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RE: “How I do it—Local anesthesia in anal surgery: a simple, safe procedure”
The American Journal of Surgery 193 (2007) 289 –292
Letters to the editor To the Editor: The July 2005 issue of the Journal leads with an editorial observing that physicians have been demoted from professionals to employees. Perhaps somewhat telling, contained within this same issue is a scientific assessment of attitudes regarding surgeons’ attire. The very fact that surgical attire is a scientific topic of interest infers a significant variation in day-to-day practice. It is notable that after examining a variance of possibilities the authors concluded that “patients expect surgeons to be dressed in a white coat with a name tag and to be addressed by their surname. Patients do not want their surgeon dressed in blue jeans. We are obligated to do what we can to impress our patients.” Dr. Fischer, whose writings have over the years inspired me, among many, has once again eloquently penned clarity as to the current state of affairs concerning surgical professionalism. Certain residents, at least in the early days of my tenure here at the University of Arkansas for Medical Sciences, expressed a degree of surprise at my insistence that a surgeon’s appearance and dress should be consistent with the expectation of patients. Said another way, and in the context of my Professor of Gynecology during my medical school days at Emory University in the 1980s, Dr. John Thompson, “If a patient expects to see a peacock, the patient should see a peacock, and not a duck.” Perhaps to the chagrin of certain current residents, I am now reaffirmed in my bias regarding appropriate resident attire. Dr. Major and his coauthors have provided scientific validation to what many of us have long considered common sense; patients do not really want operations done by surgeons who look like they belong on a John Deere tractor or at a rodeo. Given the topics which now seemingly require scientific validation, at least to some, Dr. Fisher’s points about professionalism speak to a problem that is even bigger than his editorial surmises. Michael Edwards, M.D. Professor and Chairman Department of Surgery University of Arkansas for Medical Sciences Little Rock, Arkansas doi:10.1016/j.amjsurg.2006.11.007 RE: “How I do it—Local anesthesia in anal surgery: a simple, safe procedure” To the Editor: I was interested in the submission by Argov and Levandovsky regarding the use of local anesthesia in anorectal
surgery [1]. I certainly share their enthusiasm for the described use of monitored anesthesia care (MAC) combined with a local anesthetic in the prone jackknife position for anorectal surgery. The authors’ description truly is “safe, expedient, and . . .easily performed by any surgeon.” However, I would like to correct the authors on a rather obvious error in Fig. 6. The retractor depicted is not a Lone Star retractor (Lone Star Medical Products of Houston, TX), but appears to be a Hirschman anoscope. Needless to say, any and all types of anal retractor may be used under similar conditions. William C. Cirocco, M.D. Department of Surgery University of Missouri–Kansas City Kansas City, Missouri doi:10.1016/j.amjsurg.2006.11.008 Reference [1] Argov S, Levandovsky O. Local anesthesia in anal surgery: a simple, safe procedure. Am J Surg 2006;191:111–3.
Commentary on “Biliary peritonitis requiring reoperation after removal of T-tubes from the common bile duct” To the Editor: The article by Maghsoudi et al [1] deals with biliary peritonitis requiring reoperation after removal of T-tubes from the common bile duct. The need for this comment is on account of the fairly large number of patients (34; 2.47%) who required reoperation after T-tube removal. The traditional management of choledocholithiasis has been supraduodenal choledochotomy, biliary tract exploration, and closure of the common bile duct with a T-tube in situ. The T-tubes commonly used presently are of soft latex rubber instead of earlier plastic ones that were known to increase the risk for biliary peritonitis after removal from the common bile duct [2,3]. The advent of laparoscopic cholecystectomy and therapeutic endoscopic retrograde cholangiopancreatography has considerably reduced the number of cases requiring common duct exploration with closure around a T-tube. The usual complications that occur after removal of the T-tube are localized pain; a biliary leak leading either to biloma, biliary ascites, or biliary peritonitis; prolonged biliary fistula; and late biliary stricture [4,5]. A retrospective analysis of our records from the Department of Surgery at St Stephen’s Hospital during the period
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved.
