849
an
"eating disorder" as those with bulimia nervosa. Indeed, the two overlap.
conditions
Medical Unit, Eastern General Hospital, Edinburgh EH6 7LN, UK
JOHN MUNRO
SiR,—Iwas surprised that sleep apnoea was not discussed by Dr Ravussin and Dr Swinburn and Professor Garrow in their reviews of obesity. Obesity is often seen in patients with sleep apnoea,l and both conditions are associated with an increased cardiovascular mortality.2 In a variable number of obese patients (dependent on selection criteria), sleep apnoea can be identified and if treated successfully may be associated with weight loss. Although obesity is regarded as an indication for sleep studies in North Americathis does not apply in the UK, where provision of sleep services is limited. However, referral for polysomnography should be considered in obese patients who snore loudly, have a small oropharyngeal cavity, and in whom apnoeas have been documented.4.5 MARTIN ALLEN
MB, Jefferies A, Gould G, Douglas NJ. Clinical features of the sleep
apnoea/hypopnoea syndrome. QJ Med 1989; 72: 659-66. Kryger MH, Zonck FJ, Conway W, Roth T. Mortality and apnoea index in obstructive sleep apnoea: experience in 385 male patients. Chest 1988; 94: 9-14. 3. Martin RJ. Indications and standards for cardiopulmonary sleep studies. Sleep 1985; 8: 371-79. 4. Allen MB, Douglas NJ. Is a symptom based questionnaire useful in the diagnosis of the sleep apnoea/hypopnoea syndrome. Thorax 1990; 45: 787. 5. Woodhead CJ, Davies JE, Allen MB. Obstructive sleep apnoea in adults presenting with snoring Clin Otolaryngol 1991; 16: 401-06. 2. He J,
Cytoreduction in ovarian
Institute of Obstetrics and Gynaecology, Hammersmith Hospital, London W12 0HS,UK
W. P. SOUTTER
Hacker NF, Berek JS, Lagasse LD, Nieberg RK, Elashoff RM. Primary cytoreductive surgery for epithelial ovarian cancer. Obstet Gynecol 1983; 61: 413-20. 2. Webb MJ. Cytoreduction in ovarian cancer: achievability and results. In: Burghardt E, Monaghan JM, eds. Baillière’s clinical obstetrics and gynaecology; operative treatment of ovarian cancer. London: Baillière-Tindall 1989; 3.1: 83-94. 3. Bertelsen K. Tumour reduction surgery and long term survival in advanced ovarian cancer: a DACOVA study. Gynecol Oncol 1990; 38: 203-09. 1.
Stapled anastomoses and colon
cancer
recurrence
Leeds Chest Clinic, Leeds LS1 6PH, UK 1. Whyte K, Allen
all of
which suggest that very extensive surgery to studies I mention, achieve maximum cytoreduction is unlikely to produce any substantial benefit in median survival. If I were asked to offer advice it would be this: if cytoreduction can be achieved without subjecting the patient to bowel or urinary-tract surgery, it is probably worth doing to provide symptomatic relief; the absence of clear evidence of substantial benefit to survival should argue against obsessional attempts to remove every last vestige of tumour.
