]
have also identified that patients whose surgery resulted
in stomas are also less satisfied with health care
delivery.
Our initial assessment as well as the follow-up 1-day
course revealed that the course was successful in
delivering the necessary knowledge and skills for them
to function independently. Knowles et al described a
similar educational program in Scotland which
achieved a significant improvement in disease-related
knowledge, best practice statements for nursing issues
and general issues and including attitudes that were
maintained at four months [18]. They observed that the
program achieved an increased index of achievement in
almost all the areas concerned. A program conducted in
the USA has also reported an improvement in the quality
of care as the competency increased [17].
Cost effectiveness is a very important criterion in the
assessment of the success of a training program. Even in
Europe, Foubert et al [19] reported that cost and the need
for frequent modifications of skills and knowledge are
the principle limitations. Our program utilized local
resource personnel and existing facilities and as a result
required very little additional funding. We also noted
that the improvement observed did not depend on the
age, gender or the experience, indicating that this
program is equally effective for a wide range of
participants.
The Sri Lanka Journal of Surgery 2015; 33(1): 4-8
In summary, our results suggest that a 4 week course
provides adequate knowledge and confidence for
trained nurses to function as stoma care nurses. The staff
confidence domain having the biggest increase
indicates that the program was successful in making
them confident in managing stoma patients and
functioning independently when required. Seeing an
increase in all measured domains indicates that the
program was successful in providing a comprehensive
training and a holistic approach for the participants. A
major factor affecting stoma care nurses in the west is
the infrequency of interaction with patients with stoma
and that their confidence is greatly influenced by an
opportunity to practice the skills learned [13]. The 6
month post-workshop review proved that our
participants were actively involved in stoma care patient
management on a daily basis and therefore this is less
likely to be a concern in our system.
Another important component of the course was
training the participants in patient education. Nurses are
generally trained to care for the patient than carry out
patient education [13]. Training nurses in how to
educate patients during their regular shift recognizes the
important role of patient education in patient retention
of information. Teaching nurses how to teach also
enhances nurses' confidence in their ability to teach.
Conclusions
We conclude that a 4 week full time program for trained
nurses would suffice to impart the necessary knowledge
and skills for a stoma therapy nurse. The entire program
was carried out with the help of local resource persons
with minimal cost. There was no statistically significant
correlation between age, gender or years in nursing and
the improvement in any of the measured domains.
The findings would encourage health care providers
from other developing countries to explore the
possibility of training stoma care nurses.
Authors' contributions
DPW, AMPS, AT and DNS were involved in the study
conception and design. DPW, SS and CS did the data
acquisition, analysis and interpretation of data. DPW,
SS, CS and DNS drafted the manuscript. All authors
were involved in critical revisions of the manuscript.
7
References
1. Organizarion WH. Country Information: World Health
Organization; 2012 [cited 2012]. Available from:
http://www.who.int/countries/lka/en/index.html.
2. Jayasekara RS. Issues, challenges and vision for the future
of the nursing profession in Sri Lanka: a review.
Int Nurs Rev 2009;56(1):21-7.
3. Toth PE. Ostomy care and rehabilitation in colorectal
cancer. Semin Oncol Nurs 2006;22(3):174-7.
4. Taylor C. Best practice in colorectal cancer care.
Nurs Times 2012;108(12):22-5.
5. Porrett T. Extending the role of the stoma care nurse.
Nurs Stand 1996;10(27):33-5.
6. Doughty D. Role of the enterostomal therapy nurse in
ostomy patient rehabilitation. Cancer 1992;70(5
Suppl):1390-2.
7. Escueta NA. Role of the enterostomal therapy nurse in the
care of ostomy patients. Philipp J Nurs 1991;61(3-4):147.
8. Comb J. Role of the stoma care nurse: patients with cancer
and colostomy. Br J Nurs 2003;12(14):852-6.
9. Melville A. Why nurses must get involved in colorectal
cancer management. Nurs Times 1998;94(11):56-8.
10. Programme NCC. Cancer Incidence Data: Sri Lanka Year
2001-2005. 2009.
11. Niriella MA, De Silva AP, Dayaratne AH, Ariyasinghe
MH, Navarathne MM, Peiris RS, et al. Prevalence of
inflammatory bowel disease in two districts of Sri Lanka:
The Sri Lanka Journal of Surgery 2015; 33(1): 4-8
a hospital based survey. BMC Gastroenterol 2010;10:32.
12. Boarini JC, McNichol, J. L., Carmel, J., Goldberg, M., &
Pruitt, L. . Fecal and urinary diversions: Management
principles. J. C. Colwell MTG, & J. E. Carmel, editor. St.
Louis, MO: Mosby; 2004.
13. Gemmill R, Kravits K, Ortiz M, Anderson C, Lai L, Grant
M. What do surgical oncology staff nurses know about
colorectal cancer ostomy care? J Contin Educ Nurs
2011;42(2):81-8.
14. Jackson AL, Pokorny ME, Vincent P. Relative
satisfaction with nursing care of patients with ostomies.
J ET Nurs 1993;20(6):233-8.
15. Moore S, Grant E, Katz B. Nurse perceptions of ostomy
patients & their ostomy care competence. Home Care
Provid 1998;3(4):214-20.
16. Lynch BM, Hawkes AL, Steginga SK, Leggett B, Aitken
JF. Stoma surgery for colorectal cancer: a populationbased study of patient concerns.
J Wound Ostomy Continence Nurs 2008;35(4):424-8.
17. Clayton HA, Boudreau L, Rodman R, Bak S, Embry K,
Fortier J. Development of an ostomy competency.
Medsurg Nurs 1997;6(5):256-67; quiz 68-9.
18. Knowles G, Hutchison C, Smith G, Philp ID, McCormick
K, Preston E. Implementation and evaluation of a pilot
education programme in colorectal cancer management
for nurses in Scotland. Nurse Educ Today 2008;28(1):1523.
19. Foubert J, Faithfull S. Education in Europe: are cancer
nurses ready for the future? J BUON 2006;11(3):281-4.
8
CONTINUING MEDICAL EDUCATION
Management of the injured hand - basic principles of care
K. Karunadasa
Plastic and Reconstructive Surgical Unit, North Colombo Teaching Hospital, Ragama
Introduction
The aim of this second article is to introduce basic
principles in the management of injured hand. It is
difficult to provide a uniform guideline with
“one injury–one solution” approach, as every case is
different and unique. Detailed description of the
management and surgical techniques of each structure is
beyond the scope of this article.
Hand injuries present either as an isolated injury or as a
component of multiple injuries. In poly-traumatized
patients hand injuries are not uncommon; often these
patients are referred late. Resuscitation, stabilization
and dealing with potentially life threatening injuries
take priority over the injured hand. Haemostasis and
initial wound irrigation along with a scrub of the injured
hand is an acceptable during the initial management of
multi trauma patient. Surgical management of the hand
can be deferred till the patient is stabilized. However,
there can be a significant negative impact on long-term
quality of life if the hand injuries are not treated or
significantly delayed [1].
Initial care
Thorough assessment of the injured hand is performed
and documented. This is aided with digital photography
as a means communication, teaching and recording. The
only potential life threatening problem in the injured
hand is bleeding. Haemorrhage can be controlled
initially with direct, firm compression and elevation
unless there is a coagulopathy. Initial wound irrigation
and dressing is performed at the emergency department.
Elevation of the injured hand is vital to minimize the
development of oedema. Emergency room splinting is a
useful adjunct to reduce pain.
Adequate regular analgesia should be provided. If local
anaesthetic blocks are to be administered, it is essential
Correspondence: K. Karunadasa
E-mail: kolithakarunadasa@yahoo.com
The Sri Lanka Journal of Surgery 2015; 33(1): 9-13
that a neurological examination is carried and
documented, prior to blocks. Immunization status for
tetanus is assessed and addressed accordingly.
Prophylactic antibiotics are started depending on the
degree of contamination and should be used judiciously.
Prophylactic antibiotics are not indicated in
uncomplicated hand injuries without contamination [2].
Use of antibiotics should never replace the role of
meticulous debridement and wound irrigation, which is
the key in preventing infection [3].
Plain radiographs of two views should be the routine
investigation in any injured hand. It is important to have
true lateral and true antero-posterior views of the
fingers, as rotated or angulated views might hide
apparently minor fractures, as avulsion fractures and
dislocations. In a true lateral view the radial and ulnar
condyles of the phalangeal bones should overlap. An
oblique view often provides additional information but
cannot replace a true lateral view. Radiographs without
a splint are the ideal as the splints mask details of bony
injury. Further radiologic evaluation is indicated in
selected cases by the expert.
Management of open wound
Wound debridement or wound excision, is the most
important initial step that determines the functional
outcome of the injured hand. This vital step should not
be done by the junior surgeon in the team as proper
wound excision requires experience and judgment. An
adequate form of anaesthesia, tourniquet and
magnification are essential prerequisites in operating on
an injured hand. The affected area is irrigated with saline
irrigation under anaesthesia. This step will not only help
the mechanical debridement but also clean the whole
region as the patient may not get a chance to wash the
hand for a considerable period of time after the
operation. Macroscopic contamination is carefully
removed and devitalized tissue is debrided with sharp
instruments. Loose strands of crushed and frayed
tendons are carefully debrided preserving the healthy
9
length. In debriding the injured nerves and tendons it is
important to be conservative than to be radical. At the
end of the debridement and thorough irrigation,
tourniquet is deflated to assess the viability of the tissue
and haemostasis is completed with bipolar diathermy,
clips or ligatures.
Achieving adequate surgical access is mandatory in
identifying the injured structures. These access
incisions should be placed carefully and generally
follows Brunner incisions, and are the extensions from
the existing wounds. Skin flaps are raised with sharp
dissection, guided by the palmar fascial bands and
maintaining an adequate thickness. Narrow acute
angled skin flaps are likely to become ischaemic.
Straight line incisions on the volar aspect of fingers are
strongly condemned as they will heal with contractures.
It is important to remember that neurovascular bundles
are just deep to the transversely oriented fibres of the
palmar fascia in the palm. In the fingers the
neurovascular bundles are subcutaneous in relation to
mid lateral lines.
Management of vascular injury
Revascularization of digits, hands or wrist-proximal
injuries require microsurgical expertise and appropriate
cases need to be transferred to equipped centres. Prompt
recognition of vascular compromise in partial
amputations and crush injuries is imperative to avoid
delay. Duration of ischaemia is critical for the long term
recovery of small muscle function and nerve recovery.
Thorough debridement, adequate exposure, bone
shortening and achieving skeletal stability are essential
prerequisites prior to anastomosing injured vessels. The
revascularised hand can be functionally useless, unless
all the nerves and tendons are repaired. The surgeon
should select the indicated cases as some amputations
may not be technically possible as in severe crush
injuries, and unstable patients with concomitant severe
injuries [4].
Soft tissue cover
Soft tissue coverage is crucial in terms of achieving
healing without infection and to protect the repairs
underneath. Majority of open hand trauma are amenable
for immediate closure. In the presence of significant
contamination, a subsequent debridement may be
indicated with an interval of 24 to 48 hours. Primary
closure is the best form of achieving early wound
The Sri Lanka Journal of Surgery 2015; 33(1): 9-13
closure which is the usual case in cut injuries and
majority of lacerations. In the case of soft tissue loss as
in significant crush injuries and degloving injuries, soft
tissue coverage has to be achieved. If the wound is a
graftable, vascularised bed a skin graft can be used. A
popular myth is that “one should wait till the wound is
granulated as a requirement for a skin graft”. In fact,
primarily skin grafted hands do better than with a
delayed graft. Definitive cover in the form of a graft or
flap should ideally be provided within few days rather
than weeks. The delay in achieving cover will promote
granulation tissue that is destined to form scar, which is
considered the enemy of a well-functioning hand. There
are absolute indications for a flap (vascularised tissue);
exposed bone devoid of periosteum, bare tendon
without paratenon, exposed cartilage and joints and
exposed neurovascular structures. A wound with these
structures exposed should be referred to a plastic
surgical unit without delay. The ultimate aim of soft
tissue coverage is to achieve healed wounds with stable
and durable coverage. It is best the coverage over the
tips and volar aspect to be sensate [5, 6].
Skeletal injury
Fractures and dislocations of small bones of the hand are
difficult and often unforgiving injuries. Many different
fracture patterns are described in hand bones.
Comprehensive discussion of each fracture is beyond
the scope of this article. Stabilisation of the bony
skeleton of the hand is essential prior to neurovascular
or tendon repairs. General principles of fracture
management apply to hand fractures as for other bones
in the body. But special attention should be paid in
meticulous and gentle tissue handling around these
small bones. The impact of scar formation and the
development of stiffness is significantly high in hand
fractures. Relatively thin soft tissue envelope makes
access easy, but maintaining cover for the injured bone
is difficult. Majority of closed, stable fractures heal with
splinting for 3–4 weeks followed by active moving
[7,8]. Significant displacement, angulation and rotation
have to be treated by closed manipulation or open
reduction. Indications for operative intervention exist
for individual fractures. In finger fractures, correction of
significant rotational deformity is mandatory to avoid
overriding and scissoring of fingers [9]. The aim of
surgical intervention is to correct the deformity and to
achieve stable fixation to allow early movement. Here
the benefit of surgical intervention is weighed against
10
the surgical trauma and its consequences. Wounds with
open fractures should be thoroughly and promptly
debrided and early soft tissue cover should be achieved.
K-wires are widely used fixation devices which are
cheap, quick and easily inserted. It is used after open or
closed reduction and inserted percutaneously with
radiologic guidance. K-wires involve less tissue
dissection and operative trauma compared with plate
and screw fixation. The K-wires are removed in the
clinic after 3-4 weeks. The drawback with K wires is that
the stability of fixation may not be adequate to allow
early active movement. Rigid fixations are favoured as
this will allow early active movements of the fingers.
They include plate and screws, lag screws, intraosseous
wiring and rarely intramedullary nails. These involve
significant tissue dissection and subsequent scar
formation and stiffness [10,11].
Tendon injury
Primary repair of tendon injuries are the standard
practice. Tendon injuries should be repaired early as the
wound is easy to manage, the tendon ends are fresh,
undue delay lead to changes in tendon ends and
proximally in the muscle belly. In delayed cases the
repair is technically difficult and sometimes primary
repair may be impossible, and interposition tendon graft
or staged tendon reconstruction would be the option. In
flexor tendon injuries all the tendons must be repaired,
and in the finger preferably both Flexor Digitorum
Profundus (FDP) and Flexor Digitorum Superficialis
(FDS) tendons are repaired. Isolated FDP repair,
excising the FDS, is considered in occasions with
severely injured, unclean or ragged tendon ends or
insufficient tendons. In zone one injuries tendon to bone
repairs are performed, traditionally with a core suture in
the proximal tendon passed through the base of the distal
phalanx or around it using the needle drill technique.
The suture is tied on the nail dorsally to be removed in
six weeks. Development of suture anchors has replaced
this technique but in the authors setup the traditional
method is still in practice. Zone two injures are the most
challenging as both FDS and FDP tendons are running
in the crowded flexor sheath and inherent with a higher
chances of poor outcome. Zone 3, 4, and 5 flexor tendon
injuries are treated with the same principles as for zone
two, but these are more spacious and technically easy
[12,13].
Anatomic multi strand locking suture techniques are
The Sri Lanka Journal of Surgery 2015; 33(1): 9-13
favoured as they allow early active range of movement
exercise. Repair suture should consist of a core suture
and an epitendinous suture. In selecting a core suture,
material used, caliber, number of strands crossing the
repair, knot placement and suture locking are the
important aspects to consider [14]. Epitendinous suture
of fine non absorbable material would add the fine
finishing touch to the repair site and helps to increase the
strength. Polyester, polypropylene, and nylon are the
commonly used material [15,16]. Repair site bunching
and gap formations should be avoided. Bulky repair site
may trap under a pulley. Poor repair can lead to gap
formation and is associated with increased risk of repair
rupture. The authors preferred technique is for strand
locking core suture and circumferential epitendionus
suture with non-absorbable material as polyester or
polypropylene. Atraumatic surgical technique in
retrieving and handling the tendons is essential to
minimize subsequent scar formation. In retrieving the
tendon ends several windows are made in the fibrous
flexor sheath without damaging the full length of the
pulleys. Maximal preservation of the A2 and A 4 pulleys
is important to prevent bowstringing. In the case of
severely injured pulleys can be reconstructed. Fine
hypodermic needles are used to transfix the tendons in
stabilizing the ends for the repair. The troublesome
adhesion formation is minimized with early active
movement of the fingers. Hence strict adherence to
rehabilitation protocols is recommended for a good
outcome [17,18]. Flexor tendon injuries remain a
difficult problem in hand trauma, in terms of achieving
optimal functional recovery. Hence these should not be
left to be repaired by the inexperienced junior operator.
Undesirable outcomes as stiffness, repair rupture,
flexion contractures and adhesions should be managed
by experts with the involvement of the hand therapist.
Tendon repair re-explorations, tenolysis and staged
tendon reconstruction should be done carefully in
indicated patients and are not the operations for the
occasional hand surgeon [19,20].
Extensor tendons are easily accessed as their
subcutaneous location. Extensor retinaculum,
juncturae, sagittal bands and retinacula ligaments are
the structures that keep the extensor tendons in place. As
extensor tendons are thin in calibre and flat distally the
repair techniques are modified accordingly and standard
core suture is impossible. Running suture or cross-stich
is used in these areas. Proximally they become thick and
11
a core suture is indicated especially in wrist and
forearm. Different therapy protocols are used to suit the
zone of the injury. Traditionally zone 1 and 2 injuries are
immobilized with splints for 6 weeks [21,22]. Further
details of the rehabilitation of tendon injuries will be
discussed in the third article.
Nerve injury
Early repair of injured nerves is essential for
re-innervation of specific muscles and restoration of
sensibility in the hand which are imperative for
reasonable function. Proximal injury of the upper
extremity nerves are notorious for long lasting
disabilities as, loss of fine sensory and motor function.
