Com m ent
Contributors to this section are asked to make their comments brief and to the point. Letters should comply with essential the Noticeand printed on the inside back cover.should Tablesbeand figures should be included only given. no more than five references if absolutely
Delorme's operation for rectal prolapse I read with interest the article written by A Mutaz Abulafi et al. (Annals, November 1990, vol 72, p382). My views are in complete consonance with those of the authors. However, I do not use adrenaline solution since it is not very useful in reducing the bleeding. In fact the addition of adrenaline solution makes the operative field more messy. I always stress the point of dissecting the mucosa from the muscularis as far as possible beyond the apex of the prolapse, for it is very useful to lengthen the segment that is to be plicated, as a result of which, when the healing occurs, there will be large plicated segments that get stuck together. This is an important step to prevent recurrence of prolapse. In our unit we have done 52 cases in the past 8 years. The procedure ranges from Devadhar's operation, resection and anastomosis, Ripstein's and prolene mesh repair. We have found the above procedures either too radical or not effective. For the past 4 years we have used only Delorme's operation (21 cases) irrespective of age. In the follow-up of patients, we have found the results to be satisfactory both to the surgeon and the patient. N DORAIRAJAN MS FICS Assistant Professor Department of Surgery Madras Medical College, Madras, India
Early endoscopic sphincterotomy for retained bile duct stones after gallbladder surgery We have been reading the papers and comment (Annals, May 1991, vol 73, pl94; November 1991, vol 73, p398) on retained bile duct stones with some interest. We started a programme of laparoscopic cholecystectomy at this hospital centre in April this year. In a personal series of 36 laparoscopic operations (with one conversion) we have pursued a policy of selective on-table cholangiography for difficult anatomy or dilated duct systems followed by non-urgent ERCP/ sphincterotomy when common bile duct (CBD) calculi are discovered. Four patients were found to have small stones in the CBD at the time of surgery. No patient was jaundiced during this time. Three patients were discharged home at 2 days and the fourth at 3 days. ERCP was carried out at a mean of 70 days (range 55-90 days). In two of these patients there was residual bile duct dilatation but no residual calculi. Although there is no argument with Mr Askew's comment that endoscopic sphincterotomy can be safely performed 1 week after surgery during the same hospital admission, it would seem that it is also possible to delay this procedure with possible benefit to the patient. It is interesting to speculate that too many common bile ducts have been explored in the past at the time of open surgery when some of the symptomless stones may have passed spontaneously. As more data is collected following the wider application of laparoscopic cholecystectomy, this view may be confirmed. ROBERT M KIRBY MD FRCS Consultant Surgeon J R B GREEN MA DM FRCP Consultant Gastroenterologist City General Hospital Stoke-on-Trent
Use of a breast template: an aid for orientation of breast biopsy specimens (Annals, September 1991, vol 73, p276) The fact there have been so many publications on this subject indicates that the ideal method for orientating breast biopsy specimens has yet to be described. For some time I have used ligaclips to orientate specimens. Having excised the lesion, one ligacip is placed on the anterior margin, two ligacips are placed on the medial margin and three at the inferior margin (1). The advantage of ligaclips is that for needle localisation specimens they can be visualised on the check radiograph, so that if the lesion approaches any excision margin, further tissue at the appropriate margin can be excised. This further tissue can also be orientated with ligaclips prior to a further specimen radiograph, so that it is usually possible to completely excise the mammographic lesion at one operation. The specimen is then subsequently sliced by the pathologist and if, on histology, carcinoma is seen approaching any of the excision margins, the pathologist can accurately determine which margin is involved. Although ligaclips themselves are not cheap, they are widely available in most surgical centres and I believe provide a simpler method of orientation of biopsy specimens than that previously described. J MICHAEL DIXON Senior Lecturer in Surgery The Royal Infirmary Edinburgh Reference I Nedelman R, Dixon JM. Marking of excision specimens in patients undergoing stereotactic wide local excision for breast cancer. Br J Surg 1992 (in press).
