Book Reviews

Critical Care Focus - 8 Blood and Blood Transfusion                                 
Helen F. Galley (Ed.) 
BMJ Books
ISBN 072791657 
£14.95

This is the eighth book in a series produced by BMJ Books in conjunction with the UK Intensive Care Society. It is mainly based on transcriptions from lectures given at meetings. As such it cannot be viewed either as comprehensive or altogether independent. It consists of seven chapters and a total of 85 pages. This book is a mixed bag and it is unclear as to who the target audience is or the message it is trying to put across. 

The book starts off with a chapter entitled ‘Transfusion requirements in critical care’, and is a description of the transfusion requirements in a critical care (TRICC) study performed by the trials group of which the author is a member. Discussion of why critically ill patients need blood is virtually absent as the chapter concentrates on the trial itself. This format is repeated in the chapter on protein C with virtually all of it devoted to the intricacies of the recent PROWESS trial. There are also some inaccuracies which most likely have arisen from errors in transcription such as, ‘removal of the cause such as intravenous antibiotics’, when referring to the control of bleeding and mixing up sepsis and infection. I enjoyed the chapters on transfusion-related acute lung injury and the use of colloids in the critically ill but feel the one on radical reactions of heam proteins to be out of context and too scientific compared to the rest of the book.

I cannot recommend the individual to buy this book. If your library has it then it may provide a starting point to delve into the topics that it covers. It is one of a series and as such probably should adorn training room shelves.

Mr S. Stott 
Aberdeen Royal Infirmary 
Aberdeen U.K.

Surgical treatment of haemorrhoids 
Charles V. Mann (Ed.) 
Springer 
ISBN 1852334967

The author of this text on haemorrhoids is to be congratulated for putting together a superb text book on this subject. In many respects it is an outline of the specialty of coloproctology itself. Nonetheless, the subject matter concentrates on haemorrhoids. It starts off with an excellent history of haemorrhoids taking us through from the Egyptian era through to the Romans, the barber surgeons, through the age of enlightenment to the modern era. Anatomy and physiology are well-covered and the author outlines the various theories of causation of haemorrhoids. The chapter on diagnosis is well worth reading and is comprehensively outlined, both in the early chapter and in the pre- and peri-operative work-up of the patient. Different approaches to haemorrhoidectomy are covered by experts in the field. It was somewhat surprising to see a chapter on anal dilatation in this era, when it has largely ceased to be normal practice in the management of haemorrhoidectomy; nonetheless, it provides completeness from a historical perspective.

Throughout the text where the editor was not the first author he has provided helpful comments, which add a personal touch to this text and echo his wide experience over a long career. Indeed, his thoughtful comments on the whole range of perianal symptoms and conditions provide a benchmark that could provide an excellent foundation for the senior colorectal trainee or junior consultant. Every historical and technical aspect is covered. The management is outlined in the most practical manner that illustrates in great detail every aspect of treatment with guidance on ‘how to do it’, from history taking, examination, differential diagnosis and treatment. There are thought-provoking arguments that testify to the practical experience of the authors.

There has been a huge amount of interest in stapled haemorrhoidectomy in recent years and it is inevitable that in a textbook of this type that the coverage is relatively sparse, since at the time of writing there will have been little in the published literature. The editor admits to not having experience in this area and his comments clearly reflect this.

There is much to commend this text. The chapters written by the editor are full of practical tips about whom to operate on and more importantly whom to treat conservatively. Clues as to where one should delve further and consider alternative diagnoses are well-covered. Indeed there is little in coloproctology that is not in some way referred to in the book. It may appear to be a relatively restricted subject but the book is comprehensive and worth reading.

This text can be recommended to the trainee and practicing surgeon and should represent a benchmark in the state of the art of haemorrhoid surgery.

Mr D.C.C. Bartolo 
BUPA Murrayfield Hospital 
Edinburgh U.K.