Recovery of sensation requires a long time to reach the
optimum and undue delay is likely to compromise the
ultimate sensibility of the hand. Often protective
sensibility recovers following nerve repair but tactile
discriminative function seldom recovers. Microsurgical
technique including magnification is essential in
handling peripheral nerves. Tension free nerve repairs
should be performed with micro sutures such as 8-0 or
9-0 non absorbable monofilament. In sharp cut injuries
primary repair is easy, since there is no loss of nerve
tissue. Positional changes as flexing a joint to gain
length for a primary repair, in the case of segmental
nerve loss are not recommended. Inadvertent dissection
or mobilization of a nerve over a significant length is
strongly discouraged as this can potentially
devascularise the nerve and stimulate formation of scar
tissue. Epineurial repair is the commonly practiced
technique where fascicular arrangement should be
matched under magnification. Cross sectional anatomy
and the pattern of vasa nervorum is the guide for the
proper match. Poor repair technique often lead to
fascicular escape and neuroma formation, resulting in
poor sensory and motor recovery as well as a
symptomatic neuroma [23]. In the case of a segmental
nerve loss, interposition nerve grafts should be used. In
the case of extensive soft tissue loss or severe
contamination, primary nerve repair may be delayed till
the rest of the wound is stabilized. In unsuitable wound
bed, as in established infection or the presence of tissue
with questionable viability, primary nerve grafting
should be deferred. In such occasions, delayed
reconstructive procedures as, delayed nerve grafting,
nerve transfers, tendon transfers or joint fusions are
indicated. Post-operative therapy is invaluable in
The Sri Lanka Journal of Surgery 2015; 33(1): 9-13
sensory and motor re-education and rehabilitation.
Early active movements within a protective splint
facilitate nerve gliding. Desensitisation is useful in
managing hypersensitive areas. Lack of nerve
regeneration, chronic paraesthesia, symptomatic
neuroma and complex regional pain can complicate the
recovery after a nerve injury [24].
Fingertip injury
Fingertip injuries are unique in that they are seemingly
minor but inherently associated with specialised
problems. The priority is to provide the best possible
coverage with good quality skin which is sensate. They
are commonly managed with local nerve blocks except
in small children. Crushed fingertip is probably the
commonest hand injury in the paediatric group. Simple
pulp lacerations are often primarily repaired but when
there is a significant pulp loss it should be reconstructed.
In the presence of exposed distal phalanx bone a flap is
indicated, while a hypothenar graft can be used in
replacing the pulp skin. The amount of remaining tissue
and its configuration determines the reconstructive
option. Nail bed injuries require careful repair with fine
absorbable suture. Nail plate or a substitute is placed as a
splint after nail bed repair. Minor skin loss is often
managed with dressings, although they take at least two
to three weeks to heal. A distal phalanx tuft fracture is
often present in tip crush injuries which are generally
managed only with a soft tissue repair. Even though a
large number of flaps are described for the
reconstruction of tissue loss of the fingertip, they are
generally managed with less traumatic surgical
techniques. More proximal injuries with
non-salvageable tips require proper amputation with
primary repair. The potential secondary deformities of
the fingertip injury can cause a great deal of
inconvenience to the patient preventing the use of their
hand [25].
Immediate post-operative care
Local anaesthetic nerve blocks are an essential part in
alleviating post-operative pain. Regular and adequate
analgesia is mandatory in hand injury as this is the key to
allow early rehabilitation. The dressing and the splints
used at the end of the operation should be tailored
according to the injury and the repairs done. Elevation
of the hand is essential in reducing the inevitable
oedema. Rehabilitation of the injured hand is critical to
12
ensure the best outcome after any form of trauma. Any
hand injury management is incomplete without
appropriate rehabilitation in the post repair period.
Conclusion
Hand is a complex anatomical organ which is frequently
exposed to injuries. Complex and severe hand injuries
can potentially exclude young people from their
professional life, often contributed to by improper
management. Detailed assessment of the injured hand is
the key for the successful repair of the damaged
structures. The outcome depends primarily on the
prompt and skilled treatment. The treating surgeon
should have a sound understanding of the rehabilitation
of the injured hand and be patient enough to complete
the appropriate therapy programs.
References
1. Ciclamini D, Panero B, Titolo P, et al. Particularities of
hand and wrist complex injuries in polytrauma
management. Injury 45:448-51, 2014.
2. Al-Nammari SS, Reid AJ. Towards evidence based
emergency medicine: best BETs from the Manchester
Royal Infirmary. Prophylactic antibiotics are not
indicated in uncomplicated hand lacerations.
Emerg Med J 24:218, 2007.
3. Tsai E, Failla JH. Hand infections in the trauma patient.
Hand Clin15 :373-86, 1999.
4. Prucz RB, Friedrich JB. Upper extremity replantation:
current concepts. PlastReconstrSurg133 :333-42, 2014.
5. Rockwell WB, Lister GD. Soft tissue reconstruction.
Coverage of hand injuries. OrthopClin North Am 24 :41124,1993.
6. Sabapathy SR, Bajantri B. Indications, selection, and use
of distant pedicled flap for upper limb reconstruction.
Hand Clin 30:185-99, 2014.
7. Gregory S, Lalonde DH, Fung Leung LT. Minimally
invasive finger fracture management: wide-awake closed
reduction, K-wire fixation, and early protected
movement. Hand Clin 30 :7-15, 2014
8. Bloom JM, Hammert WC. Evidence-based medicine:
metacarpal fractures. PlastReconstrSurg 133:1252-60,
2014.
9. Shah CM, Sommerkamp TG. Fracture dislocation of the
The Sri Lanka Journal of Surgery 2015; 33(1): 9-13
finger joints. J Hand Surg Am 39 :792-802, 2014.
10. Shaftel ND, Capo JT. Fractures of the digits and
metacarpals: when to splint and when to repair?
Sports Med Arthrosc 22 :2-11,2014.
11. Kollitz KM, Hammert WC, VedderNB,et al. Metacarpal
fractures: treatment and complications. Hand 9:1623,2014.
12. Wong JK, Peck F. Improving results of flexor tendon
repair and rehabilitation. PlastReconstrSurg 134:913-25,
2014.
13. Neumeister MW, Amalfi A, Neumeister E. Evidencebased medicine: Flexor tendon repair. PlastReconstrSurg
133 :1222-33, 2014.
14. Hardwicke JT, Tan JJ, Foster MA, et al. A systematic
review of 2-strand versus multistrand core suture
techniques and functional outcome after digital flexor
tendon repair. J Hand Surg Am 39 :686-695, 2014.
15. Tolerton SK, Lawson RD, Tonkin MA. Management of
flexor tendon injuries - Part 2: current practice in
Australia and guidelines for training young surgeons.
Hand Surg 19 :305-10, 2014.
16. Savage R. The search for the ideal tendon repair in zone
2: strand number, anchor points and suture thickness.
J Hand Surg (Eur) 39:20-9,2014.
17. Lutsky KF, Giang EL, Matzon JL. Flexor tendon injury,
repair and rehabilitation. OrthopClin North Am 46 :6776, 2015.
18. Sandvall BK, Kuhlman-Wood K, Recor C, et al. Flexor
tendon repair, rehabilitation, and reconstruction.
PlastReconstrSurg 132:1493-503,2013.
19. Elliot D, Giesen T. Avoidance of unfavourable results
f o l l o w i n g p r i m a r y f l e x o r t e n d o n s u r g e r y.
Indian J PlastSurg 46:312-24, 2013.
20. Dy CJ, Hernandez-Soria A, Ma Y, et al. Complications
after flexor tendon repair: a systematic review and
meta-analysis. J Hand Surg (Am) 37:543-551,2012.
21. Amirtharajah M, Lattanza L. Open Extensor Tendon
Injuries. J Hand SurgAm 40 :391-397, 2015.
22. Matzon JL, Bozentka DJ.Extensor tendon injuries.
J Hand Surg Am 35 :854-61, 2010.
23. S l o a n E P. N e r v e i n j u r i e s i n t h e h a n d .
Emerg Med Clin North Am 11:651-70,1993.
24. Lundborg G, Rosén B. Hand function after nerve repair.
ActaPhysiol (Oxf) 189:207-17, 2007.
25. Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of
the fingertip: methods of evaluation and treatment. An
algorithmic approach. PlastReconstrSurg 122:105e117e, 2008.
13
SYMPOSIUM ON GORD
Diagnosis and management of gastro-oesophageal reflux disease
N.P. Dinamithra, N.M.M. Nawarathne
Gastro-enterology and Hepatology Unit, National Hospital of Sri Lanka
Introduction
Gastro-oesophageal reflux disease (GORD) is a
common disease encountered by both
gastroenterologists and generalists alike. This article
will provide an overview of GORD and its presentation,
extra oesophageal manifestations, complications and
recommendations for an approach to the diagnosis and
management of this important disease.
Epidemiology
Epidemiologic estimates of the prevalence of GORD
are based primarily on the typical symptoms of
heartburn and regurgitation. A systematic review found
the prevalence of GORD to be 10 –20 percent in the
Western world [2]. Community prevalence of GORD in
Sri Lanka is not known but a single study done by
Nawarathne et al found it closer to 15% [1]. While
clinically troublesome heartburn is seen in about 6
percent of the population [3], chest pain may be the sole
presenting complaint of GORD [4,5]. It is imperative to
distinguish cardiac from non-cardiac chest pain, before
considering GORD as the cause of chest pain. Although
the symptom of dysphagia can be associated with
uncomplicated GORD, its presence warrants
investigation for a potential complication including
motility disorders, ring, stricture or malignancy [6]
A systematic review found that 38 % of the general
population has dyspepsia. Dyspepsia was more frequent
in patients with GORD than those without. The
symptoms of epigastric pain, early satiety, belching and
bloating were more likely to be PPI-responsive
compared to nausea. In general, these symptoms can be
considered to be a part of GORD if they respond to a PPI
trial [7]. Symptoms at night have a greater impact on
quality of life (QOL) when compared to day symptoms.
Correspondence: N.P. Dinamithra
E-mail: npdinamithra@yahoo.com
The Sri Lanka Journal of Surgery 2015; 33(1): 14-19
Therefore, nocturnal symptoms and sleep disturbances
are important to elucidate when dealing with GORD
patients [8]. Aging increases the prevalence of erosive
oesophagitis, i.e. Los Angeles (LA) grades C and D [9].
Barrett's oesophagus increases in prevalence after age
50, especially in Caucasian males [10].The patients with
erosive oesophagitis are more likely to be men. Women
are more likely to have non erosive reflux disease
(NERD). Barrett's oesophagus is more frequent in men
compared to women [11]. The male to female, gender
ratio for oesophageal adenocarcinoma is estimated to be
8:1 [10].
There is a definite link between GORD and obesity.
Several meta-analysis found an association between
body mass index (BMI), waist circumference, weight
gain and the presence of symptoms and complications
of GORD including erosive reflux disease (ERD) and
Barrett ' s oesophagus [12,13].
Establishing the diagnosis of GORD
The diagnosis of GORD is mainly clinical but it is made
using a combination of symptom presentation, objective
testing with endoscopy, ambulatory reflux monitoring,
and response to a trial of anti-secretory therapy. The
symptoms of heartburn and regurgitation are the most
reliable to arrive at a presumptive diagnosis based on
history alone. However, these are not as sensitive as
most believe. Empiric PPI therapy (a PPI trial) is a
reasonable approach to confirm GORD when it is
suspected in patients with typical symptoms. It has a
sensitivity of 78 percent and specificity of 54 percent.
Dysphagia has historically been an alarm symptom and
an indication for early endoscopy. Based on
retrospective case control studies respiratory symptoms
have been associated with GORD. In addition, dental
erosions, sinusitis, chronic laryngitis and voice
disturbance have similarly been associated with GORD.
Endoscopic findings of GORD include erosive
14
oesophagitis, strictures, and a columnar lined
oesophagus or Barrett's oesophagus. As such,
endoscopy has excellent specificity for the diagnosis of
GORD especially when erosive oesophagitis is seen. In
a study done on Sri Lankan patients who had symptoms
suggestive of GORD, hiatus hernia (HH), columnar
lined oesophagus (CLO) and reflux oesophagitis (RO)
were found in 14.3%, 9.5% and 13.3% respectively [1].
Based on current literature the use of routine biopsy of
the oesophagus to diagnose GORD cannot be
recommended in a patient with heart- burn and a normal
endoscopy. In addition, the practice of obtaining
mucosal biopsies from a normal appearing
gastro-oesophageal junction (GOJ) has not been
demonstrated to be useful in GORD patients [14].
Oesophageal manometry is of limited value in the
primary diagnosis of GORD. Neither a decreased lower
oesophageal sphincter pressure, nor the presence of a
motility abnormality is specific enough to make a
diagnosis of GORD. Manometry should be used to aid
placement of the transnasal pH-impedance probes and is
also recommended before consideration of antireflux
surgery, primarily to rule out achalasia or severe
hypomotility. Ambulatory reflux monitoring (pH or
impedance-pH) is the only test that allows for
determining the presence of abnormal oesophageal acid
exposure, reflux frequency and symptom association
with reflux episodes. GORD is common during
pregnancy and manifests as heartburn, and may begin in
any trimester. One study found its onset to be around 50
percent in the first trimester, 40 percent in the second
trimester, and 10 percent in the third trimester [15].
Severity also increased throughout pregnancy. Despite
its frequent occurrence during pregnancy, heartburn
usually resolves after delivery [16]. In the occasional
pregnant patient who does require testing, upper GI
endoscopy is the test of choice, but should be reserved
for patients whose symptoms are refractory to medical
therapy or who have suspected complications. If
possible however, upper GI endoscopy should be
delayed until after the first trimester.
Management of GORD
Lifestyle interventions are part of therapy for GORD.
Counseling is often provided regarding weight loss,
elevation of head end of bed, tobacco and alcohol
cessation, avoidance of late-night meals, and cessation
The Sri Lanka Journal of Surgery 2015; 33(1): 14-19
of foods that can potentially aggravate reflux symptoms
including caffeine, coffee, chocolate, spicy foods,
highly acidic foods such as oranges and tomatoes, and
foods with high fat content. There was an increase in
oesophageal acid exposure times with tobacco and
alcohol consumption in addition to ingestion of
chocolate and fatty foods. However, tobacco and
alcohol cessation (4 trials) were not shown to raise lower
oesophageal sphincter pressure (LOSP), improve
oesophageal pH, or improve GORD symptoms. A recent
systematic review concluded that there was lack of
evidence that consumption of carbonated beverages
causes or provokes GORD [17].
Weight gain even in subjects with a normal BMI has
been associated with new onset of GORD symptoms
[18]. Multiple cohort studies have demonstrated
reduction in GORD symptoms with weight loss [19,
20]. A large case control study based on a Nurses Health
Cohort demonstrated a 40 percent reduction in frequent
GORD symptoms for women who reduced their BMI by
3.5 or more compared with controls [18]. Assumption of
the recumbent position has been associated with
worsening of oesophageal pH values and GORD
symptoms. Three randomized controlled trials have
demonstrated improvement in GORD symptoms and
oesophageal pH values with head end elevation of the
bed [21, 22].
Medical options for patients failing lifestyle
modifications include antacids, histamine-receptor
antagonists (H2RA), or PPI therapy. PPI therapy has
been associated with superior healing rates and
decreased relapse rates compared with H2RAs and
placebo for patients with erosive oesophagitis [24]. A
1997 meta-analysis demonstrated superior healing rates
for all grades of erosive oesophagitis using PPI therapy
compared with H2RAs, sucralfate, or placebo [25]. PPIs
showed a significantly faster healing rate (12%) vs.
H2RAs (6%) and placebo (3%). A Cochrane systematic
review in patients with non-erosive reflux disease
demonstrated superiority for PPI therapy compared
with H2RAs and prokinetics for heartburn relief [26].
There are seven PPIs available in the market at present.
Meta-analyses fail to show significant difference in
efficacy for symptom relief between PPIs [27]. All of
the PPIs with the exception of omeprazole- sodium
bicarbonate
15
and dexlansoprazole, should be administered 30–60
minute before meals to assure maximal efficacy. It
would be expected that 70 – 80 percent of patients with
ERD and 60 percent of patients with NERD would
demonstrate complete relief on PPI therapy. Risk factors
for lack of symptom control have included patients with
longer duration of disease, presence of hiatal hernia,
extra oesophageal symptoms, and lack of compliance
[28]. Maintenance PPI therapy should be administered
for GORD patients who continue to have symptoms
after PPI is discontinued and in patients with
complications including erosive oesophagitis and
Barrett's oesophagus (BO). In patients found to have any
length of BO, retrospective studies have suggested a
decreased risk for dysplasia in patients continuing PPI
usage [29].
Medical options for GORD patients with incomplete
response to PPI therapy are limited. The addition of
bedtime H2RA has been recommended for patients with
symptoms refractory to PPI. Prokinetic therapy with
metoclopramide in addition to PPI therapy is another
option often considered for these patients. Combination
therapy of Metoclopramide with H2RA has not been
shown to be more effective compared with H2RA or
prokinetic therapy alone [30]. The other option is to use
baclofen for refractory GORD patients. Baclofen, a
GABA (b) agonist, has been demonstrated to be
effective in GERD by its ability to reduce transient LOS
relaxations [31], and reflux episodes [32]. Potential
surgical options for GORD include laparoscopic
fundoplication or bariatric surgery in the obese. Reasons
to refer GORD patients for surgery may include desire
to discontinue medical therapy, non-compliance,
side-effects associated with medical therapy, the
presence of a large hiatal hernia, oesophagitis refractory
to medical therapy, or persistent symptoms documented
to be caused by refractory GORD. With the introduction
of oesophageal pH-impedance monitoring, patients
found to have abnormal amounts of non-acid reflux on
PPI therapy with good symptom correlation may be
considered for surgery [34]. Refractory dyspeptic
symptoms including nausea, vomiting and epigastric
pain are less likely to demonstrate symptomatic
response. The highest surgical responses are seen in
patients with typical symptoms of heartburn and/or
regurgitation that demonstrate good response to PPI
therapy. Surgical options, its recommendation and
The Sri Lanka Journal of Surgery 2015; 33(1): 14-19
evidence are shown in table 1.
