Your Views

The Editors welcome topical correspon-dence from readers relating to articlespublished in the Journal. Responses shouldbe sent electronically via the BJS website(www.bjs.co.uk). All letters will be reviewedand, if approved, appear on the website. Aselection of these will be edited and publishedin the Journal. Letters must be no morethan 250 words in length.

Letter 1: Routine colonoscopyfollowing acute uncomplicateddiverticulitis (Br J Surg 2011; 98:1630–1634)

SirWe commend Westwood and col-leagues on their single-centre retrospec-tive longitudinal study investigating thevalidity of routine luminal imaging fol-lowing admission to hospital with acuteuncomplicated diverticulitis based oncomputed tomography (CT) diagnosis.

Their conclusions suggesting thatsubsequent colonic evaluation follow-ing acute uncomplicated diverticulitismay not be required are echoed in ourown local experience. We carried outa similar study for the year 2009 toquantify the added diagnostic value ofluminal imaging in uncomplicated acutediverticulitis treated with antibiotics andradiologically guided abscess drainageif required. We excluded all patientsrequiring surgery during their admis-sion. Ninety-six patients were included,with follow-up endoscopy arranged for80 and an attendance rate of 76 per centachieved. No cases of colorectal cancerwere identified, including in those whodid not have endoscopy. Adenomas werefound in six patients (8 per cent), withonly one having high-grade dysplasia.

Our findings support those of West-wood and colleagues, and add furtherto their proposal that, in the absence ofother factors, follow-up luminal imag-ing may not be required after CT-proven diverticulitis that is treated with-out surgery.

A. A. Page, A. Khan and R. J. DaviesCambridge Colorectal Unit, Addenbrooke’sHospital, Cambridge University HospitalsNHS Foundation Trust, Cambridge, UK

(e-mail: aravindapage@gmail.com)DOI: 10.1002/bjs.8670

Letter 2: Routine colonoscopyfollowing acute uncomplicateddiverticulitis (Br J Surg 2011; 98:1630–1634)

SirWestwood and colleagues raise impor-tant questions regarding colonic visu-alization following a computed tomog-raphy (CT) diagnosis of simple acutediverticulitis. However, there are anumber of areas that we feel are worthyof further discussion.

First, the indications for, and tim-ing of colonoscopy should be clarified.The inclusion of patients undergoingcolonoscopy before the CT diagno-sis could lead to selection bias. Theremay also be patients who underwentcolonoscopy up to 5 years after acutediverticulitis and interval carcinomamay result1. The numbers of neoplasmsdetected was low but we suggest thatthe time scale be clarified as this maybe an important factor in any change inpractice advocated by this and similarstudies.

Second, the use of a foreign popula-tion as a control group may be criticizedas there are inevitably demographicand management variations across suchbroad geography. Was there a reasonwhy a sample from less far afield wasnot considered?

Finally, we humbly suggest that thetitle of the paper is slightly misleadingin that it should make clear that thesecases of diverticulitis were diagnosed byCT in the first instance.

We would appreciate clarification ofthe above and would be interested tohear the authors’ response in the contextof published data suggesting contrastingconclusions2.

H. S. Colvin, R. Velineni,A. G. N. Robertson, S. Yalamarthi and

P. J. DriscollQueen Margaret Hospital, Dunfermline,

UK(e-mail: hcolvin@doctors.net.uk)

DOI: 10.1002/bjs.8671

1 Farrar WD, Sawhney MS, Nelson DB,Lederle FA, Bond JH. Colorectalcancers found after a completecolonoscopy. Clin Gastroenterol Hepatol2006; 4: 1259–1264.

2 Lau KC, Spilsbury K, Farooque Y,Kariyawasam SB, Owen RG,Wallace MH et al. Is colonoscopy stillmandatory after a CT diagnosis ofleft-sided diverticulitis: can colorectalcancer be confidently excluded? DisColon Rectum 2011; 54: 1265–1270.

Authors’ reply: Routine colonoscopyfollowing acute uncomplicateddiverticulitis (Br J Surg 2011; 98:1630–1634)

SirThank you for your request for fur-ther clarification of aspects of thisstudy. Our study found that the yieldof advanced colonic neoplasia resultingfrom colonoscopy in patients who havehad acute uncomplicated diverticulitis isequivalent to, or less than that detectedon screening asymptomatic average-risk individuals. These findings ques-tion the value of routine colonoscopyafter an episode of acute uncompli-cated diverticulitis. These results arein contrast to the recently publishedAssociation of Coloproctology of GreatBritain and Ireland (ACPGBI) posi-tion statement on elective resection fordiverticulitis, which states that ‘bariumenema or colonoscopy after resolutionof the acute episode is essential torule out alternative diagnosis or secondpathologies’1.

