498

in patients undergoing hernia repair or similar minor procedures, apart from those with a past history of deep vein thrombosis or women taking oral contraceptives? In otherwise fit patients undergoing this type of surgery, postoperative deep vein thrombosis is extraordinarily rare.

A study of the prevention of deep vein thrombosis in patients having hernia repairs was started at the Lambeth Hospital in the early 1970s but had to be abandoned due to failure to detect any thrombosis using the IZ51-fibrinogen uptake test. In my wards at Lewisham and Hither Green Hospitals. no patient undergoing hernia repair has developed physical signs of deep vein thrombosis or pulmonary embolism in the past 5 years. TED stockings and early ambulation have been the only methods of prophylaxis.

Experience has shown that most postoperative deep vein thromboses develop in patients undergoing major abdominal or thoracic pro- cedures, as far as general surgery is concerned. These patients certainly need vigorous prophylaxis. They also require intravenous fluids for the first few postoperative days and this is a convenient route for the heparin. Only a very small dose ( I i.u. kg-'hK1) is required ( I ) , and this also helps to prolong 'drip life' with obvious benefits to both patients and house surgeons (2).

Albert Embankment Consulting Rooms York House 199 Westminster Bridge Road London SEI I .

DAVID NEGUS

Negus D., Friedgood A,, Cox S . J. et al.: Ultra-low dose heparin in the prevention of postoperative deep vein thrombosis. Lancet 1980; 1: 891-4. Stradling J. R.: Heparin and infusion phlebitis. Br. Med. J . 1978; 2: 1196-7.

2.

Correspondence

are well aware of the information it gives. We would suggest that the technique is a lateralizing rather than a localizing aid. It is inconceiv- able that i t could differentiate between an intrathyroid and an extra- thyroid parathyroid gland. Further. in 12 of 95 patients Dunlop et al. ( I ) reported that the technique was either unhelpful or even misleading.

Ultrasound examinations have been carried out in a number of centres and seem to be able to detect large parathyroid adenomas. but there are a significant number of false positives and false negatives.

In particular, differentiation between the rather rare intrathyroid parathyroid adenoma and the common thyroid nodule would appear to be difficult.

Our policy of reserving localizing techniques for failed neck explora- tions is similar to that adopted in most centres with a major interest in parathyroid surgery. Our initial successful exploration rate in 98 cases was 94 per cent, which is in agreement with other series where localized techniques have not been employed. This series was collected over a decade and the re-explorations occurred during the early days before we fully appreciated the possibility of intrathyroid parathyroid aden- omas. In the most recent 100 cases the initial exploration was successful in 98. We are gratified to learn that Billings and Milroy find a similar instance of intrathyroid glands to our experience.

Virtually all our patients have been investigated and diagnosed by one of us (D.A.H.) almost exclusively as outpatients. The total inpatient stay is usually between 4 and 7 days. Is the expensive and invasive policy at the Middlesex Hospital giving better results? Specifi- cally. we would be interested to hear in how many cases an intrathyroid parathyroid adenoma was successfully predicted preoperatively at the Middlesex Hospital.

D. A. HEATH E. T. BAINBRIDGE

A. D. BARNES The Queen Elizabeth Hospital

Overactive intrathyroid parathyroid glands Sir We would like to comment on the paper by Bainbridge and Barnes (Br. J . Surg. 1982; 6 9 200-2) and their operative findings in patients with intrathyroid hyperactive parathyroid glands. They are somewhat dis- missive of attempts a t preoperative localization of parathyroid adenomas. Two patients in their group of 6 needed a second operation to find the adenoma and it was only by chance in 2 other patients that the correct thyroid lobe was excised at the first attempt. It is precisely in patients with unanticipated operative difficulties such as these that localization studies may save the patient a second time-consuming and hazardous operation.

Our current practice is to perform both small vein parathyroid venous sampling and ultrasound examination on all cases of primary hyperparathyroidism. Small vein sampling has previously been reported from this centre as giving helpful information in 87.5 per cent of cases (1). There is an acceptably low morbidity associated with small vein sampling. Our recent prospective study of ultrasound localization has shown preoperative localization of the adenoma in 52 per cent of cases (2) with continuing improvement in these results with increasing experience and more sensitive equipment.

With the help of these two localizing procedures, it might well have been possible to save these 2 patients a second operation, and to resolve completely the surgical problems of localization in the other 4 patients. We feel that preoperative localization studies should not be so lightly dismissed and that they do have a useful role to play.

In our recent series of 223 patients with surgically proved hyperpara- thyroidism. I 1 (4.9 per cent) were found to have an intrathyroid parathyroid adenoma. Ten of these patients had localization studies, and in 8 the adenoma was successfully localized by one of the techniques described above. None of the patients required a second operation.

PETER BILLINGS EUAN MILROY

The Middlesex Hospital Mortimer Street London WIN 8AA I . Dunlop D. A. B., Papapoulos S . E., Lodge R. W. et al.:

Parathyroid venous sampling: anatomic consideration and results in 95 patients with primary hyperparathyroidism. Br. J . Radio[. 1980; 53: 183-91. Thomas D. M . , Watson L. R., Lees W. R. et al.: An evaluation of ultrasound in 'preoperative parathyroid localisation. First Meeting of the Endocrine Surgical Group, Birmingham 1981.

