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D Westaby

Publications and source records attributed to D Westaby.

At least 19 recordsLinked to original sources
PubMed1999

Percutaneous endoscopic gastrostomy feeding in patients with cystic fibrosis.

BACKGROUND: Malnutrition is a common management problem in patients with cystic fibrosis (CF). Various approaches to supplemental nutrition by both parenteral and enteral routes have been used. AIM: To analyse the efficacy and acceptability of supplemental overnight feeding using a percutaneous endoscopic gastrostomy (PEG) in patients with CF. PATIENTS: 53 patients with CF (43 adults; age >17 years) with severe pulmonary disease. METHODS: The technical success and complications of PEG insertion were documented together with changes in nutritional and pulmonary status of the cohort. RESULTS: PEG tubes were successfully inserted in all patients, with immediate complications (respiratory depression) in two (4%) and late complications in 13 (25%). Feeding was well tolerated by 50/51 (98%) of the cohort during a mean (SEM) follow up of 14.5 (2.1) months. The adult cohort had a significant increase in weight and body mass index at six months which was maintained at 12 months. Serum albumin concentration remained stable at six months but had fallen by 12 months, although the differences were not statistically significant. These results were reflected in the paediatric cohort. Pulmonary function in those followed up for one year had apparently stabilised, but the number of admissions to hospital over the year before and the year after PEG did not change. Half of the cohort were accepted for heart-lung/lung transplantation, the improvement in nutritional status being a prerequisite for this. CONCLUSION: Supplemental PEG tube feeding is well tolerated and results in a significant improvement in nutritional status and an apparent stabilisation of pulmonary function in severely malnourished CF patients with advanced pulmonary disease

Adolescent↗
PubMed1998

Self-expanding metal oesophageal endoprostheses, covered and uncovered: a review of 30 cases.

OBJECTIVE: Oesophageal self-expanding metal endoprostheses (SEMS, or stents) are recognized as a safe means of palliating dysphagia caused by malignancy. Stent designs that have covered or uncovered walls are now available. The purpose of this study was to compare the outcome of use of these two designs. DESIGN: Thirty consecutive cases were reviewed. All the patients had been referred over a period of 25 months for palliation of dysphagia caused by malignant obstruction. Either a covered or an uncovered stent was placed in each patient. Palliation of dysphagia, 30 day mortality, mean survival time, and the number of endoscopic re-interventions required, were assessed. RESULTS: Uncovered Ultraflex stents were used in 14 patients, and Schneider Wallstents were used in 16 patients. Dysphagia improved by one grade or more in 69% of patients. The 30 day mortality was 27%, with an overall mean survival time of 99 days. There was no significant difference between the two groups for these three parameters. Ten patients needed a total of 28 repeat endoscopic procedures to maintain stent patency, with overall rates for each group of 1.64 procedures per patient, for uncovered stents, compared with 0.31 for covered stents (significant at the P < 0.05 level). The number of repeat procedures increased with survival time. CONCLUSION: The use of covered self-expanding metal oesophageal endoprostheses is associated with a significant reduction in the need for endoscopic reintervention after stent placement.

Adult↗
PubMed1997

The management of high-grade hilar strictures by endoscopic insertion of self-expanding metal endoprostheses.

BACKGROUND AND STUDY AIMS: Treatment options for unresectable hepatic hilar strictures include percutaneous or endoscopic stent insertion, using either standard Teflon or self-expanding metal endoprostheses. The use of Teflon stents is complicated by stent migration and high occlusion rates. Published series of endoscopically placed metal stents have not concentrated on their use in the treatment of high-grade hilar strictures (Bismuth grades II and III). We therefore undertook a prospective and open pilot study to evaluate the efficacy of endoscopically placed metal endoprostheses in the palliation of jaundice due to high-grade hilar strictures. PATIENTS AND METHODS: Self-expanding metal stents were placed endoscopically in 17 patients (nine women, eight men; median age 64 years, range 33-77). Of the 17 malignancies 11 patients (65%) had a diagnosis of cholangiocarcinoma, and 12 (71%) had Bismuth grade III strictures. RESULTS: The stents were inserted successfully in all 1 patients. Adequate drainage, as demonstrated by a significant reduction in bilirubin, was achieved in 1: (88%); the two patients in whom drainage failed had extensive intrahepatic disease. Early complications (cholangitis) developed in one patients (6%), and there were seven late complications (41%) in five patients (four occluded stents and three cases of duodenal compression). The stent patency appeared to be prolonged (median stent patency 12 months, range 1.5-24 months, in patients surviving five months or more). The median survival was ten months (range 1-48 months) after stent insertion. All of the patients died during follow-up. CONCLUSIONS: These results suggest that endoscopically placed metal stents offer effective palliation for high grade hilar malignancies, although controlled trial comparing the use of metal and Teflon endoprostheses in this patient group are required.

