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May 11, 1990 Dear Editor: We read with interest the article '100 Consecutive Common Duct Explorations Without Mortality' by Dr. Pappas and colleagues (Ann Surg 1990; 211:260-262). An 85% incidence of negative common bile duct (CBD) exploration is unacceptably high and makes us wonder whether the authors' indications of CBD exploration were justified and valid. In all likelihood, intraoperative cholangiograms were not done routinely before exploration. A selective (if not routine) intraoperative cholangiography would have avoided unnecessary explorations in many cases. The group undergoing emergency surgery (35%) with a proportional high incidence of complications (9 of 15 cases) is undefined in the data. Retained stones were managed successfully with endoscopic extraction. The high success rate (80% to 90%) and low morbidity (about 10%) and mortality (less than 1%) rates of endoscopic methods of extraction of CBD stones, especially in the high-risk patient group with associated comorbid conditions, should make it a favored method of treatment in most cases. The indications of surgical exploration of CBD should become more stringent through nonavailability or failure of endoscopic treatment and not weak, as used by the authors.
S. S. SIKORA V. K. KAPOOR Lucknow, India June 19, 1990 Dear Editor: Drs. Sikora and Kapoor commented on the high incidence of negative common duct exploration in our paper '100 Consecutive Common Duct Explorations without Mortality' (Ann Surg 1990; 211:260-262). As we noted in the manuscript, in reading the medical records of these patients, it was apparent that common duct stones were encountered several times and pushed to the duodenum without actually removing the stones. It is difficult to quantitate the exact number of stones that were found because the ones pushed through to the duodenum were not sent for pathologic examination. Even accounting for this, our incidence of finding stones during common duct exploration is smaller than in other published studies. We noted this in the discussion and suggested that this is one possible reason for our low rates of morbidity and mortality with these cases. Drs. Sikora and Kapoor are correct that intraoperative cholangiograms were not done routinely on every case before exploration. It is also true that some of these explorations may have been avoided with a normal cholangiogram. Drs. Sikora and Kapoor also commented on the fact that some of our patients underwent emergency surgery. These are patients who had cholecystectomy and common duct exploration on the same day that the diagnosis was made, in contrast to those in which the surgeon thought that the operation could wait until the following day or the following week. The incidence of complications in
this group of patients is consistent with that reported in the literature. Concerning the success of endoscopic extraction of gallstones quoted in Drs. Sikora and Kapoora's letter (80% to 90%), this is certainly the number that is quoted in the medical literature by major medical centers with large series of patients. Whether this is the success rate in the community has not been adequately documented. In addition the morbidity rate of 10% and the mortality rate of less than 1% with endoscopic extraction of common duct stones needs to be added to the risk of cholecystectomy if both procedures are to be done on each patient. While we agree that high-risk patients should undergo endoscopic retrograde cholangiopancreatography before cholecystectomy in an effort to avoid common duct exploration, this is certainly not true for the routine patient. For the low-risk patient, we continue to recommend exploratory laparotomy, cholecystectomy, and common duct exploration for the treatment of common duct stones. Whether laparoscopic cholecystectomy changes these recommendations has not been determined. THEODORE N. PAPPAS, M.D. DAVID C. BROOKS, M.D. Durham, North Carolina and Boston, Massachusetts 16 July, 1990 Dear Editor: I have just read the article 'Preoperative Chemotherapy for Soft-tissue Sarcomas of the Extremities' (Ann Surg 1990; 21 1: 476-481). This information is potentially very exciting and could provoke significant change in the management of patients with large, high-grade, extremity soft-tissue sarcomas. I would like some additional information and would request that the authors address these issues. First and most important is the relationship between the size of the tumor and the response of chemotherapy. I do not find in the article mention of a relationship between size of tumor and response. The tumors range from just more than 5 cm to 24 cm in diameter. Our data would suggest that although soft-tissue lesions larger than 5 cm had a worse prognosis than those less than 5 cm, there is a progressive increase in the mortality rate related to size, particularly for those lesions that are histologically high grade and larger than 10 cm in diameter. If the small lesions responded more to the preoperative chemotherapy than the large lesions, this could account for at least some of the difference in the disease-free survival rate between the responders and nonresponders. Second I assume that response is only a clinical evaluation of size because some of these patients received preoperative irradiation to the tumors and therefore the histologic response could not be measured. It is unfortunate that these treated tumors were not excised before irradiation. Finally one wonders if there is any relationship between survival rate and the use of pre- and postoperative irradiation compared to postoperative irradiation alone. DEMPSEY S. SPRINGFIELD, M.D. Boston, Massachusetts
187
May 11, 1990 Dear Editor: We read with interest the article '100 Consecutive Common Duct Explorations Without Mortality' by Dr. Pappas and colleagues (Ann Surg 1990; 211:260-262). An 85% incidence of negative common bile duct (CBD) exploration is unacceptably high and makes us wonder whether the authors' indications of CBD exploration were justified and valid. In all likelihood, intraoperative cholangiograms were not done routinely before exploration. A selective (if not routine) intraoperative cholangiography would have avoided unnecessary explorations in many cases. The group undergoing emergency surgery (35%) with a proportional high incidence of complications (9 of 15 cases) is undefined in the data. Retained stones were managed successfully with endoscopic extraction. The high success rate (80% to 90%) and low morbidity (about 10%) and mortality (less than 1%) rates of endoscopic methods of extraction of CBD stones, especially in the high-risk patient group with associated comorbid conditions, should make it a favored method of treatment in most cases. The indications of surgical exploration of CBD should become more stringent through nonavailability or failure of endoscopic treatment and not weak, as used by the authors.
