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Biomedical subjects

I A Eyre-Brook

Publications and source records attributed to I A Eyre-Brook.

At least 19 recordsLinked to original sources
PubMed2003

Conservative treatment as an option in the management of pancreatic pseudocyst.

BACKGROUND: Management of pancreatic pseudocysts is associated with considerable morbidity (15-25%). Traditionally, pancreatic pseudocysts have been drained because of the perceived risks of complications including infection, rupture or haemorrhage. We have adopted a more conservative approach with drainage only for uncontrolled pain or gastric outlet obstruction. This study reports our experience. PATIENTS AND METHODS: A consecutive series of 36 patients with pancreatic pseudocysts were treated over an 11-year period in one district general hospital serving a population of 310,000. This study group comprised of 19 men and 17 women with a median age of 55 years (range, 10-88 years). Twenty-two patients had a preceding attack of acute pancreatitis whilst 12 patients had clinical and radiological evidence of chronic pancreatitis. The aetiology comprised of gallstones (16), alcohol (5), trauma (2), tumour (2), hyperlipidaemia (1) and idiopathic (10). RESULTS: All patients were initially managed conservatively and intervention, either by radiological-assisted external drainage or cyst-enteric drainage (by surgery or endoscopy), was only performed for persisting symptoms or complications. Patients treated conservatively had 6 monthly follow-up abdominal ultrasound scans (USS) for 1 year. Fourteen of the 36 patients (39%) were successfully managed conservatively, whilst 22 patients required intervention either by percutaneous radiological drainage (12), by endoscopic cystogastrostomy (1) or by open surgical cyst-enteric anastomosis (9). Median size of the pancreatic pseudocysts in the 14 patients managed conservatively (7 cm) was nearly similar to that of the 22 patients requiring intervention (8 cm). The most common indications for invasive intervention in the 22 patients were persistent pain (16), gastric outlet obstruction (4), jaundice (1) and dyspepsia with weight loss (1). Although one patient required surgery for persistent pain, no other patients required urgent or scheduled surgery for complications of untreated pancreatic pseudocysts. Two of the 12 patients treated by percutaneous radiological drainage had recurrence of pancreatic pseudocysts requiring surgery. Two patients developed an intra-abdominal abscess following cyst-enteric drainage of pancreatic pseudocysts and one patient had a pulmonary embolism. On the mean follow-up of 37.3 months, one patient with alcoholic pancreatitis died 5 months after surgical cyst-enteric bypass. CONCLUSIONS: These results suggest that many patients with pancreatic pseudocysts can be managed conservatively if presenting symptoms can be controlled.

Adolescent↗
PubMed2002

Consequences of prolonged wait before gallbladder surgery.

The aim of this study was to document the morbidity associated with long waiting times for laparoscopic cholecystectomy and to relate this to the nature of initial presentation either routine out-patient consultation or emergency admission with acute symptoms. This study was performed over a 50-month period in a DGH (serving a population of 320,000) which lacked sufficient operating capacity to allow routine early cholecystectomy after emergency admission. A total of 387 patients underwent cholecystectomy but 22 of these had an early operation after initial emergency admission with signs of peritonitis and were excluded from the study. The median waiting time for cholecystectomy in this study population of 365 patients was 170 days (range, 6-484) days. Of these 365 patients, 246 (67.4%) were listed for surgery after initial out-patient assessment (out-patient cohort) and 119 (32.6%) were diagnosed after an index emergency admission with symptomatic gallstone disease (emergency cohort). Of the 365 patients, 42 (11.5%) had one or more emergency admissions (57 admissions) with gallstone-related complications whilst on the waiting list for surgery. Complications were acute cholecystitis/biliary colic (n = 40), jaundice/cholangitis (n = 8), acute pancreatitis (n = 6) and perforated gallbladder (n = 3). Re-admissions with gallstone-related complications were much more common in patients whose initial presentation had been as an emergency. Thus, 34 of the 119 emergency cohort (28.5%) required re-admission with complications whilst only 8 of 246 (2.8%) elective cohort were re-admitted. Of the 34 re-admissions in the emergency cohort, 22 occurred within 6 weeks of their discharge from hospital. Median total and postoperative stay were significantly shorter (P < 0.001) in the elective cohort (3 and 2 days, respectively) than the emergency cohort (10 and 3 days, respectively). These results document the high incidence of complications experienced by patients waiting for an elective laparoscopic cholecystectomy. Morbidity is highest in patients with an initial emergency admission. These results suggest that cholecystectomy should be offered to all patients presenting as an emergency with symptomatic gallstones on admission.