1. Surgical therapy is a treatment option for long-term
therapy in GORD patients. (Strong recommendation,
h i g h
l e v e l
o f
e v i d e n c e )
2. Surgical therapy is generally not recommended in
patients who do not respond to PPI therapy. (Strong
recommendation, high level of evidence)
3. Preoperative ambulatory pH monitoring is mandatory
in patients without evidence of erosive oesophagitis.
All patients should undergo preoperative manometry
to rule out achalasia or scleroderma-like esophagus.
(Strong recommendation, moderate level of evidence)
4. Surgical therapy is as effective as medical therapy for
carefully selected patients with chronic GORD when
performed by an experienced surgeon. (Strong
recommendation, high level of evidence)
5. Obese patients contemplating surgical therapy for
GORD should be considered for bariatric surgery.
Gastric bypass would be the preferred operation in these
patients. (Conditional recommendation,
m o d e r a t e l e v e l o f e v i d e n c e )
6. The usage of current endoscopic therapy or transoral
incisionless fundoplication cannot be recommended as
an alternative to medical or traditional surgical
t h e r a p y. ( C o n d i t i o n a l r e c o m m e n d a t i o n ,
m o d e r a t e l e v e l o f e v i d e n c e )
Table 1. Surgical options for GORD [33]
Extra oesophageal presentations of GORD
The spectrum of clinical presentations attributed to
GORD has expanded from typical oesophageal
symptoms of heartburn and regurgitation, to an
assortment of extra oesophageal manifestations
including respiratory and laryngeal symptoms. A
number of epidemiological studies have identified an
association between GORD and these extra
oesophageal symptoms, but causality cannot be
concluded from these studies. A systematic review of
28 studies found that symptoms of GORD and
abnormal 24-hour pH monitoring were present in 59
and 51% of asthma patients, but concluded that there
was little data to clarify the direction of causality [35].
Cohort studies suggest that GORD may be the cause
in 21–41 percent of chronic nonspecific cough [36].
GORD refractory to treatment with PPIs
We are seeing increasing numbers of patients treated
empirically with PPIs for symptoms that are suspected
to be due to GORD, but who do not respond to these
medications. The term refractory GORD encompasses
16
a heterogeneous group of patients that may differ in
symptom frequency and severity, PPI dosing regimen
(once or twice daily), and response to therapy (from
partial to absent). Dealing with this category of
patients is shown in table 2 and figure 1 [33] with the
level of evidence and degree of recommendation.
1. The first step in management of refractory GORD
i s o p t i m i z a t i o n o f P P I t h e r a p y. ( S t r o n g
recommendation, low level of evidence)
2. Upper endoscopy should be performed in refractory
patients with typical or dyspeptic symptoms
principally to exclude non-GORD etiologies.
(Conditional recommendation, low level of evidence)
3. In patients in whom oextraesophageal symptoms of
GORD persist despite PPI optimization, assessment for
other etiologies should be pursued through concomitant
evaluation by ENT, pulmonary, and allergy specialists
(Strong recommendation, low level of evidence)
4. Patients with refractory GORD and negative evaluation
by endoscopy (typical symptoms) or evaluation
by ENT, pulmonary, and allergy specialists (extra
oesophageal symptoms), should undergo
ambulatory reflux monitoring (Strong
recommendation, low level of evidence)
5. Reflux monitoring off medication can be performed
by any available modality (pH or impedance-pH)
(Conditional recommendation, moderate level of
evidence). Testing on medication should be performed
with impedance-pH monitoring in order to enable
measurement of nonacid reflux. (Strong
recommendation, moderate level of evidence)
6. Refractory patients with objective evidence of ongoing
reflux as the cause of symptoms should be considered
for additional anti reflux therapies that may include
surgery. (Conditional recommendation, low level of
evidence). Patients with negative testing are unlikely to
have GORD and PPI therapy should be discontinued.
(Strong recommendation, low level of evidence)
Table 2. Management of "refractory" GORD [33]
Complications associated with GORD
Numerous “complications” have been associated with
GORD including erosive oesophagitis, stricture, and
Barrett's oesophagus (BO). Obesity has been
demonstrated to be a risk factor for symptoms, ERD,
BO, and adenocarcinoma. It may be that the presence of
an abnormal waist-to-hip ratio is the greatest risk factor
for the presence of BO [37].
There are limited data to suggest that a columnar lined
The Sri Lanka Journal of Surgery 2015; 33(1): 14-19
Figure 1. Algorithm for the evaluation of refractory
gastroesophageal reflux disease (GORD) [33].
oesophagus (Barrett's oesophagus) can be obscured by
any grade of erosive oesophagitis, most commonly it is
obscured by grades C and D [38,39] . On the basis of
these data, a repeat endoscopy after a minimum 8-week
course of PPI therapy is recommended in patients with
grades C and D oesophagitis but also can be considered
in lower grades.
Peptic strictures are infrequent in practice, and are likely
related to the widespread use of anti-secretory therapy.
Strictures tend to occur most often in Caucasians, older
patients with a longer duration of untreated symptoms,
and in the setting of abnormal oesophageal motility.
Intra lesional corticosteroids (40 mg of triamcinolone
injected in four 1 ml aliquots) in a four quadrant pattern
can be considered in peptic strictures refractory to
dilation.
Barrett's oesophagus is the only complication of GORD
with malignant potential. BO can be found in 5 to 15
percent of patients who undergo endoscopy for
symptoms of GORD [40] and tends to be seen at the
higher end of this range in patients with long duration of
symptoms, who are over the age of 50, male, and
Caucasian.
Conclusion
In summary, refractory GORD remains a difficult
clinical challenge. Many pathological mechanisms have
17
been proposed as causes of refractory symptoms but, in
most cases, data supporting the hypotheses remain
equivocal. The work-up of a refractory patient should
clearly include a careful history, and the consideration
of alternative diseases that require alternative
treatments is paramount. Reflux monitoring studies are
helpful in determining the presence or absence of
GORD, and reflux–symptom analysis is a very
important tool that presently requires further refinement
and better outcome studies to aid our interpretation.
References
1. Navarathne M. M. Navarathne & Vasitha Abeysuriya & A.
Ileperuma & U. L. Thoufeek. Endoscopic observations
around the gastroesophageal junction in patients with
symptomatic gastroesophageal reflux disease in South
Asia. Indian J Gastroenterol (2010) 29:184–186
2. Dent J ,El Serag HB, Wallander M A et al. Epidemiology
of gastrooesophageal reflux disease: a systematic review.
Gut 2005 ; 54 : 710 – 7.
3. Camilleri M ,Dubois D ,Coulie B et al. Prevalence and
socioeconomic impact of upper gastrointestinal disorders
in the United States: results of the US Upper
Gastrointestinal Study. Clin Gastroenterol Hepatol 2005 ;
3 : 543 – 52
4. Atkins D, Briss PA, Eccles M et al. Systems for grading the
quality of evidence and the strength of recommendations
II: pilot study of a new system. BMC Health Serv Res
2005;5:25–36
5. Vakil N, van Zanten SV, Kahrilas P et al. The Montreal
definition and classification of gastroesophageal reflux
disease: a global evidence-based consensus.
Am J Gastroenterol 2006; 101:1900 – 20.
6. Vakil NB, Traxler B, Levine. Dysphagia in patients with
erosive esophagitis: prevalence, severity, and response to
proton pump inhibitor treatment.
Clin Gastroenterol Hepatol 2004;2:665–8.
7. Gerson LB, Kahrilas PJ, Fass R. Insights into
gastroesophageal reflux disease-associated dyspeptic
symptoms. Clin Gastroenterol Hepatol 2011;9: 824–33.
8. Gerson LB, Fass R. A systematic review of the definitions,
prevalence, and response to treatment of
nocturnal gastroesophageal reflux diseas.
Clin Gastroenterol Hepatol 2009;7:372–8 .
9. Johnson DA, Fennerty MB. Heartburn severity
underestimates erosive esophagitis severity in elderly
patients with gastroesophageal reflux disease.
Gastroenterology 2004; 126:660 –4 .
10. Rubenstein JH, Scheiman JM, Sadeghi S et al. Esophageal
adenocarcinoma incidence in individuals with
gastroesophageal reflux: synthesis and estimates from
population studies .Am J Gastroenterol 2011;106:254 –
60.
The Sri Lanka Journal of Surgery 2015; 33(1): 14-19
11.Lin M, Gerson LB, Lascar R et al. Features of
gastroesophageal reflux disease in women.
Am J Gastroenterol 2004; 99:1442–7 .
12.Corley D A, Kubo A. Body mass index and
gastroesophageal reflux disease: a systematic review and
meta-analysis . Am J Gastroenterol 2006 ; 101 : 2619–28.
13.Hampel H, Abraham NS, ElSerag HB. Meta-analysis:
obesity and the risk for gastroesophageal reflux disease
and its complications. Ann Intern Med 2005;143:199–
211.
14. Takubo K, Honma N, Aryal G et al. Is there a set of
histologic changes that are invariably refl ux associated?
Arch Pathol Lab Med 2005 ; 129 : 159 – 63 .
15. Olans LB, Wolf J. Gastroesophageal reflux in pregnancy.
Gastrointest Endosc Clin N Am 1994 ; 4 : 699 – 712 .
16. Richter J. Review article: the management of heartburn in
pregnancy. Aliment Pharmacol Th er 2005 ; 22 : 749 – 57 .
17.Johnson T, Gerson L, Hershcovici T et al. Systematic
review: the effects of carbonated beverages on gastrooesophageal reflux disease. Aliment Pharmacol Ther
2010 ; 31 : 607 – 14 .
18. Jacobson BC, Somers SC, Fuchs CS et al. Body-mass
index and symptoms of gastroesophageal reflux in
women. N Engl J Med 2006 ; 354 : 2340– 8 .
19. Fraser-Moodie CA, Norton B, Gornall C et al. W eight loss
has an independent beneficial effect on symptoms of
gastro-oesophageal reflux in patients who are
overweight. Scand J Gastroenterol 1999; 34 : 337– 40.
20. Mathus-Vliegen L M, T ytgat G N. Twenty-four-hour pH
measurements in morbid obesity: effects of massive
overweight, weight loss and gastric distension.
Eur J Gastroenterol Hepatol 1996 ; 8 : 635 – 40 .
21. Gagne DJ, Dovec E, Urbandt JE. Laparoscopic revision
of vertical banded gastroplasty to Roux-en-Y gastric
bypass: outcomes of 105 patients . Surg Obes Relat Dis 2
011; 7 : 4 93– 9 .
22. Stanciu C, Bennett JR. Effects of posture on gastrooesophageal reflux . Digestion 1977 ; 15 : 104 – 9.
23. Pollmann H, Zillessen E, Pohl J et al. Effect of elevated
head position in bed in therapy of gastroesophageal
reflux . Z Gastroenterol 1996 ; 34(Suppl 2) : 93 – 9 .
24. Labenz J, Malfertheine P. Treatment of uncomplicated
reflux disease . World J Gastroenterol 2005 ; 11 : 4291 – 9
25. Chiba N, De Gara CJ, Wilkinson JM et al. Speed of
healing and symptom relief in grade II to IV
gastroesophageal reflux disease: a meta-analysis
.Gastroenterology 1997 ; 112 : 1798 – 810 .
26. Van Pinxteren B, Sigterman K E, Bonis P et al. Short-term
treatment with proton pump inhibitors, H2-receptor
antagonists and prokinetics for gastro-oesophageal
reflux disease-like symptoms and endoscopy negative
reflux disease Cochrane Database Syst Rev : Cd002095.
27. Gralnek IM, Dulai GS, Fennerty MB et al. Esomeprazole
versus other proton pump inhibitors in erosive
esophagitis: a meta-analysis of randomized clinical
trials. Clin Gastroenterol Hepatol 2 006; 4 : 1 452– 8 .
28. Dickman R, Boaz M, Aizic S et al. Comparison of clinical
characteristics of patients with gastroesophageal reflux
disease who failed proton pump inhibitor therapy versus
18
those who fully responded. J Neurogastroenterol Motil
2011; 17: 387– 94.
29. El-Serag HB, Aguirre TV, Davis S et al. Proton pump
inhibitors are associated with reduced incidence of
dysplasia in Barrett's esophagus. Am J Gastroenterol
2004 ; 99 : 1877 – 83 .
30. Richter J E, Sabesin S M, Kogut D G et al. Omeprazole
versus ranitidine or ranitidine/metoclopramide in poorly
responsive symptomatic gastro-esophageal reflux
disease . Am J Gastroenterol 1996 ; 91 : 1766 – 72 . 7
31. Grossi L, Spezzaferro M, Sacco LF et al. Effect of
baclofen on oesophageal motility and transient lower
oesophageal sphincter relaxations in GORD patients: a
48-h manometric study. Neurogastroenterol Motil 2008 ;
20 : 760 –6 .
32. Koek GH , Sifrim D , Lerut T et al. Effect of the GABA(B)
agonist baclofen in patients with symptoms and duodenogastro-oesophageal reflux refractory to proton pump
inhibitors. Gut 2003 ; 52 : 1397 – 402 .
33. Katz et al. Guidelines for the Diagnosis and Management
of Gastroesophageal Reflux Disease. Am J Gastroenterol
2013; 108:308 – 328 .
34. del Genio G, Tolone S , del Genio F et al. Prospective
The Sri Lanka Journal of Surgery 2015; 33(1): 14-19
assessment of patient selection for antireflux surgery by
combined multichannel intraluminal impedance pH
monitoring. J Gastrointest Surg 2008 ; 12 : 1491 – 6
35. Havemann BD, Henderson CA, El-Serag HB. The
association between gastro-oesophageal reflux disease
and asthma: a systematic review. Gut 2007 ; 56 : 1654–64.
36. Irwin RS, Curley FJ, French CL. Chronic cough. The
spectrum and frequency of causes, key components of the
diagnostic evaluation, and outcome of specific therapy.
Am Rev Respir Dis 1990; 1 41: 6 40– 7 .
37. Havemann BD, Henderson CA, El-Serag HB. The
association between gastro-oesophageal reflux disease
and asthma: a systematic review. Gut 2007 ; 56 : 1654 –
64 .
38. Modiano N, Gerson LB. Risk factors for the detection of
Barrett's esophagus in patients with erosive esophagitis.
Gastrointest Endosc 2009; 69: 1014– 20.
39. Hanna S, Rastogi A, Weston AP et al. Detection of
Barrett's esophagus after endoscopic healing of erosive
esophagitis. Am J Gastroenterol 2006 ; 101 : 1416 – 20 .
40. Westhoff B , Brotze S , Weston A et al. The frequency of
Barrett’s esophagus in high-risk patients with chronic
GERD . Gastrointest Endosc 2005:61:226-31
19
SYMPOSIUM ON GORD
Oesophageal manometry and pH-impedance studies in
gastro-oesophageal reflux disease
1
2
SUB Dassanayake , ANR Fernandopulle
1 Gastroenterology & Hepatology unit, National Hospital of Sri Lanka,
2 Teachng Hospital, Jaffna
Introduction
disorders.
Gastro-oesophageal reflux disease (GORD) is probably
the most common disease encountered by the
gastroenterologist physician and surgeon. Its diagnosis
is mainly clinical and based on symptoms of heartburn
and reflux. Upper gastrointestinal endoscopy when
done may show evidence of reflux oesophagitis.
Oesophageal pH and manometry are used mainly for a
specific group of patients who are resistant to routine
medication and prior to surgery. Ambulatory reflux
monitoring is the only test that can assess reflux
symptom association. On the other hand, oeosophageal
manometry is recommended for preoperative
evaluation, but has no role in the diagnosis of GORD.
These rapidly evolving and highly technical fields of
study have provided major insights into our
understanding of the pathophysiology of GORD, and
have become an integral part of its evaluation in the
modern era.
The first attempts at measuring the pH changes in
GORD were made by Tuttle et al, who in 1960 used a
glass pH electrode to demonstrate a gradual sloping
gradient in the gastro-oesophageal pH in patients with
oesophagitis in contrast to a sharp one in normal
subjects [1]. Later, Johnson and DeMeester developed a
dependable external electrode in 1974, successfully
using it to measure oesophageal pH changes for up to 24
hours [2]. During the last decade, further studies
demonstrated that the use of combined pH-impedance
monitoring was more effective compared to pH
monitoring alone in clinical practice.
Kronecker and Meltzer performed the first oesophageal
manometric studies using a balloon kymograph in 1894,
but its clinical use was demonstrated by an atlas of
oesophageal manometry published by Code et al in
1958 [3]. When optimally utilized, a manometric
evaluation provides an accurate description of
oesophageal contractile function, and is useful in
characterizing a variety of oesophageal motility
Correspondence: A.N.R. Fernandopulle
E-mail: anrfernandopulle@yahoo.com
The Sri Lanka Journal of Surgery 2015; 33(1): 20-23
Technical details
pH monitoring
Intra-oesophageal acidity can be measured via a
trans-nasal catheter with a pH sensitive electrode placed
in the oesophagus (for 24h) or a telemetry capsule (for
48h). Detection of periods of oesophageal acidification
allows for a direct diagnosis of episodes of
gastro-oesophageal reflux and quantification of the
exposure of the distal oesophagus to acid [2]. For
ambulatory monitoring, the basic equipment should
include a data logger and an event marker to signal
symptoms and other events during the period of
recording. Reflux is defined as a drop in pH below 4.
The number of episodes of reflux and the acid exposure
time (the % of time with the pH <4) is recorded. The acid
exposure time has been shown to positively correlate
with the degree of mucosal damage. Although routine
studies are performed with one distal pH sensor,
experimental studies using multiple pH sensors allow
evaluation of the proximal extent of the reflux [4].
However, pH studies do not give a measurement of the
volume of the reflux. Wireless pH monitoring using a
capsule is a fairly recent advancement which is more
tolerable to the patient, but is limited by cost.
