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Sir,
“A simple method of mesorectal transection for carcinoma of upper third of rectum” by Y. Srinivas, A. Renwick, P. McArdle and A. MacDonald J R Coll Surg Edinb 2001; 46: 338-339
We read with interest the description of mesorectal transection by Srinivas et al. We have used the technique occasionally and recommended it for difficult cases, particularly for females with a bulky fibroid uterus that impedes access around the pelvic brim. However, for the upper rectal cancers referred to in the article, full rectal mobilization to the pelvic floor will usually obviate the need for this technique, as the tumour should be elevated in the bony pelvis, facilitating both handsewn and stapled anastomoses. If the position of rectal and mesorectal division is lower in the pelvis (representing the “ technical challenge” of the lower anterior resection referred to by Srinivas) TME, not mesorectal transection, is usually to be recommended. We believe that the technique described in this paper must be used as a means of avoiding a full rectal mobilization with appropriate circumferential mesorectal excision and oncological resection but should be reserved for the occasionally difficult case where there is limited access in the upper pelvis.
Mr A.G. Heriot & Mr D.P. Edwards Frimley Park Hospital Portsmouth Road Frimley Surrey, GU16 7UJ U.K.
Sir,
I read with interest the letter of Messrs Heriot and Edwards and I am pleased that they too have used this technique occasionally and indeed recommend it for dif.cult cases. Our article refers to surgery for upper third rectal cancers, the management of which varies; some surgeons advocate TME; some advocate transection of the mesorectum and bowel 5cm below the distal border of the tumour. For tumours at 10-15cm from the dentate line, distal transection will be deeper in the pelvis than Messrs Heriot and Edwards suggest, being at or below the peritoneal reflection. This will leave a rectal stump of variable length that has not been devascularised by the TME process, thus, making anastomotic leak, at least in theory, less likely (1.8% from our own series).
The traditional approach to dividing the mesorectum from behind will inevitably lead to an angled division of the tissues. If the rectum is divided first, as described in our article, the mesorectum can then be divided under direct vision in a more controlled fashion without compromising the oncological resection (own series of 4% lateral margin involvement for curative resections).
Mr Y. Srinivas Department of Surgery Monklands Hospital Airdrie U.K.
Sir,
"The role of elective colectomy for diverticular disease" by Somesakar et al J R Coll Edinb 2002; 47:2
I read with interest the article by Somesakar et al (47[2]: 481-484) on the role of elective colectomy for diverticular disease. The retrospective study that he has performed over 5 years in two adjacent district hospitals highlights an important point in that not everyone with attacks of uncomplicated diverticulitis will require an elective colectomy. In this respect it is important to consider the publications by Ambrosetti (1997) and others who have characterised the natural history of the disease.1 Having reviewed the literature, it would seem that other factors such as age, quality of life, type of complication and other co-morbid factors need to be taken into account when deciding which patient requires an elective colectomy.
It has been demonstrated that the success of medical therapy diminishes with each subsequent attack, changing from 70% after the first to less than 6% following the third episode. Consequently, elective colectomy should be offered to patients following the second attack of diverticulitis.2
Age seems to be another significant factor that in.uences the decision to offer patients an elective colectomy. Guidelines from the Lahey clinic suggest that patients younger than 55 years who have had one or more episodes of proved diverticulitis associated with constitutional symptoms (e.g. fever), leucocytosis, obstructive and urinary symptoms and/or demonstrated severe diverticulitis on a computerised tomography (CT) scan should have an elective procedure after resolution of symptoms following the first attack. Ambrosetti (1997) shows that three parameters are statistically predictive of a greater risk of secondary complications; men less than 50 years of age, severe diverticulitis on initial CT and the presence of a pelvic abscess.1
A significant co-morbid factor that would influence the choice for elective colectomy is immunosuppression. This may be defined as a diminution of host defences caused by congenital or acquired immune disorders, malnutrition, uraemia, malignant neoplasm, long-term steroid or cytotoxic drug administration and patients having organ transplant.3 These patients are likely to suffer from Hinchey stages III or IV complications and should be offered elective colectomy after successful medical treatment of an initial attack of acute uncomplicated diverticulitis.
My questions to the author with regards his interesting and detailed study are:
1. How many of the 108 patients undergoing emergency/urgent surgery were immunocompromised and/or less than 55 years of age?
2. Of the patients that did not have emergency surgery (not mentioned in this study), how many have had elective colectomy and obey the guidelines stated above?
