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during the establishment and maintenance of a high-pressure pneumoperitoneum. We suggest, in the light of these reported catastrophic complications, that patients are carefully selected for laparoscopic cholecystectomy, that penoperative subcutaneous heparin is mandatory, and that the pneumoperitoneum is periodically released during the course of the procedure.
V. Jaffe R. C. G. Russell
Department of Surgery Universiry College London 67-73 Riding House Street London WlP 7LD UK
1 Caldwell CB, Ricotta JJ. Changes in visceral blood flow with elevated intra-abdominal pressure. JSurg Res 1987; 43: 14-20.
Administration of heparin and antibiotic prophylaxis
Sir I read with interest the data from Mr Avery and colleagues (Br J Surg 1994; 81: 987-8) on prophylactic antibiotic administration. Although their figures are interesting, they provide an incomplete picture of compliance to the written protocol. Were the correct drugs administered, in the correct dose and by the correct route? Is there any contingency for #?-lactam sensitive patients, and was this adhered to correctly?
The importance of taking into account these additional data is highlighted from my own compliance studies. There is a fall in the compliance rate from 78 per cent, using the criteria of Avery and colleagues, to 42 per cent if the additional data suggested above are taken into account.
As audit results can now be quoted and used to various ends it is important that they are accurately reported.
Department of Urology Dundee Royal Infirmary Dundee DDI 9ND UK
D. J. Byrne
Sir We thank Mr Byrne for his contribution and entirely agree that every opportunity should be made available to report methodology and results as fully as possible, The study was an audit of practice in several surgical firms and was designed so that data could be unambiguously interpreted by a nonmedical audit officer. A list of acceptable drugs, doses and routes of administration was provided for each group of procedures, and any appropriate antibiotic prophylaxis was deemed as acceptable. The house officers are provided with these guidelines and alternatives for /?-lactam sensitive patients but we have no further data on their use.
Obviously if one makes the administration criteria increasingly stringent, then the apparent compliance rate will fall and there may be difficulty closing the audit circle. It may be that it will be possible to study some of these parameters in more detail in future audits and improve administration practice further.
Preliminary results of a follow-up study have shown a substantial improvement in the administration of heparin prophylaxis and continued high compliance with the antibiotic protocols.
C. M. E. Avery The HaNAnnexe Six Mile Bottom Newmarket Sufolk CB8 O W UK
Reversal of jejunoileal bypass in patients with morbid obesity Sir We read with interest the recent article by Mr Anderson and colleagues on reversal of jejunoileal bypass in morbid obesity (Br J Surg 1994; 81: 1015-17). We congratulate the authors on an honest and accurate account of the complications of what should surely now be an obsolete operation. However, we disagree with their conclusions that patients who require reversal of reconstructive surgery are particularly recalcitrant to losing weight, and that conversion to gastroplasty after reversal produces the same problems that led to the initial reversal. We have found superior long-term results with the use of a Roux-en-Y gastric bypass rather than gastroplasty in ail patients with morbid obesity. We have also found continued weight loss with few compbcations in those who had failed gastroplasty and underwent conversion to Roux-en-Y gastric bypass*. Others have also found good results with simul- taneous conversion to gastric bypass rather than gastroplasty, at the time of reversal of the jejunoileal by pas^^-^. We therefore suggest- that failure to tolerate jejunoileal bypass is not an indication of a recalcitrant patient but rather the result of a poor operation. We also suggest that conversion to Roux-en-Y gastroplasty at the time of reversal is technically feasible and will continue to produce good results, preventing the significant weight gain seen if no other operation is performed after reversal of a jejunoileal bypass.
P. Ridings H. J. Sugerman
Department of Surgery Medical College of Virginia Richmond Virginia 23 298 USA
Sugerman HJ, Londrey GL, Kellum JM et al. Weight loss with vertical banded gastroplasty and Roux-Y gastric bypass for morbid obesity with selective versus random assignment. A m J
Sugerman HJ, Wolper JL. Failed gastroplasty for morbid obesity. Am JSurg 1984; 148: 331-6. Tapper D, Hunt TK, Allen RC, Campbell I. Conversion of jejunoileal bypass to gastric bypass to maintain weight loss. Surg Gynecol Obstet 1978; 147: 353-7. Hitchcock CT, Jewel1 WR, Hardin CA, Hermreck AS. Manage- ment of the morbidly obese after small bowel bypass failure. Surgery 1977; 32: 356-61. Griffen WO, Hostetter JM, Bell RM et al. Experiences with conversion of jejunoileal bypass to gastric bypass. Arch Surg 1981; 116: 320-4.
S ~ r g 1989; 157: 93-9.
Authors reply Sir We are grateful for the comments of Dr Ridings and Professor Sugerman. We too have experimented with other procedures apart from Mason vertical banded gastroplasty, namely biliopancreatic bypass as modified by Cawthome and reported by us at the joint meeting of the Royal College of Surgeons of Edinburgh and the Section of Surgery of the Royal Society of Medicine in May 1994. Unfortunately we have found the metabolic complications unacceptable in the long term.
We recognize Professor Sugermans great expertise in the field of bariatric surgery, but feel that the gold standard is still Mason vertical gastroplasty, which is safe, reliable and uncomplicated. We are sure he will agree that in this difficult field there are patients who, for whatever reason, will fail to lose weight in spite of expert surgery and dedicated care.
P. E. Anderson T. R. E. Pilkington
J.-C. Gazet Parkside Hospital Wim bledon London SW19 5NX UK
British Journal ofSurgery 1994,81, 1827- 183 1