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6. Mason BH, Holdaway IM, Stewart AW, et al. Season of tumor detection influences factors predicting survival of patients with breast cancer. Breast Cancer Res Treat 1990; 15: 27-37. 7. Hrushesky WJM, Bluming AZ, Gruber SA, Sothem RB Menstrual influence on surgical cure of breast cancer. Lancet 1989; ii: 949-52. 8. Fisher B, Slack N, Katrych D, Wolmark N. Ten-year follow-up results of patients with carcinoma of the breast in a co-operative clinical trial evaluating surgical adjuvant chemotherapy Surgery Gynecol Obstet 1975; 140: 528-34. 9. Cohen P. Host heterogeneity in female breast cancer possible significance for pathophysiology, therapy, and prevention. Breast Cancer Res Treat 1990; 15: 205-12.

Cardiac troponin T in the diagnosis of heart contusion S!R,—Your July 6 editorial on troponin T (TnT) and myocardial damage prompts us to report our data on cardiac TnT measurements in the diagnosis of heart contusion. TnTcreatine kinase MB (CK-MB) mass concentrations, and CK and CK-MB activities were tested in 14 severely traumatised patients (10 male, 4 female; aged 13-75 years; injury severity score 27-65, median 41-5). Blood samples were obtained on admission, after 6, 12, and 24 hours, and daily thereafter for 4 days. CK-MB activities were measured by immunoinhibition with a Merck test kit (Darmstadt, Germany). CK-MB mass concentrations were measured by a microparticle enzyme immunoassay (Abbott), and TnT by an enzyme immunoassay (Boehringer Mannheim, Mannheim, Gerinany) developed’ by Katus et al.1 Because of 1-2% crossreactivity with skeletal muscle TnT/ only TnT concentrations of 1 ug/1 or more-which is ten times the analytical sensitivity (0-1 ug/1) of the test used-were assumed to indicate heart-muscle damage in traumatised patients. TnT concentrations exceeded 1 g/1 in 9 patients within 48 h after admission. Peak TnT’concentrations (median 1-5 ug/1, range 1-0-3-7) were seen between admission and the third day in hospital. They were much lower than those in patients with acute myocardial infarction1 and were similar to those noted after uncomplicated aortocoronary bypass surgery. 7 of these 9 patients were also diagnosed as having sustained heart contusion.3 In all 7 patients

Laparoscopic versus open appendicectomy surgeons question the validity of a laparoscopic for acute appendicitisl because open appendicectomy carries few life-threatening complications. However, wound infection, prolonged hospital stay, and delay in return to normal activity are risks with open appendicectomy, even for those with a non-inflamed appendix.2 From January to June, 1991, we did a prospective study to assess the feasibility of laparoscopic surgery for acute appendicitis. 65 consecutive patients with signs and symptoms of acute appendicitis necessitating surgery were assigned to open (36) or laparoscopic (29) procedures. 37 patients were female (22 open) and 28 were male (14 open); median ages were 24 years for open surgery and 18 (range 14-60) for (range randomisation was precluded by instrument Formal laparoscopic. but time of day was not an influence on allocation. Open availability appendicectomy was usually done by a registrar or by a senior house officer under a registrar’s supervision. Laparoscopic appendicectomy was performed by a senior registrar (0. McA.) with experience in laparoscopic surgery. All patients were given perioperative intravenous antibiotics. These were continued for 24 h postoperatively if the appendix was grossly inflamed or for longer if perforated or gangrenous. The open procedure was done through a grid-iron incision in the right iliac fossa, and the wound was closed-with interrupted 3-0 nylon. Laparoscopic appendicectomy required three stab incisions, (a 10 mm trocar at the umbilicus, and 5 mm trocars below the right costal margin and in the left, iliac fossa). Haemostasis was by diathermy and the appendix base was tied with ’Elhibinder No 2’ (Ethicon). The appendix was extracted through the 10 mm port under direct vision with a 5 mm telescope. These wounds were closed with 4-0 nylon. The results were:

SIR,-Most

procedure

14-64)