Intraluminal impedance monitoring
Impedance monitoring includes the concurrent
measurement of impedance from multiple intraluminal
recording segments of an impedance catheter positioned
20
within the oesophageal body [5]. The different patterns
of electrical conductivity of gas, liquid or mixed content
allows their distinction. It is also possible to distinguish
between resting states, bolus transit, and wall
contraction. The sequence of impedance changes allow
recognition of flow in either aboral (swallow related) or
oral (reflux) directions [6]. Gastro-oesophageal reflux is
demonstrated as a liquid or mixed bolus moving in the
oral direction during impedance studies, without any
measurement of the pH. The most distal electrode is
placed 2-3cm from the lower oesophageal sphincter
(LOS) to detect restricted reflux episodes not reaching
5cm beyond the LOS [5].
Combined pH-impedance electrodes allow
measurement of both parameters and their structure
combines the two principles (figure 1). With the
combination, reflux can be categorized as acid (nadir
pH<4) or non-acid (nadir pH>4). In ambulatory subjects
off proton-pump inhibitor (PPI) therapy, approximately
two-thirds of reflux episodes are acidic and one-third is
weakly acidic [7]. Conversely, if patients are on PPI
therapy, approximately 90% of reflux episodes are
weakly acidic (nadir pH 4-7) and are still responsible for
the majority of symptoms [8].
Ambulatory reflux monitoring (pH or impedance-pH) is
the only test that allows for determining the presence of
abnormal oesophageal acid exposure, reflux frequency,
and symptom association with reflux episodes.
Figure 1. Schematic representation of a combined
i m p e d a n c e - p H c a t h e t e r. T h e r e i s o n e a n t i m o n y
electrode placed 5cm above the LOS
and six pairs of impedance electrodes set at 2cm intervals .
The Sri Lanka Journal of Surgery 2015; 33(1): 20-23
Manometry
Manometry quantifies intraluminal oesophageal and
LOS pressure during swallowing to detect
abnormalities of peristalsis and sphincter relaxation.
Stationary oesophageal manometry is performed by
water-perfused catheters with volume displacement
transducers or strain gauge transducers with solid-state
circuitry. Water-perfused catheters are in wider use due
to their lower cost, reusability and versatility, but require
skilled personnel for maintenance. A perfused sleeve
assembly is commonly used to hold the catheter in place
during oesophageal shortening with swallowing.
High resolution manometry (HRM) is a relatively recent
advancement, which is characterized by the use of
catheters which have a large number of sensors
(21-36 sensors) which are very closely spaced (1-2cm).
Data from HRM is usually illustrated as an oesophageal
pressure topography (OPT) plot. OPT plots utilize
colours to illustrate different pressure domains, and can
be used to clearly demonstrate the gastro-oesophageal
junction (GOJ) and the functional anatomy of the
oesophagus [10].
Use in gastro-oesophageal reflux
pH/impedance-pH monitoring
pH monitoring in patients with endoscopy proven
erosive oesophagitis has been shown to have excellent
sensitivity (77–100%) and specificity (85–100%);
however, the sensitivity is lower in those with
endoscopy-negative reflux symptoms (<71%) [11]. The
differentiation between physiological and pathological
reflux is thought to be best achieved by recording the
percentage of time the pH is < 4 [12].
The temporal relationship between the symptoms and
reflux episodes is expressed using the symptom index
(SI) or symptom association probability (SAP). A
positive SI and/or SAP indicates a high probability that
the relationship between reflux and symptoms did not
occur due to chance and thus suggests causality [13].
Both these indices have been used in patients off PPI
therapy who are experiencing heartburn. For patient
management, a strongly positive SI or SAP may suggest
the need for a therapeutic intervention and a negative
result supports the notion that the patients symptoms are
unlikely to be due to reflux [14]. However, a major
shortcoming is that these depend on the patient
21
identifying and reporting all symptoms completely.
Additionally reflux episodes that occur as prolonged
rather than transitory events may not be reported
correctly [11].
According to current guidelines, indications for
ambulatory pH monitoring in GORD are [14.15]:
1.In the evaluation of patients refractory to PPI
therapy.
2.Before consideration of endoscopic or surgical
therapy in patients with non-erosive disease.
3.Where the diagnosis of GORD is in question.
On patients refractory to PPI therapy, cessation of
treatment prior to pH monitoring (7-14 days) is
commonly done [15]. However, it is difficult to make
recommendations on the “off vs on PPI” approaches
according to the available evidence in centers where
impedance-pH testing is available [14]. If reflux
monitoring off medication is negative, the probability of
GORD is very low, while a positive reflux test offers
objective evidence to support the diagnosis. However, it
does not provide information on the reason for the poor
response to therapy. If pH monitoring alone is used in
refractory patients while on PPI therapy, up to 96% may
show normal acid exposure levels [16]. The use of
combined pH-impedance monitoring is useful in these
cases to detect non-acid reflux, which may increase the
sensitivity up to 90% in endoscopy negative patients [5].
In patients with extra-oesophageal manifestations of
GORD (mainly laryngeal and respiratory), a negative
reflux monitoring test will point towards non-GORD
aetiologies for the symptoms. The presence of abnormal
pH monitoring results in patients with extraoesophageal symptoms vary widely in reports [17].
24-hour pH monitoring also provides important
prognostic information on patient selection for antireflux surgery [15]. It has been shown to be the strongest
outcome predictor of laparoscopic Nissen
fundoplication, although this is probably based more on
the correct identification of the disease than on its
severity [18].
The Sri Lanka Journal of Surgery 2015; 33(1): 20-23
Manometry
During oesophageal manometry, gastro-oesophageal
reflux is signified by the occurrence of absent LOS
pressure with a common cavity phenomenon which is
ended by primary and secondary peristalsis [19]. A
common cavity phenomenon is identified by the rapid
increase of intra-oesophageal pressure to match the intra
gastric pressure, which signifies the relaxation of both
the LOS and the crural diaphragm [20]. However, this
phenomenon is technically difficult to detect with a low
volume refluxate and is a relatively insensitive and nonspecific method of measuring reflux [5]. Due to these
reasons, manometry is not considered important in
establishing the diagnosis of GORD.
However, manometry is recommended prior to
antireflux surgical procedures to exclude other
dysmotility disorders. GORD may co-exist with
undiagnosed conditions such as achalasia, scleroderma
oesophagus or non-reflux induced oesophageal spasm,
which are best diagnosed by manometry [21]. The
association between post-surgical dysphagia and
preoperative peristaltic dysfunction detected by
manometry has been a controversial issue, although
current data do not support it [22].
Conclusion
Gastro-oesophageal reflux disease remains one of the
commonest conditions seen in our practice and should
be diagnosed based on its common symptoms. While
oesophageal manometry and pH studies help in the
diagnosis and management of GORD they should not be
routinely done for all patients. If used selectively and in
the proper setting, they will help alleviate some of the
most troublesome symptoms seen in the population.
References
1. Tuttle SG, Rufin F, Bettarello A. The physiology of
heartburn. Ann intern med [internet] 1961 aug
1;55(2):292–300.
2. Johnson LF, demeester TR. Development of the 24-hour
intraoesophagealph monitoring composite scoring
system. J Clin Gastroenterol 1986;8 Suppl 1:52–8.
3. Kahrilas, Clouse PJ, Ray E. Hogan WJ. An American
Gastroenterological Association Medical Position
Statement on the Clinical Use of Oesophageal
Manometry. Gastroenterology 1994;107:1865–84.
4. Weusten BL, Akkermans LM, vanberge-Henegouwen
22
GP, Smout AJ. Spatiotemporal characteristics of
physiological gastrooesophageal reflux.
Am J Physiol 1994 Mar;266(3 Pt 1):G357–62.
5. Sifrim D, Castell D, Dent J, Kahrilas PJ. Gastrooesophageal reflux monitoring: review and consensus
report on detection and definitions of acid, non-acid, and
gas reflux. Gut 2004;53(February):1024–31.
6. Nguyen HN, Silny J, Matern S. Multiple intraluminal
electrical impedancometry for recording of upper
gastrointestinal motility: current results and further
implications. Am J Gastroenterol 1999
Feb;94(2):306–17.
7. Bredenoord AJ, Weusten BLAM, Timmer R, Smout
AJPM. Characteristics of gastrooesophageal reflux in
symptomatic patients with and without excessive
oesophageal acid exposure. Am J Gastroenterol 2006
Nov;101(11):2470–5.
8. Mainie I, Tutuian R, Shay S, Vela M, Zhang X, Sifrim D, et
al. Acid and non-acid reflux in patients with persistent
symptoms despite acid suppressive therapy: a multicentre
study using combined ambulatory impedance-ph
monitoring. Gut 2006;55:1398–402.
9. Hirano I, Richter JE. ACG practice guidelines: esophageal
reflux testing. Am J Gastroenterol 2007;102:668–685.
10. Roman S, Pandolfino J, Mion F. High-resolution
manometry: A new gold standard to diagnose oesophageal
dysmotility? Gastroenterol Clin Biol [Internet] Elsevier
Masson SAS; 2009;33(12):1061–7.
11. Hirano I, Richter JE, Fass R, Baroni DS, Bernstein DE,
Bharucha AE, et al. ACG practice guidelines:
Oesophageal reflux testing. Am J Gastroenterol
2007;102(6):668–85.
12. Pandolfino JE, Vela MF. Oesophageal-reflux monitoring.
Gastrointest Endosc [Internet] Elsevier; 2009 Feb
21;69(4):917–30.e1.
13. Bredenoord a. J. Impedance-ph monitoring: New standard
for measuring gastro-ooesophageal reflux.
Neurogastroenterol Motil 2008;20:434–9.
14. Katz PO, Gerson LB, Vela MF. Guidelines for the
The Sri Lanka Journal of Surgery 2015; 33(1): 20-23
diagnosis and management of gastrooesophageal reflux
disease. Am J Gastroenterol [Internet]. Nature Publishing
Group; 2013;108(3):308–28; quiz 329.
15. Fuchs KH, Babic B, Breithaupt W, Dallemagne B,
Fingerhut A, Furnee E, et al. EAES recommendations for
the management of gastrooesophageal reflux disease.
Surg Endosc [Internet] 2014;28:1753–73.
16. Charbel S, Khandwala F, Vaezi MF. The role of
oesophagealph monitoring in symptomatic patients on
PPI therapy. Am J Gastroenterol United States; 2005
Feb;100(2):283–9.
17. Saritas Yuksel E, Vaezi MF. New Developments in
Extraoesophageal Reflux Disease. Gastroenterol Hepatol
(N Y) [Internet] Millennium Medical Publishing; 2012
Sep;8(9):590–9.
18. Csendes a. Multivariate analysis of factors predicting
outcome after laparoscopic Nissen fundoplication.
J Gastrointest Surg [Internet] 1998;4:650.
19. Wyman JB, Dent J, Holloway RH. Changes in
ooesophagealph associated with gastro-ooesophageal
reflux. Are traditional criteria sensitive for detection of
reflux? Scand J Gastroenterol NORWAY; 1993
Sep;28(9):827–32.
20. Dent J, Dodds WJ, Friedman RH, Sekiguchi T, Hogan WJ,
Arndorfer RC, et al. Mechanism of gastrooesophageal
reflux in recumbent asymptomatic human subjects.
J Clin Invest 1980;65(February):256–67.
21. Pandolfino JE, Kahrilas PJ. AGA technical review on the
c l i n i c a l u s e o f o e s o p h a g e a l m a n o m e t r y.
Gastroenterology 2005;128:209–24.
22. Mughal MM, Bancewicz J, Marples M. Ooesophageal
manometry and ph recording does not predict the bad
results of Nissen fundoplication. Br J Surg ENGLAND;
1990 Jan;77(1):43–5.
23. Zerbib F, Bruley Des Varannes S, Roman S, Pouderoux P,
Artigue F, Chaput U, et al. Normal values and day-to-day
variability of 24-h ambulatory ooesophageal impedanceph monitoring in a Belgian-French cohort of healthy
subjects. Aliment Pharmacol Ther 2005;22:1011–21.
23
SYMPOSIUM ON GORD
Nissen fundoplication: how I do it
C.A.H Liyanage, S. Kumarage
University Surgical Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
Introduction
Contraindications
Laparoscopic Nissen fundoplication is now the standard
approach for treatment of severe gastro-oesophageal
reflux disease (GORD), not responding to medical
treatment [1]. GORD affects 10% of the population and
it causes significant morbidity to this group of people.
The main cause for GORD is the dysfunctional lower
oesophageal sphincter (LOS) rather than an over
production of acid [2].
Open fundoplication is now almost an unacceptable
procedure. The contraindications for laparoscopic
fundoplication are,
Rudolph Nissen (1896-1981) described the first
fundoplication in 1950 [3,4]. The procedure has been
revised many times and currently laparoscopic Nissen
fundoplication is the gold standard for symptomatic
GORD [5]. In Sri Lanka the procedure is offered to a
very selective group of patients as pH and manometric
studies are not freely available. The preceding two
articles by our medical colleagues describe the value
and the importance of evaluating symptomatic GORD
patients.
1. Portal hypertension.
2. Contraindication for general anaesthesia.
3. Coagulopathy.
4. Inexperienced surgeon.
Previous surgery, short esophagus and morbid obesity
(BMI>35kg/m2) will make it a risky operation. For
patients with BMI of >35kg/m2 it is recommended to do
a gastric bypass surgery. Patients with esophageal
dysmotility disorders should also be excluded from the
procedure. The learning curve for a laparoscopic Nissen
fundoplication would be at least 20 mentored
procedures [6].
Procedure
Indication
The indications for surgery for a patient with GORD are,
1. Ineffective medical management.
2. Need for long term medical treatment: The long
term treatment with proton pump inhibitors can
cause undesirable side effects. In addition patients
can have a poor quality of life due to long term drug
treatment.
3. Alarming signs - asthma, chest pain, aspiration,
hoarseness.
4. Para-oesophageal hernia.
5. Recurrent reflux.
6. Complications after previous antireflux surgery.
Correspondence: Chandika Liyanage
E-mail: chandikaliyanage@hotmail.com
The Sri Lanka Journal of Surgery 2015; 33(1): 24-26
Prior to the procedure it is important to do an upper GI
endoscopy by the operating surgeon at which he should
measure the length of the gastro-oesophageal junction
(GOJ). In addition 24-hour pH monitoring, oesophageal
manometry, impedance monitoring, fluoroscopic real
time swallowing studies and gastric emptying testing
are important.
Technique
After the patient is anaesthetised, patient is placed in
Lloyd Davies stirrups in the reverse Trendelenburg
position. The operating surgeon stands in between the
legs of the patient and the camera holding surgeon will
stand on the left of the patient while the assistant stands
on the right.
We use an optical guided trocar for placement of the
camera port at the paramedian region above and lateral
24
to the umbilicus. A 10mm port is used for the camera. If
the falciform ligament is bulky and redundant, we use a
percutaneously placed and laparoscopically guided
suspension suture. Further four 5mm ports are placed; 2
ports are on the left and one on the right side of the
abdomen and one epigastric port (Figure 1).
can be made on a bougie to prevent narrowing, we do not
use this technique.
Where there is a short oesophagus, the thoracic
oesophagus has to be mobilized and pulled down prior
to forming the wrap. In addition, there are additional
procedures to lengthen the GOJ. Where there is a large
hiatus hernia the repair can be augmented by a mesh.
Post-operative period
Patient is then managed with anti-emetics and pureed
food for 2 days and gradually introduced to more solid
food.
Figure 1. Laparosopic port sites at Nissen
fundoplication
We use an improvised technique to retract the liver
utilising a laparoscopic needle holder through the
epigastric port. The left lobe of the liver is retracted and
held up with the sheath of the needle holder and the jaw
of the needle holder is used to pinch the diaphragm.
Further, the pars flaccida is divided using an ultrasonic
shear (Harmonic Scalpel, Ethicon endosurgery) and the
right crus of the diaphragm is defined. The oesophagus
is then mobilized along the crus. Retro-oesophageal
dissection is done lifting the posterior vagus nerve along
with the oesophagus, up to the lateral border of left crus
and a tunnel is made between the posterior to the
oesophagus. The vagus nerve is protected which is
retracted superiorly with the oesophagus. The fundus of
the stomach is mobilized along the greater curvature of
the stomach dividing the short gastric vessels with the
Harmonic scalpel.
The crural defect is then sutured using 2/0 silk sutures.
The fundus is pulled behind the GOJ and the fundal
wrap is formed with 2/0 silk sutures. We perform a 3600
degree wrap. There are other centres which perform
2700wraps and Dor wraps.
Patients do complain of “tightness” on swallowing but
with pre-operative counselling and reassurance that this
feeling will disappear as time progresses, the patient
usually overcomes this fear. Early post-operative
symptoms include abdominal discomfort and fullness,
mild dysphagia, and post prandial discomfort. These are
mainly due to swelling around the fundus and GOJ and
usually resolve in 2-6 weeks. Post-surgical
pneumothorax and surrounding structural damage to the
spleen or vagus nerve are very rare.
Dysphagia lasting more than 12 weeks will require
further evaluation. About 5-10% of patients who
undergo Nissen fundoplication will require re-do
surgery.
Conclusion
Laparoscopic Nissen Fundoplication is effective for
carefully selected patients with severe GORD who are
refractory to medical treatment. When performed by an
experienced surgeon in appropriately selected patients
laparoscopic anti-reflux surgery is cost effective than
life long medical treatment. However, there is no
evidence that laparoscopic fundoplication reverses the
metaplasia in Barrett oesophagus. Furthermore there is
no evidence to suggest that fundoplication reduces the
incidence of adenocarcinoma in patients with Barrett
oesophagus.
Acknowledgement :
Dr. Prasad Madushanka for secretarial assistance.
The new fundal wrap and the tightness of the GOJ is
checked using on-table endoscopy. Though the wrap
The Sri Lanka Journal of Surgery 2015; 33(1): 24-26
25
References
1. Adam R, Adam CA, Akerstorm G, el al: Gastrooesophageal reflux disease. Surgical treatment 2001;
1:68-78,.
2. Singhal V, Khaitan L: Gastroesophageal reflux disease:
diagnosis and patient selection. Indian Journal of Surgery
2 014; 76(6):453-460.
