Letters to the Editor
597
Reference 1. Farfus AW, Griffiths EA, Thompson SK, Devitt PG. Current Australian practice in the diagnosis and management of Barrett’s oesophagus. ANZ J. Surg. 2013; 83: 895–8.
Lindsay Grigg, FRCS (Eng), FRACS Canberra, Australia
3. Broeders JA, Broeders EA, Watson DI, Devitt PG, Holloway RH, Jamieson GG. Objective outcomes 14 years after laparoscopic anterior 180-degree partial versus nissen fundoplication: results from a randomized trial. Ann. Surg. 2013; 258: 233–9. 4. Lagergren J. Adenocarcinoma of oesophagus: what exactly is the size of the problem and who is at risk? Gut 2005; 54 (Suppl. 1): i1–5. 5. Wassenaar EB, Oelschlager BK. Effect of medical and surgical treatment of Barrett’s metaplasia. World J. Gastroenterol. 2010; 16: 3773–9.
doi: 10.1111/ans.12589
Dear Editor, Response to Re: Current Australian practice in the diagnosis and management of Barrett’s oesophagus We greatly appreciate Dr Grigg’s interest in our study, as documented in his letter.1 Dr Grigg provides an intriguing historical account of some of the early pioneers of surgery for gastrooesophageal reflux, including his personal experience of tutelage from Norman Barrett and Philip Allison. While the transthoracic approaches of Barrett and Allison had a strong anatomical basis,2 these procedures have now been superseded by modern laparoscopic anti-reflux procedures.3 We agree with Dr Grigg that all patients with severe reflux should be made aware of their options for treatment. All too often, we encounter patients that have a definite mechanical cause for their symptoms (i.e. a large hiatus hernia) and persistent symptoms on anti-reflux medication and yet no timely referral for an upper gastrointestinal surgical opinion. However, we do not think the increasing incidence of oesophageal cancer can be solely attributed to a decreasing occurrence of anti-reflux surgery. Morbid obesity, reflux and westernization are factors that cannot be ignored.4 Although it seems intuitive that surgical control of reflux would be more effective than medical control, no study has conclusively shown a lower risk of cancer progression.5 Therefore in many centres, Barrett’s oesophagus alone is not an indication for antireflux surgery. That said, we have just completed a study which evaluated the long-term effect of anti-reflux surgery in patients with Barrett’s oesophagus, using the catheter-free BRAVO probe to measure reflux. Preliminary results suggest that in those patients where there is an effective valve (i.e. 0% acid reflux into the lower oesophagus), there is a significantly higher incidence of Barrett’s oesophagus regression. In closing, as stated by Dr Grigg, certain groups of patients deserve an opportunity to discuss the merits of anti-reflux surgery with an upper gastrointestinal surgeon. In our unit, this includes those with a symptomatic large hiatus hernia, a severe reflux-related complication (i.e. peptic stricture), Barrett’s oesophagus with dysplasia, volume reflux and young patients wishing to avoid lifelong medical therapy.
Ewen A. Griffiths, MD Anthony W. Farfus, MBBS Peter G. Devitt, MS Sarah K. Thompson, MD Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia doi: 10.1111/ans.12663
Dear Editor, A complex Amyand’s hernia: strangulated hernia with incarceration of small bowel and vermiform appendix An 87-year-old patient was presented in the emergency department with a history of right lower abdominal pain and an onset of signs and symptoms of bowel obstruction with vomiting and not passing stools or flatus in the last 36 h. He had a previous right inguinal hernia repair with polypropylene mesh 4 years before. At examination, the abdominal was distended, painful in the right lower quadrant but not peritonitic. In the site of the previous right inguinal hernia repair, a non-reducible, incarcerated painful mass, significant for recurrent strangulated hernia, was present. The patient was brought to theatre for emergency operation. Inguinal incision was performed and after isolation and opening of the recurrent hernia sac, ischaemic strangulated small bowel loops were found and freed. However, the concomitant presence within the sac of a vermiform
References 1. Grigg L. Re: Current Australian practice in the diagnosis and management of Barrett’s oesophagus. ANZ J. Surg. 2014; 84: 596–7. 2. Stylopoulos N, Rattner DW. The history of hiatal hernia surgery: from Bowditch to laparoscopy. Ann. Surg. 2005; 241: 185–93.
