Biomedical subjects
D P Fossard
Publications and source records attributed to D P Fossard.
Rapid-bolus contrast-enhanced dynamic computed tomography in acute pancreatitis: a prospective study.
The purpose of this prospective study was to determine the clinicopathological significance of necrotic areas demonstrated by rapid-bolus contrast-enhanced computed tomography (CT) in patients with biochemically predicted severe pancreatitis. Although CT necrosis occurred significantly more frequently in patients with clinically severe (ten of 12) compared with mild (seven of 20) pancreatitis (P less than 0.025), seven of 17 (41 per cent) patients with CT necrosis developed clinically mild pancreatitis and six of ten (60 per cent) patients with clinically severe pancreatitis and CT necrosis recovered with conservative management. The site and extent of CT necrosis did not correlate with disease severity. Fine-needle aspiration cytology, operative and post-mortem findings and endoscopic retrograde cholangiopancreatography examinations all strongly suggested that CT necrosis represents true pancreatic necrosis. We conclude that the finding of CT necrosis is not in itself an indication for operative intervention, but that rapid-bolus contrast-enhanced dynamic CT greatly facilitates the planning and execution of surgical therapy.
Diverticulosis of the appendix.
Diverticulosis of the appendix is rarely reported. Two cases with this condition, including a unique example of appendiceal diverticulosis presenting at herniorrhaphy, are described. The aetiology of the condition and factors involved in incidental appendicectomy are considered.
Localization of lower gastrointestinal bleeding using in vivo technetium-99m-labelled red blood cell scintigraphy.
Technetium-99m-labelled red blood cell scintigraphy was used in the investigation of 41 patients with major rectal haemorrhage. Red cells were labelled in vivo with technetium-99m pertechnetate and serial scans (0-36 h) were taken using a large field gamma camera. Twenty-two men and 15 women, mean age 71.3 years (range 32-91 years), and four children were studied. Forty-three scans were performed in all and there were 31 positive and 12 negative results. In each case the accuracy of the scan in localizing the bleeding site was checked either by independent investigations or at laparotomy. A definite bleeding site was identified in 30 cases and red cell scintigraphy correctly localized 29 of these (sensitivity 97 per cent). In the remaining 13 cases a bleeding site was not identified by any of the independent investigations and in this group there were two false positive scans (specificity 85 per cent). The investigation had a high predictive value when both positive (94 per cent) and negative (92 per cent). These data suggest that technetium-99m-labelled red cell scintigraphy should be used more widely in the investigation of patients with suspected lower gastrointestinal haemorrhage.
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).
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.
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.
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.
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.
Long term follow-up of patients with side to side choledochoduodenostomy and transduodenal sphincteroplasty.
From a consecutive series of 190 patients with choledochoduodenostomy (CDD) and 56 patients with transduodenal sphincteroplasty (TDS), there were 10 and 3 hospital deaths respectively. A long term follow-up study was performed on the remainder. Late deaths occurred in 35 CDD and 5 TDS patients. Serious long term complications occurred in 3.3% of CDD cases, comprising 5 cases of 'sump syndrome' and a further case of cholangitis in the presence of a clear biliary tree. Cholangitis occurred in 2 of the TDS patients (3.8%). Recurrent common duct stones were found in 3 of the 'sump syndrome' cases (1.6%) and one of the TDS patients with cholangitis (1.9%). Eighty-eight per cent of the CDD patients and 90.2% of the TDS patients, who were reviewed, were subjectively well. Serum alkaline phosphatase was raised in 21.6% of the CDD patients and only 3.4% of the TDS group (P less than 0.05). Radiological studies showed that the CDD stoma admitted air and barium more often than the TDS stoma (P less than 0.001). Neither the biochemical nor the radiological findings correlated with the long term symptomatic results of the two procedures. Dynamic HIDA scans showed a shorter time to peak activity in the common hepatic duct for both CDD (P less than 0.01) and TDS (P less than 0.05) as compared with endoscopic sphincterotomy (ES). These long-term clinical, biochemical and radiological results are similar to those reported following ES.
