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Biomedical subjects

I D Anderson

Publications and source records attributed to I D Anderson.

At least 19 recordsLinked to original sources
PubMed2005

Targets and elective colorectal cancer: outcome and symptom delay at surgical resection.

OBJECTIVE: To determine, for elective patients with colorectal cancer, if associations exist between the length of symptom history at surgical resection and Dukes stage, completeness of the surgical procedure and patient survival. PATIENTS AND METHODS: A prospective cohort study was undertaken. Five hundred and eighty-two patients with colorectal cancer, admitted for surgical resection after outpatient consultation, divided into four equal quartiles according to length of symptom history (short: n = 131, 0-103 days; medium: n = 136, 104-177 days; long: n = 136, 178-318 days; very long: n = 137, 319-1997 days). The main outcome measures used were the Extent of tumour (Dukes stage) at resection, completeness of resectional surgery (curative vs palliative), patient survival after resection. RESULTS: For patients undergoing elective surgical resection of colorectal cancer we did not find an association between Dukes stage and duration of patient history (Dukes stage C tumours were seen in 37% (CI: 26.2%-48.0%) of patients with a short symptomatic history as opposed to 34% (CI: 32%-62%) with a very long symptomatic history). Elective curative resection was not associated with a significantly different symptom duration than elective palliative resection (Palliative resections were performed in 24% (CI: 11.7%-36.4%) of patients with a short symptomatic history as opposed to 16% (CI: 2.4%-29.9%) with a very long symptomatic history). The median survival time for the four elective colorectal patient groups defined by length of symptomatic history was not significantly different - (short: n = 131, 4.3 years; medium: n = 136, 5.9 years; long: n = 136, 7.1 years; very long: n = 137, 5.0 years). CONCLUSION: Tumour extent, completeness of resection and patient outcome after elective colorectal cancer resection was not found to have an association with length of patient history at the time of surgery.

Chi-Square Distribution↗
PubMed2004

Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula.

BACKGROUND: Use of total parenteral nutrition (TPN) in patients with acute intestinal failure due to enteric fistulation might be avoided if a simpler means of nutritional support was available. The aim of this study was to determine whether feeding via an intestinal fistula (fistuloclysis) would obviate the need for TPN. METHODS: Fistuloclysis was attempted in 12 patients with jejunocutaneous or ileocutaneous fistulas with mucocutaneous continuity. Feeding was achieved by inserting a gastrostomy feeding tube into the intestine distal to the fistula. Infusion of enteral feed was increased in a stepwise manner, without reinfusion of chyme, until predicted nutritional requirements could be met by a combination of fistuloclysis and regular diet, following which TPN was withdrawn. Energy requirements and nutritional status were assessed before starting fistuloclysis and at the time of reconstructive surgery. RESULTS: Fistuloclysis replaced TPN entirely in 11 of 12 patients. Nutritional status was maintained for a median of 155 (range 19-422) days until reconstructive surgery could be safely undertaken in nine patients. Two patients who did not undergo surgery remained nutritionally stable over at least 9 months. TPN had to be recommenced in one patient. There were no complications associated with fistuloclysis. CONCLUSION: Fistuloclysis appears to provide effective nutritional support in selected patients with enterocutaneous fistula.

Adult↗
PubMed2001

Mechanisms of intestinal failure in Crohn's disease.