Acute Disease↗
PubMed2001

An assessment of clinical guidelines for the management of acute pancreatitis.

BACKGROUND: Recent guidelines have been issued for the management of acute pancreatitis. The aim of this study was to audit the management of acute pancreatitis in one district general hospital, to determine the problems and benefits associated with the implementation of such guidelines. METHODS: Data were collected over the period 1991-1995 for all patients diagnosed as having acute pancreatitis who were admitted to one district general hospital. Data regarding severity grading, determination of aetiology and treatment of mild and severe pancreatitis were analysed in conjunction with the recommendations issued by the British Society of Gastroenterology Working Party on the management of acute pancreatitis in 1995. RESULTS: A total of 210 patients were admitted on 263 occasions; 16% of cases were severe but severity prediction was inaccurate. 56.1% had gallstone pancreatitis and 20.9% had idiopathic pancreatitis. Definitive treatment of gallstones was within the recommended time limit in only 70.1%. 27 patients experienced recurrent attacks of pancreatitis before definitive treatment of their gallstones, due either to inadequate investigation for gallstones after suboptimal ultrasound examination (n = 12) or to inappropriate delay before definitive treatment of gallstones (n = 15). Recommendations for the management of severe cases with early ITU/HDU admissions and CT scanning were not followed. 28 day mortality was 6.3%, median age of those dying was 80.5 years. CONCLUSIONS: Acceptable mortality can be achieved for acute pancreatitis despite failure to implement BSG guidelines for the management of severe acute pancreatitis. Inadequate investigation and treatment of gallstone disease leads to an unacceptable incidence of recurrent acute pancreatitis.

Acute Disease↗
PubMed1999

Gastrointestinal surgical workload in the DGH and the upper gastrointestinal surgeon.

Workload implications of upper gastrointestinal (UGI) subspecialisation within the district general hospital (DGH) have been assessed by prospective data collection over a 12-month period in a DGH with six general surgeons serving a population of 320,000. The single UGI surgeon (UGIS) performed all ten oesophageal resections, ten of 11 gastric resections for malignancy and all eight pancreatic operations. He also performed 91 of the 182 cholecystectomies, 164 of the 250 endoscopic retrograde cholangiopancreatograms (ERCP) and all endoscopic procedures for the palliation of unresected oesophageal tumours. The UGIS was responsible for the management of all patients with severe pancreatitis, yet he also performed 51 colorectal resections over the 12-month period. Successful management of severely ill patients with upper GI disease requires consultant supervision on a day-to-day basis. If such UGI disease is to be managed in the DGH, two surgeons with UGI experience will be required if high quality care and reasonable working conditions are to be achieved. Such UGIS will continue to perform some colorectal surgery.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1998

Palliation of dysphagia from inoperable oesophageal carcinoma using Atkinson tubes or self-expanding metal stents.

Until recently, intubation for the palliation of malignant dysphagia has relied upon the insertion of a variety of plastic tubes. Self-expanding metal stents are reported to have a lower complication rate. We have compared the results of Atkinson tube insertion with self-expanding metal stents in patients with inoperable oesophageal carcinoma. From 1990 to 1994 Atkinson tubes were inserted for the palliation of dysphagia from oesophageal cancer, from 1994 onwards self-expanding metal stents were used. Complications, mortality and hospital stay were compared in both groups of patients. In all, 87 patients with inoperable oesophageal carcinoma were treated, 46 with an Atkinson tube and 41 with metal stents. Complications occurred at similar rates in both groups (56% Atkinson tubes, 44% metal stents). There was a significantly higher perforation rate associated with Atkinson tube insertion (8 patients, 17%) compared with metal stents (1 patient, 2.4%, P = 0.02, chi 2). The length of stay was also significantly higher in the Atkinson tube group (median 10 days) compared with the metal stent group (3 days, P < 0.01, Mann-Whitney U test). Mortality rates were similar in both groups. The use of metal stents for the palliation of dysphagia in inoperable oesophageal carcinoma results in a lower perforation rate and a reduced length of stay and they represent a significant advantage over Atkinson tubes.

