Dear Sir,
Re: Baskett TF. Edinburgh connections in a painful world. Surgeon 2005; 3(2): 99-107.
We thoroughly enjoyed this historical article which was obviously well researched.
However, we have to point out an historical inaccuracy. The first ether anaesthesia in Europe was given in Dumfries at the old Dumfries Infirmary on 19 December 1846 by William Scott, two days before its use by Robert Liston at University College Hospital, London, but on the same day that Francis Boott used ether for the painless extraction of his niece's molar tooth.
The evidence for this has been meticulously researched by Thomas W. Baillie and presented in his monograph, The Dumfries Ether Diary, published in 1996 (ISBN 1 899316 35 3). Baillie relates how Dr William Fraser, a ship's doctor on board the Cunard transatlantic steamship Acadia, visited his widowed mother in Dumfries for Christmas 1846. During his stay he told William Scott, a surgeon at Dumfries Infirmary, about William Morton's demonstration of ether anaesthesia. On 19 December 1846 William Scott exhibited ether to a patient previous to an operation in the presence of Dr Fraser and James McLauchlan, then senior surgeon in Dumfries. The operation was an amputation for a fractured limb. William Scott described the events of the day in a letter to the Lancet published in October 1872. The occasion is commemorated in a wall plaque at the site of the old infirmary.
We are not trying to be pedantic in claiming credit for the first Old World ether anaesthetic for Dumfries, but delight in the fact that such an historical event occurred in a country hospital. Dumfries Infirmary has a number of other claims, including the first hospital in Scotland to put wheels on beds, the second to have an ambulance, and the last to issue nurses with a daily quart of beer!
We do realise that it was Prof Robert Liston's recommendation that ensured the rapid spread of ether use throughout the British Isles.
May we conclude with Dumfries, first in time; UCH, first in importance.
Yours sincerely
J. S. Dreyer, H. A. Brewster
Departments of Surgery and Anaesthetics
Dumfries & Galloway Royal Infirmary, Dumfries Scotland
Sir,
Re: Craigie RJ, Duncan JL, Youngson GG. Children's surgery performed by adult general surgeons in Scotland: The present and future. Surgeon 2005; 3(6): 391-94.
I read this article by Craigie et al with great interest. I was disappointed to learn that most of the general surgeons do not believe that their successors would follow their practice in contributing to paediatric surgical practice.
However, I would like to focus on a few points here. This questionnaire was well prepared except the fifth question about specific circumstances ("Are there any specific circumstances where you will not operate?"). I think this is a subjective question, compared with the rest of the objective questions, and this may have weakened the questionnaire.
The other point is that out of the general surgeons saying [152]no' to the last question ("Do you think that your successor will operate on children?"), how many of them were working in teaching hospitals? Out of 27 paediatric surgery units in the British Isles, 22 are recognised training centres, and it would make this study interesting if we knew how many teaching hospitals assessed in this study had paediatric surgery units.
As indicated in Table 1 of the article, it is quite obvious that there would be a high threshold for performing paediatric surgery in teaching hospitals, due to paediatric surgery unit availability, compared with district or rural hospitals.
According to Peter A.M. Raine (President, British Association of Paediatric Surgeons 2003), at least 28 NTN numbers were required to achieve consultant expansion to 200 by 2010.
I agree with the authors regarding the amount of training received by trainees in paediatric surgery. I would however encourage referral to paediatric surgeons rather than general surgeons.
Looking at the results of this study, 71% of surgeons do not believe that their successor would operate on children. I think we would have to motivate and encourage the young surgical trainee towards paediatric surgical specialty.
At the end, the authors suggested the need to centralise all the paediatric services. They also suggested active support for district general hospitals if centralisation is to be avoided. This needs to be rectified.
I think the goal of British paediatric surgery is to provide optimal and full surgical care to children younger than five years old by paediatric surgeons, and in order to do this, we have no choice other than the centralisation of services.
J. Sagar
Royal Free Hospital, London UK
Dear Sir,
The points in Mr Sagar's letter are noted, as is his preference for one of the three service re-design options outlined in our article.
The purpose of including the fifth question in our survey was to attempt to ascertain case complexity in surgery being undertaken by non-specialist units in this age group. The subjective nature is acknowledged.
Mr Sagar also believes the study would have been more fruitful by defining specialist surgical provision in Scotland. However, the purpose of the study was to define current service provision outside specialist units, and in that regard 54% of the adult general surgeons responding to our questionnaire worked in a teaching hospital, but only 22% treated children. Of the 41 respondents in teaching hospitals, 10% thought their successor would treat children, 75% did not, and the remainder did not know.
