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Biomedical subjects

D L Carr-Locke

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

At least 91 records · Page 5Linked to original sources
PubMed1990

Videoendoscopy in clinical application. Impact on teaching.

The introduction of videoendoscopy has had a revolutionary impact on endoscopy teaching on a small scale within the Endoscopy unit itself and on a larger scale in the Conference Room which may be local or distant. The teaching of anatomy, pathology and endoscopic techniques have all been significantly affected and further improvements in electronic peripherals may make further image manipulation possible with further applications in teaching.

Anatomy↗
PubMed1990

Endoscopic management of intragastric migration of an Angelchik prosthesis.

The Angelchik prosthesis was devised as a simple surgical solution for reflux oesophagitis. Since 1983 there have been increasing reports of complications attributed to the prosthesis, the more serious being transmural erosion through the oesophageal or gastric wall. The majority of these have required repeat surgery, which is not without risks. A case report of an Angelchik prosthesis incompletely eroding into the stomach is presented. The prosthesis was tethered by a 1 cm-thick mucosal bridge which precluded simple extraction. Using an endoscopic sphincterotome, the bridge was divided and the prosthesis removed. Endoscopic methods of extracting intragastric Angelchik prostheses should be considered before surgery is undertaken for this complication.

Aged↗
PubMed1989

A multivariate analysis of preoperative risk factors in patients with common bile duct stones. Implications for treatment.

A multivariate analysis of 30 preoperative risk factors was undertaken in 248 patients who underwent surgery alone for common bile duct (CBD) stones and in 190 patients who had endoscopic sphincterotomy (ES), 77 of whom subsequently also had surgery. Independently significant risk factors in those undergoing surgery were the serum bilirubin level, the use of preoperative ES, and the presence of medical risk factors; in patients undergoing ES, only the serum bilirubin and albumin, but not medical risk factors, were of independent significance. The major implications of this study are, first, that high-risk patients should be treated by ES without subsequent surgery, and second, that "fit patients should be treated by surgery alone without routine preoperative ES.

Adult↗
PubMed1988

Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones.

121 patients with acute pancreatitis thought to be due to gallstones were randomised to treatment with urgent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) or with conventional treatment. They were stratified by predicted severity of the attack, according to the modified Glasgow system. ERCP was done within 72 h, and if common bileduct stones were identified, patients underwent ES immediately to extract the stones. There were fewer complications in the 59 patients who underwent ERCP +/- ES than among the 62 treated conventionally, the difference being confined to those whose attacks were predicted to be severe (6/25 ERCP +/- ES [1 death] compared with 17/28 conventional treatment [5 deaths]). Hospital stay was also shorter for patients with severe attacks who underwent ERCP +/- ES than for those who received conservative treatment (median 9.5 versus 17.0 days).

Acute Disease↗
PubMed1988

Long-term survival after resection of ampullary carcinoma is associated independently with tumor grade and a new staging classification that assesses local invasiveness.

Long-term survival characteristics after resection for ampullary carcinoma are documented poorly. We have reviewed the clinical and histopathologic features of 23 long-term survivors who underwent resections between 1972 and 1984 (5-year survival rate, 52.1%). Twenty patients (87%) had intestinal type tumors and only two (9%) had papillary tumors. Associated adenomata were present in eight cases (35%) and distant ductular dysplasia was present in nine cases (39%). Long-term survival was correlated independently with tumor grade (P = 0.0031) and a new staging system that assesses local invasiveness (P = 0.0055). No correlation was found between survival and sex, tumor size, or presence of adenoma. Age was significant in univariate analysis (P = 0.0322) but not in multivariate analysis. A simple scoring system based on the grade and stage increased the predictability of survival (P = 0.0004). Application of this scoring system may allow an objective comparison of long-term survival results after resection from different series.

Adenocarcinoma↗
PubMed1988

Biochemical prediction of gallstones in acute pancreatitis: a prospective study of three systems.

