PubMed Health⌕ Search

Biomedical subjects

D L Carr-Locke

Publications and source records attributed to D L Carr-Locke.

At least 37 records · Page 2Linked to original sources
PubMed1999

Features that may predict hospital admission following outpatient therapeutic ERCP.

BACKGROUND: Some patients are admitted following outpatient therapeutic ERCP because of adverse events. This study aimed to identify factors that may predict such admissions. METHODS: We prospectively studied admissions for post-ERCP adverse events in 415 consecutive patients undergoing outpatient therapeutic ERCP. Potentially relevant predictors of admission were assessed by univariate analysis and in case of significance included in a multivariate analysis. RESULTS: Admission was necessary in 41 patients (9.9%) because of complications and in 63 (15.2%) for observation of adverse events that did not progress to definable complications. Potential predictors of admission were evaluated comparing patients who required more than an overnight admission (n = 63) with those who did not (n = 352). Multivariate analysis identified three factors that were significant: pain during the procedure (odds ratio 3.8: 95% CI [1.8, 7.9]), history of pancreatitis (odds ratio 2.3: 95% CI [1.1, 4.7]) and performance of sphincterotomy (odds ratio 2.2: 95% CI [1.1, 4.3]). The presence of all these features was associated with a 66.7% likelihood of admission, whereas the absence of pain during the procedure, history of pancreatitis and performance of sphincterotomy made admission likely in only 11.0%, 9.8% and 10.7%, respectively, of the cases. CONCLUSIONS: The occurrence of pain during the procedure, a history of pancreatitis and the performance of sphincterotomy were independent predictors of admission following outpatient therapeutic ERCP.

Adult↗
PubMed1999

Severe cholestasis related to intraconazole for the treatment of onychomycosis.

We describe a case of prolonged cholestasis temporally associated with the use of itraconazole for onychomycosis. Peak bilirubin level of 32.0 mg/dl was documented approximately 2 months after discontinuation of the patient's itraconazole therapy, with symptoms of cholestasis persisting more than 1 month after the peak in bilirubin. Physicians should be aware of the potential for severe cholestasis associated with itraconazole usage.

Aged↗
PubMed1999

Expandable metal stents for gastric-outlet, duodenal, and small intestinal obstruction.

The treatment of patients who have malignant gastric-outlet, duodenal and small intestinal obstructions is difficult. The morbidity and mortality of palliative surgery in these patients is significant. It is not uncommon for patients to be treated with supportive therapy only, which unfortunately, neither relieves the severe nausea and vomiting, nor allows adequate food intake. Over the past few years, a number of studies have reported the safety and efficacy of self-expanding metal stents used to palliate malignant upper gastrointestinal obstruction. In this article, the authors focus on the use of self-expanding metal stents to treat malignant gastric-outlet, duodenal, and small intestinal obstructions.

Biocompatible Materials↗
PubMed1999

Mucin hypersecreting neoplasms.

Mucinous pancreatic neoplasms are uncommon disorders classified as either mucinous cystic neoplasms (mucinous cystadenoma or cystadenocarcinoma) or the more recently described intraductal mucin hypersecreting neoplasms (IMHN), also termed mucinous ductal ectasia. The mucinous cystic neoplasms share many common features with IMHN's but remain distinct clinico-pathologic entities. These tumors have similar histologic appearances, produce abundant mucin, are likely to masquerade as pancreatic pseudocysts, demonstrate a biologically less aggressive course compared to typical ductal adenocarcinomas, and are treated by surgical resection. Nevertheless, IMHN is characterized by intraductal tumor growth and mucin hypersecretion causing cystic transformation of the pancreatic duct and producing a distinct appearance on ERCP of mucus extrusion through a widely patent papilla and amorphous filling defects within the duct. In contrast, the mucinous cystic tumors are proposed to secrete mucin into a peripheral branch duct leading to a cyst cavity which does not communicate with the pancreatic duct and therefore is not demonstrated on pancreatography.

Cystadenocarcinoma, Mucinous↗
PubMed1999

Role of endoscopic stenting in the duodenum.

