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Archived Comments for: The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis

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  1. points and clarifications arising

    Aninda Chandra, Department of General Surgery, Princess Royal University Hospital, Farnborough, London, UK

    16 January 2009

    Dear BMC Surgery Editors

    Re: The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis.

    Smith S, McGeehin W, Kozol R, Giles D. BMC Surgery 2007; 7(1):15.

    The paper by Smith et al [1] highlights the paucity of knowledge regarding intra-operative assessment of anastomotic integrity and deserves credit in the formulation of an alternative test to that of air insufflation. There are obviously limitations to what a single centre retrospective non-case controlled study can contribute and while the authors do acknowledge some of these, there are a number of points that arise.

    The endpoint of the study was post-operative leak (PoL), but this was poorly defined and ideally could have been tested by radiological means (e.g. contrast) and a few surgeons routinely perform a gastrograffin enema at day 5 to assess this. Given that some patients were ascribed a PoL based on clinical signs alone, the inclusion of those with a defunctioning stoma confuses the issue. While PoL occur despite a covering stoma, the clinical signs will be lessened [2]. We feel that these should have been excluded (n=16 which includes one intra-operative leak was defunctioned).

    Despite the use of methylene blue dye, PoL’s still occurred so it is difficult to know if an alternate assessment technique had been used would this have still been the case. The lack of comparison to other studies makes it difficult to assess the benefit of methylene blue enemas over our usual method of air insufflation. However the technique described may be able to provide a more objective way of assessing more proximal anastomosis, although traditionally these have often not been assessed.

    The study would have been stronger with similar results, if they had excluded right hemicolectomy (n=55) and transverse colonic resections (n =10). As the authors point out in Table 3, other studies concentrate on left hemicolectomies or more distal resections. If these are taken out, the overall leak rate is still low at 4.1% especially when compared to the average of the seven studies listed in Table 3.

    Appropriate exclusions would have improved this paper as would have comparison with other techniques, but the authors are to be congratulated for a large study that tries to peer into the depths and mysteries of (distal) colonic surgery

    Yours faithfully

    Mr Aninda Chandra MRCS MSc MA

    Mr Abdulzahra Hussain ,FRCS, FICMS, Diploma (General Surgery)

    Mr Tarun Singhal MBBS, MS, DNB

    Mr Biju Aravind FRCS

    Ms Mahrokh Davarpanah MRCS MD

    Mr Prakash Sinha MS, MD, FRCS (Gen Surg)

    Department of General Surgery, Princess Royal University Hospital, Farnborough, London, UK

    1. Smith S, McGeehin W, Kozol R, Giles D: The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis. BMC Surgery 2007, 7: 15.

    2. Wong NY, Eu KW: A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study. Dis Colon Rectum 2005, 48: 2076-2079.

    Competing interests

    None

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