BMC Surgery - Latest Comments

Table 2 Need a minor correction

kashif aziz — 2013-03-10T13:57:11Z

In Table 2, under the column of relative Exclusion criteria, it is written 'cronic thyroiditis'. I think it is a typographic mistake. It should be 'CHRONIC thyroiditis'.

Management of recurrent inguinal Hernia

Kenji Okumura — 2012-12-12T12:15:14Z

This article "Open peritoneal versus anterior approach for recurrent inguinal hernia: a randomized study" is very interesting, unique and fascinating. It is difficult to collect and randomize those patients. Unfortunately, the rate of recurrence is too much high compared to 1% or less in other previous articles. The repair for recurrent inguinal hernia is one of the most difficult operations. The operators are demanding to thinking the way of repair based on the previous surgeries. Considering these issue, the arthors should document the previous way of repair and review the reason of high recurrent rate of inguinal hernia.

Severe inflammatory reaction induced by peritoneal trauma is the key driving mechanism of postoperative adhesion formation

chris vanheihgen — 2012-05-11T15:22:51Z

This is a scholar paper with excelent design and simple assays. My comgratulations to authors!
Chris vanHeihgen, MD

Length of stay comparison.

Erik Nilsson — 2009-03-06T21:01:06Z

In our study, hospital stay for all patients (3.1 days) was compared with hospital stay for all patients who had cholecystectomy in Sweden 2002 (4.4 days). However, in a subsequent study we found that after exclusion of patients with malignant or benign intra-abdominal or kidney tumor with a procedure code for tumor resection, the mean in-hospital stay for patients who had cholecystectomy in Sweden 2002-03 was 4.1 days[1]. After adjustment for 12% ambulatory cholecystectomies in Motala Hospital, the best comparison would be 3.5 days for patients with in-hospital stay in Motala versus 4.1 for Sweden. However, the main message of the report is that open cholecystectomy and concomitant removal of bile duct stones, should be considered a cost-effective alternative in a unit with emergency service and trainee surgeons, provided small-incision surgery is aimed for.

We agree totally with Dave Hopkins that the incision should be as wide as safety requires. And furthermore, trainees should be assisted by senior colleagues during critical moments in all gallbladder surgery.
For the authors,
Erik Nilsson, M.D., Ph.D.

1. Rosenmuller M, Haapamaki MM, Nordin P, Stenlund H, Nilsson E: Cholecystectomy in Sweden 2000-2003: a nationwide study on procedures, patient characteristics, and mortality. BMC Gastroenterol 2007, 7:35.

points and clarifications arising

Aninda Chandra — 2009-01-16T16:37:09Z

Dear BMC Surgery Editors

Re: The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis.

Smith S, McGeehin W, Kozol R, Giles D. BMC Surgery 2007; 7(1):15.

The paper by Smith et al [1] highlights the paucity of knowledge regarding intra-operative assessment of anastomotic integrity and deserves credit in the formulation of an alternative test to that of air insufflation. There are obviously limitations to what a single centre retrospective non-case controlled study can contribute and while the authors do acknowledge some of these, there are a number of points that arise.

The endpoint of the study was post-operative leak (PoL), but this was poorly defined and ideally could have been tested by radiological means (e.g. contrast) and a few surgeons routinely perform a gastrograffin enema at day 5 to assess this. Given that some patients were ascribed a PoL based on clinical signs alone, the inclusion of those with a defunctioning stoma confuses the issue. While PoL occur despite a covering stoma, the clinical signs will be lessened [2]. We feel that these should have been excluded (n=16 which includes one intra-operative leak was defunctioned).

Despite the use of methylene blue dye, PoL’s still occurred so it is difficult to know if an alternate assessment technique had been used would this have still been the case. The lack of comparison to other studies makes it difficult to assess the benefit of methylene blue enemas over our usual method of air insufflation. However the technique described may be able to provide a more objective way of assessing more proximal anastomosis, although traditionally these have often not been assessed.

