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Technique to Prevent Recurrence of Lactiferous Duct Fistula
Vol. 204, No. 1, January 2007
lected the reconstruction is usually performed using an omega loop or a Roux-en-Y procedure. . . .” needs to be clarified. The published experience with enteric drained pancreas transplant suggests that reconstruction is typically performed either with a Roux limb or by directly anastomosing the donor duodenum to the recipient jejunum. The omega method was recently pioneered by our team and the series has continued to grow since 2005. We are not aware of another published series of omega jejunoduodenal anastomosis for pancreas transplant. We are surprised that Drs Gedaly and Ranjan consider the known advantage of preserving intestinal motility by not transecting the bowel as theoretical. A number of studies have shown that intestinal transit is directly related to the properties of propagating contraction.2-4 Transection decreases frequency, amplitude, and propagating distance of the intestinal contractions5 and represents the most plausible explanation of the motility disorder in the Roux limb, which results in stasis in that segment.6 A Roux limb undoubtedly diverts food from the pancreas transplant, in contrast to a side-to-side anastomosis between the donor duodenum and the recipient jejunum. Proponents of the Roux-en-Y, including Drs Gedaly and Ranjan, state that using a defunctionalized intestinal segment decreases complications, in contrast to others who think that increasing experience with a particular procedure7 and technical modifications8 can eliminate most of the morbidity. An omega jejunoduodenal reconstruction with a Braun’s anastomosis (sideto-side jejunojejunostomy) likely provides a partial diversion of the graft duodenum and preserves peristalsis, contrary to a Roux-en-Y, which affects intestinal motility. The published literature provides no firm data about the superiority of total versus partial or no diversion for pancreas transplantation. A future randomized trial with a longterm followup is expected to observe the most physiologic reconstruction method. Our novel omega jejunoduodenal anastomosis for pancreas transplantation reinforces the surgical armamentarium and provides a physiologic, simple, and easily reproducible alternative technique for gastrointestinal reconstruction. REFERENCES 1. Losanoff JE, Harland RC, Thistlethwaite JR, et al. Omega jejunoduodenal anastomosis for pancreas transplant. J Am Coll Surg 2006;202:1021–1024.
Letters
189
2. Laplace JP. Motility of the small intestine: organization, regulation and functions. 15 years’ research on migrating complexes. Reprod Nutr Dev 1984;24:707–765. 3. Husebye E. The patterns of small bowel motility: physiology and implications in organic disease and functional disorders. Neurogastroenterol Motil 1999;11:141–161. 4. Thomson ABR, Keelan M, Thiesen A, et al. Small bowel review: normal physiology part 2. Dig Dis Sci 2001;46:2588–2607. 5. Johnson CP, Cowles VE, Bonham L, et al. Changes in motility, transit time, and absorption following surgical transaction of the jejunum. Transplant Proc 1992;24:1110–1112. 6. van der Mije HC, Kleibeuker JH, Limburg AJ, et al. Manometric and scintigrafic studies of the relation between motility disturbances in the Roux limb and the Roux-en-Y syndrome. Am J Surg 1993;166:11–17. 7. Reddy KS, Stratta RJ, Shokouh-Amiri MH, et al. Surgical complications after pancreas transplantation with portal-enteric drainage. J Am Coll Surg 1999;189:305–313. 8. Steurer W, Tabbi MG, Bonatti H, et al. Stapler duodenojejunostomy reduces intraabdominal infection after combined pancreas kidney transplantation as compared with hand-sewn anastomosis. Transplant Proc 2002;34:3357–3360.
