Since the last list appeared in the Annals, the following letters have been published on our website <http://www.rcseng.ac.uk/publications/eletters/>:
letter . 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
We read with interest the article written by Olubaniyi et al. Colorectal stenting may become the first choice of modality of treatment in patients with colorectal cancer presenting with obstruction, where palliation is the desired result. It may also act as a bridge to surgery in patients requiring resection following the relief of intestinal obstruction. Although there was no stent-related mortality in this study, it will be interesting to know what the overall mortality was in this group of patients. It will also be useful to know how long the patients were followed up following stent insertion.
Fourteen previous studies have shown that the median mean patency duration was 106 days and ranged between 68 and 288 days in the palliative group of patients.1,2,3 It would be useful to determine what the patency rates at 30, 90 and 180 days were.
Footnotes
Comment on Olubaniyi BO, McFaul CD, Yip V, Abbott G, Johnson M. Stenting for large bowel obstruction – evolution of a service in a district general hospital. Ann R Coll Surg Engl 2009; 91: 55–58. doi: 10.1308/003588409X359015
References
- 1.Watt AM, Faragher IG, Griffin TT, et al. Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg. 2007;246:24–30. doi: 10.1097/01.sla.0000261124.72687.72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ptok H, Meyer F, Marusch F, et al. Palliative stent implantation in the treatment of malignant colorectal obstruction. Surg Endosc. 2006;20:909–14. doi: 10.1007/s00464-005-0594-7. [DOI] [PubMed] [Google Scholar]
- 3.Tomiki Y, Watanabe T, Ishibiki Y, et al. Comparison of stent placement and colostomy as palliative treatment for inoperable malignant colorectal obstruction. Surg Endosc. 2004;18:1572–77. doi: 10.1007/s00464-004-8106-8. [DOI] [PubMed] [Google Scholar]
Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
We appreciate the comment by Mallick et al. In our study, 88% of the colorectal stents were inserted strictly for palliation. These were patients with either metastatic disease or multiple comorbidities excluding them from major surgical resection. The median duration of patient survival following successful stent insertion in the palliative group was 126 days. No patients re-presented with intestinal obstruction prior to death.
There was no stent-related mortality in our study. Subsequent death was due to progression of underlying malignancy or co-existent medical conditions. Overall mortality figure in this group of patients is difficult to interpret as these patients die from natural progression of their pathology and emphasis should rather be on stent-related deaths. This is attested to in the systematic review on self-expandable metal stents (SEMs) published by Watt et al.1
It should, however, be taken into consideration that the level of high evidence available to support the use of SEMS despite its reported efficacy and safety is limited and many questions remain unanswered; hopefully ongoing randomised controlled trials will shed more light in the not too distant future.
References
- 1.Watt AM, Faragher IG, Griffin TT, et al. Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg. 2007;246:24–30. doi: 10.1097/01.sla.0000261124.72687.72. [DOI] [PMC free article] [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
It is a shame that Cutts et al do not touch on the issue of fitness for work after shoulder dislocation, even though they do have a paragraph on return to sport. In most patients' lives the latter is surely of lesser importance than the former?
Footnotes
Comment on Cutts S, Prempeh M, Drew S. Anterior shoulder dislocation. Ann R Coll Surg Engl 2009; 91: 2–7. doi: 10.1308/003588409X359123
Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
We read the comments about return to work with interest. There isn't a specific time duration to apply here as there is clearly variation in the physical demands of each patient's job. Most of our patients (over 70%) are under 23 and many are at school or still students, ie they aren't currently in work. The bulk of the dislocations have been sustained through sporting injuries; hence our emphasis in the paper on the timing of return to sporting activities. Therefore we feel that the clinician should attempt to tailor his or her advice on the issue of return to work to the individual patient, bearing in mind the nature of the work and the severity of the injury.
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
Most reported injuries of the oesophagus are due to endotracheal intubation or oesophagoscopy.1 Procedures that involve intubation of the pharynx are commonly performed and currently anticoagulation is not thought to be a contraindication. We highlight a case that may have been prevented if anticoagulation had been stopped prior to the procedure.