Three clinicobiochemical systems have been proposed for predicting gallstones in acute pancreatitis based on one, three and five factors respectively, but have not been compared in a single prospective study. System 1 is based on the serum transaminase alone; system 2 uses alkaline phosphatase and bilirubin in addition to transaminase; and system 3 involves female gender, age, amylase and alkaline phosphatase in addition to transaminase. Over the 4-year period 1983-86, 368 patients with 391 episodes of acute pancreatitis had clinicobiochemical analysis within 48 h. Of these episodes, 220 were related to gallstones (56 per cent), 62 to alcohol (16 per cent) and 109 to other aetiologies or were idiopathic (28 per cent). Significant differences were found between the biliary and non-biliary groups with respect to sex (139 versus 59 women, P less than 0.002), age (65 +/- 17 versus 52 +/- 19 years, P less than 0.0001) and serum amylase (6041 +/- 6335 versus 4546 +/- 3990 units/l, P less than 0.0001), alkaline phosphatase (257 +/- 225 versus 141 +/- 137 units/l, P less than 0.0001), alanine transaminase (221 +/- 227 versus 72 +/- 119 units/l, P less than 0.0001) and bilirubin (40 +/- 39 versus 24 +/- 30 mumol/l, P = 0.0001). The sensitivity and specificity was 75 per cent and 74 per cent for the one-factor system, 74 per cent and 78 per cent for the three-factor system and 62 per cent and 80 per cent for the five-factor system. The predictive value of a positive result was 78.8 per cent, 81.5 per cent and 80.1 per cent and of a negative result 69.4 per cent, 70.1 per cent and 62.3 per cent for the three systems respectively. The performances of the one- and three-factor systems were marginally better than that of the five-factor system; the one-factor system, however, had the advantage of simplicity.

Acute Disease↗
PubMed1988

Sphincter of Oddi dysfunction: results of treatment by endoscopic sphincterotomy.

From a consecutive series of 451 patients with post-cholecystectomy symptoms referred for endoscopic retrograde cholangiopancreatography (ERCP), 40 (9 per cent) were diagnosed as having sphincter of Oddi dysfunction. Eight patients were excluded from the study because of incomplete data (n = 6) or additional diagnoses (n = 2). Thirty of the patients had successful ERCP and endoscopic sphincterotomy (ES); this failed in the remaining two because of severe papillary stenosis (6.3 per cent). Endoscopic biliary manometry was performed in 23 patients (77 per cent). Immediate post-ES complications occurred in eight patients (25 per cent). At a median follow-up of 46 months (range 10-88 months) 19 patients had a good outcome (63.3 per cent) and 11 patients had a poor outcome (36.7 per cent). Patients with a good outcome tended to have a delay of months or years following cholecystectomy before the development of symptoms (median 6 years versus 0 years, P = 0.0003). At ERCP, patients with a good outcome had greater common bile duct diameters (mean +/- s.d. mm, 12.6 +/- 3.6 versus 8.8 +/- 1.8, P = 0.0003) and delayed drainage from the biliary tree of injected contrast (13 versus 2 patients, P = 0.02). Endoscopic biliary manometry was abnormal in all 15 patients with a good outcome in whom it was performed but in only 3 out of 8 patients with a poor outcome (P = 0.003). Sphincter of Oddi dysfunction is an important, albeit uncommon, cause of post-cholecystectomy symptoms. ES provides symptomatic relief in the majority of patients but improved criteria for predicting outcome are required.

Adult↗
PubMed1988

ERCP findings and the role of endoscopic sphincterotomy in acute gallstone pancreatitis.

