1333

discovered after

a

termination of pregnancy

at

18 weeks from

conception for a very severe oligoamnios, in a woman who had taken RU 486 and whose pregnancy continued"2 he was mainly

presenting a correction to a news report in Nature that had stated that "there has already been one case in France of a deformed baby being born to a woman who received RU 486 during pregnancy".3 We thought that the debate would be more informed by a published account of our experience. No follow-up studies are available on lost-to-view women who have taken mifepristone, and pharmacovigilance data to provide an objective evaluation of these cases are not yet available. Department of Obstetrics and Gynaecology, University of Paris Sud, Hôpital Antoine Béclère, Clamart 92141, France

JEAN-CLAUDE PONS

Department of Obstetrics and Gynaecology, University René Descartes, Hôpital Cochin, Paris

EMILE PAPIERNIK

1. Lim

BH, Lees DAR, Bjomsson S, et al. Normal development mifepristone in early pregnancy. Lancet 1990; 336: 257-58.

after exposure

to

2. Henrion R. RU 486 abortions. Nature 1989; 338: 110. 3. Coles P. French government approves abortion pill for commercial use. Nature 1988;

335: 486.

Laparoscopic cholecystectomy a!R,—ihe

two

papers

and

editorial

on

laparoscopic

cholecystectomy in your issue of Sept 28 are timely and welcome. Seldom, if ever, has such an important revolution in surgical practice for a common condition taken place within such a short time-span. The techniques (and even the capital costs) are within the reach of most surgeons in the UK, and the great majority of centres, at least in England and Wales, have adopted the procedure with enthusiasm. We support the regret expressed in the last paragraph of the editorial. The Royal College of Surgeons of England confidential comparative audit did attempt to document the evolution of these changes, and was partly successful. However, there is still need for a broad and comprehensive study of practices, complications, and results in the UK. A working group of the Association of Surgeons of Great Britain and Ireland (ASGBI) has examined the issue, and we are about to launch a national audit of laparoscopic cholecystectomy, in conjunction with the Society for Minimally Invasive General Surgeons, the British Surgical Stapling Group, and the British Society of Gastroenterology. Because ASGBI includes in its membership most general surgeons in the UK it is well placed to do such a study. Information about the study will be mailed this month, inviting prospective registration of the details of

all laparoscopic cholecystectomies over a two-year period starting on Jan 1,1992. Busy doctors can ill afford the time taken to fill in the proliferation of questionnaires from which we all suffer, but we believe that all surgeons practising this technique will recognise the importance of capturing this valuable information before it slips forever from our grasp. ,

BERNARD RIBIERO IRVING BENJAMIN DAVID ROSIN NORMAN DORRICOTT Association of Surgeons of SAUNDERS DAVID DUNN JOHN Great Britain and Ireland, PIERCE GRACE DAVID WATKIN, 35/43, Lincoln’s Inn Fields, for Laparoscopic Cholecystectomy Steering Group, London WC2A 3PN, UK

ASGBI

cholecystectomy. In a series of 1035 open cholecystectomies, Ganey et al’ found improving results for this procedure, with a mortality of 0-5%, bileduct injury 0%, wound infection rate 0-4%, chest infection 0-8%, and wound dehiscence 0%. The safety of laparoscopic cholecystectomy has still to be proven: for instance, some institutions have reported a 1 % frequency of bileduct injury.2 The cornerstone of the argument for laparoscopic cholecystectomy is reduced hospital stay and rapid return to work. Both are heavily influenced by social circumstances, and the surgeon’s and patient’s preconceived ideas about a "normal" duration of convalescence: these are subjective and variable indicators. With changing attitudes, similar results for hospital stay and return to work can be achieved with open "minilap" cholecystectomy.3’ Ledet3-ó reported a consecutive series of 200 "minilap" cholecystectomies in which all patients were discharged on the day of surgery, those in sedentary jobs being able to return to work 4 or 5 days after the operation. Unlike Neugebauer, Troidl, and colleagues7 or Mr Russell (Oct 26, p 1074) we do not believe a randomised trial to be unethical. We have funding from the Chief Scientist’s Office (Scotland) for a randomised study comparing laparoscopic cholecystectomy with "minilap" cholecystectomy. We are now into the fourth month, and so far no patient has refused randomisation. We are concentrating on objective end-points such as the amount of patient-controlled analgesia, postoperative pulmonary function, the effect of surgery on the acute phase neuroendocrine response, the complication rate, detailed assessment by questionnaire of recovery to normal activity, and patient satisfaction. Transurethral prostatectomy

was

introduced 20 years ago and

rapidly gained acceptance as the treatment of choice for prostatism without being put to the test of a randomised trial. Now reports8 are accumulating which suggest that there may be an increased late mortality, a higher reoperation rate, and a worryingly high frequency of urethral stricture formation after this "minimally invasive" procedure compared with open prostatectomy. If these findings are borne out, they would be a heavy price for the transient gain of a more rapid postoperative recovery. Some urologists8 are now calling for a randomised trial of transurethral versus open prostatectomy. We should learn from that experience. University Department of Surgery, Infirmary, Glasgow G11 9NT