BACKGROUND: Gastric outlet obstruction may cause the presenting symptoms, or may develop during the course of pancreatic or biliary malignancy. Treatment options for malignant gastric outlet obstruction are limited. Surgical gastrojejunostomy is commonly performed, but carries significant morbidity and mortality. METHODS: Over the past two years, we conducted a prospective study to determine the safety, feasibility and outcomes of the newly-designed Wallstent Enteral (Scneider, Minneapolis, MN) to treat a variety of malignant gastric outlet obstructions. We deployed stents 16 to 22 mm in diameter and 60 to 90 mm in length directly through the endoscope. RESULTS: Twelve patients (10 women ans 2 men, mean age = 59.7 years) underwent the procedure. After stenting, six patients were able to eat a regular diet, and three were able to eat a pureed diet. In three patients, the procedure was unsuccessful because of multiple obstructions that were not recognized prior to stenting in one and stents that were deployed either too proximally in one or too distally in another. Three patients were discharged within 24 hours after stenting and three had the procedure as an outpatient. CONCLUSIONS: Placement of the Wallstent Enteral through the endoscope is safe and effective palliation for a variety of malignant gastric outlet obstructions, and leads to significant improvement in many aspects of patients' quality of life.

Adult↗
PubMed1998

Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy.

BACKGROUND: We report our experience of selective cholangiography in a series of laparoscopic cholecystectomies and evaluate the strategy of using "stricter criteria" to select preoperative endoscopic retrograde cholangiopancreatography (ERCPs). METHODS: A total of 1847 consecutive laparoscopic cholecystectomies were analyzed for use of cholangiography. A high risk of common bile duct stones (bilirubin level more than 2 mg/dL, jaundice, alkaline phosphatase level more than 150 U/L, pancreatitis, or dilated bile duct and/or stone on ultrasound or CT) was an indication for preoperative ERCP. Selective intraoperative cholangiography was performed for intermediate risk of bile duct stones. The strategy of using "stricter criteria" (jaundice and/or demonstrated bile duct stones on ultrasound or CT) for selecting preoperative ERCP was evaluated retrospectively. RESULTS: Preoperative ERCP was performed in 135 patients (7.3%) and demonstrated bile duct stones in 43 (32%). Of 36 patients with mild gallstone pancreatitis alone, stones were found only in 6 patients (17%). Selective intraoperative cholangiography was performed in 87 (5%), and stones were found in 2 (2%); 67 (3.6%) postoperative ERCPs were performed for suspected choledocholithiasis, and stones were found in 21 (32%). Applying "stricter criteria" to select preoperative ERCP would predict ductal stones in 56%, whereas 3% of patients with stones would be missed, resulting in a 50% reduction in preoperative ERCPs. CONCLUSIONS: Even in selected patients considered likely to have choledocholithiasis, the diagnostic yield of preoperative ERCP is low. Using "stricter criteria" to select patients for preoperative ERCP can avoid unnecessary ERCPs.

Cholangiography↗
PubMed1998

Palliation of malignant gastric outlet obstruction using an endoscopically placed Wallstent.

BACKGROUND: Treatment options for malignant gastric outlet obstruction are limited. Surgical gastrojejunostomy, commonly performed, has significant morbidity and mortality. METHODS: Over 2 years, we prospectively studied the safety, feasibility, and outcomes for use of a newly designed expandable metal stent (Wallstent Enteral; Schneider, Minneapolis, Minn.) to treat malignant gastric outlet obstruction. Stents 16 to 22 mm in diameter and 60 to 90 mm in length were deployed directly through the endoscope. RESULTS: Twelve patients (ten women, two men; mean age 59.7 years) underwent stenting. Thereafter, six patients were able to eat a regular diet; three could eat pureed food. In three patients, the procedure was unsuccessful because of multiple obstructions not recognized before stenting (one) and stents deployed too proximally (one) or too distally (one). CONCLUSIONS: Placement of a newly designed stent through the endoscope is safe and effective palliation for various types of malignant gastric outlet obstruction and significantly improves many aspects of patient quality of life.

Duodenal Obstruction↗
PubMed1998

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts.

OBJECTIVE: To provide current information on the risks of endoscopic sphincterotomy for stone. SUMMARY BACKGROUND DATA: In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients. METHODS: Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria. RESULTS: Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm. CONCLUSION: Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Age Factors↗
PubMed1998

Endoscopic management of choledocholithiasis.

