778
LETTERS TO THE EDITOR
sole manufacturer of polypropylene (Proleneg), states that their suture possesses properties of "extensibility and linear prolongation" which "virtually eliminates any tendency for fracturing". Well that may be, I personally have little tolerance for the stiffness and lack of "loop holding" of monofilaments compared to the braided dacron material coated either with teflon or silicon. It must be stressed that the FDA has not granted approval for other manufacturers' polypropylene sutures as of this writing. I also believe we must reserve final opinion on the durability of any monofilaments for a while longer. The average time for the appearance of many of the anastomotic aneurysms is quite close to three years with many not occurring for as long as eight years. Prolene, incidentally, has been marketed for somewhat less than seven years, not ten as stated above. W. Graham Knox, M.D. 103 East 75th Street New York, New York 10021
February 24, 1977 Dear Editor: In 1975 we2 demonstrated and published in Annals of Surgery that the incidence of metastasis in cutaneous melanoma is proportional to tumor thickness and that survival for patients with tumors thicker than 1.50 mm. was doubled by elective lymph node dissection. Recently a reader' suggested that this apparent improvement in survival might be a result of surgical bias in patient selection. Re-examination of our data indicates that he may well be correct. Of the 57 patients with tumors this thick, 32 were axial tumors (eight head and neck and 24 trunk), 24 were extremity melanomas, and one was of an unknown site. Node dissections were performed for 50% of the extremity melanomas but for only 28% of the axial tumors. Considering that axial melanomas have a poorer prognosis than extremity tumors3 and that none of our level V tumors were treated with an elective node dissection, it is likely that the apparent difference in survival was due to bias in patient selection by our surgeons. Alexander Breslow, M.D. Professor of Pathology George Washington University Medical Center Washington, D.C. 20037 References 1. Blume, M. R. Personal Communication. 2. Breslow, A.: Tumor Thickness, Level of Invasion and Node Dissection in Stage I Cutaneous Melanoma. Ann. Surg., 182: 572, 1975.
Ann. Surg. * December 1977
3. Davis, N. C.: Cutaneous Melanoma: The Queensland Experience. Curr. Probl. Surg., 13:42, 1976.
Dear Editor: I am currently writing a biography of Dr. Alton Ochsner of the Ochsner Clinic in New Orleans. For the biography I need opinions, evaluations, anecdotes, reminiscences and photographs. All photos will be carefully handled and returned. If you and your readers could contribute material I would be grateful. Ira Harkey, Ph.D. 401 Metairie Road, 706 Metairie, Louisiana 70005
April 1, 1976 Dear Editor: We have read with interest the paper by Garcia Rinaldi in the Annals of Surgery November 1975, describing a double balloon triple lumen catheter for in situ preservation of cadaver kidneys. We developed an identical catheter four years ago and described its use in the British Journal of Urology in October 1972 (BJU vol. XLIV No. 5). The Royal Free double balloon catheter has been successfully used by us clinically for the past four years and has been available from Messrs J. G. Franklin & Sons Ltd. We ourselves prefer to remove kidneys from beating heart donors, but there are numerous occasions when this is not possible and we have obtained satisfactory kidneys from cardiac arrested donors with a minimal warm ischaemia time by the use of this double balloon catheter. We would point out that accurate placement of the catheter is facilitated by aortotomy rather than femoral artery cutdown and a pullback technique as described by Rinaldi et al. In fact it is possible to visualize actual perfusion of the kidneys and reposition the cathether if required. The enormous volumes of fluid, six litres required, are unnecessary if the catheter is positioned accurately and the mesenteric and coeliac arteries are ligated rapidly. We would confirm that ectopic and multiple arteries are perfused simultaneously and an unhurried dissection is greatly facilitated by this catheter. 0. N. Fernando F.R.C.S. Lecturer in Surgery The Royal Free Hospital London NW32QG
September 3, 1976 Dear Editor: The principle of the usage of a double balloon triple