References
1. Ambrosetti P. Diverticulitis of
the Left Colon. In: Taylor I,
Johnson CD, eds. Recent
Advances in Surgery. Edinburgh: Churchill Livingstone; 1997:
145-59.
2. Farmakis N, Tudor RG,
Keighley MR. The 5 Year
Natural History of
Complicated Diverticular Disease. Br J Surg 1994; 81: 733-5.
3. Perkins JD, Shield CF, Chang
FC, Farha GJ. Acute Diverticulitis: Comparison of
treatment in immunocompromised
and nonimmunocompromised. A J Surg 1984; 148:
745-8.
Mr D. Singh-Ranger Academic Department of Surgery University College Hospital, London U.K. E-mail: d.singh-ranger@ucl.ac.uk
Sir,
We read with interest the letter by Mr Singh-Ranger. We concluded from our study that most patients requiring emergency or urgent surgical intervention for complicated diverticular disease have no previous history of disease. However, we acknowledge the patients with repeated attacks of acute diverticulitis may be prone to future complications, but we have not studied this group of patients, as this was beyond the scope of our study.
With reference to question one by the author, we would like to clarify that only three patients (2.7%) had been admitted more than once for exacerbation of their symptoms and not 7.4% as the author had mentioned. All three of them recovered well with conservative management of both the episodes.
Thirteen of the 108 patients in our study group were less than 55 years of age, and of the eight patients admitted previously with exacerbation of their symptoms, two were less than 55 years of age. However, we did not examine the incidence of immunosuppression amongst our patients with known diverticular disease.
Four patients in our study group did not undergo surgery due to their poor general condition. All four patients died and were found to have perforated diverticular disease on post-mortem examination.
Mr K. Somasekar, Mr M.E. Foster & P.N. Haray University of Glammorgan Pontypridd, Wales
Dear Sir,
Re: “Inguinal hernia repair” by I.M.C. MacIntyre J R Coll Surg Edinb 2001; 46: 349-53
We read the “How I do it: Inguinal hernia repair” article in your journal. Unfortunately, Mr Macintyre has miscalculated the lignocaine dose and the unit of bupivacaine is a print mistake; 1ml of 1% lignocaine contains 10mg of lignocaine (1gm of lignocaine that is 1000mg of lignocaine in 100ml of sterile water constitutes 1% w/v strength of lignocaine solution). Thus, 30ml will contain 300mg of lignocaine. That still is well below the toxic dose. The dose of bupivacaine is printed as 30mg, which should be 30ml. Here the dose calculation is correct.
In the final step, in mesh insertion we bring the inferior border of the upper leaf of the mesh along with the inferior border of the lower leaf and insert it to inferior border of inguinal ligament lateral to deep ring. This gives a snug fit to the spermatic cord.
Mr D.N. Das & Mr J.P. Narain Lorns and Islands DGH Oban, PA34 4HH U.K.
Sir,
Re: “Swimmers view: a diagnostic adjunct for oesophageal foreign bodies” by Kanagalingam et al J R Coll Edinb 2002; 47: 4; 641-42
It was interesting reading this case report diagnosing a clamshell foreign body lodged in the upper oesophagus using a swimmer’s view, which also showed its level. The lateral neck radiograph did show a small opaque shadow at the level of the seventh cervical vertebra but it wasn’t clear enough due to the clavicle shadow until a swimmer’s view was done.
From our experience we think that it was possible to see such a big foreign body by carrying out the usual chest radiograph, which will identify its level.
As it is a sharp edged body the chest radiograph will help to rule out any mediastinal emphysema, which is difficult to see in the swimmer’s view.
We also know that elderly patients usually present with dysphagia secondary to foreign bodies in the upper oesophagus, due to wearing dentures, and inability to size the bite accurately. They also tend to have arthritis, which makes the swimmer’s view difficult.
Furthermore, other cases with nonopaque bolus obstruction such as a meat bolus will be diagnosed clinically due to regurgitation of saliva, which indicates complete obstruction. These cases will be taken to theatre on clinical grounds for endoscopy regardless the radiographic result.
In conclusion, it’s good practice to make use of the various imaging views to aid in deciding on the urgency of removing the object, especially sharp objects.
As we always aim for less radiation exposure to the patients it is better to do one informative view or rely on a solid clinical diagnosis and treat the patient accordingly.
Mr L. Albarzangi & Mr O. Ayoub Singleton Hospital Swansea, SA2 8QA U.K.
