Tagged - Letters to the editor

Re: Mohan IV, Thomas SD. Do patients with asymptomatic carotid stenoses still benefit from surgical intervention? (ANZ J. Surg. 2011; 81: 211-213)

I write in reference to Mohan and Thomas’s article “Do patients with asymptomatic carotid disease still benefit from surgical intervention?”. The word “still” in the title implies that patients once did benefit. They argue that medical treatment has improved and the modest benefit from surgery may no longer hold. The article concludes by warning “surgeons to stop taking comfort from the relative risks of intervention and historic studies of medical management” and urges them to look at results of future studies involving best medical management. The article is, however, somewhat inconsistent in avoiding the possibility that surgery has improved and perhaps commits the same fault that it urges against by quoting historic results of surgical management and comparing these to hypothetical results of future medical studies. (Click here to continue reading.)

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Re: Ha JF, Hodge JC, Lewis R. Comparison of nasendoscopic‐assisted cautery versus packing for the treatment of epistaxis. (ANZ J. Surg. 2011; 81: 336-339)

We read with great interest the article of Ha et al. published recently in ANZ Journal of Surgery¹ and would like to make comments on this study.

First, the authors report successful nasal examination with a rigid nasal endoscope and identification of the initial bleeding site in 100% of cases, even after nasal packing removal. In this study 97% of patients were treated initially with packings! However, these packings could lead to intranasal injuries and cause recurrent bleeding upon removal, especially if placed by an inexperienced physician. Furthermore, in case of septal deviation, such packings may traumatise the nasal (septal and/or turbinate) mucosa and create more sites of bleeding. Traditionally, prior to otolaryngological examination both sides of the nose are already packed.² That is why, the identification of the site of bleeding after packing removal is frequently a difficult problem. Moreover, septal deformation and hypertrophic turbinates often make it difficult to visualise the bleeding regions.³ Nevertheless, Ha et al. have discussed neither these common issues nor the endoscopical anatomical findings. It is also not clear whether their patients had continuous epistaxis at the moment of cauterization. (Click here to continue reading.)

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Re: Lee JI, Kang WK, Kim HJ, Kim SH, Oh, ST. Unusual metastasis from a rectal adenocarcinoma: penile metastasis. (ANZ J. Surg. 2011; 81: 102)

I read this article with great interest. It is really an unusual and interesting case. Metastatic lesion to the penis is uncommon with approximately 372 cases reported in the literature till 2006¹. I would like to add few interesting points. The most frequent sign is priapism. Priapism is due to metastatic involvement of corpora cavernosa. Penile metastasis indicates advance form of virulent disease and survival is limited. Authors had mentioned various modalities of management. I would like to state here that dorsal nerve section can also be used as a one of the modalities for the treatment of intractable pain². Radiation therapy has generally been not successful and chemotherapy has not been extensively studied in sufficient number of patients to warrant recommendation³.

Dr Vipul D Yagnik MBBS MS FMAS
Ronak Endo-laparoscopy and General Surgical Hospital, Patan, Gujarat, India

References
1. Cherian J, Rajan S, Thwaini A, Elmasry Y, Shah T, Puri R. Secondary penile tumours revisited. Int Semin Surg Oncol. 2006; 3: 33.
2. Hill JT, Khalid MA: Penile denervation. Br J Urol 1988; 61: 167.
3. Pettaway CA, Lynch DF Jr, Davis JW. Tumors of the Penis. In Wein: Campbell-Walsh Urology, 9th ed. Philadelphia: SAUNDERS, 2007; ch 31.

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Re: Wysocki AP. The ASU – Are surgeons now unaccountable? (ANZ J. Surg. 2010; 80: 944)

The surgeons at Nepean Hospital appreciate the concerns expressed by Dr Wysocki (ANZ J Surg, 2010, 944). There is no need to “ensure compliance”. Compliance occurs because of appropriate and correct professional behaviour. The ASU functions the same way every day of the year. Limited space does not permit me to correct misconceptions and address other minor concerns.