PURPOSE: The purpose of this study was to determine the mechanisms by which patients with Crohn's disease develop intestinal failure and, in particular, to assess the relative importance of severe primary disease, repeated uncomplicated elective small intestine resection, and resection performed as a consequence of intra-abdominal septic surgical complications. METHODS: This was a retrospective analysis of 41 patients with Crohn's disease referred to a specialized intestinal failure unit between January 1987 and September 1998 for permanent home parenteral nutrition. To compare the surgical activity in patient groups, a resection index was calculated by dividing the number of intestinal resections by the interval in years between the first resection for Crohn's disease and referral for management of intestinal failure. RESULTS: Extensive primary Crohn's disease was responsible for intestinal failure in 7 cases (17 percent). The remainder (n = 34, 83 percent) developed intestinal failure after intestinal resection. Nine of the "surgical" Crohn's patients developed intestinal failure after uncomplicated sequential resection, (median small-bowel length 65 (range, 60-120) cm) after a median of 3 (range, 2-8) operations over a median of 17 (range, 3-27) years. By contrast, the other 25 surgical Crohn's patients developed intestinal failure after multiple unplanned laparotomies for intra-abdominal sepsis (median small-bowel length 70 (range, 60-200) cm), with a median of 4 (range, 2-7) laparotomies performed over a median of 0.5 (range, 0.1 to 1.5) years (P < 0.001). The resection index for the 25 Crohn's patients undergoing laparotomies for intra-abdominal sepsis was significantly greater than that of the 9 patients who had planned sequential resections (2.1 (0.27-25) vs. 0.23 (0.1-1.0); P < 0.002, Mann-Whitney U test). CONCLUSION: Intestinal failure develops in Crohn's disease primarily as a result of complications of surgical treatment. The largest group of patients at risk consists of those who are undergoing multiple unplanned laparotomies to control intra-abdominal sepsis.

Adult↗
PubMed2000

The staged management of complex entero-urinary fistulae.

OBJECTIVE: To present the results of the staged management of complex entero-urinary fistulae. PATIENTS AND METHODS: Ten patients with complex entero-urinary fistulae were reviewed; all patients were referred to a national intestinal failure unit after failed treatment in other centres. Each patient was treated in three stages. The acute stage involved proximal defunctioning and distal drainage of both the gastrointestinal and urinary tracts to isolate the fistula, together with the eradication of sepsis. The recovery stage involved total parenteral nutrition, organ support, radiological planning of surgical reconstruction and intensive nursing. The reconstructive stage followed when the patient was stable, nutritionally replenished and intra-abdominal sepsis was controlled. Surgery was undertaken jointly by urological and gastrointestinal surgeons. RESULTS: The fistulae were treated successfully in all patients, with functional restoration in four, and/or diversion of the gastrointestinal and urological tracts in six. The mean (range) time to reconstruction was 5 (1-20) months. There were no postoperative deaths. CONCLUSION: A staged multidisciplinary approach with delayed reconstruction can achieve a successful outcome in the management of complex entero-urinary fistulae.

Adult↗
PubMed1996

Laparotomy for abdominal sepsis in the critically ill.

Among 125 patients admitted to an intensive care unit (ICU) with severe abdominal sepsis over a 3-year period, further laparotomy was required in 60 (48 per cent). The median age of these 60 patients was 67 (range 22-88) years and their admission APACHE (Acute Physiology and Chronic Health Evaluation) II score was 24 (range 7-40); 25 patients (42 per cent) survived to leave the ICU but only 19 (32 per cent) survived to leave hospital. These patients underwent 95 (median 1; range 1-6) operations after admission to the ICU and survival fell with increasing number of operations in the ICU (P = 0.01). A total of 81 operations (85 per cent) were therapeutic in that pus was drained or dead tissue removed, and 41 operations (43 per cent) resulted in improvement in the patient's condition within 48 h of surgery. Only nine per cent of patients not improved by their first operation in the ICU survived (P < 0.0001). The source of sepsis was eradicated from the abdomen in 37 patients (62 per cent); this was a prerequisite for survival but was achieved less frequently with increasing number of operations (P < 0.002). When operations were delayed until the diagnosis was clear, the need for subsequent procedures was significantly increased (P < 0.05). Multiple operations for patients with abdominal sepsis in the ICU were associated with diminishing returns and alternative surgical strategies merit active consideration.

Abdomen↗
PubMed1995

Outcome of patients with abdominal sepsis treated in an intensive care unit.

A group of 125 patients with abdominal sepsis admitted to the intensive therapy unit between January 1990 and June 1993 were reviewed to determine outcome. Mean(s.d.) age was 66(12) years and admission Acute Physiology And Chronic Health Evaluation (APACHE) II score 23(9). The hospital mortality rate was 63 per cent. Factors associated with mortality included age, APACHE II score, occurrence of septic shock, chronic ill health, female sex, sepsis of upper gastrointestinal origin and failure to clear the source of sepsis (all P < 0.05). Delay to surgery, anastomotic leakage and presence of malignancy did not influence survival significantly. Quality of life (measured by the World Health Organization performance score) at 15 months after discharge showed 24 of 32 survivors to be independent, ambulatory and capable of self care. No patient survived to become completely disabled. The factors associated with survival did not predict subsequent quality of life. Accurately defining the characteristics of this heterogeneous group of patients is a prerequisite for improved treatment, patient selection and research.

