152
Comment
may appear to improve if 'infected' fluid collections are included. ADAM L WIDDISON DM FRCS Surgical Registrar Norfolk and Norwich Hospital Norwich References I Vaamonde CA, Michael UF, Metzger RA, Carroll KE. Complications of acute peritoneal dialysis. J Chronic Dis 1975;28:637. 2 Berg RD. Human Intestinal Microflora in Health and Disease. London: Academic Press, 1983. 3 Ahrenholz DH, Simmons RL. Peritonitis and other intraabdominal infections. In: Simmons RL, Howard RJ eds. Surgical Infectious Diseases. New York: Appleton-CenturyCrofts, 1982:795-843.
Surgical options for left-sided large bowel emergencies We would hope that the assessor's comment, that the response of 218 consultant surgeons on their policies in the management of left-sided large bowel emergencies (Annals, November 1991, vol 73, p394) reflects 'arm-chair' practice, is true and that the figures given do not reflect 'what actually happens'. There certainly appears to be a great variation in clinical practice. Of those surgeons performing either a Hartmann's procedure or sigmoid colectomy with primary anastomosis for a case with a perforated caecum, 90% of responders leave the caecum in situ. Apparently, 12-14% of surgeons only change the site of the diverting stoma without performing a primary resection. Interestingly, a significant number of surgeons perform a subtotal colectomy and primary anastomosis for such a case, a form of management which we endorse following our recent experiences (1). However, we dispute that the operation of subtotal colectomy is unduly lengthy (the operating time is not mentioned in the paper quoted by the authors) and this option is certainly less messy than on-table lavage which the survey found to be an infrequently used procedure in this country. It is also of interest to note that the Hartmann's procedure is used in 33-79% of cases, although it is well known that these patients are often not 'reversed' for one reason or another. In the presence of residual/metastatic disease it might be kinder for the patient to succumb without the presence of a stoma, which many terminal patients find difficult to come to terms with. It would be of interest to know if the authors asked, or intend to ask, the surgical fraternity responding to their questionnaire how frequently gastrointestinal continuity was restored after a Hartmann's procedure and if residual disease was considered a contraindication for a second operation. With the recent King's Fund Forum (2,3) suggesting that every UK Health District has at least one trained colorectal
surgeon, as pointed out by the assessor, a critical evaluation of subtotal colectomy is necessary. We await, with interest, the results of prospective controlled, possibly randomised, studies. B M STEPHENSON FRCS Surgical Registrar G H GRIFFITHS FRCS Consultant Surgeon Royal Gwent Hospital Newport, Gwent
References I Stephenson BM, Shandall A, Farouk R, Griffith GH. Malignant left-sided large bowel obstruction managed by subtotal/total colectomy. BrJ Surg 1990;77:1098-1102. 2 Anonymous. Reducing deaths from large bowel cancer. Lancet 1990;335:1583. 3 Anonymous. Cancer of the colon and rectum. Br J Surg 1990;77: 1063-5.
Simulated laparoscopic cholecystectomy Mr Brian Rees, Assessor for the Annals, comments favourably upon this instrument (Annals, January 1992, vol 74, p70) and adds "This paper and the box is recommended to surgeons who intend undertaking laparoscopic cholecystectomy". This sets the scene for a repetition of the American practice, where I personally saw (in Chicago in October) many surgeons of 50 years old, 60 years old and even 70 years old, practising on a similar box, determined to go and do it upon patients in the near future. That is the reason why every biliary tract surgeon that I talked to during the week's meeting of the American College of Surgeons was busily engaged in repairing common duct injuries by general surgeons who had the idea that you can simply adapt their particular technique to laparoscopic cholecystectomy without risk. I have no wish to impede in any way the march of time in surgical technique and, properly done, laparoscopic cholecystectomy is a good operation. Nevertheless, it should be performed only by specialised biliary tract surgeons or by their pupils who have been rigorously trained in this technique. I see a good number of patients who are dissatisfied with the results of cholecystectomy, sent by their legal advisers. Of many of them, I report that the surgeon has behaved impeccably and, with a few encouraging words, the complaint is dropped. If, nevertheless, a general surgeon, untrained in laparoscopic cholecystectomy, tries to perform this operation and runs into disaster, my initial reaction would be to assume that he was negligent in starting the operation beyond his compass. LORD SMITH OF MARLOW Past President of the Royal College of Surgeons of England House of Lords
Comment
may appear to improve if 'infected' fluid collections are included. ADAM L WIDDISON DM FRCS Surgical Registrar Norfolk and Norwich Hospital Norwich References I Vaamonde CA, Michael UF, Metzger RA, Carroll KE. Complications of acute peritoneal dialysis. J Chronic Dis 1975;28:637. 2 Berg RD. Human Intestinal Microflora in Health and Disease. London: Academic Press, 1983. 3 Ahrenholz DH, Simmons RL. Peritonitis and other intraabdominal infections. In: Simmons RL, Howard RJ eds. Surgical Infectious Diseases. New York: Appleton-CenturyCrofts, 1982:795-843.
