Correspondence Preoperative localization of parathyroid
Rebound tenderness test
t umours Sir I read with interest the recent report by Serpell et al. ( B r J Surg 1991 ; 78: 589-90) on the preoperative localization of parathyroid tumours and the effect on operating time. The utilization of thallium/technetium subtraction scanning did not significantly reduce operating time in patients with positive scans since bilateral cervical exploration was performed routinely in all patients regardless of the scan result. The stated operative strategy was ‘a standard neck exploration with a view to identifying and excising the tumours and biopsing at least one normal gland’. In the vast majority of patients suffering from primary hyperparathyroidism ( H P T ) the underlying pathology is a solitary adenoma. In the reported series, 47 of the 50 patients had such a tumour and in these 47 exploration of the contralateral side of the neck proved to be quite unnecessary. In their patients with positive scans the authors very sensibly initially sought the abnormal parathyroid gland in ‘scan-directed’ fashion; then ‘a normal gland was sought on the same side’. At that point they had fulfilled the criteria of their own operative plan. If, in patients with H P T on the basis of a solitary adenoma, the single tumour can be localized accurately before operation, the case for a scan-directed unilateral neck exploration is logical and overwhelming. We have shown that the routine use of thallium/technetium isotope subtraction scanning, coupled with a scan-directed unilateral neck exploration in appropriate cases, will reduce operating time very significantly’. In our hands the ability of the scintigram to identify the site of a single adenoma is weight-dependent’. 1 would encourage M r Young and his colleagues and other groups using thallium/technetium scanning routinely for preoperative localization toembark on a prospective study ofscan-directed unilateral neck exploration in appropriately selected patients with HPT’. C. F. J. Russell
Endoi,rinu Surgerj Unit R o j d Vic,toria Hospital Grosrenor R o d BelfusI BTlZ 6 B A UK 1.
2.
Russell CFJ, Laird JD, Ferguson WR. Scan-directed unilateral cervical exploration for parathyroid adenoma : a legitimate approach’? World J Surg 1990; 14: 406-9. Maltby C, Russell CFJ, Laird JD, Ferguson W R . Thalliumtechnetium isotope subtraction scanning in primary hyperparathyroidism. J R Coll Surg Edinh 1989; 34: 40-3.
Authors’ reply Sir Mr Russell asks why I explore the second side of the neck having found a parathyroid adenoma on the first side. The answer is straightforward. The frozen section takes about 20 min to report and during that time I hope to have seen two parathyroid glands on the opposite side of the neck. Indeed, if they are normal and the adenoma seems macroscopically definite I close the neck. In any event I then have sufficient information to make a decision if the frozen section is suspicious of hyperplasia with asymmetric enlargement and I know that there is no second adenoma (yes, they do occur). In the rare event that the first ‘adenoma’ was not parathyroid tissue 1 can promptly continue my search on the first side. Even in the most competent hands failures do occur in parathyroid surgery and, as a cautious exploration of the second side carries no real risks and does not extend the duration of the operation, then our commitment to care and thoroughness should require it. I will continue to explore both sides just as I shall continue to explore the whole abdomen at laparotomy. A. E. Young Sr. Thomas’ Hospital
London S E l 7EH UK
1510
Sir Liddington and Thomson (Br J Surg 1991; 78: 795-6) are premature in their blanket condemnation of the abdominal rebound tenderness test. They clearly show that 43 of 53 patients with peritonitis had a positive test and, by their own admission, some of the ten negative responses may have been positive but were classed as equivocal. O n the other hand, I totally agree with them that the technique they describe does not discriminate between pain and surprise and in p-lients with peritonitis is frankly cruel. If one elicits rebound tenderness by gentle percussion over the four quadrants of the abdomen in turn then the pain caused by stretching of inflamed peritoneum can be demonstrated with minimal discomfort and allow one to take advantage of the fact that rebound tenderness is a feature in most patients with peritonitis. I dropped the old practice from my teaching following the publication of Prout’s paper in 1970. Interestingly, I find that it is physicians rather than surgeons who continue to teach it.
