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Incidental Meckel's diverticulectomy
Letters Incidental
Meckel’s
to the editors diverticulectomy
To the Editors: I read with interest the article by Peoples et al.’ and applaud their efforts to perform a me&analysis on incidental Meckel’s diverticulectomy in adults. However, I disagree with their conclusions. The definitions of morbidity and complications are disparate among the series used for the metaanalysis. In addition, they attribute the morbidity rate of laparotomy for symptomatic intraabdominal lesions in which incidental Meckel’s diverticulectomy was also performed to the incidental Meckel’s diverticulectomy itself and compare it directly to the actual morbidity rate for patients who underwent laparotomy for Meckel’s diverticula that were pathologic and the primary indication for surgery. The former group of patients whose morbidity was attributed to the incidental diverticulectomy are not an appropriate population for comparison. This group had indications for exploration that spanned a broad spectrum of pathologic conditions, none of which was Meckel’s diverticulum. Because surgical morbidity can be the result of anesthesia, the opening, exploration, and closing of the abdomen, the pathologic state of the organs, or the specific procedures performed, it is difficult in the clinical situation to identify one specific cause among the many as the sole cause of a complication. Perhaps a more appropriate population to consider would be those patients who undergo appendectomy and are found to have a normal appendix or other elective clean-contaminated gastrointestinal procedures.* The problems with conditional probabilities and decisional analysis are best demonstrated by their conclusion that “the probability of morbidity occurring as a result of surgically treating only those patients who require it would be . .0.2% .” From their analysis of previously published articles they determined the morbidity rate of surgically treating patients with symptomatic Meckel’s diverticula that required surgery to be 8.5%. They calculated the risk of surgical morbidity induced by only resecting symptomatic Meckel’s diverticula and apply it to the entire population of operative and nonoperative patients with Meckel’s diverticula. The risk of surgical morbidity should be zero in patients not undergoing operation. They have allowed statistics to confuse their conclusions. They demonstrated the true and real rate of morbidity in symptomatic patients to be 8.5%, compared with 4.1% for patients who undergo laparotomy for other surgical conditions and have an incidental Meckel’s diverticulectomy. We believe their results support incidental diverticulectomy. J, Christopher DiGiacomo, MD Assistant Director, Trauma Center Jersey Shore Medical Center Nqtuae, NJ F. John Cottone, MD Director of Surgery Saint Francis Medical Center Trenton, NJ References 1. Peoples JB, Lichtenberger EJ, Dunn MM. Incidental verticulectomy in adults. Surgery 1995;118:649-52. 234
SURGERY
Meckel’s
di-
2. Warren JL, Penberthy LT, Addiss DG, McBean AM. Appendectomy incidental to cholecystectomy among elderly medicare beneficiaries. Surg Gynecol Obstet 1993;177:288-94. 11/59/78412
Reply To The Editors: The comments by DiGiacomo and Cottone in reference to our article, “Incidental Meckel’s Diverticulectomy in Adults,” focus primarily on the inaccuracies inherent in ascribing surgical complications to an incidentally performed procedure rather than to the indicated primary procedure, especially when it is attempted as part of a metaanalysis based on retrospective series. We agree entirely. In our own included series of 90 patients undergoing incidental diverticulectomy, we were very careful to include surgical complications that could only be a result of the incidental procedure. This amounted to two complications for a 2% morbidity rate. If anything, this would underestimate the probable true morbidity rate. The surgical complication rate associated with indicated diverticulectomy done for complications associated with the anomaly ranges from 0% (as in our own series) to a high of 33%. For our analysis we used the cumulative rate from all previous reports, which was 8.5%. This, if anything, most likely overestimates the true current morbidity rate. The crux of the argument is not really the actual morbidity rates associated with diverticulectomy done incidentally or primarily. The overriding issue, which most directly leads to our conclusion and which Drs DiGiacomo and Cottone did not comment on, is that an individual with a Meckel’s diverticulum who has reached the age of 21 years without having a problem with the anomaly has only a 2.5% incidence of ever having a problem requiring surgical intervention during the rest of his or her lifetime. Because of this extremely low incidence, nearly 50 asymptomatic diverticula would need to be removed incidentally to prevent the development of one symptomatic lesion. It does not require sophisticated mathematics to determine on this basis that incidental diverticulectomy could only possibly be justified if the morbidity attendant to the additional procedure was zero. This has not been the finding in any reported series. We thank DiGiacomo and Cottone for their comments, but we stand by our original conclusion that incidental Meckel’s diverticulectomy in adults should be abandoned. ./ames B. Peoples, MD Professor and Chair Dqartment of Surgeq Wright State University School of Medicine Dayton, OH 11/59/78413
Angiograpbic salvage of a malpositioned catheter: A cost-effective tool To the Editors: Since the introduction in the late 1970s their
of Hickman use has grown
Hickman
