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A Companion to Specialist Surgical Practice: Upper Gastrointestinal Surgery Second Edition. Edited by S.M. Griffin and S.A. Raimes, WB Saunders UK ISBN: 0702025879 £54.95
The second edition of the upper gastrointestinal surgery volume of the companion to specialist surgical practice is now available and provides a welcome update of this textbook. The text is ideal for those preparing for the intercollegiate exam and provides a well bibliographed overview of the practice of upper gastrointestinal surgery. As with the first edition, it should be remembered that this is very much set out as a textbook in most chapters, although some have become more discursive since the first edition.
The first edition was published in 1997 and since then, the references have been extensively updated. In addition, the chapters have changed authorship and to a certain degree in emphasis. I note there is additional emphasis put on gastrooesophageal reflux, whereas upper GI bleeding is now dealt with as part of the benign ulceration chapter. I think that the main addition to the book, which is part of the whole series, is the highlighting of certain areas with the scalpel code. The reader is drawn to these as important aspects of practice.
My only criticism of this, and it is indeed a very minor criticism, is that it seems different authors have used this in different ways. Some have used it simply to refer to areas of proven practice, whereas others have highlighted areas of controversy.
None the less, each is very appropriate and I think the idea, if it can be tightened up in further additions, is very valuable. In addition to this, the second edition has benefited from a number of high quality diagrams and clinical photographs, which have been added since the first edition.
In general, the changes that have been made have added to the quality of the textbook and I believe that the book remains essential reading for all those embarking upon subspecialisation in upper GI surgery.
Mr K Park Aberdeen Royal Infirmary
Surgical Critical Care R. Ashford and N. Evans Greenwich Medical Media ISBN 1841100668 £22.50
Surgical Critical Care is an easily read book in a ‘key notes’ type format which has been written as a revision aid for those under-taking the MRCS examination. It covers not only intensive care but also key elements of physiology and some anaesthesia and analgesia. The contents of the book are based on the syllabus of the MRCS examination of the Royal College of Surgeons of England and there are numerous cross references to the two standard texts Clinical Surgery in General (The Royal College of Surgeons of England, 3rd Edition) and Surgery (the Medicine Publishing Group). After most of the sections there are some key references. As a revision aid the aim is amply met and I am sure that the book will find a useful place. The other aim of the book is as a source of information for those working on a surgical intensive care unit and I am not sure that it will find a useful role here. Much of the text is in the form of lists and bullet points with many diagrams - these all make it a success as a revision aid. However, there is inevitably little in the way of padding, discussion and debate of the more controversial issues. The book could not be used as a stand alone text as it certainly requires some background knowledge. For example, one of the figures has a diagram of the chest on it along with a compliance curve. There are two arrows from the upper and lower portions of the chest. The reader would have to know about the differential effects of gravity on pressure and volume and hence compliance to be able to fully understand the physiological principles being outlined.
There are also some areas which are not strictly correct. Not all of the lung volumes given in one of the figures can be measured by spirometry as suggested in the text. Glutamine is a conditionally essential amino acid rather than an essential one. Dobutamine would not be a good choice of a blood pressure raising agent in those with head injuries and raised intracranial pressure since it is an inodilator. Also, in the same section it suggests that norepinephrine increases cardiac output but in fact it increases cerebral perfusion pressure by its vasoconstrictor action. Blood cultures should be added to the list of investigations for patients with sepsis. Conventional burr holes are no longer required for the insertion of intracranial pressure monitoring devices as these are now much smaller than in the past. These are all relatively minor points and I doubt that they would cause the candidate to fail this section of the examination.
There are also a few omissions. I could not find figure 3.9 although it is mentioned in the text. I also think that crush injury and the effects of raised intra-abdominal pressure could have been more comprehensively covered. It is suggested in the text that alkalosis (particularly metabolic alkalosis) is not that much of a problem and that there is little in the way of specific treatment required. In fact, alkalosis is more frequent than acidosis in the hospital setting and is indeed associated with a significant mortality and morbidity. It is usually iatrogenic and requires careful correction with fluids and electolytes - most commonly normal saline.
The check list for interpreting the chest radiograph is good and I would have added ‘is there a pneumothorax’ second down the list, lower only than ‘is this the correct patient’. It is essential to be able to read correctly the chest x-ray of a critically ill patient who may have in place an endotracheal tube, various lines and catheters as well as ECG leads confusing the interpretation. It is, therefore, good practice to have a plan and a list of questions to go through when looking at such a chest radiograph.
