Vol. 183 No.
LETTERS TO THE EDITOR
cause harm. We have used 20 per cent hypertonic saline and feel that this is a safer technique and affords adequate protection during the opening of the cyst. In the simple young cyst containing clear fluid as described by Dr. Corlette, the technique of capitonnage or some other technique such as filling the cavity with omentum would seem to be one added step which should result in more rapid healing of the liver and better recovery. On the more complicated cyst, which, as Dr. Corlette states may require cystectomy and possible partial hepatectomy, we feel that both our use of the term "hepatic lobectomy" as well as Dr. Corlette's statement "anatomic hepatectomy" should probably be replaced by the term appropriate hepatic resection, as it has been shown by Lin (Lin, T.: Simplified Techniques for Hepatic Resection, Ann. Surg. 180:285-290, 1974) that neither lobectomy nor anatomic hepatectomy is necessary, but with appropriate surgical techniques, just the area of involvement may be removed. As stated in our article, arteriography is an excellent adjunctive technique for determining the amount of involvement of liver parenchyma. When and if echography (ultrasound) techniques are perfected, they also may be of benefit as another non-invasive procedure. We are in complete agreement with the use of T-tube drainage in complicated cysts and those eroding with the cannaliculi and main ducts, as stated at the conclusion of our article. In summary then, aside from our disagreement with Dr. Corlette on the use of Formalin, we are in basic agreement in each of the four other points which he brings up, and we so stated in the article'. The points are certainly important and deserve such emphasis. Neal Koss, M.D. Morris D. Kerstein, M.D. Joseph W. Lewis, M.D. Yale University School of Medicine New Haven, Connecticut 06510
91
symptoms. This was indeed the case, but the expected benefit of earlier diagnosis was not obtained. In contrast with the 12 to 18 months' delay reported in the other two series, our patients sought treatment within a maximum of 6 months after onset of symptoms. The composition of this group was similar to the two larger series, with an age range of 14 to 74 years (mean 40) and a 4 to 1 ratio of males to females. Their presenting symptoms were likewise abdominal pain, anemia, weight loss and abdominal mass. The microscopic diagnoses were also similar to the larger series, with no preponderance of rare or "good outlook" tumors. Unfortunately, our results were also similar to theirs. Only three of the original 10 patients are alive 2 to 4 years after diagnosis. Earlier diagnosis must certainly offer the only currently plausible hope for better results in these diseases. However, mildness and lack of specificity of the early symptoms make it very unlikely that patients will ever seek help early enough after onset, even in the absence of financial worries, to be able to improve their outlook to any significant degree. The paucity of early physical signs also makes it unlikely that routine physical examination will be very helpful. It seems more likely that the hope for substantially improved treatment for small bowel malignancies lies in the development of new diagnostic methods. Such approaches would include techniques for examining the systemic biochemical, endocrine and immunologic responses to a hidden tumor. The rarity of these particular tumors, along with the absence of any identifiably high risk group, dictates that any test must be feasibly applicable on a broad, screening scale at reasonable cost and convenience. Until the means are found for prevention, a vigorous investigation of symptoms and the prompt clinical application of any new approaches developed in the research laboratories will continue to offer the only possibility for relief from malignancies which grow silently in inaccessible places. Dale W. Oller, M.D. Charles L. Rice, M.D. Clifford L. Herman, M.D. National Naval Medical Center Naval Medical Research Institute Bethesda, Maryland 20014
September 15, 1975 Dear Editor: In assessing the outlook for small bowel malignancies, two large series were reviewed in the August issue of Annals of Surgery. In both reports, the authors attribute the high mortality rates to a failure to seek medical attention until long after the onset of symptoms. Our recent The opinions or assertions contained herein are those of the authors and experience with patients in a different economic setting are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large. casts doubt upon the validity of this explanation. From 1970 to 1974, 10 patients with primary small bowel malignancies were treated at the US Naval HospiSeptember 19, 1975 tal, Bethesda, Maryland. Since these patients had easy Dear Editor: access to medical care without regard for cost or loss of income, one might have expected that they would avail Thank you for the opportunity of reading the comthemselves of this care soon after noticing any ments of Drs. Oller, Rice and Herman.
