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D J Leaper

Publications and source records attributed to D J Leaper.

At least 37 records · Page 2Linked to original sources
PubMed1999

Evaluation of a protocol for the non-operative management of perforated peptic ulcer.

BACKGROUND: The non-operative management of perforated peptic ulcer has previously been shown to be both safe and effective although it remains controversial. A protocol for non-operative management was set up in this hospital in 1989. Adherence to the guidelines in the protocol has been audited over a 6-year period with a review of outcome. METHODS: The case-notes of patients with a diagnosis of perforated peptic ulcer were reviewed. Twelve guidelines from the protocol were selected for evaluation of compliance to the protocol. RESULTS: Forty-nine patients underwent non-operative treatment initially. Eight patients failed to respond and underwent operation. Complications included abscess formation (seven patients), renal failure (one), gastric ileus (one), chest infection (two), and cardiac failure and stroke (one). Four deaths occurred in this group. Adherence to certain protocol guidelines was poor, notably those concerning prevention of thromboembolism, use of antibiotics, use of contrast examination to confirm the diagnosis and referral for follow-up endoscopy. Two gastric cancers were detected on subsequent endoscopy. CONCLUSION: This experience demonstrates that non-operative treatment can be used successfully in a general hospital. Adherence to protocol guidelines was found to be variable and the protocol has therefore been simplified. This study highlights the need for an accurate diagnosis and the importance of follow-up endoscopy.

Adolescent↗
PubMed1999

Measurement of interface pressures in the evaluation of operating theatre mattresses.

This study compared the sacral interface pressures obtained in four mattresses (all supplied by the same manufacturer), in two positions adopted for surgical procedures, to determine the similarities and differences between them. The mattresses were all variations of the standard product used in operating departments. The null hypotheses were that there are no differences in interface pressures between the mattresses or between the two surgical positions, and that measurements are not influenced by subject body mass index. The measurement technology was also tested for reliability and suitability for intra-operative use. Sacral interface pressures of 25 healthy volunteers were recorded using each of the four mattresses (order individually randomised) in both the supine and the Lloyd Davies positions. A pressure-sensitive mat was used and one-way analysis of variance was the main statistical approach. Statistical significance was determined by p-values of < or = 0.05. One mattress recorded significantly lower interface pressures than the others and all pressures were influenced by body mass index. Surgical position was a significant factor, measurements in the Lloyd Davies position being 9.5-14.2% higher than in the supine position. The pressure measurement technique has proved to be reliable and easy to calibrate, position and use. Indications are that it can be used safely and effectively in operating departments. These results have implications for researchers and clinicians.

Adult↗
PubMed1999

Diagnostic laparoscopy for suspected appendicitis: only useful in young women.

The clinical diagnosis of acute appendicitis is inaccurate and can be associated with a negative appendicectomy rate in excess of 40%. The latter has an attendant, albeit low, potential for increased morbidity and mortality, particularly related to infection. In this two year prospective audit of 282 patients presenting with the symptoms and signs of acute appendicitis, preliminary diagnostic laparoscopy (PDL) was performed on 145 patients with the remainder (137) proceeding directly to open appendicectomy. In the PDL group, appendicectomy was undertaken when there was clear clinical evidence of inflammation or when the appendix was not visualised. The negative appendicectomy rate was similar in both groups (21.6% vs. 21.2%) with a male predominance in the PDL group. Whereas women of childbearing age obtained most benefit from PDL with avoidance of unnecessary open operation, the results of our audit showed little benefit for men.

Adolescent↗
PubMed1998

Defining infection.

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Anti-Bacterial Agents↗
PubMed1997

Antibiotic prophylaxis and open groin hernia repair.

Antibiotic prophylaxis is not routinely given for nonimplant, clean operations, although this view has recently been challenged. We have conducted a randomized multicenter, double-blind prospective trial to compare co-amoxiclav with placebo in 619 patients undergoing open groin hernia repair. Altogether 563 (91%) patients fulfilled the protocol; 283 received co-amoxiclav and 280 placebo. There was no difference between the groups in the number of patients receiving local or general anesthetic, the type of repair performed, the use of a subcutaneous fat suture, the type of skin closure used, the use of wound analgesia, or the use of a wound drain. Patients were given a card to return to the hospital in the event of their wound discharging or their needing to see their general practitioner. All patients were reviewed at approximately 6 weeks after operation. Fifty (8.9%) patients sustained a wound infection, 25 in the co-amoxiclav group and 25 in the placebo group. We conclude that antibiotic prophylaxis is of no benefit to patients undergoing open groin hernia repair.