Dr Wysocki’s chief concern is the loss of surgeon accountability. In the traditional system the patient was managed by a registrar-lead service with the surgeon “available”. The ASU is a consultant-lead service. All admissions are seen and assessed by a consultant on the day of admission; all surgery is supervised by the surgeon. Each patient stays in the ASU and is reviewed by the ASU consultant each day. This acts as an audit process on each surgeon’s performance. This is a higher level of consultant responsibility and involvement than in most public hospitals in Australia. We presume from Dr Wysocki’s concern that he sees each of his patients every day, including weekends and public holidays. Unfortunately this outstanding performance is not the norm. (Click here to continue reading.)

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Re: Kazi R, Sayed SI, Dwivedi RC. Post laryngectomy speech and voice rehabilitation: past, present and future. (ANZ J. Surg. 2010; 80: 770–1)

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Re: Discussion: Laparoscopic bile duct exploration

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Re: Hamdorf JM. Critical evaluation. What makes a competent surgeon? (ANZ J. Surg. 2010; 80: 656)

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Re: Kelly, MD. Results of laparoscopic bile duct exploration via choledochotomy (ANZ J. Surg. 2010; 80: 694–8)

I wish to congratulate Michael Kelly for an excellent article on the management of common bile duct (CBD) stones. However, I wish to draw the author to some comments.

First, what is the author's practice on patients who are not unwell but jaundiced (due to CBD stones)? A preoperative endoscopic retrograde cholangiopancreatography (ERCP) is not without risks; and at our institution, we would organize cholecystectomy and usually place a transcystic stent (antegrade stent). A post-operative ERCP would then ensue.

Second, a failure rate of 25% for ERCP seems high. Could the author explain this rate?

Third, if there is a suspicion for CBD stones with known gallstones, why bother with a magnetic retrograde cholangiopancreato-graphy; and not plan for surgery?

Fourth, what size of bile duct (diameter) would preclude a choledochotomy?

And finally, why place T-tubes and not consider placing an antegrade stent? T-tubes do carry their own morbidity.

Sulman Ahmed, MB BS (Syd), FRACS
Department of Surgery, Nepean Hospital, Sydney, New South Wales, Australia

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Oesophageal bolus impaction: role of glucagon, glyceryl trinitrate and carbonated drink

Glucagon, glyceryl trinitrate (GTN) and carbonated drinks are all considered measures, which can be implemented in the emergency department to relieve oesophageal food bolus impaction negating the need for urgent endoscopy. Glucagon and GTN are smooth muscle relaxants. Carbonated drinks increase intra-oesophageal pressure by releasing carbon dioxide and thereby forcing the food bolus into the stomach. The outcome of 45 episodes of oesophageal food bolus impaction presenting to the Bendigo Hospital emergency department between 2007 and 2009 was reviewed. Success was defined as the resolution of symptoms or no bolus seen on endoscopy. Symptoms resolved in three episodes and no bolus was seen on endoscopy in two episodes. Of these five episodes, all three modalities were implemented in one episode while glucagon and GTN was administered in two episodes. No significant difference was found when a comparison is made between the episodes where no intervention was implemented and where glucagon was administered alone or in conjunction with another measure (11.5 versus 10.5%, respectively). This is comparable to Tribbling et al. who found no significant difference between those given glucagon and diazepam and those given placebo.¹ Al-Haddad et al. also concluded a lack of advantage of glucagon over placebo.² There is minimal evidence regarding the efficacy of GTN in the management of oesophageal food bolus impaction. GTN was efficacious in two of 22 episodes, and on both occasions, it was administered in conjunction with glucagon. The efficacy of carbonated drinks is difficult to assess as there was no protocol in regard to the amount of carbonated drink administered. There is no strong evidence to suggest usage of these measures to relieve oesophageal food bolus impaction in this audit and endoscopy will inevitably be required to further ascertain a potential cause.

Rosemarie May Eyre, MB BS
Bendigo Health – Intern, Victoria, Australia

References
1. Tibbling L, Bjorkhoel A, Jansson E et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10: 126–7.
2. Al-Haddad M, Ward EM, Scolapio JS et al. Glucagon for the relief of esophageal food impaction: does it really work? Dig. Dis. Sci. 2006; 51: 1930–3.

