Br. J. Surg. Vol. 69 (1982) 497-499 Printed in Great Britain

Correspond en ce

Special rectoscope for the EEA stapler Sir I was interested in the paper by Marti and Fiala (Br. J . Surg. 1982; 69: 214) concerning the use of the EEA stapler for restoring continuity after a Hartmann’s procedure. I think most surgeons who have been using these instruments for some time use them much as in the way described in this paper and have not found any disadvantage in managing without a special rectoscope. I believe the choice of the site for bringing the spindle of the machine through the rectal stump is better decided by the intra-abdominal operator than by an intrarectal assessment. Two factors may make the operation less easy than it would appear on theoretical grounds. First. as a result of infection and contamination before and possibly at the first operation, the rectal stump may be glued down by a firm and thick layer of fibrosis to such an extent that the tissues are too thick, without further dissection, for the efficient functioning of the stapling device. Furthermore, this thickened layer, which obliterates the distinction between the bladder and the rectal stump, puts the former viscus at some risk, since in a low transection of the rectum, the bladder frequently spreads backwards to cover some or nearly all of the rectal pouch, so that the margins of these viscera are obscured by adhesion and fibrosis and the bladder can be damaged if it is not dissected off with care before stapling.

In spite of these cautionary words, the method has been found to be so attractive that I have been using substantially the same technique as a primary form of stapled anastomosis where the rectal stump is so short as to make the insertion of a purse-string suture difficult and tedious. In these cases, the stump has been closed with a TA55 and the anastomosis completed as described by Marti and Fiala for restoring bowel continuity after a Hartmann’s procedure. We have now used this method on 20 occasions in this hospital and we are pleased with how easy and safe the operation seems to be in the short term. The spindle may be pushed through the rectal stump in front of or behind the line of closing staples, and where the rectal stump is ultra-low, the staple line may be, of necessity, incorporated within the circular anastomosis of the EEA. Contrary to Marti and Fiala’s assertions, we have found this no disadvantage. The newer versions of the circular stapling machines have a stronger and sharper circular knife cutting down onto a firmer seating and I think these instruments will cut through staples.

Luton and Dunstable Hospital Luton Bedfordshire LU4 ODZ

R. V. FlDDlAN

Sir We are grateful to Mr Fiddian for his comments. Surely the choice of the site of the anastomosis must be decided by the intra-abdominal operator. The rectoscope helps in finding out the most suitable surface avoiding inequalities of thickness due to the scar. Palpation of the tip of the instrument allows stapling without interposition of the bladder.

We are not convinced that stapling and cutting through the line of a previously closed stump with a TA55 is without danger. Therefore, we think that the special rectoscope. although not mandatory, is a valuable help in restoring continuity of the Hartmann’s procedure and in preventing some iatrogenic complications.

M-C. MART1 I-M. FIALA

Surgical Department Cantonal Hospital of Geneva 121 I Geneva 4 Switzerland

Milk Tcm-HIDA test for enterogastric bile reflux Sir We have been surprised to see the extent of reflux of bile into the stomach reported by Mackie et al. in their recent paper (Er. J . Surg. 1982: 69: 101-4). In our experience of 350 bile reflux studies it was rare to find more than 10 per cent of the initially injected dose appearing as reflux into the stomach. Moreover. our results have been confirmed in a group of patients by aspirating the stomach contents using a naso- gastric tube and measuring the percentage of dose present.

Mackie et al. reported a maximum reflux of 47 per cent of the initial activity. In patients with T tubes inserted into the common bile duct we

have found that this figure corresponded to the total excretion of the radiopharmaceutical over the first 75 min after injection of diethyl- HIDA. Clearly, there is a systematic error in the reported amount of reflux.

We believe that this error is due predominantly to the fact that the whole liver is not included in the control view, as is evident in Fig. 2 of their paper. We have used a SO-cm field of view gamma camera which encompasses all of the abdomen and most of the chest. Under these circumstances only 2 per cent of the total dose is outside of the gamma camera field of view at 1 h.

Finally, we would like to emphasize that there are considerable errors in counting activity in the stomach due to scatter from the surrounding bowel and liver.

M. SOKGl L. K. HARDING

V. CAUSER SUE SHERWIN

1. A. DONOVAN Department of Physics and Nuclear Medicine Dudley Road Hospital Birmingham B187QH

Sir We were perplexed by the comments of Sorgi et al. and feel that they have misread the protocol of our test for enterogastric reflux recently described in your journal (Br. J . Surg. 1982; 69: 101-4). The extent of reflux of bile into the stomach was expressed as a percenrage of abdominalfield activity recorded half an hour following injection of the radiopharmaceutical agent and before administration of the milk meal stimulus. At this time, most of the radioactivity is seen in the liver. biliary system and bowel. Thus, gastric activity is compared with a function of the agent’s activity as a biliary marker, each patient providing his own reference value. We routinely monitor the radio- chemical purity of our preparations but see no advantage in expressing reflux as a percentage of dose. To d o so will only create additional errors through variations in the biological activity of the agent, the patients’ liver function and tissue absorption of radiation.

