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Biomedical subjects

T N Walsh

Publications and source records attributed to T N Walsh.

At least 55 records · Page 3Linked to original sources
PubMed1993

Erythromycin improves emptying of the denervated stomach after oesophagectomy.

Oesophagectomy, necessitating vagotomy, is associated with delayed gastric emptying. Cisapride and erythromycin have prokinetic effects and improve emptying of the innervated stomach. Their effect on the denervated stomach following oesophagectomy is unknown. The effect of pyloroplasty, cisapride and erythromycin on the rate of gastric emptying after oesophagectomy was studied using a radiolabelled meal. Oesophagectomy was associated with a marked delay in gastric emptying (56 per cent of the test meal remaining after 4 h) compared with age- and sex-matched normal controls (16 per cent; P < 0.001). Erythromycin improved the rate of gastric emptying to preoperative control values (18 per cent). Cisapride had no significant effect on gastric emptying. After pyloroplasty, 32 per cent of the label remained at 4 h (P = 0.065). The mean(s.e.m.) half-emptying time in patients receiving erythromycin was 94(29) min, which was similar to control values, 55(3) min (P = 0.26). Erythromycin may have a role in the treatment of gastric stasis following oesophagectomy or truncal vagotomy.

Aged↗
PubMed1993

Timing of extubation after oesophagectomy.

Ventilatory support for 24 h after surgery is standard practice in many units after oesophagectomy, especially for patients in whom respiratory problems are anticipated. Weaning difficulties may occur, however, and there is increasing evidence that mechanical ventilation is associated with alveolar trauma. A deliberate change in policy was instituted in the authors' unit in January 1990 to make early extubation mandatory in all patients undergoing elective oesophagectomy, apart from those in whom serious perioperative problems were encountered. The present study compared two sets of patients: group 1 (n = 36) underwent oesophagectomy in the year before the policy change and group 2 (n = 45) oesophagectomy in the year after. The two groups were similar in age, sex and respiratory risk factors. Early extubation was carried out in 38 patients in group 2 compared with eight in group 1 (P < 0.001). Only two patients in group 2 required prolonged ventilation compared with ten in group 1 (P < 0.005). No patient in group 2 required reventilation compared with seven in group 1 (P < 0.005), and no patient in group 2 who had undergone early extubation required delayed ventilation. The mean ventilation time and length of stay in the intensive care unit were significantly reduced following the policy change. Early extubation after elective oesophagectomy is an attainable goal and results in a significant reduction in both the morbidity rate and cost of surgery.

Aged↗
PubMed1993

A new technique for measuring lower oesophageal sphincter competence in patients.

Oesophageal sphincter measurements were carried out on 80 patients using the stationary pull through technique; Normals (n = 21), Nutcracker (n = 12), Refluxers (n = 21), and Barrett's (n = 26). Sphincter pressure (LOSP), abdominal length of sphincter, and overall sphincter length were measured. The Sphincter Function Index (SFI) was calculated as the product of sphincter pressure and percentage sphincter length (AL) exposed to abdominal pressure. Patients also had routine endoscopy and 24 hour pHmetry. SFI values discriminated between all four groups. LOSP was significantly different for Barrett's (p < 0.01) and Nutcracker (p < 0.01) compared to normals. AL was significant for Refluxers (p < 0.001) and Barrett's (p < 0.001) compared to normals. SFI gives better discrimination than LOSP or AL alone and may be useful in evaluating the response to treatment.

Adult↗
PubMed1993

Cholecystectomy and oesophageal pathology: is there a link?

