Correspondence
Quality of life after gastrectomy in patients w i t h carcinoma of the stomach
b
Simple diverticulectomy as described by Attwood et ul. is inadequate because it is recognized that the bleeding peptic ulceration frequently involves the adjacent ileum, even though the heterotopic gastric tissue lies within the diverticulum. Adequate resection can be performed expeditiously with the help of a CIA stapler (US Surgical). With its two forks inserted through two stab wounds on either side of the base of the diverticulum. the instrument enables fashioning of a side-to-side ileal anastomosis. This is then followed by resection of a small segment of the ileum bearing the diverticulum and the now confluent stab wound by a second firing of the C I A placed at right angles to the first one (Figure I ). With the aid of an Endo-CIA. much the same procedure can be carried out intra-abdominally, but at the expense of an increased risk of spillage, more wounds for insertion of bowel occlusion clamps and a longer operation time.
W. T. Ng M. K. Wong C. K. Kong Y. T. Chan Department of Surgerj Princess Mar(gare/ Hospitul Lui Chi Kok Kowloon Hong Kony
Sir We read with interest and surprise the article by Korenaga et a/. on quality of life after gastrectomy in patients with gastric cancer ( B r J Sury 1992; 79: 248-50). First, we would like to congratulate our Japanese colleagues for finally having discovered the issue of quality of life as a relevant endpoint for cancer treatment. The congratulations are even more important since the Japanese have been so refractory to the strategy of randomized clinical trials, despite their huge number of patients with cancer. However, their study has several flaws, presents wrong hypotheses and needs extensive comment. The literature review is incomplete. In the introduction, they write that little is known about quality of life in gastric cancer; this is not true. There is a randomized clinical trial on reconstruction techniques after radical gastrectomy', and our own group in Cologne has conducted two expert conferences on quality of life in surgery'.'. Furthermore, our group is currently testing a gastrointestinal quality-of-life index, which has already been applied in clinical trial^^,^. In the Patients and methods section, the authors introduce their 16-item survey on food tolerance, body-weight and performance status. Scores were assigned for physical and social well-being by a single interviewer and interpreted as representing the patients' quality of life. Our first criticism is that this is a subjective and non-validated way of measuring what the authors think is quality of life. We would go so far as to call it a 'housewife score'. In modern clinical research, there is no room for self-designed non-validated techniques. Our second criticism regards the concept of quality of life. As a result of a consensus conference, methodologists and clinicians look on quality of life as a four-dimensional concept comprising symptomatic, emotional, physical and social component^^.^. The emotional coping with disease is an extremely important aspect of a patient's quality of life. As an example, an amputated leg can be either a catastrophe or even a relief for a patient, depending on his or her emotional attitude. The authors do not even mention the domain of emotions. The third criticism concerns the two treatment groups. A retrospective separation and historical comparison of partial and total gastrectomy is subject to important bias and needs no further comment. The fourth criticism deals with the fact that the patients have been interviewed by a single - probably subjective - interviewer. The problem of observer variation was not addressed. Three statements in the Discussion need criticism and comment. In the first sentence, the statement that the influence of operation on quality of life is 'hard to quantify' is incorrect. The literature reports the use of validated methods such as the Spitzer index, various visual analogue scales and other tools6-'. In the second paragraph, the authors write that disturbances in performance status were improved 3 years after operation. Since they did not carry out a longitudinal observation study on their patients, this conclusion is inappropriate. In the last paragraph, they state that the quality of life is usually better after partial than after total gastrectomy. Although this hypothesis is also favoured by our group, evidence is still lacking and is not given by the present study. In future, validated and practical techniques5 have to be applied in randomized clinical trials to solve such important questions as which resection and reconstruction techniques are best for patients' well-being (provided both techniques offer equal standards of surgical safety).
E. Eypasch H. Troidl Krankenliuus Merlieini Postfacli 91 08 53 Ostnierheinier Strape 200 5000 Koln 91 Gernian?,
1. 2.
1. 2.
974
Lau WY, Fan ST, Wong ST et a/. Preoperative and intraoperative localization of gastrointestinal bleeding of obscure origin. Gut 1987; 28: 869-77. Spiller RC, Parkins RA. Recurrent gastrointestinal bleeding of obscure origin: report of 17 cases and a guide to logical management. Br J Surg 1983; 70: 489-93.
3. 4.