Technique to Prevent Recurrence of Lactiferous Duct Fistula Kimball I Maull, MD, FACS Birmingham, AL The association of lactiferous duct obstruction and recurrent breast abscess has been recognized for many years. The abscess almost always occurs at the junction of the areola and the skin and is caused by obstruction of the corresponding lactiferous duct. Komenaka and colleagues1 wisely recommend excision of the entire lactiferous duct in continuity with the juxta-areolar inflammatory process to avoid recurrence. Their technique involves resection of the overlying skin of the nipple and areola which undoubtedly results in scarring of both. In 1977, we reported a series of patients with this problem and described an association between squamous metaplasia of the lactiferous duct, nipple inversion and recurrent subareolar abscess.2 Our approach to the operative correction of this problem used total core excision of the lactiferous duct, which corrected the nipple inversion but did not violate the overlying skin, together with an elliptical excision and closure of the juxta-areolar inflammatory process. The technique of core excision was well illustrated. Because the overlying nipple and areolar skin were not resected, the cosmetic result was quite satisfactory, and additional recurrence was avoided. Whichever technique is used, the best
190
Letters
results are obtained when the inflammatory process is quiescent. REFERENCES 1. Komenaka IK, Pennington RE, Bowling MW, et al. A technique to prevent recurrence of lactiferous duct fistula. J Am Coll Surg 2006;203:253–256. 2. Powell BC, Maull KI, Sachatello CR. Recurrent subareolar abscess of the breast and squamous metaplasia of the lactiferous ducts: a clinical syndrome. South Med J 1977;70:935–937.
Avoiding Misidentification Injuries in Laparoscopic Cholecystectomy François Mosimann, MD, FRCSC Sherbrooke, Québec, Canada WM Duff is to be congratulated for his innovative cystic duct marking technique in intraoperative cholangiography during laparoscopic cholecystectomy, as described in the August 2006 issue of the Journal.1 His initial experience raises the hope that this smart approach might contribute to a decrease of bile duct injuries, a much more frequent occurrence in the laparoscopic era than in the days of open cholecystectomy.2 A word of caution seems pertinent before the average surgeon uses this technique routinely. First, the procedure can be relatively time-consuming and will require that a learning curve be overcome. Second, 69 years of literature on intraoperative imaging to prevent bile duct injuries did not settle the issue.3,4 It follows that to demonstrate a statistically significant impact of cystic duct marking on a relatively rare event (0.1% to 0.5% of laparoscopic cholecystectomies),4 thousands of randomized and prospectively followed patients would be needed. In such an unlikely study, a more standardized description than the major and minor bile duct injuries reported by Duff would also be needed to assess the results precisely. For example, had the author used the now broadly accepted classification of Strasberg and colleagues,5 his overall incidence of bile duct injuries would be ⬎ 0.9% instead of zero. REFERENCES 1. Duff WM. Avoiding misidentification injuries in laparoscopic cholecystectomy: use of cystic duct marking technique in intraoperative cholangiography. J Am Coll Surg 2006;204:258–261.
J Am Coll Surg
2. Bernard HR. Complications after laparoscopic cholecystectomy. Am J Surg 1993;165:533–535. 3. Mirizzi P. Operative cholangiography. Surg Gynecol Obstet 1937; 65:702–710. 4. Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 2006;93:158–168. 5. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101–125.
Open Abdomen after Trauma and Abdominal Sepsis Moshe Schein, MD, FACS Ladysmith, WI I enjoyed the review on the open abdomen after trauma and abdominal sepsis by Schecter and his distinguished colleagues.1 I wish to draw attention to inaccuracies stated by the authors in attributing alleged “innovations.” The authors stated, “In 1995, Brock and coauthors2 and Barker and associates (in 2000),3 introduced the vacuum pack, a “sandwich” technique. . . .” The authors also claimed that “the principles of vacuumassisted wound management” introduced by others “were rapidly applied to the open abdomen (in 2001).4 In 1987, we described suction-vacuum–assisted management of the open abdomen using a “sandwich” technique.5 The vacuum-assisted management we used (years before it was “discovered” by others) to