Letters to the Editor
797
5. Martin I, Au K. Does fibrin glue sealant decrease the rate of anastomotic leak after a pancreaticoduodenectomy? Results of a prospective randomized trial. HPB (Oxford) 2013; 15: 561–6.
Paul J. Conaglen,* MBChB Neil A. Collier,† MS, FRACS, FRCS (Eng) *Thoracic Surgery, St Vincent’s and Mercy Private Hospital, and †General Surgery and Gastroenterology Clinical Institute, Epworth Freemasons Hospital, Melbourne, Victoria, Australia doi: 10.1111/ans.12765
Dear Editor, The future of surgical outpatients It has recently come to my attention that the outpatient department at most public hospitals is under great stress. The number of new referrals and review patients has significantly increased in the last decade. For example, at our institution, new referrals per month have increased from an average of 27 per month in 2004 to 137 per month this year. Although the numbers have significantly increased, staffing has not. With the ageing population, this logarithmic increase will ultimately be unmanageable. In orthopaedic and plastic surgery, the majority of review patients can adequately be managed by a general practitioner. However in my experience, general practitioners are not happy in managing these cases due to lack of experience. An option to help alleviate the burden on public outpatients, particularly orthopaedic and plastic outpatients, would be to incorporate an outpatient rotation for training general practitioners. General practice trainees often undertake numerous resident rotations in surgery, but rarely attend the outpatient department due to time constraints. By incorporating a dedicated outpatient rotation for trainee general practitioners, we will add a helping hand to clinic; train future general practitioners to be more confident at managing simple fractures, wounds and post-operative patients; and help prevent delayed referrals for time-critical conditions. Sina Babazadeh, MBBS, PhD Australian Orthopaedic Research Group, Victoria, Australia doi: 10.1111/ans.12777
Dear Editor, Pneumothorax complicating total extraperitoneal repair of inguinal hernia under combined spinal epidural anaesthesia An 18-year-old healthy man with a right indirect inguinal hernia was taken for total extraperitoneal repair (TEP) under combined spinal epidural anaesthesia. After 20 min, the patient started straining and had pain in the abdomen, left shoulder and chest not relieved by fentanyl boluses. In view of severe pain and straining, general anaesthesia was induced. During intubation, oxygen saturation deterio© 2014 Royal Australasian College of Surgeons
rated to 83% with markedly decreased air entry on the right side of the chest with a normal resonant note on both sides of the chest. The position and patency of endotracheal tube were confirmed. Even with no evidence of peritoneal breach, CO2 was deflated immediately. Later, with a partly saline-filled syringe, with needle inserted in the second intercostal space, air bubbles were aspirated and rightsided pneumothorax was diagnosed. Following this, an intercostal tube was inserted in the fourth intercostal space after which the saturation improved. Later, TEP was abandoned and Lichtenstein repair was performed. Postoperatively, intercoastal drainage was removed on the next day and patient was discharged. Pneumothorax occurrence during TEP was well reported. Such thoracic complications find an increased incidence in the surgeries performed via retroperitoneal approach rather than via transperitoneal approach.1 It might be due to some congenital pleuroperitoneal communications or ruptured lung bullae. Both surgeon and anaesthetist need to stay watchful and promptly treat it with appropriate measures. Many a times positive end expiratory pressure ventilation was all that was needed.2 References 1. Abreu SC, Sharp DS, Ramani AP et al. Thoracic complications during urological laparoscopy. J. Urol. 2004; 171: 1451–5. 2. Joris JL, Chiche JD, Lamy ML. Pneumothorax during laparoscopic fundoplication: diagnosis and treatment with positive end-expiratory pressure. Anesth. Analg. 1995; 81: 993–1000.
Naveen Sharma, MBBS, MS (General Surgery) Amit K. Kundu, MBBS Department of General Surgery, University College of Medical Sciences, University of Delhi and Guru Teg Bahadur Hospital, New Delhi, India doi: 10.1111/ans.12770
Dear Editor, Response to Re: Accuracy of visual prediction of pathology of colorectal polyps: how accurate are we? We thank Dr Kostalas1 for his comments regarding our study.2 We are not in disagreement that narrow band imaging (NBI) is helpful. We found, however, that most endoscopists chose not to use NBI. Our point is that pathology of colorectal polyps cannot be accurately predicted with white light alone, and all visualized polyps should be excised for histology.2 Our study2 was designed to assess what happens in real life in a busy unit, with over 7000 annual colonoscopies, at two sites, by 23 endoscopists. Dr Kostalas1 raises some interesting issues. He correctly points out the evidence base for NBI distinguishing types of polyps. We do note that the studies that reported high accuracy combined NBI with a detailed classification system, such as pit patterns, Paris classification and capillary patterns. The study by Hewett et al.3 quoted by Dr Kostalas used a modified Delphi system. These classification systems are complicated, cumbersome to use, and is probably the reason why NBI is underutilized for predictive purposes.