Western

ANDREW McMAHON JOHN BAXTER IAN RUSSELL PATRICK O’DWYER

Ganey JB, Johnson PA, Prillaman PE, McSwain GR. Cholecystectomy: clinical experience with a large series. Am J Surg 1986; 151: 352-57. 2. Cameron JL, Gadacz TR. Laparoscopic cholecystectomy. Ann Surg 1991; 213: 1-2. 3. Ledet WP Ambulatory cholecystectomy without disability. Arch Surg 1990; 125: 1.

1434-35.

O’Dwyer PJ, Murphy JJ, O’Higgins NJO. Cholecystectomy through a 5 cm incision. Br J Surg 1990; 77: 1189-90. 5. Moss G. Discharge within 24 hours of elective cholecystectomy. Arch Surg 1988;

4.

256-61. 6. Merrill JR. Minimal trauma cholecystectomy Am Surg 1988; 54: 256-61.

54:

(a "no-touch"

procedure

in

a

"well").

7. Neugebauer E, Troidl H, Spangenberger W, Dietrich A, Lefering R and the Cholecystectomy Study Group. Conventional versus laparoscopic cholecystectomy and the randomized controlled trial. Br J Surg 1991; 78: 150-54. 8. Roos NP, Wennberg JE, Malenka DJ, et al. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. N Engl J Med 1989; 320: 1120-24.

Increased ventricular vulnerability during

haemodialysis Sip,—The series of laparoscopic cholecystectomies cited in Dr Holohan’s review (Sept 28, p 801) must be interpreted with some caution. Many of the patients were carefully selected and the operations done by senior surgeons with a special interest in laparoscopic or biliary surgery. In the real world, most of the open cholecystectomies are done by general surgeons and trainees, and a similar situation will probably apply to laparoscopic cholecystectomy once the initial enthusiasm dies down. There may well be under-reporting of complications due to publication bias. It is also unfair to compare early reports of laparoscopic cholecystectomy with the worst reported results from open

SIR,-QRST deflection area indicates disparity of repolarisation duration, and is associated with ventricular arrhythmia.1,2 Abnormal disparity of local recovery times is shown as a multipolar distribution of QRST area on body surface maps.3 Haemodialysis has often induced ventricular arrhythmia, including ventricular tachycardia or ventricular fibrillation, in patients with chronic renal failure. We obtained QRST isointegral maps from 26 men and 17 women, aged 34-72 years, with chronic renal failure. All maps were recorded before and 2 h after the start of haemodialysis. Patients with atrial fibrillation and bundle branch blocks, and those having

1334

digitalis, beta-blocking agents, or other antiarrhythmic agents were excluded from the study. Haemodialysis was done three times a week (4 h per day) with hollow-fibre dialysers and a single-pass dialysate delivery system. Blood flow rate was 200 ml/min and dialysate flow rate 500 ml/min. Body surface maps were recorded with a VCM-3000 system (Fukuda Denshi, Japan). Electrodes for mapping were placed at 87 points (59 anterior and 28 posterior) on the chest surface. The onset of QRS was assessed from the spatial magnitude, and baseline adjustment was done afterwards by choosing a point before the P wave and a point after the T wave in one reference channel as the time instant of the zero potential for all the 87 channels. The maximum values of QRST area significantly increased during haemodialysis (92 [21] vs 122 [16], p < 001). 12 patients had ventricular tachycardia during haemodialysis, 7 (58%) of whom had multipolar (?= 3 polars) patterns on QRST isointegral maps. On the other hand 21 patients, who did not have ventricular tachycardia, all had bipolar patterns on QRST isointegral maps. We conclude that ventricular vulnerability increases during haemodialysis, and QRST isointegral maps are useful in the assessment of arrhythmia vulnerablity in patients with chronic renal failure. Department of Medicine, National Cardiovascular Centre, Suita City, Osaka, 565 Japan

OSAMU KINOSHITA SHIRO KAMAKURA GENJIRO KIMURA TERUO OMAE

1. Fusilli L,

Lyons M, Patel B, et al. Ventricular vulnerability in diabetes and myocardial norepinephrine release. Am J Med Sci 1989; 298: 207-14. 2. Abildskov JA, Green LS, Evans AK, et al. The QRST deflection area of electrograms during global alterations of ventncular repolarization. J Electrocardiol 1982; 15: 103-07 3. Green LS, Lux RL, Merchant MH, et al. Identification of patients at nsk of ventricular arrhythmia with body surface mapping. Circulation 1982; 66: 377.