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Re: Discussion: A case of a neuropathic diabetic foot ulcer causing rupture of the Achilles tendon

We thank Behan et al. for their comments pertaining to value of reconstructive surgery in this case of a neuropathic ulcer causing rupture of Achilles tendon. Management of the diabetic foot is always associated with interesting challenges, which are increasingly being dealt with in a holistic multidisciplinary manner. The purpose of our case report was to simply highlight an unusual cause of rupture of the Achilles tendon, and not to enter into a discussion of the management of diabetic foot ulcers.

Our approach to the management of diabetic foot ulcers occurs in a multidisciplinary manner within our tertiary institute (vascular surgery, podiatry, endocrinology, nursing, infectious disease and orthopaedic surgical involvement). Reconstructive surgery is considered with plastic surgeon consultation on case-by-case basis. This is done after all issues including removal of infected tissue and long-term function are taken into account. In this particular case, the patient had significant co-morbidities, particularly a poor cardiac reserve with an ejection fraction of 11% and an implantable defibrillator. Despite not having a reconstruction, she had a very good outcome with respect to healing of the wound and functional capacity.

Hafees Saleem,*† MB BS, MRCSEd
Sheri L. Newman,* MB BS
Phillip J. Puckridge,*† MB BS, FRACS (Vascular Surgery)
J. Ian Spark,*† FRCS, MD, FRCS (Gen), FRACS, PG Cert Medical US
*Department of Vascular Surgery, Flinders Medical Centre & Repatriation General Hospital, and
†Department of Surgery, Flinders University, Bedford Park, South Australia, Australia

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Re: Diagnostic evaluation and management of benign duodenal tumours (ANZ J. Surg. 2010; 80: 526–30)

We read the article by Ji-Qi Yan and colleagues with great interest.¹ As reports on benign duodenal tumours are rare, it is important to learn how others treat these rare entities. The article nonetheless raised a number of questions.

In the methods section,Yan and colleagues state that the benignity of tumours was confirmed by post-operative pathology. It would be interesting to know if they took preoperative biopsies in all cases, in how many cases they suspected a malignancy and whether this affected their treatment decision. Since the number of minimal repairs compared to radical resection with pancreaticoduodenectomy (PD) was quite high, it seems that in most cases, benign lesions were suspected. Endoscopic ultrasound (EUS) could have been used in the preoperative assessment, too. EUS is an important diagnostic tool since it is known that EUS is a sensitive and specific method for tumour and nodal staging.² If in the preoperative assessment there were cases where malignancy was suspected, it would be interesting to know whether these were the cases treated with PD. This leads to the question of exactly when they chose a particular procedure, aware that in case of doubt, the more radical option would be the better one.3 Flow charts have proved to be useful in the management of tumours,⁴ and one wonders whether they used a particular flow chart or algorithm. (Click here to continue reading.)

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Re: A case of a neuropathic diabetic foot ulcer causing rupture of the Achilles tendon

We read with interest the case reported by Saleem et al. in which a diabetic ulcer of the posterior leg progressed to rupture of the Achilles tendon.¹ While the case was interesting in its presentation, we would like to comment on the ultimate management of the patient, who underwent debridement of the ulcer but no formal reconstruction of either the ulcer or the Achilles tendon. We feel that consideration of relatively simple reconstructive options can substantially impact on quality of life in the increasingly common presentation of diabetic leg ulcers. (Click here to continue reading.)

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Re: Author response: criticism of ASOHNS guidelines is incorrect (Re: ANZ. J. Surg. 80: 480–2)

The stated objective in Dr SV Fernandes’ letter of reply¹ differs from that stated in his previously published article.²

In his article, Dr SV Fernandes states, ‘The guidelines for evaluation of noise-induced hearing loss (NIHL) suggest that in cases of asymmetry, “the worse ear be equated to the better ear” for purposes of compensation. This method is prejudicial to theworker (plaintiff).’ His letter of reply states, ‘The objective of my article was to view the current recommended practice of equating the worse ear to the better ear in cases where an asymmetry sufficient to warrant retrocochlear investigation is shown, in the context of legal proceedings’. (Click here to continue reading.)