Bile Duct Neoplasms↗
PubMed1997

A prognostic model for the prediction of survival in cystic fibrosis.

BACKGROUND: The treatment for endstage cystic fibrosis is, where appropriate, double-lung, heart-lung or, occasionally, heart-lung-liver transplantation. Optimising the timing of transplantation depends upon an accurate prediction of survival, but while current criteria give some guidance to this, they are not based upon statistically derived prognostic models. METHODS: Data collected prospectively on 403 patients with cystic fibrosis, recruited between 1969 and 1987 (cohort A), were analysed by log rank and univariate Cox regression analysis to determine variables that accurately predict survival. The significant variables were then subject to time dependent multivariate Cox regression analysis to generate a prognostic model. The model was validated, within the study population, using split sample testing, and was subsequently validated in a further cohort of patients recruited since October 1988 (cohort B). RESULTS: One hundred and eighty eight (50.4%) of the study cohort died within the study period. Percentage predicted forced expiratory volume in one second (FEV1), percentage predicted forced vital capacity (FVC), short stature, high white cell count (WBC), and chronic liver disease (as evidenced by the presence of hepatomegaly) were negatively correlated with survival. These variables, when combined into a prognostic index, accurately predicted one year survival in the study population and in the cohort recruited since 1988. CONCLUSION: This prognostic index may prove valuable in predicting prognosis in other cohorts with cystic fibrosis and thereby improve the timing of transplantation.

Adolescent↗
PubMed1996

Randomised study of endoscopic biliary endoprosthesis versus duct clearance for bileduct stones in high-risk patients.

BACKGROUND: The value of an endoprosthesis for long-term management of bileduct stones has not been formally established. The main theoretical advantage of endoprosthesis insertion (BE) over conventional endoscopic duct clearance (DC) is the prevention of stone impaction, with obstruction and consequent cholangitis or pancreatitis. In a randomised study we compared the results of these two methods in patients with symptomatic bileduct stones who were at high risk because of old age (> 70 yr) or serious debilitating disease. METHODS: 43 high-risk patients were randomised to BE with a 7F double-pigtail endoprosthesis and < 0.75 cm sphincterotomy, and 43 to DC with standard 1.25-1.50 cm sphincterotomy and stone extraction by balloon or basket, with or without mechanical lithotripsy. The principal endpoint was the rate of biliary related complications. FINDINGS: In the BE group biliary drainage was achieved in the first session in all but one patient (who required 2 sessions). In the DC group, 24 patients had duct clearance at the first attempt and 35 (81%) after a median of 2 sessions (range 2-4); eight of this group had an endoprosthesis inserted to maintain long-term drainage. At 72 h the complication rates were 7% in the BE group and 16% in the DC group (p = 0.18). However, the long-term complication rate for BE was higher: by Kaplan-Meier analysis, at a median of 20 months the proportions free of biliary complications were 64% BE and 86% DC (p = 0.03, log-rank test). INTERPRETATION: For immediate bileduct drainage, endoprosthesis insertion proved a safe and effective alternative to duct clearance. Because of the risk of subsequent cholangitis, its use as a definitive treatment should be confined to highly selected cases.

Aged↗
PubMed1996

Systemic haemodynamic changes in patients with cystic fibrosis with and without chronic liver disease.

BACKGROUND/AIMS: There are well-documented systemic haemodynamic changes associated with chronic liver disease. Patients with cystic fibrosis may develop chronic liver disease, but it is not known whether these systemic haemodynamic changes develop and, if they do, whether they are influenced by the associated chronic lung disease. We therefore undertook a study to document the circulatory status of cystic fibrosis patients with and without chronic liver disease. METHODS: Fifty-six subjects with cystic fibrosis were studied. Systemic haemodynamic and pulmonary parameters, in sub-groups both with (LD) and without (NLD) liver disease, were measured at rest and during measured exertion. Cystic fibrosis-related chronic liver disease was diagnosed using previously validated ultrasound criteria. Patients underwent assessment at rest and in the fourth minute of seated bicycle exercise at 25W. Heart rate (ECG), blood pressure (semiautomated sphygmomanometer), aortic blood velocity (pulsed Doppler suprasternal probe), arterial oxygen saturation (pulse oximeter) and respiratory variables (pneumotachometer with expired gas analysis by an automatic system) were measured. RESULTS: A complete data set was available for 45 patients (22 LD) at rest and 40 patients (19 LD) on exercise. The patients were well matched for age, sex, height, weight, and pulmonary function. Patients with chronic liver disease had a hyperkinetic circulation while ventilatory variables before and during exercise were similar for the two groups. There was evidence that the circulatory changes were exacerbated by both deteriorating hepatic and pulmonary function. CONCLUSIONS: Cystic fibrosis patients with chronic liver disease have a hyperdynamic circulation similar to that documented in other forms of chronic liver disease. These circulatory changes are exacerbated by deteriorating hepatic and pulmonary function.