Symptoms persist in a significant proportion of patients following cholecystectomy, some of which may have an oesophageal aetiology. The oesophagus has not previously been studied in this patient group. In this study all patients who had undergone cholecystectomy over a four year period were invited for review and symptoms were documented. Oesophageal function was examined and compared with normal controls. Patients were subdivided into symptomatic and asymptomatic subgroups and their findings compared. Symptoms were present in 53 percent of the postcholecystectomy group. The mean (sem) DeMeester acid score was higher in the post-cholecystectomy group -20.6 (3.6) than in controls -6.7 (0.9) (p = 0.01). The incidence of oesophagitis and gastritis were also increased in this group. There was a trend towards increased reflux and oesophagitis in the symptomatic compared with the asymptomatic subgroup. Other findings confined to the post-cholecystectomy group included nutcracker oesophagus in 4 and irritable bowel syndrome in 3. It is suggested that cholecystectomy may be associated with changes in oesophageal function which, in turn, may be associated with persistent symptoms.

Cholecystectomy↗
PubMed1993

Endoscopic retrograde cholangiopancreatography in the elderly: a single unit audit.

Endoscopic retrograde cholangiopancreatography (ERCP) has an established role in the management of pancreato-biliary disease, but its role in elderly patients has not been evaluated. A prospective study was carried out in 50 elderly patients, aged between 65 and 94 years, to compare the sensitivity and specificity of ERCP in this age group with ultrasound and liver blood tests, and to examine its safety and therapeutic effectiveness. ERCP was successful in 46 of 50 (92%) procedures. Thirty-four patients had abnormal findings, and 18 sphincterotomies were performed. No complications were recorded. There was a poor correlation between ultrasound and ERCP with agreement in only 45% of cases; sensitivity 35% and specificity 75%. Liver blood tests, alkaline phosphatase and gamma-glutamyl transferase were elevated in all 30 cases with obstructed ducts on ERCP. Ultrasound revealed obstruction in only 10 (33%) of these. Thus, liver biochemistry proved a more reliable indicator of biliary obstruction than ultrasound. In 22 cases endoscopic stone clearance or demonstration of inoperable lesions obviated surgery while in 9 cases surgery was indicated, because of multiple large stones not cleared at ERCP, or for bypass of a malignant stricture. ERCP is therefore safe and effective with a high diagnostic and therapeutic yield even in the poor risk elderly.

Aged↗
PubMed1992

DNA quantification of squamous cell carcinoma of the oesophagus by flow cytometry and cytophotometric image analysis using formalin fixed paraffin embedded tissue.

This is the first comparative study of DNA quantification of oesophageal squamous cell carcinoma by flow cytometry (FCM) and image cytometry (ICM) using formalin fixed paraffin embedded tissue. The potential advantages of ICM include the identification of a reliable control cell population; avoidance of non-tumour stromal and inflammatory cell nuclei, nuclear fragments, degenerate cell nuclei and doublets, triplets etc., which are not possible with FCM using archival tissue. Twenty-eight cases, all of the same stage (stage 2a) and similar grade (well or moderately differentiated) were analysed. The cases were separated into two groups, those that had succumbed to tumour in less than 18 months (group A) and those that were tumour free at least 18 months post-resection (group B). Using ICM all 28 tumours yielded interpretable histograms by comparison to 25 of 28 using FCM. Aneuploidy was identified in 100% of cases in group A using ICM (in comparison to 73% by FCM) and in 73% of group B using ICM (in comparison to 44% by FCM). Any tumour aneuploid by FCM was also aneuploid by ICM. Nine cases aneuploid by ICM were euploid by FCM. The mean 5C exceeding rate (% of cells whose nuclei contain a DNA mass equivalent to > 5 sets of 23 chromosomes) was 21% in group A and 14% in group B (P < 0.01). Euploidy was confined to tumours of those patients disease free for more than 18 months. The conclusions of this study are that: firstly, ICM is superior in its yield of interpretable histograms to FCM using formalin fixed paraffin embedded tissue; secondly, ICM is more sensitive in the identification of aneuploid stemlines than FCM; and thirdly, euploid tumours (as detected by ICM) appear to have a better prognosis than aneuploid tumours of similar stage and grade.

Adult↗
PubMed1992

DNA ploidy in squamous oesophageal carcinoma.