A total of 131 patients with acute pancreatitis (of whom 100 had gallstones) underwent endoscopic retrograde cholangiopancreatography (ERCP) during the same hospital admission. Urgent ERCP (less than 72 h) was performed in 68 cases and early ERCP (3-30 days) in 63 cases; 47 had predicted severe attacks and 84 had predicted mild attacks (modified Glasgow criteria). The highest incidence of common bile duct stones occurred in those with predicted severe attacks and those who had urgent ERCP. Highly significant correlations were found between age and common bile duct and pancreatic duct diameters. Significant correlations were also found between the common bile duct and pancreatic duct (correcting for age) and between these and the admission serum bilirubin. The common bile duct diameter was greatest in those with common bile duct stones and predicted severe attacks. A considerably lower incidence of pancreatic duct filling occurred in those with predicted severe attacks and common bile duct stones; in predicted mild attacks the pancreatic duct diameter was greater in those with common bile duct stones. In gallstone patients complications were highest in those with predicted severe attacks but more significantly in those with common bile duct stones. Endoscopic sphincterotomy was undertaken in 37 patients with common bile duct stones without mortality. The overall complication rate in gallstone patients was 19 per cent and the mortality rate was 2 per cent. These findings suggest that common bile duct stones cause acute common bile duct and pancreatic duct obstruction and are closely associated with complications. Urgent ERCP for detection of common bile duct stones, and endoscopic sphincterotomy for treatment, is strongly recommended for patients with predicted severe attacks due to gallstones and should also be considered for others who fail to show clinical improvement.

Acute Disease↗
PubMed1988

Endoscopic sphincterotomy for common bile duct calculi in patients with gall bladder in situ considered unfit for surgery.

Endoscopic sphincterotomy (ES) was attempted in 106 patients with common bile duct (CBD) calculi and gall bladders present, who were considered unfit for surgery on the grounds of age and frailty alone (35%) and/or the presence of major medical problems (65%). Endoscopic sphincterotomy was successful in 105 patients (99%). Early ES related complications occurred in 21 patients (19.8%). Twelve hospital deaths occurred (11.3%), although this was due to biliary causes in only five (4.7%) and one of these was moribund on admission. Complications were more frequent in those in whom initial ES did not clear the common bile duct (30.4%) compared with those in whom this was (11.7%; p = 0.0164). The mortality was also greater in patients in whom there was no ERCP proof of CBD clearance (p = 0.01) unless operated upon. Twelve patients developed gall bladder complications (11.3%) including five with empyema (4.7%). Analysis of clinical, haematological, and biochemical factors together with ERCP findings showed that the only factor which had any value in predicting gall bladder complications was pre-existing cholangitis. The present series was compared with another using ES as a definitive procedure, and with a surgical series. Although there were significant differences in outcome, differences with respect to medical risk factors and the incidence of complications of CBD stones (jaundice, cholangitis, and acute pancreatitis) were striking. Further analysis of these factors may allow a clearer definition of patients most likely to benefit from either ES or surgery.

Age Factors↗
PubMed1987

Prospective randomised study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones.

One hundred and twenty patients with known common bile duct stones were entered into a prospective randomised study of preoperative endoscopic sphincterotomy and stone clearance (group 1) versus surgery alone (group 2). Five patients were incorrectly entered; the 55 patients randomised to group 1 and the 60 randomised to group 2 were well matched with respect to clinical features and biochemical and medical risk factors. In group 1 endoscopic stone clearance was successful in 50 patients (91%); five of these patients refused elective surgery, though this was subsequently necessary in one. In group 2 common bile duct stones were cleared surgically in 54 of 59 patients (91.5%); one patient was treated by endoscopic sphincterotomy alone because of a myocardial infarct. The overall major complication rate in group 1 was 16.4% and included two deaths; in group 2 this was 8.5% and included one death. The minor complication rate in group 1 was 16.4% and that in group 2 13.6%. These differences in outcome were not significant. Despite a significant reduction in total hospital stay of patients in group 1, these results do not support the routine use of preoperative endoscopic sphincterotomy in patients having biliary surgery for stones in the common bile duct.

Adult↗
PubMed1987

Study of common bile duct exploration and endoscopic sphincterotomy in a consecutive series of 438 patients.