3. Nissen, R. Eine einfache Operation zur Beeinflussung der
Refluxoesophagitis. Schweiz Med Wochenschr.
The Sri Lanka Journal of Surgery 2015; 33(1): 24-26
1956;86:590–592.
4. Niebisch S, Peters JH: Update on fundoplication for the
treatment of GERD. CurrGastroenterol Rep 2012;
14(3):186-96.
5. Ranmnik V, Jackson P, De coppi P, et al: Laparoscopic
Nissen fundoplication and gastrostomy for a giant hiatal
hernia in an infant with situsinversustotalis. BMJ
2013;10:1136,.
6. Lafullarde T, David I, Watson, et al: Laparoscopic Nissen
Fundoplication: Five year results and beyond. JAMA
2001; 136(2): 180-184.
26
TECHNICAL NOTE
Botulinum toxin injection to the puborectalis in the management of
pelvic floor dyssynergia.
I.H.D.S Pradeep1, P.C Chandrasinghe2, S.A.S.R Siriwardana3, S.K Kumarage2
1 Professorial Surgical Unit, Colombo North Teaching Hospital, Ragama.
2 Department of Surgery, University of Kelaniya, Ragama.
3 Department of Radiology, Colombo North Teaching Hospital, Ragama.
Introduction
Pelvic floor dyssynergia (spastic pelvic floor) is a
functional disorder that causes difficulty in evacuation
of the rectum [1]. This entity is an under diagnosed
condition which requires dynamic pelvic MRI as the
current investigation of choice. Treatment includes
biofeedback therapy, injection of botulinum toxin in to
puborectalis ring and surgical division of the
puborectalis ring. Surgical division of puborectalis ring
has irreversible effects and has a risk of causing
incontinence [2]. Botulism toxin injection provides a
reversible paralysis of the puborectalis allowing the
chance of diagnosis and treatment in short term.
perianal lesions such as fistulae, fissures or
hemorrhoids. On digital rectal examination anal tone
was normal. She underwent colonoscopy which was
normal. A dynamic pelvic MRI was done which
revealed a prominent puborectalis with impingement at
the anorectal angle (paradoxic movement) while
straining indicating spastic pelvic floor. A grade I
rectocele was also present (Figure 1; a & b).
Considering the clinical scenario it was decided to
proceed with botulinum toxin injection under ultra
sound guidance to the puborectalis sling as a short term
therapeutic trial.
This brief report describes the technique of Botulinum
toxin injection to puborectalis sling in a patient
diagnosed with pelvic floor dyssynergia.
Clinical diagnosis
A 37 year old mother of two children presented with a
history of recurrent anal fissures with chronic anal pain
and difficulty in evacuation of the rectum for two years
duration. There was sensation of incomplete bowel
emptying and tightness of the perineum. She had
adopted an unusual position to defecate in order to
overcome the difficulty and had to strain more than
thirty minutes at a time. She had undergone lateral
internal anal sphincterotomy and didn't have significant
improvement. She didn't have a past history of
abdominal or pelvic surgeries. She had two normal
vaginal deliveries and there was no history of obstetric
complications or instrumental delivery. On examination
there was no rectal prolapse, perineal floor descent or
Correspondence: I.H.D.S Pradeep
E-mail: samaniddagoda@gmail.com
The Sri Lanka Journal of Surgery 2015; 33(1): 27-29
Figure 1. Dynamic pelvic MRI at rest (a) and increased
anorectal angle during straining (b)
Technique
After taking written informed consent the patient was
positioned in the lithotomy position under spinal
anesthesia. Perineum and upper thigh were cleaned with
10% povidone iodine and draped with perineal towels.
Real time perineal ultrasound scan was performed using
a high frequency (10 MHz ) linear probe to demonstrate
the anatomical structures. In visualizing the structures
the probe was held perpendicular to the perineum on
either side of the anus and at the perineal body. The anal
sphincter complex and the puborectalis ring were
27
identified (Figure 2). The anal sphincter complex
appears on ultrasonography as a hypoechoic ring
shadow. The puborectalis appears as a 'V' shaped mixed
echogenic shadow encircling the spinchters. With
sonographic guidance a 26g needle was introduced in to
the puborectalis sling and 50 units of botulinum toxin
was injected in to each limb of the puborectalis sling
under sonographic guidance. Although the needle
cannot be visualized sonographically the movement of
muscle fibres with the penetration of the needle is used
as a guide. Post operatively the patient was managed
with oral analgesia and syrup lactulose 30 ml nocte. She
was advised to have a fibre rich diet and adequate
amount of water. Using of a squatting pan for the act of
defecation was recommended as the pelvic floor
muscles are maximally relaxed in this position. Patient
was discharged on post procedure day one and reviewed
at post procedure two weeks. Patient had dramatic
improvement of symptoms with biofeedback, two
weeks after the procedure. On further follow up her
symptoms reappeared at 1 month following the
procedure. Injection of botulinum toxin was done for the
second time in the same manner.
Figure 2. Ultrasonographic view of the puborectalis muscle
(arrow)
Discussion
Pelvic floor dyssynergia (anismus) is a functional
disorder due to spastic pelvic floor leading to defective
relaxation of pelvic floor muscles resulting in
evacuation difficulty during the act of defecation. The
exact etiology for this is not well recognized. Chronic
straining is thought to be the main cause resulting in the
The Sri Lanka Journal of Surgery 2015; 33(1): 27-29
loss of muscle coordination specifically of the
puborectalis part of the levator ani. These patients are
often misdiagnosed and continue to have constipation
and evacuation difficulty for a long period of time. In
analyzing their symptoms these patients fulfill the
ROME II criteria for functional constipation. Currently
the dynamic pelvic MRI is the choice of imaging which
shows defective relaxation of puborectalis sling and
pelvic floor muscles causing an acute ano rectal angle
during evacuation causing obstructed defaecation [8].
Other available investigations are defaecation
proctography, balloon expulsion, anorectal manometry
and electromyography of the pelvic floor muscles.
Lower GI endoscopy is mandatory to exclude colonic
pathology. Validated standard questionnaires
(PAC- SYM, PAC-QOL) are used to assess the severity
of the symptoms and response following treatment.
Treatment modalities consist of Biofeedback therapy,
botulinum toxin injection to the puborectalis sling and
surgical division of the puborectalis muscle. Bio
feedback therapy is morbidity free effective therapy for
well motivated patients diagnosed of having this
condition. Gadel Hak et al. reported 91.6% subjectively
overall improvement of symptoms in a group of 60
patients who underwent biofeedback therapy [5].
Although it has been shown to have limited therapeutic
effect in clinical practice [6] botulinum toxin injection is
useful in relieving symptoms in the short term which
causes transient relaxation of puborectalis sling
allowing confirmation of the diagnosis. It has higher
success rates compared to biofeedback training alone
[7]. Muscle coordination can be regained once the
spasticity is relieved with botulinum toxin. Symptoms
tend to return in few months when the effect of the drug
weans off. There has been no severe side effect observed
following injection of botulinum toxin to treat benign
anal conditions [4]. Farid M and El Monem et al
compared biofeed back therapy over Botulinum toxin
injection in forty eight patients with anismus [3].
Patients were assessed for initial improvement at one
month and long term success rate at one year in this
study. Patients who had biofeedback(BF) therapy had
50% initial improvement and 25% long term success
rate and patients had Botulinum toxin had 70.8% initial
improvement with 33.3% long term success rate. They
concluded highlighting the limited therapeutic effect of
biofeedback therapy and higher temporary success rate
28
of botulinum injection (BI). Partial surgical division
(PSD) of the puborectalis sling bilaterally is the
definitive surgical treatment indicated for anismus. This
procedure is found to be an effective method with low
morbidity and higher success rates compared to non
pharmacological methods. Previous authors have
administered botulinum toxin with the assistance of
endoanal ultrasound or electromyography of the
puborectalis, methods which are not freely available in
the local setting [12]. We describe the technique
performed with the use of perineal ultrasound scanning
which is a non-invasive freely available modality. The
drawback of surgical division is the risk of causing
irreversible incontinence. Faried M et al conducted a
study on 60 patients who were randomly allocated to
receive either one of the three modalities of treatment
with a follow up of up to one year [3]. The groups
differed significantly with regard to functional outcome
at 1 month (50% - BF, 75% - BI, 95% - PSD). The
difference persisted at one year post procedure. They
concluded that bilateral PSD of puborectalis has higher
success rate with less morbidity in the long run.
Incontinent for flatus or faeces (13%) and pelvic floor
descent (26%) were the complications observed in this
series with PSD. It was decided to proceed with PSD of
puborectalis in our patient as the method of relieving her
recurrent symptoms, which was proven to be effective
with less morbidity in long term basis. In conclusion
botulinum injection to the puborectalis can be
effectively administered under perineal ultrasound scan
guidance. Modality of treatment should be decided
based on each case to have best outcome and minimize
post procedure complications.
References
1. Wexner SD, Bartolo DC (eds) (1995) Constipation:
etiology, evaluation and management. ButterworthHeinemann, Oxford, pp 1–272
2. Kamm MA, Hawely PR, Lennard-Jones JE (1988) Lateral
The Sri Lanka Journal of Surgery 2015; 33(1): 27-29
division of puborectalis muscle in the management of
severe constipation. Br J Surg 75:661–663
3. Farid M, Youssef T, Mahdy T, Omar W, Ayman M, Abdul
H, El Nakeeb A, Youssef M. Comparative study between
botulinum toxin injection and partial division of
puborectalis for treating anismus. Int J Colorectal Dis
2009 Mar;24(3):327-34.
4. Madaliński MH, Sławek J, Duzyński W, Zbytek B,
Jagiełło K, Adrich Z, Kryszewski A. Side effects of
botulinum toxin injection for benign anal disorders.
Eur J Gastroenterol Hepatol 2002 Aug;14(8):853-6.
5. Gadel-Hak N, El-Hemaly M, Hamdy E, El-Raouf AA,
Atef E, Salah T, El-Hanafy E, Sultan A, Haleem M,
Hamed H. Pelvic floor dyssynergia: efficacy of
biofeedback training. Arab J Gastroenterol 2011
Mar;12(1):15-9.
6. Farid M, El Monem HA, Omar W, El Nakeeb A, Fikry A,
Youssef T, Yousef M, Ghazy H, Fouda E, El Metwally T,
Khafagy W, Ahmed S, El Awady S, Morshed M, El Lithy
R. Comparative study between biofeedback retraining
and botulinum neurotoxin in the treatment of anismus
patients. Int J Colorectal Dis 2009 Jan;24(1):115-20.
7. Faried M, El Nakeeb A, Youssef M, Omar W, El Monem
HA. Comparative study between surgical and nonsurgical treatment of anismus in patients with symptoms
of obstructed defecation: a prospective randomized
study. J Gastrointest Surg 2010 Aug;14(8):1235-43.
8. C S Reiner, MD, R Tutuian, MD, A E Solopova, MD, D
Pohl, MD, B Marincek, MD, and D Weishaupt, MD. MR
defecography in patients with dyssynergic defecation:
spectrum of imaging findings and diagnostic value.
Br J Radiol Feb 2011; 84(998): 136–144.
9. Ron Y, Avni Y, Lukovetski A, Wardi J, Geva D,
BirkenfeldS,Halpern Z. Botulinum toxin type-A in
therapy of patients with anismus. Dis Colon Rectum
2001;44:1821-1826.
10. Andromanakos N, Skandalakis P, Troupis T,
FilippouD.Constipation of anorectal outlet obstruction:
pathophysiology,evaluation and management.
J Gastroenterol Hepatol 2006;21(4):638–646.
11. Maria G, Brisinda G, Bentivoglio AR, Cassetta E,
Albanese A.Botulinuxn toxin in the treatment of outlet
obstruction constipationcaused by puborectalis
syndrome. Dis Colon Rectum 2000;43:376-380.
12. Yong Zhang, Zhen-Ning Wang, Lei He, GeGao, Qing
Zhai, Zhi-Tao Yin, Xian-Dong Zeng. Botulinum toxin
type-A injection to treat patients with intractable anismus
unresponsive to simple biofeedback training.
World J Gastroenterol 2014 September 21; 20(35):
12602-12607
29
CASE REPORTS
A Sri Lankan family with cerebellar hemangioblastoma due to a
heterozygous nonsense mutation in the von Hippel-Lindau tumor
suppressor, E3 ubiquitin protein ligase (VHL) gene.
P.K.D. Channa T. Somadasa1, Nirmala D. Sirisena1, L. Suresh C. De Silva2, Vajira H.W. Dissanayake1,2
1 Human Genetics Unit, Faculty of Medicine, University of Colombo, Sri Lanka,
2 Asiri Centre for Genomic and Regenerative Medicine, Asiri Surgical Hospital, Colombo, Sri Lanka
Key words: Genetics; hemangioblastoma; VHL gene;
Von Hippel-Lindau disease
Abstract
Mutations in the von Hippel-Lindau tumor suppressor,
E3 ubiquitin protein ligase (VHL) gene cause a variety
of phenotypes including von Hippel-Lindau (VHL)
disease. This report describes a Sri Lankan family with
three siblings with cerebellar haemangioblastoma due
to a nonsense mutation in the VHL gene. A heterozygous
nucleotide substitution in exon 3 was identified in all
three siblings resulting in a stop codon at amino acid
position 175 leading to a truncated non-functional VHL
protein [NM_000551.3(VHL):c.525C>G;p.Tyr175Ter;
rs5030835C>G]. Patients with rare tumours
characteristic of VHL should undergo clinical and
genetic evaluation for VHL.
Introduction
The von Hippel-Lindau tumor suppressor, E3 ubiquitin
protein ligase (VHL) gene [GenBank: NG_008212.3,
OMIM# 193300], is a tumor suppressor gene which
spans a 14.25-kb genomic region at 3p25.3. It encodes
for two alternatively spliced transcript variants.
Transcript variant 1 (NM_000551.3) which is encoded
by all 3 exons is translated to a protein with 213 amino
acid residues (NP_000542.1) while transcript variant 2
(NM_198156.2) is translated to a protein with 172 acid
residues (NP_937799.1) [1] .
Mutations in the VHL tumor suppresser gene cause a
variety of phenotypes including von Hippel-Lindau
disease (VHL), familial phaeochromocytoma and
inherited polycythaemia [2]. VHL is an autosomal
dominantly inherited familial cancer syndrome
Correspondence: Vajira H. W. Dissanayake
E-mail: vajirahwd@hotmail.com
The Sri Lanka Journal of Surgery 2015; 33(1): 30-32
predisposing to a variety of malignant and benign
tumors [3] such as haemangioblastomas of the
cerebellum, spinal cord, brainstem and retina, clear cell
renal carcinomas, pheochromocytomas, endolymphatic
sac tumours, pancreatic islet cell tumours,
haemangiomas of the adrenals, liver and lungs,
epididymal and broad ligament papillary cyst adenomas
as well as visceral cysts in the kidneys and pancreas [4].
A germline mutation of the VHL gene is the basis of
familial inheritance of VHL syndrome. According to
Knudson's (“Two Hit”) hypothesis, both alleles of a
tumor suppresser gene need to be mutated in order for a
tumour to develop, therefore a patient who manifests a
tumour, inherits one mutation from a parent, and
develops the second mutation in the same gene in the
affected organ as a somatic mutation, at which point the
tumour begins to manifest [5].
To date, more than 300 mutations have been identified
in families with VHL disease, consisting of partial and
whole gene deletions, frameshift, nonsense, missense,
and splice site mutations [6]. About 20% of cases are
due to de novo mutations. This report describes a Sri
Lankan family with 3 siblings with cerebellar
haemangioblastoma due to a heterozygous nonsense
mutation in the VHL gene.
The Family
A 28 year old female who was clinically diagnosed with
a cerebellar hemangioblastoma was referred to the
Human Genetics Unit for genetic evaluation. The
patient was clinically diagnosed with cerebellar
haemangioblastoma at the age of 13 years, since then,
she had undergone four surgeries for removal of the
recurrent tumour in the posterior cranial fossa. In
addition, a tumor arising from the fourth ventricle of the
brain was also surgically removed. She also developed a
30
cervical spinal cord haemangioblastoma (Figure 1).
Two of her male siblings were also diagnosed with
cerebellar hemangioblastoma. The CT scan of one of the
brothers showed dilatation and a cystic mass in the
lateral third ventricle as well as a renal cyst. Figure 2
shows the pedigree of the family with VHL disease.
Figure 1. (a) T2 weighted sagittal MRI brain of the female
proband showing the recurrent cerebellar
haemangioblastoma and (b) T1 weighted post contrast
sagittal MRI of the cervical spine showing spinal
haemangioblastoma.
comparison of the nucleotide sequences generated from
the patients and to confirm the presence of any
mutations.
A heterozygous nonsense mutation was identified in all
3 individuals in exon 3 of the VHL gene. A single
nucleotide substitution at position 13214
(NG_008212.3.g13214C>G) replaced the codon for
amino acid tyrosine (UAC) in transcript variant 1
(NM_000551.3.c525C>G) to a stop codon (UAG)
resulting in premature termination of the VHL protein at
amino acid position 175 (NP_000542.1.pTyr175Ter).
This mutation has previously been reported in other
families and documented in the dbSNP
database and assigned the SNPID rs5030835
(http://www.ncbi.nlm.nih.gov/projects/SNP/rs=50308
35). Figure 3 shows the partial electropherogram with
the point mutation at position 13214 of the VHL gene.
Figure 3. Partial electropherogram of the patient showing the
heterozygous nonsense mutation in the VHL gene.
Discussion
Figure 2. Pedigree of the family with VHL disease showing
the familial mutation in the three siblings.
Genotyping
The VHL gene was sequenced in the patient and her 2
siblings after obtaining their written informed consent.
