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Biomedical subjects

G Morris-Stiff

Publications and source records attributed to G Morris-Stiff.

At least 19 recordsLinked to original sources
PubMed2006

Haemorrhage following pancreaticoduodenectomy: risk factors and the importance of sentinel bleed.

AIM: To document the prevalence and to evaluate the management strategies of haemorrhagic complications following pancreaticoduodenectomy (PD). METHODS: All patients who underwent PD from 1/2000 to 10/2005 and experienced at least one episode of haemorrhage during the 30 first days postoperatively were recorded. Etiology of haemorrhage, treatment strategy and mortality rate were recorded and analyzed. RESULTS: A total of 362 patients underwent PD during this period and 32 (8.8%) had haemorrhage postoperatively of whom 15 died (47% mortality rate). Primary intraluminal haemorrhage was recorded in 13 patients, primary intra-abdominal haemorrhage in 5 patients and secondary haemorrhage in 14 patients. Successful management of haemorrhage with angioembilization occurred in 2 patients in the study group. Statistical analysis revealed sepsis and sentinel bleed as risk factors for post-PD haemorrhage and pancreatic leak and sentinel bleed as risk factors for secondary haemorrhage (p < 0.05). CONCLUSIONS: Haemorrhage after PD is a life-threatening complication. Sepsis, pancreatic leak, and sentinel bleed are statistical significant factors predicting post-PD haemorrhage. Sentinel bleed is not statistically significant associated with postoperative mortality, but with the onset of secondary haemorrhage. The effectiveness of therapeutic angioembolization was not demonstrated in our study.

Adult↗
PubMed2006

Abdominal radiograph requesting in the setting of acute abdominal pain: temporal trends and appropriateness of requesting.

INTRODUCTION: The biannual turnover of house surgeons has long been dreaded by paramedical staff because of fears of increased workloads generated by 'untrained' junior doctors. The aim of this study was to address this issue by examining both the quantity and quality of requests made for emergency abdominal radiographs made by 'experienced' house surgeons during the month of July and by the 'novices' during August. PATIENTS AND METHODS: All adult patients undergoing abdominal radiography (AXR) following admission as emergencies via the surgical directorate with abdominal signs were identified prospectively. The reports of the AXRs were reviewed to determine the total number of requests and the number of positive findings for the two groups. In addition, the hand-written request forms were recovered to determine the suitability of the requests according to nationally-accepted guidelines produced by the Royal College of Radiologists (RCR). RESULTS: During the study period, a total of 252 radiographs were performed consisting of 98 in July and 154 in August. The number of unreported films in each month were similar at 11 (11.2%) and 16 (10.4%), respectively, leaving 87 reported radiographs in July and 138 in August. There was no difference in the number of radiographs with positive findings (excluding degenerative spinal disease) for July (n = 19; 22%) and August (n = 33; 24%). Of the 225 reported films, RCR guidelines were followed in only 73 (32%) of 225 cases. When guidelines were adhered to, positive findings were identified in 56 (76.7%) of 73 cases whereas when guidelines were not followed positive findings were seen in only 13/139 (8.9%) of AXRs. CONCLUSIONS: We have demonstrated that the popular myth of the 'August syndrome' is unsubstantiated at least using the surrogate marker of abdominal radiograph requests. The worrying finding of a high number of unacceptable indications for the performance of abdominal radiographs deserves urgent attention both in terms of its financial implications and with regards reducing radiation exposure. A programme of education is proposed to emphasise the RCR guidelines with re-audit to assess adherence to the guidelines.

Abdominal Pain↗
PubMed2006

Gastro-colonic anastomosis--a viable option in extensive small bowel infarction.

INTRODUCTION: We have previously presented a patient with massive small and large bowel infarction and demonstrated that even with only a few inches of remaining small bowel an almost normal life-style and diet is possible. PATIENT: Recently, we have looked after a young and otherwise fit female patient who suffered mesenteric venous gangrene of the whole small bowel from the Ligament of Treitz to the caecum. In order to achieve gastro-intestinal continuity and to avoid the torrential fluid loss associated with high fistula, an anastomosis between the stomach and the transverse colon was formed. RESULTS: We are surprised to find that despite the extensive resection our patient maintains a good quality of life and is able to look after her young family.

