Correspondence perform an initial colectomy and ileostomy with preservation of the rectal stump. The pathological report of the surgical specimen confirmed ulcerative colitis, and no dysplasia was found. One year later the rectovaginal and perianal fistulae had healed and the patient underwent restorative protectomy with a protective ileostomy. After mucosectomy of a long (6-7-cm) rectal cuff, an S shaped ileal reservoir was hand-sutured to the dentate line. Recovery was uneventful, apart from an episode of small bowel obstruction that required laparotomy 2 months later. The ileostomy was closed 3 months after the pouch procedure. As commonly seen in those with an S shaped reservoir with a long efferent limb, the patient needed to catheterize the pouch, but this has been a regular and uneventful practice during the past 13 years. Pouchitis did not develop. In June 1990 the patient developed a pouch-vagmal fistula and 1 month later underwent laparotomy, at which no fistular track was detected on dissecting the pouch from the posterior wall of the vagina. Symptoms and signs recurred 14 months later, the external opening of the fistula being 7 cm from the fourchette. Pouch-vaginal fistulation is a major complication of restorative proctocolectomy, the incidence being between 7 and 14 per cent in series from different centres'.'. It may develop early before ileostomy closure or, more commonly, a few months after. The vast majority of these occur at the ileoanal anastomotic level. Aetiological factors in our experience may include extensive rectovaginal dissection, a short rectal cuff and a stapled anastomosis. Treatment is difficult and local procedures, irrespective of the technique employed, fail in about half of cases. Resuturing the anastomosis does not seem to offer better results. The best outcome is achieved in pouch-vaginal fistulae occurring before ileostomy closure. Ultimately in one-third of cases the pouch has to be excised. This is the first report of late onset of a pouch-vaginal fistula. In this case chronic trauma from self-catheterization of the pouch may have been the cause. P. S. Carraro

R. J. Nicholls J. Groom St Mark's Hospital City Road London ECI V 2PS UK

1. 2.

Wexner SD, Rothenberger DA, Jensen L el al. Ileal pouch-vaginal fistula: incidence, etiology and management. Dis Colon Rectum 1989; 32: 460-5. Keighley MRB, Asperer J, Hosie K, Grobler S. Fistula complicating restorative proctocolectomy. Gut 1991; 32: A557-A558.

Seeding of human microvascular endothelial cells onto polytetrafluoroethylene graft material Sir We were interested to read the paper by Stansby et al. (Br J Surg 1991; 78: 1189-92). The authors argued that since both endothelial and mesothelial cells are suitable for vascular cell seeding, the true origin of these cells might be academic. The assumption that mesothelial cells may also protect the seeded vascular graft against unwanted thrombosis is based on reported observations of non-thrombogenic properties like tissue plasminogen activator synthesis and prostacyclin production of these cells'.'. However, human mesothelial cells do also express procoagulant activity. In vitro experiments have shown that isolated and cultured mesothelial cells express tissue factor, the activator of the extrinsic pathway of the coagulation cascade. This is one of the known differences between mesothelial and endothelial cells. Therefore, in our opinion, cells harvested from the omental fat should be characterized. Mesothelial cells are identified by staining with monoclonal antibodies directed against cytokeratins 6 and 18, an immunofluorescence staining procedure that can be performed in every laboratory3. Expression of cytokeratins by endothelial cells has never been reported. Because a cobblestone appearance in culture, uptake of diacetylated low-density lipoprotein, and positive immunofluorescent staining for von Willebrand's factor used by Stansby et al. are also properties of mesothelial cells, the characterization of endothelial cells by these features is far from reliable4. With the use of immunofluorescence staining with monoclonal antibodies for cytokeratins, it is now generally accepted that cobblestone cells derived from omental

Br. J. Surg., Vol. 79, No. 7, July1992

fat tissue are not endothelial but mesothelial in rigi in^.^. To prevent further confusion and to stimulate more studies on the suitability of omental cells for vascular cell seeding, reliable characterization of these cells should be undertaken. A. Pronk P. Leguit Academisch Ziekenhuis Utrecht Utrecht The Netherlands 1.

2. 3.

4. 5.

