Correspondence

Sir: Whilst writing our results on 100 consecutive primary resection is of acute sigmoid volvulus, I read with interest the review by Madiba TE, and Thomson SR regarding the management of sigmoid volvulus (J.R.Coll.Surg.Edinb 2000;45:74-80) but would like to point out the misrepresentations found in the literature.

Firstly, to the best of my knowledge, there are more than 13 articles reporting their experience in primary anastomosis for acute sigmoid volvulus, not three reports detailing more than 10 patients as stated by the authors.^1-13 Although two of these three reports are stated to be written by the same author, the reference list of this review article disagrees with this finding.

Secondly, the authors reviewed the results of primary anastomosis in unprepared colon as authored by Mealy et al (1988).¹⁴ Out of 126 patients, there were 83 patients who had primary anastomosis and no colostomy, 32 underwent right-sided and 51 left-sided resections. Six anastomotic leaks occurred in patients with no colostomy. However, in their review Madiba and Thomson stated that according to Mealy et al`s article that there were 146 patients undergoing primary anastomosis in unprepared bowel with three leaks.

In order to learn the recent advances in the surgical field, most of the surgical trainees read review articles. Therefore, although the J R Coll Surg Edinb appears to support review articles, both the authors of this study and the editorial board of the journal has to be very meticulous in their work while reviewing such articles.

We have noted the correspondence from Kazu MA regarding our review article on the management of sigmoid volvulus.¹ The paragraph relating to Kazu’s query regarding primary anastomosis following sigmoid colectomy refers to Table 3 of our paper. We state that there are only three reports detailing more than 10 patients with resection and primary anastomosis, which is true when one looks at Table 3 of that paper. We do not dispute that there are other articles, which have reported good results with primary anastomosis following this procedure. The three reports on Table 3 refers to papers by Ballantyne (1982),² Ballantyne et al (1985)³ and Bagarani et al (1993).⁴ The two reports "written by the same author" refers to the Ballantyne (1982)² and Ballantyne et al (1985).³ We concede that references "2", "23" and "48" should read "2", "21" and "48".

The second query by Kazu refers to our analysis of the results reported by Mealy et al (1988).⁵ Kazu wonders why we comment on three leaks rather than six leaks. In that study by Mealy et al (1988)there were indeed six leaks, three from the left colon and three from the right colon.⁵ We were referring to the left colon since sigmoid colectomy, to which we were confining our discussion, is a left-sided resection. Kazu further wonders where we get "146" from. Seventy-two patients were reported by Irving et al (1987)⁶; another 18 were reported by Dorudi et al (1990)⁷ and a further 56 out of 126 were reported by Mealy et al (1988).⁵ Adding 72, 18 and 56 gives us a total of 146 patients with left-sided resection and primary anastomosis, of whom only three had anastomotic leaks.

The review of this subject has meticulously researched the literature and quoted many references. We have not quoted some of the references noted by Kazu because it is impossible to quote all references available in the world literature in a review article. Indeed, some of the references quoted by Kazu are referenced in our article but they do not appear in Table 3 which compares primary anastomosis and colostomy, which is why we did not quote them in that particular paragraph as they do not compare primary anastomosis and colostomy. The message in the review article remains unchanged and we re-affirm that primary anastomosis following emergency resection seems to be one of the acceptable options in the management of this condition.

Facial nerve palsy following intra-oral surgery performed with local anaesthesia
2000; 45 (5): 330-333

Sir: I found the article on "Facial nerve surgery following intra-oral surgery performed with local anaesthesia" by GCS Cousin in the October 2000 edition most interesting.

In the discussion it is stated that the chorda tympani nerve supplies sensory fibres to the anterior two-thirds of the tongue. This is misleading as the lingual nerve (with which the chorda tympani nerve runs) supplies sensation to the anterior two-thirds of the tongue. The chorda tympani leaves the base of the skull at the petro-tympanic fissure and having joined the lingual nerve, it carries parasympathetic secretomotor fibres to the submandibular ganglion. In addition, it transmits taste fibres from the fungiform papillae of the anterior two-thirds of the tongue to the geniculate ganglion. ¹

1. Cowan PW. Atrophy of fungiform papillae following lingual nerve damage - a suggested mechanism. BDJ, 1990; 168: 95

Facial nerve palsy following intraoral surgery performed with local anaesthesia 2000; 45 (5): 330-3

Sir: I read this article with interest and found out that the forehead muscles are spared in a lower motor neurone lesion. Actually, the forehead muscles are spared in upper motor lesions because of the crossover innervation at a higher level.^1,2 If it was a typographical mistake then please accept my apologies, otherwise, it is worth mentioning that the forehead is spared in upper neurone lesions of the facial nerve.

M SHARIF NAYYAR
Department of Oral and Maxillofacial Surgery, Central Middlesex Hospital, London U.K.