Adult↗
PubMed2005

Autoimmune pancreatitis: an underdiagnosed condition in Caucasians.

Unlike in Japan, autoimmune pancreatitis is uncommon in the Western world, particularly in Europe. We report the first case of a Caucasian male with typical features of autoimmune pancreatitis in the UK. Recognizing autoimmune pancreatitis as a new clinical entity in Europe will change the management of many patients who have been labelled as having acute or chronic pancreatitis.

Aged↗
PubMed2005

Is assessment of popliteal artery diameter in patients undergoing screening for abdominal aortic aneurysms a worthwhile procedure.

PURPOSE: The aim of this study was to assess whether screening of popliteal arteries in patients undergoing ultrasound screening of their abdominal aortas was worthwhile. METHODS: All male patients undergoing ultrasound screening for abdominal aortic aneurysm (AAA) during the period February 2000 to June 2002 were offered scanning of their popliteal arteries. All scans were performed by a single, trained operator using a Sonosite 180. RESULTS: Four hundred and forty-nine patients underwent screening and thus 898 popliteal arteries were assessed. The mean aortic diameter was 2.1 standard deviations (SD) 0.5 cm and the upper limit of normal (2 SD) was 2.7 cm. The mean diameter of the popliteal arteries was 0.74 SD 0.11 and the upper limit of normal was 0.96 cm. Thirty patients had aortic diameters greater than 2.5 cm (ectatic or aneurysmal aortas) but based on a popliteal diameter of 2 cm, no popliteal aneurysms were detected. However, 39 (4.3%) popliteal arteries measured > or = 1 cm (> mean+2 SD); 3/60 (5%) in the ectatic/AAA subgroup and 36/838 (4.3%) in the non-AAA subgroup. CONCLUSIONS: This study has shown that, using conventional definitions, the imaging of popliteal arteries during screening for AAAs does not detect any popliteal aneurysms and is thus of limited value. However, if a definition of popliteal aneurysm of > or = 1 cm (based on mean+2 SD) is used then 39/898 (4.3%) of arteries would be regarded as having abnormal diameters and may require surveillance.

Aortic Aneurysm, Abdominal↗
PubMed2004

Giant mature cyst formation following mesh repair of hernias: an underreported complication?

BACKGROUND: Numerous complications have been described following the implantation of synthetic meshes during hernia repair; one of the rarest, with only three reported cases, is giant mature fibrous cyst formation. Our clinical experience with this complication has led us to believe that it may be more common than previously thought. METHODS: Surgical operation notes and pathology archives were reviewed for the period January 1998-January 2002 to determine the prevalence of mature cyst formation following mesh repair of hernias. RESULTS: Out of 1100 hernia repair operations involving the use of synthetic meshes in our institution during the period of study, five developed histologically confirmed mature fibrous cysts giving a prevalence of 0.45% for this complication. CONCLUSION: The formation of a giant mature cyst following mesh repair of hernias is an underreported complication.

Abdominal Wall↗
PubMed2004

Abdominal aortic aneurysm and its correlation to plasma homocysteine, and vitamins.

BACKGROUND: Hyperhomocysteinemia is a recognised independent risk factor in the genesis of atherosclerotic diseases. However, very little is known about the relationship between homocysteine and abdominal aortic aneurysm (AAA). Vitamins, namely B12 and folic acid have been implicated in the regulation of plasma homocysteine levels. However, there has been no prospective study that has analysed the relationship of AAA and plasma homocysteine in light of serum vitamin levels. AIMS: To study the relationship between plasma homocysteine, serum B12 and folic acid levels, and AAA. METHOD: Case control study including 38 AAA patients and 36 controls. Fasting homocysteine, B12 and folic acid were determined in serum separated within 1 h of blood collection using a fluorescence polarisation immunoassay technique (FPIA). RESULTS: Twenty-six (68%) of the AAA patients had elevated levels of homocysteine compared to 2 (6%) in the case control group. The mean homocysteine level in the AAA group was 19.4 micromol/L (SE +/- 1.1) (95% CI 17.17-21.65) and in the control group was 10.9 micromol/L (SE +/- 1) (95% CI 9.95-11.88) (p<0.001). Mean vitamin B12 levels in the AAA and the controls was 332.11 pg/L (SE +/- 16.44) and 414.33 pg/L (SE +/- 19.72), respectively (p<0.004). Mean folic acid in the AAA was 8.02 (SE +/- 0.71) and the control was 9.8 etagm/L (SE +/- 0.69), (ns). CONCLUSION: This study confirms significantly higher levels of plasma homocysteine in AAA patients but lower levels of B12. Use of supplemental vitamins that should lower plasma homocysteine may modify vascular disease progression. Clinical trials in this direction are warranted.

