853
tuberculous involvement of other organs accords with
previous reports. 10.11 It is perhaps not surprising that all our patients were immigrants. Nevertheless, nine of our eleven patients had been in Britain for more than 3 years and in the series reported by Khoury et awl. 50% of the immigrants had been in Britain for more than 3 years. It seems likely, therefore, that the disease is not always acquired overseas and Shukla and Hughes2 emphasised the importance of considering the diagnosis in the indigenous
population. The clinical presentation is variable, and although ascites is common, a "doughy" abdomen is rare in the U.K. and neither of these features is necessarily present. Although it is commonly believed that tuberculous peritonitis is a chronic condition, presentation is often acute.5 If ascites is present paracentesis is the least invasive procedure, but culture for tubercle bacilli is often negative and this investigation takes 6 weeks. Percutaneous peritoneal biopsy by means of a Cope needle was advocated by Levine’ who obtained good results, but others reported less success with this technique.ll,12 Open peritoneal biopsy through a right iliac fossa gridiron incision under local anaesthetic has also been suggested,8but this presumes a fairly definite preoperative diagnosis since intraperitoneal organs cannot easily be inspected. The advantage of laparoscopy is that the peritoneal cavity can be fully inspected and the tubercles can be biopsied accurately. Miliary Crohn’s disease,13 carcinomatosis peritonei, and starch peritonitis can all simulate tuberculous peritonitis so that histological examination and culture remain essential to diagnosis. Visual diagnosis alone is insufficient. Culture of peritoneal tubercles is sometimes negative despite the presence of caseating granulomas, so the clinician should not await a positive culture before starting treatment. A recent series of two hundred and thirty-eight consecutive diagnostic laparoscopies has shown a low major-complication rate (1.25%)14 and although Hyman et a1.15 used the technique to make a diagnosis without morbidity in twenty unselected patients with tuberculous peritonitis in 1962, it has been used surprisingly little as a diagnostic aid in this disease since then. This is perhaps due to fear of perforating the bowel if extensive tuberculous adhesions are present. Although there was no morbidity in our series we have no experience of laparoscopy in a patient with an obviously "doughy" abdomen caused by matted tuberculous adhesions, and we suggest that laparoscopy should be used with caution in such a patient lest bowel should be adherent to the anterior abdominal wall. Despite this possible contraindication we believe that laparoscopy and target biopsy are important in the management of patients with suspected tuberculous peritonitis and that more widespread use of this minor procedure would reduce the need for laparotomy and enable a rapid diagnosis to be made and treatment to be started early. BB’e thank the
physicians and surgeons under whose care the paadmitted for allowing us to report the clinical details and for referring the patients to us for laparoscopy. Requests for reprints should be addressed to J. H. N. W., Department of Surgery, St. Thomas’s Hospital Medical School, London SE 1. tients were
Methods and Devices MODIFICATION OF INTRAUTERINE DEVICES FOR POSTPARTUM INSERTION LEONARD E. LAUFE ROBERT G. WHEELER PATRICK G. FRIEL International Fertility Research Program, Research Park, North Carolina 27709, U.S.A
Triangle
AN intrauterine device (i.u.D.) that could be inserted and retained during the puerperium has long been desirable. Even more attractive would be a device that could be inserted immediately after placental delivery-a time when a birth attendant is present, the cervix is patulous and easily negotiable, and the lochia will mask any bleeding associated with the LU.D. In 1966, the Population Council launched an international programme in the course of which thirteen institutions used the Lippes loop extensively during the first 10 days of the puerperium.1 In the first three months of observation, 20.5(;é of the original l.u.D.s were expelled, and the expulsion-rate was highest (26-5) for those inserted within 24 hours of delivery. More recently, Newton and others,2 using specially designed longer inserters, reported an expulsion-rate of less than 7‘c at
D with Ethicon upper eross-arm.
Lippes loop
MR
no.