Choledochoduodenostomy, transduodenal sphincteroplasty and sphincterotomy for calculi of the common bile duct.
The clinical features, indications and operative results in a consecutive series of 246 patients who underwent choledochoduodenostomy (CDD) and transduodenal sphincterotomy or sphincteroplasty (TDS) over a period of ten years (1972 to 1981) were reviewed. The over-all mortality for CDD was ten of 190 patients (5.3 per cent) and three of 56 patients for TDS (5.4 per cent). The over-all major morbidity rate for these procedures was 11.6 per cent for CDD and 21.4 per cent for TDS. This was not a statistically significant difference, but there were more elderly patients (more than 65 years old) in the CDD group (60.5 per cent) than in the TDS group (21.4 per cent) (p less than 0.001). The major morbidity rate associated with elective operations was 10.7 per cent for CDD and 20.0 per cent for TDS which is significant (p less than 0.05). Long term follow-up study (one to 12 years and mean of four and one-half years) revealed six patients in the CDD group with sump syndrome or cholangitis, or both, (3.3 per cent) and three patients in the TDS group had cholangitis develop (5.7 per cent). Over-all, the results compared favorably with the published results of endoscopic sphincterotomy. We conclude that CDD is the operation of choice when a permanent biliary drainage procedure is indicated and TDS should be reserved for instances of ampullary gallstone impaction.
Bile peritonitis and hemobilia after percutaneous liver biopsy: endoscopic retrograde cholangiopancreatography demonstration of bile leak.
A 29-yr-old woman developed portal hypertension secondary to congenital intrahepatic multiple microhamartomata. Percutaneous liver biopsy was complicated by both bile peritonitis and hemobilia. Endoscopic retrograde cholangiopancreatography was used to demonstrate the bile leak. Abdominal paracentesis failed to control the leak, which was managed by surgery. Endoscopic drainage by nasobiliary intubation with suction might have avoided surgery.
A prospective study of ERCP and endoscopic sphincterotomy in the diagnosis and treatment of gallstone acute pancreatitis. A rational and safe approach to management.
From a consecutive series of 112 patients with acute pancreatitis, 70 patients with suspected gallstones were randomized to urgent endoscopic retrograde cholangiopancreatography (ERCP) (less than 72 hours) and endoscopic sphincterotomy (ES) if choledochal stones were present (n = 35), or to conventional treatment (n = 35). Endoscopic retrograde cholangiopancreatography, successful in 89% of cases, indicated choledochal stones in 11 patients, all of whom underwent successful stone retrieval by ES. Later during hospital admission, ERCP was performed in 13 more patients and choledochal calculi were extracted from two patients by ES. No complications were attributable to ERCP or ES. Two patients died of biliary pancreatitis; both had been conventionally treated and may have benefited from urgent ERCP/ES. Our experience, which extends to another 24 patients with ERCP and ten with ES during acute pancreatitis, indicates that these are safe techniques and deserve wider consideration in the management of acute pancreatitis.
Traumatic rupture of the stomach due to a seat belt.
A case of gastric rupture is described in a patient who was wearing a lap and diagonal inertia reel seat belt at the time of a head-on collision. The literature is reviewed and the mechanism of injury is discussed.
The role of clinical and biochemical criteria and endoscopic retrograde cholangiopancreatography in the urgent diagnosis of common bile duct stones in acute pancreatitis.
