Long-term outcomes of revisional surgery following laparoscopic fundoplication (Br J Surg 2009; 96:...
2
Correspondence 955 Authors’ reply: Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients (Br J Surg 2009; 96: 473–481) Sir We are pleased to observe that our study on the effectiveness of antibiotic treatment of acute appendicitis com- pared to conventional surgery has been found interesting actually far beyond a surgical forum. We are particularly grateful to Doctors Sanabria, Sanchez, Brown, Majumder and Patel with col- leagues who took their time to provide written comments on our work. We are the first to admit that our work is not the final answer how to treat acute appendicitis, but it may be the beginning of the end to offering all patients surgery as a first treatment option. Such a development should be a stepwise process to improve and simplify treatment with less harm to patients and costs to the society. The design of our study was to mimic, as closely as possible, daily practical condi- tions in treatment of patients with acute appendicitis in most hospitals including our own. This should by no means intro- duce additional diagnostic procedures or increased costs to our departments. We agree that evaluations by intention to treat or per protocol in clinical studies may end up with different conclusions. Complication rates may also appear dif- ferent, when either open or laparoscopic surgery is applied by more or less expe- rienced surgeons. It is also true that the diagnostic accuracy of appendicitis is usually recognized to be improved to some extent, when all available imaging techniques are applied. All these con- cerns are real and represent factors that should be considered in evaluation of our study. However, we feel confident that the use of a simultaneous refer- ence population in our neighbouring hospital makes it unlikely that impor- tant bias was introduced in selection of our patients and thereby misled us to entirely wrong final conclusions. It is important to emphasize that it was not possible to refuse eligible patients to be treated either by antibiotics or surgery considering ethical considera- tions and patient integrity. Therefore, it was necessary to allow both patients and the surgeons to make their own decision when ‘deemed necessary’ or wished according to patient preference. Of course, this may have introduced unidentified bias, although our regis- tered information did not confirm such worries when comparing clinical infor- mation among subgroups of patients. A study of this kind may also be a matter of how to correctly define end- points in comparison between antibiotic treatment and surgery. We agree that intellectual aspects of study design may end up with different solutions. How- ever, from the patients’ perspective it should be enough to be relieved from acute medical symptoms at low risk fol- lowed by rapid recovery (antibiotics). Of course, this may introduce some over-treatment by antibiotics, but on the other hand it will also reduce neg- ative explorations in patients intended for conventional appendicectomy. With all these limitations in mind, we now encourage our patients, according to our next protocol, to try antibiotic treat- ment as their first treatment in order to confirm or reject our previous conclu- sion that antibiotic treatment is a safe first line therapy in acute appendicitis in the majority of unselected patients. We would also comment that we find it equally valid for patients to be random- ized according to birth date compared to a conventional envelope procedure, which was also the view of our ethical board. J. Hansson and K. Lundholm Department of Surgery, Sahlgrenska University Hospital, SE 413 45 Gothenburg, Sweden DOI: 10.1002/bjs.6765 Long-term outcomes of revisional surgery following laparoscopic fundoplication (Br J Surg 2009; 96: 391–397) Sir We read with great interest the arti- cle ‘Long-term outcomes of revisional surgery following laparoscopic fundo- plication’. We appreciate the great efforts of the authors to improve the outcome of the anti-reflux surgery (ARS) by addressing the indications and causes of the failure of the primary ARS. We have the following points which we think are complementary to the scientific value of the article. The authors suggested combination of upper gastrointestinal endoscopy, barium swallow, oesophageal manom- etry and 24-hour pH studies as initial assessment of failed ARS; however, they did not mention whether all patients were subjected to these tests or they would advise on selection criteria. It would be of great educational value to know the cause of anatomical or physiological failure especially in the group of patients who had recurrent heartburn or atypical symptoms. We are especially interested in the concept of wrap migration. Failure of hiatal closure has proven to be the most frequent complication leading to revisional surgery 1 . In prac- tice we found it difficult to assess the hiatus and mechanical problem in the majority of the patients without taking the wrap down. It is interesting that the authors’ policy is not to take the wrap down unless there is ‘concern about the wrap’. It has been mentioned that ‘patients with symptoms from a para-oesophageal hernia underwent reduction of her- niated structures with dissection of the hernia sac’. In our experience it will be difficult to close the defect in the majority of patients with large para-oesophageal hernia. Oesophageal lengthening will provide intra-abdominal length of oesophagus below the diaphragm. The new fundus can be fixed to the left crus or used as a wrap, and patients are followed up by barium swallow for anatomical assessment. The authors used ‘a standardized structured questionnaire that evaluated symptom scores and overall satisfaction with the outcome’. In every ARS the ultimate goal is to relieve the symp- toms. In certain cases there will be no symptoms in spite of anatomical Copyright 2009 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2009; 96: 951–960 Published by John Wiley & Sons Ltd
Transcript of Long-term outcomes of revisional surgery following laparoscopic fundoplication (Br J Surg 2009; 96:...