2 chromic sutures fixed to the
WOLFE, F.R.C.S. AND OTHERS: REFERENCES
1. Mandal, B. K., Schofield, P. F Practitioner, 1976, 216, 683. 2. Shukla, H. S., Hughes, L. E. Br. J Surg. 1978, 65, 403. 3. Shattuck, F. C Am. J. med. Sci. 1902, 124, 1 4. Stubenbord, J. G., Spies, J. Surgery Gynec. Obstet 1938, 67, 269. 5 Khars, T. Tubercle, 1952, 33, 132. 6 Sochocky, S. Am. Rev. resp. Dis. 1967, 95, 398. 7 Levine, H ibid 1968, 97, 889. 8. Das, P, Shukla, H S Br J Surg 1976, 63, 941. 9. Khoury, G A., Payne, C. R., Harvey, D R. ibid 1978, 65, 808. 10. Kaufmann, H. D., Donovan, I. Jl Coll Surg. Edinb 1974, 19, 337. 11. Singh, M. M., Bargava, A. N., Jam, K. P. New Engl. J. Med. 1969, 281, 1091 12. Jain, S. C., Misra, S. M., Misra, N P, Tandon, P. L. Jl Indian med. Ass
1969, 43, 291. 13 Bartnik, W ., Krynski, J., Butruk, E., Orlowska, J. Br. med. J 1977, ii, 1135. 14 Barry, R. E., Brown, P., Read, A. E., ibid. 1978, ii, 1276. 15 Hyman, S., Villa, F., Avarez, S., Stergmann, F. Gastroenterology, 1962, 42,
854 six weeks after immediate-postplacental insertion of the Lem device, the copper 7 200, and the ’Progestasert’ system. Our own programme is aimed at the development of an l.U.D. that will be retained after simple hand insertion immediately after delivery. Because the programme is directed towards developing countries, our efforts have been focused on devices available to the public sector, the Lippes loop D and the copper T. Our plan was to add lateral or anterior and posterior projections made of biodegradable materials which would aid retention of the device but which would disappear within about 6 weeks after insertion, leaving a standard device in place. We describe her: ou. modification of the Lippes loop.
The, Modified Loop (see figure) are drilled through the upper cross-arm, perthe plane of the device. Strands of moistened chromic suture material (Ethicon, no. 2) are tied through the holes and trimmed to 0-5 cm. The projections become stiff when dry and are directed by the shape of the knot to a downward 45° angle, which facilitates the anchoring of the device. (No. 2 chromic suture material was chosen because it should disappear in about 6 weeks, within the period of uterine invo-
Three holes
pendicular
to
lution.)
Preliminary Results In four international trials, 341 hand insertions have so far been made. Table I gives the expulsion-rate per 100 women
A SAFE EXPIRATORY VALVE FOR ANÆSTHESIA AND ARTIFICIAL VENTILATION
B. M. WRIGHT Clinical Research Centre,
Watford Road, Harrow, Middlesex 3UJ
HA1
connected to an anxsthetic machine or a ventioff from the atmosphere in a closed system in which pressures of hundreds of KPa can be easily generated. The lungs can be damaged by pressures as low as 5 KPa, and unless an efficient safety valve is fitted the patient is in a hazardous situation. Every year one defence society records several deaths from pneumothorax, surgical emphysema, and even gas embolism caused by abnormally high pressures, and this society probably only hears about one-third of such cases (personal communication, Dr F. C. Shelley). Newton and Adamsl reviewed 25 such accidents and they believe that these accidents are more common than is apparent from published reports. Nevertheless, it is not standard practice to fit a safety valve to protect the lungs, though valves are commonly set at a higher pressure to protect the equipment. A safety valve set to lift at about 3 KPa (30 cm H2O) will interfere with hand ventilation by squeezing the bag ("bagging") and with artificial ventilation at the higher pressures that are sometimes necessary to overcome high airways resistance. A
PATIENT
lator is
cut
TABLE I-LIFE-TABLE EXPULSION-RATES FOR THE POSTPARTUM
SUTURED LOOP
*Standard error.
TABLE
!I—6-MONTH
NET LIFE-TABLE EVENT-RATES FOR THE
POSTPARTUM SUTURED
LOOP*
Fig. I-Modified Heidbrink adjusting screw.
valve with washer under head of
*341 insertions.
tStandard error.
according to the Potter life-table method. Table ii gives eventrates. The single pregnancy occurred in the fourth month after insertion. These preliminary data are encouraging. The modification of a standard device by addition of catgut projections is a technology which can be applied to any device in any part of the world. This work was supported in part by the International Fertility Research Program and the Office of Population, United States Agency for International Development. (AID/pha-C-1 111). REFERENCES 1. 2. 3.
Zatuchm, G. I. Postpartum Family Planning; p. 30. New York, 1970. Newton, J., Harper, M., Chan, K. K. Lancet, 1977, ii, 272. Potter, R. G. Jr. in Family Planning in Taiwan (edited by R. Freedman and J. Y. Takeshita). Princeton, 1969.