It has been reported that rapid reflux of 200-300ml of mixed duodenal juice may be required to induce symptoms in a patient suffering from post-gastrectomy bile vomiting syndrome (1) . It seems likely that this will contain a good deal more than 10 per cent of the biliary output during a reflux episode.

We believe that reflux must be related to the patient’s posture and the nature of the provocation employed. For example, our recent studies suggest that gallbladder evacuation in response to a bolus injection of cholecystokinin is very different to that produced by a meal.

Since enterogastric reflux may be influenced by gastric accumulation of refluxate, tests involving the aspiration of gastric contents are of doubtful validity.

We agree that many potential sources of error accompany all non- invasive scintigraphic methods so far described. Nevertheless, tests such as the one we have described are required if our understanding of the significance of enterogastric reflux is to be furthered.

C. R. MACKIE M. L. WISBEY A. CUSCHlERl

Department of Surgery Ninewells Hospital Dundee DDI 9SY Scotland I . Toye D. K. M. and Alexander Williams J . : Post-gastrectomy bile

vomiting. Lancet 1965; 2: 524-6.

Low dose heparin in inguinal herniorrhaphy Sir Samuel de Lange (&’. J . Surg. 1982: 69: 234-5) points out that subcutaneous low dose heparin not infrequently results in a wound haematoma which is ‘inconvenient to the patient and costly as it prolongs hospital stay’. His carefully organized controlled trial has demonstrated that the arm is preferable to the abdominal wall as an injection site.

One question remains. Is it ever necessary to use heparin prophylaxis

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in patients undergoing hernia repair or similar minor procedures, apart from those with a past history of deep vein thrombosis or women taking oral contraceptives? In otherwise fit patients undergoing this type of surgery, postoperative deep vein thrombosis is extraordinarily rare.

A study of the prevention of deep vein thrombosis in patients having hernia repairs was started at the Lambeth Hospital in the early 1970s but had to be abandoned due to failure to detect any thrombosis using the IZ51-fibrinogen uptake test. In my wards at Lewisham and Hither Green Hospitals. no patient undergoing hernia repair has developed physical signs of deep vein thrombosis or pulmonary embolism in the past 5 years. TED stockings and early ambulation have been the only methods of prophylaxis.

Experience has shown that most postoperative deep vein thromboses develop in patients undergoing major abdominal or thoracic pro- cedures, as far as general surgery is concerned. These patients certainly need vigorous prophylaxis. They also require intravenous fluids for the first few postoperative days and this is a convenient route for the heparin. Only a very small dose ( I i.u. kg-'hK1) is required ( I ) , and this also helps to prolong 'drip life' with obvious benefits to both patients and house surgeons (2).

Albert Embankment Consulting Rooms York House 199 Westminster Bridge Road London SEI I .

DAVID NEGUS

Negus D., Friedgood A,, Cox S . J. et al.: Ultra-low dose heparin in the prevention of postoperative deep vein thrombosis. Lancet 1980; 1: 891-4. Stradling J. R.: Heparin and infusion phlebitis. Br. Med. J . 1978; 2: 1196-7.

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Correspondence

are well aware of the information it gives. We would suggest that the technique is a lateralizing rather than a localizing aid. It is inconceiv- able that i t could differentiate between an intrathyroid and an extra- thyroid parathyroid gland. Further. in 12 of 95 patients Dunlop et al. ( I ) reported that the technique was either unhelpful or even misleading.

Ultrasound examinations have been carried out in a number of centres and seem to be able to detect large parathyroid adenomas. but there are a significant number of false positives and false negatives.

In particular, differentiation between the rather rare intrathyroid parathyroid adenoma and the common thyroid nodule would appear to be difficult.

Our policy of reserving localizing techniques for failed neck explora- tions is similar to that adopted in most centres with a major interest in parathyroid surgery. Our initial successful exploration rate in 98 cases was 94 per cent, which is in agreement with other series where localized techniques have not been employed. This series was collected over a decade and the re-explorations occurred during the early days before we fully appreciated the possibility of intrathyroid parathyroid aden- omas. In the most recent 100 cases the initial exploration was successful in 98. We are gratified to learn that Billings and Milroy find a similar instance of intrathyroid glands to our experience.

Virtually all our patients have been investigated and diagnosed by one of us (D.A.H.) almost exclusively as outpatients. The total inpatient stay is usually between 4 and 7 days. Is the expensive and invasive policy at the Middlesex Hospital giving better results? Specifi- cally. we would be interested to hear in how many cases an intrathyroid parathyroid adenoma was successfully predicted preoperatively at the Middlesex Hospital.