Troidl H, Kusche J, Vestweber K-H, Eypasch E, Maul U . Pouch uersus esophagojejunostomy after total gastrectomy: a randomized clinical trial. World J Surg 1987; 11: 699-712. Troidl H, Kusche J, Vestweber K-H, Eypasch E, Koppen L, Bouillon B. Quality of life: an important endpoint both in surgical practice and research. J Chron Dis 1987; 40: 523-8. Neugebauer E, Troidl H, Wood-Dauphinee S, Bullinger M. Meran conference on quality-of-life assessment in surgery. Theor Surg 1991; 6 : 121-165, 195-220. Eypasch E, Troidl H, Wood-Dauphinee S et a/. Quality of life and gastrointestinal surgery - a clinimetric approach to develop an instrument for its measurement. Theor Sury 1990; 5 : 3-10.
Br. J. Surg.. Vol. 79, No. 9. September 1992
Correspondence Eypasch E, Wood-Dauphinee S , Neugebauer E, Williams JI. The gastrointestinal quality of life index (GIQL) a new tool to measure quality of life in gastrointestinal disease. Gastroenterology 1991; 100: A6. Selby PJ, Chapman JAW, Etazadi-Amoli J, Dalley D, Boyd NF. The development of a method for assessing quality of life in cancer patients. Br J Cancer 1984; 50: 13. Priestman T, Baum M. Evaluation of quality of life in patients receiving treatment for advanced breast cancer. Lancet 1976; i: 899. Spilker B. Quality of Life Assessment in Clinical Trials. New York: Raven Press, 1990. ~
Proctoscopic polyp delivery after colonoscopic polypectomy Sir The suggestion of Messrs Chuah and Kelly ( B r J Surg 1992; 79: 32) to thread the colonoscope through a proctoscope to remove polyps seems complicated and unnecessary. The manoeuvre impedes adequate insumation and may therefore interfere with visualization of the polyp. We remove the lesion with a grasper or by continuous suction and ask the patient to press at the moment that we retract the tip of the 'scope through the anal canal. In this way the polyp will always follow. If a polyp is lost higher up in the descending or sigmoid colon, it can usually be retrieved with an enema. A. B. Bijnen P. de Ruiter
Authors' reply Sir We thank D r Eypasch and Professor Troidl for their constructive comments. The purpose of our study was to determine whether a radical R, gastrectomy prevents the patient's well-being. T o our knowledge, the present report is the first concerning quality of life in patients undergoing gastrectomy with extensive lymph node dissection ( a standard procedure in Japan since the 1960s). Questions and scoring for quality of life were made by several members of the gastric cancer group, and patients were free to select the answers. Average scores were calculated for the response to each question and used as the index for the quality of life. Rohrer et a/.' reported the quality of life following repair of abdominal aortic aneurysm using the same analytical method. Therefore, this survey seems objective. Although a retrospective separation of partial and total gastrectomy was present, the effect of historical comparison was thought to be negligible because determination of the type of gastrectomy usually depended on the location of the tumour. Our policy is to undertake total gastrectomy only when a tumour is located in the upper third of the stomach. When there is a tumour in the middle and lower third of the stomach, partial gastrectomy is the treatment of choice. This study is a step in the right direction in assessing the patient's well-being. Our results suggest that quality of life is usually better after partial than after total gastrectomy. A randomized trial to solve questions such as which resection is best for long-term survival and quality of life in patients with a tumour in the lower two-thirds of the stomach warrants further attention.
D. Korenaga Department of Surgery I I Fuculty of Medicine Kyushu University 3-1-1 Maidashi Higashi-ku Fukuoka 812 Japan 1.
Rohrer MJ, Cutler BS, Brownell Wheeler H. Long-term survival and quality of life following ruptured abdominal aortic aneurysm. Arch Sury 1988; 123: 1213-17.
Easy delivery of the gallbladder in laparoscopic cholecystectomy: a grooved director Sir We read with interest the Surgical Workshop of Williams et al. ( B r J Surg 1992; 79: 344). At our hospital we have performed over 50 laparoscopic cholecystectomies and use Brodie's grooved director for the easy delivery of the gallbladder through the abdominal incision. It is available in every hospital, and is safe and reusable.
