and that associations with low infant growth rates are partly determined before birth.' It is not clear what D P Davies and J Matthes mean by "nutritional and metabolic stress." Whatever it is, for their explanation to be correct it would have to be independent of social class to explain our observations. In the Hertfordshire study birth weight and plasma glucose, insulin, and proinsulin concentrations were not related to social class, either at birth or currently. D J P BARKER C FALL C OSMOND P WINTER
MRC Environmental Epidemiology Unit, University of Southampton, Southampton S09 4XY C N HALES LORNA COX P M S CLARK Department of Clinical Biochemistry,
Addenbrooke's Hospital, Cambridge CB2 2QR 1 Barker DJP, Winter PD, Osmond C, Margetts B, Simmons SJ. Weight in infancy and death from ischaemic heart disease. Lancet 1989;ii:577-80. 2 Barker DJP, Bull AR, Osmond C, Simmonds SJ. Fetal and placental size and risk of hypertension in adult life. BMJ
1990;301:259-62. 3 Barker DJP, Meade TW, Fall CHD, Lee A, Osmond C, Phipps K, et al. The relation of fetal and infant growth to plasma fibrinogen and factor VII levels in adult life. BMJ (in press).
Injuries to common bile duct during laparoscopic cholecystectomy SIR,-I recently returned from attending the annual clinical meeting of the American College of Surgeons in Chicago. The surgeons attending numbered roughly 10 000 from all over the world, and there were various experts from every centre in the United States. Just before I went to the meeting I was disturbed by a report by a leading biliary tract surgeon in the United Kingdom that he had experience of 10 patients who had sustained damage to the common bile duct during laparoscopic cholecystectomy. I determined that in Chicago I would ask every biliary tract surgeon what his or her experience was. I report my findings. I spoke to biliary tract surgeons from numerous American cities and from many other countries. All the surgeons, without exception, reported that they had seen or heard of damaged common bile ducts from laparoscopic cholecystectomy out of all proportion to the damaged ducts from open surgery. From the first four discussions I had with surgeons-Claude Welch, Ken Warren, Olga Johannson, and Bill Longmire-I "collected" more than 30 injuries to the common duct seen by these surgeons after laparoscopic cholecystectomies. Many surgeons reported that they had experience of other injuries, such as injury to the portal vein or small and large bowel. My conclusions are as follows. Firstly, laparoscopic cholecystectomy requires technical skill and should be performed by only a skilled biliary tract surgeon. I have no possible reason to obstruct the advance of surgery, and if surgeons with skill, experience, and judgment perform laparoscopic cholecystectomy on a number of patients I would not dream of criticising them. Secondly, for a general surgeon whose skill as an operator is not above average and who is not prepared to become a specialist in biliary surgery, laparoscopic cholecystectomy is far too often a recipe for disaster- a keyhole scar and catastrophe within.
BMJ VOLUME 303
7 DECEMBER 1991
Thirdly, the surgical colleges should take note of the position and arrange their teaching programmes accordingly. Finally, a general surgeon who is not an expert on the biliary tract and has a disaster with laparoscopic cholecystectomy should study the legal position and understand that he or she may be accused of negligence in performing an operation beyond his or her compass. RODNEY SMITH House of Lords, Westminster SW IA OPW
Bile duct stones and laparoscopic cholecystectomy SIR,-David Scott-Coombes and Jeremy Thompson's editorial on bile duct stones and laparoscopic cholecystectomy leaves not only some bile ducts unexplored but some issues too.' The main difficulty is embodied in the first two sentences. If I may paraphrase, the authors say: "Patients with symptomatic gall bladder stones may also have stones in the common bile duct." How do you know which stone is symptomatic? The clinical criteria they quote are all indicators of an obstructive episode in the common bile duct. To operate then on the gall bladder, with a 50% chance of cholangiography and an even lower chance of successful exploration and removal ofthe stone through the laparoscope, or conversion to open surgery for conventional exploration of the duct, with between 6% and 20% of missed stones at the end of it, smacks of surgical hubris. In Brighton, which has a population of 300 000, most obstructions of the bile duct are managed endoscopically. Thus there were 100 fewer cholecystectomies in 1990 than 1980 (164 v 262). Bile duct stones have been found more often, but their management has swung to endoscopic retrograde cholangiopancreatography. In 1980 there were 27 surgical explorations and 20 sphincterotomies (our first year of endoscopic retrograde cholangiopancreatography). In 1990 there were 15 surgical explorations and 78 endoscopic explorations. These figures apply only to residents of Brighton Health District. If there is evidence of obstruction of the common duct then surely that is the primary target of care, with some guarantee to the patient that the probable cause of the pain will be dealt with. Younger patients may well be recommended to have cholecystectomy for their other stones, though the reasons, if they are by then symptom free, are hard to find. Similarly, the authors' reference 31, to a paper by Neoptolemos et al,2 stretches the point a little far. The paper showed no advantage in terms of morbidity and mortality in fit patients who had either conventional open surgery-cholecystectomy, cholangiography, and exploration where indicated -or preliminary clearance of the bile duct at endoscopic retrograde cholangiopancreatography. From the numbers in their series it is clear that most of the patients managed endoscopically would not now proceed to cholecystectomy. We know little about the likely morbidity and mortality of laparoscopic exploration of the bile duct. Selection for cholangiography leaves a high failure rate, so that the whole strategy of the editorial seems to leave half the selected patients with their original problem- stones in the common duct-and facing a further procedure.