There are currently three specialist paediatric surgical units in teaching hospital cities in Scotland and proximity to one of these units with established referral patterns are likely to explain these figures. However, the precise reasons were not elicited by the questionnaire and the fact that 22% of adult general surgeons treating children work within a teaching hospital environment may surprise some.
Mr Sagar's preference for referral to specialist units for this age group of child is noted. The dispersed nature of a significant proportion of the Scottish population and the stated health policy of provision of safe care as locally as possible indicate that investment in clinical networking with appropriate training and educational support, while adhering to requisite standards, might provide an alternative to centralising care.
However, if by default the option of centralisation of surgical services for this age group does occur, there are issues of capacity in the specialist centres, implications for transfer services which will have to deal with the entire case load i.e. those needing assessed as well as those needing treated, and a need to manage the expectation of the 170,000 population of Scotland who live more than two hours' drive away from their nearest hospital and considerably farther from a specialist centre. The purpose of our study was to highlight that such change in service provision will require active planning and management and should not merely develop as a consequence of trainees' preference in sub-specialty choices.
G. G. Youngson
Royal Aberdeen Children's Hospital, Scotland
Dear Sir,
Re: Wheatley DJ. The future role of surgery in ischaemic heart disease. Surgeon 2005; 3(3): 150-58.
The article by Dr J Wheatley in the Surgeon is excellent in providing indepth core knowledge of recent advances in the surgical management of ischaemic heart diseases. However, I would like to focus on a couple of points which I think may be relevant to junior doctors reading this article. Regarding acute coronary syndrome, the European Resuscitation Council does not include Q-wave/ST segment myocardial infarction as part of acute coronary syndrome. This may be irrelevant to senior physicians or surgeons due to their vast experience and knowledge. However, it may create confusion for trainee doctors like me as the immediate thrombolysis is the mainstay in management of Q-wave myocardial infarction but does not have any role in the treatment of acute coronary syndrome at present. I think clarification of this will help junior doctors to understand the article better.
Due to the vast nature of the subject discussed in this article, it may not be possible to consider all the aspects but the following points may have a significant role in the recent advances discussed in this article: the use of drug eluting stents, as this may have the potential benefit of reducing restenosis rates1; the use of autologous bone marrow-derived mononuclear cells in patients waiting for heart transplantation2; conscious off- pump coronary artery bypass surgery with the use of epidural anaesthesia, as it may be a revolutionary step in cardiovascular surgery due to possible potential reduction in post-operative mortality and morbidity.3
REFERENCES
1.- Lozano I, Herrera C, Moris C, Gomez-Hospital JA, Rondan J, Iraculis E, et al. Drug-eluting stents in patients with main coronary lesions who are not candidates for surgical revascularization. Rev Esp Cardiol 2005;58:145-52.
2.- Silva GV, Perin EC, Dohmann HF, Borojevic R, Silva SA, Sousa AL et al. Catheter-based transendocardial delivery of autologous bone-marrow-derived mononuclear cells in patients listed for heart transplantation. Tex Heart Inst J 2004;31:214-19.
3.- Chakravarthy M, Jawali V, Manohar M, Patil TA, Jayaprakash K, Shivananda NV et al. Conscious off-pump coronary artery bypass surgery. Indian Heart J 2005;57:49-53.
Yours sincerely,
J. Sagar
Royal Free Hospital, London UK
Sir,
Dr Sagar's points are well made. The rapid evolution of understanding of coronary disease and its management inevitably means that accepted policies and practice guidelines often lag behind. This does not mean that guidelines are irrelevant. They represent general contemporary consensus on clinical management backed up by scientific evidence and, as such, have considerable authority. Not all advances will stand the test of time and caution is required in their application. Thrombolysis and angioplasty/stenting in the acute coronary syndrome are still being evaluated and their general applicability is not yet proven.
Drug eluting stents certainly reduce immediate restenosis rates. They require antiplatelet and antithrombotic therapy to avoid sudden occlusion within the first year. Their true long-term outcome remains unproven.
Autologous bone marrow derived mononuclear cell delivery to the myocardium of patients listed for transplant is an excellent example of the ingenuity being applied to repopulation of failing myocardium with contractile myocytes, but is a technique still under evaluation.
Off-pump surgery with epidural anaesthesia may well have a role in those with severe co-morbidity, particularly respiratory insufficiency - again, further evaluation is necessary before general acceptance.
Dr Sagar highlights good examples of likely advances on the horizon. He gives further support for an optimistic view of the future of surgery in ischaemic heart disease.
D. J. Wheatley, Royal Infirmary, Glasgow, Scotland
Dear Sir,
Re: Downes M, Mohan P, Little D, Hickey D. Pancreas transplantation in Ireland. Surgeon 2005; 3(1):17-20.