central venous catheters quite rapidly. Their effi-
Meckel’s
to the editors diverticulectomy
To the Editors: I read with interest the article by Peoples et al.’ and applaud their efforts to perform a me&analysis on incidental Meckel’s diverticulectomy in adults. However, I disagree with their conclusions. The definitions of morbidity and complications are disparate among the series used for the metaanalysis. In addition, they attribute the morbidity rate of laparotomy for symptomatic intraabdominal lesions in which incidental Meckel’s diverticulectomy was also performed to the incidental Meckel’s diverticulectomy itself and compare it directly to the actual morbidity rate for patients who underwent laparotomy for Meckel’s diverticula that were pathologic and the primary indication for surgery. The former group of patients whose morbidity was attributed to the incidental diverticulectomy are not an appropriate population for comparison. This group had indications for exploration that spanned a broad spectrum of pathologic conditions, none of which was Meckel’s diverticulum. Because surgical morbidity can be the result of anesthesia, the opening, exploration, and closing of the abdomen, the pathologic state of the organs, or the specific procedures performed, it is difficult in the clinical situation to identify one specific cause among the many as the sole cause of a complication. Perhaps a more appropriate population to consider would be those patients who undergo appendectomy and are found to have a normal appendix or other elective clean-contaminated gastrointestinal procedures.* The problems with conditional probabilities and decisional analysis are best demonstrated by their conclusion that “the probability of morbidity occurring as a result of surgically treating only those patients who require it would be . .0.2% .” From their analysis of previously published articles they determined the morbidity rate of surgically treating patients with symptomatic Meckel’s diverticula that required surgery to be 8.5%. They calculated the risk of surgical morbidity induced by only resecting symptomatic Meckel’s diverticula and apply it to the entire population of operative and nonoperative patients with Meckel’s diverticula. The risk of surgical morbidity should be zero in patients not undergoing operation. They have allowed statistics to confuse their conclusions. They demonstrated the true and real rate of morbidity in symptomatic patients to be 8.5%, compared with 4.1% for patients who undergo laparotomy for other surgical conditions and have an incidental Meckel’s diverticulectomy. We believe their results support incidental diverticulectomy. J, Christopher DiGiacomo, MD Assistant Director, Trauma Center Jersey Shore Medical Center Nqtuae, NJ F. John Cottone, MD Director of Surgery Saint Francis Medical Center Trenton, NJ References 1. Peoples JB, Lichtenberger EJ, Dunn MM. Incidental verticulectomy in adults. Surgery 1995;118:649-52. 234
SURGERY
Meckel’s
di-
2. Warren JL, Penberthy LT, Addiss DG, McBean AM. Appendectomy incidental to cholecystectomy among elderly medicare beneficiaries. Surg Gynecol Obstet 1993;177:288-94. 11/59/78412
Reply To The Editors: The comments by DiGiacomo and Cottone in reference to our article, “Incidental Meckel’s Diverticulectomy in Adults,” focus primarily on the inaccuracies inherent in ascribing surgical complications to an incidentally performed procedure rather than to the indicated primary procedure, especially when it is attempted as part of a metaanalysis based on retrospective series. We agree entirely. In our own included series of 90 patients undergoing incidental diverticulectomy, we were very careful to include surgical complications that could only be a result of the incidental procedure. This amounted to two complications for a 2% morbidity rate. If anything, this would underestimate the probable true morbidity rate. The surgical complication rate associated with indicated diverticulectomy done for complications associated with the anomaly ranges from 0% (as in our own series) to a high of 33%. For our analysis we used the cumulative rate from all previous reports, which was 8.5%. This, if anything, most likely overestimates the true current morbidity rate. The crux of the argument is not really the actual morbidity rates associated with diverticulectomy done incidentally or primarily. The overriding issue, which most directly leads to our conclusion and which Drs DiGiacomo and Cottone did not comment on, is that an individual with a Meckel’s diverticulum who has reached the age of 21 years without having a problem with the anomaly has only a 2.5% incidence of ever having a problem requiring surgical intervention during the rest of his or her lifetime. Because of this extremely low incidence, nearly 50 asymptomatic diverticula would need to be removed incidentally to prevent the development of one symptomatic lesion. It does not require sophisticated mathematics to determine on this basis that incidental diverticulectomy could only possibly be justified if the morbidity attendant to the additional procedure was zero. This has not been the finding in any reported series. We thank DiGiacomo and Cottone for their comments, but we stand by our original conclusion that incidental Meckel’s diverticulectomy in adults should be abandoned. ./ames B. Peoples, MD Professor and Chair Dqartment of Surgeq Wright State University School of Medicine Dayton, OH 11/59/78413
Angiograpbic salvage of a malpositioned catheter: A cost-effective tool To the Editors: Since the introduction in the late 1970s their
of Hickman use has grown
Hickman
central venous catheters quite rapidly. Their effi-