© 2014 Royal Australasian College of Surgeons
Fig. 1. Intraoperative picture showing the strangulated ischaemic bowel and the vermiform appendix herniated in the hernia sac with inflamed and ischaemic tip.
598
structure was found (Fig. 1). The isolation of this structure revealed to be the appendix. Reduction of the strangulated small bowel, after careful assessment of its viability, was performed, as well as appendectomy. Hernia repair was performed avoiding mesh placement because of the potentially contaminated field. Pathology showed mild inflammation with ischaemic changes of the tip of the appendix. His post-operative course was uneventful. The Amyand’s hernia was described in an 11-year-old boy who presented with inflamed appendix in inguinal hernia sac perforated by a pin. In treatment of this case, a British surgeon, Claudius Amyand, in 1735 performed appendiceal resection and the case was published in Philosophical Transactions of the Royal Society of London.1,2 Dr Salomone Di Saverio, consultant surgeon, performed the surgical operation.
Corrigendum
2. Malayeri AA, Siegelman SS. Images in clinical medicine. Amyand’s hernia. N. Engl. J. Med. 2011; 364: 2147.
Salomone Di Saverio,*† MD Andrea Biscardi,† MD Gregorio Tugnoli,† MD Elio Jovine,* MD, PhD *Department of General Surgery, Emergency Surgery Unit, and †Departments of Emergency and Surgery, Emergency Surgery and Trauma Surgery Unit, Trauma Center, Maggiore Hospital, Bologna, Italy doi: 10.1111/ans.12660
References 1. Amyand C. Of an inguinal rupture, with a pin in the appendix caeci encrusted with stone; and some observations on wounds in the gut. Philos. Trans. R. Soc. Lond. 1736; 39: 329–36.
Corrigendum The publisher would like to draw the reader’s attention to errors in the following article: Fosh BG, Asokan G, Hainsworth A, Gilhotra A, Hoffmann C. Radiation-induced necrosis and calcinosis of the breast: a case report. ANZ J. Surg. 2014; 84: 489–91.
The name and qualifications for one of the co-authors should read ‘Beverley G. Fosh, FRACS, MD, MBChB, BSc (Hons)’. The authors apologize for the above errors and any confusion they may have caused. doi: 10.1111/ans.12780
© 2014 Royal Australasian College of Surgeons
597
Reference 1. Farfus AW, Griffiths EA, Thompson SK, Devitt PG. Current Australian practice in the diagnosis and management of Barrett’s oesophagus. ANZ J. Surg. 2013; 83: 895–8.
Lindsay Grigg, FRCS (Eng), FRACS Canberra, Australia
3. Broeders JA, Broeders EA, Watson DI, Devitt PG, Holloway RH, Jamieson GG. Objective outcomes 14 years after laparoscopic anterior 180-degree partial versus nissen fundoplication: results from a randomized trial. Ann. Surg. 2013; 258: 233–9. 4. Lagergren J. Adenocarcinoma of oesophagus: what exactly is the size of the problem and who is at risk? Gut 2005; 54 (Suppl. 1): i1–5. 5. Wassenaar EB, Oelschlager BK. Effect of medical and surgical treatment of Barrett’s metaplasia. World J. Gastroenterol. 2010; 16: 3773–9.
doi: 10.1111/ans.12589
Dear Editor, Response to Re: Current Australian practice in the diagnosis and management of Barrett’s oesophagus We greatly appreciate Dr Grigg’s interest in our study, as documented in his letter.1 Dr Grigg provides an intriguing historical account of some of the early pioneers of surgery for gastrooesophageal reflux, including his personal experience of tutelage from Norman Barrett and Philip Allison. While the transthoracic approaches of Barrett and Allison had a strong anatomical basis,2 these procedures have now been superseded by modern laparoscopic anti-reflux procedures.3 We agree with Dr Grigg that all patients with severe reflux should be made aware of their options for treatment. All too often, we encounter patients that have a definite mechanical cause for their symptoms (i.e. a large hiatus hernia) and persistent symptoms on anti-reflux medication and yet no timely referral for an upper gastrointestinal surgical opinion. However, we do not think the increasing incidence of oesophageal cancer can be solely attributed to a decreasing occurrence of anti-reflux surgery. Morbid obesity, reflux and westernization are factors that cannot be ignored.4 Although it seems intuitive that surgical control of reflux would be more effective than medical control, no study has conclusively shown a lower risk of cancer progression.5 Therefore in many centres, Barrett’s oesophagus alone is not an indication for antireflux surgery. That said, we have just completed a study which evaluated the long-term effect of anti-reflux surgery in patients with Barrett’s oesophagus, using the catheter-free BRAVO probe to measure reflux. Preliminary results suggest that in those patients where there is an effective valve (i.e. 0% acid reflux into the lower oesophagus), there is a significantly higher incidence of Barrett’s oesophagus regression. In closing, as stated by Dr Grigg, certain groups of patients deserve an opportunity to discuss the merits of anti-reflux surgery with an upper gastrointestinal surgeon. In our unit, this includes those with a symptomatic large hiatus hernia, a severe reflux-related complication (i.e. peptic stricture), Barrett’s oesophagus with dysplasia, volume reflux and young patients wishing to avoid lifelong medical therapy.