The study would have been stronger with similar results, if they had excluded right hemicolectomy (n=55) and transverse colonic resections (n =10). As the authors point out in Table 3, other studies concentrate on left hemicolectomies or more distal resections. If these are taken out, the overall leak rate is still low at 4.1% especially when compared to the average of the seven studies listed in Table 3.

Appropriate exclusions would have improved this paper as would have comparison with other techniques, but the authors are to be congratulated for a large study that tries to peer into the depths and mysteries of (distal) colonic surgery

Yours faithfully

Mr Aninda Chandra MRCS MSc MA

Mr Abdulzahra Hussain ,FRCS, FICMS, Diploma (General Surgery)

Mr Tarun Singhal MBBS, MS, DNB

Mr Biju Aravind FRCS

Ms Mahrokh Davarpanah MRCS MD

Mr Prakash Sinha MS, MD, FRCS (Gen Surg)

Department of General Surgery, Princess Royal University Hospital, Farnborough, London, UK

1. Smith S, McGeehin W, Kozol R, Giles D: The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis. BMC Surgery 2007, 7: 15.

2. Wong NY, Eu KW: A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study. Dis Colon Rectum 2005, 48: 2076-2079.

FISTULA PLUG TECHNIQUE - A FEASIBLE INNOVATION?

JOHN GRIFSON — 2008-11-16T16:37:15Z

The fistula plug technique is a new appreciable innovation.However some of the high fistulas have side branches and associated cavities. Filling all these tree like fistulas is practically not possible.Furthermore we should also take into consideration the cost and availability of such biological plug. For selected patients with simple high fistulas,this new technique is a truly good innovation.

Appendicitis- a common presentation of uncommon diseases

JOHN GRIFSON — 2007-12-10T14:17:39Z

Appendicitis ,a common surgical emergency is known for its complex presentations.Although appendicitis usually results secondary to luminal obstruction,one has to remember that tumors of appendix also presents as appendicitis(1).There are case reports of caecal carcinoma(2),ileocaecal tuberculosis presenting as appendicitis.Histopathological examination of appendectomy specimens is a routine in most hospitals.It is essential to document inflamed appendix as the cause of pain abdomen and to rule out a tumor of appendix

REFERENCES

1)McCusker ME, Cote TR, Clegg LX, Sobin LH. Primary malignant neoplasms of the appendix: A population-based study from the surveillance, epidemiology and end-results program, 1973-1998. Cancer 2002;94:3307-12

2)Bizer LS.Acute appendicitis is rarely the initial presentation of cecal cancer in the elderly patient.

J Surg Oncol. 1993 Sep;54(1):45-6.

alternative possibilities

ashish ohri — 2006-11-14T11:11:04Z

Sir,

a very good case report of necrotizing fascitis secondary to cecal perforation.

i would like to add that radiological investigations in these cases provide with the diagnosis of retroperitoneal abscess but not with the source of the abscess definitely.

in this case while doing the debridement, the source could be localized but in practice, the more common source would be a perforated retrocecal appendix or pyonephrosis, for which a deliberate effort should be made if the source is not readily clear.

with warm regards,

Dr Ashish Ohri

Deptt of Surgery.

Dayanand Medical COllege & Hospital,

Ludhiana

India.

Field Restriction

Dave Hopkins — 2006-04-25T11:29:48Z

The only possible contraindication to an open small incision cholecystectomy is that an unexperienced surgeon may be impacted by the limited range of the field. However, seeing as many of these cases were elective cases, unexperienced surgeons probably did not perform them. Looking at this scenario from the perspective of a busy Emergency Department, I would have to say that during a time of increased patient flow or heavy trauma, a case like this would be deemed a non-life-threatening emergency and would most likely be handed off to a less experienced surgeon. This could result in extreme morbidity or mortality in a severe case. This is a very unusual situation and may never occur. But, this is a subject and scenario that could possibly be postulated before such a scenario became standard procedure.

Can bile duct injuries be prevented? A grossly underpowered study.

P Sufi — 2005-07-04T21:44:06Z

This study is not powered to detect bile duct injuries (BDI). If we assume that BDI incidence is around 0.5%, then a study population of 46 patients can not realistically detect any difference in the BDI rate.