B. Mistry R. T. Waddington Barnsley District General Hospital Barnsley South Yorkshire S75 2EP UK
Br. J. Surg., Vol. 79, No. 9, September 1992
Department of Surgery Alkrnaar Medical Centre Wilhelminalaan I 2 1815 J D Alkmaar The Netherlands
Authors' reply Sir We were pleased with the interest in our Surgical Workshop shown by Drs Bijnen and de Ruiter, but disagree completely with their conclusions. First, they do not seem fully to have understood our manoeuvre, which is to wait until the severed polyp held in the graspers against the tip of the colonoscope is actually situated in the already inflated lower rectum before railroading in the proctoscope over the endoscope to allow easier removal of the endoscope with polyp in one simple movement. Second, we just do not seem to be as skilful as our Dutch colleagues in coaxing polyps through the anal sphincters without the help of the proct oscope.
M. J. Kelly S. Y. Chuah The Nufield Hospital Leicester Scraptoft Lane Leicester LE5 I H Y UK
Upper thoracic sympathectomy for primary palmar and axillary hyperhidrosis: long-term follow-up Sir It was with great interest and some concern that we read the recent communication from Hashmonai et al. ( B r J Surg 1992; 79: 268-71 ). The authors imply that the supraclavicular approach should. remain the method of choice as the long-term results of the newer forms of sympathectomy such as the transthoracic approach are not yet available. This advice is both inaccurate and misleading. Variations of the thoracoscopic approach have been in routine clinical practice' since the 1970s, and indeed endoscopic sympathectomy has been the approach of choice in our own unit for the past 12 years. In a previous paper in this journal', we communicated our experience from 1980 to 1987, reviewing 112 cases of palmar and axillary hyperhidrosis treated by endoscopic transthoracic electrocautery of the sympathetic chain. Some differences in outcome deserve comment. Far from requiring two separate teams of surgeons working simultaneously, in our unit one surgeon operates on each side sequentially, completing both in 30-40 min. The complications of lymphatic duct injury, subclavian artery damage and phrenic nerve injuries were not seen in our series, and to our knowledge have not been reported by others in relation to the endoscopic approach. We encountered no case of permanent Horner's syndrome. Indeed, when the endoscopic approach is utilized, the stellate ganglion is protected by a characteristic yellow fat pad. This experience has been echoed by others. Claes and Gothberg3 and Banerjee et a[." in their reviews of 100 and 50 patients, respectively, reported no incidence of permanent
975
Quality of life after gastrectomy in patients w i t h carcinoma of the stomach
b
Simple diverticulectomy as described by Attwood et ul. is inadequate because it is recognized that the bleeding peptic ulceration frequently involves the adjacent ileum, even though the heterotopic gastric tissue lies within the diverticulum. Adequate resection can be performed expeditiously with the help of a CIA stapler (US Surgical). With its two forks inserted through two stab wounds on either side of the base of the diverticulum. the instrument enables fashioning of a side-to-side ileal anastomosis. This is then followed by resection of a small segment of the ileum bearing the diverticulum and the now confluent stab wound by a second firing of the C I A placed at right angles to the first one (Figure I ). With the aid of an Endo-CIA. much the same procedure can be carried out intra-abdominally, but at the expense of an increased risk of spillage, more wounds for insertion of bowel occlusion clamps and a longer operation time.
W. T. Ng M. K. Wong C. K. Kong Y. T. Chan Department of Surgerj Princess Mar(gare/ Hospitul Lui Chi Kok Kowloon Hong Kony
Sir We read with interest and surprise the article by Korenaga et a/. on quality of life after gastrectomy in patients with gastric cancer ( B r J Sury 1992; 79: 248-50). First, we would like to congratulate our Japanese colleagues for finally having discovered the issue of quality of life as a relevant endpoint for cancer treatment. The congratulations are even more important since the Japanese have been so refractory to the strategy of randomized clinical trials, despite their huge number of patients with cancer. However, their study has several flaws, presents wrong hypotheses and needs extensive comment. The literature review is incomplete. In the introduction, they write that little is known about quality of life in gastric cancer; this is not true. There is a randomized clinical trial on reconstruction techniques after radical gastrectomy', and our own group in Cologne has conducted two expert conferences on quality of life in surgery'.'. Furthermore, our group is currently testing a gastrointestinal quality-of-life index, which has already been applied in clinical trial^^,^. In the Patients and methods section, the authors introduce their 16-item survey on food tolerance, body-weight and performance status. Scores were assigned for physical and social well-being by a single interviewer and interpreted as representing the patients' quality of life. Our first criticism is that this is a subjective and non-validated way of measuring what the authors think is quality of life. We would go so far as to call it a 'housewife score'. In modern clinical research, there is no room for self-designed non-validated techniques. Our second criticism regards the concept of quality of life. As a result of a consensus conference, methodologists and clinicians look on quality of life as a four-dimensional concept comprising symptomatic, emotional, physical and social component^^.