In summary, I am sure the book will find a place in the revision aids for those taking the MRCS examination and I think that it will help many to pass this section of the examination. I am not so sure that others, either those working on surgical ICU for the first time, or experienced practitioners, will find it a useful addition to their libraries.
Professor N Webster Aberdeen Royal Infirmary
A Companion to Specialist Surgical Practice: Transplantation Surgery: Current Dilemmas, Second Edition Edited by JLR Forsythe, WB Saunders ISBN 07020 2588 7 £49.95
This second edition as part of the companion and specialists surgical practice addresses current dilemmas within transplantation surgery and is aimed very much for higher surgical trainees and busy practitioners. In large measure it meets these goals and provides a readable, entertaining and informative update in current issues. It documents very clearly indeed the dilemmas faced in the United Kingdom with a decline in thoracic transplantation because of organ shortage and the pressures that this brings.
While I think this will prove invaluable to young surgeons, on an international basis, perhaps inclusion of the challenges faced in Europe and North America might be helpful. In particular in the Far East the whole ethical issues associated with live related liver transplantation and the risk to donors would I am sure be a valuable edition. I think it is a splendid series and a first class up date in this important area.
Professor P McMaster University Hospital Birmingham
Safe Transfer and Retrieval: The Practical Approach BMJ Books, UK 2002 ISBN 0727915835 £25.00
This book is produced by the Advanced Life Support Group, with contributions from a large body of medical, nursing, and ambulance service staff, edited by leading Emergency Medicine and Anaesthetic/ITU consultants. It is designed primarily to accompany the STaR (Safe Transfer and Retrieval) course, but it is also intended as a stand-alone text for any healthcare professional undertaking retrievals or transfers. The need for this course and book is explained by the increasing numbers of patient transfers in the United Kingdom, which is of course the result of inadequate provision of intensive care beds.
The book is divided into five main parts: Part one addresses the principles of the StaR approach, and thus provides an introduction and overview. Part two deals with the management of the transfer or retrieval, with particular emphasis on communication, patient evaluation, safe transportation and arrival at the receiving unit. Part three discusses practical procedures, including useful advice on securing tubes and lines, radio communication procedure, and a bit of a novelty for medical texts, a chapter on moving and handling the patient - a sensible inclusion in this context. Part four provides an overview of the clinical care, based very much around an ABC Primary Survey and resuscitative approach and, includes both trauma and medical problems. The Special Situations chapter includes useful sections on paediatrics, burns, and head injuries. Part five covers legal and safety aspects, and there is a very brief section on helicopter transfers
The style includes helpful checklists highlighted in boxes, but the book would be more reader friendly if there were some (any!) photographs to liven it up. I suspect that the book suffers here, and in other areas, because it accompanies a course, which presumably contains the visual material. It is also rather surprising that there is really no practical advice on the range of drugs which should accompany a patient for analgesia, sedation and paralysis, whilst the paediatric transfer equipment list includes nearly every intravenous fluid known to man, along with five antibiotics. I think the section on anaphylaxis is unhelpful (IM epinephrine does not require ECG control but the IV route does), and it is not clear that it refers to the patient group in question, given that the reader is advised to admit the patient for 8-12 hours - I thought they were going to ITU anyway!
I am not convinced by the need for a section on “advanced message handling” for radio communication. Ambulance personnel are very well trained in this area, and will happily take responsibility for this role, leaving medical staff free to manage the patient. I personally usually find the latter quite challenging enough.
In summary, although there is much that is good in this book, and many useful hints, it would not inspire me to buy it for its own merits. The systematic approach and practical advice might persuade me to do the STaR course, however, and I think the combined product would be much more satisfying.
Mr N Nichol Ninewells Hospital and Medical School Dundee
Urology Highlights 2001-02 Edited by J Shah Health Press 2002 ISBN 1903734118 £15.00
As the editor says in the preface many changes take place in one year in a subject such as urology. Most of us don’t have time to look through the vast number of journals that come through the post, so it is pleasant to browse through a well written synopsis of the latest papers on subjects from the prostate, urological tumours, female incontinence, sexual dysfunction, reconstructive urology and endourology.
On each subject there was a summary: WHAT’S IN, WHAT’S NEW, WHAT’S OUT. Some of the synopses were erudite science and others were on basic every day urology such as the use of Finasteride to treat haematuria associated with BPH. The knotty problem of follow-up with microlithiasis of the testis, whether TVT - tension free vaginal tape-slings are more benefit than colposuspension, synthetic materials for penile reconstruction in Peyronie’s disease are OUT and insitu appendix continence stomas with rectus muscle wrap all NEW and in.