LETTERS TO THE EDITOR
sole manufacturer of polypropylene (Proleneg), states that their suture possesses properties of "extensibility and linear prolongation" which "virtually eliminates any tendency for fracturing". Well that may be, I personally have little tolerance for the stiffness and lack of "loop holding" of monofilaments compared to the braided dacron material coated either with teflon or silicon. It must be stressed that the FDA has not granted approval for other manufacturers' polypropylene sutures as of this writing. I also believe we must reserve final opinion on the durability of any monofilaments for a while longer. The average time for the appearance of many of the anastomotic aneurysms is quite close to three years with many not occurring for as long as eight years. Prolene, incidentally, has been marketed for somewhat less than seven years, not ten as stated above. W. Graham Knox, M.D. 103 East 75th Street New York, New York 10021
February 24, 1977 Dear Editor: In 1975 we2 demonstrated and published in Annals of Surgery that the incidence of metastasis in cutaneous melanoma is proportional to tumor thickness and that survival for patients with tumors thicker than 1.50 mm. was doubled by elective lymph node dissection. Recently a reader' suggested that this apparent improvement in survival might be a result of surgical bias in patient selection. Re-examination of our data indicates that he may well be correct. Of the 57 patients with tumors this thick, 32 were axial tumors (eight head and neck and 24 trunk), 24 were extremity melanomas, and one was of an unknown site. Node dissections were performed for 50% of the extremity melanomas but for only 28% of the axial tumors. Considering that axial melanomas have a poorer prognosis than extremity tumors3 and that none of our level V tumors were treated with an elective node dissection, it is likely that the apparent difference in survival was due to bias in patient selection by our surgeons. Alexander Breslow, M.D. Professor of Pathology George Washington University Medical Center Washington, D.C. 20037 References 1. Blume, M. R. Personal Communication. 2. Breslow, A.: Tumor Thickness, Level of Invasion and Node Dissection in Stage I Cutaneous Melanoma. Ann. Surg., 182: 572, 1975.
Ann. Surg. * December 1977
3. Davis, N. C.: Cutaneous Melanoma: The Queensland Experience. Curr. Probl. Surg., 13:42, 1976.
Dear Editor: I am currently writing a biography of Dr. Alton Ochsner of the Ochsner Clinic in New Orleans. For the biography I need opinions, evaluations, anecdotes, reminiscences and photographs. All photos will be carefully handled and returned. If you and your readers could contribute material I would be grateful. Ira Harkey, Ph.D. 401 Metairie Road, 706 Metairie, Louisiana 70005
April 1, 1976 Dear Editor: We have read with interest the paper by Garcia Rinaldi in the Annals of Surgery November 1975, describing a double balloon triple lumen catheter for in situ preservation of cadaver kidneys. We developed an identical catheter four years ago and described its use in the British Journal of Urology in October 1972 (BJU vol. XLIV No. 5). The Royal Free double balloon catheter has been successfully used by us clinically for the past four years and has been available from Messrs J. G. Franklin & Sons Ltd. We ourselves prefer to remove kidneys from beating heart donors, but there are numerous occasions when this is not possible and we have obtained satisfactory kidneys from cardiac arrested donors with a minimal warm ischaemia time by the use of this double balloon catheter. We would point out that accurate placement of the catheter is facilitated by aortotomy rather than femoral artery cutdown and a pullback technique as described by Rinaldi et al. In fact it is possible to visualize actual perfusion of the kidneys and reposition the cathether if required. The enormous volumes of fluid, six litres required, are unnecessary if the catheter is positioned accurately and the mesenteric and coeliac arteries are ligated rapidly. We would confirm that ectopic and multiple arteries are perfused simultaneously and an unhurried dissection is greatly facilitated by this catheter. 0. N. Fernando F.R.C.S. Lecturer in Surgery The Royal Free Hospital London NW32QG
September 3, 1976 Dear Editor: The principle of the usage of a double balloon triple