Fig. 2—Adjusting screw removed to show double spring.
tuberculous involvement of other organs accords with
previous reports. 10.11 It is perhaps not surprising that all our patients were immigrants. Nevertheless, nine of our eleven patients had been in Britain for more than 3 years and in the series reported by Khoury et awl. 50% of the immigrants had been in Britain for more than 3 years. It seems likely, therefore, that the disease is not always acquired overseas and Shukla and Hughes2 emphasised the importance of considering the diagnosis in the indigenous
population. The clinical presentation is variable, and although ascites is common, a "doughy" abdomen is rare in the U.K. and neither of these features is necessarily present. Although it is commonly believed that tuberculous peritonitis is a chronic condition, presentation is often acute.5 If ascites is present paracentesis is the least invasive procedure, but culture for tubercle bacilli is often negative and this investigation takes 6 weeks. Percutaneous peritoneal biopsy by means of a Cope needle was advocated by Levine’ who obtained good results, but others reported less success with this technique.ll,12 Open peritoneal biopsy through a right iliac fossa gridiron incision under local anaesthetic has also been suggested,8but this presumes a fairly definite preoperative diagnosis since intraperitoneal organs cannot easily be inspected. The advantage of laparoscopy is that the peritoneal cavity can be fully inspected and the tubercles can be biopsied accurately. Miliary Crohn’s disease,13 carcinomatosis peritonei, and starch peritonitis can all simulate tuberculous peritonitis so that histological examination and culture remain essential to diagnosis. Visual diagnosis alone is insufficient. Culture of peritoneal tubercles is sometimes negative despite the presence of caseating granulomas, so the clinician should not await a positive culture before starting treatment. A recent series of two hundred and thirty-eight consecutive diagnostic laparoscopies has shown a low major-complication rate (1.25%)14 and although Hyman et a1.15 used the technique to make a diagnosis without morbidity in twenty unselected patients with tuberculous peritonitis in 1962, it has been used surprisingly little as a diagnostic aid in this disease since then. This is perhaps due to fear of perforating the bowel if extensive tuberculous adhesions are present. Although there was no morbidity in our series we have no experience of laparoscopy in a patient with an obviously "doughy" abdomen caused by matted tuberculous adhesions, and we suggest that laparoscopy should be used with caution in such a patient lest bowel should be adherent to the anterior abdominal wall. Despite this possible contraindication we believe that laparoscopy and target biopsy are important in the management of patients with suspected tuberculous peritonitis and that more widespread use of this minor procedure would reduce the need for laparotomy and enable a rapid diagnosis to be made and treatment to be started early. BB’e thank the
physicians and surgeons under whose care the paadmitted for allowing us to report the clinical details and for referring the patients to us for laparoscopy. Requests for reprints should be addressed to J. H. N. W., Department of Surgery, St. Thomas’s Hospital Medical School, London SE 1. tients were
Methods and Devices MODIFICATION OF INTRAUTERINE DEVICES FOR POSTPARTUM INSERTION LEONARD E. LAUFE ROBERT G. WHEELER PATRICK G. FRIEL International Fertility Research Program, Research Park, North Carolina 27709, U.S.A
Triangle
AN intrauterine device (i.u.D.) that could be inserted and retained during the puerperium has long been desirable. Even more attractive would be a device that could be inserted immediately after placental delivery-a time when a birth attendant is present, the cervix is patulous and easily negotiable, and the lochia will mask any bleeding associated with the LU.D. In 1966, the Population Council launched an international programme in the course of which thirteen institutions used the Lippes loop extensively during the first 10 days of the puerperium.1 In the first three months of observation, 20.5(;é of the original l.u.D.s were expelled, and the expulsion-rate was highest (26-5) for those inserted within 24 hours of delivery. More recently, Newton and others,2 using specially designed longer inserters, reported an expulsion-rate of less than 7‘c at
D with Ethicon upper eross-arm.
Lippes loop
MR
no.