2.

Sir We were interested and surprised to receive the comments of Billings and Milroy which appeared to show a number of misunderstandings of the presently available localizing techniques. One of us (D. A. H.) has had extensive experience of small vessel venous catheterization and we

Edgbaston Birmingham B15 2TH - 1. Dunlop D. A. B., Papapoulos S . E., Lodge R. W. et al.:

Parathvroid venous samdine: anatomic consideration and results in 95 patients with primary"hyperparathyr0idism. Br. J . Radio/. 1980; 53: 183-91.

Intravenous and oral metronidazole Sir The paper from Peterborough (Br. J . Silrg. 1982; 6 9 226-7) comparing intravenous and oral metronidazole as prophylaxis in colorectal surgery confirms the controversy between some surgeons in the UK and the US about the relative efficacy of these two methods of administration.

The debate has not been helped by the fact that the Aeberhard ( I ) and Burdon (2) papers were reported separately, although they had been set up as one study initially. If systemic antibiotics are better or worse than oral ones in this situation, they may be acting in different ways. The former to reduce bowel flora at the time of excision and contamination, and the latter to produce high bactericidal tissue and serum levels for the critical short postoperative period. The paper from Peterborough does not add much weight to this argument as only the anaerobes were significantly affected by the oral course. However. no details of bacterial concentrations were given.

Until the Birmingham paper in the same issue of the journal (3), a course of antibiotics longer than 24 h had never been shown to be more effective than one lasting that time alone in colorectal prophylaxis. This concept will remain, as the inflammatory bowel disease studied in this paper must be considered (as the authors concede) as a case of 'therapy' and not 'prophylaxis'. I emphasize this point as papers are 'misread' so easily. This paper was reported to me by a colleague as evidence that we should be using 5-day courses of antibiotics in all colorectal surgery.

The Peterborough group used a 5-day course of oral antibiotics. This is unnecessary as bowel flora is maximally altered within only 16 h, as Bartlett and others have shown (4).

Thus, although the verdict between ,short oral and shori systemic prophylaxis is still awaited, there is no indication that anything more than a 24-h course of antibiotics, whether preoperative. postoperative or both, is justified. In the words of Peter Pindar (1738-1819): 'People may have too much of a good thing'.

Faculty of Medicine University Surgical Unit F Level, Centre Block Southampton General Hospital SO1 6HU 1.

PETER MCDONALD

Aeberhard P., Berger J. and Casey P. A,: A comparison of oral bowel preparation and intravenous chemotherapy given at the time of operation. R. Soc. Med. Int. Congr. Sjmp. Ser. 1979; 18: 173-7. Burdon D. W. and Keighley M. R. B.: A comparison of the prophylactic effect of parenteral metronidazole and kanamycin with oral metronidazole and kanamycin in colorectal surgery. R . SOL.. Med. Int. Congr. Synip. Ser. 1979; 18: 179-83.

2.

Correspondence 499

3. Hares M. M., Bentley S., Allan R. N. et al.: Clinical trials of the When this study began in 1978. 5-day courses of antibiotics were eficacy and duration of antibacterial cover for elective resection commonly given, though we would agree that most evidence now in inflammatory bowel disease. Br. J . Surg. 1982: 69: 215-17. suggests that courses longer than 36-48 h are probably unnecessary.

4. Bartlett J. G.. Condon R. E. Gorbach S. L. et al.: Veterans Of more importance, perhaps. is the fact that the paper by Bartlett et administration cooperative study on bowel preparation for al. ( I ) found no evidence of development of resistant organisms after elective colorectal operations. .4nn. Surg. 1978; 188: 249-55. oral neomycin and erythromycin

F. U. BtGGS Sir We would agree with the letter from Mr McDonald that prophylactic oral and systemic antibiotics may act in different ways and highlighted this in our paper.

Although we did not measure bacterial counts, and the aerobic recovery rate from bowel washings was the same in both groups, the infection rate was not significantly different in the two groups. The infection rate of 13 per cent in the oral group was much lower than would have been expected if the neomycin had had no effect.

R. S. JOBANPUTRA J . T. HOLMES

Peterborough District Hospital Thorpe Road Peterborough PE3 6DA 1 . Bartlett J. G., Condon R. E., Gorbach S. L. et al.: Veterans

administration cooperative study on bowel preparation for elective colorectal operations. Ann. Surg. 1978; 188: 249-55.

Br. J. Surg. Vol. 69 (1982) 499-500 Printed in Great Britain

Book reviews

Complications in Surgery and Their Management James D. Hardy. Fourfh edition. 265 x 190mm. Pp. 919+xxxii. Illustrated. 1981. Eustbourne: Saunders. f47.90. In this age of surgical audit it is increasingly difficult to explain away postoperative problems with comments such as ‘this has never happened to me before’. Postoperation complications have a unique fascination for surgeons-specially if the patient belongs to someone else. It is only by a proper and objective study of the incidence and causes of postoperative complications that such problems can be reduced or eliminated.

