Correspondence
interest to know some of the more general characteristics of the study group and of these 12 patients. Specifically there is no mention of whether patients underwent laparoscopic, laparoscopic converted to open or open surgery or previous abdominal surgery. There is no information on operator experience, the accuracy of using a visual assessment tool for blood loss, and any variation in blood transfusion criteria and postoperative management across centres. Many of the above factors contribute to the degree of blood loss intra-operatively and without details of the use of blood products it is difficult to speculate on the potential to create an immunosuppressed environment contributing to tumour recurrence for example. While there is no statistical significance between stage and degree of blood loss one cannot ignore the observation that patients with the greatest blood loss had more preoperative irradiation and, together with the greater incidence of postoperative complications, this might suggest that blood loss was more a surrogate marker of poorer tumour biology and need for radicality of surgery rather than an indicator of recurrence. Several reports point to a relationship between increased blood loss and postoperative complications and long-term survival [2]. It would therefore be of interest to know what particular types of postoperative complication are being referred to in patients with increased blood loss, as infective complications have been noted to be associated with poorer long-term disease-free and overall survival in patients undergoing liver resection for colorectal metastasis [3]. Furthermore the use of the Dindo Clavien classification of complications would have added to the study, by permitting an assessment of the impact of bleeding on complications. Nevertheless we concur with the authors that blood loss is an important marker of quality of surgery and impacts on the outcome of oncological surgery.
S. G. Farid, S. Pathak, D. Longbotham and I. Wijetunga Department of Surgery, St James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK E-mail: [email protected] Received 10 May 2014; accepted 17 May 2014; Accepted Article online 24 June 2014
References 1 Egenvall M, M€ orner M, P ahlman L, Gunnarsson U. Degree of blood loss during surgery for rectal cancer: a population-based epidemiologic study of surgical complications and survival. Colorectal Dis 2014; 16: 696–702. 2 Aramaki O, Takayama T, Higaki T et al. Decreased blood loss reduces postoperative complications in resection for
740
hepatocellular carcinoma. J Hepatobiliary Pancreat Sci 2014; doi: 10.1002/jhbp.101. 3 Farid SG, Aldouri A, Morris-Stiff G et al. Correlation between postoperative infective complications and long-term outcomes after hepatic resection for colorectal liver metastasis. Ann Surg 2010; 251: 91–100.
Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids a clear classification is needed doi:10.1111/codi.12690
Dear Sir, I read with interest the paper from Giordano et al. [1] and must congratulate them on the excellent result. There is an important conceptual matter, however, which needs to be clarified. The definition of Stage IV haemorrhoids that the authors adopted, namely ‘constant prolapse, regardless of being reducible or not’, is their personal interpretation of the classic definition of Stage IV haemorrhoids by Goligher which is still accepted all over the world. This was ‘an irreducible prolapse’, or to use Goligher’s own words ‘long lasting piles . . . that cannot be properly returned to the anal canal, but remain as a permanent projection of anal mucosa. These completely irreducible piles are hemorrhoids of the fourth degree’ [2]. In their paper, Giordano et al. have artificially upgraded some degree III haemorrhoids to degree IV. In so doing they may have given the false impression that transanal haemorrhoidal dearterialization is a suitable treatment for ‘true’ degree IV haemorrhoids. This applies to any type of mucopexy which if adopted will result in unsuccessful and useless surgery in such patients.