Aged↗
PubMed2004

Registrar operating experience over a 15-year period: more, less or more or less the same?

BACKGROUND: Concerns have been raised on the effects that recent changes in junior doctor work patterns may have on the breadth and depth of operative exposure achieved during specialist registrar training. This study aimed to determine whether there was any justification for these concerns by assessing whether there have been significant changes in either the number of cases or the case mix operated upon by registrars over the course of the past fifteen years. METHODS: A retrospective review of theatre records was undertaken, looking at the caseload of the registrars working for the same two consultant surgeons at one district general hospital in four one-year periods (1986-7; 1991-2; 1998-9; 2001-2). The number, subspecialty, and time of each operation were recorded. RESULTS: Whilst operating experience for the first three periods of the study was static, the most recent assessment point has demonstrated a significant reduction in trainee routine operative experience and also a small reduction in the emergency workload performed by both firms. There was also a significant change in the elective case mixes corresponding to consultant sub-specialisation during this period. In addition, there were notable changes in the nature of the emergency workload and a reduction in the number of cases performed after midnight. CONCLUSION: SpRs trained during the Calman era appear to be gaining less operative experience than their predecessors in both the elective and emergency settings. With further changes in working patterns currently being implemented, major changes to SpR programmes are required if surgeons are to be adequately trained.

Adult↗
PubMed2004

Transmission of donor melanoma to multiple organ transplant recipients.

Malignant melanoma represents the most common tumour responsible for donor-derived post transplantation malignancies. We report the varied presentation and outcome of three graft recipients (two kidney and hepatic) who developed metastatic melanoma following cadaveric organ transplantation from a single multiorgan donor. Two of the recipients presented with symptomatic metastatic lesions and the third patient, despite being carefully monitored, developed evidence of metastatic cutaneous melanoma. Two of the patients died as a direct result of their melanomas. The recipients of corneal and cardiac grafts remain disease-free. We conclude that despite careful screening, donor-derived tumours remain a not uncommon clinical entity. The identification of a lesion in one recipient should prompt immediate examination and investigation of the remaining recipients of multiorgan donations.

Adult↗
PubMed2002

Intestinal ischaemia.

Over the past three decades major advances have been made in the diagnosis and management of mesenteric ischaemia. Early identification and treatment of this condition has reduced its mortality and morbidity. This review discusses the causes, preliminary and definitive investigations, and treatment protocols relating to gut ischaemia.

Acute Disease↗
PubMed2001

Issues of consent in renal transplantation.

BACKGROUND: Renal transplantation is a semi-elective procedure. The specific risks of surgery are well-known. Obtaining informed consent is a complex process made more complicated in transplantation by the long-term nature of some of the risks involved. METHODS: A questionnaire survey was conducted of consultant transplant surgeons to establish current practice regarding the levels of information and risks discussed as part of the consent process. RESULTS: Responses were received from 47 (76%) of consultants. Risks were discussed by a range of individuals. Pre-assessment clinics were used by 70% of units to start the process. Only 74% routinely discussed malignancy and only 75% the risks of cytomegalovirus infection. Risks with individual organs were discussed by 32 (68%)--particularly HLA match, cold ischaemia, sensitisation, donor age and caused of donor death. CONCLUSIONS: The current practice identified by this study falls broadly within General Medical Council guidelines on informed consent. There is wide variation in current practice which is highlighted and discussed in relation to case law and the levels of risk that a patient should expect to be informed of.

Guideline Adherence↗
PubMed1998

Single centre experience with mycophenolate mofetil for refractory rejection in cadaveric renal transplantation.

