Correspondence

Colonic haemorrhage Sir We have read with interest the view of Berry e t al . (Br J Surg 1988; 75: 637-9) on the management of colonic haemorrhage.

We wholeheartedly support their concept that a thorough search be made to identify the source of bleeding and decry blind colonic resection.

The need to exclude upper gastrointestinal bleeding is important; though surely they cannot seriously advise that nasogastric aspiration be used as a method of exclusion. Brisk duodenal bleeding can present with fresh blood per rectum and gastroduodenoscopy should be mandatory before any other more invasive procedure.

In our view it is ill advised to rule out preoperative arteriography which may be helpful and is readily available at most district general hospitals. Selective arteriography has the advantage of looking at the coeliac axis, superior and inferior mesenteric vessels. If a bleeding point is confirmed the catheter may be left in situ to help in the identification of the bleeding point. This is particularly useful in bleeding from the small bowel.

If arteriography is not helpful we would agree with the approach of laparotomy, antegrade washout and colonoscopy. A technical point is that colonic mobilization be avoided before colonoscopy or the appearances of angiodysplasia may be masked by mural bruising. Should colonoscopy be unhelpful, endoscopy of the small bowel should be performed.

N. D. Karanjia D. Schache

M. Rees Basingstoke District Hospital Basingstoke Hampshire RG24 9 N A U K

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We are intrigued by the concept of localized oedematous collections clinically mimicking cysts related to breast tumours.

We agree that there is a tendency in patients who have multiple cysts for the cysts to be mainly apocrine. This is only a tendency and, as Miller agrees, is not absolute. The trend appears stronger in the Scottish data and may in fact only be a sampling bias if our hypothesis that cysts all develop as apocrine and then mature to flattened is true. Previous studies, including those from his unit, have not indicated their frequency of follow-up: we suspect patients were seen at short intervals. In this setting a high proportion of immature apocrine cysts would have been detected. With time some of these cysts may not have been detected clinically as they dispersed or would change type as they matured to become flattened cysts. Follow-up protocols may introduce selection bias and might explain the large difference in magnitude seen between the two centres.

The study of the evaluation of risk factors for the subsequent development of breast cancer is largely one of failures of proposed predictors. Whatever his prejudices, Mr Miller must accept that our results show that breast cyst type is not constant for an individual; it does not predict whether further cysts will develop or what type they will be. Its inconsistency means that it does not, and cannot, predict the risk of a subsequent breast cancer.

S. R. Ebbs T. Bates

The Breast C h i c William Harvey Hospital Ashford U K

1. Dupont WD, Page DL. Risk factors for breast cancer in women with proliferative breast disease. N Engl J Med 1985; 312: 14651.

Doppler ultrasonography in the diagnosis of acute scrota1 pain

Sir I wish to add a note ofcaution on the use of Doppler ultrasonography in diagnosing testicular torsion (Br J Surg 1988; 75: 238-9). 1 have been using the Doppler ultrasound in the manner recommended by Bickerstaff and his colleagues and have had two false negatives with this technique. These were both in 15-year-olds with intravaginal torsion where on pointing the Doppler to the lower pole of the testis, there appeared to be no reduction in flow compared with the other side. Both torsions involved the cord close to the testis and in one patient the blood supply to the distal half only was impaired. These patients support their view that a careful clinical assessment is necessary for safe interpretation of Doppler results.

.I. M. Dixon The Royal Injirmary Edinburgh EH3 9 Y W U K

Authors‘ reply Sir In reply to the letter from M e w s N. Karanjia, D. Schache and M. Rees, we accept that the most reliable way of excluding gastroduodenal bleeding is by oesophagogastroduodenoscopy . However, if the nasogastric aspirate contains obvious bile with no trace of blood in a patient with brisk gastrointestinal bleeding, we feel that it is unlikely that bleeding will be from that area.

With regard to their comments on pre-operative angiography, we have shown that this investigation in patients with major colonic haemorrhage is both hazardous and unhelpful’. Patients with continuing major bleeding require emergency surgery and on-table colonoscopy with antegradeirrigation to identify the source of bleeding. This technique is simple, requires no specialized expertise and is within the capabilities of any general surgeon. An experienced colonoscopist is not essential as the instrument can be easily guided round the colon by the assistant.

Even if a radiologist with the necessary experience of emergency selective mesenteric angiography is ‘readily’ available (as the correspondents claim) the technique confers no advantages and delays potentially life saving surgery. We feel that timeshould not be wasted on pre-operative angiography in these patients.

A. R. Berry M. G. W. Kettlewell

John Radcliffe Hospital Oxford OX3 9DU U K

1. Cussons PD, Fletcher EWL, Berry AR. A comparison of value of mesenteric angiography and on-table colonoscopy in massive acute large bowel haemorrhage. Gut 1988; 29: A727.

Use of drains after cholecystectomy Sir We were interested to read the article by Irwin et al. (Br J Surg 1988; 75: 476) indicating that drains may be unnecessary after cholecystectomy. In February 1987 we decided to abandon the routine use of drains after cholecystectomy having previously always inserted a number 10 Fr Exudrain (Astra Meditec): this drain had usually resulted in the collection of about 50ml of fluid. We have studied the effect of this policy change by comparing the results in the 54 patients operated on before and the 87 patients after the change.

A standard cholecystectomy technique was being used throughout. In the first group, drainage was not used in two patients and in the second group it was deemed prudent to insert drains on two occasions.

Br. J. Surg., Vol. 75, No. 12, December 1988 1277