Adult↗
PubMed1997

A multi-centre study to compare meropenem and cefotaxime and metronidazole in the treatment of hospitalized patients with serious infections.

We conducted a prospective, multi-centre, open, randomized study in 11 UK hospitals to compare iv meropenem 1 g tds with the combination of iv cefotaxime 1 g tds and iv metronidazole 500 mg tds in patients with serious infections. One hundred and sixty-one patients were enrolled, of whom 131 were clinically evaluable (meropenem, n = 68; cefotaxime/metronidazole, n = 63). The most common infections were subsequent to intra-abdominal pathology (meropenem, n = 77%; cefotaxime/metronidazole, n = 75%), and were usually accompanied by septicaemia (meropenem, n = 61%; cefotaxime/metronidazole, n = 53%). The incidence of a satisfactory clinical response was similar in the two groups at the end of treatment (93% for meropenem; 92% for cefotaxime/metronidazole) and up to 8 weeks later (96% for meropenem; 93% for cefotaxime/metronidazole). Satisfactory bacteriological response (success or presumed success) was recorded at the end of therapy in 86% of meropenem and 88% of cefotaxime/metronidazole patients. Adverse events were reported in 32% of meropenem and 25% of cefotaxime/metronidazole patients, and most were mild or moderate and did not require discontinuation of therapy. Twenty-one patients (ten meropenem and 11 cefotaxime/metronidazole) died during the trial, underlining the severity of the infections being treated in this group of patients. None of the deaths was thought to be related to study therapy.

Adult↗
PubMed1997

Postsurgical wound progression monitored by temporal changes in the expression of matrix metalloproteinase-9.

It is important to monitor the early stages of postoperative wound repair in order to identify those problems associated with impaired healing. Many of the crucial cellular responses of early wound healing, such as inflammatory infiltration, angiogenesis and re-epithelialization, are made possible through the action of matrix metalloproteinases (MMPs). Expression of MMP-2 and MMP-9 is elevated in acute wounds, and still greater levels are found in chronic wounds, indicating that uncontrolled proteolysis is a characteristic of retarded healing. Therefore, comparative measurements of MMPs may be used to monitor the progression of early wound healing. To investigate this, wound fluids and sera were collected from mastectomy and colectomy patients throughout early stages of repair, and the temporal expression profile established. Wounds which were healing were expressed maximal levels of MMP-9 at 24 h, followed by a significant decline by 48 h. Persistent elevation of MMP-9 expression was associated with infected and chronic wounds, and was identified in postoperative wounds by the absence of the significant decline between 24 and 48 h. Measurement of MMP-9 in postoperative wound fluids, therefore, provides an early indicator of impaired healing, which may be evaluated non-invasively within 48 h of closure.

Biomarkers↗
PubMed1995

Prospective evaluation of ultrasonography and liver function tests for preoperative assessment of the bile duct.

Current means of predicting the presence of bile duct stones are sensitive but produce a large number of false-positive results, potentially leading to added morbidity from unnecessary invasive investigation. This study prospectively assessed 545 patients with gallbladder stones, including 55 patients with bile duct stones, to refine criteria for further investigation of the bile duct. The sensitivity, specificity, and positive and negative predictive values were calculated for bile duct dilatation (diameter abnormal if larger than 5 mm below age 50 years, normal value increasing by 1 mm per decade) and elevation of three liver function tests, singly or in combination. Depending on the number of abnormalities used the sensitivity ranged from 46 to 96 per cent and the positive predictive value from 35 to 77 per cent. All groupings gave at least 96 per cent negative predictive value for the absence of stones but none combined both high sensitivity and positive predictive value. The specificity was improved if the tests were done on the working day before operation. Refining criteria for predicting bile duct stones allows the selective use of cholangiography and may reduce the number of negative cholangiograms.

Adolescent↗
PubMed1995

Risk factors for surgical infection.

In the last century remarkable advances have been made in surgery, associated with the lowest recorded rates of infection or sepsis. Many surgical practices are time honoured but have little scientific basis to prevent postoperative infection whereas some local and systemic factors are well recognized and can be modified to lower infection risks. Surgical skill is not easily measurable but shorter operations in experienced hands leaving the minimum of tissue damage, haematoma or dead space have the lowest infection rates in general surgery: < 2% in clean and < 10% in contaminated operations. Adequate surgical scrub, appropriate suture materials and antibiotic prophylaxis, perioperative correction of dehydration and poor nutrition are examples of effective therapy which can be conformed to by all surgeons. Other factors, such as the use of wound guards, drains and surgical dressings are less easy to estimate for effectiveness or be sure that they could be changed or left out of surgical ritual.