DNA was extracted from peripheral blood using
QIAamp blood DNA midi kit from Qiagen. All 3 exons
and flanking intronic regions of the VHL gene were
sequenced using an ABI PRISM 3130 Genetic
A n a l y z e r. T h e p u b l i s h e d h u m a n V H L g e n e
Reference Sequence file obtained from GenBank
(http://www.ncbi.nlm.nih.gov) was used for
The Sri Lanka Journal of Surgery 2015; 33(1): 30-32
This report describes a Sri Lankan family with three
siblings with cerebellar haemangioblastoma due to a
heterozygous nonsense mutation in the VHL gene. VHL
mutations are associated with various benign and
malignant tumours resulting in high morbidity and
mortality rates. Mutations in the VHL gene are known to
cause haemangioblastomas of the central nervous
system (CNS) in 60-80% of VHL patients [6,7].
A study conducted by van der Harst et al. in 1998
reported that 8 out 68 patients with pheochromocytoma
had mutations in the VHL gene. Among these patients,
two were relatives and had a familial mutation [8].
Familial mutations in the VHL gene have also been
reported in VHL families presenting with clear cell renal
cell carcinoma. Recent advances in understanding the
genetic basis of VHL disease has resulted in improved
diagnosis of VHL disease and provided greater insights
into the molecular pathogenesis of the disease [1]. The
31
prognosis can be improved through early screening,
diagnosis and surveillance [9]. Molecular genetic
testing coupled with genetic counseling is now
considered standard for the evaluation of patients and
families with suspected VHL [10].
Acknowledgments
We would like to express our thanks to Dr. Udari
Liyanage, Senior Lecturer & Consultant Radiologist,
Department of Anatomy, Medical Faculty, Colombo for
providing radiological information and Mr. Sanka P.
Bandara of the Audio-Visual Unit, Medical Faculty,
Colombo for preparing the radiological photographs.
References
1. Maher, E.R., H.P. Neumann, and S. Richard, von HippelLindau disease: a clinical and scientific review.
Eur J Hum Genet 2011, 19(6): p. 617-23.
2. Maher, E.R, Von Hippel-Lindau disease. Curr Mol Med
2004, 4(8): p. 833-42.
3. Pastore, Y., et al., Mutations of von Hippel-Lindau tumor-
suppressor gene and congenital polycythemia.
Am J Hum Genet 2003, 73(2): p. 412-9.1
4. Kaelin, W.G., Jr., The von Hippel-Lindau tumour
s u p p r e s s o r p r o t e i n : O 2 s e n s i n g a n d c a n c e r.
Nat Rev Cancer 2008, 8(11): p. 865-73.
5. Berger, A.H., A.G. Knudson, and P.P. Pandolfi, A
continuum model for tumour suppression. Nature 2011,
476(7359): p. 163-9.
6. Hasani-Ranjbar, S., et al., Mutation screening of VHL
gene in a family with malignant bilateral
pheochromocytoma: from isolated familial
pheochromocytoma to von Hippel-Lindau disease.
Fam Cancer 2009, 8(4): p. 465-71.
7. Tootee, A. and S. Hasani-Ranjbar, Von hippel-lindau
disease: a new approach to an old problem.
Int J Endocrinol Metab 2012, 10(4): p. 619-24.
8. Van der Harst, E., et al., Germline mutations in the vhl
gene in patients presenting with phaeochromocytomas.
Int J Cancer 1998, 77(3): p. 337-40.
9. Gallou, C., et al., Mutations of the VHL gene in sporadic
renal cell carcinoma: definition of a risk factor for VHL
patients to develop an RCC. Hum Mutat 1999, 13(6): p.
464-75.
10. Friedrich, C. Genotype-phenotype correlation in von
Hippel-Lindau syndrome. Human Molecular Genetics
2001, 10(7): p. 763-767.
Key Points:

Mutations in the VHL gene are known to predispose to haemangioblastomas of the central nervous system in
60-80% of patients with VHL disease.

Molecular genetic testing coupled with genetic counseling should be offered to patients and families with
suspected VHL disease.

The prognosis can be improved through early screening, diagnosis and surveillance.
The Sri Lanka Journal of Surgery 2015; 33(1): 30-32
32
CASE REPORTS
Laparoscopic resection with minilaparotomy anastomosis for
pancreatico-duodenectomy
K B Galketiya, V Pinto, R Rohankumar, B G Jayawickrama, A Herath
Teaching Hospital Peradeniya, Kandy, Sri Lanka.
Key words: Pancreatico-duodenectomy; laparoscopy
Introduction
Pancreatico-duodenectomy is the surgical treatment of
choice for carcinoma of the periampullary region and
head of pancreas. The open procedure is associated with
considerable morbidity and occasional mortality. The
long incision, continuous handling and prolonged use of
retractors can result in post operative respiratory
inadequacy due to severe pain and ileus. There is often
significant blood loss. Laparoscopic assisted Whipples
resection is an achievable alternative minimizing postoperative complications, thus facilitating early feeding,
mobilization and discharge from hospital [1,2,4,6].
However literature indicates the need of further studies
to recommend its routine use [4,5,6,7,8].
the mid transverse colon to caecum. The duodenum was
identified and 'kocherized' and the inferior vena cava
was exposed until the left renal vein crossed the
abdominal aorta . Mobilization of the duodenum was
continued until the ligament of Treitz was divided
allowing the jejunum to be pulled freely to the right side.
The portal vein was exposed to the neck of pancreas and
the dissection continued until the common bile duct and
common hepatic artery hepatic artery and gastroduodenal artery were exposed. The gastro-duodenal
artery was divided in between clips. The stomach was
transected with a stapler. The pancreas was divided in
front of the portal vein.
Case Report
A year 50 year old male presented with obstructive
jaundice who was deeply icteric with a palpable Gall
bladder. Imaging were suggestive of a periampullary
carcinoma which was confirmed by endoscopy and
b i o p s y. L a p a r o s c o p i c a s s i s t e d p a n c r e a t i c o duodenectomy was planned.
Patient was evaluated for co-morbidities and optimized
as required. His weight was 58kg with a BMI of
25.1kg/m2 . Procedure was carried out under general
anaesthesia with invasive monitoring and supplemented
by epidural analgesia. The patient was placed in
reverse-trendelenburg 20 degrees and rotated to the left
by 30 degrees with legs abducted to 60 degrees. Five
ports were used. Pneumoperitoneum was created by
insufflation of CO2 at a pressure of 14 mmHg. The
gastro-colic omentum was divided, entering in to lesser
sac exposing the pancreas. Colon was mobilized from
The jejunum was transected with a stapler. The divided
pancreas and uncinate process were taken off from the
portal vein. The common bile duct was transected and
the resection was complete. The time for resection was
330 minutes with a blood loss of 400ml. The patient was
stable during procedure and did not require blood
transfusion.
Correspondence: K.B. Galketiya
E-mail: kbgalketiya@yahoo.com
A mid line laparotomy of about 10 cm was made to
retrieve the specimen and perform the anastomoses -
The Sri Lanka Journal of Surgery 2015; 33(1): 33-34
Figure1. Picture showing transected stomach and pancreas
being divided in front of the portal vein
33
pancreatico-jejunostomy, hepatico-jejunostomy and
gastro-jejunostomy.
The respiratory and cardiovascular parameters were
monitored carefully and were stable. Following
extubation, the patient was managed in the ICU. Pain
relief was provided using the epidural catheter for the
first day. Subsequently the patient was comfortable
with diclofenac sodium suppositoies100mg twice a day.
He was mobilized after twenty four hours and started on
oral sips forty eight hours after surgery. Semisolids were
started after four days and a normal diet by the sixth day.
He was discharged on the eighth post operative day.
Discussion
Laparoscopic pancreatico-duodenectomy creates a new
learning curve for the gastrointestinal surgeon. The
patient positioning, port placement, adequate retraction,
traction and counter traction, precise appreciation of
anatomy and tissue planes are all required for successful
completion. Adherence to meticulous haemostasis is
crucial.
We successfully completed the laparoscopic resection
in this patient. This was after conversion to open surgery
at various stages of resection in seventeen patients. For
the reconstruction, we opted for a minilaparotomy [3].
Anastomoses could be performed laparoscopicaly, for
which a skill in laparoscopic suturing is essential. The
next goal to achieve is performing the hepaticojejunostomy laparoscopically. Then the pancreas can be
anastomsed to the posterior wall of the stomach. This
and the gastro-jejunostomy could be performed with a
mini incision of about 5cm.
The meticulous fluid balance, monitoring and vigilance
reduced complications due to altered physiology owing
to pneumoperitonium, position, abdominal
compartment syndrome with aorto- caval compression
leading to impediment of perfusion to organs,
possibility of gas embolism during this surgery which
took 330 minutes [9].
Conclusion
Laparoscopic pancreatico-duodenectomy may well be
performed safely with minimum blood loss in an
acceptable time with minimal complications and speedy
post operative recovery. Persistence during the learning
curve is a must in reaching the goal.
References
1. Gagner M, Palermo M.Laparoscopic Whipple procedure:
review of the literature J HepatobiliaryPancreat Surg.
2009;16(6):726-30. doi:10.1007/s00534-009-0142-2.
Epub 2009 Jul 28.
2. Dulucq JL, Wintringer P, Stabilini C, Feryn T, Perissat J,
Mahajna A. Are major laparoscopic pancreatic resections
worthwhile? A prospective study of 32 patients in a single
institution. SurgEndosc. 2005 Aug;19(8):1028-34. Epub
2005 May 26
3. Lee JS, Han JH, Na GH, Choi HJ, Hong TH, You YK,
Kim DG.Laparoscopic pancreaticoduodenectomy
assisted by mini-laparotomy.JSLS. 2013 JanMar;17(1):68-73.
4. Lei P, Wei B, Guo W, Wei H. Minimally Invasive Surgical
Approach Compared With Open
Pancreaticoduodenectomy: A Systematic Review and
Meta-analysis on the Feasibility and Safety.
Surg Laparosc Endosc Percutan Tech. 2014 Apr 16.
[Epub ahead of
5. Tan-Tam C, Chung SW.Minireview on laparoscopic
h e p a t o b i l i a r y a n d p a n c r e a t i c s u r g e r y.
World J Gastrointest Endosc. 2014 Mar 16;6(3):60-67.
6. Nigri G1, Petrucciani N2, La Torre M2, Magistri P2,
Va l a b r e g a S 2 , A u r e l l o P 2 , R a m a c c i a t o
G2.Duodenopancreatectomy: Open or minimally
invasive approach? Surgeon. 2014 Feb 10. pii: S1479666X(14)00012-2. doi: 10.1016/j.surge.2014.01.006.
[Epub ahead of print]
7. Bao PQ1, Mazirka PO, Watkins KT.Retrospective
Comparison of Robot-Assisted Minimally Invasive
Ve r s u s O p e n P a n c r e a t i c o d u o d e n e c t o m y f o r
Periampullary Neoplasms. J Gastrointest Surg. 2013
Nov 15. [Epub ahead of print]
8. Zenoni SA1, Arnoletti JP2, de la Fuente SG2.Recent
developments in surgery: minimally invasive approaches
for patients requiring pancreaticoduodenectomy. JAMA
Surg. 2013 Dec;148(12):1154-7. doi:
10.1001/jamasurg.2013.366.
9. Gerges FJ, Kanazi G, Jabbour-khoury S. Anesthesia for
laparoscopy: a review. J Clin Anesth. 2006;18:67-78.
Key Points:

Laproscopic pancreatico-duodenectomy is a treatment method which leads to reduced perioperative
complications and speedy recovery. However there is a steep learning curve to be negotiated before it becomes
standard practice.
The Sri Lanka Journal of Surgery 2015; 33(1): 33-34
34
CASE REPORTS
Axial torsion and gangrene of a giant Meckel's diverticulum causing
small bowel obstruction.
S. N. Deshmukh, S. P. Jadhav, A. G. Asole
Dr. Vaishampayan Memorial Government Medical College, Solapur, Maharashtra, India.
Key words: Meckel's diverticulum; torsion; gangrene;
small bowel obstruction
Introduction
Meckel's diverticulum is the most prevalent congenital
anomaly of the gastrointestinal tract, affecting
approximately 2% of the general population [1]. It
results from incomplete obliteration of the most
proximal portion of the vitelline or omphalomesenteric duct [2]. Bleeding, obstruction, and
inflammation are the three most common
complications of Meckel's diverticulum [3]. Here, we
report a case of axial torsion and gangrene of
Meckel's diverticulum which is the rarest
complication.
Case history
A 13-year-old girl presented with abdominal pain,
vomiting, distension and constipation of 2 days
duration. On physical examination her abdomen was
distended, tender and guarding was present. There was
no history of previous abdominal surgery. Per rectal
examination was unremarkable. Plain abdominal
radiograph depicted multiple air-fluid levels suggesting
small bowel obstruction. All the laboratory parameters
were within normal limits except elevated leucocyte
count. Emergency exploratory laparotomy was
performed. At exploration the loop of the ileum was
found entrapped due to axially torsed gangrenous
Meckel's diverticulum leading to small bowel
obstruction (Figure 1). The tip of the Meckel's
diverticulum was found adherent to the umbilicus
(Figure 2). Simple diverticulectomy was performed.
The diverticulum measured 8cm x 1.5cm. Postoperative
course was uneventful. Histopathological examination
confirmed acute Meckel's diverticulitis with focal
gangrenous change.
Figure 1. Ileal loop entrapped by axially torsed gangrenous
Meckel's diverticulum.
Figure 2. Gangrenous Meckel's diverticulum with tip
adherent to the umbilicus.
Correspondence: S.N. Deshmukh
E-mail: santoshkumarndeshmukh@gmail.com
The Sri Lanka Journal of Surgery 2015; 33(1): 35-36
35
Discussion
Meckel's diverticulum was first described by Fabricius
Hildanus in 1598 and later named after Johann Friedrich
Meckel, a German comparative anatomist who first
recognized its developmental origin in 1809 [3]. It is a
true diverticulum containing all the layers of the small
bowel wall [3]. It is invariably found on the antimesenteric border of the ileum, with 90% located within
90 cm of the ileocaecal valve [2]. Meckel's Diverticula
are called giant when they are longer than 5cm [4].
Majority of Meckel's diverticula are clinically silent and
are incidentally identified at surgery or at autopsy. The
lifetime risk of complications is estimated to be 4% with
most of the complications occurring in adults [2].
Gangrene due to axial torsion of a Meckel's
diverticulum is the rarest of the complications that have
been reported, particularly in children [5]. Predisposing
factors for axial torsion include, presence of
mesodiverticular bands, a narrow base, excessive
length, and associated neoplastic growth or
inflammation of the diverticulum [2].
The correct diagnosis of Meckel's diverticulum before
surgery is often difficult because a complicated form of
this condition may be clinically indistinguishable from
a variety of other intra-abdominal diseases such as acute
appendicitis, inflammatory bowel disease, or other
causes of small bowel obstruction [3]. Therefore high
index of suspicion is warranted to correct and
expeditious diagnosis especially in patients with
atypical presentation [5].
The management of incidentally found (asymptomatic )
Meckel's diverticulum is controversial [1]. Treatment of
complicated Meckel's diverticulum is always surgical
and includes simple diverticulectomy or ileal resection
either by open or laparoscopic approach [3]. Segmental
ileal resection may be necessary if the diverticulum
contains tumour or if the base of the diverticulum is
inflamed or perforated [1].
References
1. Tavakkolizadeh A, Whang EE, Ashley SW, Zinner M.
Small intestine. In: Brunicardi FC, Anderson DK, (eds):
Schwartz's principles of surgery New York: McGraw Hill,
2010; 1002-1004.
2. Seth A, Seth J. Axial torsion as a rare and unusual
complication of a Meckel's diverticulum: a case report
and review of the literature. Journal of Medical Case
Reports 2011;(5):118
3. Cartanese C, Petitti T, Marinelli E, et al. Intestinal
obstruction caused by torsed gangrenous Meckel's
diverticulum encircling terminal ileum.
World J Gastrointest Surg 2011;
4. Ruiz VA, Camacho LA, Diaz DC. Giant Meckel's
diverticula with necrosis due to axial torsion.
Rev Col Gastroenterol 2010; 25(4):398–400.
5. Limas C, Seretis K, Soultanidis C, Anagnostoulis S. Axial
torsion and gangrene of a giant Meckel's diverticulum
Gastrointestin Liver Dis 2006;15:67-68.
Key Points:

Axial torsion and gangrene of a Meckel's diverticulum is a rare complication.

It can rarely account for small bowel osbtruction.

Treatment of complicated Meckel's diverticulum is always surgical and includes simple diverticulectomy or
ileal resection.
The Sri Lanka Journal of Surgery 2015; 33(1): 35-36
36
CASE REPORTS
Incisional hernia after ventriculoperitoneal shunt
M. Jayant, R. Kaushik
Department of Surgery, Government Medical College and Hospital, Chandigarh, India
Abstract
Ventriculoperitoneal (VP) shunt is a common
neurosurgical procedure that is performed to drain the
cerebrospinal fluid (CSF) into the peritoneal cavity.
Although a relatively safe procedure, at times, it can be
associated with a variety of complications at the
abdominal end such as displacement, cyst formation,
inguinal hernia, hydrocele, perforation of intraabdominal organs, or extrusion. Rarely, an incisional
hernia may occur at the abdominal incision. We present
a rare case of an incisional hernia occurring at the
abdominal site of shunt insertion and highlight the
problems faced while repairing it.
Introduction
Since the first reports by Kausch in the early part of the
20th century of the use of the peritoneal cavity for
diverting CSF, ventriculoperitoneal (VP) shunts have
become the standard procedure for the treatment of
hydrocephalus [1,2]. Like any surgical procedure, VP
shunting is also associated with complications; the most
common causes of shunt malfunction are proximal
obstruction and infection [1] and these usually present
with headache, changes in the mental status, and
vomiting [3].
