British Journal of Surgery 1995,82,564-570

Correspondence

Urine testing for acute lower abdominal pain in adults

Sir We read with interest the recent article pointing out the value of urine testing with reagent strips on the ward to rule out urinary tract infection (Br J Sutg 1994; 81: 1460-1). We would like to point out that, apart from this valuable test, a dipstick test of urine to assess the presence of bilirubin is also very useful. Any doctor faced with the emergency admission of a patient with upper abdominal pain and tenderness, and with clinical evidence of cholecystitis, would like to know whether there was an element of subclinical jaundice. Liver function testing, although very satisfactory, is usually not available after normal working hours and particularly over weekends. If there has been transient obstruction to the common bile duct abnormal liver function may recover completely in 24 h and may therefore never be documented. This problem could be obviated if a simple test of the urine was carried out soon after admission with reagent strips sensitive to bilirubin.

We carry out this test routinely and find it invaluable for the immediate assessment of patients admitted as an emergency with abdominal symptoms outwith routine laboratory hours. However, recently, newer and less expensive reagent strips without the ability to test for bile have been introduced for routine use on all wards at our hospital, and it is only with some considerable difficulty and perseverance that we have managed to continue the use of bile-sensitive strips on our ward (the only one in this hospital). Although there may be some financial advantage in using strips with fewer reagents, we feel that this is only a short- term benefit and that expenditure will be incurred by keeping patients in hospital longer as they await the results of blood tests.

We therefore recommend the routine dipstick testing of urine for bilirubin in the immediate assessment of patients with abdominal pain as well as the described tests for urine infection, as reported by Mr Ravichandran et al.

P. N. Harary 0. Hughes H. Shukla

M. H. Lewis Department of Sutgery East Glamotgan General Hospital Church W a g e Nx Pontypridd Mid Glamorgan CF38 IAB UK

Patterns of reflux in recurrent varicose veins assessed by duplex scanning

Sir We read with interest the Short Note by Messrs Redwood and Lambert on patterns of reflux in recurrent varicose veins (Br J S u e 1994; 81: 1450-1). They make no mention in their series of neovascularity' -3, a well established cause of recurrent varicose veins. Is this because they cannot see this phenomenon by duplex scanning or because it was not present? An incompetent saphenofemoral junction (SFJ) is quoted to be present, either alone or in combination, in 87 limbs (68.5 per cent). However, under Methods they mention recurrence 'from the area of the SFJ. Could it be that some of these recurrences actually represent ncovascularity? Using colour flow duplex (Acuson, Uxbridge, UK) scanning we have found recurrence from the area of the SFJ, alone or in combination, in 72 per cent (84 legs) - similar to the figure quoted by Messrs Redwood and Lambert. Of these, 54 per cent were due to neovascularity and the

remaining 18 per cent were persistent SJFs. The presence or absence of the long saphenous vein (LSV) is not mentioned. We found it to be present in 76 per cent of cases and 88 per cent of these were present in the upper thigh, indicating that no attempt was made to strip the LSV. Neovascularity was found in seven legs in the absence of the LSV - these patients had thigh varicosities.

Another phenomenon we have noted is the presence of long thin tortuous veins arising from the pelvis and contributing to the recurrence in two of 84 legs. Have Messrs Redwood and Lambert seen such veins?

H. S. Khaira A. Parnell

Good Hope Hospital Rectory Road Sutton Coldfield West Midlands B7.5 7RR UK

1 Starnes HF, Vallance R, Hamilton DNH. Recurrent varicose veins: a radiological approach to investigation. Clin Radio1

2 Glass GM. Neovascularisation in recurrence of varices of the great saphenous vein in the groin: phlebography. Angiology

3 Darke SG. The morphology of recurrent varicose veins. Eur J Vasc Surg 1992; 6: 512-17.

1984; 35: 95-9.

1988 39: 577-82.

Subcuticular wound closure: alternative method of securing the suture

Sir With the advent of monofilament absorbable sutures one has to question why Mr Williams and his colleagues (Br J Surg 1994; 81: 1312) are still using removable sutures for subcuticular wound closure. A study in our unit showed that for this type of closure PDS I1 (Ethicon, Edinburgh, UK) gave better results than Prolene (Ethicon)l. Experience in our unit of using the method of securing the suture described by Mr Williams and colleagues would suggest that this might cause skin irritation. For many years we closed all our wounds with subcuticular Prolene and tried a number of alternative ways of securing the suture. The only effective way we identified, without causing irritation at the skin exit sites, was to pass the suture through a piece of sterile foam sponge before either tying a knot or applying beads and collars. Knots at the end of sutures, whether on absorbable or non-absorbable sutures, are recognized as causing irritation2, and even when using monofilament absorbable sutures they should be avoided's2.

J. M. Dixon Department of Surgery The University of Edinburgh Royal Infirmary Edinburgh EH3 9YW UK

1 Johnstone AJ, John TG, Thompson AM, Charles MH, Dixon JM. PDS I1 (polydioxanone) is the monofilament suture of choice for subcuticular wound closure following breast biopsy. J R Coll Surg Edinb 1992; 37: 94-6.

2 Aitken RJ, Anderson EDC, Goldstaw S, Chetty U. Subcuticular skin closure following minor breast surgery: Prolene is superior to polydioxanone (PDS). J R Coll Surg Edinb 1989; 35: 1-9.

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