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Richard Fishburn wrote:
Thank you to Hansson et al for sharing the results of their study which I read with interest. However, I dispute their conclusion that '[comparison of] antibiotics and surgery to treat acute appendicitis found comparable treatment efficacy'.
The design of the study allowed patients, once randomised to a particular treatment, to receive the alternative treatment based on patient preference or medical judgement. Almost 50% of the group allocated to receive antibiotic therapy instead received surgery. Consequently, the authors have chosen to evaluate the data on a per protocol basis (i.e. based on the treatment received rather than on their original allocation). This cannot therefore be considered to be a randomised trial. In 67% of cases where patients allocated to the antibiotic treatment actually received surgery, this occurred because the surgeon deemed surgery to be necessary. Although it is not clear that this decision was made for sound medical reasons in every case, this has led to a highly selected group of patients undergoing surgery and introduced significant bias. Analysis of the patient characteristics of the two groups shows that those undergoing surgery had higher rates of local and general peritonitis and higher mean white cell count pre-operatively. This may in part account for the higher rates of complications in the surgery group.
If the data are instead analysed on an intention to treat basis then the efficacy of treatment with antibiotics is only 48% compared with the figure of 90.8% quoted widely throughout the paper.
Analysis is further confounded by the fact that the authors chose different end-points for the two groups. Efficacy for antibiotic treatment was defined as definite improvement without the need for surgery, whereas efficacy for surgery was defined as confirmed appendicitis at operation or another appropriate surgical indication for operation. As a proportion of patients undergoing surgery did not have appendicitis, efficacy of surgery by this definition is only 89.2%. It follows that a proportion of the group treated with antibiotics also did not have appendicitis, but these are considered as treatment successes. It would perhaps have been a fairer comparison to have as the primary end-point for surgery 'resolution of presenting symptoms' or 'prevention of recurrent appendicitis' which is effectively the same as the antibiotic group, and would make the efficacy of surgery 100% or thereabouts.
The authors state that 13.9% of patients successfully treated primarily with antibiotics developed recurrent appendicitis over a median follow-up of 1 year. Only 60% of patients, however, had reached 1 year follow-up at the time of analysis and only 55% attended follow-up. As patients developed recurrences up to 16 months after the primary episode, the long-term risk of recurrent appendicitis may be considerably higher.
This study presents some evidence for the efficacy of primary treatment of acute appendicitis with antibiotics. However, it does not in my opinion provide sufficient evidence that antibiotics should be considered as a primary therapy in unselected patients. I look forward to the results of the authors¿ follow-up study which I hope will address some of the shortcomings of this paper.
Cheltenham General Hospital
Sun Aug 08 23:36:49 UTC 2010
We'd like to thank Dr. Winters for her comments. We too agree that additional study is required to evaluate the quality of life issues in patients who undergo mastectomy with or without reconstruction. This is reflected in the development of the BREAST-Q © by our colleagues Drs. Pusic and Cordeiro at Memorial Sloan-Kettering Cancer Center. The use of this instrument in the UK NHS Breast Surgery Audit will undoubtedly provide useful information on quality of life outcomes for women undergoing mastectomy with and without reconstruction. Although the benefits of immediate breast reconstruction have not been definitively confirmed with Level I data, there are clearly many compelling reasons to provide this option to patients undergoing prophylactic mastectomy. For instance, Dr. Winters fails to discuss aesthetic considerations in her reply. There is little argument that immediate reconstruction with skin sparing or nipple sparing approaches has improved aesthetic outcomes (1). This issue, taken together with the existing literature in support of the psychological benefit of immediate breast reconstruction for patients who desire reconstruction at the time of mastectomy, makes the proposed randomized trial of immediate versus delayed reconstruction proposed by Dr. Winters particularly problematic to us. As a further point, as discussed in our manuscript, delayed reconstruction is associated with significantly increased resource costs (2), which are an obvious concern in our current health care environment.
Thus, while we agree that future research is warranted, we respectfully disagree with Dr. Winters' contention that patients undergoing prophylactic mastectomy may be ethically denied the option of immediate reconstruction in the interest of a randomized clinical trial. In contradistinction, we anticipate that data collected by the NHS Audit will provide important insight into this complex issue; ultimately, such prospective data will strongly support shared medical-decision, advocacy for breast cancer survivors, and optimal resource allocation.
Breast Surgery Service
Memorial Sloan-Kettering Cancer Center
Anne Burnett Windfohr Chair of Clinical Oncology
1. Kroll SS, Coffey JA Jr, Winn RJ, Schusterman MA. A comparison of factors affecting aesthetic outcomes of TRAM flap breast reconstructions. Plast Reconstr Surg 1995 Sep;96(4):860-4.