We must commend the Beaumont Hospital transplant team for achieving international standards in pancreas transplantation. The article provides a nice opportunity to view the current immunosuppressive drug protocols in pancreas transplantation and their usage to achieve long-term graft survival and decreasing immunologic graft loss.
Most centres in the world still use triple drug maintenance immunosuppression consisting of corticosteroids, calcineurin inhibitors (cyclosporine or tacrolimus) and an anti-metabolite (azathioprine or mycophenolate mofetil), with a T cell depleting agent (ATG/ALG) or an interleukin-2 blocker (Basiliximab/Daclizumab) being used as an induction agent.
During the last couple of decades there has been an overall decline in the antibody induction therapy. Burke et al (2004) reported similar three-year actual patient and pancreas graft survival in patients between the induction and non-induction groups.1 Of the former group, induction with IL-2 blockers, when compared with ATG induction, was associated with significantly lower rates of CMV viraemia and CMV syndrome. The long-term malignant potential of T cell depleting agents is well known in literature. Post-transplant lymphoproliferative disease has been reported in 4% of patients at a mean of ten weeks after ATG therapy. Newer and more potent agents like tacrolimus, mycophenolate mofetil (MMF) and sirolimus, in particular, have allowed safe performance of simultaneous kidney-pancreas transplantation (SPKT) without ATG induction.2
Efforts are being made to produce better drug combinations to reduce or avoid the diabetogenic effects of corticosteroids, especially when used in combination with calcineurin inhibitors. Sirolimus, a powerful immunosuppressant devoid of nephrotoxic and diabetogenic potential, has emerged as an important agent for favorable drug combinations for SPKT.
Excellent patient and graft survival have been achieved by using tacrolimus/MMF or tacrolimus/sirolimus combination without chronic corticosteroid exposure.3 In our experience, non-antilymphocyte induction followed by tacrolimus and MMF as maintenance therapy has produced favourable results. Out of 32 pancreas transplants we performed in the last five years, basiliximab induction was used in 23 (72%) patients. Tacrolimus with MMF has been our most favored combination for maintenance immunosuppression (66%). We successfully avoided corticosteroids in 28 (87.5%) cases.
The incidence of CMV infection in our experience was 12.5%. Fortunately, none of the pancreas grafts were lost due to immunologic causes (unpublished data).
The differential effects on risk of rejection and infection need to be considered for routine use of induction therapy, particularly with T cell depleting agents.
REFERENCES
1.- Burke GW 3rd, Kaufman DB, Millis JM, Gaber AO, Johnson CP, Sutherland DE et al. Prospective, randomized trial of the effect of antibody induction in simultaneous pancreas and kidney transplantation: three-year results. Transplantation 2004; 77(8):1269-75.
2.- Reddy KS, Stratta RJ, Shokouh-Amiri H, Alloway R, Somerville T, Egidi MF et al. Simultaneous kidney-pancreas transplantation without antilymphocyte induction. Transplantation 2000; 69(1):49-54.
3.- Kaufman DB, Leventhal JR, Koffron AJ, Gallon LG, Parker MA, Fryer JP et al. A prospective study of rapid corticosteroid elimination in simultaneous pancreas-kidney transplantation: comparison of two maintenance immunosuppression protocols: tacrolimus/mycophenolate mofetil versus tacrolimus/sirolimus. Transplantation 2002; 73(2):169-77.
Yours faithfully,
R. K. Dhanda
D. Majid
A. Hammad
Sir Peter Medawar Transplant Unit, Royal Liverpool University Hospital, Liverpool UK
Dear Sir,
Re: Golash V, Cutress R. Laparoscopic cytogastrostomy for a giant pseudocyst of pancreas. Surgeon 2004; 3(1): 37-41.
We read with interest Dr Golash's article. We performed a similar case, but in a slightly different way. The case was presented in a symposium of the Hong Kong College of Surgeons several years ago. Intragastric cystogastrostomy was performed without a long anterior gastrotomy. It started with laparoscopy, clearing adhesions, which are common after pancreatitis, and then the anterior gastric wall was punctured with two 10mm ports, one for the telescope and the other for a 10mm harmonic scalpel. Slight traction was maintained to create working space inside the stomach. The posterior gastric wall was punctured after confirmation of the position of the pseudocyst. Cystogastrostomy was performed by means of the harmonic scalpel. It has the additional advantage of haemostasis, in addition to creating a connection between the stomach and the pseudocyst. The content of the cyst was aspirated and the lumen irrigated. We did not suture the edge of the cystogastrostomy. The two port sites in the anterior gastric wall were sutured with absorbable stitches. Our method obviates the need for extensive suturing of the cystogastrostomy and anterior gastrotomy. Our patient recovered uneventfully after the operation and imaging study six months post-operation showed complete cyst resolution.