Complications that occur at the distal (abdominal) end
are also a cause of significant morbidity, and in various
series, nearly 5 - 47 % of all shunt failures are thought to
be due to malfunction of the distal catheter [4-7] with a
higher incidence in patients with scoliosis, obesity and
those who have undergone prior abdominal surgery
[4,8]. Abdominal complications that have been reported
are; shunt infection, development of an inguinal hernia,
subcutaneous collections of CSF, peritoneal or omental
cyst formation, mesenteric pseudotumors, bowel
perforation, intestinal volvulus around the shunt tubing,
Correspondence: Dr. Robin Kaushik
E-mail: robinkaushik@yahoo.com
The Sri Lanka Journal of Surgery 2015; 33(1): 37-40
catheter disconnection; and various types of catheter
migrations such as extraperitoneal retraction and
displacement, migration of the catheter into the pleural
cavity or heart, or protrusion of the catheter through the
mouth, umbilicus, bladder, vagina, anus, or scrotum.
Knotting of the shunt has also been reported on occasion
[1–7], as have been other less common complications
such as adhesive bowel obstruction, intra-abdominal
abscesses, cerebrospinal–enteric fistula and intractable
CSF ascites [1,3].
The development of an incisional hernia at the
abdominal end after shunt placement is an extremely
rare complication. Theoretically, any abdominal
operation has the potential for developing into an
incisional hernia, but the incidence of this problem after
a VP shunt is quite low. Although many reviews on the
topic of complications or abdominal complications after
shunt do mention this complication, we could come
across only two actual reports of incisional hernia
occurring at the abdominal end [9,10], and we present
another such case, highlighting the various problems we
faced while dealing with this rare type of hernia.
Case Report
This 23 years old gentleman came to our outpatient
department with swelling and pain in the upper
abdomen. The swelling gave a typical history of a
hernia, with increase in size on exertion and reduction
while lying down. The patient gave history of surgery
about a year and a half back, when he underwent VP
shunt insertion followed by endoscopic surgery for a
third ventricular colloid cyst. He remained well for
nearly a year, after which he noticed this gradually
increasing swelling over his upper abdomen.
On examination, there was a visible, horizontal scar in
the epigastrium, with a palpable soft lump that showed
cough impulse, and reduced in size on lying down. A
defect of approximately 2x2 cms was palpable in the
37
abdominal wall here. The VP shunt could also be
palpated to the left of this defect (Figure 1). The patient
was worked up for elective surgery for the incisional
hernia, and a neurosurgical opinion was taken for the
removal of VP shunt. The neurosurgical team felt that it
would be better if the shunt remained in situ, and
advised avoidance of injury to the shunt while operating
the hernia.
Figure1. Photograph showing incisional hernia at the
abdominal site of VP shunt insertion
Surgery was performed under general anesthesia. Scar
tissue from the previous surgery was excised and the
incision was extended on either side. Carefully, the skin
flaps were mobilized, repeatedly palpating the shunt and
taking care not to damage it as it ran in the subcutaneous
planes onto its point of entry into the peritoneal cavity.
The muscle sheath was mobilized all around, as was the
hernial sac. The sac was invaginated, and an incision
was given onto the muscle sheath parallel to the closure.
The free edges of the sheath were sutured together to
provide additional support, as well as to reduce tension
on the closure. A polypropylene mesh was then used to
cover the area and was sutured to the margins of the
sheath all around. Closure was performed over a drain.
The patient remained well in the post-operative period,
The Sri Lanka Journal of Surgery 2015; 33(1): 37-40
and is well on a short follow up, with no recurrence of
the hernia.
Discussion
An incisional hernia can occur after any type of
abdominal wall incision, although the highest incidence
is seen with midline and transverse incisions. Multiple
risk factors are implicated in the development of an
incisional hernia, and can be broadly classified into
surgical or technical factors (expertise, choice of suture
material, technique of closure, closure under excessive
tension, wound infections, emergent surgery, postoperative infections, etc.), and patient factors (advanced
age, malnutrition, obesity, ascites, corticosteroid usage,
diabetes, cigarette smoking, obesity, other illnesses,
etc.) [11]. In our patient, it was quite possibly a
combination of increased intra-abdominal pressure (due
to CSF drainage into the peritoneal cavity) and a
compromised technique of abdominal wound closure
that contributed to the formation of his incisional hernia.
Surprisingly, an exhaustive search through the internet,
various databases and cross referencing through article
bibliographies (even a search for articles on the etiology
of incisional hernias) did not yield much information
about the occurrence of incisional hernia after VP shunt
surgery. Although many series mention incisional
hernia at the abdominal end of the shunt as a
complication of the procedure, despite going through a
large amount of literature available on VP shunts (and its
complications), we found only two reports that actually
reported the occurrence incisional hernia in their
patients [9,10].We accept the fact that given the vast
amount of literature on the topic of VP shunts, despite
our efforts, we still might have missed some reports on
this topic, but even then, the development of an
incisional hernia after VP shunt remains the rarest of
complications. Quite possibly, the rarity of this
complication in comparison to the other reported
abdominal complications after VP shunt is responsible
for the paucity of information on this topic.
Unfortunately, this translates into very practical
problems while managing such cases since there is not
much evidence or guidelines to go on except one's own
experience in dealing with incisional hernias.
We felt that the continued presence of the shunt tubing at
the hernia site, and the point of its entry into the
38
peritoneal cavity would always act as a weak point in the
anterior abdominal wall and a potential site of
herniation. Therefore, to our minds, removal of the
shunt if it was no longer required, and repair of the
incisional hernia was the best option, but this had
already been vetoed by the treating neurosurgeons who
wanted to keep the shunt in place. The second option
that we discussed was re-positioning of the abdominal
end of the shunt through another area and mesh repair of
the incisional hernia, both laparoscopically, but the
patient was not willing for this since (a) he did not want
any manipulation of the shunt, and (b), the costs of this
procedure in our set up are quite high and were
unaffordable for him. In the end, we were left with no
other option but to perform an open hernioplasty, taking
care not to damage the shunt during surgery.
Not surprisingly, laparoscopy has found application in
VP shunts also, not only to deal with the complications
of the procedure, but also initially, at the time of
performing the shunt. With its advantage of better vision
and less tissue trauma, laparoscopic placement of the
abdominal end of the shunt is rapidly becoming
accepted as a procedure of choice, and has reportedly
brought down the incidence of complications at the
distal end [3,4,6,8–10]. In addition, laparoscopic
placement of the shunts allows for confirmation of shunt
patency and function by direct visualization of CSF
flow from the shunt tubing [10]. The advantages of the
laparoscopic approach also include a shorter hospital
stay, less post-operative pain, lower chance of incisional
hernia formation, and, since the catheter is positioned
under direct vision with minimal bowel manipulation,
there is a much lower chance of bowel injury and
adhesion formation [6,8]. Even when dealing with
complications, laparoscopy offers a distinct advantage
over laparotomy, especially in terms of superior
visualization of the peritoneal cavity, retrieval of
displaced shunts, lysis of adhesions, culture of
abdominal fluid, repositioning of displaced tubings, and
assessing the abdomen for any other pathology [2-4,6,8,
10]. However, the flip side is that separate incisions (for
port and shunt placement) as well as two separate teams
(neurosurgical and laparoscopic) are required, which
may not be available everywhere.
Being unable to perform laparoscopic surgery in our
patient, we proceeded with open, onlay hernioplasty.
The Sri Lanka Journal of Surgery 2015; 33(1): 37-40
Marking of the shunt pre-operatively, repeated digital
palpation, careful dissection, and taking care not to pass
the suture needle through the shunt tubing at the time of
fixing the mesh were important steps that we took to
avoid inadvertent damage to the shunt tubing during
surgery, which could have had disastrous consequences.
As we mentioned above, the application of laparoscopic
surgery in VP shunt placement will further reduce the
incidence of incisional hernia after VP shunting, but we
hope that our experience with open repair of such a rare
hernia might help those who may occasionally come
across such cases who do not have access to
laparoscopic facilities.
References
1. Chung JJ, Yu JS, Kim JH, et al. Intraabdominal
complications secondary to ventriculoperitoneal
shunts: CT findings and review of the literature. AJR
Am J Roentgenol 2009;193:1311-7
2. Acharya R, Ramachandran CS, Singh S. Laparoscopic
management of abdominal complications in
ventriculoperitoneal shunt surgery. J
LaparoendoscAdvSurg Tech A 2001; 11:167-70
3. Popa F, Grigorean VT, Onose G, et al. Laparoscopic
treatment of abdominal complications following
ventriculoperitoneal shunt. J Med Life 2009; 2: 426 - 36
4. RaysiDehcordi S, De Tommasi C, Ricci A, et al.
Laparoscopy-assisted ventriculoperitoneal shunt
surgery: personal experience and review of the
literature. Neurosurg Rev 2011; 34:363-70; discussion
370-1
5. Coley BD, Kosnik EJ. Abdominal complications of
ventriculoperitoneal shunts in children. Semin
Ultrasound CT MR 2006; 27: 152 – 60
6. Nfonsam V, Chand B, Rosenblatt S, et al. Laparoscopic
management of distal ventriculoperitoneal shunt
complications. SurgEndosc 2008; 22:1866 – 70
7. Agha FP, Amendola MA, Shirazi KK, et al. Unusual
abdominal complications of ventriculo-peritoneal
shunts. Radiology1983; 146:323- 6
8. Park YS, Park IS, Park KB, et al. Laparotomy versus
Laparoscopic Placement of Distal Catheter in
Ventriculoperitoneal Shunt Procedure. J Korean
NeurosurgSoc 2010; 48: 325-329
9. Jea A, Al-Otibi M, Bonnard A, Drake JM.
Laparoscopy-assisted ventriculoperitoneal shunt
surgery in children: a series of 11 cases. J Neurosurg
2007; 106:421-5
10. Kavic SM, Segan RD, Taylor MD, Roth JS.
Laparoscopic Management of Ventriculoperitoneal and
Lumboperitoneal Shunt Complications. JSLS 2007;
11:14–19
11. Javid JP, Greenberg JA, Brook DC. Hernias. In: Zinner
MJ, Ashley SW Jr. (Eds.) Maingot's Abdominal
Operations, 12th Edition, 2012 McGraw-Hill
Professional, New York
39

Incisional hernia after VP shunt insertion is a rare complication at the abdominal end.

Treatment options include:
-Removal of the shunt if it is no longer required, and repair of the incisional hernia.
-Laparoscopic re-positioning of the abdominal end of the shunt through another area and mesh repair of
the incisional hernia.
-Open, onlay hernioplasty, avoiding inadvertent damage to the shunt tubing during surgery.
The Sri Lanka Journal of Surgery 2015; 33(1): 37-40
40
CASE REPORTS
Epidermal splenic cyst
G. H. M. Pinsara, N. Liyanage, P. G. K. Anuradha, P.M. Lambiyas, H. Gamage
Gastrointestinal Surgical Unit, Teaching Hospital Karapitiya, Galle.
Key words: Epithelial cysts; splenectomy; spleen
1. A cyst arising from the pancreas
Abstract
2. A cyst arising from the spleen
We report a case of a large epithelial cyst of the spleen of
an 18 year old man who was treated with splenectomy.
The management of splenic cysts has changed from
total splenectomy to splenic preservation surgery. But
complete splenectomy is reserved for cases in which
cyst excision cannot be done.
Introduction
Splenic cysts are rare lesions with 800 cases reported in
the world literature [1]. Splenic cysts are classified into
primary (true) or secondary (false) cysts on the basis of
presence or absence of cellular lining of the cystic wall
[2].
The true incidence of splenic cysts is unknown. The
prevalence of splenic cysts has increased recently
secondary to increased detection with the computerized
tomography and the non-operative management of
certain types of splenic injury [3]. Here we present a
case of non-parasitic large epithelial cyst.
Case report
An 18 year old man presented with left sided abdominal
distension for 4 years. There was no history of
abdominal pain, history of trauma, significant medical
illness or surgical intervention in the past. Abdominal
examination revealed a large mass in the left
hypochondrium extending to the umbilical region and
epigastrium.
The patient had a contrast enhanced CT scan of the
abdomen which showed a large cystic lesion measuring
20×20×21cm in relation to the pancreas. Based on
imaging, the following diagnoses were considered;
In order to determine whether it was a pancreatic cyst or
a splenic cyst an ultrasound guided aspiration of the cyst
was arranged and the aspirate was sent for amylase,
carcino-embryonic antigen (CEA), CA 19-9 and
cytology. Cytology revealed a straw coloured
proteinaceous fluid with no evidence of micro-organism
growth or malignant cells. CEA, CA 19-9 and amylase
levels were normal. Other haematological
investigations were unremarkable. This makes the
diagnosis more in favour of a cyst arising from the
spleen. Exploratory laparotomy was planned.
As there was a possibility of a splenectomy he was
referred to the haematology unit and he was given
polyvalent pneumococcal and meningcoccal vaccines.
At laparotomy a large splenic cyst was found in relation
to the hilum of the spleen. The spleen was elongated,
flattened and was sandwiched between the anterolateral
abdominal wall and the cyst. Stomach and left kidney
were displaced towards the right side. There were
adhesions with the tail of the pancreas and also dense
inseparable adhesions with the diaphragm. Firstly,
reduction of cyst with intraoperative drainage of
approximately 3 litres of straw coloured fluid was
carried out. It was followed by complete splenectomy
due to the large size of the cyst, cyst location and
presence of adhesions with adjacent structures.
Histologically it was a unilocular cyst with dense
fibrous cyst wall lined by flattened epithelium.
Therefore the histopathological diagnosis was primary
splenic (epithelial) cyst.
Post-operative clinical course was satisfactory and at
follow up the patient was asymptomatic and was started
on lifelong penicillin prophylaxis.
Correspondence: Dr. Prageeth Lambiyas
E-mail: prageeth.lambiyas11@gmail.com
The Sri Lanka Journal of Surgery 2015; 33(1): 41-44
41
Figure 1. CECT abdomen showing a large cyst compressing
the surrounding structure.
Figure 4. Specimen of the aspirated cyst removed from the
patient
Figure5. Interior appearance of the cyst
Figure 2. Sagittal section of the CECT abdomen
Discussion
Figure 3. Intraoperative picture of the cyst
The spleen plays an important role in haemopoiesis,
immune function and protection against infections and
malignancies. Splenic cysts are very rare. They are
classified as primary (true) or secondary (pseudo/false)
cyst. Primary cysts have a cellular lining in the cyst wall
and are parasitic or non-parasitic in origin. Non parasitic
type primary cysts are further classified as congenital or
neoplastic. Congenital splenic cysts are also called
epidermoid or epithelial cysts. They are uncommon and
account for only 10% of all splenic cysts. 80% of
epithelial splenic cysts occur in patients aged under 20
year but can occur in children and infants [4,5].
The Sri Lanka Journal of Surgery 2015; 33(1): 41-44
42
Secondary cysts without cellular lining usually occur
following blunt trauma to the upper abdomen and is
considered responsible for 75% of secondary cysts [6].
Both types of splenic cysts usually do not produce any
specific symptoms until they reach a significant size and
may remain asymptomatic in 30–60% of patients [7].
Splenic cysts may present with localized or referred
pain, splenomegaly, abdominal distension and
symptoms and signs relating to compression of nearby
structures. The latter include early satiety, dysphagia,
nausea, vomiting, atelectasis and left lower lobe
pneumonia [8]. Cysts may also be an incidental finding
on abdominal imaging for another purpose.
A comprehensive differential diagnosis includes cystic
lesions of adjacent structures (eg: pancreas, liver,
omentum), intrasplenic aneurysms, benign & malignant
splenic tumours, pyogenic splenic abscesses and rare
parasitic ecchinococcal disease which is more common
in Africa and Central America [9].
Physical examination is usually normal apart from the
abdominal distension with abdominal mass. Routine
haemotological and biochemical investigations are also
within normal range. Tumour markers such as CEA and
CA19.9 levels are usually elevated in the true cyst and
rarely high in pseudo cysts due to the absence of
epithelial lining [10,11]. But CA 19.9 and CEA levels
were in the normal range in our case.
Indications for operative intervention of the splenic
cysts include symptomatic splenic cysts and cysts with a
diameter >5 cm because of increased risk of
complications [12]. Surgical intervention aims to
eradicate the cyst and prevent recurrence. Operative
methods include both open and laparoscopic
techniques. Traditionally splenic cysts have been
treated with the open complete splenectomy. Currently
the trend is to more conservative surgery preserving the
spleen with the demonstration of life long risk of
overwhelming post splenectomy sepsis (OPSI). Post
splenectomy patient has 5% life time risk of developing
OPSI which carries a mortality rate of 38-69 % [13].
Options available for the splenic preservation include
total cystectomy, marsupialization, cyst decapsulation
(unroofing) or partial splenectomy; accessed either by
open laparotomy or laparoscopy. Other conservative
The Sri Lanka Journal of Surgery 2015; 33(1): 41-44
methods include sclerosis or drainage using radiological
guidance. The incidence of recurrence of these methods
has been reported high as 100% [3]. Partial splenectomy
preserves more than 25% splenic parenchyma which is
the minimal splenic tissue to preserve immunological
protection without increasing the risk of recurrence
[14].
In unroofing/ partial splenic cystectomy, the cyst wall
should be resected as much as possible to prevent
recurrence of the cyst. Marsupialization is another
conservative surgery which reduces the duration of
surgery and carries no risk of recurrence.
But it is difficult to perform any type of conservative
surgery if the cyst is very large; if it is completely
covered by the splenic parenchyma (intrasplenic cyst);
if it is located in the hilum of the spleen, if there are
multiple cysts (polycystic cases) or dense vesicular
adhesions to adjacent structures; in these situations, a
complete splenectomy should be performed using open
or laparoscopic approach [15]
In our case it was impossible to manage with
percutaneous drainage and sclerosis technique due to
the large size of the cyst. We had to treat a very large cyst
located in the splenic hilum with dense inflammatory
adhesions around the spleen, whereas splenic
parenchyma consisted of rim of tissue pushed to
periphery making any possibility of splenic
preservation surgery highly unlikely. Therefore the
patient was treated with open complete splenectomy.
References
1.
2.
3.
4.
5.
6.
Geraghty M, Khan IZ, Conlon KC. Large primary
splenic cyst: a laparoscopic technique. J Minim Access
Surg 2009; 5:14-6.
