Annals of the Royal College of Surgeons of England (1992) vol. 74, 74-76 Com ment
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. Tables and figures should be included only if absolutely no more than five references should be given.
Cetrimide lavage: ineffective and potentially toxic May I comment on the article by Saeed and others (Annals, January 1991, vol 73, p26). The writer has been using cetrimide and of recent years, Savlon® 1/100 (cetrimide 0.15% + chlorhexidine 0.015%) to wash out cavities suspected of being contaminated with cancer cells, eg after mastectomies and axillary clearance and abdominoperineal excision of the rectum. In the latter case, care has been taken not to allow the cetrimide-containing solution to diffuse amongst the bowel and in all cases the solution is washed out immediately with water, another cytocidal agent. In none of the cases, over about 30 years that the writer has used this substance, has there been any sign of toxicity. Its use amongst the bowel should be avoided because of the possibility of rapid absorption. One would also agree with the writers of the above article that povidine iodine is now a safer and more effective agent. Perhaps the effectiveness of washout of the peritoneal cavity with water alone can be illustrated by describing two brief cases. The first occurred when the writer was a surgical registrar in Britain in the 1950s. A man with an acute obstruction of the colon due to a carcinoma of the sigmoid was found at operation to have perforated the colon at the site of the growth. Immediate operation and resection was temporarily successful, but he died within 12 months of carcinomatosis peritonei. A few years ago, a patient was found at operation to have a perforated rectum with a large villous carcinoma lying free in the pelvis, having prolapsed through the perforation. Resection was carried out and liberal washout of the peritoneal cavity with water. Though this man did die of recurrence, the only site of tumour in the peritoneal cavity was a lesion on the sacrum underlying the site of the primary. There was no carcinomatosis peritonei. K B ORR FRCS FRACS 24 Belgrave Street Kogarah 2217, Australia
Assessment of the use of disposable skin staplers in bowel anastomoses to reduce laparotomy time in penetrating ballistic injury to the abdomen It was with interest that I read the article by Howell et al. (Annals, March 1991, vol 73, p87). There are, however, some points that I would like to raise. The use of skin staples to form a small bowel anastomosis seems rather interesting. However, in terms of the timing, which is heavily stressed in the article, I would be interested to know if the difference between stapling and suturing would be as great, if any different at all, if the authors used the wellrecognised, single layer, interrupted serosubmucosal closure technique (1-4). This method enables a rapid, 'one' layer closure ensuring inversion of the mucosal layer - which appears to have been of some difficulty in the paper reported. I would also raise the question of cost. The Autosuture® Premium disposable skin staplers used in the study cost approximately £10 each. This is compared with £2.50 for two 2/0 coated polyglactin (Vicryl®, Ethicon Ltd) sutures.
In these times of NHS cuts, do we need to spend more money to achieve altogether similar results? MICHAEL J DAVIES FRCS Surgical Registrar Western General Hospital Edinburgh
References I Irwin SR, Krukowski ZH, Matheson NA. Single layer anastomosis in the upper gastrointestinal tract. Br j Surg 1990;77:643-4. 2 Matheson NA, Irving AD. Single layer anastomosis in the gastrointestinal tract. Surg Gynecol Obstet 1976;143:619-24. 3 Matheson NA. Single layer interrupted serosubmucosal anastomosis. In: Dudley HAF, ed. Rob and Smith's Operative Surgery, Vol. 1, Alimentary Tract and Abdominal Wall, 4th Edition. London: Butterworths, 1983:77-83. 4 Krukowski ZH. Bowel anastomosis. Surgery 1990;77:18357.