D. A. HEATH E. T. BAINBRIDGE

A. D. BARNES The Queen Elizabeth Hospital

Overactive intrathyroid parathyroid glands Sir We would like to comment on the paper by Bainbridge and Barnes (Br. J . Surg. 1982; 6 9 200-2) and their operative findings in patients with intrathyroid hyperactive parathyroid glands. They are somewhat dis- missive of attempts a t preoperative localization of parathyroid adenomas. Two patients in their group of 6 needed a second operation to find the adenoma and it was only by chance in 2 other patients that the correct thyroid lobe was excised at the first attempt. It is precisely in patients with unanticipated operative difficulties such as these that localization studies may save the patient a second time-consuming and hazardous operation.

Our current practice is to perform both small vein parathyroid venous sampling and ultrasound examination on all cases of primary hyperparathyroidism. Small vein sampling has previously been reported from this centre as giving helpful information in 87.5 per cent of cases (1). There is an acceptably low morbidity associated with small vein sampling. Our recent prospective study of ultrasound localization has shown preoperative localization of the adenoma in 52 per cent of cases (2) with continuing improvement in these results with increasing experience and more sensitive equipment.

With the help of these two localizing procedures, it might well have been possible to save these 2 patients a second operation, and to resolve completely the surgical problems of localization in the other 4 patients. We feel that preoperative localization studies should not be so lightly dismissed and that they do have a useful role to play.

In our recent series of 223 patients with surgically proved hyperpara- thyroidism. I 1 (4.9 per cent) were found to have an intrathyroid parathyroid adenoma. Ten of these patients had localization studies, and in 8 the adenoma was successfully localized by one of the techniques described above. None of the patients required a second operation.

PETER BILLINGS EUAN MILROY

The Middlesex Hospital Mortimer Street London WIN 8AA I . Dunlop D. A. B., Papapoulos S . E., Lodge R. W. et al.:

Parathyroid venous sampling: anatomic consideration and results in 95 patients with primary hyperparathyroidism. Br. J . Radio[. 1980; 53: 183-91. Thomas D. M . , Watson L. R., Lees W. R. et al.: An evaluation of ultrasound in 'preoperative parathyroid localisation. First Meeting of the Endocrine Surgical Group, Birmingham 1981.

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Sir We were interested and surprised to receive the comments of Billings and Milroy which appeared to show a number of misunderstandings of the presently available localizing techniques. One of us (D. A. H.) has had extensive experience of small vessel venous catheterization and we

Edgbaston Birmingham B15 2TH - 1. Dunlop D. A. B., Papapoulos S . E., Lodge R. W. et al.:

Parathvroid venous samdine: anatomic consideration and results in 95 patients with primary"hyperparathyr0idism. Br. J . Radio/. 1980; 53: 183-91.

Intravenous and oral metronidazole Sir The paper from Peterborough (Br. J . Silrg. 1982; 6 9 226-7) comparing intravenous and oral metronidazole as prophylaxis in colorectal surgery confirms the controversy between some surgeons in the UK and the US about the relative efficacy of these two methods of administration.

The debate has not been helped by the fact that the Aeberhard ( I ) and Burdon (2) papers were reported separately, although they had been set up as one study initially. If systemic antibiotics are better or worse than oral ones in this situation, they may be acting in different ways. The former to reduce bowel flora at the time of excision and contamination, and the latter to produce high bactericidal tissue and serum levels for the critical short postoperative period. The paper from Peterborough does not add much weight to this argument as only the anaerobes were significantly affected by the oral course. However. no details of bacterial concentrations were given.

Until the Birmingham paper in the same issue of the journal (3), a course of antibiotics longer than 24 h had never been shown to be more effective than one lasting that time alone in colorectal prophylaxis. This concept will remain, as the inflammatory bowel disease studied in this paper must be considered (as the authors concede) as a case of 'therapy' and not 'prophylaxis'. I emphasize this point as papers are 'misread' so easily. This paper was reported to me by a colleague as evidence that we should be using 5-day courses of antibiotics in all colorectal surgery.

The Peterborough group used a 5-day course of oral antibiotics. This is unnecessary as bowel flora is maximally altered within only 16 h, as Bartlett and others have shown (4).

Thus, although the verdict between ,short oral and shori systemic prophylaxis is still awaited, there is no indication that anything more than a 24-h course of antibiotics, whether preoperative. postoperative or both, is justified. In the words of Peter Pindar (1738-1819): 'People may have too much of a good thing'.

Faculty of Medicine University Surgical Unit F Level, Centre Block Southampton General Hospital SO1 6HU 1.

PETER MCDONALD

Aeberhard P., Berger J. and Casey P. A,: A comparison of oral bowel preparation and intravenous chemotherapy given at the time of operation. R. Soc. Med. Int. Congr. Sjmp. Ser. 1979; 18: 173-7. Burdon D. W. and Keighley M. R. B.: A comparison of the prophylactic effect of parenteral metronidazole and kanamycin with oral metronidazole and kanamycin in colorectal surgery. R . SOL.. Med. Int. Congr. Synip. Ser. 1979; 18: 179-83.

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