Since the last issue of the Annals, the following letters have been published on our website <http://www.rcseng.ac.uk/publications/eletters/>:
letter . 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
letter Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
I totally agree with the author. PACS has definitely reduced time wasted searching for lost x-rays and sifting through numerous bulky x-ray packets. It has also increased the workload of the SHO on call by increasing the number of referrals to just ‘look at an x-ray’ by a nurse practitioner.
There can be a significantly high number of such referrals leading to a high degree of frustration when a PACS terminal is not in the vicinity; the nurse practitioner will usually not know how to describe the image in any way, shape or form. This prompts the question: should they undergo further training in order to continue their ‘advanced’ role in that centre?
Footnotes
Comment on Davda K, Graham A. Is describing fractures a dying art? e-letter.
Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
Thank you Dr Nwachuku for your comments. Unfortunately the fact of the modern NHS is one of ever-increasing target-driven performance coupled with a decrease in junior doctors' hours, resulting in the training of further nurse practioners within subspecialities. In accident and emergency departments, emergency nurse practitioners do undergo a rigorous training programme and certainly in our unit do have a good level of senior ‘doctor’ cover for advice.
In addition, most benefit from a long experience of accident and emergency nursing that will often outweigh the relatively short training period of a transient accident and emergency SHO. Hence I do believe that they have a significant role to play, particularly in the minor injury setting, where by definition the fractures they are likely to encounter can wait for a fracture clinic review. The onus lies with both the referrer and orthopaedic trainee to describe what the x-ray shows and not just ‘look at an x-ray’.
letter Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
We read with interest the recent article by O'Flynn. The innovation of safe disposable instruments is a laudable goal. This paper, however, failed to allay our concerns. The second phase of the audit still highlighted misgivings, particularly with the Boyle-Davis gag (29% thought it was worse than reusable instruments and 2.3% thought it better) and this suggests that there is still scope for further product development.
The paper, moreover, failed to present any data on the curved Negus forceps, nor a suitable alternative. It is of course possible to perform a tonsillectomy without such a tool. The National Tonsillectomy Audit,1 however, highlighted the value of traditional cold steel dissection and ties for haemostasis. Such an instrument is essential for this accepted technique; therefore, we would welcome this important information.
Footnotes
Reference
- 1.Lowe D. Tonsillectomy technique as a risk factor for postoperative haemorrhage. Lancet. 2004;364:697–702. doi: 10.1016/S0140-6736(04)16896-7. [DOI] [PubMed] [Google Scholar]
Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
Thank you. I would seek to respond as follows:
1. A curved Negus forcep was used so infrequently that the data are unhelpful.
2. Our study was contemporaneous with the National audit so the ‘preferrred technique’ was not known.
3. We make no effort to hide the fact that further development, particularly of the Boyle-Davis gag, is desirable.
4.The results are published ‘warts and all’. If the surgeons did not rate the instrument this is accurately reflected.
letter Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
I read this article with interest but noted that the references to pancreas-sparing duodenectomy have failed to mention the publication cited below,1 which pre-dates any of the quoted references describing this procedure by several years. I also note that the papers quoted have also failed to mention this paper, which is in a not totally inconspicuous journal. When I researched the potential for the procedure described in this paper I could find no previous references to a similar procedure but it seemed the appropriate operation for the pathology that presented, as others have subsequently concurred.
Footnotes
Comment on Spalding DRC, Isla AM, Thompson JN, Williamson RCN. Pancreas-sparing distal duodenectomy for infra-papillary neoplasms. Ann R Coll Surg Engl 2007; 89: 130–135. doi: 10.1308/003588407X155815
Reference
- 1.Vallance S. Duodenectomy without pancreatectomy for extensive benign villous adenoma of the duodenum. Aust N Z J Surg. 1990;60:311–14. doi: 10.1111/j.1445-2197.1990.tb07374.x. [DOI] [PubMed] [Google Scholar]
Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
We thank Mr Vallance for his comment on our article and have read his own publication describing a pancreas-sparing total duodenectomy (PSTD) with interest. The two procedures are performed for different indications, although they have in common the wish to preserve the pancreas when operating for benign duodenal conditions. Our pancreas-sparing distal duodenectomy (PSDD) is indicated for diseases involving the third and fourth parts of the duodenum and it avoids the need for pancreatic and biliary anastomoses (following conventional pancreatoduodenectomy) by duodenojejunal anastomosis just distal to the papilla; it is a conservative distal duodenectomy.
