Correspondence This mechanism may result in more veins regaining competence, thereby improving venous function. Neither of our studies addressed the question of whether small-sized veins (1-2 mm in diameter) are restored to competence by external compression, a mechanism that we suggested may explain the plethysmographic findings of some authors who have shown improved venous function following application of compression hosiery. Finally, Mr Payne and colleagues also mention that the application of compression hosiery reduced the peak reflux velocity. This may be due simply to the fact that stockings raise the interstitial tissue pressure, resulting in a reduced pressure gradient in the veins along the limb, or alternatively that external compression does indeed restore competence in small-sized veins. Our own feelings are that, while compression hosiery may act by restoring competence in large veins, it is unlikely to explain the overall efficacy of compression therapy, and we have turned our attention to investigating the effect on the microcirculation of the skin. This part of the circulation seems to be much more directly influenced by local compression than d o the large veins.
S. Sarin Departmenl of Surgery University Colleye and Middlesex School of Medicine The Middlesex Hospital A4orlimer Street London WIN 8 A A UK
Py lo rus- preservi ng versus standard pa nc reat icod uodenect o my: a n a na Iys is of 110 pancreatic and periampullary carcinomas Sir We note with interest the article by Dr Roder and colleagues ( B r J Surg 1992; 79: 152-5 ) comparing pylorus-preserving pancreaticoduodenectomy ( P P P D ) with standard pancreaticoduodenectomy ( P D )in the treatment of 110 pancreatic and periampullary carcinomas. This report is an important effort in the evaluation of the new pylorus-preserving operation, which has joined a wide range of optional procedures in the treatment of these malignancies. The authors found that there was no difference in t.he survival rate of patients undergoing PPPD or PD with partial gastrectomy for stage I pancreatic and periampullary cancers. This finding is in spite of the fact that there was a bias in favour of the standard PD operation, since 24 of 62 patients (39 per cent) had a favourable tumour grade for PD and only nine of48 (19 per cent) for PPPD. This difference is significant at P = 0.02 (Miettinen’s modification of Fisher’s exact test). For patients with stage 111 tumours, there did not appear to be any tendency for bias as to tumour grade or staging for either pancreatic or periampullary carcinoma. This report suggested that there was a significantly improved survival with PD oersus PPPD for stage 111 carcinoma of the pancreas but not for periampullary cancer. This difference was apparent for up to 26 months; the survival rate for PD was i10 per cent at 5 years. According to the classification used by Roder and colleagues, stage 111 tumours had one or more positive nodes and included patients in whom the tumour extended directly to either the stomach, spleen, colon or adjacent large vessels (T3).It is our practice not to resect carcinomas of the pancreas if they are classified T, either before operation or at exploration. We would, therefore, agree that the pylorus-preserving procedure should not be applied as a palliative resection or cure in patients with a T, tumour. The authors have not given a breakdown of stage I11 cases as to T status. Their resectability rates of 30 per cent overall, 48 per cent of cases fit for surgery and 83 per cent of those thought suitable for resection before operation are quite high and indicate that a significant proportion of resected tumours are T,. Indeed, whether any resection is advisable for T, pancreatic lesions is open to question. In another vein, the follow-up in these patients was a median of only 24 (range 8-92) months. The Kaplan-Meier statistical technique was used. It would be interesting to see what the actual survival rate was after all cases had been followed up for 5 years or more. The only way these questions can be answered is with a strictly prospective blind study in which rigid protocols are followed in the decision-making process as to the operation performed, and the decision is not left to the individual surgeon’s preference (five in this report). Idqlly, in addition follow-up should extend for 5 years in all cases.
1386
In summary, we applaud the effort of the authors in attempting to shed light on the controversy as to what the extent of resection should be in the attempted cure or palliation of cancers of the pancreas, a question that we feel is as yet unanswered.