LETTERS TO THE EDITOR
cause harm. We have used 20 per cent hypertonic saline and feel that this is a safer technique and affords adequate protection during the opening of the cyst. In the simple young cyst containing clear fluid as described by Dr. Corlette, the technique of capitonnage or some other technique such as filling the cavity with omentum would seem to be one added step which should result in more rapid healing of the liver and better recovery. On the more complicated cyst, which, as Dr. Corlette states may require cystectomy and possible partial hepatectomy, we feel that both our use of the term "hepatic lobectomy" as well as Dr. Corlette's statement "anatomic hepatectomy" should probably be replaced by the term appropriate hepatic resection, as it has been shown by Lin (Lin, T.: Simplified Techniques for Hepatic Resection, Ann. Surg. 180:285-290, 1974) that neither lobectomy nor anatomic hepatectomy is necessary, but with appropriate surgical techniques, just the area of involvement may be removed. As stated in our article, arteriography is an excellent adjunctive technique for determining the amount of involvement of liver parenchyma. When and if echography (ultrasound) techniques are perfected, they also may be of benefit as another non-invasive procedure. We are in complete agreement with the use of T-tube drainage in complicated cysts and those eroding with the cannaliculi and main ducts, as stated at the conclusion of our article. In summary then, aside from our disagreement with Dr. Corlette on the use of Formalin, we are in basic agreement in each of the four other points which he brings up, and we so stated in the article'. The points are certainly important and deserve such emphasis. Neal Koss, M.D. Morris D. Kerstein, M.D. Joseph W. Lewis, M.D. Yale University School of Medicine New Haven, Connecticut 06510
91
symptoms. This was indeed the case, but the expected benefit of earlier diagnosis was not obtained. In contrast with the 12 to 18 months' delay reported in the other two series, our patients sought treatment within a maximum of 6 months after onset of symptoms. The composition of this group was similar to the two larger series, with an age range of 14 to 74 years (mean 40) and a 4 to 1 ratio of males to females. Their presenting symptoms were likewise abdominal pain, anemia, weight loss and abdominal mass. The microscopic diagnoses were also similar to the larger series, with no preponderance of rare or "good outlook" tumors. Unfortunately, our results were also similar to theirs. Only three of the original 10 patients are alive 2 to 4 years after diagnosis. Earlier diagnosis must certainly offer the only currently plausible hope for better results in these diseases. However, mildness and lack of specificity of the early symptoms make it very unlikely that patients will ever seek help early enough after onset, even in the absence of financial worries, to be able to improve their outlook to any significant degree. The paucity of early physical signs also makes it unlikely that routine physical examination will be very helpful. It seems more likely that the hope for substantially improved treatment for small bowel malignancies lies in the development of new diagnostic methods. Such approaches would include techniques for examining the systemic biochemical, endocrine and immunologic responses to a hidden tumor. The rarity of these particular tumors, along with the absence of any identifiably high risk group, dictates that any test must be feasibly applicable on a broad, screening scale at reasonable cost and convenience. Until the means are found for prevention, a vigorous investigation of symptoms and the prompt clinical application of any new approaches developed in the research laboratories will continue to offer the only possibility for relief from malignancies which grow silently in inaccessible places. Dale W. Oller, M.D. Charles L. Rice, M.D. Clifford L. Herman, M.D. National Naval Medical Center Naval Medical Research Institute Bethesda, Maryland 20014
September 15, 1975 Dear Editor: In assessing the outlook for small bowel malignancies, two large series were reviewed in the August issue of Annals of Surgery. In both reports, the authors attribute the high mortality rates to a failure to seek medical attention until long after the onset of symptoms. Our recent The opinions or assertions contained herein are those of the authors and experience with patients in a different economic setting are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large. casts doubt upon the validity of this explanation. From 1970 to 1974, 10 patients with primary small bowel malignancies were treated at the US Naval HospiSeptember 19, 1975 tal, Bethesda, Maryland. Since these patients had easy Dear Editor: access to medical care without regard for cost or loss of income, one might have expected that they would avail Thank you for the opportunity of reading the comthemselves of this care soon after noticing any ments of Drs. Oller, Rice and Herman.