treat open abdomens of different etiology,6,7 subsequently modifying the inner layer of the “sandwich,” proved a significant improvement in the care of this problematic abdominal defect. I am aware that the commercial vacuum pack, which is based directly on principles used in our original vacuum “sandwich,” has become an extremely profitable product worldwide. But 20 years ago, when we described this “patent” of vacuum management, the notion that a simple surgical technique, which could benefit many patients, could be, or should be, formally patented for commercial profits was alien to us, as it is now. Although application of suction or vacuum to problematic and, in particular, productive wounds greatly facilitates their management, the theories put forward by industry and its clinical mouthpieces, namely, that applying suction on open wounds improves the process of healing, are, to the best of my knowledge,
lected the reconstruction is usually performed using an omega loop or a Roux-en-Y procedure. . . .” needs to be clarified. The published experience with enteric drained pancreas transplant suggests that reconstruction is typically performed either with a Roux limb or by directly anastomosing the donor duodenum to the recipient jejunum. The omega method was recently pioneered by our team and the series has continued to grow since 2005. We are not aware of another published series of omega jejunoduodenal anastomosis for pancreas transplant. We are surprised that Drs Gedaly and Ranjan consider the known advantage of preserving intestinal motility by not transecting the bowel as theoretical. A number of studies have shown that intestinal transit is directly related to the properties of propagating contraction.2-4 Transection decreases frequency, amplitude, and propagating distance of the intestinal contractions5 and represents the most plausible explanation of the motility disorder in the Roux limb, which results in stasis in that segment.6 A Roux limb undoubtedly diverts food from the pancreas transplant, in contrast to a side-to-side anastomosis between the donor duodenum and the recipient jejunum. Proponents of the Roux-en-Y, including Drs Gedaly and Ranjan, state that using a defunctionalized intestinal segment decreases complications, in contrast to others who think that increasing experience with a particular procedure7 and technical modifications8 can eliminate most of the morbidity. An omega jejunoduodenal reconstruction with a Braun’s anastomosis (sideto-side jejunojejunostomy) likely provides a partial diversion of the graft duodenum and preserves peristalsis, contrary to a Roux-en-Y, which affects intestinal motility. The published literature provides no firm data about the superiority of total versus partial or no diversion for pancreas transplantation. A future randomized trial with a longterm followup is expected to observe the most physiologic reconstruction method. Our novel omega jejunoduodenal anastomosis for pancreas transplantation reinforces the surgical armamentarium and provides a physiologic, simple, and easily reproducible alternative technique for gastrointestinal reconstruction. REFERENCES 1. Losanoff JE, Harland RC, Thistlethwaite JR, et al. Omega jejunoduodenal anastomosis for pancreas transplant. J Am Coll Surg 2006;202:1021–1024.
Letters
189
2. Laplace JP. Motility of the small intestine: organization, regulation and functions. 15 years’ research on migrating complexes. Reprod Nutr Dev 1984;24:707–765. 3. Husebye E. The patterns of small bowel motility: physiology and implications in organic disease and functional disorders. Neurogastroenterol Motil 1999;11:141–161. 4. Thomson ABR, Keelan M, Thiesen A, et al. Small bowel review: normal physiology part 2. Dig Dis Sci 2001;46:2588–2607. 5. Johnson CP, Cowles VE, Bonham L, et al. Changes in motility, transit time, and absorption following surgical transaction of the jejunum. Transplant Proc 1992;24:1110–1112. 6. van der Mije HC, Kleibeuker JH, Limburg AJ, et al. Manometric and scintigrafic studies of the relation between motility disturbances in the Roux limb and the Roux-en-Y syndrome. Am J Surg 1993;166:11–17. 7. Reddy KS, Stratta RJ, Shokouh-Amiri MH, et al. Surgical complications after pancreas transplantation with portal-enteric drainage. J Am Coll Surg 1999;189:305–313. 8. Steurer W, Tabbi MG, Bonatti H, et al. Stapler duodenojejunostomy reduces intraabdominal infection after combined pancreas kidney transplantation as compared with hand-sewn anastomosis. Transplant Proc 2002;34:3357–3360.