Mr Vallance's operation was a conservative near-total duodenectomy for villous adenoma of the second part of the duodenum. Since it required reimplantation of the bile duct and pancreatic duct into the duodenum its advantage over pancreatoduodenectomy is debatable, though others have subsequently described a slight variant in patients with familial adenomatous polyposis.1
We are sorry to have omitted any reference to Mr Vallance's paper. Our paper focused on PSDD and the bibliography of PSTD was meant to be extensive rather than exhaustive. In the earliest reference that we cite,1 Chung and colleagues state that the technique of PSTD was first described by Mann and Kawamura in 1922 in a variety of experimental animals; removal of the duodenum caused no detectable physiological impairment.2
The authors themselves carried out PSTD in five dogs in 1984 and found the operation to be safe, with no leaks, pancreatitis or deaths.3 Although they claim that their 1995 clinical series was the first use of this operation in man, Kavlie and associates described something very similar in 1973: a 21-year-old man bleeding from an arteriovenous malformation of the duodenum received a total duodenectomy, with preservation of the pancreas and papilla and subsequent anastomosis to the jejunum.4
References
- 1.Chung RS. Pancreas-sparing duodenectomy: indications, surgical technique, and results. Surgery. 1995;117:254–9. doi: 10.1016/s0039-6060(05)80198-9. [DOI] [PubMed] [Google Scholar]
- 2.Mann FC. Duodenectomy: an experimental study. Ann Surg. 1922;75:208–20. doi: 10.1097/00000658-192202000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Sillin LF. Ninety-five percent duodenectomy. An experimental study. Am J Surg. 1984;148:337–9. doi: 10.1016/0002-9610(84)90466-5. [DOI] [PubMed] [Google Scholar]
- 4.Kavlie H. Duodenectomy with reimplantation of the papilla into the jejunum as a treatment for benign duodenal lesions. Surgery. 1973;73:230–3. [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
I found this paper hard to follow. The authors claim benefit from reviewing case notes and x-rays in the next day trauma meeting without making it clear whether or not the same patients were subsequently reviewed on the next day or subsequent fracture clinic. Clearly there would be no advantage in having a trauma meeting discussion if ther patients were going to be seen in the fracture clinic anyway. This is especially so in those patients who had soft tissue injuries, which could not be accurately diagnosed from x-rays and case notes alone.
Additionally, some of the figures do not seem to add up. For example, it is stated that 12.6% of the patients had false positive diagnosis and 4%, false negative diagnosis. This adds up to a ‘wrong diagnosis’ rate of 17%, whereas the authors state that only 7.8% of patients were wrongly diagnosed. Furthermore, it is stated that (in the series) there were '390 fractures, 15 joint injuries and 48 soft tissue injuries, adding up to 453 patients, 50 fewer patients than were in the series overall (503). Did these 50 patients have diagnoses - and what were they?
Further, the text is ambiguous in parts. Under ‘patients and methods’ was it only the inexperienced SHOs who placed notes and x-rays into a separate box or did all casualty staff of all levels of experience do this? Towards the end of the same section, a ‘missed injury’ was described as one that had been missed first time around by the accident and emergency (A&E) staff but was subsequently diagnosed at a later attendance by these staff, although the authors also referred to missed injuries elsewhere in the paper as the ones misdiagnosed at the original A&E attendance.
I am also puzzled as to why errors in fracture diagnosis as outlined in Table 1 under the heading ‘Inadequate history/inadequate physical examination’ were not considered to be ‘Radiological misinterpretation/inadequate radiographic views’. Furthermore, it must have been very difficult for the orthopaedic team at the next-day trauma meeting review confidently to exclude an Achilles tendon rupture, for example, on the basis of case notes/x-rays only?
Finally, the authors state that 50 patients had unnecessary fracture clinic referrals because of soft tissue injuries, even though earlier in the ‘results’ section this figure had been given as 48. On a practical point, soft tissue injury can be quite serious, such as knee ligaments, and would normally qualify for justifiable fracture clinic appointment. This prompts the question of exactly the criteria for deciding these were ‘unnecessary,’ assuming this decision was made on the basis of x-rays and A&E notes only. The authors also imply that scaphoid fractures are often overdiagnosed even though it is well accepted that all suspected scaphoid injuries should be reviewed at a later date.
Footnotes
Comment on Sharma H, Bhagat S, Gaine WJ. Reducing diagnostic errors in musculoskeletal trauma by reviewing non-admission orthopaedic referrals in the next-day trauma meeting. Ann R Coll Surg Engl 2007; 89: 692–695. doi: 10.1308/003588407X205305
Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
We thank Mr Grace for his interest in our work. With regard to the review of patients, it is mentioned in the first paragraph of the results section that these patients were seen in the next-day fracture clinics. These new fracture patients were reviewed by the orthopaedic SHO or experienced SHO in the clinic and that is why the trauma meeting, attended by several senior staff, was quite useful to guide them making final management plans.