^. The emotional coping with disease is an extremely important aspect of a patient's quality of life. As an example, an amputated leg can be either a catastrophe or even a relief for a patient, depending on his or her emotional attitude. The authors do not even mention the domain of emotions. The third criticism concerns the two treatment groups. A retrospective separation and historical comparison of partial and total gastrectomy is subject to important bias and needs no further comment. The fourth criticism deals with the fact that the patients have been interviewed by a single - probably subjective - interviewer. The problem of observer variation was not addressed. Three statements in the Discussion need criticism and comment. In the first sentence, the statement that the influence of operation on quality of life is 'hard to quantify' is incorrect. The literature reports the use of validated methods such as the Spitzer index, various visual analogue scales and other tools6-'. In the second paragraph, the authors write that disturbances in performance status were improved 3 years after operation. Since they did not carry out a longitudinal observation study on their patients, this conclusion is inappropriate. In the last paragraph, they state that the quality of life is usually better after partial than after total gastrectomy. Although this hypothesis is also favoured by our group, evidence is still lacking and is not given by the present study. In future, validated and practical techniques5 have to be applied in randomized clinical trials to solve such important questions as which resection and reconstruction techniques are best for patients' well-being (provided both techniques offer equal standards of surgical safety).
E. Eypasch H. Troidl Krankenliuus Merlieini Postfacli 91 08 53 Ostnierheinier Strape 200 5000 Koln 91 Gernian?,
1. 2.
1. 2.
974
Lau WY, Fan ST, Wong ST et a/. Preoperative and intraoperative localization of gastrointestinal bleeding of obscure origin. Gut 1987; 28: 869-77. Spiller RC, Parkins RA. Recurrent gastrointestinal bleeding of obscure origin: report of 17 cases and a guide to logical management. Br J Surg 1983; 70: 489-93.
3. 4.
Troidl H, Kusche J, Vestweber K-H, Eypasch E, Maul U . Pouch uersus esophagojejunostomy after total gastrectomy: a randomized clinical trial. World J Surg 1987; 11: 699-712. Troidl H, Kusche J, Vestweber K-H, Eypasch E, Koppen L, Bouillon B. Quality of life: an important endpoint both in surgical practice and research. J Chron Dis 1987; 40: 523-8. Neugebauer E, Troidl H, Wood-Dauphinee S, Bullinger M. Meran conference on quality-of-life assessment in surgery. Theor Surg 1991; 6 : 121-165, 195-220. Eypasch E, Troidl H, Wood-Dauphinee S et a/. Quality of life and gastrointestinal surgery - a clinimetric approach to develop an instrument for its measurement. Theor Sury 1990; 5 : 3-10.
Br. J. Surg.. Vol. 79, No. 9. September 1992
Correspondence Eypasch E, Wood-Dauphinee S , Neugebauer E, Williams JI. The gastrointestinal quality of life index (GIQL) a new tool to measure quality of life in gastrointestinal disease. Gastroenterology 1991; 100: A6. Selby PJ, Chapman JAW, Etazadi-Amoli J, Dalley D, Boyd NF. The development of a method for assessing quality of life in cancer patients. Br J Cancer 1984; 50: 13. Priestman T, Baum M. Evaluation of quality of life in patients receiving treatment for advanced breast cancer. Lancet 1976; i: 899. Spilker B. Quality of Life Assessment in Clinical Trials. New York: Raven Press, 1990. ~
Proctoscopic polyp delivery after colonoscopic polypectomy Sir The suggestion of Messrs Chuah and Kelly ( B r J Surg 1992; 79: 32) to thread the colonoscope through a proctoscope to remove polyps seems complicated and unnecessary. The manoeuvre impedes adequate insumation and may therefore interfere with visualization of the polyp. We remove the lesion with a grasper or by continuous suction and ask the patient to press at the moment that we retract the tip of the 'scope through the anal canal. In this way the polyp will always follow. If a polyp is lost higher up in the descending or sigmoid colon, it can usually be retrieved with an enema. A. B. Bijnen P. de Ruiter
Authors' reply Sir We thank D r Eypasch and Professor Troidl for their constructive comments. The purpose of our study was to determine whether a radical R, gastrectomy prevents the patient's well-being. T o our knowledge, the present report is the first concerning quality of life in patients undergoing gastrectomy with extensive lymph node dissection ( a standard procedure in Japan since the 1960s). Questions and scoring for quality of life were made by several members of the gastric cancer group, and patients were free to select the answers. Average scores were calculated for the response to each question and used as the index for the quality of life. Rohrer et a/.' reported the quality of life following repair of abdominal aortic aneurysm using the same analytical method. Therefore, this survey seems objective. Although a retrospective separation of partial and total gastrectomy was present, the effect of historical comparison was thought to be negligible because determination of the type of gastrectomy usually depended on the location of the tumour. Our policy is to undertake total gastrectomy only when a tumour is located in the upper third of the stomach. When there is a tumour in the middle and lower third of the stomach, partial gastrectomy is the treatment of choice. This study is a step in the right direction in assessing the patient's well-being. Our results suggest that quality of life is usually better after partial than after total gastrectomy. A randomized trial to solve questions such as which resection is best for long-term survival and quality of life in patients with a tumour in the lower two-thirds of the stomach warrants further attention.