Shackelford’s Surgery of the Alimentary Tract (Vol. 5 of 5 Volume Set) 
George D. Zuidema, Charles J. Yeo, Keith D. Lilliemoe 
Saunders, 2001 
ISBN 0721682081 £145.00

This is a monumental text with over 40 authors drawn entirely from the United States. The quality of production, hard backed on quality paper is extremely high. There are ample line drawings, photographic reproductions of anatomical materials and x-rays with occasional photographs. There is no use of colour and as such some of the operative photographs are difficult to interpret. Diagrams range from old style, with fine detail drawings, to the more modern simple line diagrams. There are ample and recent references at the foot of each section.

The book covers both theoretical and practical aspects of operative surgery. Each section begins with a historical perspective. Surgical anatomy is covered in considerable detail. Clinical presentation and investigations are described. There is appropriate discussion of surgical approaches and materials. Operative technique is described in some detail but this is not an operative manual step-by-step guide.

The text is well up to date as illustrated by the comprehensive discussion of laparoscopic hernia surgery. This book seems to be aimed at the advanced post-graduate surgeon. It is perhaps too detailed for those preparing for examinations that generally prefer a more concentrated text. Any surgeon wishing to explore the history of surgery and the application of anatomy to the development of operative techniques could do no better than to start here. However, this book is much more than a historical perspective. It is a modern and up to date textbook of surgery. I can highly recommend it.

Mr S.J. Nixon 
Edinburgh Royal Infirmary 
Edinburgh, U.K.

Surgery of the Alimentary Tract, 
Fifth Edition, Volume IV - Colon 
John J Pemberton (Ed.) 
Shackleford
ISBN 0721682073 £145.00

The fifth edition of Shackelford’s world famous series presents itself as an imposing tome. It is comprehensive in its approach. It is rather old fashioned in appearance with not a single colour illustration in the entire book. It certainly makes no attempt to use modern publishing approaches to education - there are no highlighted bullet points or boxes with practice points here. Having made these minor criticisms, what is in the book?

The author list is almost exclusively North American in origin and this is reflected in the tone and presentation of many of the chapters - as is only reasonable bearing in mind the main audience in the US. As a multi-author book the editor has done a fine job of ensuring a high degree of uniformity of presentation and style. For the most part the illustrations are of high quality particularly the excellent line drawings by David Factor at the Mayo Clinic. Bearing in mind the lead time in publishing it is almost inevitable that any fully referenced textbook will be missing some new and exciting references by the time the book hits the shops. This is true for this book but the bibliography is generally impressively current. In general, the authors have done a good job in updating somewhat standard reviews of standard subjects with recent developments - an easier job for some than others. For example, it is suggested that coil embolotherapy for massive colonic bleeding only be undertaken in desperate situations due to the risk of bowel infarction whereas, in fact, this has been shown not to be true using modern techniques. This omission has resulted in the presentation of a management algorithm for bleeding that I feel is rather outdated.

As with most texts from the US, trans-anal endoscopic microsurgery (TEMS) for rectal neoplasms gets pretty short shrift, rating only a single paragraph. At this stage I think it was rather myopic and the editor could easily have rectified this omission by seeking a European contribution on what is a genuinely important technique.

This book should be on the office bookshelf of every serious colorectal surgeon. It might not be the easiest reading experience but the information is there for the most part and will be regularly accessed, largely as a reference text.

Mr J.R.T. Monson, 
University of Hull 
Hull, U.K.

Female Reconstructive Pelvic Surgery 
Stuart L. Stanton, Philippe E. Zimmern (Eds.) 
Springer 
ISBN 1852333626 £120.00

An easy to read extensively covered book on the female pelvic floor is welcome. The editors are well known and have collected a number of eminent authors to contribute - most leaders in their field. The book covers the anatomy, the causes of incontinence and prolapse with MRI and ultrasound scan as well as diagrams.

The investigations cover both urodynamics and ano-rectal investigations although in this section video urodynamics (not routinely used in in urogynaecology) are barely mentioned and most urologists would use them more frequently. The section on congenital abnormalities is excellent.

