LJTI’ERS TO THE EDITOR

and comfortable digestion. As with so many commonplace things, the pylorus is best appreciated when it is missed. Such is the plight of the pa- tient, lacking a functional pylorus, whose ingested food is precipitously ‘dumped’ into his duodenum or jeju- num.”

In the totality of gastric surgery, which deals with many issues includ- ing ulcer disease, malignancy, post- gastrectomy syndromes, anatomic abnormalities, and surgery for mor- bid obesity, surgeons cannot divorce themselves from the postoperative se- quelae and syndromes that have re- sulted from the loss of normal pyloric function in otherwise healthy individ- uals or have occurred following sur- gery, which have been written about repeatedly since 188 1.

In statistical reporting, one can- not merely indicate the incidence of hrforation, hemorrhage, and ob- struction following surgery while ig- noring the residuum of distressing signs, sequelae, and syndromes or rel- egating these problems to the care of others. It has been accepted that they are the result of surgical interven- tions and, rightfully, should be the concern of surgeons.

These diverse signs and symp toms are the result of a single ana- tomiephysiologic disruption, the loss of pyloric function. The postopera- tive syndrome groupings of these iat- rogenic variances, and their report- ing, depend upon the totality of the particular patient’s anatomy and physiology as interpreted by the sur- geon studying the patient.

Isn’t it possible that the restora- tion of the anatomic-physiologic rela- tionships by the introduction of a sur- rogate pyloric mechanism during ini- tial gastric surgery to a status approximating preoperative normal- cy might prevent syndromes from oc- curring by iatrogenesis? Isn’t it possi- ble that a reevaluation of philosophi- cal surgical considerations might help to resolve the unfulfilled prag-

matic gastric operative procedures? Doesn’t the supplanting of horizontal banded gastric Roux-en-Y bypass by vertical banded gastroplasty in mor- bid obesity surgery so as to preserve pyloric function for the regulatory egress of gastric contents suggest its significance in surgery for ulcer dis- ease and malignancy?

The history of the Roux-en-Y op- eration dates back to Woelfler in 1883, whereas the Y juncture, which permits the flow of bile and pancreat- ic juices through a common duct as it enters the efferent conduit from the stomach, the duodenum, below a functioning efferent gastric sphinc- ter, has existed since the origin of man. This provides the regulatory egress of the gastric reservoir con- tents and prevents duodenal reflux, while correcting adverse hyperglyce- mia and hypoglycemia, in postgas- trectomy states.

Leon A. Frankel, MD

Philadelphia, PA

1. Haglund UF, Jansson RL, Lindhagen JGE. Lundell LR. Svartholm EG. Olbe LC. Primary Roux-Y ‘gastrojejunostcmy versus gastroduodencstomy after antrectomy and selective vagotomy. Am J Surg 1990; 159: 546-9. 2.Herrington JL Jr. Editorial comment. Am J Surg 1990; 159: 549. 3. B&us HL. Gastroenterology. Vol. 1.2nd ed. Philadelphia: WB Saunders, 1963: 714- 5.

To the Editor: I read with interest the editorial

by Voyles et al [I]. The lesson that electrocautery is superior to laser for laparoscopic cholecystectomy is one that should be learned in the United Kingdom as well as the United states.

Surgeons in the UK have begun to use the laparoscopic method of cholecystectomy with great enthusi- asm but generally at a later date than

their colleagues in the US. One would have thought that, by studying the American experience, British surgeons would have been able to avoid some of the pitfalls inherent in the technique.

Nevertheless, lasers have been aggressively marketed as a piece of equipment vital to the performance of a laparoscopic cholecystectomy, and, despite the financial strictures imposed by Health Service budgets, many surgical units have raised the money to purchase one.

Laparoscopic cholecystectomies were first performed in this hospital in May 1990, and a total of 34 have been completed. A Nd:YAG (neo dynium:yttrium-aluminum-garnet) laser was initially used for gallblad- der dissection but in the last 31 pa- tients has been discarded in favor of the electrocautery hook.

There are a number of reasons for preferring diathermy over laser: the cautery hook is easier to use; the elec- trocautery unit can be moved be+ tween operating theaters; the strin- gent safety precautions necessary when using the laser such as wearing goggles and having an extra staff member to operate the on/off control are not needed, and, last but not least, the laser is expensive to pur- chase.

As with Dr. Voyles and his asso ciates, we turned to electrocautery by default only, to discover that it, was our @referred tool. This sort of obser- vation should teach us to restrain our enthusiasm for technologically ad- vanced equipment until we have eval- uated it critically with respect to that which we already have at our diipos- ail.

Susan Hill, FRCS Department of Surgery

We&minister Hospital London, United Kingdom

l.Voyles CR, Meena AL, Petro AB, Haick AJ, Koury AM. Electrocautery is superior to laser for laparoscopic cholecystectomy. Am J Surg 1990; 160: 457.

4S8 THE AMERICAN JOURNAL OF SURGERY VOLUME 163 APRIL 1992