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Indian Journal of Surgery, Vol. 66, No. 6, November-December, 2004, pp. 377-378 Letter To Editor Laparoscopy, a tool in diagnosis of lower abdominal pain Ramakrishna HK Lakshmi Surgical Clinic, New Bridge Road, Bhadravathi - 577 301, AP Code Number: is04099 Sir, This has reference to the article by Arya et al.[1] Of late, it has become a routine or a custom or a style to conclude all articles on laparoscopy as "Laparoscopy is safe, quick, cost effective etc. without giving adequate data to substantiate it in the main article.[2] Today, in the era of evidence based medicine (EBM), we cannot make any statement, especially in prestigeous journals like IJS, unless supported by adequate data to substantiate. The above conclusion though correct as supported by a number of authors, cannot be quoted in a particular article unless data presented supports it. What is the point in simply making the statement discovered by others? This we all know by reading various text books and journals. Just recently I had written a letter to the editor on this.[2] The authors have concluded that laparoscopy is safe, quick and cost effective. There is no cost analysis in the main article. Neither it has been compared with any other data to say it is safe and quick. Also, I notice a number of errors in the article. 1. Statastics:, (procedures done) shows that out of 37 procedures 13 are appendicectomy. In this one case turned out to be normal on HPE. So, there are 12 appendicites cases as proved by HPE. However, (Diagnosis after HPE), Appendicitis (Chronic/ resolving) 13. If we think "normal" appendix case is also included in this, see No organic cause. This has 5 cases including one normal appendix. How is this possible? In the discussion part authors write in 3rd para "...finally only 4 patients required an open procedure or laparotomy performed." However, 5 open procedures- appendicectomy- 3, jejunal resection for diverticula- 1, adhesiolysis- 1. 2. Under discussion, in para 2, authors write "laparoscopy is very sensitive for the diagnosis of appendicitis whether acute or chronic." What are the criteria for dignosis of chronic appendicitis on laparoscopy (for that matter in open surgery -gross morphology)? Can authors give referances for the "sensitive" criteria and sensitivity of laparoscopy in the diagnosis? They continue to mention that "It not only detects appendicitis but also avoids negative appendicectomy". I’ve done dissertation on appendicitis in my PG days and read extensively on the topic in various journals. One such article I would like to quote here. This is an excellent article all PG students should read to know how an article should be written and how to analyse the data. In this the authors, Hoffman & Rosmussen,[3] have extensively reviwed the articles on aids in the diagnosis of appendicitis. Various modalities of diagnosis are reviwed. The modalities are WBC counts, Urine examination, Plain X ray abdomen, Barium enema, Ultrasound examination, Laparoscopy, Computers, Scoring systems and Miscellaneous (CT scan, Radioisotope scan, diagnostic peritoneal lavage, Barium fallow). On laparoscopy, authors note that sensitivity of 80 to100% and specificity of 73 to 95% are reported. That means 0-20% cases of appendicitis are still missed in laparoscopy and 5-27% of the appendix removed are "Normal" (Negative appendicectomy). Further, in 7-85% (Average 15%) cases appendix "Couldnot be visualised". So, laparoscopy has succeeded in reducing negative appendicectomy only in 25-50% cases. Infact, none of the investigations mentioned above including laparoscopy could avoid negative appendicectomy. They can only reduce and not avoid negative appendicectomy. The authors of this study are also cautious to mention the disadvantages of diagnostic laparoscopy in appendicitis. It is invasive, requires anesthesia, incidence of complications, requirement of special instruments and expertise. The procedure itself is an operation. So, it is an operation done to avoid another operation (negative appendicectomy). Lastly, an appendix thought normal macroscopically may be inflammed microscopically and vice versa is also true. I hope to see only articles with conclusions based on evidence in IJS. REFERENCES
Copyright 2004 - Indian Journal of Surgery |
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