I found it easy to read, and very reasonably priced at £15.00. All authors were leaders in their field. It did, however, take me longer than one hour to read which the editor said it would take, but then I read carefully. Very useful for any urology department to buy and keep as a good read.
Ms Christine Evans Glan Clwyd Hospital, Rhyl
Oculoplastic Surgery Atlas - Eyelid Disorders Edited by Geoffrey J Gladstone, Evan H Black, Shoib Myint, Brain G Brazzo and Frank A Nesi ISBN 0-387-95316-7 £66.50
This text is aimed at ophthalmologists, oculoplastic surgeons, ENT and general plastic surgeons. It adopts a novel approach combining relatively brief but lucid descriptions of eyelid surgical procedures with digital video footage on CD-ROM (make sure you have Windows 95 or 98; I found it would not perform on Windows 2000). The text and surgical atlas, which takes the form of black and white drawings throughout the text mirrors the video footage and provides a stimulating format. It is most readable and user friendly and would provide a very useful aide memoir for all involved in eyelid surgery. The section on surgical anatomy is well written, my only disappointment being the use of a cadaver rather than a live patient in demonstrating the surface anatomy. The range of procedures presented is adequate but not comprehensive. For example the only procedures described for involutional entropion correction are capsulopalpebral fascia reattachment and Quickert sutures. Upper lid entropion and blepharoplasty are not mentioned. Ectropion is well covered and there is an excellent description of lateral canthal strip, a procedure that is becoming increasingly popular for all causes of lower lid laxity. The authors go into some detail describing procedures for eyelid retraction in thyroid disease. It has an excellent chapter on ptosis surgery with a good description of the preoperative evaluation and the section on eyelid reconstruction is a standard review of available procedures.
There is no mention of basic suturing techniques or tissue handling, eyelid anaesthesia, the complications of surgery or how to manage them. For surgeons other than ophthalmologists the importance of corneal protection could have been emphasised. The authors use catgut sutures frequently and surgeons in the UK would have to find an alternative to this.
If it weren’t for the video CDs I would not recommend this book, but at the price of £66.50 with a comprehensive video collection of most of the common procedures, most practicing eyelid surgeons would find it a worthwhile purchase.
S T D Roxburgh Ninewells Hospital and Medical School, Dundee
I have read with interest the article entitled “Risk group-based management of differentiated thyroid carcinoma” by Kuriakose et al that was published in the August 2001 issue of the Journal. This article reviews the available literature on treatment of differentiated thyroid cancer including extent of surgery, radioactive iodine therapy, use of post-operative thyroid suppression medication and the treatment of lymph nodes.
The authors also reviewed prognostic factors in risk group assignment. In this portion of the manuscript, they described the influence of age, gender, tumor size, extrathyroidal extension, tumour multifocality, and nodal and distant metastases.
Only one paragraph on histology of the tumour as a prognostic factor is included. However, they have included four multipart figures each comprised of four photomicro- graphs of the histology of thyroid neoplasms.
It was disturbing to me to examine these photos and the accompanying legends since I think there are diagnostic problems in all of the illustrations. For example figure 1 is entitled “follicular carcinoma;” in fact it is a follicular variant of papillary carcinoma based on the nuclear features seen in figure 1 C. What is described, as “vascular invasion” is also problematic since it appears that the lining of the space in which the tumor is present looks epithelial. In this case, immunohistochemical stains for endothelial and epithelial markers are needed to prove whether these are epithelial cells or endothelial cells. Obviously, if they are epithelial this is just an artifact of tissue fixation and sectioning and does not equate with vascular invasion.
Figure 2 is diagnosed as a “follicular adenoma with Hurthle cell change”. Hurthle cells are defined as oncocytes or eosinophilic cells and that implies that they should show an eosinophilic or pink cytoplasm on hematoxylin and eosin stain. However figure 2 C has basophilic cytoplasm. It is also of concern because the nuclei here at least raise the possibility of a medullary carcinoma.