APACHE↗
PubMed1995

Symptomatic outcome following resection of gastric cancer.

The extent to which the different resections relieve the symptoms of gastric cancer is poorly defined. The symptoms of 57 consecutive patients undergoing standard resection of gastric adenocarcinoma by oesophagogastrectomy (n = 19), total gastrectomy [16] or partial gastrectomy [22] were studied prospectively. Common symptoms were relieved in 80% of cases and this was independent of tumour stage. Symptoms were significantly more frequent after total gastrectomy than after partial gastrectomy or oesophagogastrectomy, the difference being attributable principally to the development of new symptoms after total gastrectomy. While abdominal pain, nausea and vomiting were largely relieved by resection, dyspepsia or dysphagia worsened in 31% of patients following surgery, especially total gastrectomy (P < 0.05). Resection relieves the symptoms of gastric cancer adequately but outcome is influenced by operation type. As total gastrectomy gives a poorer symptomatic outcome, it should be avoided when the performance of an alternative procedure does not compromise established principles of resection.

Adenocarcinoma↗
PubMed1994

Reducing the risk of viral transmission at operation by electronic monitoring of the surgeon-patient barrier.

A new electronic device designed to detect glove holes, wet gowns and glove permeability was assessed during 50 general surgical operations. The cause of each alarm was recorded and the surgeon's awareness of any breach noted. Some 266 alarms were recorded of which 45 were ascribed to glove holes, 86 to wet gowns, 115 to glove porosity and 20 to other causes. Glove holes occurred in 29 of the 50 procedures; the surgeon was unaware of the hole in almost 70 per cent of cases. Holes were more common in laparotomy than in laparoscopic procedures (P = 0.006). In 20 per cent of instances surgeons did not respond immediately to the alarm (median delay 16 min). Six of eight surgeons who used the device indicated that they would do so regularly for major abdominal surgery. The electronic system accurately detects breaches in the surgeon-patient barrier. Its use should improve surgical discipline in acting to restore the barrier, protecting patient and surgeon alike.

Elective Surgical Procedures↗
PubMed1993

Relief of metastatic biliary obstruction by stent placement: is it worthwhile?

Twenty-one patients undergoing stent placement for extra-hepatic biliary obstruction by metastatic disease were reviewed. Primary tumours (colorectal 8, stomach 4, breast 2, ovary 2, others 5) had been diagnosed 13 months (median) before presentation with bile duct obstruction, which was at the porta hepatis or common hepatic duct in 14 patients and in the common bile duct in seven. Endoscopic stent placement was achieved in 14 out of 20 patients in whom it was attempted. A percutaneous trans-hepatic procedure was necessary in five patients. Two patients could not be stented. Median survival was 5 months (range 1 month to 6 years) in patients stented successfully but only 1 month (2 weeks to 3 months) in unsuccessful cases (P < 0.01). Nine patients survived more than 4 months. Patients with proximal obstruction fared less well than those with distal obstruction; they required more procedures and survived for shorter periods (median 1 month versus 5 months, P < 0.05). Worthwhile palliation is afforded to almost half these patients by endoscopic stent placement and individual patients may achieve prolonged, symptom-free survival.

Adult↗
PubMed1992

An improved means of faecal diversion: the trephine stoma.

Twenty-four patients in whom trephine stoma formation was performed over a 4-year period are described. This procedure permits the formation of an end ileostomy or colostomy without laparotomy. It is simple, rapid, safe and allows speedy recovery. It is widely applicable and previous abdominal surgery is no contraindication. The procedure was impossible in two patients who required laparotomy and in a third in whom a loop colostomy was created. Operation time was shorter and postoperative opiate requirements less than when laparotomy was undertaken for stoma formation. Follow-up (median 1 year) of 17 patients confirmed a low incidence of complications (two prolapses, one parastomal hernia) after trephine stoma formation. This procedure is recommended as the preferred method of ileostomy or colostomy formation when laparotomy is not otherwise indicated.