A 58-year-old man attended for an elective transoesophageal echocardiogram (TOE). Transthoracic echocardiography had previously been unrewarding due to large body habitus. The patient was anticoagulated with warfarin (chronic AF) and had a persistent cough. Coughing during oesophageal intubation forced the examination to be abandoned. On waking, the patient described pain in the left anterior neck. ENT identified a tender swelling in the left neck, left submucosal supraglottic swelling and dysphonia. A CT scan showed surgical emphysema and a 4cm haematoma. His INR was 1.5 and warfarin was stopped but not reversed. He was transferred to the ENT unit, where he was managed with steroids, antibiotics and fluids. His symptoms and signs resolved after several days and he was discharged uneventfully.
Injuries to the pharynx and oesophagus may have life-threatening sequelae. In recent history, TOE is performed in anticoagulated patients during cardiac valve replacements, which may be more commonly seen in the future in an ageing population. This case raises interesting questions such as should anticoagulated patients undergoing oesophagoscopy have their anticoagulation reversed (when medically safe)?2 Further, should we have a higher threshold for surgical intervention given the uncomplicated resolution of symptoms in this patient?
Procedures involving pharyngeal intubation may be traumatic with potentially severe consequences, but may be managed conservatively on occasion.
References
- 1.Massey SR, Pitsis A, Mehta D, Callaway M. Oesophageal perforation following perioperative transoesophageal echocardiography. Br J Anaesth. 2000;84:643–6. doi: 10.1093/bja/84.5.643. [DOI] [PubMed] [Google Scholar]
- 2.Bonnette P, Lansac E, Fritsch J, Scherrer A. [Intramural haematoma of the esophagus: a rare diagnosis] [Article in French] Rev Mal Respir. 1999;16:114–50. [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
read with interest the article by Hameed and colleagues. The authors conclude that the frequency of cutaneous purpura in Henoch–Schonlein purpura (HSP) is 100%; I disagree. Cutaneous purpura does not need to present in every patient diagnosed with such vasculitis.1 HSP must be listed in the differential diagnosis of a patient who manifests with arthralgia, abdominal pain and gastrointestinal bleeding, even in the absences of classic cutaneous purpura.
Footnotes
Comment on Hameed S, Dua S, Taylor HW. Henoch-Schonlein purpura with ischaemic bowel. Ann R Coll Surg Engl 2009; 90: 605. doi: 10.1308/147870808X303155
Reference
- 1.Gunasekaran TS, Berman J, Gonzalez M. Duodenojejunitis: is it idiopathic or is it Henoch–Schönlein purpura without the purpura? J Pediatr Gastroenterol Nutr. 2000;30:22–8. doi: 10.1097/00005176-200001000-00013. [DOI] [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
Having read the above paper with interest we wish to report a case that casts doubt on the authors' conclusion that acute blue finger can be regarded as a benign condition.
Case report
A 63-year-old female patient presented to the general medical on call with irregular dusky patches affecting the ulnar three digits of her dominant right hand. While these were acutely painful there was also non-tender discolouration noted on the lateral borders of her feet. Daily aspirin treatment had been initiated for these symptoms three days prior to presentation by her GP. In view of the fact that her symptoms had spontaneously improved, she was discharged home the next day for review in the clinic.
Initial investigation revealed a platelet count of 582 × 10 9/l and all other investigations at the time of initial assessment were normal. The patient was reviewed in the outpatient department at two weeks and her recovery was progressing well. At four weeks following the initial presentation the patient returned with irreversible ischaemia of the same digits, as well as further purple discolouration of the feet. Investigations at this time revealed a platelet count of 617 × 10 9/l rising to 967 × 10 9/l within 72 hours of admission. A bone marrow biopsy at this time confirmed the diagnosis of essential thrombocythaemia and appropriate treatment was initiated. Despite improvements in the perfusion of the other areas the right hand remained irreversibly ischaemic and the patient underwent a staged amputation six weeks later.