J. W. Braasch R. L. Rossi Lahey Clinic Medical Center 41 Mall Roud Burlington Massachusetts 01 805
USA
Authors’ reply Sir We appreciate the comments of Drs Braasch and Rossi and thank you for the opportunity to reply. As outlined in the paper and according to international agreement, periampullary tumours (i.e. those of the papilla of Vater and the distal portion of the common bile duct) and adenocarcinoma of the head of the pancreas are two different entities with significant differences in prognosis. When analysing the effect of various operative procedures, these tumours should therefore be evaluated separately. The significant difference in the distribution of tumour grade between patients who had a standard or pylorus-preserving pancreaticoduodenectomy (PPPD),which was noted by Drs Braasch and Rossi, exists only when periampullary tumours and those of the pancreatic head are evaluated as one group. When these tumours are evaluated separately, as in our study, there is no significant difference in grading between the two types of operation. The presence of a T, tumour can frequently be diagnosed only during operation once the procedure has progressed beyond the ‘point of no return’. This is particularly so with infiltration of the portal or superior mesenteric veins. Nine of the 53 patients with carcinoma of the pancreatic head had a T, tumour. In seven of nine patients the tumour infiltrated the portal vein; in two there was infiltration of the superior mesenteric vein. Of the nine patients, five had a standard pancreaticoduodenectomy ( P D ) and four underwent PPPD. Consequently, there was no difference in the distribution of T, tumours between the procedures. Finally, we agree with Drs Braasch and Rossi that the controversy between pylorus-preserving and standard PD in patients with malignant disease can ultimately be decided only by a prospective randomized study. Based on our observations, standard PD with distal gastric resection remains, however, the procedure of choice for resection of carcinoma of the head of the pancreas at this institution, for the time being.
J. D. Roder H. J. Stein J. R. Siewert Department of Surgery Technische Universitut Miinchen Ismaninger Strape 22 0-8000 Miinchen 80 Germany
Technique for laparoscopic appendicectomy Sir We read with interest the recent Surgical Workshop by Mr Byrne and colleagues on laparoscopic appendicectomy ( B r J Surg 1992; 79: 574-5). We applaud the lack of complications in the 25 patients but are concerned about the potential risk of infection. The method was originally described by Browne’ in 1990, who reported a wound infection rate (superficial wound abscess requiring drainage) of 7 per cent in 100 patients. This accords with our own early experience of one wound infection in seven cases, which led us to discontinue the technique. We now prefer to deliver the appendix into a waterproof bag before removal from the abdomen or via the right-hand I I-mm cannula (if the appendix is small enough), avoiding contact with any wounds. Another worry is that, when attempting to deliver a friable appendix, fragmentation could occur resulting in peritoneal contamination. In obese patients or those in whom the mesentery is short, difficulty may also be encountered when attempting this procedure.
Br. J. Surg., Vol. 79, No. 12, December 1992
Correspondence
The mean operating time of 62 min does not show any advantage over the intra-abdominal method of laparoscopic appendicectomy, although we accept that this time would probably decrease with experience. Unless further large studies show the safety and efficacy of this technique, we feel it cannot be recommended as the method of choice for removing the appendix laparoscopically.
A. Lob T. Loosemore R. S. Taylor Department of Surgery St George’s Hospital Blackshaw Road London S W17 OQ T UK 1.
inflamed appendix and wound edges by withdrawing the appendix into the right iliac fossa cannula before delivering it on to the skin. We believe that this can reduce the incidence of wound sepsis encountered by Browne’, who delivered the appendix directly through the wound after an incision in the right iliac fossa, a technique different from the one we described. In the series reported, we were able to deliver friable appendices to the surface by grasping them closer to the caecum. Mobilization of the caecum also facilitates this process where the mesoappendix is short, We recognize, however, that these circumstances together with obesity of the patient can present serious difficulties. Consequently, we do not advocate this as the method of choice for all appendicectomies but rather as an option, especially suited to cases of early inflammation of a mobile appendix.
D. S. Byrne G. Bell J. J. Morrice G. Orr
Browne DS. Laparoscopic-guided appendicectomy. A study of 100 consecutive cases. Aust N Z J Obstet Gynaecol 1990; 30: 231-3.