All case notes and x-rays of those patients attended and referred by SHOs (the majority) and/or by senior-level staff to fracture clinics were kept in the box. With regard to the number of patients, the rest of the 50 patients had nonspecific problems like back pain, neck pain, shoulder pain, foreign body, wrist tendinitis, blood-stained wound discharge, prepatellar bursitis, suspected cellulitis, etc.
We agree that soft tissue injuries can not be diagnosed on the basis of inadequate history/inadequate physical examination alone. Therefore patients' subsequent appointments to the clinics were retained. A missed injury has been defined as an injury missed at the first presentation. These were subsequently diagnosed by trauma meeting and not by A&E staff. Nowhere in the paper is it stated that the missed injuries were picked up by the A&E staff.
We agree with the comment that soft tissue injuries cannot be diagnosed adequately on the basis of case notes and x-rays. All these patients were discussed in the meeting and subsequently reviewed in the fracture clinic where appropriateness of referral was decided by the orthopaedic team. We also agree that scaphoid injuries must be subsequently evaluated. However, to suggest that scaphoid fractures are overdiagnosed is merely an observation of the study after following them up further.
We would like to make a further clarification about false positive (diagnosing a fracture when none existed, 12.6%), false negative (missed diagnosis, 4%, eg missing talus fracture in a patient with lateral malleolar fracture), missed incidental diagnosis (2.4%, eg missing enchondroma in a finger phalangeal fracture) and wrong diagnosis (7.8%, eg naming fracture as arthritis, calling cuboid navicular, etc). There are no miscalculations in the percentages: all these are separate, although we feel that this could have been made clearer.
letter Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
We read this article on port closure with interest and allude to a previous technique reported by our senior author,1 where a similar method without pneumoperitoneum is used, with a Langenbeck retractor placed within the port site wound at right angles, retracting upwards to tent all layers of the incised margins away from intra-abdominal contents. However, with our technique, a J needle is used to ensure a better deep bite than with a 3/4 curved needle and easier rotation before insertion of the suture into the opposite incised margin. We also advocate the first suture is inserted from in-to-out then from out-to-in on the opposite side to ensure that the knot is intra-abdominal. We report no complications associated with this technique.
Footnotes
Comment on Manimaran N, Rao V. Simple and safe technique of port closure. Ann R Coll Surg Engl 2007; 89: 179–180. doi: 10.1308/003588406X149255
Reference
- 1.Haq A, et al. Letter. Ann R Coll Surg Engl. 2002;84:434. [PMC free article] [PubMed] [Google Scholar]
Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
I have routinely employed this simple technique of using a vertically held Langenbeck retractor for closure of transversus and internal oblique muscles in short appendicectomy incisions (results unpublished), before using it for the port site closure (as discussed in my article). While J needles may be useful for additional safety during the port site closure, they compromise on the ergonomics of needle handling. Further it is important that the needle tip enters the tissue at a 90-degree angle for a good bite and to avoid sliding tangentially. This is particularly difficult with a J needle.
letter Ann R Coll Surg Engl. 2008 Jul;90(5):370. doi: 10.1308/003588408X318075
This worthy article is a little unclear in a few areas.
1. The timing of the swabs and aspirates post-operatively, which could influence the results obtained, is not given.
2. There is no indication within the article as to whether the wounds were clinically suspicious of an existent inflammatory response of an infective nature, or whether this was just a ‘routine swab and aspirate’.
3. It is unclear how the term ‘wound swab,’ as used by the authors, is defined. Is this a surface or skin swab? A wound that a surgeon creates begins at the portal of entry and continues to the destination of the incision. The wound therefore has depth, more than the skin surface. It would appear that the authors are actually comparing a surgically closed wound skin swab with an intra-wound aspirate.
While such observations do not detract from the conclusions or benefits of performing intra-wound infection assessment, it would be preferable to some to have an illustration of the science and detail of the research in regard to what a wound consists of anatomically. But then again, perhaps I am an old pedant!
Footnotes
Comment on Parikh AR, Hamilton S, Sivarajan V, Withey S, Butler PEM. Diagnostic fine-needle aspiration in postoperative wound infections is more accurate at predicting causative organisms than wound swabs. Ann R Coll Surg Engl 2006; 88: 166–167. doi: 10.1308/003588407X155761