LE'B'ERS TO THE EDITOR

L O N G - T E R M E V O L U T I O N O F A S Y M P T O M A T I C C H O L E L I T H I A S I S IN P A T I E N T S W I T H C IRR H O S I S

To the Editor: The article by Orozco and colleagues 1

in the September 1994 issue of The American Journal of Surgery ® addresses an important issue with regard to the management of incidental cholelithia- sis in patients undergoing laparotomy for other indications. I must disagree, however, with the authors' conclusions from the data presented.

The authors describe a group of 34 patients with asymptomatic cholelithi- asis available for long-term follow-up after surgery for portal hypertension. Most (28 patients, 82%) remained asymptomatic during their 6-year fol- low-up period, but the bulk of the ev- idence2--including the evidence added by the authors' own admittedly small number (5) of patients who un- derwent incidental cholecystectomy without complication--suggests that this is not usually the case.

Incidental cholecystectomy is safe, but is it necessary? Although there is some evidence to suggest that surgery for other indications does increase the risk of symptom development in pa- tients with asymptomatic stones, 2 the evidence from the present study does not support this hypothesis. It is not disputed that most (consistently around 80% of patients) with asymp- tomatic gallstones remain asympto- matic, but the high mortality (3 out of 6 patients) in those who developed symptoms suggests that this group of patients might have been better served by undergoing incidental cholecystec- tomy. In summary, 34 incidental chole- cystectomies would have prevented 3 subsequent deaths and the necessity for 3 additional major surgeries in this high-risk group of patients.

Eugene J. Gibney, FRCSI Lloydminster Hospital

Saskatchewan, Canada

1. Orozco H, Takahashi T, Mercado MA, et al. Long-term evOlution of asympto- matic cholelithiasis diagnosed during ab- dominal operations for variceal bleeding in patients with cirrhosis. Am J Surg. 1994;168:232-234. 2. GibneY EJ, Asymptomatic gallstones. Br J Surg. 1990;77:368-372.

The Reply: We read with interest the comments

of Dr. Gibney to our paper. 1 His points are well taken, and remark the con- troversy regarding this issue.

We agree with Dr. Gibney that in- cidental cholecystectomy could be useful to prevent the deaths or the necessity of major operations in some patients. Nevertheless, the majority of patients (80%) who are expected not to develop any symptom or com- plication of cholelithiasis would not have any benefit, and would have to take the risk of an incidental chole- cystectomy, too, If this risk were low, it would be clearly justified; however, it is important to remark that chole- cystectomy is a surgical procedure with a recognized higher morbidity and mortality in cirrhotics, z and re- sults of patients without this disease should not be compared. The absence of complications in the 5 patients who underwent incidental cholecys- tectomy in our series is not a solid da- tum from which to estimate the risk.

Furthermore, because the 3 pa- tients who died due to complica- tions of cholecystitis presented pre- vious symptoms that were neglected by their primary physi- cians, it is possible that the out- come could have been better with an earlier operation.

Until future research can clarify the risk of incidental cholecystectomy in cirrhotics, we still believe that it should not be performed, and that the emphasis should be directed to close follow-up and early surgical manage- ment when symptoms supervene. This may not be the case in patients without liver disease.

Hector Orozco, MD Takeshi Takahashi, MD

Miguel Angel Mercado, MD Eduardo Prado, MD Delia Borunda, MD

Instituto Nacional de la Nurricion Mexico City, Mexico

1. Orozco H, Takahashi T, Mercado MA, et ai. Long-term evolution of asympto- matic cholelithiasis diagnosed during ab- dominal operations for variceal bleeding in patiefits with cirrhosis. Am J Surg. 1994;168:232-234. 2. Kanglaski J. Cholecystectomy: haz- ardous in patients with cirrhosis. JAMA. 1981 ;90:577-583.

H A R T M A N N ' S O P E R A T I O N - - B A C K T O T H E F U T U R E ?

To the Editor: We h a v e read with interest the

article entitled "Hartmann's Operation," by L.D. Rosenman. 1 The author suggests that surgeons should get back to the original "Hartmann," that is, with a short rectal remnant. In the recent Rob series, z we have de- scribed the Hartmann procedure with the current modifications, ie, with a rectal remnant sectioned at the level of the sacral promontory. We chose not to retain Hartmann's original de- scription for the following reasons: (1) Henri Hartmann, in 1921, de. scribed (out of 2 cases) a procedure addressing the management of ob- structive rectal cancer) At that time, the usual approach was either a colostomy or the resection of the tu- mor via a sacral approach 15 days later. The problem during the latter procedure (done exclusively by the sacral approach) was to deal with the intermediary segment between the il- iac colostomy and the upper end of the rectal resection. 4 Presently, indi- cations for Hartmann's operation have changed, the main ones being perforated diverticulitis and acute colitis. For such indications, rectal re- section is not required anymore, and restoration of continuity is consid- ered most of the time.

Dr. Rosenman points out that leav- ing a long rectal stump may induce the risk of leakage, allegedly due to poor blood supply. We agree that leakage from the stump may occur as a result of the accumulation of fluid in the rectum, the presence of pri- mary sepsis, or some other cause; but there is no threat of ischemia, pro- vided the rectum is sectioned at the level of the sacral promontory, what- ever the type of vascular section. Problems of vascularization may oc- cur if a longer rectal stump is left in place, and this should be avoided. We all perform high anterior resection for cancer with ligation of the superior hemorrhoidal artery with few, if any, ischemic problems, on the rectal side at least.

Still, leakage from the rectal stump is a threat. In order to prevent abscess formation from such leakage, we have

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