Authors’ reply Sir We thank Messrs Loh, Loosemore and Taylor for their comments. As described in our paper, we too aim to avoid contact between the
Br. J. Surg., Vol. 79, No. 12, December 1992
Inuerclyde Royal Hospital Larkjield Road Greenock PA16 OXN UK 1.
Browne DS. Laparoscopic-guided appendicectomy. A study of 100 consecutive cases. Ausr N Z J Obstet Gynaecol 1990; 30: 231-3.
I 387
S. Sarin Departmenl of Surgery University Colleye and Middlesex School of Medicine The Middlesex Hospital A4orlimer Street London WIN 8 A A UK
Py lo rus- preservi ng versus standard pa nc reat icod uodenect o my: a n a na Iys is of 110 pancreatic and periampullary carcinomas Sir We note with interest the article by Dr Roder and colleagues ( B r J Surg 1992; 79: 152-5 ) comparing pylorus-preserving pancreaticoduodenectomy ( P P P D ) with standard pancreaticoduodenectomy ( P D )in the treatment of 110 pancreatic and periampullary carcinomas. This report is an important effort in the evaluation of the new pylorus-preserving operation, which has joined a wide range of optional procedures in the treatment of these malignancies. The authors found that there was no difference in t.he survival rate of patients undergoing PPPD or PD with partial gastrectomy for stage I pancreatic and periampullary cancers. This finding is in spite of the fact that there was a bias in favour of the standard PD operation, since 24 of 62 patients (39 per cent) had a favourable tumour grade for PD and only nine of48 (19 per cent) for PPPD. This difference is significant at P = 0.02 (Miettinen’s modification of Fisher’s exact test). For patients with stage 111 tumours, there did not appear to be any tendency for bias as to tumour grade or staging for either pancreatic or periampullary carcinoma. This report suggested that there was a significantly improved survival with PD oersus PPPD for stage 111 carcinoma of the pancreas but not for periampullary cancer. This difference was apparent for up to 26 months; the survival rate for PD was i10 per cent at 5 years. According to the classification used by Roder and colleagues, stage 111 tumours had one or more positive nodes and included patients in whom the tumour extended directly to either the stomach, spleen, colon or adjacent large vessels (T3).It is our practice not to resect carcinomas of the pancreas if they are classified T, either before operation or at exploration. We would, therefore, agree that the pylorus-preserving procedure should not be applied as a palliative resection or cure in patients with a T, tumour. The authors have not given a breakdown of stage I11 cases as to T status. Their resectability rates of 30 per cent overall, 48 per cent of cases fit for surgery and 83 per cent of those thought suitable for resection before operation are quite high and indicate that a significant proportion of resected tumours are T,. Indeed, whether any resection is advisable for T, pancreatic lesions is open to question. In another vein, the follow-up in these patients was a median of only 24 (range 8-92) months. The Kaplan-Meier statistical technique was used. It would be interesting to see what the actual survival rate was after all cases had been followed up for 5 years or more. The only way these questions can be answered is with a strictly prospective blind study in which rigid protocols are followed in the decision-making process as to the operation performed, and the decision is not left to the individual surgeon’s preference (five in this report). Idqlly, in addition follow-up should extend for 5 years in all cases.
1386
In summary, we applaud the effort of the authors in attempting to shed light on the controversy as to what the extent of resection should be in the attempted cure or palliation of cancers of the pancreas, a question that we feel is as yet unanswered.