Anti-Infective Agents, Local↗
PubMed1995

Infection after laparoscopic cholecystectomy: are antibiotics really necessary?

OBJECTIVE: To establish the incidence of infection after laparoscopic cholecystectomy, and assess the need for antibiotic prophylaxis. DESIGN: Prospective open study. SETTING: University teaching hospital, United Kingdom. SUBJECTS: 253 consecutive patients undergoing laparoscopic cholecystectomy between September 1990 and January 1993. INTERVENTIONS: A single intravenous dose of cefuroxime 1.5 g at induction of general anaesthesia. MAIN OUTCOME MEASURES: Infective complications. RESULTS: Patients were reviewed at two weeks and 12 months. At two weeks there had been two wound infections (one resolved spontaneously and the other required removal of a gallstone from the subcutaneous tissue), two chest infections (treated with antibiotics orally and physiotherapy), and one subhepatic abscess (drained percutaneously under ultrasonographic control). No other complications were reported at 12 months. CONCLUSIONS: Routine antibiotic prophylaxis may be unnecessary during elective laparoscopic cholecystectomy, but a randomised controlled trial is necessary to confirm this.

Adolescent↗
PubMed1994

Prophylactic and therapeutic role of antibiotics in wound care.

Even though surgical infection rates have decreased dramatically during the past 25 years, questions and clinical problems with respect to prophylaxis, diagnosis, and treatment remain. After it was realized that widespread use of antibiotics resulted in a rise of resistant organisms, indiscriminate use of these drugs was curtailed. Studies soon showed that antibiotic prophylaxis for a limited period of time was not only effective, but also reduced the incidence of side effects. Today, clean surgical procedures that involve no implantation of a prosthesis do not warrant routine antibiotic use. Prophylactic antibiotic coverage is indicated for clean contaminated or contaminated surgical procedures, and dirty wounds need both prophylactic and therapeutic antibiotic use. The most effective administration route of prophylactic antibiotics remains a matter of discussion. With respect to open wounds, antibiotic-containing topical wound treatments are widely used, even though their efficacy has not been established. Open wounds do not have to be sterile to heal, and the emergence of allergy, sensitivity, and resistant organisms following the use of these topical treatments is of concern. Controlled clinical studies are needed to provide us with more definitive guidelines on these issues. In the meanwhile, we do know that meticulous surgical and nursing techniques, as well as surveillance of infection rates, are important in achieving and maintaining a low infection rate.

Anti-Bacterial Agents↗
PubMed1994

Assessment of the common bile duct before cholecystectomy using ultrasound and biochemical measurements: validation based on follow-up.

The selective use of operative cholangiography with cholecystectomy is controversial. We have combined measurement of the serum bilirubin, alkaline phosphatase and alanine aminotransferase with ultrasound measurement of the bile duct diameter to assess the common bile duct before cholecystectomy. Direct contrast cholangiography was not performed if the results of these measurements were normal on the day before operation. There were 253 patients assessed in this way before laparoscopic cholecystectomy. Patients with known bile duct stones were excluded, but those with a previous history of jaundice, pancreatitis or abnormal liver function tests were included. In 47 cases abnormalities were found and X-ray cholangiograms were performed; only six patients were found to have bile duct stones. Follow-up of all 253 patients, including repeating the preoperative measurements after 12 months in 93, found only two patients with evidence that common duct stones had been missed and these two stones passed spontaneously. No bile duct injuries have occurred. We conclude that preoperative assessment of the bile duct using ultrasound and liver function tests safely obviates the need for 'routine' operative cholangiography.

Adolescent↗
PubMed1992

Eusol.

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Anti-Infective Agents↗
PubMed1991

Carcinoma of the gallbladder: a diagnostic challenge.

Since the introduction and availability of abdominal ultrasound and computed tomography, 38 patients have been admitted to the Department of Surgery, Queen Mary Hospital, University of Hong Kong with a subsequently confirmed histological diagnosis of carcinoma of the gallbladder. The majority of patients presented with abdominal pain, anorexia or weight loss, jaundice, and anaemia or an abdominal swelling. Abnormal liver function tests were found in 70-90%. Cholangiography, ultrasound and particularly computed tomography helped to confirm clinical suspicion when performed but 23 patients (61%) had an inaccurate diagnosis made before surgery. Operative intervention was only of benefit when the carcinoma was confined to the gallbladder (median survival after cholecystectomy alone 13 months; other procedures 2 months; P less than 0.01). Carcinoma of the gallbladder carries a poor prognosis but ultrasound and computed tomography can help select patients for appropriate treatment (surgery, endoscopic stenting, radiotherapy, chemotherapy) if clinical suspicion is raised.

Adult↗