Pulse oximetry in closed limb fractures With reference to the article by David (Annals, September 1991, vol 73, p283). I would like to take issue with the author of this paper over several important points. (a) Pulse oximetry measures the percentage saturation of oxygenated haemoglobin in pulsatile arterial blood. It is not a measure of tissue oxygen saturation or perfusion. Therefore, no reliance can be put on an oximetry reading in a pulseless limb, especially if the oximeter has no waveform display. This point is not confirmed in the paper. (b) The concern in closed limb fractures is the development of compartment syndrome. It is well-established that the cycle of oedema leading to venous congestion, microcirculatory hypoperfusion and tissue ischaemia in turn leading to further oedema can become well advanced in the presence of a bounding peripheral pulse and therefore a normal or near normal oximetry reading. By the time tissue pressure exceeds arterial perfusion pressure, an ischaemic contracture is inevitable. For this reason, I think it dangerous to even suggest using pulse oximetry to detect early compartment syndrome since one will be misled with consequent disastrous results. (c) The author fails to mention the most sensitive, objective clinical test in determining the onset of compartment syndrome-that of passively stretching muscle groups -which if ischaemic is exquisitely painful for the patient.
Comment In addition, he fails to mention the use of intracompartmental pressure monitoring which, second to clinical examination, is a well-established diagnostic tool. (d) For these reasons, the case of a supracondylar fracture in an 8-year-old child concerns me greatly in that no pulse was palpable for 48 h, the management apparently being determined by the oximetry reading. No mention was made of the clinical indicators of tissue perfusion. The pulse oximeter was designed to measure arterial oxygen saturation in relation to pulsatile flow. It is not an indicator of tissue perfusion and reliance on it as such could be disastrous. It should remain in the armamentarium of the anaesthetists. R A MARSTON BSc FRCS Orthopaedic Registrar Whipps Cross Hospital London
Nasogastric suction after abdominal surgery Congratulations to Mr Nathan and Mr Pain on their study which questions the use of nasogastric suction after abdominal surgery (Annals, September 1991, vol 73, p291). Perhaps they could respond to three small points. First, some surgeons see a relationship between having a nasogastric tube in place and the amount of fluid which they allow patients to take orally. There was no mention of this in the study and a comment certainly would be interesting. Second, the authors chose different standard times at which to remove the nasogastric tubes after different types of surgery, but did not comment on these separate groups of patients in the results. Did any one of these groups more frequently require prolonged intubation beyond the expected time? Finally, it was disappointing to see no reference to the rare, but very serious, complication of acute gastric dilatation as an urgent indication for insertion of a nasogastric tube postoperatively. Audit meetings at our own hospital expose two or three cases of this problem each year and for educational purposes it would be nice to see a reference to this potentially fatal condition in any article which suggests rationing (however logical) of nasogastric tubes postoperatively. W BRUCE CAMPBELL MS MRCP FRCS Consultant Surgeon Royal Devon and Exeter Hospital Exeter
Amputations in diabetics I read with interest the letter from Mr G A Pryor (Annals, September 1991, vol 73, p333) writing in favour of tarsometatarsal (Lisfranc) and mid-tarsal (Choparts) amputations in the diabetic foot. He points out correctly that equinovarus stump deformity can be avoided, but this is not the real reason that these amputations prove unsuitable for the neuropathic foot. The problem lies in the considerable reduction of the weightbearing surface following these operations on a foot with sensory loss, and the great difficulty in preventing further breakdown and ulceration, despite providing suitable footwear with adequate cushioning. So often the patient becomes the subject of repeated disabling ulceration that it would be much better to opt, from the beginning, for a below-knee amputation and a highly satisfactory modern prosthesis. FRANK I TOVEY OBE ChM FRCS Diabetic Foot Clinic Basingstoke District Hospital Basingstoke, Hants
151