The first description of endoscopic sphincterotomy 25 years ago spearheaded the widespread use of endoscopic treatment of choledocholithiasis. It is largely accepted that common bile duct stone removal should be endoscopic rather than surgical in patients who have undergone previous cholecystectomy, in the high-risk surgical patient when the gallbladder is still present, in patients with severe acute cholangitis, in selected patients with acute biliary pancreatitis, and in special circumstances for the average risk surgical patient with suspected choledocholithiasis before laparoscopic cholecystectomy. We have summarized a number of endoscopic techniques that are used in the management of bile duct stone disease.

Catheterization↗
PubMed1998

Management of occluded biliary Wallstents.

BACKGROUND: Wallstents (Schneider Stent, Inc., USA) used for the palliation of malignant biliary strictures, although associated with prolonged patency, can occlude. There is no consensus regarding the optimal management of Wallstent occlusion. AIMS: To evaluate the efficacy of different endoscopic methods for managing biliary Wallstent occlusion. METHODS: A multicentre retrospective study of patients managed for a biliary Wallstent occlusion. RESULTS: Data were available for 38 patients with 44 Wallstent occlusions, all of which had initial endoscopic management. Twenty four patients had died and 14 were alive after a median follow up of 231 (30-1095) days following Wallstent occlusion. Occlusions were managed by insertion of another Wallstent in 19, insertion of a plastic stent in 20, and mechanical cleaning in five. Endoscopic management was successful in 43 (98%). Following management of the occlusion, bilirubin decreased from 6.0 (0.5-34.3) to 2.1 (0.2-27.7) mg/100 ml (p < 0.05). No complications occurred. The median duration of second stent patency was 75 days (95% confidence interval 43 to 107) after insertion of another Wallstent, 90 days (71 to 109) after insertion of a plastic stent, and 34 days (30 to 38) after mechanical cleaning (NS). The respective median survivals were 70 days (22-118), 98 days (54-142), and 34 days (30-380) (NS). Incremental cost effective analysis showed that plastic stent insertion is the most cost effective option. CONCLUSION: Although all three methods are equally effective in managing an occluded Wallstent, the most cost effective method appears to be plastic stent insertion.

Cholestasis↗
PubMed1998

Endoscopic management of acute gallstone pancreatitis.

Urgent management of acute biliary pancreatitis has increasingly included early endoscopic intervention. Endoscopic intervention allows effective removal of the offending stone(s) and reestablishment of biliary drainage. Four randomized controlled trials involving more than 800 patients in Western and Asian countries have been completed. This article summarizes the findings of these studies and proposes a preferred approach to the management of acute biliary pancreatitis.

Acute Disease↗
PubMed1997

Therapeutic ERCP in outpatients.

BACKGROUND: We evaluated the safety of outpatient therapeutic ERCP since most complications are apparent within a few hours. METHODS: We reviewed 190 patients undergoing planned outpatient therapeutic ERCP from a cohort of 409 consecutive therapeutic ERCP procedures. Patients were selected for outpatient therapeutic ERCP based on relative good health and overnight accommodation near our institution. RESULTS: Outpatient therapeutic ERCPs included plastic biliary stent insertion (n = 71), biliary sphincterotomy (45), pancreatic stent insertion (28), Wallstent insertion (19), biliary balloon or catheter dilation (10), pancreatic balloon or catheter dilation (8), biliary stone extraction with prior sphincterotomy (7), pancreatic sphincterotomy (5), and duodenal ampullectomy (1). Admission was necessary in 31 (16%) because of complications in 22 (11.6%) and observation of post-ERCP symptoms in 9. Twenty-six (13%) of these patients were admitted directly from the endoscopy unit recovery room and 5 (3%) from home after a median interval of 24 hours following discharge (range 5 to 48 hours). Reasons for admission were pancreatitis in 17, hemorrhage in 3, cholangitis in 3, endoscopic but not clinical hemorrhage in 4, pain in 4, and vomiting in 1. Of the patients who were admitted from home, 3 had pancreatitis (following sphincterotomy in 1, pancreatic stenting in 1, pancreatic balloon dilation in 1) and 2 had hemorrhage (postsphincterotomy in 1 and ampullectomy in 1). In comparison, of the 219 consecutive inpatients undergoing therapeutic ERCP, 28 (13%) developed complications with 1 (0.4%) death. CONCLUSIONS: A policy of selective outpatient therapeutic ERCP, with admission reserved for those with established or suspected complication, appears to be safe and reduces health care costs.

Biliary Tract Diseases↗