Speiser W, Anders E, Preisdsner KT, Wagner 0, Muller Berghaus G. Differences in coagulant and fibrinolytic activities of cultured human endothelial cells derived from omental tissue microvessels and umbilical veins. Blood 1987: 3: 964-7. Bull HA, Pitillo RM, Drury J et al. Effects of autologous mesothelial cell seeding on prostacyclin production within Dacron arterial prosthesis. Br J Surg 1988; 75: 671-4. Wu YJ, Parker LM, Beckett MA. The mesothelial keratins: a new family of cytoskeletal proteins identified in cultured mesothelial cells and nonkeratinizing epithelia. Cell 1982; 31:693-703. Visser MJT, Van Bockel JH, Goos N P et al. Cells derived from omental fat tissue and used for seeding vascular prostheses are not endothelial in origin. J Vasc Surg 1991; 13: 373-81. Takahashi K, Goto T, Mukai K et al. Cobblestone monolayer cells from the human omental adipose tissue are possibly mesothelial, not endothelial. In Vitro Cell Deu Biol 1989; 25: 109-11.

Surgical implications of drug-induced rha bdomyolysis Sir We read with interest the paper by Rutgers et al. (Br JSurg 1991; 78: 490-2) in which four cases of acute drug-induced rhabdomyolysis with secondary compartment syndromes are described. We agree that drug-induced toxic rhabdomyolysis is uncommon and that many cases are associated with coma which may cause secondary muscle damage. The few drugs that have been implicated in causing direct toxic rhabdomyolysis include alcohol, barbiturates and other psychotropic drugs which have been reviewed comprehensively by Gabow et al.'. We recently reported a case of rhabdomyolysis and compartment syndrome secondary to theophylline overdose2. In the paper cited all the patients were alcoholics but no mention was made of delirium tremens, hypocalcaemia and the toxic effect of alcohol and benzodiazepines, all of which may contribute to rhabdomyolysis. Furthermore, there was no report of the serum levels of calcium, benzodiazepines or alcohol. Even though the authors rightly point out the value of monitoring compartment pressures, in none of the cases presented was the compartment pressure quoted. We would suggest that pressure monitoring is mandatory when a diagnosis of compartment syndrome is considered in a patient who is unwilling or unable to cooperate in eliciting clinical signs, and that full documentation of serum toxicology is essential when discussing the complications of drug overdose. S. P.K. Payne D. M. L. Lloyd University Department of Surgery Leicester Royal Injirmary Leicester LEI 5 WW UK 1.

2.

Gabow PA, Kachny WE, Kelleher SP. The spectrum of rhabdomyolysis. Medicine 1982; 61: 141-52. Lloyd DML, Payne SPK, Tomson CRV, Barnes MR, Allen MJ. Acute compartment syndrome secondary to theophylline overdose. Lancet 1990: 335: 312.

Current management of trauma t o the pancreas Sir Messrs Wilson and Moorehead attempted an exhaustive review of the management of pancreatic trauma (Br J Surg 1991; 78: 1196-202). Unfortunately, certain laconic statements make the title 'current management' questionable.

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Correspondence 1. ‘One dose (of antibiotics) before operation should be followed by two doses thereafter unless there is colonic injury, in which case a therapeutic course for 5 days should be used.’ This suggestion does not reflect the state of the art. Currently, most trauma surgeons do not recommend antibiotic therapy beyond 48 h after colonic injury’. In fact, when contamination is minimal, a short perioperative course is satisfactory. 2. ‘Some suggest splenic preservation (during distal pancreatectomy), but this involves a tedious dissection and added time, which could be considered inappropriate in an acute situation.’ This is not true: using Warshaw’s manoeuvre*, tedious and time-consuming dissection of the pancreas off the splenic vessels is no longer necessary. Instead the pancreas is separated from the spleen by dividing the splenic artery and vein distal to the pancreatic tail, allowing the spleen to survive on the short gastric vessels. The latter are carefully preserved by staying away from the splenic hilum. 3. The authors dogmatically endorse the use of sump drains which ‘should always be used’. Recent articles that question the superiority of these drains in pancreatic trauma are not stated, and topics such as the two-stage pancreaticoduodenectomy and pancreatic ‘sequestrum’ formation are not mentioned. M. Schein Department of Surgery B Rambam Medical Centre Haifa Israel 1. 2.

Burch JM, Martin RR, Richardson RJ, Muldowny DS, Mattox KL, Jordan GL. Evolution of the treatment of the injured colon in the 1980s. Arch Surg 1991; 126: 979-84. Warshaw AL. Conservation of the spleen with distal pancreatectomy. Arch Surg 1988; 123: 550-3.