M. Irving University of hlanchester Department of Surgery Clinical Sciences Building Hope Hospital Eccles Old Road Salford M6 8 H D UK
Importance of unilateral absence of the vas Sir Further to the short article by H. Hashimi and A. L. Stewart ( B r J Surg 1991 ; 78: 631 ), unilateral absence of the vas deferens is a common congenital anomaly occurring in 0.5-1 per cent of the population’. Unilateral renal agenesis is less common, however, with an estimated incidence of 0.1 per cent’ and is associated with early failure of mesonephric duct development. Bilateral early failure of mesonephric duct development is usually associated with bilateral renal agenesis and is incompatible with fetal survival. Late failure of mesonephric duct development results in vasal aplasia with normal renal tract development and may be bilateral3. Bilateral vasal aplasia has been considered to be pathognomonic of cystic fibrosis, but this is not strictly so4. The ipsilateral testis is usually normal in size and appearance, although epididymal development is variable. In addition, ipsilateral absence of the adrenal gland has been reported in 15-25 per cent of patients with renal agenesis’. Most patients appear to remain asymptomatic, and it seems unnecessary to examine routinely for the absence of the vas deferens unless indicated clinically, either as part of the assessment for infertility and vasectomy or for patients with cystic fibrosis. This physical sign is particularly useful in patients presenting with blunt abdominal trauma requiring emergency surgery. Those patients with unilateral absence of the vas deferens should be assumed to have a unilateral renal anomaly or absence unless they are clinically stable and can have appropriate imaging.
N. D. Heaton J. D. Nawrocki Firm III Ofice Department of Surgery King’s Coffege Hospital London SES 9 R S UK Ochsner M G , Brannan W, Goodier EH. Absent vas deferens associated with renal agenesis. J A M A 1972; 222: 1055-6. Soloway H M . Bilateral and unilateral renal agenesis. Ann Surg 1939; 109: 267-73. Charney CW, Gillenwater JY. Congenital absence of the vas deferens. J Urol 1965 ; 33 : 399-401. Heaton ND, Pryor JP. Vasa aplasia and cystic fibrosis. Br J Urol 1990; 66: 538-40.
Br. J. Surg., Vol. 78, No. 12, December 1991
Rebound tenderness test
t umours Sir I read with interest the recent report by Serpell et al. ( B r J Surg 1991 ; 78: 589-90) on the preoperative localization of parathyroid tumours and the effect on operating time. The utilization of thallium/technetium subtraction scanning did not significantly reduce operating time in patients with positive scans since bilateral cervical exploration was performed routinely in all patients regardless of the scan result. The stated operative strategy was ‘a standard neck exploration with a view to identifying and excising the tumours and biopsing at least one normal gland’. In the vast majority of patients suffering from primary hyperparathyroidism ( H P T ) the underlying pathology is a solitary adenoma. In the reported series, 47 of the 50 patients had such a tumour and in these 47 exploration of the contralateral side of the neck proved to be quite unnecessary. In their patients with positive scans the authors very sensibly initially sought the abnormal parathyroid gland in ‘scan-directed’ fashion; then ‘a normal gland was sought on the same side’. At that point they had fulfilled the criteria of their own operative plan. If, in patients with H P T on the basis of a solitary adenoma, the single tumour can be localized accurately before operation, the case for a scan-directed unilateral neck exploration is logical and overwhelming. We have shown that the routine use of thallium/technetium isotope subtraction scanning, coupled with a scan-directed unilateral neck exploration in appropriate cases, will reduce operating time very significantly’. In our hands the ability of the scintigram to identify the site of a single adenoma is weight-dependent’. 1 would encourage M r Young and his colleagues and other groups using thallium/technetium scanning routinely for preoperative localization toembark on a prospective study ofscan-directed unilateral neck exploration in appropriately selected patients with HPT’. C. F. J. Russell
Endoi,rinu Surgerj Unit R o j d Vic,toria Hospital Grosrenor R o d BelfusI BTlZ 6 B A UK 1.
2.
Russell CFJ, Laird JD, Ferguson WR. Scan-directed unilateral cervical exploration for parathyroid adenoma : a legitimate approach’? World J Surg 1990; 14: 406-9. Maltby C, Russell CFJ, Laird JD, Ferguson W R . Thalliumtechnetium isotope subtraction scanning in primary hyperparathyroidism. J R Coll Surg Edinh 1989; 34: 40-3.