We believe that our way of doing the laparoscopic cystogastrostomy is simpler and more manageable.
Yours sincerely,
L. Siu Fai
Kwong Wah Hospital, Hong Kong
Sir,
I thank Dr Lo Siu Fai for his interest in this article.
There are several laparoscopic techniques of dealing with pseudocyst of pancreas depending on the local expertise and experience. The anastomosis between the cyst wall and the stomach is either stapled or sutured so that the anastomosis is not dependent on the adherence of the cyst wall to the posterior gastric wall. Because the entire anastomosis is sutured or stapled, haemostasis is ensured.
Yours sincerely,
V. Golash
Sultan Qaboos Hospital, Sultanate of Oman
Dear Sir,
Re: Langer's axillary arch: Anatomy, embryological features and surgical implications. Surgeon 2005;3(5):325-27.
I read the article by Besana-Ciani and Greenall with keen interest and wish to add a few comments with regards to sentinel lymph node biopsy and Langer's axillary arch.
Sentinel lymph node biopsy has taken an increasingly significant role in the surgical treatment of breast cancer and, pending the results of ongoing randomised controlled trials, is likely to become the procedure of choice for the initial determination of axillary lymph node status.1 Familiarity of the anatomy of the axilla is a key factor in enabling optimal sentinel node identification. Knowledge of Langer's axillary arch will therefore be of heightened importance as this procedure becomes more commonplace.
In my personal experience of 74 sentinel lymph node procedures with isosulphan blue dye alone, over a three-year period from November 2002 to November 2005, there have been three occasions when the sentinel node was not identified. The first two occurred when there was a high tumour load in the axilla with 14 of 15 and 16 of 28 nodes involved, respectively. Failure of sentinel node identification in the third case was due to the presence of a Langer's axillary arch. Axillary dissection revealed none of 34 nodes with metastatic disease.
During a more recent sentinel node procedure, there was an instance in which the sentinel node was related posteromedially to the Langer's arch. Initially, the leading blue lymphatic appeared to course in a medial direction through the muscle, but further dissection revealed that its course was in fact immediately posterior to the lateral margin of the muscle. To one not familiar with the anatomy of Langer's arch, it may have seemed that it was entering the serratus anterior, and further dissection for the sentinel node possibly abandoned. This situation, and the one described in the preceding paragraph, could have an impact on successful identification rates.
The most common position of the axillary sentinel lymph node has been described as being within a 5cm circle, the centre of which is marked by the intersection of a line drawn tangential to the axillary hairline and another through the middle of the hairline in the axis of the axilla.2 The lower lateral group of lymph nodes, as described by Besana-Ciani and Greenall, to which access might be limited by the presence of Langer's arch, would lie within this circle.2
There have been several publications with regards to factors influencing successful identification of the axillary sentinel lymph node in breast cancer surgery. While several authorities have suggested that learning curves, technical features, patient and tumour factors have a role in the successful identification of the sentinel node, none have included anatomical variations such as Langer's arch as a possible contributing factor. With a prevalence of 7% to 27%, and the increasing importance of sentinel node biopsy in the surgical treatment of breast cancer, familiarity of the anatomy of Langer's arch is likely to take on greater significance.2
REFERENCES
1.- Leong SP. Selective sentinel lymphadenectomy for breast cancer in the United States. Asian J Surg 2004;27(4)269-74.
2.- Dauway EL, Giuliano R, Pendas S, Haddad F, Costello D, Cox CE, et al. Lymphatic Mapping: A technique providing accurate staging for breast cancer. Breast Cancer 1999;6(2):145-54.
Yours sincerely,
M. P. Tan
Mammocare The Breast Clinic and Surgery, Singapore
Dear Sir,
Dr Tan is correct in emphasising the importance of thorough knowledge of axillary anatomy when performing sentinel node biopsy. Although the prevalence rate of an axillary arch may be as high as 27%, in most of these cases this anatomic abnormality is only very rudimentary and in practice may be difficult to identify in vivo. Nonetheless, in a small number of patients it is a substantial structure and, particularly with the small incision demanded by sentinel node biopsy, may well obscure identification of appropriate nodal tissue. Such difficulties may also be compounded by bleeding as a result of increased dissection required to correctly identify the anatomy. The false negative rate using sentinel node biopsy is up to 7% and it is possible that in some of these cases anatomic variations account for failure of the technique.
Yours Sincerely,
I. Besana-Ciani, M. J. Greenall
Oxford Radcliffe NHS Trust, Oxford UK