Thank you for allowing me to address some of the points raised in correspondence following the publication of this article. I am pleased at the interest the paper has generated. However, there were some errors in it, and I am grateful that readers of the Journal have written to the Journal about them.

I am pleased to agree with the correspondents’ point that the chorda tympani’s contribution to the sensory nerve supply of the anterior two-thirds of the tongue is purely that of the special sense of taste. I should have emphasised that the chorda tympani joins the lingual nerve, and with this branch of the trigeminal nerve is responsible for the other sensory modalities of the anterior tongue. The forehead is spared in upper motor lesions of the facial nerve.

I am grateful for the clarification about the House-Brackmann facial nerve palsy grading system.

GCS COUSIN
East Lancashire Maxillofacial Service, The Royal Infirmary, Blackburn, U.K.

Centralisation of oesophageal cancer services: the view from the periphery
2000; 45 (3): 164-167

Sir: I read the article "Centralisation of oesophageal cancer services: the view from the periphery" by Milne AA et al in the June 2000 edition of your Journal with a lot of interest and reflection. Although it is methodologically weak by scientific standards, comparing experiences between different cohorts of patients in different institutions is quite revealing and produces some information of educational quality for practising surgeons. From Table 1, the adenocarcinoma subclass in particular needs elaboration by further reclassification in terms of their location in the oesophagus. It is well known that the lower oesophageal adenocarcinomas (those that transform from Barrett’s oesophagus or arose de novo) are sometimes difficult to distinguish from carcinoma of the cardia, especially if both of these tumours were at advanced stages. This should be paralleled with further elaboration on the types of surgical resections in Table 2. It is conventionally practised in the West that for the tumour in the lower third, a 2-stage oesophagogastrectomy is done and the 3-stage McKeown procedure for the middle third squamous carcinoma and quite often the upper third tumours may be subjected to radiotherapy alone. However, it has been shown that for squamous cell carcinoma of the oesophagus of any level is best treated by the 3-stage total oesophagectomy with 3-field lymphadenectomy.¹

In the same table, the non-resectional intervention for palliation is said to be similar in both groups (19 vs 20) but the actual numbers for stents and operative intubations in each category do not add up accurately (17 vs 19).

Are we to assume that all the mortality in the survival curve is due to cancer recurrence? If not, the other parameters of interest would be the recurrence rate and the time that this happened. These immediate outcome measures become very important since there is no 5-year survival in this series and, hence, one can assume that all surgical resections were retrospectively palliative in purpose. This is debatable considering the very high resection rates, namely 12.5% and 5.6%, respectively. It is a traditional view held by surgeons that operative resections or even bypasses offer the best palliation to patients, as compared with intubation. This perception has to be challenged in view of the availability lately of more durable stents and also the significant peri-operative morbidity and mortality associated with any form of thoracic operations, even in tertiary centres with all the necessary intensivist support.

One of the arguments put forward to support the referral of all oesophageal cancers to tertiary specialist centres is the multidisciplinary team approach in the management of this disease and most, if not all patients, could be enrolled in to some form of trial protocols using various multimodal therapy. However, sometimes, as is also observed in this study, the ultimate decision on the definitive therapeutic plan does not reflect the team approach to every patient. There were only 63% of patients referred to the surgeon by the gastroenterologist in Group 2 who must have, presumably, decided on their own (perhaps based on the radiologist reports) that the other 37% of the tumours were unresectable or the patients not suitable for surgery. It is well accepted that there is no ideal pre-operative staging methods for oesophageal cancers thus far, although endoscopic ultrasound has been shown to be very reliable with good sensitivity and specificity.² Although most patients will get adequate palliation by the latest minimally invasive methods and materials used by the endoscopist, as also suggested by the authors, surgical perspective to the management of all patients is still required for optimal decision making and overall therapeutic strategy.

The authors also alluded to the issue of training and experience, which ultimately related to competence. It is mentioned that oesophagectomy has a long learning curve and operative outcomes improve over a number of years as experience grows. Advanced surgical training to acquire the necessary kills to function as a specialist is highly controversial and, thus, far there is no single ideal system in the world that could prepare a specialist completely in all aspects of his chosen specialised surgical discipline before exiting the training programme and acquiring specialist responsibility. A lot of emphasis is given to the volume of the clinical materials as an indicator of training adequacy. However, I believe that qualitative discourse in the training is much more important than the quantitative exposure. The trainee’s essential background knowledge, enthusiasm and discipline and the trainer’s parallel basic science knowledge, enthusiasm and willingness to interact with the former for mutual feedback on every case at hand are more useful ingredients to the quality training with good prospects of instilling the necessary competence in to the trainee.³ Advanced trainees, however, are often left on their own to read and to practise with minimal supervisory input. This method of skills acquisition continues in a new capacity of a specialist (now without any supervisory input at all) and as such only time and experience (i.e. clinical volume) will mature a person. Perhaps, a specialist should make visits to other well-known centres of excellence in a particular field for continuous professional development.