A comparative study between Michel and Proximate clips for the closure of neck incisions I was interested in the article of Doble, Ingham and Lumley on the comparative study of Michel and Proximate clips (Annals, July 1991, vol 73, p204) and would like to make a comment. For the past 25 years I have been using Michel clips on all surgical wounds, viz. carotid endarterectomies, aortic repair and femoropopliteal bypass with satisfactory healing. Proximate staples have also been used. It has been my impression that the wounds closed with Michel clips have healed better and more quickly-possibly because of the pressure applied to the skin edges by the clip. I think comfort of removal depends largely on the expertise of the person doing the clip removal. I have always instructed nursing staff to support the base of the clip with a forcep, pinch the clip with the point of the remover which causes it to open slightly and allows the remover to be passed easily under it. Easy and painless removal of the Michel clip is achieved. REGINALD MAGEE FRCS FRACS FACS Vascular Surgeon 201 Wickham Terrace Brisbane 4000, Australia
Pulse oximetry in closed limb fractures I read with interest the paper by Huw G David (Annals, September 1991, vol 73, p283) suggesting that pulse oximetry may be of value in assessing distal blood flow in fractures. As the author states in his discussion, arterial flow is rarely occluded by raised intracompartmental pressures and therefore it is predictable that there should be no significant change in distal pulse oximetry where a distal pulse is palpable, even if there is clinical evidence of a compartment syndrome. In a series of 15 patients with tibial fractures, Transcutaneous Po2 (TcPo) has been measured over the anterior tibial compartment close to the site of the fracture and in the same site in the contralateral normal limb. The limb differences correlate with the mode of injury and the results of fracture healing after 2 years. In one patient who had a clinical
Comment compartment syndrome the TcPo2 approached 0 mmHg in the injured limb and improved dramatically after fasciotomies were performed. In three patients the compartment pressure has been measured at the same time as the TcPo2 and abnormalities have been recorded in both readings. It has been shown in anatomical studies that the blood supply to the skin over the anterior compartment of the lower leg is by septal and intracompartmental vessels (1). These are presumably susceptible to compression in the presence of raised intracompartmental pressures resulting in reduced cutaneous blood supply. I would like to suggest that the measurement of TcPo2 is likely to be of more use in the assessment of the injured limb than distal pulse oximetry. KAREN E DALY FRCS Registrar in Orthopaedics South West Thames Training Programme
Reference I Carraquiry C, Aparecida Costa M, Vasconez LO. An anatomic study of the septocutaneous vessels of the leg. Plast Reconstr Surg 1985;76:354-61. I read with interest the above paper by David (Annals, September 1991, vol 73, p283). We have found pulse oximetry especially useful during the manipulation of supracondylar fractures of the humerus (1), which are commonly associated with vascular compromise. David's conclusion seems to emphasise oximetric detection of pulsatile flow, but this per se may not be evidence of adequate perfusion-Lawson et al. (2) have shown that oximeters may detect pulsatile flow at levels as low as 4% resting limb flow. More useful would be a combination of pulsatile flow and 95% (or control limb) saturation by oximeter as used successfully by Graham et al. (3) whilst monitoring replanted digits. It is unfortunate that David did not continue oximetric monitoring into the postoperative period where its role in the early detection of compartment syndrome could have been investigated too. S A RAY MA FRCS Registrar in General Surgery Royal Hampshire County Hospital Winchester
References I Ray SA, Ivory JP, Beavis JP. Use of pulse oximetry during manipulation of supracondylar fractures of the humerus. Injury 1991;22: 103. 2 Lawson D, Norley I, Korbon G, Loeb R, Ellis J. Blood flow limits and pulse oximeter signal detection. Anesthesiology 1987;67: 599-603. 3 Graham B, Paulus DA, Caffee HH. Pulse oximetry for vascular monitoring in upper extremity replantation surgery. J Hand Surg 1986;11A: 687-92.