The first edition of this book appeared in 1960 and the appearance of a fourth edition attests to its success. The first part contains a discussion of general topics including infection, shock and cardiovascu- lar, renal and pulmonary complications which may follow any opera- tion or injury. Separate contributions follow by individual specialty.

It is difficult to know at whom this book is aimed, for, with present day specialization, there must be very few surgeons whose interest will encompass coronary artery bypass surgery, burns, transplantation, vaginal surgery and common long bone fractures, not to mention 70 pages on anaesthesia.

The content of the chapters is somewhat uneven. The contribution on thyroid surgery includes a detailed account of thyroidectomy in an effort to emphasize the ,prevention of complications, whereas the section on biliary tract surgery does not contain a formal description of cholecystectomy. The emphasis placed on various topics will also seem somewhat uneven to the British reader. The complications of vago- tomy, pyloroplasty and gastrostomy are all dealt with on part of one page (inadvertent oesophageal damage is not mentioned). whereas adrenal surgery rates 15 pages. The complications of appendicitis are discussed at length and, although the importance of the role of anaerobes in the development of residual infection is emphasized, metronidazole, which has recently become available in the USA, is not mentioned, despite the extensive British literature. Also there is no discussion of the possible value of delayed primary suture of the appendicectomy wound when severe bacterial peritonitis has been found.

The book is well produced and well illustrated. At the end of most sections there is an up-to-date list of references, predominantly North American. These attributes make it a pleasant and interesting book to browse through and a good starting point from which to pursue references on a particular topic. Whether it is the sort of book that a surgeon will want to own seems less certain, for by attempting to be comprehensive it inevitably contains much that is outside the daily experience of any one individual.

J . DAWSQN

Surgical Problems in Chitdren. Recognition and Referral Howard C. Filston. -770 x I85 mm. Pp. 596 -k svii. Illustrated. 1981 London: Yecir Book. €39.50. THE main role of the primary care physician, better known as the general practitioner in the UK. is the recognition and early referral of surgical conditions, without undue delay which might compromise the final result. The primary care physician should also be aware of complications which may occur in the long term follow-up. He plays an important role in the management of children with malignant disease

with special emphasis on the administration of cytotoxic therapy according to specific protocol, and he is the lynchpin of support for the family and the child, especially where therapy fails. Dr Filston lays particular stress on the recognition of various conditions which the primary care physician is likely to encounter.

The book is subdivided into sections according to the age of the child, and in each section general, urological, neurosurgical and orthopaedic problems are discussed. In the neonatal section I should like to have seen a chapter devoted to transportation, including the equipment and drugs required for the successful transfer of the critically ill infant. The chapter on the acute abdomen is outstanding. especially that part relating to the examination of the child. Rebound tenderness is quite correctly condemned as a useless and unnecessarily disturbing manoeuvre. I was a little surprised that suction rectal biopsies are only used as a screening test for Hirschsprung’s disease and that full-thickness biopsy is considered essential for definitive diagnosis. A slightly irritating and recurrent paragraph is headed ‘Medical versus surgical treatment’ when at times medical management is clearly inappropriate, e.g. atresias, diaphragmatic hernia, Meckel’s diverticulum, etc.

Apart from these minor criticisms. I would consider this book valuable for paediatricians and family practitioners. It deliberately exludes reference to surgical technique as its stated purpose is the recognition and referral of children with surgical conditions to those best equipped to deal with them, namely paediatric surgeons.

L. SPITZ

Alimentary Sphincters and their Disorders Paul A . Thomas and Charles V. Mann. 240 x 160mm. Pp. 236-k.v Illustrated. 1981. London: Macmillan. E35.00. THE alimentary sphincters have fascinated physicians, frustrated research workers and flawed physiologists for a long time. It is therefore timely and bold of the editors of this book to try to bring together an up-to-date account of all the possible sphincters in the intestinal tract. ‘Possible’, indeed, since many readers will remain unconvinced of the true sphincter function of the ileocaecal valve or the rectosigmoid junction. Fashion and physiology have now probably justified placing the pylorus in the category of a true sphincter.

Although the book has been well produced with a high proportion of excellent contributions, one must question if there is a need for yet another gastrointestinal text to describe a highly specialized aspect of intestinal function. The book is unlikely to be read except by the enthusiast who has an interest in investigating intestinal physiology. If indeed this is the aim of the book, then it has an important contribution and should stand on the shelves of those involved in such studies. The editors have been well advised therefore to include details of compara- tive anatomy and physiology including those animals likely to be used for laboratory research. It would have been even more stimulating if each contributor had defined the problem areas and the ways in which studies might proceed in the future.

The book contains an excellent account of the gastro-oesophageal sphincter with a balanced description of the applied physiology of the region as well as the abnormalities of functions encountered in disease. Particularly valuable is Professor Johnson’s chapter on the pylorus, but in the chapter on the biliary sphincter I am surprised that greater emphasis has not been placed upon endoscopic pressure studies. It is