Adult↗
PubMed1992

Testing arterial baroreflex function in acutely unwell patients.

Cardiovascular function is deranged in acute illnesses but specific details of this pathophysiological phenomenon are poorly understood. With advances in intensive care it is now necessary to define these changes. Existing tests of cardiovascular reflex function are ill-suited to the study of acutely unwell patients. The arterial baroreflex is the principal cardiovascular homeostatic reflex. We have modified the neck suction test of baroreflex function such that it can be performed in 30 min using portable equipment. The protocol was validated on control subjects. Testing of injured patients showed that this test and protocol could be used sequentially, beginning within 2 h of injury, to demonstrate acute changes in baroreflex function and to follow these changes through the disease process. Patient tolerance of the test was excellent. Subsequently, further modification developed an even shorter protocol whereby similar information could be obtained within 15 min. The cardiac response to deep respiration can be measured with minimal patient upset or compliance and is ideal for repetitive testing in critically ill patients. This is not a specific test of baroreflex function but responses to it show interesting parallels with changes in baroreflex function which merit further study.

Acute Disease↗
PubMed1990

Changes in cardiovascular homeostasis after injury are mediated by tissue damage and not haemorrhage.

During treatment of the injured patient it is assumed that the cardiovascular responses follow recognized physiological principles. Studies in humans have shown that injury causes a profound suppression of arterial baroreflex function which alters the normal relationship between heart rate and blood pressure and casts doubt on this assumption. To investigate the mechanism of baroreflex suppression, we have studied the effects of the two major components of injury, blood loss and tissue damage, on baroreflex function in healthy volunteers. Baroreflex function was assessed using suction stimulation of the carotid sinus. The loss of 500 ml blood had no effect on baroreflex sensitivity. A human laboratory model of tissue injury reduced the ability of the baroreflex to compensate for a rise in blood pressure (P less than 0.05, Wilcoxon signed rank test). We conclude that tissue damage, rather than hypovolaemia, appears to mediate the effect of injury on baroreflex function in the injured. Blockade of neural signals from damaged tissue may have a role in the treatment of injury.

Adolescent↗
PubMed1990

An effect of trauma on human cardiovascular control: baroreflex suppression.

Survival from injury depends on the interaction between the patient's own homeostatic responses and treatment given. The function of the principal homeostatic reflex of the cardiovascular system, the arterial baroreflex, was studied in 22 healthy controls and in 21 moderately injured patients (ISS range, 9 to 17; median, 9) using suction stimulation of the carotid sinus baroreceptors. When compared to controls, marked baroreflex suppression was evident 3 hours after injury (p less than 0.05), at 3 days after injury (p less than 0.001), and even 15 days after injury (p less than 0.05, all Wilcoxon rank sum test). Partial recovery of baroreflex function occurred between 3 and 15 days after injury (p less than 0.005, all Wilcoxon signed rank test) and was complete by 5 months after injury. The suppression of baroreflex activity was accompanied by a "fixed" rise in heart rate and a rise in systolic blood pressure. This study has shown that moderate injury results in a profound and prolonged suppression of baroreflex function. Further advances in the resuscitation and critical care of the injured may need to take account of such derangements of cardiovascular physiology.

Adolescent↗
PubMed1989

Faint heart.

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Humans↗
PubMed1989

Preventability of death from penetrating injury in England and Wales.

A total of 1000 deaths from injury in England and Wales have been reviewed to establish the incidence and pattern of penetrating injury and the adequacy of its management. Of the 1000 deaths, 71 (7.1 per cent) were due to penetrating injury. There were 32 knife wounds and 30 firearm injuries. Most of the latter were suicides. Only 17 patients (24 per cent) reached hospital alive. Of these cases, 10 had extracranial injury and all 10 deaths were considered to have been potentially preventable when reviewed by four external assessors. One of seven patients with cranial injury was considered to have been a potentially preventable death. The median age of the 11 cases of potentially preventable death was 37 years (range: 7-61 years). Of these, three did not have any surgery for surgically treatable injuries. Seven patients underwent operation and difficulty was encountered in six of these. It appears from our figures that whilst penetrating injury is an uncommon cause of death, it is poorly managed. The implications of this finding for systems of injury care in the United Kingdom are discussed.

Adolescent↗