Proposed definitions for the audit of postoperative infection: a discussion paper We all recognise the need to improve standards of reporting of postoperative complications, and the proposed definitions of postoperative infection by Peel and Taylor (Annals, November 1991, vol 73, p385) aim to help. Wisely these authors have done no more than proffer their suggestions as a basis for discussion, because few vascular surgeons are likely to be content with their proposals for 'infection after implant surgery'. We are uncertain of the true incidence of arterial graft infection for several reasons. Chief among these is the very late presentation-often much longer than the 1 year interval after operation which Peel and his colleague suggest. The trend towards graft infection by organisms of low virulence (eg Staphylococcus epidermidis) not only delays the onset of signs but also means that the classic indicators of infection suggested in this article are frequently absent. An apparently minor groin sinus from which it may be difficult to culture any organisms is well-recognised as a good pointer to underlying graft infection which may be extensive and serious. These late infections are nevertheless likely to result from implantation of bacteria at the original procedure and should certainly be included in any audit of postoperative infection in vascular surgery. W BRUCE CAMPBELL MS MRCP FRCS Consultant Surgeon Royal Devon and Exeter Hospital Exeter
I read with interest the article by Peel and Taylor (Annals, November 1991, vol 73, p385). I am concerned that pelvic and subphrenic abscesses were defined as localised collections of infected fluid with either clinical or laboratory evidence of infection. The presence of bacteria in fluid on microscopy or culture does not necessarily constitute infection, let alone an abscess. Bacteria may be cultured with varying frequency from most body fluids including bile and blood in normal, healthy people. Furthermore, experience with peritoneal dialysis has shown that enteric bacteria can be isolated from outflow dialysis fluid in the absence of clinical infection (1). It is likely that the same applies to postoperative fluid collections. Indeed, in animal experiments enteric bacteria readily translocate from the intestines to areas of peritoneal inflammation (2); an inevitable consequence of intra-abdominal surgery. Indeed, bacteria are occasionally isolated from drainage fluid in a patient making an uneventful postoperative recovery with no clinical evidence of infection. Is the fluid being drained coming from an abscess as would be implied from this definition? A localised 'infected' fluid collection is different from a true abscess defined as a localised collection of pus bounded by a wall of collagen and granulation tissue. If the definition of an abscess is relaxed to include 'infected' fluid collections, then it is likely that the incidence of 'abscesses' will increase as more collections are diagnosed using ultrasound and CT scans. At present the outcome of 'infected' postoperative fluid collections is uncertain. It is likely that many small collections with low concentrations of bacteria resolve as the fluid is absorbed and the host defences eradicate the bacteria (3). Alternatively, larger collections may either remain localised and develop into a true abscess or spread causing generalised peritonitis. It is very difficult for the host defences to deal with a true abscess and it is associated with a high morbidity and mortality. The prognosis
Contributors to this section are asked to make their comments brief and to the point. Letters should comply with essential the Noticeand printed on the inside back cover.should Tablesbeand figures should be included only given. no more than five references if absolutely
Delorme's operation for rectal prolapse I read with interest the article written by A Mutaz Abulafi et al. (Annals, November 1990, vol 72, p382). My views are in complete consonance with those of the authors. However, I do not use adrenaline solution since it is not very useful in reducing the bleeding. In fact the addition of adrenaline solution makes the operative field more messy. I always stress the point of dissecting the mucosa from the muscularis as far as possible beyond the apex of the prolapse, for it is very useful to lengthen the segment that is to be plicated, as a result of which, when the healing occurs, there will be large plicated segments that get stuck together. This is an important step to prevent recurrence of prolapse. In our unit we have done 52 cases in the past 8 years. The procedure ranges from Devadhar's operation, resection and anastomosis, Ripstein's and prolene mesh repair. We have found the above procedures either too radical or not effective. For the past 4 years we have used only Delorme's operation (21 cases) irrespective of age. In the follow-up of patients, we have found the results to be satisfactory both to the surgeon and the patient. N DORAIRAJAN MS FICS Assistant Professor Department of Surgery Madras Medical College, Madras, India