Martin JW. Congenital splenic cysts. Am J Surg 1958;
96:302–8
Wu H, Kortbeek J. Management of splenic pseudo cysts
following trauma: A retrospective case series. Am J Surg
2006;5:631–4.
Carpenter G, Cotter PW, Davidson JRM. Epidermoid cyst
of the spleen. Aust N Z J Surg 1986;56:365-8.
Sakamoto Y, Yunotani S, Edakuni G, Mori M, Iyama A,
Miyazaki K. Laparoscopic splenectomy for a giant
splenic epidermoid cyst: report of a case. Surg Today
1999;29:1268–72.
Pachter HL, Hofstetter SR, Elkowitz A, Harris L, Liang
HG. The role of cystectomy and splenic preservation:
Experience with seven consecutive patients. J Trauma
43
1993;35:430–6.
7. Labruzzo C, Haritopoulos KN, Tayar AR, Hakim NS.
Posttraumatic cyst of the spleen: A case report and review
of the literature. Int Surg 2002;82:152–6.
8. Gibeily GJ, Eisenberg BL. Splenic cysts-diagnosis and
management. West j Med 1988;148:464-6.
9. Sellers GJ, Starker PM. Laparoscopic treatment of
benign splenic cysts. Surg Endoscopy 1997;11:766–8.
10. Walz MK, Metz KA, Sastry M, Eigler FW, Leder LD.
Benign mesothelial splenic cyst may cause high serum
concentrations of CA-19-9. Eur J Surg
1994;160:389–91.
11. Madia C, Lumachi F, Veroux M, Fiamingo P, Gringeri E,
12.
13.
14.
15.
Brolese A, et al. Giant splenic epithelial cyst with
elevated serum markers CEA and CA 19-9 levels: an
incidental association. Anticancer Res 2003;23:773-6.
Till H, Schaarschmidt K. Partial laparoscopic
decapsulation of congenital splenic cysts. SurgEndosc
2004;18:626–8.
Davidson RN, Wall RA. Prevention and management of
infections in patients without a spleen.
ClinMicrobiol Infect 2001;12:657–60.
Hansen MB, Moller AC. Splenic cysts.
SurgLaparoscEndoscPercutan Tech 2004;14:316–22.
Avital S, Kashtan H. A large epithelial splenic cyst.
N Engl J Med 2003; 349: 2173-2174.
Key Points:

Splenic cysts are a rare phenomenon now increasingly identified due to increased imaging

Symptomatic and large cysts are an indication for surgery

Splenic preservation surgery is the treatment of choice when possible
The Sri Lanka Journal of Surgery 2015; 33(1): 41-44
44
SELECTED ABSTRACTS
C-reactive protein to predict the need for surgical
intervention in acute renal colic
McSorley ST et al. Journal of Clinical Urology 2014;
7(6):380-383.
Objectives
C-reactive protein (CRP) is a serum marker of systemic
inflammation which has been suggested to predict need
for emergent surgical intervention in patients with acute
renal colic at a value of > 28 mg/l on admission. We
aimed to determine if this applied to our patients.
Patients and methods
We prospectively collected data from all patients
admitted with symptomatic urolithiasis, confirmed by
CT-KUB, over three months. Fifty-nine patients were
included; however, four were excluded because of comorbidites which could influence CRP, or recent
urological surgery, giving N = 55, age 50.0±14.6 years
(mean±SD), M:F 40:15. The decision to proceed to
intervention was made by each patient's clinical team
and not by the authors; however, there was no blinding
to CRP.
Commentary
Ajith Malalasekera
Consultant urological surgeon and senior lecturer in
anatomy
Faculty of Medicine, University of Colombo
This study reinforces the importance of assessing for the
presence of sepsis in patients with renal colic. Apart
from clinical evidence of infection, CRP, especially
rising CRP will, according to this study, add to the
information that will identify those requiring
intervention. While this marker rises in response to
inflammation in the patient, it is not specific to the site
nor a particular cause. Clinicians must be aware of
factors which may raise the CRP (e.g. inflammation,
trauma, infection) when utilising this information in the
management of renal colic patients.
Use of drains versus no drains after burr-hole
evacuation of chronic subdural haematoma: a
randomised controlled trial.
Santarius T et al. Lancet 2009 Sep 26;374(9695):106773.
Results
Background
A total of 24 of 55 patients required intervention on their
index admission (22 retrograde ureteric stent, one
nephrostomy, one ureteroscopic stone extraction), and
31 were managed conservatively. Those undergoing
intervention had higher CRP on admission (mean 16.3
vs 9.4 mg/l, p = 0.06) and higher maximum CRP (mean
94.7 vs 25.7 mg/l, p < 0.001) than those managed
conservatively. Nineteen (79%) of those requiring
intervention had CRP < 28 mg/l on admission. There
were no deaths, no intensive care admissions and all
were discharged to outpatient follow-up.
Chronic subdural haematoma causes serious morbidity
and mortality. It recurs after surgical evacuation in
5-30% of patients. Drains might reduce recurrence but
are not used routinely. Our aim was to investigate the
effect of drains on recurrence rates and clinical
outcomes.
Conclusion
Rising CRP during admission is a strong predictor of the
need for emergency surgical intervention in patients
with acute renal colic; however, CRP at admission is
less useful.
The Sri Lanka Journal of Surgery 2015; 33(1): 45-49
Methods
We did a randomised controlled trial at one UK centre
between November, 2004, and November, 2007. 269
patients aged 18 years and older with a chronic subdural
haematoma for burr-hole drainage were assessed for
eligibility. 108 were randomly assigned by block
randomisation to receive a drain inserted into the
subdural space and 107 to no drain after evacuation. The
primary endpoint was recurrence needing redrainage.
The trial was stopped early because of a significant
45
benefit in reduction of recurrence. Analyses were done
on an intention-to-treat basis. This study is registered
with the International Standard Randomised Controlled
Trial Register (ISRCTN 97314294).
Findings
cytoreductive surgery (CCRS) of colorectal peritoneal
carcinomatosis (PC) followed by intraperitoneal
chemotherapy (IPC) are completeness of the resection
and extent of the disease. This study aimed to determine
a threshold value above which CCRS plus IPC may not
offer survival benefit compared with systemic
chemotherapy.
Recurrence occurred in ten of 108 (9.3%) people with a
drain, and 26 of 107 (24%) without (p=0.003; 95% CI
0.14-0.70). At 6 months mortality was nine of 105
(8.6%) and 19 of 105 (18.1%), respectively (p=0.042;
95% CI 0.1-0.99). Medical and surgical complications
were much the same between the study groups.
Between March 2000 and May 2010, 180 patients
underwent surgery for PC from colorectal cancer with
intended performance of CCRS plus IPC.
Intrpretation
Results
Use of a drain after burr-hole drainage of chronic
subdural haematomas is safe and associated with
reduced recurrence and mortality at 6 months
Among the 180 patients, CCRS plus IPC could be
performed for 139 patients (curative group, 77%),
whereas it could not be performed for 41 patients
(palliative group, 23%). The two groups were
comparable in terms of age, gender, primary tumor
characteristics, and pre and postoperative systemic
chemotherapy. The mean peritoneal cancer index (PCI)
was lower in the curative group (11±7) than in the
palliative group (23±7) (p < 0.0001). After a median
follow-up period of 60 months (range 47–74 months),
the 3-year overall survival (OS) rate was 52 % [95%
confidence interval (CI) 43–61%] in the curative group
compared with 7% (95% CI 2–25%) in the palliative
group. Comparison of the survivals for each PCI
(ranging from 5 to 36) shows that OS did not differ
significantly between the two groups of patients when
the PCI was higher than 17 (hazard ratio 0.64; range
0.38–1.09).
Commentary
Ruvini Abeygunaratne
Consultant Neurosurgeon
Hope hospital, Manchester and Lanka hospitals,
Colombo
This is a landmark paper in neurosurgery dealing with a
common but important condition with a high mortality
and morbidity. Chronic subdural haematomas are
common and generally affect the elderly population
who suffer from a number of pre-existing pathologies.
Therefore there are risks associated with recurrent
surgery, and thereby morbidity and mortality increases.
The most effective treatment is that which involves one
surgical procedure which is quick and safely done with
measures taken to reduce the incidence of recurrence.
This randomised trial demonstrates that the use of
subdural drains routinely reduces the rate of recurrence
and the 6 month mortality.
Extent of colorectal peritoneal carcinomatosis:
Attempt to define a threshold above which HIPEC
does not offer survival benefit: a comparative study
Goéré D et al. Annals of Surgical Oncology 2015;
(Online First) 1-7
Background
The main prognostic factors after complete
The Sri Lanka Journal of Surgery 2015; 33(1): 45-49
Methods
Conclusion
This study confirmed the major prognostic impact of PC
extent. When the PCI exceeds 17 in PC of colorectal
origin, CCRS plus IPC does not seem to offer any
survival benefit.
Commentary
Dulantha de Silva
Senior Lecturer in Surgery
General Sir John Kotelawala Defence University
Presence of peritoneal metastases in colorectal cancer
has been generally associated with dismal prognosis,
conferring a virtual death sentence on the sufferer. In the
46
last two decades however, the introduction of Cytoreductive Surgery (CRS) combined with hyperthermic
intra-peritoneal chemotherapy (HIPEC) has given rise
to 5-year survival rates of up to 30-50% in select groups
of patients.
controversial. The purpose of this study is to conduct a
systematic review of randomized clinical trials
assessing the results of hemiarthroplasty and total hip
replacement in patients undergoing either alternative
using meta-analysis.
This prospective study from a centre with significant
experience in this technique is an attempt to further
define the group of patients with potential to benefit
from this treatment strategy. Two major factors affecting
outcome in these patients are the completeness of
cytoreduction i.e. removal of all macroscopic tumour
nodules greater than 1mm and the extent of peritoneal
metastases as defined by the peritoneal carcinomatosis
index (PCI score).
Methods
Evidence has long indicated that inability to achieve
complete cytoreduction is associated with poor
prognosis with survival no better than with palliative
chemotherapy. The data from this study supports that
contention. The study also shows an impressive overall
3-year survival rate of 52% for complete CRS and
HIPEC. However sub-group analysis does indicate that
with PCI scores greater than 17, it confers no survival
advantage even in the presence of complete cytoreduction. The data from this study adds to the evidence
that in patients with relatively limited peritoneal
disease, CCRS and HIPEC can be associated with
significant survival benefits.
The place of this technique is still controversial among
some authorities, perhaps due to the paucity of good
quality randomised control trials evaluating its efficacy.
Nevertheless, it is hard to ignore the potential promise of
this procedure in offering a chance of survival in a
number of patients otherwise condemned to palliation.
Outcome of hemiarthroplasty and total hip
replacement for active elderly patients with
displaced femoral neck fractures: A meta-analysis of
8 randomized clinical trials
Yiqiong Zhao, A Meta-Analysis of 8 Randomized
Clinical Trials. PLoS ONE 9(5):e98071.
Background
Displaced fracture of the femoral neck has been a
common clinical problem, especially in aged patients.
However, the optimal treatment choice remains
The Sri Lanka Journal of Surgery 2015; 33(1): 45-49
A literature search for randomized clinical trials was
conducted through Medline, Embase and Cochrane
library between 1969 and 2013 with no restrictions.
Additional relevant articles were referred as source of
information by way of manual searches on major
orthopedic journals. Upon the search, two authors
independently evaluated study quality and relevant data
was extracted.
Results
A total of 8 studies with 983 patients were included in
this meta-analysis. After pooling the available data, a
significant dominance of Harris hip score was found for
total hip replacement compared with hemiarthroplasty
( S M D : 2 7 . 11 , 9 5 % : 2 1 0 . 7 0 , 2 3 . 5 3 ) o n e y e a r
postoperatively and the advantage kept over (SMD:
26.91, 95%:212.98, 20.85) two years after surgery. A
trend toward a higher dislocation rate was found in total
hip replacement group (RR: 0.46, 95%: 0.21,1.02), of
which the difference was considered insignificant. The
risk of revision in group hemiarthroplasty appeared to
be more than two fold higher than that after total hip
replacement (RR: 4.14, 95%CI: 2.09, 8.19).
Conclusion
Even though there is a higher rate of dislocation after
total hip replacement, this disadvantage could be
accounted for, on the basis of a better functional score
and the lower revision rate. However, from the results, it
stands to reason that total hip replacement should be
strongly suggested in elderly active patients with
femoral neck fracture.
Commentary
Hiran Amarasekera
Consultant Orthopaedic Surgeon
Neville Fernando Teaching Hospital
Malabe
The treatment of choice for sub capital femoral neck
fractures in last decades has been hemi arthroplasty.
47
Either cementless (Austin-Moore) or cemented
(Thompson) type prosthesis has been widely used.
However with increasing life expectancy and increased
active lifestyle in the elderly total hip replacement
(THR) has been preferred as the first line of treatment by
some orthopaedic surgeons. Where is the evidence
helping orthopaedic surgeons to make that decision?
Zhao et al has combined eight randomized control trials
in this meta-analysis to answer this question. Eight
randomised trials done in Germany, Italy, Sweden,
Holland, UK and USA with a total of 983 patients were
included in the meta-analysis.
Authors conclude that apart from a slightly higher
dislocation rate the benefits of a total hip replacement in
the active elderly outweigh the risks and suggest this as
the treatment of choice. As all these studies have been
done in developed countries the information should be
cautiously applied in a developing country such as Sri
Lanka. Points to consider in our setting are the cost
difference between the two implants, time taken for the
surgery, expertise level available in the health service,
workload of the surgeon, age and activity level of the
patient. Cost difference between the two implants is
significant, a THR costing 10 to 15 times that of a
h e m i a r t h r o p l a s t y. S k i l l l e v e l n e e d e d f o r
hemiarthroplasty is less than for a THR enabling junior
surgeons such as SHOs and trainees to do them. Time
taken for a hemiarthroplasty is far less than for a THR a
key factor in a setting with a high workload and limited
theatre time. The activity level and demand for
independent mobility of Sri Lankans may be less than
that of the European patients.
Nevertheless the times are changing with increasing life
expectancy, and increasing number of elderly living
alone, leading to increased demand for THR over the
years.
However if we were to adopt THR as primary treatment
for femoral neck fractures our own criteria should be
developed considering above factors to suite the Sri
Lankan setting.
Prior to developing these criteria it will be interesting to
know the percentage of hemi arthroplasties that are
revised for a THR and the indication for the revision. A
research project to find this information is essential to
move forward in the right direction
The Sri Lanka Journal of Surgery 2015; 33(1): 45-49
The Society for Vascular Surgery lower extremity
threatened limb classification system based on
wound, ischemia, and foot infection (WIfI)
correlates with risk of major amputation and time to
wound healing
Zhan, Luke X. et al. Journal of Vascular Surgery,
Volume 61, Issue 4 , 939 - 944
Objective
The purpose of this study was to evaluate whether the
new Society for Vascular Surgery (SVS) Wound,
Ischemia, and foot Infection (WIfI) classification
system correlates with important clinical outcomes for
limb salvage and wound healing.
Methods
A total of 201 consecutive patients with threatened
limbs treated from 2010 to 2011 in an academic medical
center were analyzed. These patients were stratified into
clinical stages 1 to 4 on the basis of the SVS WIfI
classification. The SVS objective performance goals of
major amputation, 1-year amputation-free survival
(AFS) rate, and wound healing time (WHT) according
to WIfI clinical stages were compared.
Results
The mean age was 58 years (79% male, 93% with
diabetes). Forty-two patients required major amputation
(21%); 159 (78%) had limb salvage. The amputation
group had a significantly higher prevalence of advanced
stage 4 patients (P < .001), whereas the limb salvage
group presented predominantly as stages 1 to 3. Patients
in clinical stages 3 and 4 had a significantly higher
incidence of amputation (P < .001), decreased AFS
(P < .001), and delayed WHT (P < .002) compared with
those in stages 1 and 2. Among patients presenting with
stage 3, primarily as a result of wound and ischemia
grades, revascularization resulted in accelerated WHT
(P = .008).
Conclusions
These data support the underlying concept of the SVS
WIfI, that an appropriate classification system
correlates with important clinical outcomes for limb
salvage and wound healing. As the clinical stage
progresses, the risk of major amputation increases,
48
1-year AFS declines, and WHT is prolonged. We further
demonstrated benefit of revascularization to improve
WHT in selected patients, especially those in stage 3.
Future efforts are warranted to incorporate the SVS
WIfI classification into clinical decision-making
algorithms in conjunction with a comorbidity index and
anatomic classification.
Commentary
Dr. Nalaka Gunawansa
Consultant Vascular and Transplant Surgeon
National Institute for Nephrology Dialysis and
Transplantation
National Hospital of Sri Lanka
Salvaging the infected diabetic foot and preventing
major amputation is a tremendous challenge to all
general and vascular surgeons worldwide. Deciding
which patient can be safely salvaged without major
amputation and which patient will benefit with a
revascularization procedure to attempt such limb
salvage has been an ongoing debate even amongst
vascular surgeons. While not all diabetic foot ulcers
The Sri Lanka Journal of Surgery 2015; 33(1): 45-49
with infection warrant amputation, neither do all
ischaemic diabetic feet benefit by revascularization,
especially if the infection has destroyed the tissue
beyond a point of potential salvage.
The Society of Vascular Surgery (SVS) has thus
introduced a scoring system that incorporates the three
main determinants of such limb salvage (wound extent,
degree of limb ischaemia and degree of foot infection) to
shed some light and guidelines in this area of
controversy. This study was the first major study that
adopted the said scoring system in clinical practice to
assess its applicability across a wide spectrum of
patients suffering from different degrees of ischamic
diabetic foot ulcers.
Although the sample size was relatively small to be used
as a benchmark for future revascularization attempts,
the study has shown the clinical applicability and use of
such a scoring system to predict limb salvage and
amputation free survival rates. This will invariably
assist in the decision making process of clinicians
before embarking on revascularization or condemning
for major amputation.
49
The Sri Lanka Journal of Surgery can now be viewed online.
Please visit:
www.lankasurgeons.org
or
Sri Lanka Journals online (http://sljs.sljol.info/)
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