Comment too, we can expect some of these cases to start reaching hospital alive. This point needs to be borne in mind when planning future resource allocation. P BURDETT-SMITH FRCS DA Registrar The Royal Victoria Infirmary Newcastle upon Tyne
An improved nipple prosthesis We were interested in the article by Sainsbury et al. (Annals, March 1991, vol 73, p67). The authors suggest that surgical reconstruction of the nipple-areola complex is technically difficult with poor long-term results, but we were unable to verify this in the reference they quote (1). Furthermore, several other techniques have been described since the book by Bostwick in 1983. In our experience the skate flap (2) gives a good aesthetic result and the patient avoids the disadvantages of a glued silastic prosthesis with a one-stage nipple-areola reconstruction which can be performed under local anaesthesia. For patients who prefer an external prosthesis, the technique described by Sainsbury et al. should give very satisfactory results, but a significant proportion of our patients prefer the permanency of surgical reconstruction and this should be offered to them. JAGDEEP NANCHAHAL PhD FRCS Senior House Officer DAI DAVIES FRCS Consultant Plastic Surgeon Charing Cross Hospital London
References I Bostwick J. Reconstruction of the nipple areola. Aesthetic and Reconstructive Breast Surgery. St Louis: CV Mosby, 1983: 675-720. 2 Little JW. Nipple-areola reconstruction. In: M Harbal ed. Advances in Plastic and Reconstructive Surgery, Vol 3. Chicago: Year Book Medical Publishers, 1986.
Two kinds of diverticular disease The small historical hint mentioned in the introduction of this article by Ryan (Annals, March 1991, vol 73, p73) needs an addition. The author rightly noted that two of John Hunter's specimens contained diverticula, but I would like to add that Sir Erasmus Wilson (1809-1884) was the first to record the presence of diverticula in the large intestine (1) in 1840. B NATHAN FRCS Surgical Registrar Mayday University Hospital Croydon, Surrey
Reference I Nathan BN. Who first described colonic diverticula? Can J Surg (in press).
Duration of intravenous fluid replacement after abdominal surgery: a prospective randomised study We were interested to read the above article by Salim (Annals, March 1991, vol 73, pl19). We feel that he has been overselective in his criteria for patient selection: (a) He has excluded patients with coexisting medical disease (diabetes, hypertension, cardiorespiratory/renal/hepatic disorders). These problems are common in a population undergoing elective and emergency surgery, and should have been included in the study. (b) The exclusion of patients given gastrokinetic drugs (metoclopramide, domperidone) may have eliminated the very patients he should be identifying. A record of the drugs given to each group would be much more informative. We are conducting a similar study involving all procedures where a degree of ileus might be expected. We aim to achieve a clinically useful answer by quantifying nasogastric aspirates or vomiting, and anti-emetic dosage. Lastly, we are recording the patient's feeling of well-being by an objective assessment of nausea and dryness. This is probably the most important measurement of all if we are to improve the patient's lot. S A RAY MA FRCS Surgical Registrar
Surgery for Cancer of the Esophagus (Book review) Re: Professional standards in a finance driven service. Your review of Hiroshi Akiyama's book on oesophageal cancer (Annals, March 1991, vol 73, p72) gives little credit to the professional standards of British Surgeons. You suggest that we are unlikely to emulate his excellent results because "the emphasis on 'throughput' . . . in a finance driven service" will prejudice the need to "take time, operate gently, meticulously prevent bleeding, carry out radical tumour and gland clearance and re-establish continuity perfectly". If you have any evidence that this is actually happening it should be thoroughly investigated by the College. Personally, I do not share such gloomy predictions-indeed, there is reason to believe that the managers of a finance driven service will look less kindly on the expense of poor results and surgical complications than their predecessors. Also it is worth noting that Akiyama's success was achieved when there was less emphasis on the cost of patient care in this country. D L CROSBY Consultant Surgeon University Hospital of Wales Cardiff
267
R M RAINSBURY MS FRCS
Consultant Surgeon Royal Hampshire County Hospital Winchester Regarding the article by Salim (Annals, March 1991, vol 73, p1 19). There appears to be a major flaw in the study design and the conclusions drawn from it. The study design compares a group of early oral hydration patients with a group of patients who, it is claimed, have a 'conventional' intravenous hydration regimen. This conventional regimen is unnecessarily protracted. It demands that food cannot be given until a minimum of 96 h after surgery. This is a much longer period than can be acceptably called conventional. A more realistic period would be between 36 and 48 h particularly after cholecystectomy. The main conclusions of the study, ie early oral hydration allows patients to eat and be discharged at significantly earlier times after surgery, cannot be termed a conclusion but rather an inevitable consequence of the study design. Even if the patients could eat or be discharged earlier the study design denies patients in the intravenous
An improved nipple prosthesis We were interested in the article by Sainsbury et al. (Annals, March 1991, vol 73, p67). The authors suggest that surgical reconstruction of the nipple-areola complex is technically difficult with poor long-term results, but we were unable to verify this in the reference they quote (1). Furthermore, several other techniques have been described since the book by Bostwick in 1983. In our experience the skate flap (2) gives a good aesthetic result and the patient avoids the disadvantages of a glued silastic prosthesis with a one-stage nipple-areola reconstruction which can be performed under local anaesthesia. For patients who prefer an external prosthesis, the technique described by Sainsbury et al. should give very satisfactory results, but a significant proportion of our patients prefer the permanency of surgical reconstruction and this should be offered to them. JAGDEEP NANCHAHAL PhD FRCS Senior House Officer DAI DAVIES FRCS Consultant Plastic Surgeon Charing Cross Hospital London
References I Bostwick J. Reconstruction of the nipple areola. Aesthetic and Reconstructive Breast Surgery. St Louis: CV Mosby, 1983: 675-720. 2 Little JW. Nipple-areola reconstruction. In: M Harbal ed. Advances in Plastic and Reconstructive Surgery, Vol 3. Chicago: Year Book Medical Publishers, 1986.