It is common for patients with essential thrombocythaemia to present to vascular surgeons to rule out embolic phenomena, or to orthopaedic surgeons via rheumatological colleagues. We wish to recommend a high level of suspicion of essential thrombocythaemia when assessing patients with one or more acute blue digits, as presentation can often be with only a mildly elevated platelet count. This case is not alone in the literature although all other reported cases of digital loss affect the toes.1 We wish to emphasise caution when accepting the authors' last statement that reassurance can be given and that spontaneous resolution of the condition is to be expected.
Footnotes
Comment on Cowen R, Richards T, Dharmadasa A, Handa A, Perkins JMT. The acute blue finger: management and outcome. Ann R Coll Surg Engl 2009; 90: 557–560. doi: 10.1308/003588408X318237
References
- 1.Annets DL, Tracy GD. Idiopathic thrombocythaemia presenting with ischaemia of the toes: report of three cases. Med J Aust. 1966;2:180–3. doi: 10.5694/j.1326-5377.1966.tb73496.x. [DOI] [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
We read the article by Garner et al with great interest. We have recently conducted a similar study on the cost implication of adopting a policy of early cholecystectomy in Bedford Hospital. This was a retrospective analysis of 28 emergency admissions (including four readmissions) with either biliary colic or acute cholecystitis over a three-month period (January to March 2007). In this group we identified 19 patients (68%) who potentially could have had an early cholecystectomy
In our study we compared the combined cost of the emergency admission and subsequent elective readmission with the cost of performing early cholecystectomy on the emergency admission. We based our costings on national average costings and looked at the national tariffs attracted by this activity. Furthermore, we took into account the potential savings incurred in freeing up elective lists by carrying out this work on the existing emergency lists (assuming two cholecystectomies per list).
The potential saving of adopting a policy of early cholecystectomy in an average UK district general hospital is £52,177 plus 9.5 elective lists per three-month period, projecting into a saving of £208,708 and 38 operating lists per annum. Furthermore, in an average UK hospital the hypothetical cost of performing an early cholecystectomy would be £51,509 and would attract a tariff of £61,161 over a three-month period, projecting to an overall gain of £38,608 per annum over tariff.
Our study has shown that performing early cholecystectomy results in significant savings in terms of costings as well as gains over tariff. Agreeing with the conclusions of Garner et al we would like to emphasise that adopting a policy of early cholecystectomy results in a significant saving of operating costs, costs against tariff and a freeing up of elective lists.
Footnotes
Comment on Garner JP, Sood SK, Robinson J, Barber W, Ravi K. The cost of ignoring acute cholecystectomy. Ann R Coll Surg Engl 2009; 91: 39–42. doi: 10.1308/003588408X359079
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
We read this recent article with great interest. The senior author in our department frequently performs total completion thyroidectomies and pararthyroidectomies. We follow the same protocol of checking serum calcium six hours postoperatively and on the first postoperative day. We agree with the authors that this is a very useful protocol in management of postoperative hypocalcaemia, in predicting both short and long-term hypocalcaemia. However, the authors have failed to address hypomagnesaemia as a cause of refractory hypocalcaemia. Transient hypocalcaemia and hypomagnesaemia are known to occur frequently after total thyroidectomy.1 Serum calcium is checked routinely after total thyroidectomy, completion thyroidectomy and pararthyroidectomies.
We advocate checking serum magnesium in patients refractory to intravenous calcium and those at risk. Poor nutrition associated with chronic alcohol use, prolonged diarrhoea, treatment with diuretics and certain chemotherapeutics (such as cisplatin) causes hypomagnesaemia.2 Serum magnesium is important for the synthesis and release of parathyroid hormone.3 Recognition of hypomagnesaemia is important in this setting as it is difficult to reverse hypocalcaemia without magnesium repletion in turn affecting short and long-term hypocalcaemia.
