Letters to the Editor
993
Dear Editor, Re: Do medical procedures in the arm increase the risk of lymphoedema after axillary surgery? A review It was with relief that I read this paper1 reviewing the literature on the risk of iatrogenic lymphoedema after mastectomy and concluding that there is no evidence base for banning the use of intravenous (IV) puncture or sphygmomanometers in the arms of patients who have had axillary surgery associated with breast cancer treatment. This and other studies confirm my own 35-year experience of following breast cancer patients in the reconstructive arena, noting no correlation between the development of lymphoedema and IV access in the ipsilateral arm. However, in recent years, those of us seeing these patients for breast reconstruction encounter many who are terrified by the prospect of lymphoedema occurring after IV access for anaesthesia in the arm on the side of their mastectomy. These fears have been magnified, if not generated, by well-meaning paramedicals, including breast-care nurses, some physiotherapists and even some doctors. Many who have had veins in the other arm made inaccessible by chemotherapy are doubly anxious, as further IV access in that arm sometimes becomes impossible. The anxiety caused by the unnecessary ban on the use of the ipsilateral arm for IV access is unhelpful for any patient about to undergo surgery and puts the anaesthetist under needless pressure. There are a number of us in this field, including oncologists, anaesthetists, surgeons, physiotherapists and others (personal correspondence with six senior workers in breast cancer care, including four professors, in Sydney, Melbourne and New Zealand) who feel that provision of more evidence-based material to those caring for patients with breast cancer should help to alleviate some of the lymphoedema anxiety currently being experienced by these patients. If evidence-based practice is to be taken seriously, it is incumbent on us as surgeons, who often are team leaders in caring for these patients with cancer, to encourage a uniform approach to patient education in this and other areas. Reference 1. Cheng CT, Deitch JM, Haines IE, Porter DJ, Kilbreath SL. Do medical procedures in the arm increase the risk of lymphoedema after axillary surgery? A review. ANZ J. Surg. 2014; 84: 510–4.
David G. Pennington, FRCS (Ed), FRACS Plastic and Reconstructive Surgery, Macquarie University Hospital, Sydney, New South Wales, Australia
Teleflex Medical, issued a product warning in June 20062 contraindicating the use of these clips on the renal artery during laparoscopic donor nephrectomy. The U.S. Food and Drug Administration (FDA) issued a Medical Device Safety Communication3 to the same effect in 2011. Teleflex’s action followed at least three donor deaths that occurred in similar circumstances: after uncomplicated laparoscopic donor nephrectomy, sudden death in the recovery room from exsanguination occurred which was thought to be due to clip dislodgement. Because no similar cases had been reported after the use of identical clips during nephrectomy for disease, the manufacturer concluded that something distinctly different was occurring in the live kidney donor setting (Teleflex Medical USA, pers. comm., 2006) and issued the product recall specific to laparoscopic live donor nephrectomy. The Google search term ‘kidney donor death after clip’ reveals considerable legal interest in the use of these clips by surgeons despite the FDA product warnings. Apart from the profound human tragedy, dire legal consequences and transplant programme disruption are inevitable. No clip dislodgement occurred in my experience of placing two Hem-o-lok clips on each artery in more than 200 live renal donors prior to 2006, but in light of the unequivocal product warnings, an alternative (stapled) technique was adopted. Regardless of the incident-free personal experiences of surgeons with the Hem-o-lok, until definitive understanding, albeit unlikely, of the deaths described earlier absolves the clip of blame, it is not acceptable practice to use or recommend using the clips alone to secure the renal artery in live renal donors.
