Biomedical subjects
N D Carr
Publications and source records attributed to N D Carr.
Internal anal sphincter repair.
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Anal endosonography in patients with anorectal symptoms after haemorrhoidectomy.
BACKGROUND: Anorectal symptoms after haemorrhoidectomy are common and treatment is often empirical. Because of this, an audit was carried out of the value of anal endosonography in patients with anorectal symptoms after haemorrhoidectomy. METHODS: Between May 1993 and February 1997, 16 patients (ten men and six women of median age 56 (range 35-77) years) were investigated by anal endosonography for anorectal symptoms after haemorrhoidectomy which involved anorectal incontinence (n = 10), anal pain (n = 4) and obstructive defaecation (n = 2). The findings were compared with those in a matched group of asymptomatic patients after haemorroidectomy. RESULTS: Anal endosonography demonstrated an abnormality in 12 symptomatic patients. Of the ten patients with anorectal incontinence, endosonography showed an internal anal sphincter defect (n = 5), a combined sphincter defect (n = 2) and an isolated external anal sphincter defect (n = 1). Normal appearances were seen in all asymptomatic patients. The endosonographic abnormalities of the four patients with anal pain included internal anal sphincter defect (n = 1), extrinsic mass (n = 1), and intersphincteric abscess (n = 1). One of the two patients with obstructive defaecation had an isolated external anal sphincter defect on endosonography. CONCLUSION: These results show a high yield of endosonographic abnormalities in patients who experience symptoms after haemorrhoidectomy. In particular, occult sphincter injury as a cause of incontinence in these patients can frequently be demonstrated.
Pancreatitis in childhood associated with villous adenoma of the ampulla of Vater.
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Endorectal repair of rectocoele revisited.
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Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases.
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Surgical management of anorectal incontinence due to internal anal sphincter deficiency.
BACKGROUND: The aetiology, surgical management and outcome in 15 patients with anorectal incontinence due to internal and sphincter (IAS) deficiency as a result of previous anal surgery (n = 14) or penetrating trauma (n = 1) was studied. METHODS: The degree of anorectal incontinence was scored by the Cleveland Clinic system; median score was 14 (range 11-16) before surgery. In all patients the anal sphincter mechanism was assessed by endoanal ultrasonography. Thirteen of the 15 patients underwent either rotation (n = 5), island (n = 5) or advancement (n = 3) anoplasty to correct the contour defect in the anal canal. In the remaining two patients direct IAS repair was performed. RESULTS: Four of the 13 patients who underwent anoplasty developed wound breakdown as the result of infection (n = 3) or inadvertent suture removal (n = 1). A defunctioning stoma was required in three of these patients but all of these have been closed. At median follow-up of 34 (range 6-72) months, all patients who underwent anoplasty have normal defaecatory control and a median continence score of 2 (range 0-4). Direct IAS repair produced no symptomatic improvement in either patient. CONCLUSION: These results suggest that anoplasty deserves further evaluation in the treatment of anorectal incontinence due to discrete IAS defects, but that the place of IAS repair remains uncertain.
Myths in management of colorectal malignancy.
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A case of pneumatosis coli managed by restorative proctectomy and ileal pouch-anal anastomosis.
Pneumatosis coli is a rare condition in which gas filled cysts occur in the wall of the intestines. Most symptomatic patients can be managed conservatively but those who fail medical management or who develop bowel obstruction will require surgery. Surgery usually involves a limited colectomy with a potential for recurrence. We describe a case of pneumatosis coli managed successfully by restorative proctocolectomy and ileal pouch-anal anastomosis.
Randomized trial of modified Bassini versus Shouldice inguinal hernia repair.
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Male homosexuality, HIV infection and colorectal surgery.
The sexual practices of male homosexuals may lead to the development of a wide variety of colorectal and perianal diseases. This review describes the pathogenesis of these conditions, their management, and the influence of HIV infection on these conditions.
Non-condylomatous, perianal disease in homosexual men.
This retrospective study details the findings and outcome in 34 homosexual men, out of a total of 177 patients, who underwent surgery for non-condylomatous perianal disease over a 2-year period. Of 34 homosexuals 20 presented with anorectal sepsis compared with 11 of 79 heterosexual male patients (X2 = 24.07, P less than 0.001). Lesions included chronic intersphincteric abscess (eight patients), anal fistula (seven patients) and chronic intersphincteric abscess and fistula (five patients). Anal fissure occurred in 15 patients, anal ulcer in three, skin tags in six, haemorrhoids in two and Kaposi's sarcoma in one. Eight patients were human immunodeficiency virus (HIV) antibody negative, four were asymptomatic HIV antibody positive, 12 had symptomatic HIV infection using the Centers for Disease Control classification and in ten patients HIV status was unknown. Irrespective of the type of surgery performed, healing occurred within 6 weeks of operation in all HIV antibody negative patients, all asymptomatic HIV antibody positive and in only one of nine patients with symptomatic HIV infection. Eight of nine patients with symptomatic HIV infection failed to heal by this time (X2 = 8.98, P less than 0.05). These findings suggest that the prevalence of anorectal sepsis in homosexual men is high and that symptomatic HIV infection is an important determinant of progress after surgery.