The role of DNA ploidy in the management of oesophageal carcinoma is unclear. Most studies have employed flow cytometry (FC) for DNA analysis but some have used image analysis (IA) of tissue sections. In this study aneuploidy rates in stage IIa squamous tumours were determined by both FC and IA of cell suspensions and results were compared with outcome in two patient subgroups. Group 1 (n = 15) were patients who died from tumour recurrence within 1 year of surgery while Group 2 (n = 21) were patients who survived tumour free for at least 1 year. Aneuploidy rates differed significantly between techniques; 29 of 36 tumours (81%) were aneuploid by IA compared with 19 of 34 (56%) by FC (P < 0.05). Aneuploidy rates differed significantly between groups 1 and 2 as determined by FC (79%) versus 40%) (P < 0.05) but not by IA (93% versus 71%) (P = ns). Euploid status was a good prognostic indicator; 6 of 7 (86%) patients with euploid tumours by IA and 12 of 15 (80%) by FC (P < 0.05) survived more than 1 year. The sensitivity and specificity of euploidy was 93% and 28.6% for IA compared with 78.6% and 60% for FC. Since 33 (92%) of these tumours exhibited a marked peritumoral desmoplastic or chronic inflammatory reaction IA, being more sensitive to subtle nuclear change, may be a more appropriate technique than FC for evaluation of the role of ploidy in such tumours.

Adult↗
PubMed1992

Minimal change chronic pancreatitis.

In patients with severe abdominal pain, of pancreatic origin, there are a few with minimal or equivocal findings on pancreatic investigation and in whom the aetiology of their pancreatic disease is elusive. The findings and outcome in 16 of these patients (four men and 12 women) who underwent resection are reported. Pancreatic imaging showed minimal or equivocal findings in all 16; pancreas divisum was present in five. All were managed conservatively at first but resection was required for progression of symptoms. A drainage procedure was performed initially in five patients but relief of pain was at best transitory before further surgery was required. Partial resection was needed in 12, of whom eight required subsequent completion pancreatectomy and four had a one stage total resection. Nine patients are currently pain free after resection or are very much improved, while six are no better and one patient has died from an unrelated cause. Histology of resected specimens showed chronic inflammatory changes accompanied by subtle non-inflammatory changes in all but one. These changes include duct proliferation, duct complex formation, adenomatous nodules, and acinar cell atrophy, the significance of which is unclear. These findings suggest a syndrome of minimal macroscopic and radiological change chronic pancreatitis with pain as its chief clinical feature and a distinct histology, the aetiology of which is unclear. It seems that there is a distinct syndrome of minimal change pancreatitis, among the group of patients which presents with the clinical features of chronic pancreatitis.

Adolescent↗
PubMed1992

Audit of an oesophageal unit.

We report an audit of 786 oesophageal procedures, including 53 oesophagectomies, performed during 1990 in a specialist oesophageal unit. Apart from assessing morbidity and mortality, audit allows a review of cost efficiency and justification for certain practices with regard to patient management. The data reported here may provide a framework against which individual surgeons may assess their own results and compare costs of procedures with a similar outcome.

Costs and Cost Analysis↗
PubMed1992

Carcinoma arising in Barrett's esophagus.

During the period 1971 and 1990, 500 patients underwent resection for carcinoma of the esophagus, 51 of whom had an associated Barrett's esophagus. Of these, 49 had adenocarcinoma and two had squamous cell carcinoma. Barrett's carcinoma accounted for 23.7 percent of the surgically treated adenocarcinomas during this period. Reflux symptoms were present in 13 patients preoperatively. Tumors developed in four patients who had undergone previous antireflux operation and in two patients on the surveillance program. By postresection staging, 18 patients had stage II tumors and 33 patients had stages III and IV tumors. Stage and length of the tumor were the only prognostic determinants. The overall 90 day hospital mortality rate was 17.6 percent. The hospital mortality rate before 1986 was 22.9 percent, but decreased to 6.3 percent in the last five years. The one, two and five year survival rates were 45.9, 25.0 and 13.6 percent, respectively. The five year survival rate was significantly greater for patients with stage II (25 percent) than for patients with stages III and IV (4.5 percent) (p less than 0.05) and for tumor length less than 6 centimeters (21 percent) than for tumors greater than 6 centimeters (zero percent; p less than 0.001).