The authors also concluded that the key to improving outcome is early diagnosis and the method to achieve this is by public education and rapid investigation. However, there is no data on the mean duration of dysphagia in this series but a mean of 7.5 days for the general practitioner to refer patients to hospital indicates that the health service is quite optimal. It is also well-established that whenever a patient presents with dysphagia, the oesophageal cancer is already at an advanced stage locally. Perhaps, the more important issue is not just early diagnosis but diagnosis of early cancers. General practitioners should screen for high-risk patients and send these patients for endoscopic surveillance utilizing chromoendoscopy to detect asymptomatic early cancers. Economics permitting, this policy has been shown to improve the outcome of oesophagogastric cancers dramatically.⁴

In conclusion, I would agree with the authors that centralisation of services alone is not the answer to improving outcome in the management of oesophageal cancers.

We are grateful for Dr Sain’s comments on this paper which seem to be broadly in agreement with our own interpretation. We did not feel that it would be useful to further subdivide patients according to the level of their tumours as the numbers involved were quite small and we felt that further subdivision of these patients in to smaller groups would not yield any significant information. The figures in Table 2 are correct; those patients in the palliative group did not undergo either stenting or intubation. Some of these patients underwent simple dilation and some who had advanced tumours without significant dysphagia required no intervention. We did not use recurrence as an outcome measure as we had concerns over the accurate recording of recurrence in a retrospective study such as this one. For example, the earlier detection of recurrence in one group may reflect more thorough post-op surveillance rather than any true difference in recurrence rate.

Renal cell carcinoma: Incidental detection and pathological staging, J.R.Coll.Surg.Edinb. 2001; 45 (1): 69

Due to a production error, the names of the authors of this letter should have appeared as follows:

J MASOOD, T LANE, J M BARUA, M T VANDAL and J T HILL
Department of Urology, Harold Wood Hospital, Romford, U.K.

THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH

KING JAMES IV PROFESSORSHIPS

Up to five lectureships will be awarded annually by the College, in open competition, to distinguished practitioners of surgery or dental surgery -two to dental and three to surgical Fellows of the College. The courtesy title of Professor will be accorded to the individuals for the duration of the College year in which their lectures are delivered.

The closing date for receipt of applications is Friday 7 September 2001

ETHICON FOUNDATION FUND TRAVEL GRANTS

Grants are available to Fellows of the College towards expenses which will be incurred during travelling overseas to obtain further training or experience. Travel for the sole purpose of attending a scientific meeting will not be supported.

The closing date for receipt of applications is Friday 18 May 2001

RESEARCH FELLOWSHIPS
The Ann Gloag Research Fellowship in Surgery - £25,000 The Legal & General Research Fellowship (in cochlear implants) - £30,000

Applicants must be Fellows of the College in good standing and under 40 years-of-age.

Closing date for receipt of applications is Friday 25 May 2001

THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH

and

THE LLOYDS TSB TRUST FELLOWSHIP

invite applications for

LLOYDS TSB FOUNDATION FOR SCOTLAND

This Fellowship is being awarded initially for a one year period with a possible extension for a further year. The recipient will be based at Queens University Hospital and the University of Nottingham, working with Professor O Eremin, Special Professor of Surgery. The research project will study inflammatory bowel disease.

The applicant must be a Fellow or Associate Fellow of The Royal College of Surgeons of Edinburgh, in good standing, and under 40 years-of-age.

Closing date for receipt of applications is Friday 25 May 2001

For further particulars and application forms for all of the above, please contact:

The Awards and Grants Secretary
The Royal College of Surgeons of Edinburgh
Nicolson Street Edinburgh EH8 9DW
Tel.: +44 (0) 131 527 1618; Fax: +44 (0) 131 527 1730; Email: e.wright@rcsed.ac.uk

THE MELVILLE TRUST FOR THE CARE AND CURE OF CANCER

Research Grants

The trustees invite applications for grants in cancer research whether related to care or cure. These may include the provisions of scientific, technical or clerical assistance, laboratory costs and equipment but must not exceed expenditure of £20,000 in any one year. Subject to satisfactory progress the grant is renewable for a further year, but extension beyond that period cannot be entertained.

Research support by the Trust will be carried out in a clinical or scientific department in Lothian, Borders, Fife or Dundee, the head of which must signify his or her approval of the application. The research may deal with any aspect of malignant disease, its care or its cure, and applicants need not necessarily hold a medical qualification.

All applications must be submitted with all sections completed (so far as applicable) on a standard application form, by no later than the 30th April, 2001 to: Messrs Tods Murray, WS 66 Queen Street Edinburgh EH2 4NE

Note: Application forms are available upon written request from Messrs Tods Murray, WS