D. Korenaga Department of Surgery I I Fuculty of Medicine Kyushu University 3-1-1 Maidashi Higashi-ku Fukuoka 812 Japan 1.
Rohrer MJ, Cutler BS, Brownell Wheeler H. Long-term survival and quality of life following ruptured abdominal aortic aneurysm. Arch Sury 1988; 123: 1213-17.
Easy delivery of the gallbladder in laparoscopic cholecystectomy: a grooved director Sir We read with interest the Surgical Workshop of Williams et al. ( B r J Surg 1992; 79: 344). At our hospital we have performed over 50 laparoscopic cholecystectomies and use Brodie's grooved director for the easy delivery of the gallbladder through the abdominal incision. It is available in every hospital, and is safe and reusable.
B. Mistry R. T. Waddington Barnsley District General Hospital Barnsley South Yorkshire S75 2EP UK
Br. J. Surg., Vol. 79, No. 9, September 1992
Department of Surgery Alkrnaar Medical Centre Wilhelminalaan I 2 1815 J D Alkmaar The Netherlands
Authors' reply Sir We were pleased with the interest in our Surgical Workshop shown by Drs Bijnen and de Ruiter, but disagree completely with their conclusions. First, they do not seem fully to have understood our manoeuvre, which is to wait until the severed polyp held in the graspers against the tip of the colonoscope is actually situated in the already inflated lower rectum before railroading in the proctoscope over the endoscope to allow easier removal of the endoscope with polyp in one simple movement. Second, we just do not seem to be as skilful as our Dutch colleagues in coaxing polyps through the anal sphincters without the help of the proct oscope.
M. J. Kelly S. Y. Chuah The Nufield Hospital Leicester Scraptoft Lane Leicester LE5 I H Y UK
Upper thoracic sympathectomy for primary palmar and axillary hyperhidrosis: long-term follow-up Sir It was with great interest and some concern that we read the recent communication from Hashmonai et al. ( B r J Surg 1992; 79: 268-71 ). The authors imply that the supraclavicular approach should. remain the method of choice as the long-term results of the newer forms of sympathectomy such as the transthoracic approach are not yet available. This advice is both inaccurate and misleading. Variations of the thoracoscopic approach have been in routine clinical practice' since the 1970s, and indeed endoscopic sympathectomy has been the approach of choice in our own unit for the past 12 years. In a previous paper in this journal', we communicated our experience from 1980 to 1987, reviewing 112 cases of palmar and axillary hyperhidrosis treated by endoscopic transthoracic electrocautery of the sympathetic chain. Some differences in outcome deserve comment. Far from requiring two separate teams of surgeons working simultaneously, in our unit one surgeon operates on each side sequentially, completing both in 30-40 min. The complications of lymphatic duct injury, subclavian artery damage and phrenic nerve injuries were not seen in our series, and to our knowledge have not been reported by others in relation to the endoscopic approach. We encountered no case of permanent Horner's syndrome. Indeed, when the endoscopic approach is utilized, the stellate ganglion is protected by a characteristic yellow fat pad. This experience has been echoed by others. Claes and Gothberg3 and Banerjee et a[." in their reviews of 100 and 50 patients, respectively, reported no incidence of permanent
975