Sir,
Mr Albarzangi raises some interesting points in his letter. Whilst a plain chest radiograph would certainly exclude mediastinal emphysema, the image of a radio-opaque foreign body in the upper aerodigestive tract is often superimposed on the cervico-thoracic spine, making interpretation dif.cult. Lateral chest radiographs are often unhelpful as the shoulder girdle obscures the prevertabral area. The ‘Swimmer’s View’ has the advantage of clearly imaging the pre-vertbral region at the cervicothoracic junction where a foreign body or bolus impaction is common. We accept that in a select few elderly patients, with arthritis of the shoulder, this investigation may impossible.
We certainly agree that the decision to take these cases to theatre should be made on sound clinical grounds, regardless of the imaging results. However, when the nature of the impacted bolus is in doubt, radiographs may help differentiate soft, meat boluses from hard animal bones. This knowledge allows for conservative management overnight, for example with anti-spasmodic agents, in cases of soft bolus impaction. Clearly, if the radiograph reveals a sharp-edged hard foreign body, there is no place for such measures and a greater urgency to proceed to endoscopic removal.
Mr J. Kanagalingam & Mr C. Georgalas North Thames Deanery London U.K.
Sir,
Re: “Clinical relevance of the delay in endoscopic diagnosis of gastric cancer” by Amin et al J R Coll Surg Edinb 2002; 47: 681-84
Dr. Amin and colleagues1 reported that the diagnosis of gastric adenocarcinoma was missed at the initial endoscopy in 18 of 137 patients (14%) diagnosed with the condition over a 5-year period, and that this has resulted in a median delay of diagnosis of 13 weeks. However, the clinical relevance of this delay in diagnosis was not made clear, and the reader is interested to learn of its impact on disease outcome. Did the group of patients with the delayed diagnosis have a higher proportion of patients with more advanced disease (say stages III and IV) compared with the nondelayed group? Was there a difference in resectability rates and survival between the two groups? And, were there other reasons for undue delay in delivery of care to these patients, such as delay in referral, and times to first endoscopy, admission or intervention?
References
1. Amin A, Gilmour H, Graham L, Paterson-Brown S, Terrace J, Crofts TJ. Gastric adenocarcinoma missed at endoscopy. J R Coll Surg Edinb 2002; 47:681-684.
Mr. B.J. Ammori Department of Surgery, Manchester Royal Infirmary & the University of Manchester Oxford Road, Manchester M13 9WL Email: Bammori@aol.com
Sir,
We thank Mr Ammori for his interest in our article.
The main focus of our study was to identify the proportion of gastric adenocarcinomas missed at the time of first endoscopy and evaluate any subsequent delay to histological diagnosis in these missed cancers. We therefore did not study the stage at presentation, resectability rates and survival in the non-delayed group. However, data from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC) suggest that about half of all cases of gastric cancer are suitable for resection. In the delayed group, 14/18(78%) missed cancers were resectable at diagnosis. The small number of patients involved in the delayed group, make reliable conclusions difficult but the higher resection rate may be a direct consequence of a higher proportion of early stage tumours missed at the time of first endoscopy which, despite progression in stage, may still be resectable at diagnosis.
Diagnostic delay was measured as the interval between the date of the biopsy report at first endoscopy (or from date of the first endoscopy when no biopsy specimens were obtained) to the date of the biopsy report confirming the histological diagnosis of gastric adenocarcinoma. This delay did not include the preceding referral delay or times to first endoscopy, admission or intervention. The overall delay from initial presentation to a general practitioner to histological diagnosis would, therefore, be much longer in the delayed group.
Mr T.J. Crofts & Dr A. Amin Edinburgh Royal Infirmary Edinburgh U.K.
Dear Sir,
Re: “Percutaneous extra-articular excision of femoral neck osteoid osteoma: a report of a new method” by Chaarani et al J R Coll Surg Edinb 2002 Volume 47: 5; 705-08
I read with interest the article by Chaarani et al. Not only is this not a new method, it is an obsolete method. This precise technique was reported in a series of patients by myself and coworkers “Minimally invasive surgery
for osteoid osteoma of the proximal femur”, Graham HK, Laverick MD, Cosgrove AP, Crone MD. J Bone Joint Surg. 1993; 75-B: 115-18. At that time, we considered it to be pretty much state-of-the-art and continued to use it for a few years. We now consider that localisation of the nidus is much more accurately performed in the CT scanning suite, because of the superior resolution of CT compared with fluroscopy. We also consider radio frequency ablation to be much better than removing large cores of bone from the femoral neck in growing children. Dr Chaarani cannot possibly suggest that fractures of the femoral neck are more likely with drill biopsy under CT guidance than trephine biopsy under fluroscopy.
