Correspondence

FFP in pancreatitis Unusual isolated iliac artery aneurysm

Sir The recent paper by Goodman et al. (Br J Surg 1986; 73 7968) demonstrates the interesting changes of serum antiprotease levels in acute pancreatitis. In view of the very small number of patients entered into the trial of fresh frozen plasma (three to FFP, two to colloid control) no conclusion can be drawn from their work regarding the possible therapeutic role of FFP in acute pancreatitis. Four of these five patients died and, although the authors do not state the timing of the deaths, a comparison between antiprotease levels in the two groups is difficult. They may have overstated the volume of FFP administered as three standard units of FFP represents a volume of approximately 700ml rather than 1200 ml.

A multicentre trial co-ordinated in Leicester has been in progress since March 1985 in which patients with acute pancreatitis are randomized to receive either FFP (six units over 3 days) or colloid control as part of the intravenous fluid therapy. The major antiproteases are measured on days 1, 3 and 7.

To date 160 patients have been entered into the trial. No significant difference has been shown between the two groups in terms of clinical outcome (12 severe outcomes with 6 deaths in the FFP group, 19 severe outcomes with 8 deaths in the colloid control group). In both groups ctI antiprotease levels were already elevated at diagnosis and rose significantly fromday 1 to day 3 ( P i0.0001)remaining elevated at day 7. These findings correspond with those of Mr Goodman and confirm an acute phase response which is not influenced by the administration of FFP. a2 macroglobulin levels were subnormal at diagnosis in both groups (as found by Mr Goodman) and fell significantly from day 1 to day 3 in the colloid control group (P<0.05) whilst remaining substantially unaltered in the FFP group (P=0.91, two-tailed Mann-Whitney ranking test).

The place for fresh frozen plasma in the therapy of acute pancreatitis has yet to be determined, but it appears that fresh frozen plasma can reduce the fall in serum a2 macroglobulin levels seen in the early stages of the disease.

T. Leese

Leicester Royal Infirmary Leicester LE2 7LX U K

Author's reply

Sir I am grateful to MI Leese for pointing out the error in volume of FFP per standard unit, three of which our patients received daily.

The entry numbers into the Leicester trial are impressive, but is the use of FFP justified in mild pancreatitis which is a self-limiting disease? I understand that the severity prediction criteria used in Leicester include patient age, whereas we prefer those of Osborne, Imrie, Carter (Br J Surg 1981; 68: 758-61), which allow for the predominance of elderly biliary pancreatitis seen in Britain. This may account for the higher incidence of severe pancreatitis in Leicester than in Shefield (19.4 per cent compared with 11.9 per cent) and consequently our higher mortality.

I accept our numbers are small, but our antiprotease results are undiluted by mild cases receiving FFP and may give the true picture in severe pancreatitis, although larger numbers are needed to be conclusive.

A. J. Goodman

Royal Hallamshire Hospital Shefield S10 2JF UK

Sir The recent case report by Gilfillan et al. (Br J Surg 1986; 73 375-6) emphasizes that these aneurysms are rare, their presentation unusual and if they rupture the characteristic signs of blood loss may not be present as a result of containment by the gluteal muscles. Recently, a 66- year-old man with a ruptured right iliac artery aneurysm was admitted under our care. The management of this patient emphasized that a ruptured iliac aneurysm can be confused with a ruptured aortic aneurysm and that these lesions may be associated with dilatation of the aorta and iliac arteries making reconstruction technically difficult. It is suggested that if such an aneurysm is suspected an angiogram is performed before exploration to delineate the site of rupture and the appropriate reconstructive procedure.

G. C. Pansini I. Donini

Which leg for skin grafts?

Sir I read with interest the article by D. Flook et al. regarding which limb skin grafts should be taken from in the surgery for malignant melanoma (Br J Surg 1986; 73: 793-795). I would like to comment that, irrespective of tumour consideration, most surgeons would prefer to harvest the skin graft from the contralateral limb for a different reason. If the skin graft is harvested from the ipsilateral limb then the necessary skin graft dressing is often noted to exert a tourniquet effect which may result in troublesome bleeding at the excisional site which is contributory to haematoma formation under applied split skin grafts. For the same reason, in the surgery of limb trauma where split skin grafting is required, the contralateral limb, though less convenient, is the preferred site.

N. Waterhouse

West Middlesex University Hospital Isleworth Middlesex W 6AF UK

Authors' reply

Sir We are grateful for the interest shown by Mr Waterhouse in our paper and accept that there are many variations available on any surgical technique. We understand his concern with his experience of a tourniquet effect, but we would not be willing to accept proximal venous compression on either leg. A simple OpSite dressing for donor areas has been in widespread use for a number of years, and gives excellent results without circumferential pressure. We do not find haematoma formation under the graft a major problem, since a number of techniques may be used to control troublesome oozing, including uniform pressure to the skin graft with a tailor-made Silastic foam dressing' or delayed open grafting2.

L. E. Hughes D. Hook

University Department of Surgery Heath Park Cardiff CF4 4XN U K

1.

2.

Groves AR, Lawrence JC. Silastic foam dressing: An appraisal. Ann R Coll Surg Engl 1985; 67: 11618. Rees BI, Hughes LE. Delayed exposed grafting in surgery for breast cancer and melanoma. Clin Oncol 1975; 1: 131-9.

Br. J. Surg., Vol. 74, No. 1, January 1987 75