Technique to Prevent Recurrence of Lactiferous Duct Fistula Kimball I Maull, MD, FACS Birmingham, AL The association of lactiferous duct obstruction and recurrent breast abscess has been recognized for many years. The abscess almost always occurs at the junction of the areola and the skin and is caused by obstruction of the corresponding lactiferous duct. Komenaka and colleagues1 wisely recommend excision of the entire lactiferous duct in continuity with the juxta-areolar inflammatory process to avoid recurrence. Their technique involves resection of the overlying skin of the nipple and areola which undoubtedly results in scarring of both. In 1977, we reported a series of patients with this problem and described an association between squamous metaplasia of the lactiferous duct, nipple inversion and recurrent subareolar abscess.2 Our approach to the operative correction of this problem used total core excision of the lactiferous duct, which corrected the nipple inversion but did not violate the overlying skin, together with an elliptical excision and closure of the juxta-areolar inflammatory process. The technique of core excision was well illustrated. Because the overlying nipple and areolar skin were not resected, the cosmetic result was quite satisfactory, and additional recurrence was avoided. Whichever technique is used, the best
190
Letters
results are obtained when the inflammatory process is quiescent. REFERENCES 1. Komenaka IK, Pennington RE, Bowling MW, et al. A technique to prevent recurrence of lactiferous duct fistula. J Am Coll Surg 2006;203:253–256. 2. Powell BC, Maull KI, Sachatello CR. Recurrent subareolar abscess of the breast and squamous metaplasia of the lactiferous ducts: a clinical syndrome. South Med J 1977;70:935–937.
Avoiding Misidentification Injuries in Laparoscopic Cholecystectomy François Mosimann, MD, FRCSC Sherbrooke, Québec, Canada WM Duff is to be congratulated for his innovative cystic duct marking technique in intraoperative cholangiography during laparoscopic cholecystectomy, as described in the August 2006 issue of the Journal.1 His initial experience raises the hope that this smart approach might contribute to a decrease of bile duct injuries, a much more frequent occurrence in the laparoscopic era than in the days of open cholecystectomy.2 A word of caution seems pertinent before the average surgeon uses this technique routinely. First, the procedure can be relatively time-consuming and will require that a learning curve be overcome. Second, 69 years of literature on intraoperative imaging to prevent bile duct injuries did not settle the issue.3,4 It follows that to demonstrate a statistically significant impact of cystic duct marking on a relatively rare event (0.1% to 0.5% of laparoscopic cholecystectomies),4 thousands of randomized and prospectively followed patients would be needed. In such an unlikely study, a more standardized description than the major and minor bile duct injuries reported by Duff would also be needed to assess the results precisely. For example, had the author used the now broadly accepted classification of Strasberg and colleagues,5 his overall incidence of bile duct injuries would be ⬎ 0.9% instead of zero. REFERENCES 1. Duff WM. Avoiding misidentification injuries in laparoscopic cholecystectomy: use of cystic duct marking technique in intraoperative cholangiography. J Am Coll Surg 2006;204:258–261.
J Am Coll Surg
2. Bernard HR. Complications after laparoscopic cholecystectomy. Am J Surg 1993;165:533–535. 3. Mirizzi P. Operative cholangiography. Surg Gynecol Obstet 1937; 65:702–710. 4. Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 2006;93:158–168. 5. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101–125.
Open Abdomen after Trauma and Abdominal Sepsis Moshe Schein, MD, FACS Ladysmith, WI I enjoyed the review on the open abdomen after trauma and abdominal sepsis by Schecter and his distinguished colleagues.1 I wish to draw attention to inaccuracies stated by the authors in attributing alleged “innovations.” The authors stated, “In 1995, Brock and coauthors2 and Barker and associates (in 2000),3 introduced the vacuum pack, a “sandwich” technique. . . .” The authors also claimed that “the principles of vacuumassisted wound management” introduced by others “were rapidly applied to the open abdomen (in 2001).4 In 1987, we described suction-vacuum–assisted management of the open abdomen using a “sandwich” technique.5 The vacuum-assisted management we used (years before it was “discovered” by others) to treat open abdomens of different etiology,6,7 subsequently modifying the inner layer of the “sandwich,” proved a significant improvement in the care of this problematic abdominal defect. I am aware that the commercial vacuum pack, which is based directly on principles used in our original vacuum “sandwich,” has become an extremely profitable product worldwide. But 20 years ago, when we described this “patent” of vacuum management, the notion that a simple surgical technique, which could benefit many patients, could be, or should be, formally patented for commercial profits was alien to us, as it is now. Although application of suction or vacuum to problematic and, in particular, productive wounds greatly facilitates their management, the theories put forward by industry and its clinical mouthpieces, namely, that applying suction on open wounds improves the process of healing, are, to the best of my knowledge,