D. F. Altomare Department of Emergency and Organ Transplantation, General Surgery and Liver Transplantation Units, University of Bari, Policlinico, Piazza G. Cesare, 11, Bari, 70124, Italy E-mail: [email protected] Received 11 May 2014; accepted 17 May 2014; Accepted Article online 24 June 2014
References 1 Giordano P, Tomasi I, Pascariello A, Mills E, Elahi S. Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids. Colorectal Dis 2014; 16: 373–6. 2 Goligher J. Surgery of the Anus Rectum and Colon. 5th edition, p. 101. London: Balliere Tindall, 1985.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 739–740
interest to know some of the more general characteristics of the study group and of these 12 patients. Specifically there is no mention of whether patients underwent laparoscopic, laparoscopic converted to open or open surgery or previous abdominal surgery. There is no information on operator experience, the accuracy of using a visual assessment tool for blood loss, and any variation in blood transfusion criteria and postoperative management across centres. Many of the above factors contribute to the degree of blood loss intra-operatively and without details of the use of blood products it is difficult to speculate on the potential to create an immunosuppressed environment contributing to tumour recurrence for example. While there is no statistical significance between stage and degree of blood loss one cannot ignore the observation that patients with the greatest blood loss had more preoperative irradiation and, together with the greater incidence of postoperative complications, this might suggest that blood loss was more a surrogate marker of poorer tumour biology and need for radicality of surgery rather than an indicator of recurrence. Several reports point to a relationship between increased blood loss and postoperative complications and long-term survival [2]. It would therefore be of interest to know what particular types of postoperative complication are being referred to in patients with increased blood loss, as infective complications have been noted to be associated with poorer long-term disease-free and overall survival in patients undergoing liver resection for colorectal metastasis [3]. Furthermore the use of the Dindo Clavien classification of complications would have added to the study, by permitting an assessment of the impact of bleeding on complications. Nevertheless we concur with the authors that blood loss is an important marker of quality of surgery and impacts on the outcome of oncological surgery.
S. G. Farid, S. Pathak, D. Longbotham and I. Wijetunga Department of Surgery, St James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK E-mail: [email protected] Received 10 May 2014; accepted 17 May 2014; Accepted Article online 24 June 2014
References 1 Egenvall M, M€ orner M, P ahlman L, Gunnarsson U. Degree of blood loss during surgery for rectal cancer: a population-based epidemiologic study of surgical complications and survival. Colorectal Dis 2014; 16: 696–702. 2 Aramaki O, Takayama T, Higaki T et al. Decreased blood loss reduces postoperative complications in resection for
740
hepatocellular carcinoma. J Hepatobiliary Pancreat Sci 2014; doi: 10.1002/jhbp.101. 3 Farid SG, Aldouri A, Morris-Stiff G et al. Correlation between postoperative infective complications and long-term outcomes after hepatic resection for colorectal liver metastasis. Ann Surg 2010; 251: 91–100.
Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids a clear classification is needed doi:10.1111/codi.12690
Dear Sir, I read with interest the paper from Giordano et al. [1] and must congratulate them on the excellent result. There is an important conceptual matter, however, which needs to be clarified. The definition of Stage IV haemorrhoids that the authors adopted, namely ‘constant prolapse, regardless of being reducible or not’, is their personal interpretation of the classic definition of Stage IV haemorrhoids by Goligher which is still accepted all over the world. This was ‘an irreducible prolapse’, or to use Goligher’s own words ‘long lasting piles . . . that cannot be properly returned to the anal canal, but remain as a permanent projection of anal mucosa. These completely irreducible piles are hemorrhoids of the fourth degree’ [2]. In their paper, Giordano et al. have artificially upgraded some degree III haemorrhoids to degree IV. In so doing they may have given the false impression that transanal haemorrhoidal dearterialization is a suitable treatment for ‘true’ degree IV haemorrhoids. This applies to any type of mucopexy which if adopted will result in unsuccessful and useless surgery in such patients.
D. F. Altomare Department of Emergency and Organ Transplantation, General Surgery and Liver Transplantation Units, University of Bari, Policlinico, Piazza G. Cesare, 11, Bari, 70124, Italy E-mail: [email protected] Received 11 May 2014; accepted 17 May 2014; Accepted Article online 24 June 2014
References 1 Giordano P, Tomasi I, Pascariello A, Mills E, Elahi S. Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids. Colorectal Dis 2014; 16: 373–6. 2 Goligher J. Surgery of the Anus Rectum and Colon. 5th edition, p. 101. London: Balliere Tindall, 1985.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 739–740