J. W. Braasch R. L. Rossi Lahey Clinic Medical Center 41 Mall Roud Burlington Massachusetts 01 805
USA
Authors’ reply Sir We appreciate the comments of Drs Braasch and Rossi and thank you for the opportunity to reply. As outlined in the paper and according to international agreement, periampullary tumours (i.e. those of the papilla of Vater and the distal portion of the common bile duct) and adenocarcinoma of the head of the pancreas are two different entities with significant differences in prognosis. When analysing the effect of various operative procedures, these tumours should therefore be evaluated separately. The significant difference in the distribution of tumour grade between patients who had a standard or pylorus-preserving pancreaticoduodenectomy (PPPD),which was noted by Drs Braasch and Rossi, exists only when periampullary tumours and those of the pancreatic head are evaluated as one group. When these tumours are evaluated separately, as in our study, there is no significant difference in grading between the two types of operation. The presence of a T, tumour can frequently be diagnosed only during operation once the procedure has progressed beyond the ‘point of no return’. This is particularly so with infiltration of the portal or superior mesenteric veins. Nine of the 53 patients with carcinoma of the pancreatic head had a T, tumour. In seven of nine patients the tumour infiltrated the portal vein; in two there was infiltration of the superior mesenteric vein. Of the nine patients, five had a standard pancreaticoduodenectomy ( P D ) and four underwent PPPD. Consequently, there was no difference in the distribution of T, tumours between the procedures. Finally, we agree with Drs Braasch and Rossi that the controversy between pylorus-preserving and standard PD in patients with malignant disease can ultimately be decided only by a prospective randomized study. Based on our observations, standard PD with distal gastric resection remains, however, the procedure of choice for resection of carcinoma of the head of the pancreas at this institution, for the time being.
J. D. Roder H. J. Stein J. R. Siewert Department of Surgery Technische Universitut Miinchen Ismaninger Strape 22 0-8000 Miinchen 80 Germany
Technique for laparoscopic appendicectomy Sir We read with interest the recent Surgical Workshop by Mr Byrne and colleagues on laparoscopic appendicectomy ( B r J Surg 1992; 79: 574-5). We applaud the lack of complications in the 25 patients but are concerned about the potential risk of infection. The method was originally described by Browne’ in 1990, who reported a wound infection rate (superficial wound abscess requiring drainage) of 7 per cent in 100 patients. This accords with our own early experience of one wound infection in seven cases, which led us to discontinue the technique. We now prefer to deliver the appendix into a waterproof bag before removal from the abdomen or via the right-hand I I-mm cannula (if the appendix is small enough), avoiding contact with any wounds. Another worry is that, when attempting to deliver a friable appendix, fragmentation could occur resulting in peritoneal contamination. In obese patients or those in whom the mesentery is short, difficulty may also be encountered when attempting this procedure.
Br. J. Surg., Vol. 79, No. 12, December 1992
Correspondence
The mean operating time of 62 min does not show any advantage over the intra-abdominal method of laparoscopic appendicectomy, although we accept that this time would probably decrease with experience. Unless further large studies show the safety and efficacy of this technique, we feel it cannot be recommended as the method of choice for removing the appendix laparoscopically.
A. Lob T. Loosemore R. S. Taylor Department of Surgery St George’s Hospital Blackshaw Road London S W17 OQ T UK 1.
inflamed appendix and wound edges by withdrawing the appendix into the right iliac fossa cannula before delivering it on to the skin. We believe that this can reduce the incidence of wound sepsis encountered by Browne’, who delivered the appendix directly through the wound after an incision in the right iliac fossa, a technique different from the one we described. In the series reported, we were able to deliver friable appendices to the surface by grasping them closer to the caecum. Mobilization of the caecum also facilitates this process where the mesoappendix is short, We recognize, however, that these circumstances together with obesity of the patient can present serious difficulties. Consequently, we do not advocate this as the method of choice for all appendicectomies but rather as an option, especially suited to cases of early inflammation of a mobile appendix.
D. S. Byrne G. Bell J. J. Morrice G. Orr
Browne DS. Laparoscopic-guided appendicectomy. A study of 100 consecutive cases. Aust N Z J Obstet Gynaecol 1990; 30: 231-3.
Authors’ reply Sir We thank Messrs Loh, Loosemore and Taylor for their comments. As described in our paper, we too aim to avoid contact between the
Br. J. Surg., Vol. 79, No. 12, December 1992
Inuerclyde Royal Hospital Larkjield Road Greenock PA16 OXN UK 1.
Browne DS. Laparoscopic-guided appendicectomy. A study of 100 consecutive cases. Ausr N Z J Obstet Gynaecol 1990; 30: 231-3.
I 387