References 1. Yu S, Men C, Liu L et al. Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy. ANZ J. Surg. 2014; 84: 649–52. 2. Recalls.org. July 2006. [Cited 16 Sept 2014.] Available from URL: http:// www.recalls.org/medical07-06.htm 3. U.S. Food and Drug Administration. Weck Hem-o-lok ligating clips contraindicated for ligation of renal artery during laparoscopic livingdonor nephrectomy: FDA and HRSA joint safety communication. [Cited 16 Sept 2014.] Available from URL: http://www.fda.gov/ MedicalDevices/Safety/AlertsandNotices/ucm253237.htm
Michael Edye, MBBS, FRACS Blacktown Mount Druitt Clinical School, University of Western Sydney, Sydney, New South Wales, Australia doi: 10.1111/ans.12918
doi: 10.1111/ans.12845 Dear Editor, Dear Editor, Re: Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy In this recent publication, the authors describe the use of Weck Hem-o-lok clips for ligature of the renal artery during what is effectively laparoscopic donor nephrectomy.1 Yet the manufacturer, © 2014 Royal Australasian College of Surgeons
Trends in the management of local complications of acute pancreatitis in Australia Acute pancreatitis occurs at an incidence of between five and 73 cases per 100 000 population.1 A number of these patients go on to suffer local complications from the disease process itself; these include pancreatic or peripancreatic necrosis, peripancreatic fluid collections, pseudocysts and walled-off necrosis.2
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
993
Dear Editor, Re: Do medical procedures in the arm increase the risk of lymphoedema after axillary surgery? A review It was with relief that I read this paper1 reviewing the literature on the risk of iatrogenic lymphoedema after mastectomy and concluding that there is no evidence base for banning the use of intravenous (IV) puncture or sphygmomanometers in the arms of patients who have had axillary surgery associated with breast cancer treatment. This and other studies confirm my own 35-year experience of following breast cancer patients in the reconstructive arena, noting no correlation between the development of lymphoedema and IV access in the ipsilateral arm. However, in recent years, those of us seeing these patients for breast reconstruction encounter many who are terrified by the prospect of lymphoedema occurring after IV access for anaesthesia in the arm on the side of their mastectomy. These fears have been magnified, if not generated, by well-meaning paramedicals, including breast-care nurses, some physiotherapists and even some doctors. Many who have had veins in the other arm made inaccessible by chemotherapy are doubly anxious, as further IV access in that arm sometimes becomes impossible. The anxiety caused by the unnecessary ban on the use of the ipsilateral arm for IV access is unhelpful for any patient about to undergo surgery and puts the anaesthetist under needless pressure. There are a number of us in this field, including oncologists, anaesthetists, surgeons, physiotherapists and others (personal correspondence with six senior workers in breast cancer care, including four professors, in Sydney, Melbourne and New Zealand) who feel that provision of more evidence-based material to those caring for patients with breast cancer should help to alleviate some of the lymphoedema anxiety currently being experienced by these patients. If evidence-based practice is to be taken seriously, it is incumbent on us as surgeons, who often are team leaders in caring for these patients with cancer, to encourage a uniform approach to patient education in this and other areas. Reference 1. Cheng CT, Deitch JM, Haines IE, Porter DJ, Kilbreath SL. Do medical procedures in the arm increase the risk of lymphoedema after axillary surgery? A review. ANZ J. Surg. 2014; 84: 510–4.
David G. Pennington, FRCS (Ed), FRACS Plastic and Reconstructive Surgery, Macquarie University Hospital, Sydney, New South Wales, Australia
Teleflex Medical, issued a product warning in June 20062 contraindicating the use of these clips on the renal artery during laparoscopic donor nephrectomy. The U.S. Food and Drug Administration (FDA) issued a Medical Device Safety Communication3 to the same effect in 2011. Teleflex’s action followed at least three donor deaths that occurred in similar circumstances: after uncomplicated laparoscopic donor nephrectomy, sudden death in the recovery room from exsanguination occurred which was thought to be due to clip dislodgement. Because no similar cases had been reported after the use of identical clips during nephrectomy for disease, the manufacturer concluded that something distinctly different was occurring in the live kidney donor setting (Teleflex Medical USA, pers. comm., 2006) and issued the product recall specific to laparoscopic live donor nephrectomy. The Google search term ‘kidney donor death after clip’ reveals considerable legal interest in the use of these clips by surgeons despite the FDA product warnings. Apart from the profound human tragedy, dire legal consequences and transplant programme disruption are inevitable. No clip dislodgement occurred in my experience of placing two Hem-o-lok clips on each artery in more than 200 live renal donors prior to 2006, but in light of the unequivocal product warnings, an alternative (stapled) technique was adopted. Regardless of the incident-free personal experiences of surgeons with the Hem-o-lok, until definitive understanding, albeit unlikely, of the deaths described earlier absolves the clip of blame, it is not acceptable practice to use or recommend using the clips alone to secure the renal artery in live renal donors.
References 1. Yu S, Men C, Liu L et al. Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy. ANZ J. Surg. 2014; 84: 649–52. 2. Recalls.org. July 2006. [Cited 16 Sept 2014.] Available from URL: http:// www.recalls.org/medical07-06.htm 3. U.S. Food and Drug Administration. Weck Hem-o-lok ligating clips contraindicated for ligation of renal artery during laparoscopic livingdonor nephrectomy: FDA and HRSA joint safety communication. [Cited 16 Sept 2014.] Available from URL: http://www.fda.gov/ MedicalDevices/Safety/AlertsandNotices/ucm253237.htm
Michael Edye, MBBS, FRACS Blacktown Mount Druitt Clinical School, University of Western Sydney, Sydney, New South Wales, Australia doi: 10.1111/ans.12918
doi: 10.1111/ans.12845 Dear Editor, Dear Editor, Re: Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy In this recent publication, the authors describe the use of Weck Hem-o-lok clips for ligature of the renal artery during what is effectively laparoscopic donor nephrectomy.1 Yet the manufacturer, © 2014 Royal Australasian College of Surgeons
Trends in the management of local complications of acute pancreatitis in Australia Acute pancreatitis occurs at an incidence of between five and 73 cases per 100 000 population.1 A number of these patients go on to suffer local complications from the disease process itself; these include pancreatic or peripancreatic necrosis, peripancreatic fluid collections, pseudocysts and walled-off necrosis.2
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