versus surgerv alone for common bile duct stones. 1987;294:470-4.
BMJ7
SIR,-Although there is good evidence to support the practice of selective cholangiography at open cholecystectomy, the same is not yet true for the laparoscopic procedure. Just as in the past surgeons in training struggled to learn intraoperative cholangiography at open surgery, so they must now adapt to the different skills required for laparoscopic cholangiography. David Scott-Coombes and Jeremy Thompson state that technical failures occur at laparoscopy in up to a quarter of cases, but the success rates of 90% reported in other series have been achieved only by perseverance and practice.' 2 The time to learn is during routine operation and not when it becomes mandatory, such as when choledocholithiasis is suspected after failed endoscopic retrograde cholangiopancreatography or when the biliary anatomy cannot be readily identified. Furthermore, the laparoscopic surgeon does not have the advantage of being able to palpate the biliary tree.3 It is not uncommon to encounter cystic duct stones during attempted laparoscopic cholangiography which would be left in the proximal cystic duct stump if operative cholangiography was not performed. We agree that preoperative endoscopic retrograde cholangiopancreatography is inappropriate but cannot understand why intravenous cholangiography should be recommended as a useful screening method when it was abandoned by many surgeons owing to its poor results and allergic reactions. We recommend that laparoscopic cholecystectomy should be accompanied by routine peroperative cholangiography. It prevents the need for preoperative endoscopic retrograde cholangiopancreatography and allows any ductal stones identified at operation to be managed by laparoscopic exploration or postoperative endoscopic retrograde cholangiopancreatography. It also reduces the risk of "silent" bile duct stones going undetected and at the same time allows the laparoscopic surgeon to become proficient in the technique. It should also be performed in patients with proved choledocholithiasis who have already undergone apparent clearance of the common bile duct by preoperative endoscopic retrograde cholangiopancreatography and sphincterotomy as in our experience this investigation does not guarantee a clear duct. In a recent prospective study in our unit of 82 patients undergoing laparoscopic cholecystectomy the time taken to dissect the gall bladder in those undergoing operative cholangiography (n= 60) was only 15 minutes longer (mean 81 (range 32-166) minutes) than that in patients not undergoing cholangiography (n=22; 66 (18-154) minutes). Among the 60 patients in whom operative cholangiography was attempted there were seven failures and eight abnormal cholangiograms (five of these patients were subsequently shown to have
choledocholithiasis). Based on our own experience we recommend that surgeons should follow a policy of routine operative cholangiography in all cases. Well established surgical principles for open procedures must not be abandoned just to facilitate the
laparoscopic procedure. S PATERSON-BROWN 0 J GARDEN
Department of Surgery, Royal Infirmary, Edinburgh EH3 9YW
ANDREW CLARK Royal Sussex County Hospital, Brighton BN2 5BE
1 Scott-Coombes D, Thompson J. Bile duct stones and laparoscopic cholecystectomy. BMJ 1991;303:1281-2. (23 November.) 2 Neoptolemos JP, Carr-Locke DL, Fossard DP. Prospective randomised study of preoperative endoscopic sphincterotomy
1 Scott-Coombes D, Thompson J. Bile duct stones and laparoscopic cholecystectomy. BMJ 1991;303:1281-2. (23 November.) 2 Berci G, Sackier JM, Paz-Partlow M. Routine or selective intraoperative cholangiography during laparoscopic cholecystectomy. Am7Surg 1991;161:355-60. 3 Cassie GF, Kapadia CR. Operative cholangiography or extraductal palpation: an analysis of 418 cholecystectomies. BrTJSurg 1981;68:516-7.