Adult↗
PubMed1995

Endoscopic sphincterotomy without cholecystectomy for gall stone pancreatitis.

Fifty one patients (median age 78, range 54-92) who had endoscopic sphincterotomy for gall stone pancreatitis without planned cholecystectomy were followed up to assess the effectiveness of this treatment in preventing further acute pancreatitis. In 48 patients sphincterotomy was technically successful and none had further acute pancreatitis after a mean follow up of 26.9 months. In three patients sphincterotomy was incomplete and two developed recurrent pancreatitis. These results suggest that endoscopic sphincterotomy alone is an acceptable alternative to cholecystectomy in the prevention of further attacks of acute pancreatitis in the elderly.

Acute Disease↗
PubMed1995

Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy.

A policy of preoperative endoscopic retrograde cholangiography (ERC) for suspected bile duct stones was used in 1507 patients considered for laparoscopic cholecystectomy in three district general hospitals. Altogether 306 patients underwent ERC, and bile duct cannulation was achieved in 276 (90%). Bile ducts were cleared by endoscopic sphincterotomy in 128 of 161 patients (79%) with proven duct stones. Laparoscopic cholecystectomy was completed in 1396 patients. Ten laparotomies were necessary for complications of laparoscopic cholecystectomy. The complication rate for endoscopic sphincterotomy/laparoscopic cholecystectomy was 2.7%, with no mortality. Overall, a combined endoscopic/laparoscopic approach succeeded in 1386 patients (92%). Fourteen patients (1%) had retained stones during a median of 14 months (range 1-42) follow up, all of which were removed by ERC/endoscopic sphincterotomy. If a policy of selective ERC before laparoscopic cholecystectomy is used for all patients with symptomatic gall stones, most will avoid an open operation and laparoscopic exploration of the bile duct is not necessary.

Adolescent↗
PubMed1994

Preservation of gastric antral mucus is associated with failure of eradication of Helicobacter pylori by bismuth, metronidazole and tetracycline.

METHODS: Forty-three patients positive for Helicobacter pylori by histology and culture of antral biopsies (n = 40) or histology alone (n = 3) were investigated. They received either regimen 1--tripotassium dicitrato bismuthate 120 mg q.d.s. and tetracycline 250 mg q.d.s. for 4 weeks, with metronidazole 200 mg q.d.s. for the first 2 weeks, or regimen 2--omeprazole 20 mg b.d., amoxycillin 500 mg t.d.s., tetracycline 500 mg q.d.s. each for 3 weeks. Gastric antral biopsies were scored (0-3) histologically for mucus depletion, polymorphonuclear and mononuclear cell infiltrate. H. pylori eradication was assessed by biopsy and culture 1 month after the cessation of treatment. RESULTS: With regimen 1, pre-treatment mucus depletion was significantly higher where eradication was successful (median score 2) compared to where it was not (median score 1, P < 0.01); there were no differences in the scores for polymorphonuclear or mononuclear cell infiltrates. In patients receiving regimen 2, there were no differences in either mucus depletion or polymorphonuclear or mononuclear cell infiltrate, between those where eradication was successful and those where it was not. Metronidazole minimum inhibitory concentrations rose when eradication with regimen 1 was unsuccessful (median before 0.19 mg/L, median after treatment 16 mg/L; P = 0.04). CONCLUSION: Pre-treatment mucus depletion is identified as a factor affecting H. pylori eradication. Preservation of mucus may facilitate acquisition of metronidazole resistance.

Adult↗
PubMed1993

Results of a prospective randomized trial of the Angelchik prosthesis and of a consecutive series of 119 patients.