Mr H. Kerr Graham Royal Children’s Hospital Melbourne Australia
Dear Sir,
Thank you for giving me the opportunity to clarify some points regarding our procedure.
Looking through the literature, it is true that osteoid osteoma excision using a trephine was reported by Graham and co-authors. The idea for this technique was even earlier as Iceton and Rang (1986) excised a similar lesion from the distal femur using the same technique.1
Although we utilised the same technique our operation and strategy were different in many aspects. In our introduction, we stressed the importance of “the accuracy of computed tomography (CT), and the magnetic resonance imaging (MRI) in locating the exact site of the tumour, assisted in planning the procedure”, we also indicated how CT “allows an accurate evaluation of the tumour location within the bone”, and how CT and MRI “can demonstrate in which quadrant the lesion has developed”.
The femoral neck is more or less a regular cylinder which is easy to access from the subtrochanteric region. Through this source most orthopaedic surgeons are well-experienced in inserting K-wires accurately in the femoral neck. These unique femoral neck properties that allow easy access, together with exact pre-operative three dimensions localisation allows the surgeon to place his K-wire in the tumour area with fluroscopy guidance. After the trephine, the rest of the tumour area should be curetted under fluroscopy guidance. Even it the tumour was seen with an image intensifier, curetting the surrounding area needs an exact pre-operative knowledge of the location. This is what we meant, “the operative strategy was based on findings from the pre-operative bone scan, CT, and MRI”. On a plain radiograph “the tumour could be seen with difficulty, as a faint shadow”. This is the reason that we don’t believe that fluroscopy is a good tool to localise for osteoid osteoma during surgery, but only as a transport to reach the area planned pre-operatively, and this is easily applicable to the femoral neck. If well-planned by those who are confident with the approach, it should be a straight-forward procedure. In case of doubt, as expected in many other areas, then we recommend to deal with each case on its merits. On reviewing Graham and Laverlick’s (1993) article, we believe they failed to excise a lesion at the trochanteric line because they did not define the lesion pre-operatively, and that was our point. When it was performed through the medullary canal it failed, while at the second operation they had a successful anterior approach. That was an intracortical osteoid osteoma, which could not be excised through the medullary canal, and that is what we recommended at the end of our article, “to excise intramedullary and internal cortex osteoid osteoma”.
In other words, not for external cortex or intracortical lesions, as they are not easily accessible through the medullary canal. We believe these recommendations are important for the success of this operation, otherwise this simple procedure might be abandoned due to some failures “it is an obsolete method”.
In contrast to other operations we thought the curette would provide a better assessment of the sclerotic area, and give more biopsy material. We agree that CT localisation is more accurate, but this should be left for lesions in difficult areas to avoid elongating and complicating the procedure. We do not consider excising a core from the femoral neck a contraindication, especially in growing children. Doubt about stability will be dealt with accordingly.
Radiofrequency has been reported for many years. It has its failures and contraindications. Near vital structures, the heat generated can be a problem.2 Together with neurovascular bundles, we believe the epiphyseal plate is one of them. It is complicated by intraoperative biopsy, otherwise the diagnosis would not be confirmed. When done through the hip joint directly through the femoral neck cortex, the risk of femoral neck fracture is more likely with drill biopsy under CT, and that is different from going through the subtrochanteric area. It is obvious that going through the same route would have the same effect on femoral neck stability. It appears that a number of points in our article were misinterpreted!
References
1. Iceton J, Rang M. An osteoid
osteoma in an open distal
femoral epiphysis. Clin Orthop 1986; 206: 162-65.
2. Rosenthal DI, Springfield DS, Gebhardt MC,Rosenberg
AE, Mankin HJ. Radiology
1995; 197: 451-54.
Mr M. Chaarani Department of Orthopaedics Hamad Medical Corporation Doha Qatar
Addendum
Surg J R Coll Surg Edinb Irel 2003 1: 1; 61
The following information was omitted from a letter by Ribeiro et al featured in the February issue of The Surgeon.
Re: “Potentially fatal oro-facial infections: five cautionarytales” J R Coll Surg Edinb 2002 47: 3; 585-586