622 CASE FOR MIDLINE INCISIONS SiR,—Because of the reduced operating-time and proven early strength of the properly closed midline laparotomy incisio...

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SiR,—Because of the reduced operating-time and proven early strength of the properly closed midline laparotomy incision, many surgeons have abandoned the paramedian incision and consider it old-fashioned and cumbersome. Dr Cahalane and associates (Jan 21, p 146) present a well-researched and anatomically sound defence of the paramedian incision and condemn the midline incision because of a higher reported incidence of incisional hernia. The studies cited support their conclusions but results with midline incisions have not been uniformly poor. My own unpublished series of over 6000 consecutive midline laparotomies has produced no eviscerations to date. Only the first 1700 cases were reviewed for incisional hernias. The frequency of that complication was 1-05% after one year and 17% after four years (77% follow-up), and my clinical impression is that the frequency has remained about the same since then. I use a continuous, wide-bite, far/near monofilament suture, burying the ends to avoid painful suture ends beneath the skin. The peritoneum is included. This line is reinforced with absorbable polyglactin internal retention sutures every 5 cm. Grossly contaminated wounds are left with skin and subcutaneous tissues open to reduce the risk of local sepsis. The paramedian incision has disadvantages other than prolonged operating time, including problems with exposure and a slightly higher incidence of wound sepsis and haematoma. Painful external retention sutures may also be necessary to prevent an unacceptably high incidence of evisceration, since the paramedian layer closure technique does not lend itself to wide bite sutures which distribute the tension. My personal experience does not support routinely replacing the midline laparotomy incision with the paramedian, although I am persuaded by Cahalane’s argument to adopt the contralateral paramedian incision for patients requiring stomas.

only four sessions, which may explain their lower response rate. Perhaps they should be more persistent although this can be a daunting prospect for the hypnotherapist. Department of Medicine, University Hospital of South Manchester, Manchester M20 8LR

1 Whorwell PJ, Prior A. Faragher EB Controlled trial of hypnotherapy m the treatment of severe refractory irritable-bowel syndrome. Lancet 1984; ii: 1232-34. 2. Whorwell PJ, Prior A, Colgan SM Hypnotherapy in severe irritable bowel syndrome further experience. Gut 1987; 28: 423-25.


SIR,-In adult systemic lupus erythematosus and lupus-like disorders, anti-cardiolipin (CL) antibodies and the lupus

anticoagulant have been associated with thrombocytopenia and arterial and venous thromboses.1 Dr Foreman and colleagues (Dec 17, p 1159) describe a child with parvovirus infection associated with transient thrombocytopenia presumably due to peripheral destruction of platelets. Dr Lefrere and colleagues (Feb 4, p 279) support the association between parvovirus and idiopathic thrombocytopenic purpura (ITP). This prompts us to report the preliminary results of a study of anti-CL antibodies in viral diseases. Anti-CL antibodies were measured by ELISA.2 Epstein-Barr virus (EBV), hepatitis A virus, rubella virus, and parvovirus sera from Oxford showed a high frequency of IgM and IgG anti-CL in each group (table). These results agree with a previous report of anti-CL in EBV infection,3 and illustrate how non-organ-specific autoantibody production might be driven non-specifically by a variety of infective agents. ANTI-CL ANTIBODY STATUS IN VIRAL INFECTION

2699 First Avenue

North, St Petersburg, Florida 33713, USA


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SIR,-Mr Sagar and colleagues (Jan 21, p 165) direct attention to the difference in 5-year-survival rate reported for patients with gastric cancer in the UK and Japan. The 1979 Japanese report by K. Miwa, who described increased resectability with 5-yearsurvival rates of up to 50%, was contrasted with rates elsewhere of only 10% or so. However, the figure for Japan is not 5-year survival among all patients with gastric cancer but among those who underwent a "curative" resection. Recorded deaths from gastric cancer in Japan were consistently about 50 000 a year between 1975 and 1984. Even this may be an underestimate because the statistics were based on death certificate diagnoses. The number of new cases of gastric cancer in Japan in 1978 has been estimated at 70 000 or so, on the basis of registry data from several prefectures. Since registries do not exclude dual counting when a patient visits another hospital (which is not rare in Japan) the time incidence may well be below 70 000. 50 000 deaths and 70 000 new cases suggest, crudely, cure rates well below 50%, perhaps 29% or even less, and true 5-year survival could be close to 10%. Electrotechnical Laboratory, 1-1-4 Umezono, Tsukuba 305, Japan



*Normal range up to 3 tNormal range up to 5

t(Mean [SD])

The putative role of these antibodies in the mechanism of thrombocytopenia has not been elucidated. However, we have detected anti-CL antibodies in ITP4 and have shown their binding to platelet membrane in vitro (unpublished). Anti-CL and anti-platelet antibodies have also been correlated in a study of ITP.5 It is possible that the thrombocytopenia described in Foreman and colleagues’ case was antibody-mediated as distinct from the marrow suppression described in anaemia or leucopenia of parvovirus disease. The role of anti-CL antibody needs further examination in such


Department of Rheumatology Research and Haematology, Middlesex Hospital, London W1P 9PG; and Department of Virology, John Radcliffe Hospital, Oxford

SIR,-Dr Harvey and colleagues (Feb 25, p 425) confirm the beneficial effects of hypnotherapy in irritable bowel syndrome (IBS) that we reported.1.2 We have now treated over 200 patients by this technique and our overall success rate is about 85%. As might be expected, increasingly severe cases of IBS are being referred to us and sometimes the number of sessions of hypnotherapy has to be increased to achieve a response. Our current practice is to abandon treatment if there is no improvement by the twelfth session. However, if a response has started by this time it may be necessary to go on longer to consolidate the effect. Harvey and colleagues used

IgM phospholipid units. IgG phospholipid units.




Colaço CB, Male

DK Anti-phospholipid antibodies in syphilis and a thrombotic subset of SLE: distinct profiles of epitope specificity. Clin Exp Immunol 1985; 59:


EN, Gharavi AE, Patel BP, Hughes G Evaluation of the anti-cardiolipin antibody test: report of an International Workshop. Clin Exp Immunol 1987; 68:

2 Harris

215-22. 3 Misra R, Venables

PJW, Watkins RPF, Maini RN Autoimmunity to cardiolipin in infectious mononucleosis. Lancet 1987; ii: 629. 4. Colaço CB, Male DK, Mackie IJ, Machin SJ. Anti-phospholipids are associated with idiopathic and lupus thrombocytopenia. Br JHaematol 1985, 60: 365. 5. Hams EN, Gharavi A, Hegde U, et al Anti-cardiolipin antibodies in autoimmune thrombocytopemc purpura BrJ Haematol 1985; 59: 231-34