The results of a randomized multicentre trial comparing the Angelchik prosthesis with floppy Nissen fundoplication for gastro-oesophageal reflux were assessed 4-6 years after surgery. Of the original 52 patients 48 were traced. A good or excellent result (Visick grade 1 or 2) was obtained in 21 of 25 after insertion of the Angelchik prosthesis compared with 18 of 23 after fundoplication. Poor results were due to recurrent heartburn after fundoplication and to dysphagia after prosthesis insertion. In a separate consecutive series of 119 patients receiving Angelchik prostheses, results were good or excellent in 101 (85 per cent) and poor in 18 (15 per cent). Control of reflux with a correctly positioned prosthesis was good. Troublesome dysphagia (Visick grade 3 or 4) was experienced in eight of the 119 patients. There was no mortality and no incidence of splenectomy or gas-bloat syndrome.

Adolescent↗
PubMed1993

Regression of columnar lined (Barrett's) oesophagus with continuous omeprazole therapy.

Twenty-three adult patients with a columnar lined (Barrett's) oesophagus are being treated with long-term omeprazole, 40 mg daily. Twelve had never undergone anti-reflux surgery (Group 1), the other eleven having previously had insertion of an Angelchik anti-reflux prosthesis (Group 2). Endoscopy was carried out six months before, immediately before and six months, one year and two years into treatment. Multiple and standardized biopsies were taken at each endoscopy. Results from the two groups were similar. During the 6-month run-in period there was a statistically non-significant increase in the linear extent of the columnar mucosa, but this showed a progressive, statistically significant decrease during the two years of treatment. Other evidence for regression of the Barrett's mucosa includes the emergence of large numbers of macroscopic squamous islands within the abnormal mucosa, an increase in the number of microscopic squamous islands, and microscopic squamous encroachment of the abnormal mucosa at the squamo-columnar junction. Histological assessment showed a reduction in the proportion of sulphomucin-rich intestinal metaplasia, but this only achieved statistical significance in Group 1. The results substantiate the importance of acid in the pathogenesis of Barrett's oesophagus. Omeprazole may have a therapeutic role in bringing about regression of the metaplastic epithelium.

Adult↗
PubMed1993

An emergency daytime theatre list: utilisation and impact on clinical practice.

A prospective study of all weekday emergency surgery performed in a district general hospital over an 18-month period was undertaken to assess the impact of a fully staffed, daytime operating theatre for emergency surgery on night-time operating and on consultant supervision of trainees. In the 12 months following the introduction of the emergency list there was a 46% reduction in the number of general surgical operations performed after midnight compared with the preceding 6 months. Despite the increase in daytime operating the degree of consultant participation was unchanged, with the majority of emergency procedures being performed by unsupervised junior surgeons and anaesthetists. Although the emergency theatre was available to all specialties and was used for 'scheduled' and occasional 'elective' cases when there were no emergencies, only 37% of total theatre time was used. Without a change in consultant workload and practice which permits their increased involvement in emergency surgery, a dedicated daytime emergency theatre may be a costly measure which fails to fulfil all CEPOD recommendations.

Anesthesia↗
PubMed1987

Relative contribution of bile and pancreatic juice duodenogastric reflux in gastric ulcer disease and cholelithiasis.

Bile acid concentrations, phospholipase A2 activity and pH in the stomach were measured in the fasting state and for 2 h after a fat-containing test meal in patients with an active gastric ulcer (GU), in patients with gallstones before and after cholecystectomy and in normal subjects. Fasting and peak postprandial bile acid concentrations in the stomach were low in all normal controls. Although high concentrations were found in many patients with GU (P less than 0.01), similar concentrations were found in many patients with radiologically non-functioning gallbladders containing gallstones (NFG) (P less than 0.01) and also after cholecystectomy (AC) (P less than 0.01). Fasting intragastric phospholipase A2 activities were similar, and very high in GU and NFG patients compared with control subjects (P less than 0.01). High values were not found after cholecystectomy. There was no difference in pH profile or in postprandial phospholipase A2 between patient groups. Since patients with cholelithiasis or after cholecystectomy are not known to have an increased incidence of gastric ulceration, the significance of duodenogastric reflux in the aetiology of gastric ulcers must be questioned. If reflux does produce ulcers in GU patients then factors in addition to bile acid are probably involved. However, neither patterns of phospholipase A2 reflux nor pH profiles can explain the absence of gastric ulceration in those patients with gallstones who reflux large quantities of bile acid.