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Re: Prasad S, Wilson J, Kalade A, Desmond P, Chen R. Endoscopic ultrasound of pancreatic cystic lesions. ANZ J Surg 2010; 80: 600-604

I read this article with great interest. Cystic lesions in the pancreas are being increasingly recognized. 1.2% of 24309 CT or MRI studies reviewed at the Wisconsin Medical College revealed cystic lesion in the pancreas¹. The primary aim of diagnosis is to differentiate benign from malignant. Findings which suggest potentially malignant tumors are: cyst fluid contains mucin, high CEA, high viscosity, and biopsy reveals mucin secreting cells². A recent history of pancreatitis, amylase-rich fluid, and communication with the pancreatic duct suggests pseudocyst. CEA in cystic fluid is a good marker and helps to distinguish mucinous cystadenoma (MCN) from serous cystadenoma (SCN). SCAs have very low levels of CEA, with the cut-off value being 5ng/ml³. The authors mentioned that the benefit of prophylactic antibiotics is unknown. I would like to state here that EUS–FNA, from pseudocyst or cystic tumors, is at increased risk of infectious complications and antibiotic prophylaxis is recommended^{4, 5}.

Dr Vipul D Yagnik MBBS MS FMAS
Ronak Endo-laparoscopy and General Surgical Hospital, Patan, Gujarat, India

References
1. Spinelli KS, Fromwiller TE, Daniel RA, Kiely JM, Nakeeb A, Komorowski RA, et al. Cystic pancreatic neoplasms: observe or operate. Ann Surg 2004; 239:651-9.
2. Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al: Diagnosis of pancreatic cystic neoplasms: A report of the cooperative pancreatic cyst study. Gastroenterology 2004; 126:1330-1336.
3. Hammel P, Levy P, Voitot H, et al: Preoperative cyst fluid analysis is useful for the differential diagnosis of cystic lesions of the pancreas. Gastroenterology 108. 1230 1995.
4. Adler DG, Jacobson BC, Davila RE et al. ASGE guideline: complications of EUS. Gastrointest. Endosc. 2005; 61: 8-12. Erratum in: Gastrointest. Endosc. 2005; 61: 502.
5. American Society for Gastrointestinal Endoscopy: Guideline on antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2008; 67:791-8.

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Re: Criticism of ASOHNS Guidelines incorrect.

I thank Dr. B. Williams for his comments. However his response seems to have missed the point entirely.

The objective of my article¹ was to view the current recommended practice of equating the worse ear to the better ear in cases where an asymmetry sufficient to warrant retrocochlear investigation is shown, in the context of legal proceedings. Most ENT surgeons would be aware of the pathology yield in cases of ‘asymmetric hearing loss sufficient to warrant retrocochlear investigation’ in routine clinical practice. The medical literature is also rife with such experience. In other words in the real world, asymmetric hearing loss is common, identifiable pathology is not.

The Worker’s Compensation Legislation allows the medical expert to provide an opinion based on ‘the preponderance of evidence’ standard (civil). This means that no hard proof is required for establishing a link but that other factors can allow a conclusion to be reached. In cases where the probability (greater than 0.5) exists that noise is a substantial factor (more likely than not) in the causation of the asymmetry, the legal process allows the expert to infer so. Here we need to note that a medicolegal opinion is not the same as a medical diagnosis². (Click here to continue reading.)

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RE: Jariwala SK. Is radical prostate cancer radical? ANZ J Surg 2010; 80: 570-571

We read with interest this correspondence from Dr Jariwala¹ and would like to highlight our difference of opinion on some of the key points.

Although we talk about fundamental oncological principals, in fact the heterogeneity of malignant tumours necessitates widely differing surgical approaches. Using the example of testis cancer aforementioned in the letter, lymph nodes are not routinely removed when performing a radical orchidectomy as although this would adhere to "oncological principles", the additional morbidity of retroperitoneal surgery would be unjustified in the majority of cases. Therefore calling it a radical operation may be a misnomer, but it is still the correct cancer operation.