2. Khoo A, Kroll SS, Reece GP, Miller MJ, Evans GR, Robb GL, Baldwin BJ, Wang BG, Schusterman MA. A comparison of resource costs of immediate and delayed breast reconstruction. Plast Reconstr Surg 1998;101(4): 964-968.
Acute Colonic Pseudo-obstruction / Ogilvie syndrome - Reply
We thank Dr. Kittisupamongkol for the comment to our article . Because of space restraint, we could not cover in detail each of the multiple factors involved in the complex pathogenesis of acute colonic pseudo-obstruction (Ogilvie syndrome). On the other hand, we do acknowledge that coronary artery bypass grafting and prolonged bed rest may precipitate massive colonic distention.
R. De Giorgio*, C. H. Knowles
Department of Clinical Medicine and Centro Unificato di Ricerca, BioMedica Applicata, University of Bologna, Bologna, Italy;
Centre for Academic Surgery, Royal London Hospital, London, UK
 De Giorgio R, Knowles CH. Acute colonic pseudo-obstruction. Br J Surg 2009; 96: 229-239.
We thank Prof. J. Bellon for his accurate and interesting reply on our recent article. We concur that the modifications to polypropylene in both Timesh® and Ultrapro® are of a different nature than the absorbable layers of Proceed®, C-Qur® and Parietex Composite®. With Timesh®, all fibres are covered all around with titanium; with Ultrapro®, absorbable polyglecaprone fibres are part of the mesh design. Both meshes therefore show a reticular surface. The early differences in adhesiogenic properties of the meshes with an absorbable, layered surface (Proceed®, C-Qur® and Parietex Composite®) might then indeed be explained by different mesothelial cell deposition patterns. However, whether an explanation for the increase of adhesions with these meshes over time can also be explained by these deposition patterns, remains unclear and requires further research.
Marc H.F. Schreinemacher
Department of General Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
Thank you for your interested response and discussion concerning the use of PTFE during portal vein reconstruction. Your points are well taken and center on the traditional concern of graft patency and graft infection.
The article cited in the critique  concerns the patency rate of PTFE grafts used for lower extremity arterial bypass for peripheral arterial disease. In this systematic review, patency rates for PTFE were found to be inferior to the patency rates of native saphenous vein. However, arterial reconstruction for peripheral vascular disease is very dissimilar to the reconstruction of the mesenteric venous system. As is well known to vascular surgeons, the patency of the graft is as dependant on the arterial inflow and outflow as the graft itself. In our patient population, mesenteric flow is constant and the portal system remains unobstructed, creating reliable inflow and outflow through the grafts used in our study. Additionally, all grafts that were used in the referenced article were only 5-8 mm in diameter and were of unknown length, but were likely estimated to be at least 40-80 cm in length. The grafts used in our series were short in length (around 5-8 cm) with large diameter (14 mm). The impact of graft diameter, graft length, flow characteristics are unknown but make it highly probable that comparison between these two uses of PTFE grafts are not valid.
The second point brought up by Al-Ghnaniem et al include the risk of graft infection. This was a concern and reason for the precautions taken to prevent graft infections as described in the manuscript. However, the use of prosthetic graft material for venous reconstruction in the abdomen has been well described , even in the face of concomitant multivisceral resection including the pancreas .
The purpose of our report is to highlight a complementary technique to the use of autologous vein for portal vein reconstruction. This method gives the surgeon an alternative to performing time consuming large calibre vein harvest with subsequent potential for morbidity. However, we agree that further study is warranted on this subject and reasonable patency and low complication rates must be demonstrated before this method can verified as superior to autologous vein use.
J. H. Nguyen,
Division of Transplant Surgery,
4500 San Pablo Road,
1.Mamode N, Scott RN. Graft type for femoro-popliteal bypass surgery. Cochrane Database Syst Rev. 2000;(2):CD001487.
2.Illuminati G, Calio' FG, D'Urso A, Giacobbi D, Papaspyropoulos V, Ceccanei G. Prosthetic replacement of the infrahepatic inferior vena cava for leiomyosarcoma. Arch Surg. 2006 Sep;141(9):919-24;
3.Stauffer JA, Fakhre GP, Dougherty MK, Nakhleh RE, Maples WJ, Nguyen JH. Pancreatic and multiorgan resection with inferior vena cava reconstruction for retroperitoneal leiomyosarcoma. World J Surg Oncol. 2009 Jan 6;7:3.
Sun Aug 08 23:36:50 UTC 2010
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