Correspondence

Priapism and thalassaemia intermedia

Sir The report by Jackson et al. (Br J Surg 1986; 73: 678) of recurrent priapism following splenectomy for thalassaemia intermedia was of interest to us. We encountered a similar case recently and were unable to find previous reports of such an occurrence.

A 25-year-old Pakistani man was seen because of easy fatigue, bone pains in the legs and a history of chronic blood transfusion therapy for 5 years. Findings on examination included icterus, bilateral tibia1 tenderness and a firm spleen extending 13 cm below the costal margin. A complete blood count showed a leucocyte count of 6.8 x lo9/! with a normal differential, nucleated red blood cell count of 0 2 x 109/1, Hb 8.8 g/dl, MCV 72 fl, platelet count 176 x 109/1 and the reticulocytes, 37 per cent. A diagnosis of a-thalassaemia intermedia was established based on the demonstration of Hb H (4.5 per cent) on haemoglobin electrophoresis on cellulose acetate and in oitro globin chain synthesis ratio determination (a / j =0.64). Autologous erythrocyte survival study using ”Cr tagged erythrocytes showed an erythrocyte of 5 days. A splenectomy was performed for hypersplenism.

Four weeks following splenectomy, he was admitted for recurrent episodes of priapism, each lasting 2-3 h, of 3 days duration. The Hb was 11.9 g/dl, total leucocyte count 24.5 x 109/1, nucleated red blood cell count 0.7 x 109/1 and the platelets 814 x 109/1. Priapism resolved on treatment with bed rest and analgesics and he was discharged 2 days later without medication. When next seen 5 months later, hereported no further episodes of priapism. His Hb was 12.3g/dl, leucocyte count 20.3 x 109/1, nucleated red blood cell count 0 6 x 109/1 and the platelets 1804 x 109/1. A reticulocyte preparation showed Hb H inclusions in most erythrocytes.

Priapism in our patient was associated with the rise in the blood Hb concentration and the platelet count. The lack of further episodes of priapism despite further marked rise in the platelet count cannot be commented upon in view of the short duration of follow-up. Hb H inclusions (normally removed by the spleen) are known to cause disturbances in red cell metabolism and interfere with normal membrane function and deformability. Their role in contributing to the pathogenesis of priapism in our patient is unknown.

K. R. P. Rao A. R. Patel

Hektoen Institute for Medical Research Chicago USA

International Society of Surgery

Sir Your publication of the comment on the cover with the arms of the time- honoured ‘Socitte Internationale de Chirurgie’ (Br J Surg 1986; 73 (July)) has been very much appreciated. I must, however, draw your attention to the fact that publication of the World Journal ofsurgery was initiated in 1976 independent of the transfer of the general secretariat to Basle, Switzerland in 1979.

M. AUgower Secretary General

International Society of Surgery Kantonspitale Bade Switzerland

Iatrogenic bile duct stricture

Sir We read with interest the letter from Mr N. V. Addison, ‘Iatrogenic bile duct stricture’ (Br J Surg 1986; 73: 681). We agree wholeheartedly that there is a place for ’fundus first’ cholmystectomy, the indications for which have been so well outlined by Mr Addison. However, we would like to take issue with the statement that ‘for an experienced surgeon, in the interest of safety, to have to content himself with a cholecystostomy in this day and age is . . . inexcusable’; and further, ‘If the gallbladder is left behind, a further operation is inevitable.. .’.

We must therefore confess to doing the ‘inexcusable’ on our service. Our indications for it include purulent cholecystitis complicated by cholangitis, peritonitis and abscess; and severe coexistent systemic disease, particularly at an advanced age. Moreover, in our experience with 24 cholecystostomies over the past 11 years there has never been a need for a further operation. This is in striking contrast with Mr Addison’s claim of‘inevitability’. When at the end of acholecystostomy a Foley catheter or a Pezzer catheter is placed in the lumen of the gallbladder, it stimulates inflammatory reaction that usually leads to complete or nearly complete obliteration of the lumen. This we have proved by ultrasound studies of our patients. Many surgeons like to remove these gallbladders electively at a later date, in order to prevent some future ‘trouble’. However, when such a gallbladder is left undisturbed, these ‘troubles’ are almost never seen.

D. Weissberg M. Kaufman

I. Schwartz

Department of Surgery E . Wolfson Hospital Holon Israel

Supplementary feeds following femoral neck fracture

Sir Several studies have now shown how inadequate the voluntary food intake of patients with femoral neck fractures can be’ - 3 and how this can adversely affect outcome3.

Mr Stableforth (Br J Surg 1986; 73 651--5) has added to this body of evidence and has shown an improvement in nitrogen balance in those patients given a supplementary sip feed. He has however found, like Banerjee4, that supplementary sip feeding tends to suppress voluntary food intake from other sources such that the net effect is small. He suggests that overnight nasogastric tube feeding might allow the provision of nutritional supplements without suppression of daytime voluntary food intake and this has indeed been shown to be the case3. The technique is well tolerated by the patients, reduces rehabilitation time and may reduce mortality and shorten hospital stay.

M. D. Bastow

Royal Infirmary Manchester U K

1. Hessov I. Energy and protein intake in elderly patients in an orthopaedic surgical ward. Acta Chirurgica Scand 1977; 143: 145-9. Older MWT, Edwards D, Dickerson JWT. A nutrient survey in elderly women with femoral neck fractures. Br J Surg 1980; 67: 884-6. Bastow MD, Rawlings J, Allison SP. Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial. Br Med J 1983; 287: 1589-92.

4. Banerjee AK, Brocklehurst JC, Wainwright H, Swindell R. Nutritional status of long stay geriatric inpatients: effects of a food supplement (Complan). Age Ageing 1978; 7 237-43.

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1048 Br. J. Surg.. Vol. 73, No. 12, December 1986