Cancer in the Ukraine,

post-Chernobyl

SIR,-After the accident at the Chernobyl nuclear plant in northern Ukraine on April 26, 1986, radioactive material contaminated the surrounding areas. People living within 30 km of the plant were evacuated soon afterwards. In nearby unevacuated areas, the heaviest contamination, as judged by radioactive caesium levels in soil, was in the three raions (districts) of Polesskoye, Naroditchy, and Ovrutch,’ adjacent to the evacuation zone and within 80 km of the plant. The population of each district was estimated from 1979 and 1989 census data and from local statistics on births, deaths, and migration. The population of the three districts was 146 000 at the time of the accident; by 1990 the population numbered 131 000. Cancer incidence statistics are collected at district and oblast (regional) level, and annual summaries for certain cancer sites in some age groups are reported to the Ukraine Institute of Oncology in Kiev. In 1987 A. P. began a detailed study of cancers diagnosed in residents of the three contaminated districts from 1980. This involved a search of oncology, haematology, and other records in the regional and district hospitals and in specialist institutes. Each

district has one central hospital and outpatient department. Cancer patients are usually referred to specialist hospitals in the Kiev region (for Polesskoye district) and the Zhytomir region (for Naroditchy and Ovrutch), and some are referred to specialist institutes in Kiev. Death registrations from 1980-90 were also scrutinised. All records were cross-checked before a register of cancers diagnosed since 1980 was compiled. Comparison of these figures with official reports to the Ukraine Institute of Oncology indicate that the proportion of diagnosed cancers included in the official reports rose from 80% in 1980 to 100% in 1990. The table shows annual age-specific incidence rates for leukaemia, thyroid cancer and all other cancers during the 10 years 1981-90 in the three districts surveyed. The numbers are small but the age-specific incidence for most cancers was broadly similar before and after 1986. There are three exceptions: the observed incidence of leukaemia at age 65 + increased abruptly in 1987 and has remained two or three times higher than the pre-accident rates; there were no cases of thyroid cancer at age 0-14 in 1981-89 but 3 cases were diagnosed in 1990; and the incidence of all other cancers at age 65 + increased the year after the accident by about one third and has remained at about that level since then. The increase in leukaemia and in all cancers except leukaemia and thyroid cancer does not follow the usual pattern found for radiation-induced cancers. For those living near Chernobyl, the increases in these cancers were concentrated in age groups 65 +, whereas in other exposed populations increases in radiationinduced cancer affects all agesand the youngest groups especially. Furthermore, the timing of the increase in cancers other than leukaemia and thyroid cancer is well before the latency usually observed in populations exposed to ionising radiationEven if the accident were to cause an increase in these cancers, any change would probably not be evident yet. Leukaemia has the shortest latency of all radiation-induced cancers, with the largest proportional increase 2-5 years after exposureand an effect would be expected to be seen for all age groups. The observed increases in leukaemia and other cancers at age 65 + probably resulted from local concern about cancer after the accident, leading to more thorough investigation of elderly patients for cancer. Before 1985, the incidence rates of leukaemia and of all cancers combined were lower at ages 65 + than in other eastern European countries;’ since 1986 the rates are more in line with those from other countries, suggesting underdiagnosis in the elderly before the accident. At other ages the incidence rates are similar to those from other eastern

European countries,4 suggesting that substantial underdiagnosis of did not occur at young ages. The increase in thyroid cancer in children is difficult to interpret. All 3 cases were confirmed by experienced histopathologists. Children in contaminated areas received substantial doses of radiation to the thyroid, primarily from 1311 but also from "1, "1, and y radiation. A more marked increase in thyroid than other cancers has been predicted for this age group, although the latency for radiation-induced thyroid cancer is uncertain, as is the risk per unit dose of 1311. Contamination from 131and other sources was not confined to the three most contaminated districts. In the Ukraine, outside these districts, official statistics show that the incidence of cancer

AGE-SPECIFIC INCIDENCE OF LEUKAEMIA,THYRO I D CANCER, AND ALL OTHER CANCERS IN POLESSKOYE, NARODITCHY, AND OVRIJTCH DISTRIC:TS OF THF lJKRAINE 1 gR1-g0