Correspondence 4. 5.
Morton KA, Karwande SV, Davis RK, Datz FL, Lynch RE. Gastric emptying after gastric interposition for cancer of the esophagus or hypopharynx. Ann Thorac Surg 1991; 51: 759-63. Moreno-Osset E, Tomas-Ridocci M, Paris F e t a l . Motor activity of esophageal substitute (stomach, jejunal, and colon segments). Ann Thorac Surg 1986; 41: 515-19.
Mesosigmoplasty as a definitive operation for sigmoid volvulus Sir
We read with interest Dr Subrahmanyam’s article on mesosigmoplasty as a definitive operation for sigmoid volvulus (Br J Surg 1992; 79: 683-4). He is to be congratulated on the remarkably low mortality and recurrence rates achieved when treating the emergency sigmoid volvulus by the method described. We have recently studied 30 patients with sigmoid volvulus who presented as emergencies to Nottingham hospitals over the past 4 years. The mean age was 70 (range 40-96) years; the sex distribution was equal. In all cases, the diagnosis was made from clinical features and abdominal radiography. Flatus tube decompression was attempted in all patients and was considered to produce an acceptable result in 15. A total of 15 patients underwent operation for an emergency sigmoid volvulus during the presenting admission; the sigmoid colon was always resected, whether gangrenous or not. In seven patients a defunctioning colostomy and mucus fistula was formed and in eight a primary anastomosis was fashioned, none with covering colostomies. In this last group there were two anastomotic leaks and one small bowel obstruction. Overall, nine patients died: five from the group treated conservatively, one among those who had a defunctioning colostomy and three from the group undergoing primary anastomosis. To date there have been three recurrences, all occurring in patients initially treated conservatively. They have been managed with surgical resection of the sigmoid colon and primary anastomosis. Our audit reveals morbidity, mortality and ‘recurrence rates higher than those of Dr Subrahmanyam, although this can be explained by the cohort being older and in poor general health. The mesosigmoplasty operation is a valued addition to the treatment options available to manage sigmoid volvulus.
D. Baker P. Wardrop Department of Surgery University Hospital Queen’s Medical Centre Nottingham NG7 2UH UK
Perforation of the bowel by suction drains Sir We read with interest the Case Report by Mr Reed and colleagues (Br J Surg 1992; 79: 679) on injury to the bowel caused by suction drains. We have recently had two similar cases.
In the first, a 63-year-old man was admitted with peritonitis. He had previously undergone total cystectomy and ileal conduit. At operation a perforated sigmoid diverticulum was found. Hartmann’s procedure was performed and a 25-mm suction drain inserted into the pelvis. After 5 days, a biliary leak through the wound and drain developed. At laparotomy the patient had two focal perforations in the small bowel and two other areas of focal necrosis of the serosa and muscle. These lesions were lying against corresponding holes in the suction drain. The bowel was repaired and the patient has since been discharged. In the second case, an 80-year-old man was admitted for Hartmann’s procedure for carcinoma of the rectum. The pelvis was packed with ribbon gauze to control generalized oozing, and a larger suction drain ( 5 mm) was left in the gauze. The gauze was removed 2 days later. The following day peritonitis and a biliary leak through the wound developed. A t laparotomy there were two perforations in the small bowel similar to those already described (Figure 1 ). There was also a
I384
Figure 1 Suction injuries of the small bowel
transverse tear in the small bowel that was thought to have been caused by removal of the ribbon gauze with the suction drain still in place. The patient had a stormy postoperative recovery and died nearly 2 months later. These injuries have occurred since we replaced glass bottles with flexible rubber tops by rigid plastic bottles that do not ‘give’ at all. We have since reverted to sump, tube and corrugated drains for laparotomy for bowel surgery. Suction drains are not without their hazards, and we have now issued appropriate warnings to the supply department.
F. C. Oppong W. A. F. McAdam C. R. Kapadia A. Yousuf Airedale General Hospital Skipton Road Keighley West Yorkshire BD20 6 T D
UK
Screening for large bowel neoplasms in individuals w i t h a family history of colorectal cancer Sir
Mr Dunlop (Br J Surg 1992; 79: 488-94) deduces from a review of seven papers (not in fact all those that explore the subject) that flexible sigmoidoscopic screening is inappropriate for those at risk of colorectal cancer because of a family history of the disease. We would like to comment on this conclusion. First, there are a number of misinterpretations of the literature. He points out that McConnell et al.’ would have missed six lesions (size not given) by screening with the flexible sigmoidoscope; however, this figure represents only 4.8 per cent of the individuals screened. These data imply that 95 per cent of the patients screened may have undergone unnecessary colonoscopy with its inherent risks. More importantly, he fails to include in his analysis McConnell’s report’ of a further 130 individuals in whom only two lesions (size again not given) were found proximal to 55 cm. MI Dunlop states that Grossman and Milos3 would have missed lesions in 16 of 28 individuals. However, in their paper they state that 43 per cent of lesions were beyond the reach of the flexible sigmoidoscope, which may not mean that lesions were missed in 43 per cent of individuals. Furthermore, he seems to have failed to note that this study excluded all individuals with rectal disease. In addition, only 4.5 per cent of lesions found were 25 mm in size, so, until the significance of diminutive polyps is understood, it is unwise to draw too many conclusions from this finding. ‘Inferred data’ were calculated from an abstract4 to guess how many lesions would have been found in the randomization process involved and, as such important details as age and strength of family history of those who did and did not proceed to colonoscopy are not stated, this inference is open to question. Second, although Mr Dunlop points out that it is possible to stratify the risk to which a particular individual is exposed, he fails to mention
Br. J. Surg., Vol. 79. No. 12, December 1992
Morton KA, Karwande SV, Davis RK, Datz FL, Lynch RE. Gastric emptying after gastric interposition for cancer of the esophagus or hypopharynx. Ann Thorac Surg 1991; 51: 759-63. Moreno-Osset E, Tomas-Ridocci M, Paris F e t a l . Motor activity of esophageal substitute (stomach, jejunal, and colon segments). Ann Thorac Surg 1986; 41: 515-19.