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MRC Environmental Epidemiology Unit, University of Southampton, Southampton S09 4XY C N HALES LORNA COX P M S CLARK Department of Clinical Biochemistry,
Addenbrooke's Hospital, Cambridge CB2 2QR 1 Barker DJP, Winter PD, Osmond C, Margetts B, Simmons SJ. Weight in infancy and death from ischaemic heart disease. Lancet 1989;ii:577-80. 2 Barker DJP, Bull AR, Osmond C, Simmonds SJ. Fetal and placental size and risk of hypertension in adult life. BMJ
1990;301:259-62. 3 Barker DJP, Meade TW, Fall CHD, Lee A, Osmond C, Phipps K, et al. The relation of fetal and infant growth to plasma fibrinogen and factor VII levels in adult life. BMJ (in press).
Injuries to common bile duct during laparoscopic cholecystectomy SIR,-I recently returned from attending the annual clinical meeting of the American College of Surgeons in Chicago. The surgeons attending numbered roughly 10 000 from all over the world, and there were various experts from every centre in the United States. Just before I went to the meeting I was disturbed by a report by a leading biliary tract surgeon in the United Kingdom that he had experience of 10 patients who had sustained damage to the common bile duct during laparoscopic cholecystectomy. I determined that in Chicago I would ask every biliary tract surgeon what his or her experience was. I report my findings. I spoke to biliary tract surgeons from numerous American cities and from many other countries. All the surgeons, without exception, reported that they had seen or heard of damaged common bile ducts from laparoscopic cholecystectomy out of all proportion to the damaged ducts from open surgery. From the first four discussions I had with surgeons-Claude Welch, Ken Warren, Olga Johannson, and Bill Longmire-I "collected" more than 30 injuries to the common duct seen by these surgeons after laparoscopic cholecystectomies. Many surgeons reported that they had experience of other injuries, such as injury to the portal vein or small and large bowel. My conclusions are as follows. Firstly, laparoscopic cholecystectomy requires technical skill and should be performed by only a skilled biliary tract surgeon. I have no possible reason to obstruct the advance of surgery, and if surgeons with skill, experience, and judgment perform laparoscopic cholecystectomy on a number of patients I would not dream of criticising them. Secondly, for a general surgeon whose skill as an operator is not above average and who is not prepared to become a specialist in biliary surgery, laparoscopic cholecystectomy is far too often a recipe for disaster- a keyhole scar and catastrophe within.
BMJ VOLUME 303
7 DECEMBER 1991
Thirdly, the surgical colleges should take note of the position and arrange their teaching programmes accordingly. Finally, a general surgeon who is not an expert on the biliary tract and has a disaster with laparoscopic cholecystectomy should study the legal position and understand that he or she may be accused of negligence in performing an operation beyond his or her compass. RODNEY SMITH House of Lords, Westminster SW IA OPW
Bile duct stones and laparoscopic cholecystectomy SIR,-David Scott-Coombes and Jeremy Thompson's editorial on bile duct stones and laparoscopic cholecystectomy leaves not only some bile ducts unexplored but some issues too.' The main difficulty is embodied in the first two sentences. If I may paraphrase, the authors say: "Patients with symptomatic gall bladder stones may also have stones in the common bile duct." How do you know which stone is symptomatic? The clinical criteria they quote are all indicators of an obstructive episode in the common bile duct. To operate then on the gall bladder, with a 50% chance of cholangiography and an even lower chance of successful exploration and removal ofthe stone through the laparoscope, or conversion to open surgery for conventional exploration of the duct, with between 6% and 20% of missed stones at the end of it, smacks of surgical hubris. In Brighton, which has a population of 300 000, most obstructions of the bile duct are managed endoscopically. Thus there were 100 fewer cholecystectomies in 1990 than 1980 (164 v 262). Bile duct stones have been found more often, but their management has swung to endoscopic retrograde cholangiopancreatography. In 1980 there were 27 surgical explorations and 20 sphincterotomies (our first year of endoscopic retrograde cholangiopancreatography). In 1990 there were 15 surgical explorations and 78 endoscopic explorations. These figures apply only to residents of Brighton Health District. If there is evidence of obstruction of the common duct then surely that is the primary target of care, with some guarantee to the patient that the probable cause of the pain will be dealt with. Younger patients may well be recommended to have cholecystectomy for their other stones, though the reasons, if they are by then symptom free, are hard to find. Similarly, the authors' reference 31, to a paper by Neoptolemos et al,2 stretches the point a little far. The paper showed no advantage in terms of morbidity and mortality in fit patients who had either conventional open surgery-cholecystectomy, cholangiography, and exploration where indicated -or preliminary clearance of the bile duct at endoscopic retrograde cholangiopancreatography. From the numbers in their series it is clear that most of the patients managed endoscopically would not now proceed to cholecystectomy. We know little about the likely morbidity and mortality of laparoscopic exploration of the bile duct. Selection for cholangiography leaves a high failure rate, so that the whole strategy of the editorial seems to leave half the selected patients with their original problem- stones in the common duct-and facing a further procedure.