Correspondence 955
Authors’ reply: Randomized clinicaltrial of antibiotic therapy versusappendicectomy as primarytreatment of acute appendicitis inunselected patients (Br J Surg 2009;96: 473–481)
SirWe are pleased to observe that our
study on the effectiveness of antibiotictreatment of acute appendicitis com-pared to conventional surgery has beenfound interesting actually far beyonda surgical forum. We are particularlygrateful to Doctors Sanabria, Sanchez,Brown, Majumder and Patel with col-leagues who took their time to providewritten comments on our work.
We are the first to admit that ourwork is not the final answer how totreat acute appendicitis, but it may bethe beginning of the end to offeringall patients surgery as a first treatmentoption. Such a development shouldbe a stepwise process to improve andsimplify treatment with less harm topatients and costs to the society. Thedesign of our study was to mimic, asclosely as possible, daily practical condi-tions in treatment of patients with acuteappendicitis in most hospitals includingour own. This should by no means intro-duce additional diagnostic proceduresor increased costs to our departments.We agree that evaluations by intentionto treat or per protocol in clinical studiesmay end up with different conclusions.Complication rates may also appear dif-ferent, when either open or laparoscopicsurgery is applied by more or less expe-rienced surgeons. It is also true thatthe diagnostic accuracy of appendicitisis usually recognized to be improved tosome extent, when all available imagingtechniques are applied. All these con-cerns are real and represent factors thatshould be considered in evaluation ofour study. However, we feel confidentthat the use of a simultaneous refer-ence population in our neighbouringhospital makes it unlikely that impor-tant bias was introduced in selectionof our patients and thereby misled usto entirely wrong final conclusions. Itis important to emphasize that it wasnot possible to refuse eligible patients
to be treated either by antibiotics orsurgery considering ethical considera-tions and patient integrity. Therefore,it was necessary to allow both patientsand the surgeons to make their owndecision when ‘deemed necessary’ orwished according to patient preference.Of course, this may have introducedunidentified bias, although our regis-tered information did not confirm suchworries when comparing clinical infor-mation among subgroups of patients.
A study of this kind may also be amatter of how to correctly define end-points in comparison between antibiotictreatment and surgery. We agree thatintellectual aspects of study design mayend up with different solutions. How-ever, from the patients’ perspective itshould be enough to be relieved fromacute medical symptoms at low risk fol-lowed by rapid recovery (antibiotics).Of course, this may introduce someover-treatment by antibiotics, but onthe other hand it will also reduce neg-ative explorations in patients intendedfor conventional appendicectomy. Withall these limitations in mind, we nowencourage our patients, according toour next protocol, to try antibiotic treat-ment as their first treatment in order toconfirm or reject our previous conclu-sion that antibiotic treatment is a safefirst line therapy in acute appendicitisin the majority of unselected patients.We would also comment that we find itequally valid for patients to be random-ized according to birth date comparedto a conventional envelope procedure,which was also the view of our ethicalboard.
