Comment could theoretically allow cross-infection, and although the conscientious clinician cleans the glass tip between patients this would not prevent cross-contamination. Perhaps the 'time honoured' use of Rogers' Crystal Spray should be reviewed. SIMON N ROGERS MB ChB FDSRCS Senior House Officer NICHOLAS VIOLARIs FRCS Senior Registrar Dudley Road Hospital Birmingham The paper by Rowe-Jones and Pringle (Annals, January 1992, vol 74, p5) raises some interesting points about how surgeons are facing up to the hazard of HIV infection. Of the 179 HIV-positive patients seen in the ENT clinic at St Mary's between 1989 and 1991, 20 (13%) of cases had pathology that was only visible by mirror examination or flexible endoscopy, and therefore it is essential not to shirk from giving all HIV-positive patients a full examination in the ENT clinic. Nevertheless, there have only been two occasions when salivary contamination of the examiner's facial region, fortunately protected by goggles, has occurred. Epistaxis, especially associated with zidovudine-related marrow-suppression, complicated 3% of our recent workload and so presents a real risk. Therefore, I was very encouraged to see the attention respondents gave to this situation. The questionnaire correctly distinguished between 'highrisk' and other patients. The majority of the patients we see fall into one of the well-recognised risk categories, but among the patients I have seen are a 16-year-old girl and a septagenarian lady, both with heterosexually acquired infection. Whilst such cases are rare, this may not always be the case as patterns of spread change, and so restriction of prophylactic measures to those judged 'at-risk' may become increasingly ineffective. With this in mind, I should like to draw attention to some of the practical measures outlined by Stotter et al. (1). We endorse the message carried in the Assessor's comment, and suggest a reappraisal of our practices for all patients and not just for those with overt AIDS. MARTIN A BIRCHALL FRCS FRCS(Otol) ENT Registrar St Mary's Hospital London
Reference I Stotter AT, Vipond MN, Guillou PJ. The response of general surgeons to HIV in England and Wales. Ann R Coll Surg Engl 1990;72:281-6.
Paraoesophageal hiatus hernia: surgery for all ages The paper by Hallissey et al. (Annals, January 1992, vol 74, p23) implies that mobilisation of the omentum and transverse colon to the left upper quadrant was advocated by Tanner in the surgical correction of paraoesophageal hernia. This is incorrect. Tanner devised this procedure for the treatment of gastric volvulus associated with eventration of the left diaphragm. He described only two patients with paraoesophageal hernia in that paper and both were treated by hiatal repair only. R WHISTON FRCS Registrar J D STAMATAKIS MS FRCS Consultant The Princess of Wales Hospital Bridgend
227
Contamination of underwater seal drainage systems in thoracic surgery The article by Hornick et al. (Annals, January 1992, vol 74, p26) introduces a subject which we feel has previously been neglected. While we would agree with the authors' main conclusion that underwater seal drainage systems may be left for up to 6 days postoperatively without routine replacement, other aspects of the paper merit discussion. Only to culture the underwater seal fluid ignores the possibility of contamination of the intrathoracic part of the drain occurring via the open drain wound with a foreign body (the drain) passing through it. We suggest that if the authors had submitted the tips of the drains for culture, when removed, their results may have been different. The number of patients (38) in this study is too small to make any comment on the incidence of wound infections given the reported rate of 1% in non-cardiac thoracic surgery (1). The antibiotic regimen described (flucloxacillin 500 mg and ampicillin 500 mg four times daily until drains removed) would, we feel, result in a delayed presentation of any wound infection. By only reporting wound infections if present on the day of drain removal (in all patients by 6 days postoperatively and, in most, earlier) those occurring later will be missed. We suggest that this regimen is not typical in non-cardiac thoracic surgery and is unnecessarily prolonged. In a randomised controlled trial involving 119 patients and 185 drainage systems, we found that significant contamination did occur, even in those present for less than 6 days. However, these did not appear to be associated with clinical sequelae. There was no significant difference between systems changed daily and those left unchanged until removal. ALASTAIR N J GRAHAM FRCSEd Surgical Registrar JOHN R P GIBBONS MBE TD FRCS FCCP Consultant Thoracic Surgeon JIM A MCGUIGAN FRCSEd Consultant Thoracic Surgeon Royal Victoria Hospital Belfast Reference I Wells FC, Newsom SWB, Rowlands C. Wound infection in cardiothoracic surgery. Lancet 1983;1:1209-10.