cancer
SIR,-I welcome your Aug 29 editorial based on the metaanalysis of surgery in advanced ovarian cancer undertaken by myself and my colleagues. I should like to clarify some of the points you raised. You suggest that the inclusion of patients who were not treated with platinum weakened the conclusions of the analysis. The reverse is true. The analysis specifically took into account whether or not platinum was used and the intensity of the chemotherapy that
administered. Both of these, in particular the use of platinum, conferred a significant survival advantage, and that advantage was taken into account when assessing the effect of surgery. Similarly, women with stage IV carcinoma had a worse prognosis, and this too was included in the final analysis, which examined the apparent effects of surgery. Once all the relevant variables had been taken into account there was no significant upturn in median survival time with increasing use of maximum cytoreductive surgery. You do not mention other evidence of the value of cytoreductive surgery. Hacker et aP have shown that women with large metastatic masses of ovarian cancer do very badly even with cytoreductive surgery, and others2 have cautioned against the use of bowel resection in such surgery because of the poor results associated with these additional procedures. A multicentre Danish study3 in which was
were operated on in gynaecological oncology units, general gynaecology units, or surgical units showed that, although the gynaecological oncologists achieved a higher rate of cytoreductive
patients
surgery than the other two groups, the survival curves were identical. Nor do you discuss the role of cytoreductive surgery in providing symptomatic relief. This is a potential benefit of this surgery that our meta-analysis could not address. Although it has never been the subject of a controlled trial, most gynaecologists would probably agree that women in whom maximum cytoreductive surgery has been possible are more comfortable and have fewer symptoms than those in whom a substantial mass of tumour remains after surgery. I was puzzled by your suggestion that the effects of the type of chemotherapy, dose intensity, and remaining tumour mass cannot always be measured in an overview analysis. These were precisely the factors that were assessed in out meta-analysis. I do not agree with the advice to all surgeons to undertake extensive debulking in view of the evidence from the meta-analysis and from the other
SiR,—In your Aug 1 editorial you discuss a report by Akyol et all in which 294 patients undergoing curative colorectal operations were randomised into sutured and stapled groups. At the end of 2 years, overall tumour recurrence was 29-4% in the sutured group and 19-1 % in the stapled group (p < 0-05). These figures have been used to give credibility to the hypothesis that local recurrence is higher after sutured anastomoses. We would raise several points. The local recurrence rates quoted by Akyol et al are worryingly high. After total mesorectal excision of the rectum2 local recurrence rates of less than 5% may be achieved. In their series Akyol et al included 109 rectal resections. They do not state whether total mesorectal excision was done for the low cancers: we think probably not. Certainly they have categorically stated in their paper that they did not routinely wash out the bowel intraoperatively. This simple manoeuvre may guard against implantation and thus local recurrence.
At this hospital, after colonic and high rectal cancers are resected, the gut is reconstituted with sutures (interrupted extramucosal vicryl).7 All low rectal cancers are excised with the technique of total mesorectal excision, and the descending colon is stapled to the residual stump of anorectum. Washout to prevent implantation is an integral part of all procedures. In this series between 1978 and 1991, there were 271 consecutive patients with rectal cancer, of whom 244 were treated by anterior resection and 27 by abdominoperineal excision. About 75% of the patients undergoing anterior resection had a curative procedure and in this subgroup the computed local recurrence rate was 3-4%. The 6 patients with local recurrence all had stapled anastomoses. There was a causative factor in 4 of the 6 patients, such as clamp slippage. We did not fmd any significant difference in recurrence rates between the two anastomotic techniques. The overall local recurrence rates after curative resection for colonic cancer are much the same in this series, suggesting that sutured anastomoses are not associated with an increased rate of recurrence. Sutured anastomoses were associated with a reduced frequency of leakage, but this may well be because stapled anastomoses were used for very low anastomoses. Colorectal Research Unit, Basingstoke District Hospital,
Basingstoke, Hampshire RG24 9NA, 1.
UK
N. D. KARANJIA R. J. HEALD
Akyol AM, McGregor JR, Galloway DJ, Murray G, George WD. Recurrence of colorectal cancer after sutured and stapled large bowel anastomoses. Br J Surg 1991; 78: 1297-300.
2. Heald
RJ, Ryall RDH, Husband E. The mesorectum in rectal cancer surgery: clue to pelvic recurrence Br J Surg 1982; 69: 613-16. 3. Heald RJ, Ryall RDH. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986; ii: 1479-82. 4. Karanjia ND, Schache DJ, North WRS, Heald RJ The close shave in anterior resection. Br J Surg 1990; 77: 510-12. 5. Dixon AR, Maxwell WA, Thornton-Holmes J. Carcinoma of the rectum: a 10 year experience. Br JSurg 1991; 78: 308-11. 6. Fazio VW, Tjandra JJ. Primary therapy of carcinoma of the large bowel World J Surg 7.