J. Hansson and K. LundholmDepartment of Surgery, Sahlgrenska
University Hospital, SE 413 45Gothenburg, Sweden
DOI: 10.1002/bjs.6765
Long-term outcomes of revisionalsurgery following laparoscopicfundoplication (Br J Surg 2009; 96:391–397)
SirWe read with great interest the arti-
cle ‘Long-term outcomes of revisional
surgery following laparoscopic fundo-plication’.
We appreciate the great efforts ofthe authors to improve the outcomeof the anti-reflux surgery (ARS) byaddressing the indications and causes ofthe failure of the primary ARS. We havethe following points which we think arecomplementary to the scientific value ofthe article.
The authors suggested combinationof upper gastrointestinal endoscopy,barium swallow, oesophageal manom-etry and 24-hour pH studies as initialassessment of failed ARS; however, theydid not mention whether all patientswere subjected to these tests or theywould advise on selection criteria.
It would be of great educational valueto know the cause of anatomical orphysiological failure especially in thegroup of patients who had recurrentheartburn or atypical symptoms. Weare especially interested in the conceptof wrap migration.
Failure of hiatal closure has provento be the most frequent complicationleading to revisional surgery1. In prac-tice we found it difficult to assess thehiatus and mechanical problem in themajority of the patients without takingthe wrap down. It is interesting that theauthors’ policy is not to take the wrapdown unless there is ‘concern about thewrap’.
It has been mentioned that ‘patientswith symptoms from a para-oesophagealhernia underwent reduction of her-niated structures with dissection ofthe hernia sac’. In our experienceit will be difficult to close thedefect in the majority of patientswith large para-oesophageal hernia.Oesophageal lengthening will provideintra-abdominal length of oesophagusbelow the diaphragm. The new funduscan be fixed to the left crus or usedas a wrap, and patients are followedup by barium swallow for anatomicalassessment.
The authors used ‘a standardizedstructured questionnaire that evaluatedsymptom scores and overall satisfactionwith the outcome’. In every ARS theultimate goal is to relieve the symp-toms. In certain cases there will beno symptoms in spite of anatomical
Copyright 2009 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2009; 96: 951–960Published by John Wiley & Sons Ltd
956 Correspondence
failure of the repairs and the reverseis true2. We agree with authors thatsubjective assessment is important andthe response to surgery therefore high-lighted. Nevertheless, objective testswill provide complete assessment of theproposed technique.
The authors noted that the patternof failure appeared to be related to thetype of original fundoplication. Stewartet al. has pointed out that the level ofexperience of the surgeon in a particularoperation was more important than theprocedure performed3.
A. Hussain, T. Singhal, T. Ansari,B. Aravind and S. El-Hasani
Minimal Access Unit, General SurgeryDepartment, Princess Royal University
Hospital, Farnborough Common,Orpington, Kent, BR6 8ND, UK
DOI: 10.1002/bjs.6766
1 Granderath FA, Granderath UM,Pointner R. Laparoscopic revisionalfundoplication with circular hiatalmesh prosthesis: the long-term results.World J Surg 2008; 32: 999–1007.
2 Khajanchee YS, O’Rourke RW,Lockhart B, Patterson EJ, Hansen PD,Swanstrom LL. Postoperativesymptoms and failure after antirefluxsurgery. Arch Surg 2002; 137:1008–1013.
3 Stewart GD, Watson AJ, Lamb PJ,Lee AJ, Krukowski ZH, Griffin SM,et al. Comparison of three differentprocedures for antireflux surgery. Br JSurg 2004; 91: 724–729.