There are chapters on all the present  techniques of stress incontinence surgery, injectables, retropubic suspension, slings including tensionfree vaginal tape. The latter seemingly having overtaken all other techniques. We are awaiting the long-term results of this procedure but it has been received with enthusiasm due to the ease of the procedure, the short hospital stay and despite the cost of the equipment, the reduction in cost.

There is a brief chapter on artificial urinary sphincters. The book also covers anal sphincter repair. It is good to see all aspects of surgery in one book together.

There are sections on neuromodulation for urge incontinence, pelvic pain syndromes and idiopathic retention as this is a newer procedure which undoubtedly will benefit a large group of patients who are poorly managed at present; although how many specialists will take up this technique remains to be seen.

This is a useful book and essential for a urogynaecological, urological and lower gastro intestinal surgery department. This group of surgeons is beginning to work together. This book reinforces the need for closer cooperation in the management of female pelvic floor problems between these specialist surgeons and doctors.

Miss C. Evans
Glan Clwyd Hospital 
Bodelwydden 
RHYL 
Clywd U.K.

Advances in Gynaecological Surgery 
Edited by Peter J. O’Donovan and Ellis G.R. Downes 
GMM Publishing 2002 
ISBN 1900151499 £55.00

Gynaecological practice has undergone enormous change over the past 25 years. Many procedures, which required in-patient management and general anaesthesia, are now performed  in an outpatient setting under local anaesthesia or without anaesthetic.

This change in the nature of gynaecological practice which has become more ‘medicalised’ has been accompanied by a wave of new surgical techniques some of which represent real advances in gynaecological surgery. The principal feature of this change has been the advent of laparoscopic and endoscopic procedures, developed on the back of technical advances in operating equipment. Pioneering surgeons, several of whom are contributors to this book, have enthusiastically demonstrated the feasibility of these new procedures and have changed the nature of this area of surgical practice.

The portfolio of surgical developments are described in this book which is a timely update not only of the procedures but of the evidence for their effectiveness. It is true that the ‘advances’ in technique have been followed sometimes by a long delay in seeing clinical trials, which compare the new operations with standard procedures. In some cases no robust trial evidence is available. More emphasis could have been placed by the authors on this aspect in these days of NICE.

On the other hand the book contains a concise account of new procedures with an assessment of their role. It is generally well illustrated, nicely formatted and easy to read. The contributors are all well known for their expertise in this field. The only notably absent topic is laparoscopic surgery for ectopic surgery, which is now an established technique. In conclusion, this book is an indication that the new gynaecological surgery has come of age. Although such books look dated after a while, it should continue to look fresh for 3-4 years at least during which time all grades of postgraduates will find something of interest, particularly at SpR stage.

Professor H. Kitchener 
Manchester U.K.

Source Control A Guide to the Management of Surgical Infections 
by Moshe Schein & John C. Marshall 
Springer Verlag Germany 2002 
ISBN 3540429735 £56.00

It is very difficult to know what readership the editors had in mind when this book was planned. In its totality it is likely to appeal only to those who are already members of the Surgical Infection Society, but very few individuals will require information about such a wide range of infections.

The concept of source control in managing surgical infections is clearly very important but many surgeons would suggest that within their own area of special interest it is a principle which is already well established.

The initial impression of this volume is dull and is unlikely to be attractive to any browser. The format within each chapter is very variable - sometimes there is one editorial comment, sometimes two and sometimes none at all. The concept of having a contribution followed by an invited commentary is excellent but in this book it does not work in no small part because in some chapters four different opinions are being expressed and the reader is left in some confusion about what is standard policy and what is not.

To compound the problem, several topics are dealt with in a number of different chapters, best exemplified by relaparotomy for sepsis or the problems associated with gastrointestinal perforation or anastomotic failure. Some of the chapters are discursive while others are very short and didactic and the method chosen does not appear to relate to the overall importance of the subject being discussed.