1991, 15: 568-75. Carty N, Keating J, Campbell J, Karanjia ND, Heald RJ. Prospective audit on an extramucosal technique for intestinal anastomosis. Br J Surg 1991, 78: 1439-41.
an
"eating disorder" as those with bulimia nervosa. Indeed, the two overlap.
conditions
Medical Unit, Eastern General Hospital, Edinburgh EH6 7LN, UK
JOHN MUNRO
SiR,—Iwas surprised that sleep apnoea was not discussed by Dr Ravussin and Dr Swinburn and Professor Garrow in their reviews of obesity. Obesity is often seen in patients with sleep apnoea,l and both conditions are associated with an increased cardiovascular mortality.2 In a variable number of obese patients (dependent on selection criteria), sleep apnoea can be identified and if treated successfully may be associated with weight loss. Although obesity is regarded as an indication for sleep studies in North Americathis does not apply in the UK, where provision of sleep services is limited. However, referral for polysomnography should be considered in obese patients who snore loudly, have a small oropharyngeal cavity, and in whom apnoeas have been documented.4.5 MARTIN ALLEN
MB, Jefferies A, Gould G, Douglas NJ. Clinical features of the sleep
apnoea/hypopnoea syndrome. QJ Med 1989; 72: 659-66. Kryger MH, Zonck FJ, Conway W, Roth T. Mortality and apnoea index in obstructive sleep apnoea: experience in 385 male patients. Chest 1988; 94: 9-14. 3. Martin RJ. Indications and standards for cardiopulmonary sleep studies. Sleep 1985; 8: 371-79. 4. Allen MB, Douglas NJ. Is a symptom based questionnaire useful in the diagnosis of the sleep apnoea/hypopnoea syndrome. Thorax 1990; 45: 787. 5. Woodhead CJ, Davies JE, Allen MB. Obstructive sleep apnoea in adults presenting with snoring Clin Otolaryngol 1991; 16: 401-06. 2. He J,
Cytoreduction in ovarian
Institute of Obstetrics and Gynaecology, Hammersmith Hospital, London W12 0HS,UK
W. P. SOUTTER
Hacker NF, Berek JS, Lagasse LD, Nieberg RK, Elashoff RM. Primary cytoreductive surgery for epithelial ovarian cancer. Obstet Gynecol 1983; 61: 413-20. 2. Webb MJ. Cytoreduction in ovarian cancer: achievability and results. In: Burghardt E, Monaghan JM, eds. Baillière’s clinical obstetrics and gynaecology; operative treatment of ovarian cancer. London: Baillière-Tindall 1989; 3.1: 83-94. 3. Bertelsen K. Tumour reduction surgery and long term survival in advanced ovarian cancer: a DACOVA study. Gynecol Oncol 1990; 38: 203-09. 1.
Stapled anastomoses and colon
cancer
recurrence
Leeds Chest Clinic, Leeds LS1 6PH, UK 1. Whyte K, Allen
all of
which suggest that very extensive surgery to studies I mention, achieve maximum cytoreduction is unlikely to produce any substantial benefit in median survival. If I were asked to offer advice it would be this: if cytoreduction can be achieved without subjecting the patient to bowel or urinary-tract surgery, it is probably worth doing to provide symptomatic relief; the absence of clear evidence of substantial benefit to survival should argue against obsessional attempts to remove every last vestige of tumour.