Authors’ reply: Long-termoutcomes of revisional surgeryfollowing laparoscopicfundoplication (Br J Surg 2009; 96:391–397)
SirThank you for the opportunity to
respond to the letter from Dr Hus-sain and colleagues in regard to ourmanuscript entitled ‘Long-term out-comes of revisional surgery follow-ing laparoscopic fundoplication’. Thepoints raised are addressed as follows:
Before undertaking revisional surgerywe believe we need as much fore-knowledge as possible. Other tests, suchas radionuclide oesophageal emptying,radionuclide gastric emptying, specialmanometry, etc. are sometimes used inindividual patients and for specific indi-cations.
Aside from anatomical abnormalitiessuch as a para-oesophageal hiatus her-nia, we often find that assessing whathas gone wrong at operation is difficult.Nevertheless, we always try to answerthe question and in the group of revi-sional operations that we reported, themain operative findings are as follows:tight hiatus, 26 patients (18 patients pos-sible iatrogenic narrowing, 8 patientsexcessive hiatal fibrosis); incompetenceof the wrap, 19 patients (15 an anteriorpartial wrap); para-oesophageal hiatushernia, 16 patients; surgeon uncertainof the cause, 15 patients; tight wrap, 12patients; hiatal disruption with migra-tion, 12 patients, and slippage of thewrap, 4 patients. As you can see, migra-tion of the wrap was not somethingwhich we considered to be a very com-mon cause of failure.
Similarly, hiatal disruption was notthe most frequent reason leading torevisional surgery in our patients. Ourpolicy at revisional surgery is always tomobilize the oesophagus first. If we areunable to do this then usually we find itnecessary to take the wrap down.
Our unit believes that an oesophageallengthening procedure is rarely indi-cated in patients having anti-refluxsurgery. That does not mean we alwaysobtain what might be regarded asan adequate length of intra-abdominaloesophagus in all patients. In manycases, the gastro-oesophageal junctionis at about the level of the hiatus at theend of these procedures. It is just that,in practice, this does not seem to lead topoor outcomes.
I don’t think anybody doubts that inan ideal world objective testing wouldbe obtained in all patients. However,in practice, many patients decline suchthings as 24-hour pH testing unless it isregarded as absolutely crucial.
We have previously published ourexperience with a learning curve inlaparoscopic anti-reflux surgery. We
have unpublished data which suggestthat, providing trainees are assistedby an experienced surgeon, then theexperience factor can be largely ignored.This probably holds for revisionalsurgery as well but we do not have datato support this contention.
G. G. Jamieson, P. J. Lamb andS. K. Thompson
University of Adelaide, North Terrace,Adelaide, South Australia 5005, Australia
DOI: 10.1002/bjs.6767
Faecal occult blood test-basedscreening programme with highcompliance for colonoscopy has astrong clinical impact on colorectalcancer (Br J Surg 2009; 96:533–540)
SirThis study reflects the results of
some other faecal occult blood (FOB)based screening programmes and actsto remind us that even if the screeningtest was accurate, compliance of thoseat most risk of colorectal cancer (CRC)is lowest1. The truth of the matteris that the FOB test is not verysensitive or specific, thus when theUK flexible sigmoidoscopy trial2 reporttheir results shortly, there may haveto be a reassessment of the UK CRCscreening programme.
Anecdotal evidence of our early UKCRC screening results suggests the vastmajority of lesions would have beenpicked up by a flexible sigmoidoscopyalone. This is supported by a recentDutch study that demonstrated thatflexible sigmoidoscopy in a similar agepopulation allows detection of almost80 per cent of CRC cases3; whilst ourown results suggest that the FOBtest misses two-thirds of CRC4. Theabove may be a consideration beforethe authors lend support to their ownnational CRC screening being FOB-based.
G. F. NashPoole Hospital NHS Foundation Trust,
Longfleet Road, Poole, Dorset BH15 2JB,UK
DOI: 10.1002/bjs.6768
Copyright 2009 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2009; 96: 951–960Published by John Wiley & Sons Ltd