Adenocarcinoma↗
PubMed1991

Chylothorax after oesophagectomy.

Chylothorax is an uncommon complication of oesophagectomy. In a review of 537 oesophageal resections there were 11 cases of chylothorax, an incidence of 2.0 per cent. There was no correlation with site, size, penetration, lymph node status, length or type of tumour but there was a significant correlation between chylothorax and the type of operative procedure carried out. The incidence in 95 transhiatal resections was 10.5 per cent. The incidence following 442 transthoracic procedures was 0.2 per cent (P less than 0.001) with one chylous fistula occurring after a three-stage oesophagectomy. Initial management was conservative with chest drainage and total parenteral nutrition. Thoracotomy and duct ligation was subsequently carried out in three patients and was successful in two. The third patient died. Conservative management alone was successful in four out of eight patients, with closure of the fistula at a median of 35 days (range 14-42 days). Four patients treated conservatively died. Transhiatal oesophagectomy greatly increases the risk of chylothorax, a condition that carries a high mortality rate (46 per cent in this series) whether managed conservatively or by surgical intervention.

Chylothorax↗
PubMed1990

Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis.

Endoscopic transthoracic electrocautery of the sympathetic chain has been the preferred treatment for palmar or axillary hyperhidrosis in this unit since 1980. A retrospective study was carried out of the first 112 patients with case material derived from a postal questionnaire, chart review and outpatient assessment. Eighty-five patients undergoing bilateral transthoracic electrocautery who replied to the questionnaire (76 per cent response rate) form the basis of this study. There were 65 females and 20 males with a mean age of 24.3 years (range 15-40 years). The hands alone were affected in 20 patients (24 per cent), the axillae alone in 17 (20 per cent) and both areas in 48 (56 per cent). Mean hospital stay was 3.1 days (range 1-7 days). Outcome was assessed by 92 per cent of patients immediately after operation as 'very much improved' or 'moderately improved', and this assessment persisted in 85 per cent after a mean follow-up of 43 months (range 3-95 months). Cosmetic results were rated as satisfactory by 95 per cent. Apart from pain after operation, morbidity was limited to transient Horner's syndrome in three patients, surgical emphysema in three, and pneumothorax requiring a chest drain in one. A repeat procedure was needed in one patient because of an inadequate first operation. Some compensatory hyperhidrosis occurred in 54 (64 per cent) patients. As a minimally invasive procedure, endoscopic transthoracic electrocautery should be considered the treatment of choice for palmar and axillary hyperhidrosis.

Adolescent↗
PubMed1990

The warm knee sign--an evaluation.

The presence of an area of warmth at the knee has been described in cases of arterial occlusion at the popliteal fossa. A study was carried out to evaluate the significance of this sign by comparing clinical and thermographic findings with arteriographic results in a group of 30 patients. The clinical and thermographic findings were described with reference to the symptomatic limb. Clinically, 14/30 (47%) and thermographically, 16/30 (53%) had "positive" warm knee signs. The overall agreement between clinical impressions and thermographic findings was 28/30 (93%). The commonest arteriographic finding in patients with a positive warm knee sign was that the occlusion or stenosis ended at the adductor hiatus. Comparing this arteriographic finding with a positive warm knee sign, sensitivity, specificity, positive and negative predictive values of 73%, 75%, 79% and 69% respectively were obtained suggesting that this is a useful sign, is of proven value and deserves its place in the initial screening of patients with peripheral vascular disease.

Aged↗