797
5. Martin I, Au K. Does fibrin glue sealant decrease the rate of anastomotic leak after a pancreaticoduodenectomy? Results of a prospective randomized trial. HPB (Oxford) 2013; 15: 561–6.
Paul J. Conaglen,* MBChB Neil A. Collier,† MS, FRACS, FRCS (Eng) *Thoracic Surgery, St Vincent’s and Mercy Private Hospital, and †General Surgery and Gastroenterology Clinical Institute, Epworth Freemasons Hospital, Melbourne, Victoria, Australia doi: 10.1111/ans.12765
Dear Editor, The future of surgical outpatients It has recently come to my attention that the outpatient department at most public hospitals is under great stress. The number of new referrals and review patients has significantly increased in the last decade. For example, at our institution, new referrals per month have increased from an average of 27 per month in 2004 to 137 per month this year. Although the numbers have significantly increased, staffing has not. With the ageing population, this logarithmic increase will ultimately be unmanageable. In orthopaedic and plastic surgery, the majority of review patients can adequately be managed by a general practitioner. However in my experience, general practitioners are not happy in managing these cases due to lack of experience. An option to help alleviate the burden on public outpatients, particularly orthopaedic and plastic outpatients, would be to incorporate an outpatient rotation for training general practitioners. General practice trainees often undertake numerous resident rotations in surgery, but rarely attend the outpatient department due to time constraints. By incorporating a dedicated outpatient rotation for trainee general practitioners, we will add a helping hand to clinic; train future general practitioners to be more confident at managing simple fractures, wounds and post-operative patients; and help prevent delayed referrals for time-critical conditions. Sina Babazadeh, MBBS, PhD Australian Orthopaedic Research Group, Victoria, Australia doi: 10.1111/ans.12777
Dear Editor, Pneumothorax complicating total extraperitoneal repair of inguinal hernia under combined spinal epidural anaesthesia An 18-year-old healthy man with a right indirect inguinal hernia was taken for total extraperitoneal repair (TEP) under combined spinal epidural anaesthesia. After 20 min, the patient started straining and had pain in the abdomen, left shoulder and chest not relieved by fentanyl boluses. In view of severe pain and straining, general anaesthesia was induced. During intubation, oxygen saturation deterio© 2014 Royal Australasian College of Surgeons
rated to 83% with markedly decreased air entry on the right side of the chest with a normal resonant note on both sides of the chest. The position and patency of endotracheal tube were confirmed. Even with no evidence of peritoneal breach, CO2 was deflated immediately. Later, with a partly saline-filled syringe, with needle inserted in the second intercostal space, air bubbles were aspirated and rightsided pneumothorax was diagnosed. Following this, an intercostal tube was inserted in the fourth intercostal space after which the saturation improved. Later, TEP was abandoned and Lichtenstein repair was performed. Postoperatively, intercoastal drainage was removed on the next day and patient was discharged. Pneumothorax occurrence during TEP was well reported. Such thoracic complications find an increased incidence in the surgeries performed via retroperitoneal approach rather than via transperitoneal approach.1 It might be due to some congenital pleuroperitoneal communications or ruptured lung bullae. Both surgeon and anaesthetist need to stay watchful and promptly treat it with appropriate measures. Many a times positive end expiratory pressure ventilation was all that was needed.2 References 1. Abreu SC, Sharp DS, Ramani AP et al. Thoracic complications during urological laparoscopy. J. Urol. 2004; 171: 1451–5. 2. Joris JL, Chiche JD, Lamy ML. Pneumothorax during laparoscopic fundoplication: diagnosis and treatment with positive end-expiratory pressure. Anesth. Analg. 1995; 81: 993–1000.
Naveen Sharma, MBBS, MS (General Surgery) Amit K. Kundu, MBBS Department of General Surgery, University College of Medical Sciences, University of Delhi and Guru Teg Bahadur Hospital, New Delhi, India doi: 10.1111/ans.12770
Dear Editor, Response to Re: Accuracy of visual prediction of pathology of colorectal polyps: how accurate are we? We thank Dr Kostalas1 for his comments regarding our study.2 We are not in disagreement that narrow band imaging (NBI) is helpful. We found, however, that most endoscopists chose not to use NBI. Our point is that pathology of colorectal polyps cannot be accurately predicted with white light alone, and all visualized polyps should be excised for histology.2 Our study2 was designed to assess what happens in real life in a busy unit, with over 7000 annual colonoscopies, at two sites, by 23 endoscopists. Dr Kostalas1 raises some interesting issues. He correctly points out the evidence base for NBI distinguishing types of polyps. We do note that the studies that reported high accuracy combined NBI with a detailed classification system, such as pit patterns, Paris classification and capillary patterns. The study by Hewett et al.3 quoted by Dr Kostalas used a modified Delphi system. These classification systems are complicated, cumbersome to use, and is probably the reason why NBI is underutilized for predictive purposes.