Early endoscopic sphincterotomy for retained bile duct stones after gallbladder surgery We have been reading the papers and comment (Annals, May 1991, vol 73, pl94; November 1991, vol 73, p398) on retained bile duct stones with some interest. We started a programme of laparoscopic cholecystectomy at this hospital centre in April this year. In a personal series of 36 laparoscopic operations (with one conversion) we have pursued a policy of selective on-table cholangiography for difficult anatomy or dilated duct systems followed by non-urgent ERCP/ sphincterotomy when common bile duct (CBD) calculi are discovered. Four patients were found to have small stones in the CBD at the time of surgery. No patient was jaundiced during this time. Three patients were discharged home at 2 days and the fourth at 3 days. ERCP was carried out at a mean of 70 days (range 55-90 days). In two of these patients there was residual bile duct dilatation but no residual calculi. Although there is no argument with Mr Askew's comment that endoscopic sphincterotomy can be safely performed 1 week after surgery during the same hospital admission, it would seem that it is also possible to delay this procedure with possible benefit to the patient. It is interesting to speculate that too many common bile ducts have been explored in the past at the time of open surgery when some of the symptomless stones may have passed spontaneously. As more data is collected following the wider application of laparoscopic cholecystectomy, this view may be confirmed. ROBERT M KIRBY MD FRCS Consultant Surgeon J R B GREEN MA DM FRCP Consultant Gastroenterologist City General Hospital Stoke-on-Trent
Use of a breast template: an aid for orientation of breast biopsy specimens (Annals, September 1991, vol 73, p276) The fact there have been so many publications on this subject indicates that the ideal method for orientating breast biopsy specimens has yet to be described. For some time I have used ligaclips to orientate specimens. Having excised the lesion, one ligacip is placed on the anterior margin, two ligacips are placed on the medial margin and three at the inferior margin (1). The advantage of ligaclips is that for needle localisation specimens they can be visualised on the check radiograph, so that if the lesion approaches any excision margin, further tissue at the appropriate margin can be excised. This further tissue can also be orientated with ligaclips prior to a further specimen radiograph, so that it is usually possible to completely excise the mammographic lesion at one operation. The specimen is then subsequently sliced by the pathologist and if, on histology, carcinoma is seen approaching any of the excision margins, the pathologist can accurately determine which margin is involved. Although ligaclips themselves are not cheap, they are widely available in most surgical centres and I believe provide a simpler method of orientation of biopsy specimens than that previously described. J MICHAEL DIXON Senior Lecturer in Surgery The Royal Infirmary Edinburgh Reference I Nedelman R, Dixon JM. Marking of excision specimens in patients undergoing stereotactic wide local excision for breast cancer. Br J Surg 1992 (in press).
Pulse oximetry in closed limb fractures With reference to the article by David (Annals, September 1991, vol 73, p283). I would like to take issue with the author of this paper over several important points. (a) Pulse oximetry measures the percentage saturation of oxygenated haemoglobin in pulsatile arterial blood. It is not a measure of tissue oxygen saturation or perfusion. Therefore, no reliance can be put on an oximetry reading in a pulseless limb, especially if the oximeter has no waveform display. This point is not confirmed in the paper. (b) The concern in closed limb fractures is the development of compartment syndrome. It is well-established that the cycle of oedema leading to venous congestion, microcirculatory hypoperfusion and tissue ischaemia in turn leading to further oedema can become well advanced in the presence of a bounding peripheral pulse and therefore a normal or near normal oximetry reading. By the time tissue pressure exceeds arterial perfusion pressure, an ischaemic contracture is inevitable. For this reason, I think it dangerous to even suggest using pulse oximetry to detect early compartment syndrome since one will be misled with consequent disastrous results. (c) The author fails to mention the most sensitive, objective clinical test in determining the onset of compartment syndrome-that of passively stretching muscle groups -which if ischaemic is exquisitely painful for the patient.