This is not a book which I would recommend to anyone with a general interest in infection and even the specialist in this field would be unlikely to find it helpful.

Mr J.A.R. Smith 
Sheffield, U.K.

Immunology for Surgeons 
A.P. Zbar, P.J. Gillou, K.I. Bland and K.N. Syrigos (Eds) 
Published by Springer-Verlag London, 2002
ISBN 1852334827 £49.50

Immunology is a diverse and burgeoning discipline, whose concepts and methods have important implications for many fields of biology and medicine. Hence the appropriateness of the current volume, which sets out to highlight aspects of immunology relevant to surgeons. The major area for consideration is tumour immunology, and there are excellent sections on trauma and sepsis, allo and xeno transplantation, immune deficiency and mucosal immunology.

The task undertaken is made difficult both by the different levels at which immune responses can be viewed, from molecular mechanisms through cellular interactions to whole body and population responses; and the complexity of interactions that these analyses reveal. Immunology is also a young field, with rapid developments which sometimes leads to controversial changes in approach. The introductory chapter to the book is very helpful in this regard, introducing ideas such as the Danger Model, which has stimulated much debate and experimentation about the nature of immunogenicity - what controls the extent of an immune response to an antigen.

This issue is of course fundamental for several relevant areas of immunology, particularly tumour immunity and mucosal immunology. The traditional view has emphasised the importance of the T cell receptor repertoire, with deletion or tolerisation of T cells capable of recognising self antigens seen as the pre-eminent mechanism for avoiding self reactivity and responding to non-self. This is now complemented by consideration of the role of the innate immune system, highlighted by Janeway’s memorable exposure of ‘the immunologist’s dirty secret’ - the fact that antigens often do not induce an immune response unless they are mixed with microorganisms or other irritants (adjuvant). The cellular mechanism underlying this process centres on dendritic cells, which are now recognised as the critical antigen presenting cell for the induction of naïve immune cells.

Related to this is the means by which naïve class I restricted T cells are activated. Because of the dogma that only endogenously synthesised antigens can be presented by class I MHC molecules, it had been assumed that tumour cells would have to directly activate T cells to induce a CD8 T cell response. Lack of responses was ascribed to inadequate expression of costimulatory molecules by tumour cells, and this view is repeated in several of the chapters of the book. However, there is now much evidence to show that dendritic cells can take up exogenous antigens and present them via their class I antigens, a process known as cross-presentation or cross-priming. This shifts the focus from the tumour cell to the dendritic cell: the costimulatory and activation signals the dendritic cell receives seem to determine the outcome of the interaction with naïve T cells.

These issues receive little airing in the body of the book, and whilst definition of the exact roles for danger signals, cross priming and dendritic cells are not fully clear, their contribution surely deserves a more balanced consideration. This is especially so in the case of dendritic cells, when numerous clinical trials directly investigating dendritic cell immunisation are in progress. One is also surprised that there is little emphasis on the measurement of antigen specific T cells, where new technologies are revolutionising the way in which specific responses to tumour antigens can be quantified. MHC-peptide tetrameric complexes, intracellular cytokine analysis, and elispot are briefly mentioned in the chapter on melanoma, but none of these appear in the index.

Some of these shortcomings are perhaps the consequence of the multiauthor format; this has the advantage of excellent articles in specific topic areas, but it is very difficult to avoid overlap on one hand (for example, there are quite a few diagrams of the ‘conventional’ view of antigen processing) and major gaps on the other; timeliness is also an issue. Some of these shortcomings are mitigated by ‘commentary’ pieces, which draw together take home messages from each section of the book and are a useful addition.

Overall, this book has many attractive features: it draws together expert views in diverse areas of immunology that are relevant to surgical practice. However, its limitations must also be recognised, particularly the lack of a balanced, up to date view of critical issues in cellular immunology of tumours.

Dr R.A. Robins 
Nottingham University Medical School 
Nottingham, U.K.