Authors’ reply Sir Mr Russell asks why I explore the second side of the neck having found a parathyroid adenoma on the first side. The answer is straightforward. The frozen section takes about 20 min to report and during that time I hope to have seen two parathyroid glands on the opposite side of the neck. Indeed, if they are normal and the adenoma seems macroscopically definite I close the neck. In any event I then have sufficient information to make a decision if the frozen section is suspicious of hyperplasia with asymmetric enlargement and I know that there is no second adenoma (yes, they do occur). In the rare event that the first ‘adenoma’ was not parathyroid tissue 1 can promptly continue my search on the first side. Even in the most competent hands failures do occur in parathyroid surgery and, as a cautious exploration of the second side carries no real risks and does not extend the duration of the operation, then our commitment to care and thoroughness should require it. I will continue to explore both sides just as I shall continue to explore the whole abdomen at laparotomy. A. E. Young Sr. Thomas’ Hospital
London S E l 7EH UK
1510
Sir Liddington and Thomson (Br J Surg 1991; 78: 795-6) are premature in their blanket condemnation of the abdominal rebound tenderness test. They clearly show that 43 of 53 patients with peritonitis had a positive test and, by their own admission, some of the ten negative responses may have been positive but were classed as equivocal. O n the other hand, I totally agree with them that the technique they describe does not discriminate between pain and surprise and in p-lients with peritonitis is frankly cruel. If one elicits rebound tenderness by gentle percussion over the four quadrants of the abdomen in turn then the pain caused by stretching of inflamed peritoneum can be demonstrated with minimal discomfort and allow one to take advantage of the fact that rebound tenderness is a feature in most patients with peritonitis. I dropped the old practice from my teaching following the publication of Prout’s paper in 1970. Interestingly, I find that it is physicians rather than surgeons who continue to teach it.
M. Irving University of hlanchester Department of Surgery Clinical Sciences Building Hope Hospital Eccles Old Road Salford M6 8 H D UK
Importance of unilateral absence of the vas Sir Further to the short article by H. Hashimi and A. L. Stewart ( B r J Surg 1991 ; 78: 631 ), unilateral absence of the vas deferens is a common congenital anomaly occurring in 0.5-1 per cent of the population’. Unilateral renal agenesis is less common, however, with an estimated incidence of 0.1 per cent’ and is associated with early failure of mesonephric duct development. Bilateral early failure of mesonephric duct development is usually associated with bilateral renal agenesis and is incompatible with fetal survival. Late failure of mesonephric duct development results in vasal aplasia with normal renal tract development and may be bilateral3. Bilateral vasal aplasia has been considered to be pathognomonic of cystic fibrosis, but this is not strictly so4. The ipsilateral testis is usually normal in size and appearance, although epididymal development is variable. In addition, ipsilateral absence of the adrenal gland has been reported in 15-25 per cent of patients with renal agenesis’. Most patients appear to remain asymptomatic, and it seems unnecessary to examine routinely for the absence of the vas deferens unless indicated clinically, either as part of the assessment for infertility and vasectomy or for patients with cystic fibrosis. This physical sign is particularly useful in patients presenting with blunt abdominal trauma requiring emergency surgery. Those patients with unilateral absence of the vas deferens should be assumed to have a unilateral renal anomaly or absence unless they are clinically stable and can have appropriate imaging.
N. D. Heaton J. D. Nawrocki Firm III Ofice Department of Surgery King’s Coffege Hospital London SES 9 R S UK Ochsner M G , Brannan W, Goodier EH. Absent vas deferens associated with renal agenesis. J A M A 1972; 222: 1055-6. Soloway H M . Bilateral and unilateral renal agenesis. Ann Surg 1939; 109: 267-73. Charney CW, Gillenwater JY. Congenital absence of the vas deferens. J Urol 1965 ; 33 : 399-401. Heaton ND, Pryor JP. Vasa aplasia and cystic fibrosis. Br J Urol 1990; 66: 538-40.
Br. J. Surg., Vol. 78, No. 12, December 1991