Ten patients with refractory rejection following renal transplantation were treated with mycophenolate mofetil (MMF) in an attempt to salvage the allografts. All cases of rejection were biopsy-proven. Seven of the patients had initially been on tacrolimus-based triple therapy and three were on cyclosporin-based regimens. Those on cyclosporin had been unsuccessfully converted to tacrolimus prior to receiving MMF. All patients had received at least one course of methylprednisolone pulse therapy and three had been given OKT3 prior to MMF. MMF was prescribed at a dose of 2000 mg per day in two divided doses and was given in addition to tacrolimus and prednisolone. Eight of the ten patients showed evidence of reversal of rejection, as indicated by improvement in renal function following commencement on MMF, whilst two patients experienced ongoing rejection and underwent graft nephrectomy. One of the patients successfully treated has since had his MMF discontinued due to gastrointestinal intolerance. We conclude that MMF is effective in salvaging renal allografts with resistant rejection and that it has an acceptable side-effect profile.

Adult↗
PubMed1998

Conversion of renal transplant recipients from cyclosporin to low-dose tacrolimus for refractory rejection.

Twenty-five patients with refractory rejection following renal transplantation were converted from cyclosporin to tacrolimus in an attempt to salvage the allografts. All patients had received two or three pulses of methylprednisolone, 6 had OKT3, 14 had antithymocyte globulin (ATG) and 2 had both OKT3 and ATG prior to conversion. The median time from transplantation to conversion to tacrolimus was 32 days (range 12-322). Patients underwent a simple switch from cyclosporin- to tacrolimusbased therapy with tacrolimus administered at a median dose of 0.15 mg/kg per day. Doses were adjusted according to clinical response and trough blood levels. Twenty-one of the 25 patients (84%) with refractory rejection showed evidence of reversal of rejection as indicated by a significant reduction in serum creatinine (Student's paired t-test, P < 0.05) following conversion to tacrolimus. None of these patients had further episodes of rejection. Three patients had ongoing rejection and returned to dialysis, and 1 patient showed deteriorating renal function associated with a cytomegalovirus infection. Of 18 patients currently on tacrolimus, 15 have improved renal function and 3 have shown no further deterioration. We conclude that low-dose tacrolimus appears to be effective in salvaging renal allografts with resistant rejection.

Adult↗
PubMed1998

Conversion of renal transplant recipients from cyclosporin (neoral) to tacrolimus (prograf) for haemolytic uraemic syndrome.

Five patients with cyclosporin-related haemolytic uraemic syndrome (HUS) following cadaveric renal transplantation were converted from cyclosporin- to tacrolimus-based immunosuppression. All patients had biochemical, haematological and biopsy evidence of HUS at the time of conversion. Four of the patients showed complete resolution of the syndrome within 1 week of conversion with normalisation of haemoglobin, platelets and lactate dehydrogenase levels. In the fifth patient renal function stabilised with slow resolution of the haematological and biochemical parameters. Four of the five patients are still taking tacrolimus, one having converted back to cyclosporin due to marked hair loss. We conclude that conversion to tacrolimus appears to be an effective treatment for cyclosporin-related HUS following renal transplantation.

Adult↗
PubMed1998

Prospective randomised study comparing tacrolimus (Prograf) and cyclosporin (Neoral) as primary immunosuppression in cadaveric renal transplants at a single institution: interim report of the first 80 cases.

As part of an ongoing study, 80 patients undergoing cadaveric renal transplantation were randomised to receive either Prograf [PTT (patients receiving Prograf); n = 40]- or Neoral [NTT (patients receiving Neoral); n = 40]-based immunosuppression as part of a triple therapy regimen. Prograf was commenced at a dose of 0.2 mg/kg per day and Neoral at 8 mg/kg per day. Both groups received identical azathioprine and corticosteroid regimens. Trough levels for Prograf were maintained between 5 and 15 ng/ml and for Neoral between 100 and 200 ng/ml. During the 3-month follow up 40% of PTT and 33% of NTT experienced biopsy-proven acute rejection. In each group 81% of rejection episodes were classified as either borderline or grade 1. The median 3-month serum creatinine levels were 128 mumol/l and 135 mumol/l, respectively, for PTT and NTT. Six grafts were lost in the NTT group including three deaths with functioning grafts whilst none were lost in the PTT group (chi 2, P < 0.02). The prevalence of other complications was similar for the two groups. We conclude that Prograf represents an effective and safe therapy as a primary immunosuppressive agent following cadaveric renal transplantation and appears to have a similar side-effect profile to Neoral.

Adult↗