Letters to the editor To the Editor: The July 2005 issue of the Journal leads with an editorial observing that physicians have been demoted from professionals to employees. Perhaps somewhat telling, contained within this same issue is a scientific assessment of attitudes regarding surgeons’ attire. The very fact that surgical attire is a scientific topic of interest infers a significant variation in day-to-day practice. It is notable that after examining a variance of possibilities the authors concluded that “patients expect surgeons to be dressed in a white coat with a name tag and to be addressed by their surname. Patients do not want their surgeon dressed in blue jeans. We are obligated to do what we can to impress our patients.” Dr. Fischer, whose writings have over the years inspired me, among many, has once again eloquently penned clarity as to the current state of affairs concerning surgical professionalism. Certain residents, at least in the early days of my tenure here at the University of Arkansas for Medical Sciences, expressed a degree of surprise at my insistence that a surgeon’s appearance and dress should be consistent with the expectation of patients. Said another way, and in the context of my Professor of Gynecology during my medical school days at Emory University in the 1980s, Dr. John Thompson, “If a patient expects to see a peacock, the patient should see a peacock, and not a duck.” Perhaps to the chagrin of certain current residents, I am now reaffirmed in my bias regarding appropriate resident attire. Dr. Major and his coauthors have provided scientific validation to what many of us have long considered common sense; patients do not really want operations done by surgeons who look like they belong on a John Deere tractor or at a rodeo. Given the topics which now seemingly require scientific validation, at least to some, Dr. Fisher’s points about professionalism speak to a problem that is even bigger than his editorial surmises. Michael Edwards, M.D. Professor and Chairman Department of Surgery University of Arkansas for Medical Sciences Little Rock, Arkansas doi:10.1016/j.amjsurg.2006.11.007 RE: “How I do it—Local anesthesia in anal surgery: a simple, safe procedure” To the Editor: I was interested in the submission by Argov and Levandovsky regarding the use of local anesthesia in anorectal
surgery [1]. I certainly share their enthusiasm for the described use of monitored anesthesia care (MAC) combined with a local anesthetic in the prone jackknife position for anorectal surgery. The authors’ description truly is “safe, expedient, and . . .easily performed by any surgeon.” However, I would like to correct the authors on a rather obvious error in Fig. 6. The retractor depicted is not a Lone Star retractor (Lone Star Medical Products of Houston, TX), but appears to be a Hirschman anoscope. Needless to say, any and all types of anal retractor may be used under similar conditions. William C. Cirocco, M.D. Department of Surgery University of Missouri–Kansas City Kansas City, Missouri doi:10.1016/j.amjsurg.2006.11.008 Reference [1] Argov S, Levandovsky O. Local anesthesia in anal surgery: a simple, safe procedure. Am J Surg 2006;191:111–3.
Commentary on “Biliary peritonitis requiring reoperation after removal of T-tubes from the common bile duct” To the Editor: The article by Maghsoudi et al [1] deals with biliary peritonitis requiring reoperation after removal of T-tubes from the common bile duct. The need for this comment is on account of the fairly large number of patients (34; 2.47%) who required reoperation after T-tube removal. The traditional management of choledocholithiasis has been supraduodenal choledochotomy, biliary tract exploration, and closure of the common bile duct with a T-tube in situ. The T-tubes commonly used presently are of soft latex rubber instead of earlier plastic ones that were known to increase the risk for biliary peritonitis after removal from the common bile duct [2,3]. The advent of laparoscopic cholecystectomy and therapeutic endoscopic retrograde cholangiopancreatography has considerably reduced the number of cases requiring common duct exploration with closure around a T-tube. The usual complications that occur after removal of the T-tube are localized pain; a biliary leak leading either to biloma, biliary ascites, or biliary peritonitis; prolonged biliary fistula; and late biliary stricture [4,5]. A retrospective analysis of our records from the Department of Surgery at St Stephen’s Hospital during the period
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved.