- Email: [email protected]
ANOTHER HAZARD OF PERCUTANEOUS RENAL BIOPSY
778 chronic rejection, remain hypertensive and require drug therapy. In a further three patients, renal-artery stenosis developed and resulted in progressive hypertension: in one, the stenosis was successfully excised, in another the kidney infarcted after an attempted patch graft, and in the third patient the hypertension has now lessened and is easily controlled by drug therapy. It is therefore our policy to carry out renal angiography in transplanted patients whose hypertension persists after removal of their own kidneys: this has given useful information on both major and minor blood-vessels of the grafted kidney. Department of Surgery, Royal Postgraduate Medical School, London W.12.
M. PAPADIMITRIOU A. E. KULATILAKE G. D. CHISHOLM.
ANOTHER HAZARD OF PERCUTANEOUS RENAL BIOPSY SiR,ŅThe accompanying figure illustrates a potential hazard of percutaneous renal biopsy which we have not seen reported. After two attempts to obtain tissue from the kidney of a 59-year-old man, it was observed that a portion of the Franklin modification of the Vim-Silverman biopsy needle was absent. X-rays failed to disclose its presence in the patient, and we
Bisected Vim-Silverman needle lower half.
showing absence of metal plug in
is blocking the movement to the U.S. of qualified professionals from developed countries. If this legislation becomes law its effect will be to swallow up the entire backlog of 50,000 professionals waiting for entry into the U.S. in little more than a year. By that time a new list, more evenly balanced between professionals from developed and developing countries, will have built up. Science
Policy Research Unit, University of Sussex, Brighton BN1 9QN.
O. GISH.
VAGOTOMY AND ACID SECRETION IN GASTRIC ULCER SIR,-Iwas glad to read the paper by Mr. Giles and his colleagues (Aug. 10, p. 306), and hope that it will encourage surgeons to use vagotomy and pyloroplasty for benign gastric ulceration, no matter where the lesion may be placed in the stomach, for there is enough evidence now to justify this. Of my series of 120 patients with benign lesser-curve gastric ulcer treated in this way, the first 72 were studied and the early results published1 The first of these 72 patients was operated on six years ago and the last three years ago. In all there was a long history of peptic disease. In about 80% either duodenal ulceration or pyloric-channel disease could be demonstrated on X-ray examination or at operation. Grassi2 found pyloric-channel disease in 80% of his cases with lesser-curve gastric ulcer. He has used vagotomy and pyloroplasty successfully in cases in which this could be demonstrated. Since 1962 I have chosen to perform vagotomy and pyloroplasty for all cases of gastric ulcer needing surgical treatment, whether or not pyloric or duodenal disease could be shown. In Spain, De Miguel has done the same with excellent results.33 My 5-year results show that recurrent lesser-curve ulcer does occur in a few cases after vagotomy and pyloroplasty for lesser-curve gastric ulcer. The remainder are clinically cured and without X-ray evidence of recurrence. It is generally agreed that benign gastric ulcer cannot occur in the absence of hydrochloric acid. Possibly, as Mr. Giles and his colleagues suggest, incomplete vagotomy is an important cause of recurrent disease when vagotomy is performed for gastric ulcer, just as it is when the operation is done for duodenal ulcer. If vagotomy is important, presumably its completeness
important too. However, at operation in my 2 recurrent cases only was nerve section found to be complete by the electrical-stimulation test but in each patient a single insulin test was negative at the time of recurrence. There was no evidence of gastric retention in either patient. is
therefore concluded that this small piece of metal had been lost during sterilisation. The thought that it might have come loose in the patient, however, remains to disquiet us. This experience has led us to stress the inclusion in our procedure of a scrupulous examination of the biopsy needle before any attempt at biopsy. We test the security of both halves of the small metal plug by probing it firmly with the base of a wooden applicator stick. Department of Medicine, K. D. GARDNER, Jr. Stanford University School of Medicine, N. S. COPLON. Palo Alto, California 94304.
U.S. MEDICAL IMMIGRANTS SIR,-Lately (Aug. 3, p. 277) I described proposed changes in the U.S. Immigration and Nationality Act intended to " eliminate an unintentional discrimination against immigration from [developed countries] while moderating the brain drain from [developing countries] ". The actual legislation takes a form somewhat different from that of the proposals of the Congressional Committee which I described. Instead of sharing out the 17,000 immigration places reserved for professionals between developed and developing countries, the intention is to increase the number of such places to at least 42,500 per year. There is at present a backlog of about 50,000 applicants for professional-category immigration visas. It is this backlog, of professionals from developing countries (virtually all in Asia, for Latin Americans are mainly exempt from American immigration control), which
not
Kennedy and George 4 have reported excellent results from vagotomy and pyloroplasty for gastric ulcer but found that pyloroplasty alone was not successful in preventing recurrence. Pyloroplasty without vagotomy for lesser-curve gastric ulcer would seem unreasonable, for this operation fails to take into account underlying duodenal or pyloric-channel disease, both of which are cured by vagotomy, no matter what the gastricacid levels are. There is no doubt that free acid is important in the xtiology of lesser-curve gastric ulcer. Let us therefore reduce both the cephalic and the hormonal phases of acid secretion by selective vagal section. The problem of malignancy, often put forward as evidence against vagotomy and pyloroplasty for gastric ulcer, is easily solved. To perform a total or near-total gastric resection, with its disturbing mortality and morbidity, for an ulcer thought to be malignant and later shown to be benign, is An inadequate perhaps the greatest mistake in gastric surgery. gastric resection a little distance above a " doubtful" ulcer which in fact is malignant is also a serious error, for it is these patients who return with recurrent cancer in the gastric remnant. The only way to deal with this problem of malig1. Burge, H. Ann. Roy. Coll. Surg. 1966, 38, 349. 2. Grassi, G. Chirurg. Gastroent. 1967, 1, 431. 3. De Miguel, J. Revta esp. Enferm. Apar. dig. 1968, 4. Kennedy, T., George, J. D. Gut, 1967, 8, 632.
27,
no.
1.
M. PAPADIMITRIOU A. E. KULATILAKE G. D. CHISHOLM.
ANOTHER HAZARD OF PERCUTANEOUS RENAL BIOPSY SiR,ŅThe accompanying figure illustrates a potential hazard of percutaneous renal biopsy which we have not seen reported. After two attempts to obtain tissue from the kidney of a 59-year-old man, it was observed that a portion of the Franklin modification of the Vim-Silverman biopsy needle was absent. X-rays failed to disclose its presence in the patient, and we
Bisected Vim-Silverman needle lower half.
showing absence of metal plug in
is blocking the movement to the U.S. of qualified professionals from developed countries. If this legislation becomes law its effect will be to swallow up the entire backlog of 50,000 professionals waiting for entry into the U.S. in little more than a year. By that time a new list, more evenly balanced between professionals from developed and developing countries, will have built up. Science
Policy Research Unit, University of Sussex, Brighton BN1 9QN.
O. GISH.
VAGOTOMY AND ACID SECRETION IN GASTRIC ULCER SIR,-Iwas glad to read the paper by Mr. Giles and his colleagues (Aug. 10, p. 306), and hope that it will encourage surgeons to use vagotomy and pyloroplasty for benign gastric ulceration, no matter where the lesion may be placed in the stomach, for there is enough evidence now to justify this. Of my series of 120 patients with benign lesser-curve gastric ulcer treated in this way, the first 72 were studied and the early results published1 The first of these 72 patients was operated on six years ago and the last three years ago. In all there was a long history of peptic disease. In about 80% either duodenal ulceration or pyloric-channel disease could be demonstrated on X-ray examination or at operation. Grassi2 found pyloric-channel disease in 80% of his cases with lesser-curve gastric ulcer. He has used vagotomy and pyloroplasty successfully in cases in which this could be demonstrated. Since 1962 I have chosen to perform vagotomy and pyloroplasty for all cases of gastric ulcer needing surgical treatment, whether or not pyloric or duodenal disease could be shown. In Spain, De Miguel has done the same with excellent results.33 My 5-year results show that recurrent lesser-curve ulcer does occur in a few cases after vagotomy and pyloroplasty for lesser-curve gastric ulcer. The remainder are clinically cured and without X-ray evidence of recurrence. It is generally agreed that benign gastric ulcer cannot occur in the absence of hydrochloric acid. Possibly, as Mr. Giles and his colleagues suggest, incomplete vagotomy is an important cause of recurrent disease when vagotomy is performed for gastric ulcer, just as it is when the operation is done for duodenal ulcer. If vagotomy is important, presumably its completeness
important too. However, at operation in my 2 recurrent cases only was nerve section found to be complete by the electrical-stimulation test but in each patient a single insulin test was negative at the time of recurrence. There was no evidence of gastric retention in either patient. is
therefore concluded that this small piece of metal had been lost during sterilisation. The thought that it might have come loose in the patient, however, remains to disquiet us. This experience has led us to stress the inclusion in our procedure of a scrupulous examination of the biopsy needle before any attempt at biopsy. We test the security of both halves of the small metal plug by probing it firmly with the base of a wooden applicator stick. Department of Medicine, K. D. GARDNER, Jr. Stanford University School of Medicine, N. S. COPLON. Palo Alto, California 94304.
U.S. MEDICAL IMMIGRANTS SIR,-Lately (Aug. 3, p. 277) I described proposed changes in the U.S. Immigration and Nationality Act intended to " eliminate an unintentional discrimination against immigration from [developed countries] while moderating the brain drain from [developing countries] ". The actual legislation takes a form somewhat different from that of the proposals of the Congressional Committee which I described. Instead of sharing out the 17,000 immigration places reserved for professionals between developed and developing countries, the intention is to increase the number of such places to at least 42,500 per year. There is at present a backlog of about 50,000 applicants for professional-category immigration visas. It is this backlog, of professionals from developing countries (virtually all in Asia, for Latin Americans are mainly exempt from American immigration control), which
not
Kennedy and George 4 have reported excellent results from vagotomy and pyloroplasty for gastric ulcer but found that pyloroplasty alone was not successful in preventing recurrence. Pyloroplasty without vagotomy for lesser-curve gastric ulcer would seem unreasonable, for this operation fails to take into account underlying duodenal or pyloric-channel disease, both of which are cured by vagotomy, no matter what the gastricacid levels are. There is no doubt that free acid is important in the xtiology of lesser-curve gastric ulcer. Let us therefore reduce both the cephalic and the hormonal phases of acid secretion by selective vagal section. The problem of malignancy, often put forward as evidence against vagotomy and pyloroplasty for gastric ulcer, is easily solved. To perform a total or near-total gastric resection, with its disturbing mortality and morbidity, for an ulcer thought to be malignant and later shown to be benign, is An inadequate perhaps the greatest mistake in gastric surgery. gastric resection a little distance above a " doubtful" ulcer which in fact is malignant is also a serious error, for it is these patients who return with recurrent cancer in the gastric remnant. The only way to deal with this problem of malig1. Burge, H. Ann. Roy. Coll. Surg. 1966, 38, 349. 2. Grassi, G. Chirurg. Gastroent. 1967, 1, 431. 3. De Miguel, J. Revta esp. Enferm. Apar. dig. 1968, 4. Kennedy, T., George, J. D. Gut, 1967, 8, 632.
27,
no.
1.