Authors’ reply Sir We disagree with the criticisms by Dr Schein of our paper. 1. A short perioperative course of broad-spectrum antibiotics is appropriate with minimal contamination from colonic injury. A therapeutic course is the policy of ourselves and most others if there is major contamination. 2. The technique described by Warshaw for splenic preservation involves sacrifice of the splenic artery and vein’. Ligation of the splenic artery may not protect against overwhelming postsplenectomy infection as there is evidence that it impairs pneumococcal clearance2. This type of splenic preservation has no clear benefit and is inadvisable in the acutely-injured patient. 3. We reviewed all the recent English language literature for the article and found that the vast majority of authors endorse our view that sump drains should be used in pancreatic trauma.

R. H. Wilson R. J. Moorehead Department of Surgery Queen’s University of Belfast Belfast BTI2 6BJ UK 1.

2.

Warshaw AL. Conservation of the spleen with distal pancreatectomy. Arch Surg 1988; 123: 550-3. Wilson RH, Moorehead RJ. Management of splenic trauma. Injury 1992; 23: 5-9.

Surgical training: a report t o the Association of Surgeons of Great Britain and Ireland Sir The continuing debate on surgical training in Great Britain and Ireland is being followed with avid interest in many parts of the world, not least in the Commonwealth countries whose surgical training and traditions closely follow the British school. The report by Professor Jones (Br J Surg 1991; 78: 1156-8) highlighted many of the problems of the current training programme, and proposed solutions. He noted the difficulty being encountered by trainees in Great Britain and Ireland in acquiring the necessary

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exposure to conventional procedures in gastrointestinal surgery in the light of recent advances in endoscopic techniques and changes in the pattern and presentation of these diseases. This difficulty is further compounded by the requirement of The Royal College of Surgeons of England for surgeons undertaking laparoscopic surgery to be competent in the standard techniques. I should like to suggest that this problem can be solved if trainees in Great Britain and Ireland spend time in hospitals in the developing countries where the bulk of gastrointestinal surgery still uses open methods. In this way, their requirement for training in conventional techniques will be satisfied, an avenue will be created for exchange of ideas and contacts (necessary for the continual growth of surgical disciplines worldwide) and those in surgical departments in the developing world who have benefited from the Overseas Doctors Training Scheme will derive a sense of accomplishment in providing what is ‘lacking’ in the training programmes in Great Britain and Ireland. The Royal Colleges can identify appropriate surgical departments and establish methods of monitoring to ensure that such a scheme satisfies the need that produced it.

C. A. Adebamowo Department of Surgery University College Hospital Ibadan Nigeria

Ag g ressive a rteria I reconstruct ion for critical lower limb ischaemia Sir We read with interest the paper by Hickey et al. (Br J Surg 1991; 78: 1476-8), in which they report on their excellent results for femorocrural surgery. I can confirm that these results are entirely achievable but would point out that the authors’ insistence that the results can be obtained without angiographic selection is somewhat dependent on local factors in Birmingham. The reason that the group does not use angiography before operation is that they do not routinely offer angioplasty to such patients. In our own practice an angiogram as a first investigation is mandatory simply because it will reveal a large number of patients who can be dealt with in this way. In our own practice this is now 40 per cent of such cases. When these patients have undergone successful angioplasty, the remainder that are available for surgical treatment are those cases with very poor run-off. The series of Hickey et al. therefore includes such ‘good’ patients who would normally not come to surgery. While applauding their good results, we would caution that an angiogram is important and that angioplasty should be made available to these patients as it can either obviate the need for surgery or improve inflow in some cases.

P. R. F. Bell N. J. M. London

Leicester Royal In$rmary PO Box 65 Leicester LE2 7LX UK

Authors’ reply Sir We agree with Professor Bell and Mr London that many patients with symptomatic femoropopliteal occlusive disease can benefit from transluminal angioplasty. However, in our patients with unequivocally critical lower limb ischaemia and a satisfactory femoral pulse, we proceed straight to operative arteriography and it is extremely rare for this to reveal an anatomical situation that could conceivably be relieved by transluminal angioplasty alone, even in the most expert hands. In patients with less severe symptoms or those in whom femoral pulse palpation suggests inflow disease, we do obtain preoperative arteriograms as many of these patients will benefit from a percutaneous procedure as Messrs Bell and London suggest.

M. H. Simms N. C. Hickey Department of Surgery Selly Oak Hospital Birmingham B29 6JD UK

Br. J. Surg., Vol. 79, No. 7, July1992

Current management of trauma to the pancreas.

Correspondence perform an initial colectomy and ileostomy with preservation of the rectal stump. The pathological report of the surgical specimen conf...
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