Footnotes
Comment on Pfleiderer AG, Ahmad N, Draper MR, Vrotsou K, Smith WK. The timing of calcium measurements in helping to predict temporary and permanent hypocalcaemia in patients having completion and total thyroidectomies. Ann R Coll Surg Engl 2009; 91: 140–146. doi: 10.1308/003588409X359349
References
- 1.Wilson RB, Erskine C, Crowe PJ. Hypomagnesemia and hypocalcemia after thyroidectomy: prospective study. World J Surg. 2000;24:722–6. doi: 10.1007/s002689910116. [DOI] [PubMed] [Google Scholar]
- 2.Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ. 2008;336:1,298–302. doi: 10.1136/bmj.39582.589433.BE. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Anast CS, Winnacker JL, Forte LR, Burns TW. Impaired release of parathyroid hormone in magnesium deficiency. J Clin Endocrinol Metab. 1976;42:707–17. doi: 10.1210/jcem-42-4-707. [DOI] [PubMed] [Google Scholar]
Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
We appreciate the comments made by Gadepalli and Hargreaves regarding the role of hypomagnesaemia and therefore the need to consider checking magnesium levels in cases of refractory hypocalcaemia following total thyroidectomy. However, as we did not come across this scenario in our series and the thrust of the article was focused on the timing of calcium measurements, we did not refer to this issue in our report.
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
This study like others1,2 demonstrates the inadequacies in the consent process. Previous studies comparing routine and BAUS consent forms demonstrated no difference in patients' understanding or recall of complications.2 The three key elements of consent are competence, that it is voluntary and that the patient is informed. It is this last point that causes most concern as the amount of information required to ensure that patients are fully informed is unclear.
The authors fail to comment on the significant relationship existing between the patients' education level and age and the recall of potential complications of surgery.3 Information directed to patients should have a readability index of < 40 (level of the popular press).4 The authors asked patients to complete the questionnaires the evening before surgery when anxiety levels are high.
Verbal and written information supplied to patients might be understood but it is easily and quickly forgotten. Patients' recall of information is generally poor and the sheets may only be useful medico-legally, as a permanent record of what was discussed.5 Verbal and written information is inadequate and audiovisual aids may be the way forward. We are conducting a study comparing audiovisual, written and verbal consent.
Footnotes
Comment on Finch WJG, Rochester MA, Mills RD. A randomised trial of conventional versus BAUS procedure-specific consent forms for transurethral resection of prostate. Ann R Coll Surg Engl 2009; 91: 232–238. doi: 10.1308/003588409X359277
References
- 1.Stanley BM, Walters DJ, Maddern GJ. Informed consent: how much information is enough? Aust N Z J Surg. 1998;68:788–91. doi: 10.1111/j.1445-2197.1998.tb04678.x. [DOI] [PubMed] [Google Scholar]
- 2.Masood J, Hafeez A, Wiseman O, Hill JT. Informed consent: are we deluding ourselves? A randomized controlled study. BJU Int. 2007;99:4–5. doi: 10.1111/j.1464-410X.2007.06516.x. [DOI] [PubMed] [Google Scholar]
- 3.Hekkenberg RJ, Irish JC, Rotstein LE, et al. Informed consent in head and neck surgery: how much do patients actually remember? J Otolaryngol. 1997;26:155–9. [PubMed] [Google Scholar]
- 4.Holm S. [Written patient information. Analysis of Danish biomedical research programs] [Article in Danish] Ugeskr Laeger. 1992;154:2,432–5. [PubMed] [Google Scholar]
- 5.Langdon IJ, Hardin R, Learmonth ID. Informed consent for total hip arthroplasty: does a written information sheet improve recall by patients? Ann R Coll Surg Engl. 2002;84:404–8. doi: 10.1308/003588402760978201. [DOI] [PMC free article] [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
While Meyer et al succinctly demonstrate a method for templating hip arthroplasty using traditional acetate templates superimposed on a computer screen image, their literature search failed to acknowledge an earlier report of this technique.1 We previously examined methods for templating hip arthroplasty at a time when software templating packages were not widely available. While we favoured the use of a coin as described by Conn2 to scale for magnification, assessment was made of two ‘digital line methods’ utilising the PACS calibration tool (with a drawn 50mm line) compared to a 20% magnified acetate ruled scale and also a normal ruler.
Our study demonstrated that since the PACS calibration software is applied to an image magnified during its acquisition, it should therefore be scaled to a normal ruler but templated with magnified acetate templates as Meyer et al correctly state. The digital line methods, however, showed lower inter-observer reproducibility than when the image was scaled using a ten pence coin marker in arthroplasty templating.