A controlled trial of short-term versus standard axillary drainage after axiliary clearance and iridium implant treatment of early breast cancer We were interested to read the study by Inwang et al. looking at short term drainage of the axilla after axillary clearance (Annals, September 1991, vol 73, p326). In concluding the authors state that early drain removal was not associated with any increase in wound complications. It is
75
unclear what the statistical analysis shows (P < 0.1), but clearly there is a difference between the 49% with seroma in the shortterm group and 28% in the standard group. One of the stated aims of the proposed change of policy was the shortening of hospital stay and thus cost. While this is a laudable aim, it must surely not be the overriding consideration. Other factors must be taken into account. The cost of the excess 24 or so wound aspirations in the short-term drainage group was not assessed. Similarly, no mention was made of the pain or emotional impact of the seromas. To the patient, a seroma may represent a cancerous lump at the site of an operation for proven breast cancer. This may obviously cause considerable distress. Finally we question whether the authors' radiotherapy colleagues should manage the local surgical postoperative complications. M W SCRIVEN BSc FRCS Registrar N A BURGESS FRCS Registrar M SOWTER BSc MB BS Senior House Officer M H LEWIS MD FRCS Consultant
East Glamorgan General Hospital Church Village, Mid Glamorgan
Assessment of burn injury in the accident and emergency department: a review of 100 referrals to a regional burns unit The paper by Laing et al. (Annals, September 1991, vol 73, p329) shows that burn surface area assessment can be inaccurate and inconsistent, when compared with their own assessment. Unfortunately, their own assessment, as the standard by which others are judged, may not be unerring. Other studies have shown that an observer charts a burn accurately, but error occurs when estimating the percentage burn from the chart (1,2). Inaccuracy seems to be reduced, but not absent, even for those with experience of burns. After developing a computerised burn assessment system, I was able to verify assessments of charted bums, by 24 surgeons of various grades, against a computerised assessment. Although estimating from a chart only, and with no time restriction, average percentage errors still varied between 19% and 44%. Even those experienced with burns were inaccurate despite having adequate time to assess the burn area and with no patient to manage. Inaccurate assessment leads to inaccurate treatment, which at best means that accurate audit is impossible and, at worst, resuscitation may be dangerously inappropriate. A computerised assessment is standardised, more accurate, consistently reproducible and eliminates estimation of the burn area from a chart. A database could also be used to record detailed information about a burn injury (3). A computer forces the user into a structured, formalised and rigorous assessment of a patient (4). It minimises variation and inaccuracy between doctors, even in a specialised unit, and should inevitably lead to an improvement in care. D A MOSQUERA BSc FRCS East Birmingham Hospital, Bordesley Green East, Birmingham
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. Tables and figures should be included only if absolutely no more than five references should be given.
Cetrimide lavage: ineffective and potentially toxic May I comment on the article by Saeed and others (Annals, January 1991, vol 73, p26). The writer has been using cetrimide and of recent years, Savlon® 1/100 (cetrimide 0.15% + chlorhexidine 0.015%) to wash out cavities suspected of being contaminated with cancer cells, eg after mastectomies and axillary clearance and abdominoperineal excision of the rectum. In the latter case, care has been taken not to allow the cetrimide-containing solution to diffuse amongst the bowel and in all cases the solution is washed out immediately with water, another cytocidal agent. In none of the cases, over about 30 years that the writer has used this substance, has there been any sign of toxicity. Its use amongst the bowel should be avoided because of the possibility of rapid absorption. One would also agree with the writers of the above article that povidine iodine is now a safer and more effective agent. Perhaps the effectiveness of washout of the peritoneal cavity with water alone can be illustrated by describing two brief cases. The first occurred when the writer was a surgical registrar in Britain in the 1950s. A man with an acute obstruction of the colon due to a carcinoma of the sigmoid was found at operation to have perforated the colon at the site of the growth. Immediate operation and resection was temporarily successful, but he died within 12 months of carcinomatosis peritonei. A few years ago, a patient was found at operation to have a perforated rectum with a large villous carcinoma lying free in the pelvis, having prolapsed through the perforation. Resection was carried out and liberal washout of the peritoneal cavity with water. Though this man did die of recurrence, the only site of tumour in the peritoneal cavity was a lesion on the sacrum underlying the site of the primary. There was no carcinomatosis peritonei. K B ORR FRCS FRACS 24 Belgrave Street Kogarah 2217, Australia
Assessment of the use of disposable skin staplers in bowel anastomoses to reduce laparotomy time in penetrating ballistic injury to the abdomen It was with interest that I read the article by Howell et al. (Annals, March 1991, vol 73, p87). There are, however, some points that I would like to raise. The use of skin staples to form a small bowel anastomosis seems rather interesting. However, in terms of the timing, which is heavily stressed in the article, I would be interested to know if the difference between stapling and suturing would be as great, if any different at all, if the authors used the wellrecognised, single layer, interrupted serosubmucosal closure technique (1-4). This method enables a rapid, 'one' layer closure ensuring inversion of the mucosal layer - which appears to have been of some difficulty in the paper reported. I would also raise the question of cost. The Autosuture® Premium disposable skin staplers used in the study cost approximately £10 each. This is compared with £2.50 for two 2/0 coated polyglactin (Vicryl®, Ethicon Ltd) sutures.