Clearly some tumours, e.g. sarcoma, require extensive excision to optimise cure rate, however, one must remember that the patient has to live with the surgical sequelae. Therefore optimization of functional outcome while achieving oncological control has driven the evolution of many cancer operations. The refinements in breast cancer surgery from radical mastectomy to lumpectomy is evidence of this move away from radical surgery for the sake of it. (Click here to continue reading.)

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Re: Hugh TB. Chappel v Hart: res judicata? ANZ J Surg. 80: 576 and Hugh TB. Surgical Sense and Legal Non-Sense – Chappel v Hart revisited. ANZ J Surg 79: 554-557

I applaud Dr TB Hugh on his article¹ and letter². I add a system error perspective.

The issue is, was there a failure to warn of the risk of R vocal cord palsy (VCP) in 1983; not whether there was a breach in 1994 when the trial occurred.

I agree the incidence of R VCP due to a Dohlman operation before 1983 was not established at trial and I agree it was zero; unlike the known incidence of 1:14,000 in Rogers v Whitaker. With respect, even the trial judge’s objected question was not referenced to the period before 1983. Expert opinion after 1983 or in 19913 is not relevant. It is probable the expert opinion quoted in 1994 as “vocal cord paralysis has been described” referred to Dr Benjamin’s 1991 article³ which is presumed to be Mrs Hart. There was no evidence as to the incidence of R VCP before 1983. (Click here to continue reading.)

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Re: Fernandes SV. Asymmetric hearing loss in industry. ANZ J. Surg. 80: 480-482

Dr Fernandes has made a serious criticism of the Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) Guidelines for Evaluation of Occupational Noise Induced Hearing Loss (ONIHL) of Gradual Process (2nd Edition)¹. He states they are “prejudicial to the worker (plaintiff)” and “unjustly favour the employer” because they “suggest that in cases of asymmetry, ‘the worse ear be equated to the better ear’ for purposes of compensation” and the “improbability of a non-NIHL in asymmetric cases”.

In fact the ASOHNS Guidelines do not “suggest that in cases of asymmetry, ‘the worse ear be equated to the better ear’”. They state under the heading Interpretation:

“In cases of asymmetry of sensorineural loss sufficient to warrant retro-cochlear investigation but otherwise consistent with NIHL, the worse ear is equated to the better.” (My emphasis.)

This paragraph must be read with the full guidelines, especially Diagnosis below. The phrase “consistent with” is not a diagnosis and it is too speculative to use it as a positive indicator of actual NIHL. Adelman² reports the Workers Compensation Board of British Columbia found 10 claimants over a 5 year period had undiagnosed acoustic tumours. (Click to continue reading.)

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Re: Slattery D. Dupuytren’s disease in Asia and the migration theory of Dupuytren’s disease. ANZ J Surg 2010; 80: 495-499.

This useful literature review, which draws attention to the migration theory of the incidence of Dupuytren’s contracture and discusses occurrences of the condition in East Asian countries, appropriately argues against causation by sporadic genetic mutation, but other aspects of the following conclusion are less convincingly argued: ‘This review shows that there is a low but significant incidence of DD across Asia, which supports the hypothesis of a widespread genetic susceptibility to the disease. Therefore, the prevalence of DD in this community is not likely due to sporadic genetic mutation as previously presumed’ (did many people think this?) ‘but rather individual genetic susceptibility and that risk factors play a major role in the expression of DD in this population.’

It seems that it is felt relevant that there is a positive family history of the disease in only 9% of afflicted Asians, but in any population many people whose Dupuytren’s diathesis is mild and whose disease first appears late in life lack a positive family history. Apart from a positive family history, no evidence is put forwards that the cited risk factors – diabetes, trauma, epilepsy, alcoholism and manual labour – play a greater role in countries where the incidence of the disease is low than where it is high.

An alternative explanation is that fewer genes responsible for Dupuytren’s contracture have reached Asia, and that Asian genetic pools are less likely to allow expression of the genes of Dupuytren’s contracture.

Some risk factors, including alcoholism, are widely accepted but others, such as manual work, are still hotly debated. I think it is fair to say that most hand surgeons believe manual work to have little influence upon the causation of Dupuytren’s contracture.

John A Buntine FRACS
Box Hill Hospital, Box Hill, Victoria, Australia

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