Two kinds of diverticular disease The small historical hint mentioned in the introduction of this article by Ryan (Annals, March 1991, vol 73, p73) needs an addition. The author rightly noted that two of John Hunter's specimens contained diverticula, but I would like to add that Sir Erasmus Wilson (1809-1884) was the first to record the presence of diverticula in the large intestine (1) in 1840. B NATHAN FRCS Surgical Registrar Mayday University Hospital Croydon, Surrey
Reference I Nathan BN. Who first described colonic diverticula? Can J Surg (in press).
Duration of intravenous fluid replacement after abdominal surgery: a prospective randomised study We were interested to read the above article by Salim (Annals, March 1991, vol 73, pl19). We feel that he has been overselective in his criteria for patient selection: (a) He has excluded patients with coexisting medical disease (diabetes, hypertension, cardiorespiratory/renal/hepatic disorders). These problems are common in a population undergoing elective and emergency surgery, and should have been included in the study. (b) The exclusion of patients given gastrokinetic drugs (metoclopramide, domperidone) may have eliminated the very patients he should be identifying. A record of the drugs given to each group would be much more informative. We are conducting a similar study involving all procedures where a degree of ileus might be expected. We aim to achieve a clinically useful answer by quantifying nasogastric aspirates or vomiting, and anti-emetic dosage. Lastly, we are recording the patient's feeling of well-being by an objective assessment of nausea and dryness. This is probably the most important measurement of all if we are to improve the patient's lot. S A RAY MA FRCS Surgical Registrar
Surgery for Cancer of the Esophagus (Book review) Re: Professional standards in a finance driven service. Your review of Hiroshi Akiyama's book on oesophageal cancer (Annals, March 1991, vol 73, p72) gives little credit to the professional standards of British Surgeons. You suggest that we are unlikely to emulate his excellent results because "the emphasis on 'throughput' . . . in a finance driven service" will prejudice the need to "take time, operate gently, meticulously prevent bleeding, carry out radical tumour and gland clearance and re-establish continuity perfectly". If you have any evidence that this is actually happening it should be thoroughly investigated by the College. Personally, I do not share such gloomy predictions-indeed, there is reason to believe that the managers of a finance driven service will look less kindly on the expense of poor results and surgical complications than their predecessors. Also it is worth noting that Akiyama's success was achieved when there was less emphasis on the cost of patient care in this country. D L CROSBY Consultant Surgeon University Hospital of Wales Cardiff
267
R M RAINSBURY MS FRCS
Consultant Surgeon Royal Hampshire County Hospital Winchester Regarding the article by Salim (Annals, March 1991, vol 73, p1 19). There appears to be a major flaw in the study design and the conclusions drawn from it. The study design compares a group of early oral hydration patients with a group of patients who, it is claimed, have a 'conventional' intravenous hydration regimen. This conventional regimen is unnecessarily protracted. It demands that food cannot be given until a minimum of 96 h after surgery. This is a much longer period than can be acceptably called conventional. A more realistic period would be between 36 and 48 h particularly after cholecystectomy. The main conclusions of the study, ie early oral hydration allows patients to eat and be discharged at significantly earlier times after surgery, cannot be termed a conclusion but rather an inevitable consequence of the study design. Even if the patients could eat or be discharged earlier the study design denies patients in the intravenous