Comment In addition, he fails to mention the use of intracompartmental pressure monitoring which, second to clinical examination, is a well-established diagnostic tool. (d) For these reasons, the case of a supracondylar fracture in an 8-year-old child concerns me greatly in that no pulse was palpable for 48 h, the management apparently being determined by the oximetry reading. No mention was made of the clinical indicators of tissue perfusion. The pulse oximeter was designed to measure arterial oxygen saturation in relation to pulsatile flow. It is not an indicator of tissue perfusion and reliance on it as such could be disastrous. It should remain in the armamentarium of the anaesthetists. R A MARSTON BSc FRCS Orthopaedic Registrar Whipps Cross Hospital London
Nasogastric suction after abdominal surgery Congratulations to Mr Nathan and Mr Pain on their study which questions the use of nasogastric suction after abdominal surgery (Annals, September 1991, vol 73, p291). Perhaps they could respond to three small points. First, some surgeons see a relationship between having a nasogastric tube in place and the amount of fluid which they allow patients to take orally. There was no mention of this in the study and a comment certainly would be interesting. Second, the authors chose different standard times at which to remove the nasogastric tubes after different types of surgery, but did not comment on these separate groups of patients in the results. Did any one of these groups more frequently require prolonged intubation beyond the expected time? Finally, it was disappointing to see no reference to the rare, but very serious, complication of acute gastric dilatation as an urgent indication for insertion of a nasogastric tube postoperatively. Audit meetings at our own hospital expose two or three cases of this problem each year and for educational purposes it would be nice to see a reference to this potentially fatal condition in any article which suggests rationing (however logical) of nasogastric tubes postoperatively. W BRUCE CAMPBELL MS MRCP FRCS Consultant Surgeon Royal Devon and Exeter Hospital Exeter
Amputations in diabetics I read with interest the letter from Mr G A Pryor (Annals, September 1991, vol 73, p333) writing in favour of tarsometatarsal (Lisfranc) and mid-tarsal (Choparts) amputations in the diabetic foot. He points out correctly that equinovarus stump deformity can be avoided, but this is not the real reason that these amputations prove unsuitable for the neuropathic foot. The problem lies in the considerable reduction of the weightbearing surface following these operations on a foot with sensory loss, and the great difficulty in preventing further breakdown and ulceration, despite providing suitable footwear with adequate cushioning. So often the patient becomes the subject of repeated disabling ulceration that it would be much better to opt, from the beginning, for a below-knee amputation and a highly satisfactory modern prosthesis. FRANK I TOVEY OBE ChM FRCS Diabetic Foot Clinic Basingstoke District Hospital Basingstoke, Hants
151
Proposed definitions for the audit of postoperative infection: a discussion paper We all recognise the need to improve standards of reporting of postoperative complications, and the proposed definitions of postoperative infection by Peel and Taylor (Annals, November 1991, vol 73, p385) aim to help. Wisely these authors have done no more than proffer their suggestions as a basis for discussion, because few vascular surgeons are likely to be content with their proposals for 'infection after implant surgery'. We are uncertain of the true incidence of arterial graft infection for several reasons. Chief among these is the very late presentation-often much longer than the 1 year interval after operation which Peel and his colleague suggest. The trend towards graft infection by organisms of low virulence (eg Staphylococcus epidermidis) not only delays the onset of signs but also means that the classic indicators of infection suggested in this article are frequently absent. An apparently minor groin sinus from which it may be difficult to culture any organisms is well-recognised as a good pointer to underlying graft infection which may be extensive and serious. These late infections are nevertheless likely to result from implantation of bacteria at the original procedure and should certainly be included in any audit of postoperative infection in vascular surgery. W BRUCE CAMPBELL MS MRCP FRCS Consultant Surgeon Royal Devon and Exeter Hospital Exeter
I read with interest the article by Peel and Taylor (Annals, November 1991, vol 73, p385). I am concerned that pelvic and subphrenic abscesses were defined as localised collections of infected fluid with either clinical or laboratory evidence of infection. The presence of bacteria in fluid on microscopy or culture does not necessarily constitute infection, let alone an abscess. Bacteria may be cultured with varying frequency from most body fluids including bile and blood in normal, healthy people. Furthermore, experience with peritoneal dialysis has shown that enteric bacteria can be isolated from outflow dialysis fluid in the absence of clinical infection (1). It is likely that the same applies to postoperative fluid collections. Indeed, in animal experiments enteric bacteria readily translocate from the intestines to areas of peritoneal inflammation (2); an inevitable consequence of intra-abdominal surgery. Indeed, bacteria are occasionally isolated from drainage fluid in a patient making an uneventful postoperative recovery with no clinical evidence of infection. Is the fluid being drained coming from an abscess as would be implied from this definition? A localised 'infected' fluid collection is different from a true abscess defined as a localised collection of pus bounded by a wall of collagen and granulation tissue. If the definition of an abscess is relaxed to include 'infected' fluid collections, then it is likely that the incidence of 'abscesses' will increase as more collections are diagnosed using ultrasound and CT scans. At present the outcome of 'infected' postoperative fluid collections is uncertain. It is likely that many small collections with low concentrations of bacteria resolve as the fluid is absorbed and the host defences eradicate the bacteria (3). Alternatively, larger collections may either remain localised and develop into a true abscess or spread causing generalised peritonitis. It is very difficult for the host defences to deal with a true abscess and it is associated with a high morbidity and mortality. The prognosis