In these times of NHS cuts, do we need to spend more money to achieve altogether similar results? MICHAEL J DAVIES FRCS Surgical Registrar Western General Hospital Edinburgh
References I Irwin SR, Krukowski ZH, Matheson NA. Single layer anastomosis in the upper gastrointestinal tract. Br j Surg 1990;77:643-4. 2 Matheson NA, Irving AD. Single layer anastomosis in the gastrointestinal tract. Surg Gynecol Obstet 1976;143:619-24. 3 Matheson NA. Single layer interrupted serosubmucosal anastomosis. In: Dudley HAF, ed. Rob and Smith's Operative Surgery, Vol. 1, Alimentary Tract and Abdominal Wall, 4th Edition. London: Butterworths, 1983:77-83. 4 Krukowski ZH. Bowel anastomosis. Surgery 1990;77:18357.
A comparative study between Michel and Proximate clips for the closure of neck incisions I was interested in the article of Doble, Ingham and Lumley on the comparative study of Michel and Proximate clips (Annals, July 1991, vol 73, p204) and would like to make a comment. For the past 25 years I have been using Michel clips on all surgical wounds, viz. carotid endarterectomies, aortic repair and femoropopliteal bypass with satisfactory healing. Proximate staples have also been used. It has been my impression that the wounds closed with Michel clips have healed better and more quickly-possibly because of the pressure applied to the skin edges by the clip. I think comfort of removal depends largely on the expertise of the person doing the clip removal. I have always instructed nursing staff to support the base of the clip with a forcep, pinch the clip with the point of the remover which causes it to open slightly and allows the remover to be passed easily under it. Easy and painless removal of the Michel clip is achieved. REGINALD MAGEE FRCS FRACS FACS Vascular Surgeon 201 Wickham Terrace Brisbane 4000, Australia
Pulse oximetry in closed limb fractures I read with interest the paper by Huw G David (Annals, September 1991, vol 73, p283) suggesting that pulse oximetry may be of value in assessing distal blood flow in fractures. As the author states in his discussion, arterial flow is rarely occluded by raised intracompartmental pressures and therefore it is predictable that there should be no significant change in distal pulse oximetry where a distal pulse is palpable, even if there is clinical evidence of a compartment syndrome. In a series of 15 patients with tibial fractures, Transcutaneous Po2 (TcPo) has been measured over the anterior tibial compartment close to the site of the fracture and in the same site in the contralateral normal limb. The limb differences correlate with the mode of injury and the results of fracture healing after 2 years. In one patient who had a clinical
Comment compartment syndrome the TcPo2 approached 0 mmHg in the injured limb and improved dramatically after fasciotomies were performed. In three patients the compartment pressure has been measured at the same time as the TcPo2 and abnormalities have been recorded in both readings. It has been shown in anatomical studies that the blood supply to the skin over the anterior compartment of the lower leg is by septal and intracompartmental vessels (1). These are presumably susceptible to compression in the presence of raised intracompartmental pressures resulting in reduced cutaneous blood supply. I would like to suggest that the measurement of TcPo2 is likely to be of more use in the assessment of the injured limb than distal pulse oximetry. KAREN E DALY FRCS Registrar in Orthopaedics South West Thames Training Programme
Reference I Carraquiry C, Aparecida Costa M, Vasconez LO. An anatomic study of the septocutaneous vessels of the leg. Plast Reconstr Surg 1985;76:354-61. I read with interest the above paper by David (Annals, September 1991, vol 73, p283). We have found pulse oximetry especially useful during the manipulation of supracondylar fractures of the humerus (1), which are commonly associated with vascular compromise. David's conclusion seems to emphasise oximetric detection of pulsatile flow, but this per se may not be evidence of adequate perfusion-Lawson et al. (2) have shown that oximeters may detect pulsatile flow at levels as low as 4% resting limb flow. More useful would be a combination of pulsatile flow and 95% (or control limb) saturation by oximeter as used successfully by Graham et al. (3) whilst monitoring replanted digits. It is unfortunate that David did not continue oximetric monitoring into the postoperative period where its role in the early detection of compartment syndrome could have been investigated too. S A RAY MA FRCS Registrar in General Surgery Royal Hampshire County Hospital Winchester