Adult↗
PubMed1995

An ultrasound scoring system for the diagnosis of liver disease in cystic fibrosis.

Advances in the management of the pulmonary complications of cystic fibrosis may result in an increasing prevalence of patients with chronic liver disease which may, therefore, become more important in the long-term management of cystic fibrosis patients. However, no simple and reliable test is available for the diagnosis of liver disease in cystic fibrosis. In particular percutaneous liver biopsy is highly inaccurate and potentially dangerous. Imaging techniques, including real-time ultrasound scanning, have been used to evaluate the hepato-biliary system in cystic fibrosis and may represent the best available techniques for documenting hepatic involvement. The purposes of this study were to construct an ultrasound scoring system using three cardinal features of hepatic ultrasound in cystic fibrosis: coarseness of the parenchyma, nodularity of the liver edge and increased periportal echogenicity, to enable the accurate, early diagnosis of liver involvement in cystic fibrosis. The scoring system was validated by correlating the results against ultrasound markers of portal hypertension, clinical and haematological data. The scoring system proved to be reproducible and to correlate well with the markers of hepatic disease detailed above. The results also suggest that the scoring system may allow the identification of patients with pre-cirrhotic chronic liver disease and so may prove of value in selecting a sub-group of patients more likely to respond to therapy.

Adult↗
PubMed1995

Recent advances in the endoscopic management of variceal bleeding.

For the first time the endoscopist has more than one option for the management of gastro-oesophageal varices. It is now feasible to select the appropriate therapy on the basis of the clinical setting. Acute injection sclerotherapy remains a quick and simple technique for the control of active bleeding from oesophageal varices, and could be followed two or three days later by banding ligation. Earlier obliteration of varices with this technique may offer the prospect of only two or three sessions of therapy. The availability of the tissue adhesives and thrombin as injectates for fundal gastric varices provide the option of an initial attempt at endoscopic therapy in this high risk group.

Esophageal and Gastric Varices↗
PubMed1994

Management of variceal haemorrhage.

Fig 2 gives an algorithm for the treatment of bleeding oesophageal varices. Initial resuscitation of the patient is of paramount importance, ideally followed by early interventional endoscopy. Recent advances in available endoscopic techniques enable the endoscopist to suit the therapeutic approach to the clinical situation. Injection sclerotherapy remains the initial treatment of choice in bleeding patients. Endoscopic banding ligation is an alternative, best used in patients who have spontaneously stopped bleeding or as a complementary treatment a few days after the initial session of injection sclerotherapy. The tissue adhesives and thrombin can be used to treat bleeding gastric varices. [table: see text] Should the endoscopic expertise not be available, drug treatment (with somatostatin or octreotide) or balloon tamponade are the treatments of choice. Transjugular intrahepatic portal-systemic stent shunt is a new effective technique, not yet widely available, which has a documented complication rate that has yet to be fully defined. It is a good alternative to surgery as a "rescue" procedure for patients who continue to bleed despite two sessions of endoscopic intervention.

Balloon Occlusion↗
PubMed1994

Strongyloidiasis.

Explore the source record for details and available documents.

HTLV-I Infections↗
PubMed1994

Thrombin--an effective treatment for gastric variceal haemorrhage.

The optimum treatment of gastric varices has still to be defined. Lesser curve gastric varices may be treated by injection sclerotherapy, but this has a limited role in the treatment of fundal gastric varices. Surgical intervention is commonly needed but carries a high mortality in patients with advanced liver disease. This study evaluated the use of thrombin for the treatment of gastric varices in 11 consecutive patients (nine with fundal, two with high lesser curve varices), identified as having bled from this site. Bovine thrombin (1000 U/ml) was injected intravariceally (mean volume 5.5 ml, range 2-10 ml) producing initial haemostasis in all 11 cases. Varices were considered thrombosed or obliterated in all patients after a median of two injection episodes (range 1-3). After a median follow up of nine months only one patient had rebled from a gastric varix. Thrombin may represent a valuable alternative injectate for the treatment of gastric varices.

Acute Disease↗
PubMed1994

Primary amyloidosis and severe intrahepatic cholestatic jaundice.

Liver involvement in systemic amyloidosis is frequent but is rarely of clinical importance. Five patients with severe cholestatic jaundice are described and an additional 20 from published reports are reviewed. The most frequent presenting symptoms were lethargy and abdominal pain, which were present for a median of 11 months before the onset of jaundice. Hepatomegaly, usually marked, was present in 92%, with ascites in 56% of the cases. The serum bilirubin concentration was noticeably high and the serum globulin low. Histology of the liver showed considerable perisinusoidal deposition with a slight predilection for the periportal area. Two patients presented with predominant centrilobular deposition. Congo red staining was not uniformly positive. A variety of treatment regimens was tried but median survival was only three months from the onset of jaundice.

Aged↗