2 chromic sutures fixed to the
WOLFE, F.R.C.S. AND OTHERS: REFERENCES
1. Mandal, B. K., Schofield, P. F Practitioner, 1976, 216, 683. 2. Shukla, H. S., Hughes, L. E. Br. J Surg. 1978, 65, 403. 3. Shattuck, F. C Am. J. med. Sci. 1902, 124, 1 4. Stubenbord, J. G., Spies, J. Surgery Gynec. Obstet 1938, 67, 269. 5 Khars, T. Tubercle, 1952, 33, 132. 6 Sochocky, S. Am. Rev. resp. Dis. 1967, 95, 398. 7 Levine, H ibid 1968, 97, 889. 8. Das, P, Shukla, H S Br J Surg 1976, 63, 941. 9. Khoury, G A., Payne, C. R., Harvey, D R. ibid 1978, 65, 808. 10. Kaufmann, H. D., Donovan, I. Jl Coll Surg. Edinb 1974, 19, 337. 11. Singh, M. M., Bargava, A. N., Jam, K. P. New Engl. J. Med. 1969, 281, 1091 12. Jain, S. C., Misra, S. M., Misra, N P, Tandon, P. L. Jl Indian med. Ass
1969, 43, 291. 13 Bartnik, W ., Krynski, J., Butruk, E., Orlowska, J. Br. med. J 1977, ii, 1135. 14 Barry, R. E., Brown, P., Read, A. E., ibid. 1978, ii, 1276. 15 Hyman, S., Villa, F., Avarez, S., Stergmann, F. Gastroenterology, 1962, 42,
854 six weeks after immediate-postplacental insertion of the Lem device, the copper 7 200, and the ’Progestasert’ system. Our own programme is aimed at the development of an l.U.D. that will be retained after simple hand insertion immediately after delivery. Because the programme is directed towards developing countries, our efforts have been focused on devices available to the public sector, the Lippes loop D and the copper T. Our plan was to add lateral or anterior and posterior projections made of biodegradable materials which would aid retention of the device but which would disappear within about 6 weeks after insertion, leaving a standard device in place. We describe her: ou. modification of the Lippes loop.
The, Modified Loop (see figure) are drilled through the upper cross-arm, perthe plane of the device. Strands of moistened chromic suture material (Ethicon, no. 2) are tied through the holes and trimmed to 0-5 cm. The projections become stiff when dry and are directed by the shape of the knot to a downward 45° angle, which facilitates the anchoring of the device. (No. 2 chromic suture material was chosen because it should disappear in about 6 weeks, within the period of uterine invo-
Three holes
pendicular
to
lution.)
Preliminary Results In four international trials, 341 hand insertions have so far been made. Table I gives the expulsion-rate per 100 women
A SAFE EXPIRATORY VALVE FOR ANÆSTHESIA AND ARTIFICIAL VENTILATION
B. M. WRIGHT Clinical Research Centre,
Watford Road, Harrow, Middlesex 3UJ
HA1
connected to an anxsthetic machine or a ventioff from the atmosphere in a closed system in which pressures of hundreds of KPa can be easily generated. The lungs can be damaged by pressures as low as 5 KPa, and unless an efficient safety valve is fitted the patient is in a hazardous situation. Every year one defence society records several deaths from pneumothorax, surgical emphysema, and even gas embolism caused by abnormally high pressures, and this society probably only hears about one-third of such cases (personal communication, Dr F. C. Shelley). Newton and Adamsl reviewed 25 such accidents and they believe that these accidents are more common than is apparent from published reports. Nevertheless, it is not standard practice to fit a safety valve to protect the lungs, though valves are commonly set at a higher pressure to protect the equipment. A safety valve set to lift at about 3 KPa (30 cm H2O) will interfere with hand ventilation by squeezing the bag ("bagging") and with artificial ventilation at the higher pressures that are sometimes necessary to overcome high airways resistance. A
PATIENT
lator is
cut
TABLE I-LIFE-TABLE EXPULSION-RATES FOR THE POSTPARTUM
SUTURED LOOP
*Standard error.
TABLE
!I—6-MONTH
NET LIFE-TABLE EVENT-RATES FOR THE
POSTPARTUM SUTURED
LOOP*
Fig. I-Modified Heidbrink adjusting screw.
valve with washer under head of
*341 insertions.
tStandard error.
according to the Potter life-table method. Table ii gives eventrates. The single pregnancy occurred in the fourth month after insertion. These preliminary data are encouraging. The modification of a standard device by addition of catgut projections is a technology which can be applied to any device in any part of the world. This work was supported in part by the International Fertility Research Program and the Office of Population, United States Agency for International Development. (AID/pha-C-1 111). REFERENCES 1. 2. 3.
Zatuchm, G. I. Postpartum Family Planning; p. 30. New York, 1970. Newton, J., Harper, M., Chan, K. K. Lancet, 1977, ii, 272. Potter, R. G. Jr. in Family Planning in Taiwan (edited by R. Freedman and J. Y. Takeshita). Princeton, 1969.
Fig. 2—Adjusting screw removed to show double spring.