Mesosigmoplasty as a definitive operation for sigmoid volvulus Sir
We read with interest Dr Subrahmanyam’s article on mesosigmoplasty as a definitive operation for sigmoid volvulus (Br J Surg 1992; 79: 683-4). He is to be congratulated on the remarkably low mortality and recurrence rates achieved when treating the emergency sigmoid volvulus by the method described. We have recently studied 30 patients with sigmoid volvulus who presented as emergencies to Nottingham hospitals over the past 4 years. The mean age was 70 (range 40-96) years; the sex distribution was equal. In all cases, the diagnosis was made from clinical features and abdominal radiography. Flatus tube decompression was attempted in all patients and was considered to produce an acceptable result in 15. A total of 15 patients underwent operation for an emergency sigmoid volvulus during the presenting admission; the sigmoid colon was always resected, whether gangrenous or not. In seven patients a defunctioning colostomy and mucus fistula was formed and in eight a primary anastomosis was fashioned, none with covering colostomies. In this last group there were two anastomotic leaks and one small bowel obstruction. Overall, nine patients died: five from the group treated conservatively, one among those who had a defunctioning colostomy and three from the group undergoing primary anastomosis. To date there have been three recurrences, all occurring in patients initially treated conservatively. They have been managed with surgical resection of the sigmoid colon and primary anastomosis. Our audit reveals morbidity, mortality and ‘recurrence rates higher than those of Dr Subrahmanyam, although this can be explained by the cohort being older and in poor general health. The mesosigmoplasty operation is a valued addition to the treatment options available to manage sigmoid volvulus.
D. Baker P. Wardrop Department of Surgery University Hospital Queen’s Medical Centre Nottingham NG7 2UH UK
Perforation of the bowel by suction drains Sir We read with interest the Case Report by Mr Reed and colleagues (Br J Surg 1992; 79: 679) on injury to the bowel caused by suction drains. We have recently had two similar cases.
In the first, a 63-year-old man was admitted with peritonitis. He had previously undergone total cystectomy and ileal conduit. At operation a perforated sigmoid diverticulum was found. Hartmann’s procedure was performed and a 25-mm suction drain inserted into the pelvis. After 5 days, a biliary leak through the wound and drain developed. At laparotomy the patient had two focal perforations in the small bowel and two other areas of focal necrosis of the serosa and muscle. These lesions were lying against corresponding holes in the suction drain. The bowel was repaired and the patient has since been discharged. In the second case, an 80-year-old man was admitted for Hartmann’s procedure for carcinoma of the rectum. The pelvis was packed with ribbon gauze to control generalized oozing, and a larger suction drain ( 5 mm) was left in the gauze. The gauze was removed 2 days later. The following day peritonitis and a biliary leak through the wound developed. A t laparotomy there were two perforations in the small bowel similar to those already described (Figure 1 ). There was also a
I384
Figure 1 Suction injuries of the small bowel
transverse tear in the small bowel that was thought to have been caused by removal of the ribbon gauze with the suction drain still in place. The patient had a stormy postoperative recovery and died nearly 2 months later. These injuries have occurred since we replaced glass bottles with flexible rubber tops by rigid plastic bottles that do not ‘give’ at all. We have since reverted to sump, tube and corrugated drains for laparotomy for bowel surgery. Suction drains are not without their hazards, and we have now issued appropriate warnings to the supply department.
F. C. Oppong W. A. F. McAdam C. R. Kapadia A. Yousuf Airedale General Hospital Skipton Road Keighley West Yorkshire BD20 6 T D
UK
Screening for large bowel neoplasms in individuals w i t h a family history of colorectal cancer Sir
Mr Dunlop (Br J Surg 1992; 79: 488-94) deduces from a review of seven papers (not in fact all those that explore the subject) that flexible sigmoidoscopic screening is inappropriate for those at risk of colorectal cancer because of a family history of the disease. We would like to comment on this conclusion. First, there are a number of misinterpretations of the literature. He points out that McConnell et al.’ would have missed six lesions (size not given) by screening with the flexible sigmoidoscope; however, this figure represents only 4.8 per cent of the individuals screened. These data imply that 95 per cent of the patients screened may have undergone unnecessary colonoscopy with its inherent risks. More importantly, he fails to include in his analysis McConnell’s report’ of a further 130 individuals in whom only two lesions (size again not given) were found proximal to 55 cm. MI Dunlop states that Grossman and Milos3 would have missed lesions in 16 of 28 individuals. However, in their paper they state that 43 per cent of lesions were beyond the reach of the flexible sigmoidoscope, which may not mean that lesions were missed in 43 per cent of individuals. Furthermore, he seems to have failed to note that this study excluded all individuals with rectal disease. In addition, only 4.5 per cent of lesions found were 25 mm in size, so, until the significance of diminutive polyps is understood, it is unwise to draw too many conclusions from this finding. ‘Inferred data’ were calculated from an abstract4 to guess how many lesions would have been found in the randomization process involved and, as such important details as age and strength of family history of those who did and did not proceed to colonoscopy are not stated, this inference is open to question. Second, although Mr Dunlop points out that it is possible to stratify the risk to which a particular individual is exposed, he fails to mention
Br. J. Surg., Vol. 79. No. 12, December 1992