Surgical options for left-sided large bowel emergencies We would hope that the assessor's comment, that the response of 218 consultant surgeons on their policies in the management of left-sided large bowel emergencies (Annals, November 1991, vol 73, p394) reflects 'arm-chair' practice, is true and that the figures given do not reflect 'what actually happens'. There certainly appears to be a great variation in clinical practice. Of those surgeons performing either a Hartmann's procedure or sigmoid colectomy with primary anastomosis for a case with a perforated caecum, 90% of responders leave the caecum in situ. Apparently, 12-14% of surgeons only change the site of the diverting stoma without performing a primary resection. Interestingly, a significant number of surgeons perform a subtotal colectomy and primary anastomosis for such a case, a form of management which we endorse following our recent experiences (1). However, we dispute that the operation of subtotal colectomy is unduly lengthy (the operating time is not mentioned in the paper quoted by the authors) and this option is certainly less messy than on-table lavage which the survey found to be an infrequently used procedure in this country. It is also of interest to note that the Hartmann's procedure is used in 33-79% of cases, although it is well known that these patients are often not 'reversed' for one reason or another. In the presence of residual/metastatic disease it might be kinder for the patient to succumb without the presence of a stoma, which many terminal patients find difficult to come to terms with. It would be of interest to know if the authors asked, or intend to ask, the surgical fraternity responding to their questionnaire how frequently gastrointestinal continuity was restored after a Hartmann's procedure and if residual disease was considered a contraindication for a second operation. With the recent King's Fund Forum (2,3) suggesting that every UK Health District has at least one trained colorectal
surgeon, as pointed out by the assessor, a critical evaluation of subtotal colectomy is necessary. We await, with interest, the results of prospective controlled, possibly randomised, studies. B M STEPHENSON FRCS Surgical Registrar G H GRIFFITHS FRCS Consultant Surgeon Royal Gwent Hospital Newport, Gwent
References I Stephenson BM, Shandall A, Farouk R, Griffith GH. Malignant left-sided large bowel obstruction managed by subtotal/total colectomy. BrJ Surg 1990;77:1098-1102. 2 Anonymous. Reducing deaths from large bowel cancer. Lancet 1990;335:1583. 3 Anonymous. Cancer of the colon and rectum. Br J Surg 1990;77: 1063-5.
Simulated laparoscopic cholecystectomy Mr Brian Rees, Assessor for the Annals, comments favourably upon this instrument (Annals, January 1992, vol 74, p70) and adds "This paper and the box is recommended to surgeons who intend undertaking laparoscopic cholecystectomy". This sets the scene for a repetition of the American practice, where I personally saw (in Chicago in October) many surgeons of 50 years old, 60 years old and even 70 years old, practising on a similar box, determined to go and do it upon patients in the near future. That is the reason why every biliary tract surgeon that I talked to during the week's meeting of the American College of Surgeons was busily engaged in repairing common duct injuries by general surgeons who had the idea that you can simply adapt their particular technique to laparoscopic cholecystectomy without risk. I have no wish to impede in any way the march of time in surgical technique and, properly done, laparoscopic cholecystectomy is a good operation. Nevertheless, it should be performed only by specialised biliary tract surgeons or by their pupils who have been rigorously trained in this technique. I see a good number of patients who are dissatisfied with the results of cholecystectomy, sent by their legal advisers. Of many of them, I report that the surgeon has behaved impeccably and, with a few encouraging words, the complaint is dropped. If, nevertheless, a general surgeon, untrained in laparoscopic cholecystectomy, tries to perform this operation and runs into disaster, my initial reaction would be to assume that he was negligent in starting the operation beyond his compass. LORD SMITH OF MARLOW Past President of the Royal College of Surgeons of England House of Lords