Late complications of pancreatic trauma.
Pancreatic trauma is rare and experience concerning its management is consequently limited. Lessons learnt in the investigation and treatment of a group of 11 patients (median age 28.0 years, range 14-44 years), who presented with the sequelae of trauma, are described. These patients were referred to a centre with an interest in pancreatic disease at a median time of 6.0 months (range 1.5-34 months) after blunt (n = 9) or penetrating (n = 2) injury to the pancreas. Ten of the 11 patients had undergone either single (n = 4) or multiple (n = 6) previous operations. Ten of the 11 patients had either strictures or disruptions of the main pancreatic duct demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) and ultrasonography (n = 8) or by exploration of the pancreas (n = 2). Satisfactory results were achieved by non-operative treatment in one patient and by distal pancreatectomy in eight. One further patient, who underwent distal pancreatectomy, later required completion resection because of unsuspected ductal injury in the head of the gland. The final patient continued with symptoms of pancreatitis after pancreaticoduodenectomy. It is concluded that the non-resolving sequelae of pancreatic trauma are associated with injury to the main pancreatic duct and that specialist investigation should be performed before surgical intervention is contemplated.
Vertical banded gastroplasty in the treatment of morbid obesity: results of three year follow up.
Vertical banded gastroplasty has replaced jejunoileal bypass in the surgical treatment of morbid obesity. Although this procedure carries a low incidence of early postoperative complications there is little information on either longer term follow up or the impact on nutritional status. The present study describes the outcome in 42 patients with morbid obesity who underwent vertical banded gastroplasty and were followed up in a special nutrition clinic between nine and 36 months postoperatively. Body mass index (BMI) fell from a preoperative value of 47.4 (6.7) kg/m2 (mean (SD] to 37.5 (5.8), 35 (6.2), 33.9 (6.1), and 33.1 (5.7) kg/m2 at 6, 12, 24, and 36 months respectively. Immediate postoperative complications were minimal but during follow up four patients developed stenosis of the gastroplasty stoma and required reoperation. Plasma albumen concentrations were maintained but three patients developed iron deficiency anaemia. Most patients were able to eat a normal diet in reduced quantities and noted a marked improvement in the quality of life. The benefits and safety of vertical banded gastroplasty suggest an important role for this operation in the management of morbid obesity.
Intestinal ischaemia associated with phaeochromocytoma.
The present case report describes a patient with an adrenal phaeochromocytoma who presented with infarction of the small intestine. The clinical features, diagnosis and treatment of this case are described. Despite excision of the tumour and necrotic intestine, this patient died in the postoperative period from overwhelming sepsis and multi-organ failure. Special reference is made to the delayed effects of established intestinal ischaemia on immune function and it is suggested that this was major contributory factor to the fatal outcome in the present case. The onset of gastro-intestinal symptoms in patients with phaeochromocytoma should suggest the possibility of imminent gut ischaemia and indicate the necessity for prompt excision of the tumour.
Quantitative study of intimal longitudinal smooth muscle in human small mesenteric arteries.
The present paper examines the results of quantitative assessment of intimal longitudinal smooth muscle (ILSM) in small arteries from normal mesentery in man. 212 vessels from 24 patients who underwent colectomy for colorectal carcinoma were studied. The mean amount of ILSM in these vessels was found to be 1.42% (range 0.00-8.90%) of external vessel diameter. A statistically significant (p = 0.018) positive correlation was demonstrated between the mean amount of ILSM in vessels from any individual patient and the level of diastolic blood pressure. It is concluded that increased intravascular tension is one factor which influences the development of ILSM in human small mesenteric arteries.
Are we using the correct dose of metronidazole in colorectal surgery?
In a series of 20 patients undergoing elective colorectal surgery, 10 received an infusion of metronidazole 500 mg and 10 an infusion of 1500 mg commencing at the induction of anaesthesia. The concentrations of metronidazole in the plasma, rectus muscle and colon of the two groups during the course of the operation were compared. In those patients who received 1500 mg, the plasma and tissue concentrations were all well above the minimum inhibitory concentration (MIC) of metronidazole against Bacteroides fragilis. In those patients who received 500 mg, serum and tissue concentrations were at or only just above the MIC. It may be that 1500 mg would be a more effective dose of metronidazole for prophylactic use in colorectal surgery.