The role of clinical and biochemical criteria in predicting common bile duct (CBD) stones was analyzed in 76 patients with acute pancreatitis undergoing endoscopic retrograde cholangiopancreatography (ERCP) during the same hospital admission. Forty patients had ERCP within 72 hours; cholangiography was successful in 92%. Fifty patients had biliary pancreatitis; 25 patients had CBD stones and all were successfully removed by endoscopic sphincterotomy (ES). Twenty-six patients had nonbiliary pancreatitis. Two patients had complications from ERCP and/or ES; two patients died (no CBD stones) but ERCP was noncontributory. Significant differences were found between the biliary and nonbiliary disease groups with respect to age, and bilirubin. gamma-glutamyl transpeptidase, alkaline phosphatase, alanine transaminase, and amylase levels. The first four factors also discriminated between those patients with and without CBD stones. Logistic discriminant functions were estimated providing probabilities for the presence of CBD stones for each patient but were too cumbersome for clinical use. A simple scoring system was devised on the basis of cut-off levels: bilirubin greater than or equal to 40 mumol/L, gamma-glutamyl transpeptidase greater than or equal to 250 IU/L, alkaline phosphatase greater than or equal to 225 IU/L, and age greater than or equal to 70 years, indicating CBD stones. Bilirubin alone had a sensitivity and specificity of 80%; the specificity increased to 93% with all four factors. These results suggest that clinical and biochemical criteria and ERCP and/or ES may have important roles in the management of patients with suspected biliary pancreatitis.
Sump syndrome following choledochoduodenostomy and its endoscopic treatment.
The clinical features of eight patients with 'sump syndrome' following side-to-side choledochoduodenostomy are reported. The syndrome is defined and its aetiology discussed with special reference to debris in the common bile duct, bacterial overgrowth and the clinical picture of acute cholangitis, which does not appear to be necessary for the diagnosis to be made. Five patients were successfully treated by endoscopic sphincterotomy and a sixth by endoscopic removal of food debris from the sump. The other two patients had further surgery.
Inguinal herniotomy in children: a five year survey.
This retrospective review covers our experience over 5 years of 436 hernia repairs in 392 children upto the age of 15 years. The number of emergency presentations was 71 (18.1 per cent) and 66.2 per cent of these were under the age of 12 months. Most cases were initially treated conservatively and only 18 children required operation on the day of admission. There were 11 recurrences (7 elective and 4 emergency cases) giving a recurrence rate of 2.5 per cent. In all eleven cases the original operation was performed by a junior surgeon. The complication rate (excluding recurrences) was 2.8 per cent but may be an underestimate because of the limitations of a retrospective study. We suspect our results are typical of those to be found in any large British hospital and that with careful training and supervision of junior staff in the technique of inguinal herniotomy the results could be improved and approach those found in specialist paediatric units in America.
Detection of gall stones after acute pancreatitis.
Four methods of gall stone diagnosis after an attack of acute pancreatitis are analysed. Of 128 consecutive patients with acute pancreatitis, 99 patients were discharged from hospital without a definite aetiology. These patients had biochemical tests performed on admission and ultrasonography and oral cholecystography performed six weeks later. The sensitivity for ultrasonography was 87% and the specificity was 93%; the respective figures for oral cholecystography were 83% and 90%. The predictive value of positive ultrasonography was 100% and of negative ultrasonography 75%; the respective values for oral cholecystography were 95% and 68%. A combination of ultrasonography and oral cholecystography failed to detect nine of 70 patients with gall stones (13%). Of 35 patients with normal ultrasonography and oral cholecystography, 33 patients had an endoscopic retrograde cholangiogram (ERCP) which showed gall stones in a further seven patients. All three methods failed to reveal gall stones in two patients, confirmed by laparotomy. The sensitivity of admission biochemical analysis was 73% and the specificity was 94%; the predictive value of a positive result was 97% and of a negative result was 57%. Biochemical analysis predicted gall stones in six of the seven patients shown by ERCP. Only 9% of patients were finally considered to be idiopathic. In conclusion ultrasonography is the investigation of choice and ERCP should be undertaken in all patients who have normal ultrasonography and/or oral cholecystography but have biochemical criteria indicative of gall stones.