Endoscopic transanal resection of large vilious tumours of the rectum We read with interest the paper by Stephenson et al.(Annals, January 1992, vol 94, p54) describing the endoscopic resection of six large villous tumours of the rectum varying in size up to 5 cm and arising up to 12 cm from the anal verge. When considering the alternatives to endoscopic resection, the authors state that submucous resection of a villous adenoma is generally only applicable to small, mobile, easily accessible lesions, and they offer endoscopic resection as an alternative to a more radical resection. In a series of 98 rectal villous adenomas in 87 patients reported from this unit (1), 61 sessile lesions could not be snared and 51 (84%) of these lesions were successfully removed by the technique of submucous resection employed in our unit (2) with low morbidity and no mortality. Far from being small, accessible and mobile, these lesions were up to 12 cm in length, extending up to 18 cm from the anal verge. Many were circumferential and fixed by areas of previous biopsy or malignant transformation with invasion, the latter having occurred in 14 patients. Our overall benign recurrence rate of 12.5% probably reflects to some extent a field change, since the interval from surgery to recurrence was up to
Reference I Stotter AT, Vipond MN, Guillou PJ. The response of general surgeons to HIV in England and Wales. Ann R Coll Surg Engl 1990;72:281-6.
Paraoesophageal hiatus hernia: surgery for all ages The paper by Hallissey et al. (Annals, January 1992, vol 74, p23) implies that mobilisation of the omentum and transverse colon to the left upper quadrant was advocated by Tanner in the surgical correction of paraoesophageal hernia. This is incorrect. Tanner devised this procedure for the treatment of gastric volvulus associated with eventration of the left diaphragm. He described only two patients with paraoesophageal hernia in that paper and both were treated by hiatal repair only. R WHISTON FRCS Registrar J D STAMATAKIS MS FRCS Consultant The Princess of Wales Hospital Bridgend
227
Contamination of underwater seal drainage systems in thoracic surgery The article by Hornick et al. (Annals, January 1992, vol 74, p26) introduces a subject which we feel has previously been neglected. While we would agree with the authors' main conclusion that underwater seal drainage systems may be left for up to 6 days postoperatively without routine replacement, other aspects of the paper merit discussion. Only to culture the underwater seal fluid ignores the possibility of contamination of the intrathoracic part of the drain occurring via the open drain wound with a foreign body (the drain) passing through it. We suggest that if the authors had submitted the tips of the drains for culture, when removed, their results may have been different. The number of patients (38) in this study is too small to make any comment on the incidence of wound infections given the reported rate of 1% in non-cardiac thoracic surgery (1). The antibiotic regimen described (flucloxacillin 500 mg and ampicillin 500 mg four times daily until drains removed) would, we feel, result in a delayed presentation of any wound infection. By only reporting wound infections if present on the day of drain removal (in all patients by 6 days postoperatively and, in most, earlier) those occurring later will be missed. We suggest that this regimen is not typical in non-cardiac thoracic surgery and is unnecessarily prolonged. In a randomised controlled trial involving 119 patients and 185 drainage systems, we found that significant contamination did occur, even in those present for less than 6 days. However, these did not appear to be associated with clinical sequelae. There was no significant difference between systems changed daily and those left unchanged until removal. ALASTAIR N J GRAHAM FRCSEd Surgical Registrar JOHN R P GIBBONS MBE TD FRCS FCCP Consultant Thoracic Surgeon JIM A MCGUIGAN FRCSEd Consultant Thoracic Surgeon Royal Victoria Hospital Belfast Reference I Wells FC, Newsom SWB, Rowlands C. Wound infection in cardiothoracic surgery. Lancet 1983;1:1209-10.
Endoscopic transanal resection of large vilious tumours of the rectum We read with interest the paper by Stephenson et al.(Annals, January 1992, vol 94, p54) describing the endoscopic resection of six large villous tumours of the rectum varying in size up to 5 cm and arising up to 12 cm from the anal verge. When considering the alternatives to endoscopic resection, the authors state that submucous resection of a villous adenoma is generally only applicable to small, mobile, easily accessible lesions, and they offer endoscopic resection as an alternative to a more radical resection. In a series of 98 rectal villous adenomas in 87 patients reported from this unit (1), 61 sessile lesions could not be snared and 51 (84%) of these lesions were successfully removed by the technique of submucous resection employed in our unit (2) with low morbidity and no mortality. Far from being small, accessible and mobile, these lesions were up to 12 cm in length, extending up to 18 cm from the anal verge. Many were circumferential and fixed by areas of previous biopsy or malignant transformation with invasion, the latter having occurred in 14 patients. Our overall benign recurrence rate of 12.5% probably reflects to some extent a field change, since the interval from surgery to recurrence was up to