cancer
SIR,-I welcome your Aug 29 editorial based on the metaanalysis of surgery in advanced ovarian cancer undertaken by myself and my colleagues. I should like to clarify some of the points you raised. You suggest that the inclusion of patients who were not treated with platinum weakened the conclusions of the analysis. The reverse is true. The analysis specifically took into account whether or not platinum was used and the intensity of the chemotherapy that
administered. Both of these, in particular the use of platinum, conferred a significant survival advantage, and that advantage was taken into account when assessing the effect of surgery. Similarly, women with stage IV carcinoma had a worse prognosis, and this too was included in the final analysis, which examined the apparent effects of surgery. Once all the relevant variables had been taken into account there was no significant upturn in median survival time with increasing use of maximum cytoreductive surgery. You do not mention other evidence of the value of cytoreductive surgery. Hacker et aP have shown that women with large metastatic masses of ovarian cancer do very badly even with cytoreductive surgery, and others2 have cautioned against the use of bowel resection in such surgery because of the poor results associated with these additional procedures. A multicentre Danish study3 in which was
were operated on in gynaecological oncology units, general gynaecology units, or surgical units showed that, although the gynaecological oncologists achieved a higher rate of cytoreductive
patients
surgery than the other two groups, the survival curves were identical. Nor do you discuss the role of cytoreductive surgery in providing symptomatic relief. This is a potential benefit of this surgery that our meta-analysis could not address. Although it has never been the subject of a controlled trial, most gynaecologists would probably agree that women in whom maximum cytoreductive surgery has been possible are more comfortable and have fewer symptoms than those in whom a substantial mass of tumour remains after surgery. I was puzzled by your suggestion that the effects of the type of chemotherapy, dose intensity, and remaining tumour mass cannot always be measured in an overview analysis. These were precisely the factors that were assessed in out meta-analysis. I do not agree with the advice to all surgeons to undertake extensive debulking in view of the evidence from the meta-analysis and from the other
SiR,—In your Aug 1 editorial you discuss a report by Akyol et all in which 294 patients undergoing curative colorectal operations were randomised into sutured and stapled groups. At the end of 2 years, overall tumour recurrence was 29-4% in the sutured group and 19-1 % in the stapled group (p < 0-05). These figures have been used to give credibility to the hypothesis that local recurrence is higher after sutured anastomoses. We would raise several points. The local recurrence rates quoted by Akyol et al are worryingly high. After total mesorectal excision of the rectum2 local recurrence rates of less than 5% may be achieved. In their series Akyol et al included 109 rectal resections. They do not state whether total mesorectal excision was done for the low cancers: we think probably not. Certainly they have categorically stated in their paper that they did not routinely wash out the bowel intraoperatively. This simple manoeuvre may guard against implantation and thus local recurrence.
At this hospital, after colonic and high rectal cancers are resected, the gut is reconstituted with sutures (interrupted extramucosal vicryl).7 All low rectal cancers are excised with the technique of total mesorectal excision, and the descending colon is stapled to the residual stump of anorectum. Washout to prevent implantation is an integral part of all procedures. In this series between 1978 and 1991, there were 271 consecutive patients with rectal cancer, of whom 244 were treated by anterior resection and 27 by abdominoperineal excision. About 75% of the patients undergoing anterior resection had a curative procedure and in this subgroup the computed local recurrence rate was 3-4%. The 6 patients with local recurrence all had stapled anastomoses. There was a causative factor in 4 of the 6 patients, such as clamp slippage. We did not fmd any significant difference in recurrence rates between the two anastomotic techniques. The overall local recurrence rates after curative resection for colonic cancer are much the same in this series, suggesting that sutured anastomoses are not associated with an increased rate of recurrence. Sutured anastomoses were associated with a reduced frequency of leakage, but this may well be because stapled anastomoses were used for very low anastomoses. Colorectal Research Unit, Basingstoke District Hospital,
Basingstoke, Hampshire RG24 9NA, 1.
UK
N. D. KARANJIA R. J. HEALD
Akyol AM, McGregor JR, Galloway DJ, Murray G, George WD. Recurrence of colorectal cancer after sutured and stapled large bowel anastomoses. Br J Surg 1991; 78: 1297-300.
2. Heald
RJ, Ryall RDH, Husband E. The mesorectum in rectal cancer surgery: clue to pelvic recurrence Br J Surg 1982; 69: 613-16. 3. Heald RJ, Ryall RDH. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986; ii: 1479-82. 4. Karanjia ND, Schache DJ, North WRS, Heald RJ The close shave in anterior resection. Br J Surg 1990; 77: 510-12. 5. Dixon AR, Maxwell WA, Thornton-Holmes J. Carcinoma of the rectum: a 10 year experience. Br JSurg 1991; 78: 308-11. 6. Fazio VW, Tjandra JJ. Primary therapy of carcinoma of the large bowel World J Surg 7.
1991, 15: 568-75. Carty N, Keating J, Campbell J, Karanjia ND, Heald RJ. Prospective audit on an extramucosal technique for intestinal anastomosis. Br J Surg 1991, 78: 1439-41.
