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acute abdomen which do not require surgery, e.g. starch peritonitis,
peritoneal carcinomatosis, the serositis of rheumatic fever and some
cirrhotics with ascites2.
Even though the presence of leucocytes alone in peritoneal aspirate
is a highly accurate index of intra-abdominal pathology, assessment
for bile, amylase and bacteria will increase the diagnostic value of the
test and may help the surgeon out of a clinical dilemma.
J. Hoffmann
Department of Surgery
Horsholni Hospital
2970 Horsholm
Giocobine JW, Siler VE. Evaluation of diagnostic abdominal
paracentesis with experimental and clinical studies. Surg Gynecol
Obstet 1960; 110: 6 7 6 8 6 .
Hoffman J. Peritoneal lavage as an aid in the diagnosis of acute
peritonitis of non-traumatic origin. Dig Dis 1988; 6 : 185-93.
Hepatic resection for colorectal
I am afraid there are two unproven assumptions made by Karanjia et
a / . (Br J Surg 1990; 77: 27-9) in their recent paper advocating a more
liberal policy for liver resection of colorectal liver metastases. First,
although it is often quoted that 10 per cent of all patients with liver
metastases might be suitable for resection, the actual proportion is
likely to be much lower than this (probably less than 5 per cent) since
factors other than surgical feasibility are usually taken into account
( e g age, coexisting medical conditions, etc.). In their survey, 354 liver
resections were identified during a 1 year period. This represents
approximately 3 per cent of all patients developing colorectal liver
metastases in the U K and may well be a fairly accurate indication of
the prevalence of resectable lesions.
Second, although postoperative screening by means of liver
ultrasound scanning would probably reveal a higher incidence of
solitary metastases it is by no means certain that resection at this
asymptomatic stage would enhance overall survival compared with an
unscreened group diagnosed when symptomatic. As with all screening
techniques the lag time bias is important and benefit can only be
established by randomized prospective studies. In addition postoperative
mortality and morbidity rates (which were not mentioned in the survey)
would influence overall results.
Nevertheless the survey is a valuable contribution and I would agree
that patients with solitary (or even 2-3) colorectal metastases in the
liver might be suitable for resection and careful assessment of such
patients is important.
1. Taylor
Unioersity Surgical Unit
Southampton General Hospitul
Southampton SO1 6HU
Authors’ reply
In our experience patients with hepatic secondaries from colorectal
cancer d o not develop local symptoms until deposits are large. Resection
of these lesions is often not possible or may entail complicated hepatic
resection including the inferior vena cava, etc. The extra operative risk
incurred and the difliculty in achieving radical clearance behoves us
to identify these patients at the asymptomatic stage as outlined in our
article. A substantial proportion of our first 35 resected patients had
deposits in excess of I5 cm. We are afraid that Professor Taylor’s
optimism that enough is being done for these patients in the U K is
M. Rees
R. J. Heald
Department of’ General Surgery
Basingsroke District Hospital
Basingsruke RG24 9NA
A Chair of Tropical Surgery
I read with keen interest M r Holcombe’s article on, ‘The need for a
Chair of Tropical Surgery’ (Br J Surg 1990; 77: 3 4 ) . The need for
such a Chair cannot be over emphasized.
Much new information on tropical pathology and surgery has
accumulated and needs to be carefully annotated but the resources
have been a major constraint. There is an amazing amount of material
for research and challenging clinical situations should stimulate
investigation and scholarship.
Basically three categories of surgical conditions are found in the
tropics. The first are what one would call universal diseases; those that
can be found anywhere in the world such as duodenal ulcer. The second
group are those found either exclusively or excessively in the tropics.
These include amoebiasis, drancontiasis, schistosomiasis, ascariasis,
tuberculosis, poliomyelitis, Hansen’s disease, Burkitt’s lymphoma, and
leishmaniasis. The third group are in fact universal diseases that have
developed peculiar characteristics in the tropics because of later
presentation. Some assume such large dimensions, that the prefix ‘giant’
has been used to qualify them.
The tropical surgeon is thus a surgeon that is tackling difficult cases
with limited resources and even limited renumeration. The practice of
surgery in the tropics calls not only for knowledge and skill but also
for diligence, courage and innovation, and above all willingness to offer
service for poor financial reward.
Rather than establishing Institutes of Tropical Surgery in the UK
or in any European country far away from the scene of action, the
Royal Colleges of Surgeons should collaborate with medical schools
in the Tropics and centres of excellence to develop that discipline of
tropical surgery into a fully fledged specialty so that a specialty
fellowship can be awarded following a prescribed training to surgeons
who already hold a fellowship diploma of one of the Royal Colleges.
This will fill in the gap that exists at the present time in the fellowship
training overseas. Surgeons-in-training from the UK and Europe could
come out to this Tropical College to broaden their experience and carry
out research.
S. E. E. Efem
Unioersity Department of Surgery
University Teaching Hospital
Iatrogenic pancreatitis
The excellent review by Clavien, Burgan and Moossa (Br J Surg 1989;
76: 123443) was notable for its careful attention to detail. However,
there are two points which require further clarification.
In the article, aminosalicylates, cholinergic substances and
chlorthalidone were all stated as ‘having been clearly proved to induce
pancreatitis’. This is rather misleading as only anecdotal evidence exists
of these associations: more than 30 other drugs have been implicated
similarly’. Certainly, stronger evidence exists for thiazide diuretics and
steroids as being causative.
Secondly, although it is true that endoscopic retrograde
cholangiopancreatography (ERCP) is associated with hyperamylasaemia and in some cases clinical pancreatitis, there is now good
evidence that this can be reduced by the use of low osmolar, non-ionic
contrast ~ n e d i a ~ . ~ .
The study of both these conditions is also interesting in that further
light may be shed on the actual mechanism of pancreatitis.
A. K. Banerjee
King’s College Hospital
London SE5 9PJ
Banerjee AK, Patel KJ, Grainger SL. Drug induced acute
pancreatitis - a critical review. Med Tusicol Aduerse Drug E.vp
1989; 4: 1 8 6 9 8 .
Banerjee AK. The non ionic dimers - a new class of contrast
agent. Br J Radio1 1987; 60:728.
Banerjee AK. Grainger SL, Manners R, Thompson RPH. Safer
endoscopic retrograde cholangiopancreatography? Gut 1986; 27:
Br. J. Surg.. Vol. 77, No. 7 , July 1990
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