Ewen A. Griffiths, MD Anthony W. Farfus, MBBS Peter G. Devitt, MS Sarah K. Thompson, MD Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia doi: 10.1111/ans.12663
Dear Editor, A complex Amyand’s hernia: strangulated hernia with incarceration of small bowel and vermiform appendix An 87-year-old patient was presented in the emergency department with a history of right lower abdominal pain and an onset of signs and symptoms of bowel obstruction with vomiting and not passing stools or flatus in the last 36 h. He had a previous right inguinal hernia repair with polypropylene mesh 4 years before. At examination, the abdominal was distended, painful in the right lower quadrant but not peritonitic. In the site of the previous right inguinal hernia repair, a non-reducible, incarcerated painful mass, significant for recurrent strangulated hernia, was present. The patient was brought to theatre for emergency operation. Inguinal incision was performed and after isolation and opening of the recurrent hernia sac, ischaemic strangulated small bowel loops were found and freed. However, the concomitant presence within the sac of a vermiform
References 1. Grigg L. Re: Current Australian practice in the diagnosis and management of Barrett’s oesophagus. ANZ J. Surg. 2014; 84: 596–7. 2. Stylopoulos N, Rattner DW. The history of hiatal hernia surgery: from Bowditch to laparoscopy. Ann. Surg. 2005; 241: 185–93.
© 2014 Royal Australasian College of Surgeons
Fig. 1. Intraoperative picture showing the strangulated ischaemic bowel and the vermiform appendix herniated in the hernia sac with inflamed and ischaemic tip.
598
structure was found (Fig. 1). The isolation of this structure revealed to be the appendix. Reduction of the strangulated small bowel, after careful assessment of its viability, was performed, as well as appendectomy. Hernia repair was performed avoiding mesh placement because of the potentially contaminated field. Pathology showed mild inflammation with ischaemic changes of the tip of the appendix. His post-operative course was uneventful. The Amyand’s hernia was described in an 11-year-old boy who presented with inflamed appendix in inguinal hernia sac perforated by a pin. In treatment of this case, a British surgeon, Claudius Amyand, in 1735 performed appendiceal resection and the case was published in Philosophical Transactions of the Royal Society of London.1,2 Dr Salomone Di Saverio, consultant surgeon, performed the surgical operation.
Corrigendum
2. Malayeri AA, Siegelman SS. Images in clinical medicine. Amyand’s hernia. N. Engl. J. Med. 2011; 364: 2147.
Salomone Di Saverio,*† MD Andrea Biscardi,† MD Gregorio Tugnoli,† MD Elio Jovine,* MD, PhD *Department of General Surgery, Emergency Surgery Unit, and †Departments of Emergency and Surgery, Emergency Surgery and Trauma Surgery Unit, Trauma Center, Maggiore Hospital, Bologna, Italy doi: 10.1111/ans.12660
References 1. Amyand C. Of an inguinal rupture, with a pin in the appendix caeci encrusted with stone; and some observations on wounds in the gut. Philos. Trans. R. Soc. Lond. 1736; 39: 329–36.
Corrigendum The publisher would like to draw the reader’s attention to errors in the following article: Fosh BG, Asokan G, Hainsworth A, Gilhotra A, Hoffmann C. Radiation-induced necrosis and calcinosis of the breast: a case report. ANZ J. Surg. 2014; 84: 489–91.
The name and qualifications for one of the co-authors should read ‘Beverley G. Fosh, FRACS, MD, MBChB, BSc (Hons)’. The authors apologize for the above errors and any confusion they may have caused. doi: 10.1111/ans.12780
© 2014 Royal Australasian College of Surgeons