CK-MB activities were increased and exceeded 5% of the total CK

activity. In addition, ventricular arrhythmias were found in 2 of these patients-ST segment increase with T inversion in 1 and intermittent left bundle branch block in the other. The remaining 2 patients with increased TnT concentrations (peak values 3-7 and 1 -0 gg/1) were not diagnosed as having heart contusions. Both, however, had obvious severe blunt thoracic trauma and we assume that they had had heart contusion not detected by the CK/CK-MB activity index. 2 further patients have been diagnosed as having heart contusion;’ they had TnT concentrations below 1 g/1 and no abnormalities in their electrocardiograms. One,of them had severe head trauma and CK-MB mass concentrations within the normal range ( 7 pg/1) and the other had no obvious blunt thoracic trauma and only borderline increases in CK-MB mass concentrations (7-8 Jlgjl). Since CK-MB activity measured by immunoinhibition is known to lack specificity4 we assume that the CK/CK-MB activity index in both patients was falsely positive for heart contusion. We suggest ’

that serial cardiac TnT

measurements

could be a new criterion in

the laboratory diagnosis of blunt heart trauma. Departments of Anaesthesia and Intensive Care Medicine, and Medical Chemistry and Biochemistry, University of Innsbruck, A-6020 Innsbruck, Austria 1. Katus

PETER MAIR JOHANNES MAIR

1 patient in the laparoscopic group was converted to an open procedure because the appendix was perforated at the base and the ethibinder could not be safely applied. This was the only patient in the laparoscopic group to have a wound infection and postoperative stay beyond four days. Another was converted for technical reasons. 2 patients had laparoscopy only, after identification of ovarian lesions. 5 of the open and 3 laparoscopic cases were either perforated or

gangrenous.

As with any operative procedure, there is a learning curve. 7 cases in the laparoscopic group were retrocaecal but, although more dissection is required, this is not a contraindication. With increasing laparoscopic experience identification of a truly non-inflamed appendix is easier. The risk of wound infection is reduced by removal of the appendix through the trocar; the wound is thus not contaminated by the infected organ. Suction of purulent material and irrigation of the pelvis can be done with better visualisation if the laparoscopic technique is used. A randomised trial may be easier when the laparoscopic instruments are more freely available but results do suggest that this technique should be further explored as an alternative to open

surgery.

JOHANN KOLLER CHRISTIAN WIESER ERIKA ARTNER-DWORZAK BERND PUSCHENDORF

HA, Remppis A, Neumann FJ, et al. Diagnostic efficiency of troponin T in acute myocardial infarction. Circulation 1991; 83: 902-12. 2. Mair J, Wieser C, Seibt I, et al. Troponin T in the diagnosis of myocardial infarction in bypass surgery. Lancet 1991; 337: 434-35. 3. Fabian TC, Mangiante EC, Patterson R, et al. Myocardial contusion in blunt trauma: clinical characteristics, means of diagnosis, and implications for patient management. J Trauma 1988; 28: 50-55. 4. Chan KM, Ladenson JH, Pierce GF, Jaffe AS. Increased creatine kinase MB in the absence of acute myocardial infarction Clin Chem 1986; 32: 2044-51.

Department of Surgery, Mater Misericordiae Hospital, Dublin 7, Ireland

OLIVER J. MC ANENA* ORLA AUSTIN WILLIAM P. HEDERMAN THOMAS F. GOREY JOHN FITZPATRICK P. RONAN O’CONNELL

measurement

*Present address.

Surgical Unit, Royal London Hospital, London

E1 1 BB, UK.

1. Gangal HT, Gangal MH. Laparoscopic appendicectomy. Endoscopy 1987; 19: 127-29. diagnosis of acute appendicitis Br J Surg 1989;

2. Hoffman J, Rasmussen OO. Aids in the 76: 774-79.

Laparoscopic versus open appendicectomy.

693 6. Mason BH, Holdaway IM, Stewart AW, et al. Season of tumor detection influences factors predicting survival of patients with breast cancer. Bre...
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