S. S. SIKORA V. K. KAPOOR Lucknow, India June 19, 1990 Dear Editor: Drs. Sikora and Kapoor commented on the high incidence of negative common duct exploration in our paper '100 Consecutive Common Duct Explorations without Mortality' (Ann Surg 1990; 211:260-262). As we noted in the manuscript, in reading the medical records of these patients, it was apparent that common duct stones were encountered several times and pushed to the duodenum without actually removing the stones. It is difficult to quantitate the exact number of stones that were found because the ones pushed through to the duodenum were not sent for pathologic examination. Even accounting for this, our incidence of finding stones during common duct exploration is smaller than in other published studies. We noted this in the discussion and suggested that this is one possible reason for our low rates of morbidity and mortality with these cases. Drs. Sikora and Kapoor are correct that intraoperative cholangiograms were not done routinely on every case before exploration. It is also true that some of these explorations may have been avoided with a normal cholangiogram. Drs. Sikora and Kapoor also commented on the fact that some of our patients underwent emergency surgery. These are patients who had cholecystectomy and common duct exploration on the same day that the diagnosis was made, in contrast to those in which the surgeon thought that the operation could wait until the following day or the following week. The incidence of complications in
this group of patients is consistent with that reported in the literature. Concerning the success of endoscopic extraction of gallstones quoted in Drs. Sikora and Kapoora's letter (80% to 90%), this is certainly the number that is quoted in the medical literature by major medical centers with large series of patients. Whether this is the success rate in the community has not been adequately documented. In addition the morbidity rate of 10% and the mortality rate of less than 1% with endoscopic extraction of common duct stones needs to be added to the risk of cholecystectomy if both procedures are to be done on each patient. While we agree that high-risk patients should undergo endoscopic retrograde cholangiopancreatography before cholecystectomy in an effort to avoid common duct exploration, this is certainly not true for the routine patient. For the low-risk patient, we continue to recommend exploratory laparotomy, cholecystectomy, and common duct exploration for the treatment of common duct stones. Whether laparoscopic cholecystectomy changes these recommendations has not been determined. THEODORE N. PAPPAS, M.D. DAVID C. BROOKS, M.D. Durham, North Carolina and Boston, Massachusetts 16 July, 1990 Dear Editor: I have just read the article 'Preoperative Chemotherapy for Soft-tissue Sarcomas of the Extremities' (Ann Surg 1990; 21 1: 476-481). This information is potentially very exciting and could provoke significant change in the management of patients with large, high-grade, extremity soft-tissue sarcomas. I would like some additional information and would request that the authors address these issues. First and most important is the relationship between the size of the tumor and the response of chemotherapy. I do not find in the article mention of a relationship between size of tumor and response. The tumors range from just more than 5 cm to 24 cm in diameter. Our data would suggest that although soft-tissue lesions larger than 5 cm had a worse prognosis than those less than 5 cm, there is a progressive increase in the mortality rate related to size, particularly for those lesions that are histologically high grade and larger than 10 cm in diameter. If the small lesions responded more to the preoperative chemotherapy than the large lesions, this could account for at least some of the difference in the disease-free survival rate between the responders and nonresponders. Second I assume that response is only a clinical evaluation of size because some of these patients received preoperative irradiation to the tumors and therefore the histologic response could not be measured. It is unfortunate that these treated tumors were not excised before irradiation. Finally one wonders if there is any relationship between survival rate and the use of pre- and postoperative irradiation compared to postoperative irradiation alone. DEMPSEY S. SPRINGFIELD, M.D. Boston, Massachusetts
187