versus surgerv alone for common bile duct stones. 1987;294:470-4.
BMJ7
SIR,-Although there is good evidence to support the practice of selective cholangiography at open cholecystectomy, the same is not yet true for the laparoscopic procedure. Just as in the past surgeons in training struggled to learn intraoperative cholangiography at open surgery, so they must now adapt to the different skills required for laparoscopic cholangiography. David Scott-Coombes and Jeremy Thompson state that technical failures occur at laparoscopy in up to a quarter of cases, but the success rates of 90% reported in other series have been achieved only by perseverance and practice.' 2 The time to learn is during routine operation and not when it becomes mandatory, such as when choledocholithiasis is suspected after failed endoscopic retrograde cholangiopancreatography or when the biliary anatomy cannot be readily identified. Furthermore, the laparoscopic surgeon does not have the advantage of being able to palpate the biliary tree.3 It is not uncommon to encounter cystic duct stones during attempted laparoscopic cholangiography which would be left in the proximal cystic duct stump if operative cholangiography was not performed. We agree that preoperative endoscopic retrograde cholangiopancreatography is inappropriate but cannot understand why intravenous cholangiography should be recommended as a useful screening method when it was abandoned by many surgeons owing to its poor results and allergic reactions. We recommend that laparoscopic cholecystectomy should be accompanied by routine peroperative cholangiography. It prevents the need for preoperative endoscopic retrograde cholangiopancreatography and allows any ductal stones identified at operation to be managed by laparoscopic exploration or postoperative endoscopic retrograde cholangiopancreatography. It also reduces the risk of "silent" bile duct stones going undetected and at the same time allows the laparoscopic surgeon to become proficient in the technique. It should also be performed in patients with proved choledocholithiasis who have already undergone apparent clearance of the common bile duct by preoperative endoscopic retrograde cholangiopancreatography and sphincterotomy as in our experience this investigation does not guarantee a clear duct. In a recent prospective study in our unit of 82 patients undergoing laparoscopic cholecystectomy the time taken to dissect the gall bladder in those undergoing operative cholangiography (n= 60) was only 15 minutes longer (mean 81 (range 32-166) minutes) than that in patients not undergoing cholangiography (n=22; 66 (18-154) minutes). Among the 60 patients in whom operative cholangiography was attempted there were seven failures and eight abnormal cholangiograms (five of these patients were subsequently shown to have
choledocholithiasis). Based on our own experience we recommend that surgeons should follow a policy of routine operative cholangiography in all cases. Well established surgical principles for open procedures must not be abandoned just to facilitate the
laparoscopic procedure. S PATERSON-BROWN 0 J GARDEN
Department of Surgery, Royal Infirmary, Edinburgh EH3 9YW
ANDREW CLARK Royal Sussex County Hospital, Brighton BN2 5BE
1 Scott-Coombes D, Thompson J. Bile duct stones and laparoscopic cholecystectomy. BMJ 1991;303:1281-2. (23 November.) 2 Neoptolemos JP, Carr-Locke DL, Fossard DP. Prospective randomised study of preoperative endoscopic sphincterotomy
1 Scott-Coombes D, Thompson J. Bile duct stones and laparoscopic cholecystectomy. BMJ 1991;303:1281-2. (23 November.) 2 Berci G, Sackier JM, Paz-Partlow M. Routine or selective intraoperative cholangiography during laparoscopic cholecystectomy. Am7Surg 1991;161:355-60. 3 Cassie GF, Kapadia CR. Operative cholangiography or extraductal palpation: an analysis of 418 cholecystectomies. BrTJSurg 1981;68:516-7.
1475