It is also important to point out that most PACS systems allow images to be displayed anonymously, which are therefore more appropriate for inclusion in presentations and publications (vide Figure 3).
Footnotes
Comment on Meyer C, Kotecha A, Richards O, Isbister E. Acetate templating for total hip arthroplasty using PACS. Ann R Coll Surg Engl 2009; 91: 161–170. doi: 10.1308/003588409X392063
References
- 1.Oddy MJ, Jones MJ, Pendegrass CJ, et al. Assessment of reproducibility and accuracy in templating hybrid total hip arthroplasty using digital radiographs. J Bone Joint Surg Br. 2006;88:581–5. doi: 10.1302/0301-620X.88B5.17184. [DOI] [PubMed] [Google Scholar]
- 2.Conn KS, Clarke MT, Hallett JP. A simple guide to determine the magnification of radiographs and to improve the accuracy of preoperative templating. J Bone Joint Surg br. 2002;84:269–72. doi: 10.1302/0301-620x.84b2.12599. [DOI] [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
We read with interest the article on microbial colonisation of orthopaedic tourniquets. The fact that 100% of tourniquets were colonised with bacteria has already been reported in orthopaedic literature. Walsh E et al have studied microbial colonisation of tourniquets in orthopaedic surgery. Results showed that 100% of main theatre tourniquets were colonised, 40% of day surgery tourniquets were colonised and none of the sterile tourniquets were colonised. Tourniquets used in main orthopaedic theatres showed that coagulase-negative staphylococci, bacillus species and Staphylococcus aureus were present in 100%, 60% and 20% of the tourniquets, respectively.1
Using the traditional tourniquet often also means use of an exsanguinator. Many hospitals in the UK use Rhys-Davies exsanguinators. These are also a haven for bacteria and a second source of contamination.2 It has been shown in the study that decontamination with Clinell (detergent and disinfectant) wipes (GAMA Healthcare Ltd, London) is 99.2% effective. What has not been shown is whether, outside the environmemt of a study like this such decontamination will ever be properly carried out.
We prefer single-use disposeable tourniquets that exsanguinate at the time of application. The cost is small in relation to the financial implications of an avoidable hospital-acquired infection – even before litigation is considered. Various sterile tourniquets are available. They are safe, affordable and effective as an alternative to traditional pneumatic tourniquets. The risk of cross infection is 0%.
Footnotes
Comment on Ahmed SMY, Ahmad R, Case R, Spencer RF. A study of microbial colonisation of orthopaedic tourniquets. Ann R Coll Surg Engl 2009; 91: 131–134. doi: 10.1308/003588409X359402
References
- 1.Walsh EF, Ben-David D, Ritter M, et al. Microbial colonization of tourniquets used in orthopedic surgery. Orthopedics. 2006;29:709–713. doi: 10.3928/01477447-20060801-08. [DOI] [PubMed] [Google Scholar]
- 2.Ballal MSG, Emms N, O'Donoghue M, Redfern TR. Re: Rhys-Davies exsanguinator: a haven for bacteria. J Hand Surg Eur Vol. 2007;32E:452–56. doi: 10.1016/J.JHSB.2007.02.011. [DOI] [PubMed] [Google Scholar]
Ann R Coll Surg Engl. 2009 Oct;91(7):625. doi: 10.1308/003588409X464766
Thank you for the interest in the article. In response to your comments:
The practice of exsanguination is very variable, with many surgeons not employing it and using elevation of the limb instead. But we agree that wherever exsanguinators are used attention should be given to their storage and cleaning.
The decontamination employed in our study was simple, with cleaning both surfaces, and is easily reproducible in normal clinical situations in theatres.
The suggestion for employing disposable sterile tourniquets needs to be balanced against their cost. Sterile tourniquets cost approximately £16–18 per case. Considering the number of total knee replacements undertaken in the NHS in a year this would be a substantial amount.
As yet there is no proven case of infection from a tourniquet and we imagine it would be very difficult to prove so in a case of litigation.
We agree that in an ideal situation sterile tourniquets would remove a potential source of infection in orthopaedic surgery.