Adult↗
PubMed1986

Incidence and clinical significance of colonic cytomegalovirus infection in idiopathic inflammatory bowel disease requiring colectomy.

Evidence of cytomegalovirus infection has been sought in a consecutive series of patients requiring colonic resection for idiopathic inflammatory bowel disease confined to the colon. Colonic tissue was examined by light and electron microscopy for cytomegalovirus inclusion bodies and cytomegalovirus antigen was sought using an immunoperoxidase technique. Cytomegalovirus infection was identified in three of 26 patients studied, but the infection did not appear to influence the course of the colitis. Although all three patients with cytomegalovirus infection needed urgent surgery, none had toxic megacolon. No evidence of cytomegalovirus infection was found in three other patients with toxic megacolon. One patient, who had a rising titre of IgG to cytomegalovirus received treatment with acyclovir which eradicated cytomegalovirus from the colon without altering the course of the colitis.

Colectomy↗
PubMed1984

New developments in the evaluation of gastroduodenal motility with special reference to duodenogastric reflux and its clinical significance.

New techniques in the study of gut motility must aim to improve our understanding of the flow of luminal contents, since this is the ultimate function of such motility. This paper reviews some areas of gastroduodenal motility relevant to our understanding of duodenogastric reflux. Antroduodenal motility has been studied in the past both manometrically and radiologically, but the function of the pylorus remains in doubt. Observations made using a new impedance technique at endoscopy on the timing of pyloric closure during antroduodenal motor activity suggest that the pylorus, in addition to being a functional appendage of the terminal antrum, can contract independently and in association with isolated duodenal contractions to prevent reflux. Retroperistaltic duodenal contractions, however, may not close the pylorus in time to prevent reflux, and duodenal activity rather than the pylorus may be the key to duodenogastric reflux. Studies using invasive techniques have implicated reflux in the aetiology of some gastric ulcers and gallstone dyspepsia. Non-invasive studies on reflux with the HIDA radionuclide scan have confirmed that reflux is minimal in normal subjects, more common in gallstone dyspepsia, and related to gallbladder function.

Animals↗
PubMed1984

Is bile reflux at endoscopy a significant finding?

Postprandial duodenogastric reflux (DGR) was assessed scintigraphically in 10 patients with postprandial dyspepsia and endoscopic evidence of bile reflux (EBR) and in two control groups comprising seven patients with similar symptoms but normal endoscopic findings and 10 asymptomatic subjects without gastrointestinal pathology. DGR of iminodiacetic acid (IDA) after a liquid Lundh meal (250 ml) was assessed dynamically with 1 minute scintiscans and DGR expressed as the percentage of IDA secreted by the liver which appeared in the gastric region. DGR varied from 0-5% in asymptomatic controls and from 0-6% in dyspeptics without EBR. DGR in patients with EBR ranged from 0-16% but only two of 10 had values outside the normal range (0-5%).

Bile Reflux↗
PubMed1984

Human antroduodenal motility, pyloric closure, and domperidone.

The action of the peripheral dopamine antagonist, domperidone, on human antroduodenal coordination, has been studied in a double-blind study. Thirty dyspeptic patients without antroduodenal pathology were studied at upper alimentary endoscopy, being studied for two 10-minute periods before and after receiving intravenous domperidone (20 mg) or placebo. Antral and proximal duodenal contractions were recorded with Fogarty balloon catheters and pyloric closure recorded as the fall in impedance measured across four small electrodes maintained at the pylorus. Domperidone significantly increased the number of antral contractions. When spontaneous duodenal activity was present, domperidone reduced the number of isolated duodenal contractions (no preceding antral contractions within 10 seconds) without detectably altering the behaviour of the pylorus.

Adult↗