The outcome of 438 consecutive patients who had exploration of the common bile duct and/or endoscopic sphincterotomy (ES) in a 5-year period was reviewed. Patients were analysed according to four groups: 59 patients had planned ES followed by surgery resulting in 14 major complications (23.7 per cent) including 3 deaths (5.1 per cent) (group 1); 248 patients had surgery alone with 21 major complications (8.5 per cent) including 10 deaths (4.0 per cent) (group 2); 114 patients with gallbladder in situ underwent ES alone with 22 major complications (19.3 per cent) including 9 deaths (7.9 per cent) (group 3); 17 patients with remote cholecystectomy also had ES alone with 3 major complications (17.6 per cent) including 3 deaths (17.6 per cent) (group 4). There was no difference in mortality between the groups. Compared with group 2, major complications were significantly higher in group 1 (chi 2 = 11.0, d.f. = 1, P less than 0.001) and in group 3 (chi 2 = 8.6, d.f. = 1, P less than 0.003). Patients in group 3, however, were significantly older than those in groups 1 and 2, and the former also had higher medical and total risk factor scores than the latter (all P less than 0.001). The results indicate that routine pre-operative ES is of questionable value. ES alone is justified in elderly high risk patients; mortality in this group might be reduced by improved management of post-ES complications.

Adolescent↗
PubMed1987

Treatment and outcome in 52 consecutive cases of ampullary carcinoma.

The results of treatment and outcome in 52 consecutive patients presenting to Leicester from 1972 to 1984 are presented. The number of patients diagnosed increased from two per year before the introduction of duodenoscopy to nearly five per year afterwards. Endoscopic drainage (ED) was attempted in 21 patients with a success rate of 81 per cent. In eight cases ED was used pre-operatively and in the remainder as definitive treatment. Twenty-four patients had a Whipple's resection (12.5 per cent mortality), four patients had a local resection (no deaths), ten patients had surgical bypass (60 per cent mortality) and thirteen patients had ED alone (23 per cent mortality). The major risk factor score was significantly greater in patients undergoing surgical bypass compared with Whipple's resection. Age and risk factor scores were significantly greater in patients who had ED drainage alone than in surgical patients. The 5 year survival rate for resection was 56 per cent versus 13 per cent for drainage procedures (P less than 0.001). Survival in resection cases was directly related to the degree of tumour differentiation and a new staging system. It is proposed that all patients with ampullary tumours should have endoscopic biopsy followed by ED; Whipple's resection remains the surgical treatment of choice.

Adenocarcinoma↗
PubMed1987

Acute cholangitis in association with acute pancreatitis: incidence, clinical features and outcome in relation to ERCP and endoscopic sphincterotomy.

Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) have been shown to be valuable in managing patients with acute cholangitis, their role in patients who have simultaneous acute cholangitis and acute pancreatitis is not known. We have reviewed 32 consecutive patients presenting with both conditions over ten years which represents 23.0 per cent of all cases of gallstone-related acute cholangitis and 14.4 per cent of all cases of biliary acute pancreatitis admitted during the same period. The majority of patients were elderly (median 76 years) and female (75 per cent). Five patients had previously undergone cholecystectomy. Eleven patients were clinically shocked (34 per cent) and blood cultures were positive in 9/14 cases (64 per cent). Twenty patients (63 per cent) had a predicted severe attack of acute pancreatitis (modified Glasgow criteria). Common bile duct (CBD) stones were identified in 15 of 23 patients with successful ERCP. Of these 23 patients, 9 were treated by endoscopic sphincterotomy (ES) alone, 5 by ES and surgery, 4 by surgery alone and 5 were treated conservatively. There was one death (4.3 per cent). Nine patients were managed without cholangiography; four had surgery and five were treated conservatively. There were three deaths (33 per cent; P = 0.10). Evidence of recent CBD stone passage was apparent in eight patients (25 per cent) compared with five out of eighty-seven patients (5.7 per cent) with acute cholangitis alone (P less than 0.005). The results indicate that ERCP and ES may have an important role in the management of these patients.

Acute Disease↗