Correspondence

Author’s response: reply from Professor M. H. Hamdy

Sir I thank M r Lennard and Mr Rich for their comments. Unfortunately, my paper was prepared during 1983 before the case described by Mr Rich and colleagues was published. I thank them for pointing out this publication. I agree that anorectal myectomy is not recommended in an emergency. but it is unusual for cases in the adult to present as an emergency. However, in an emergency I would do first a colostomy and then later a myectomy with or without anterior resection.

M. H. Hamdy Faculty of Medicine Suez Canal University Ismailia Egypt

Sir The article ‘Anorectal myectomy in adult Hirschsprung’s disease: a report of six cases’ by M. H. Hamdy and W. G. Scobie (Br J Surg 1984; 71 : 61 I- I 2) promotes a valuable method of treatment for an uncommon disorder. However I would like to put forward two points which may be of interest to the general reader.

Firstly, in describing the features of the cases reported, an atypical picture arises. Of the six cases, four are women and in four of them soiling was a prominent feature. In the largest series from St Mark’s Hospital’ 73 per cent were men and there were no reports of soiling. As the nature of the disease is a failure to relax the anal sphincteric mechanism, this is not altogether surprising.

Secondly, the diagnosis of this disease requires a demonstration of something which is not there, namely ganglion cells. This being the case, a pathologist skilled and/or interested in interpreting rectal biopsies should be consulted. Even with this experience, interpretation must not be regarded as absolute; a recent report in children’ highlighted discrepancies between histochemical and histological features in 15 per cent of a large series. These cases were noted to be of the short segment type, precisely that which can present as an adult.

M. Davenport

Department of Paediatric Surgery Clarendon Wing General Infirmary at Leeds Leeds L S l 3 E X

1. Todd IP. Adult Hirschsprung’s disease. Br J Surg 1977; 64: 311-12. 2. Chow, Campbell. Short segment Hirschsprung’s disease as acause of

discrepancy between histologic, histochemical and clinical features. J . Paed Surg 1983; 18: 167.

Author‘s response: reply from Professor M. H. Hamdy

Sir In reply to Mr Davenport’s comments I would like to make the following points:

(1) The sex ratio in this small group does not reflect by any means the sex incidence of Hirschsprung’s disease.

(2) Soiling in these patients was mainly due to the increase in dose of laxatives and purgatives leading to liquid stools above the hard bolus in the lower rectum.

(3) We definitely agree with his points on thedifficulties in histological diagnosis. We have been interested in the histochemistry of this disease since 1970 and routinely make acetylcholinesterase studies in all the biopsies, mucosal or full thickness. This was emphasized in the article but it also needs someone who is experienced in this field.

M. H. Hamdy

Department of Paediatric Surgery Faculty of Medicine Suez Canal University Ismailia Egypt

Treatment of pilonidal sinus

Sir It is with great interest that we read the article by C. A. McLaren (Br J Surg 1984; 71 : 561-2). concerning partial closure and other techniques in pilonidal surgery. Using the technique of excision and partial closure in 22 patients with chronic uninfected sinus there were no recurrences, a 5 per cent wound breakdown rate and no patients requiring further surgery. These results are certainly impressive particularly when com- pared with those of the author’s following excision and primary suture. It would also have been of interest had the author used the same technique in those patients with chronic sinus and cellulitis.

The prolonged hospital stay in all forms of treatment for all types of pilonidal disease was rather disturbing, this particularly so for a benign condition.

We have used the Millar-Lord treatment’ now on 33 consecutive patients with at present a complete follow up in 15 of these. All forms of pilonidal disease were treated. Of the 15 patients completely followed up 5 had pilonidal abscesses.

Although this technique can be used on an outpatient basis as advocated by P. H. Lord and D. M. Millar, we have treated all our patients on an inpatient basis and operated under general anesthesia. In the I5 patients postoperative stay ranged from 1 to 3 days. In addition postoperative care is very much simpler particularly from the patient’s point of view. We would also stress the necessity for keeping the skin surrounding the wound clear of hair. We feel that this is an important factor in preventing recurrences, and we make a point of stressing this to the patients. Our follow up has now ranged from 2 to? years and we have had only one recurrence and this was a patient with pilonidal abscess.

H. A. Schwarz, S. Abrahami, E. Dvir, 1. L. Horowitz

Department of Surgery A and Plastic Surgery Haifa C i t y Medical Center (Rothchild) H a f a Israel

1. Lord PH, Millar DM. Pilonidal sinus: a simple treatment. Br J Surg 1965; 52: 298-9.

Penetration of bowel by vegetable matter

Sir A report of ‘Tomato skin penetrating the small bowel’ notes that ‘penetration or perforation of the bowel by fruit or vegetable matter is exceedingly rare, with only five cases recorded in the literature’ (Br J Surg 1984; 71: 648).

In 1958 I reported the perforation of a Meckel’s Diverticulum which was packed with grape seeds (Med J Aust 1958). I also have seen a perforation by grass stalk. As far back as 1958, there was recorded a multitude of problems with all sorts of foreign bodies in a Meckel’s Diverticulum. Although there may be more than just five reported cases of fruit and vegetable matter penetrating the bowel, penetration seems to be almost invariably associated with an anomaly or pathology of the bowel.

A. Rumore

838 Punchbowl Road Punchbowl 2/96 Australia

Authors‘ response: reply from J. M. Dixon and A. 6. Lumsden

Sir Thank you for allowing us to comment on Dr Runmore’s letter. Despite an extensive literature search. we apologize for missing his 1958 paper in the Medical Journal of Australia. Even if one includes the two extra patients with perforation by grape seeds and a grass stalk, this still makes penetration or perforation of the bowel by fruit or vegetable matter ‘extremely rare’, as we stated. None of the other references cited in Dr Runmore’s paper include any other patients with this complication.

J. M. Dixon A. B. Lumsden

University Department of Clinical Surgery The Royal Infirmary Edinburgh EH3 9YW

Br. J. Surg., Vol. 72, No. 1, January1985 75