References I Ray SA, Ivory JP, Beavis JP. Use of pulse oximetry during manipulation of supracondylar fractures of the humerus. Injury 1991;22: 103. 2 Lawson D, Norley I, Korbon G, Loeb R, Ellis J. Blood flow limits and pulse oximeter signal detection. Anesthesiology 1987;67: 599-603. 3 Graham B, Paulus DA, Caffee HH. Pulse oximetry for vascular monitoring in upper extremity replantation surgery. J Hand Surg 1986;11A: 687-92.
A controlled trial of short-term versus standard axillary drainage after axiliary clearance and iridium implant treatment of early breast cancer We were interested to read the study by Inwang et al. looking at short term drainage of the axilla after axillary clearance (Annals, September 1991, vol 73, p326). In concluding the authors state that early drain removal was not associated with any increase in wound complications. It is
75
unclear what the statistical analysis shows (P < 0.1), but clearly there is a difference between the 49% with seroma in the shortterm group and 28% in the standard group. One of the stated aims of the proposed change of policy was the shortening of hospital stay and thus cost. While this is a laudable aim, it must surely not be the overriding consideration. Other factors must be taken into account. The cost of the excess 24 or so wound aspirations in the short-term drainage group was not assessed. Similarly, no mention was made of the pain or emotional impact of the seromas. To the patient, a seroma may represent a cancerous lump at the site of an operation for proven breast cancer. This may obviously cause considerable distress. Finally we question whether the authors' radiotherapy colleagues should manage the local surgical postoperative complications. M W SCRIVEN BSc FRCS Registrar N A BURGESS FRCS Registrar M SOWTER BSc MB BS Senior House Officer M H LEWIS MD FRCS Consultant
East Glamorgan General Hospital Church Village, Mid Glamorgan
Assessment of burn injury in the accident and emergency department: a review of 100 referrals to a regional burns unit The paper by Laing et al. (Annals, September 1991, vol 73, p329) shows that burn surface area assessment can be inaccurate and inconsistent, when compared with their own assessment. Unfortunately, their own assessment, as the standard by which others are judged, may not be unerring. Other studies have shown that an observer charts a burn accurately, but error occurs when estimating the percentage burn from the chart (1,2). Inaccuracy seems to be reduced, but not absent, even for those with experience of burns. After developing a computerised burn assessment system, I was able to verify assessments of charted bums, by 24 surgeons of various grades, against a computerised assessment. Although estimating from a chart only, and with no time restriction, average percentage errors still varied between 19% and 44%. Even those experienced with burns were inaccurate despite having adequate time to assess the burn area and with no patient to manage. Inaccurate assessment leads to inaccurate treatment, which at best means that accurate audit is impossible and, at worst, resuscitation may be dangerously inappropriate. A computerised assessment is standardised, more accurate, consistently reproducible and eliminates estimation of the burn area from a chart. A database could also be used to record detailed information about a burn injury (3). A computer forces the user into a structured, formalised and rigorous assessment of a patient (4). It minimises variation and inaccuracy between doctors, even in a specialised unit, and should inevitably lead to an improvement in care. D A MOSQUERA BSc FRCS East Birmingham Hospital, Bordesley Green East, Birmingham