Figure 3 is entitled “tall cell follicular variant of papillary carcinoma”. I do not understand what this designation means. There is a category of tall cell papillary carcinoma and of course there is follicular variant of papillary carcinoma. In my experience it is unusual to have a combination of the two but when it does occur, it is considered papillary carcinoma with mixed histology; it is not categorized as a tall cell follicular variant. The statement is made in figure 3 that “this variant of papillary carcinoma (and I assume that means follicular variant) may be difficult to distinguish from follicular adenoma” That is certainly true but in figure 3 A the lesion is obviously infiltrative and an adenoma would not grow in that fashion.
Figure 4 is entitled “papillary carcinoma” and is considered a “classical papillary carcinoma”. However, figure 4 D shows tall cell histology.
In addition, the text of the article does not include some very important recent data, which showed that in papillary thyroid carcinoma, the presence of vascular invasion is an important prognostic indicator. 1 Certain histologic features such as marked pleomorphism, spontaneous tumour necrosis, and extensive mitotic activity including abnormal mitoses are predictive of poor prognosis in papillary carcinoma. 2,3
The stated intent of this article to review and evaluate the current concepts of management of differentiated thyroid carcinoma is a good one. However, as with all research endeavors, new knowledge can be gained only if one relies on known established facts. One of the established facts for differentiated thyroid carcinoma is the histologic classification of these various tumours into specific groups with specific histological data points. The histologic criteria for the differentiation of these tumour groups are well known, but they are not expressed in the illustrations in this publication. 4
It is hoped that whatever group or multi-institutional groups attempt to evaluate risk and assess management issues in differentiated thyroid carcinoma in the future, that some very basic data such as clinical factors, demographic and epidemiologic factors, and pathologic (especially histologic factors) will be taken into account prior to examining differences in therapeutic modalities.
Yours Sincerely,
V. A. LIVOLSI M.D.
Professor of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, Philadelphia, PA, USA
Sir,
We appreciate the comments by Dr. LiVolsi, an expert and respected thyroid pathologist, who has raised several important points we would like to clarify.
The case illustrated in figure 1 fulfills the criteria both clinically and pathologically for a follicular carcinoma. Figure 1c contains somewhat enlarged neoplastic follicular cells some of which display nuclear features we have attributed to fixation artefact. Figure 1d is a blood vessel with prominent “epithelioid” appearing endothelial cells. The space showing invasion is a blood vessel where its muscular wall was more evident at much lower magnification.
Figure 2 illustrates principally a follicular adenoma with Hurthle cell change; the Hurthle cell change was present in approximately 20% of the adenoma. There is no evidence of medullary carcinoma and there are no amyloid deposits, as one would expect to find in a patient with medullary carcinoma.
The legends for figure 3 and 4 have unfortunate typographical errors and we agree with Dr. LiVolsi’s comments that figure 3 is a follicular variant of papillary carcinoma while figure 4 is a papillary carcinoma with tall cell features. We regret these typographical errors.
The purpose of our articlewas to provide a treatment algorithm to manage patients with differentiated thyroid carcinoma, which may be used to make key treatment decisions- the extent of surgical resection (lobectomy versus total thyroid-ectomy), role of radioiodine treatment, thyroxine suppression and the treatment of nodes. Prognostic factors such as vascular invasion and other histologic features are important and has been reported in the literature. For this review, we have selected only those prognostic factors which are validated through large studies with long-term follow up and proved to be significant in assigning patients to different prognostic risk groups.
Improvements in these prognostic criteria are required for further refining the risk groups, particularly the patients in the intermediate risk group. With the improved understanding of the genetic basis of thyroid carcinoma, it is quite likely that the emerging molecular prognostic markers, briefly outlined in the paper, may assist in this process. However, a practicing clinician at present can offer a selective treatment approach based on assigning patients to the currently established prognostic risk group.
Yours sincerely,
M. A KURIAKOSE M.D. H.YEE M.D, PhD
Division of Head and Neck Surgery and Department of Pathology, NewYork University School of Medicine, NewYork, NY 10016, USA
REFERENCES
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RB, Ringel MD. Prognostic importance of vascular
invasion in papillary thyroid carcinoma. Arch
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309-312
2. Akslen LA. Prognostic importance of histologic grading in papillary thyroid carcinoma. Cancer 1993; 72:
2680-2685
3. Akslen LA, LiVolsi VA. Prognostic significance of
histologic grading compared with subclassification
of papillary thyroid carcinoma. Cancer 2000; 88:
1902-1908
4. Rosai J, Carcangiu ML, De Lellis RA. Tumors of the Thyroid Gland Fascicle 5; series 3, Atlas of Tumor
Pathology. Washington, DC, Armed Forces Institute
of Pathology, 1992