In their letter, Aravinda Page and col-leagues reported similar results to oursin a smaller series. However, they appearto have included some patients withcomplicated diverticular disease requir-ing percutaneous drainage. In our studycomplicated diverticulitis was deliber-ately excluded as this is more difficultto differentiate from neoplasia on com-puted tomography (CT). This is oneof a number of important differencesbetween this investigation and a recentstudy published by Lau and colleagues2.Lau’s group found a neoplasia rateof 2·1 per cent in patients after CT‘suggesting’ acute diverticulitis. Com-plicated cases were included and thesewere associated with a much higher riskof neoplasia on subsequent colonoscopycompared with uncomplicated cases(odds ratio 6·7, 4 and 18 for abscess,

2012 British Journal of Surgery Society Ltd British Journal of Surgery 2012; 99: 300–302Published by John Wiley & Sons Ltd

Your Views 301

perforation and fistula respectively).These results in fact support the findingsof the present study and vindicate theexclusion of complicated diverticulitis.

In their letter, Colvin and colleaguesask three questions. First, what werethe indications for, and timing ofcolonoscopy? In the published articlewe state: ‘Some 205 (70·2 per cent) ofthe 292 patients underwent subsequentcolonic evaluation or had undergonecolonoscopy/CT colonography withinthe preceding 2 years’. The indica-tions for those who had colonoscopybefore the episode of acute divertic-ulitis were not looked at; for thosewho had their colonic assessment after-wards, it was the index episode of acuteuncomplicated diverticulitis that led tothis evaluation. Colonoscopies within2 years of the index episode of diver-ticulitis were included in our study asit is common practice not to reinvesti-gate the colon in patients admitted witha diagnosis of diverticulitis and recentluminal imaging. Although the colonicvisualization rate of 70·2 per cent washigh compared with other studies, theNew Zealand cancer registry was cross-checked to ensure that no cancershad been missed in patients for whomcolonoscopy results were not available;no cancers were found in this group witha median follow-up of 43 months.

Colvin and co-workers also ask whywe used a foreign population as a controlgroup, which may be criticized as thereare inevitably demographic and man-agement variations across such broadgeography, and go on to ask why asample from less far afield was not con-sidered? I am not certain what theyrefer to here as the study was done inNew Zealand (the UK is not the onlyplace with a city called Christchurch).If they are referring to the discussionand reference to the meta-analysis of68 324 participants having screeningcolonoscopy3, then they should notethat this meta-analysis includes studiesfrom many countries around the world.

Finally, they ask whether the titleof the paper is slightly misleading inthat it should make clear that thesecases of diverticulitis were diagnosedby CT in the first instance. In keepingwith the ACGBI guidelines, we believe

that ‘patients should not be told thatthey have diverticulitis unless there iscolonoscopic and/or radiological evi-dence of inflammation in the presenceof diverticular disease’1. The authors ofthe present study stress in the meth-ods, discussion and conclusion that thepaper is dealing with diverticulitis diag-nosed by CT, the current ‘gold stan-dard’ for diagnosis. We point out thatthe need for follow-up luminal imagingin those with only a clinical diagnosis ofdiverticulitis, complicated diverticulitisor those with other factors indepen-dently warranting colonoscopy shouldbe considered separately. The findingsof the present study should obviouslybe applied only to those with a diagno-sis of uncomplicated acute diverticulitismade by CT performed on modernscanners and reported by radiologistsexperienced in gastrointestinal imaging.

D. A. Westwood, T. W. Eglinton andF. A. Frizelle

Colorectal Unit, Department of Surgery,Christchurch Hospital, Christchurch, New

Zealand(e-mail: frank.frizelle@cdhb.govt.nz)

DOI: 10.1002/bjs.8672

1 Fozard JB, Armitage NC, Schofield JB,Jones OM; Association ofColoproctology of Great Britain andIreland. ACPGBI position statementon elective resection for diverticulitis.Colorectal Dis 2011; 13(Suppl 3): 1–11.

2 Lau KC, Spilsbury K, Farooque Y,Kariyawasam SB, Owen RG,Wallace MH et al. Is colonoscopy stillmandatory after a CT diagnosis ofleft-sided diverticulitis: can colorectalcancer be confidently excluded? DisColon Rectum 2011; 54: 1265–1270.

3 Niv Y, Hazazi R, Levi Z, Fraser G.Screening colonoscopy for colorectalcancer in asymptomatic people: ameta-analysis. Dig Dis Sci 2008; 53:3049–3054.

Self-expanding metallic stents forlarge bowel obstruction (Br J Surg2011; 98: 1625–1629)

SirThe authors conclude that the relativerisk of an adverse event is increased

in the group of patients undergo-ing ‘bridge to surgery’ stenting. How-ever, this group of patients consti-tuted 11 patients, of whom seven hadbenign disease. Adverse events are wellknown to be increased in patients withbenign compared with malignant dis-ease undergoing colorectal stenting1,2.If a self-expanding metallic stent is usedin a patient with benign disease, theplanned bowel resection should not bedelayed more than 4 weeks. It is notsurprising that, as the inflammatoryresponse subsides, the benign stricturewill widen and increase the risk of stentmigration. The time to operation afterstenting was not presented, making itdifficult for the reader to know whetherthis time factor played a role in thepresent study. Moreover, the group ofpatients with malignant disease stentedas a ‘bridge to surgery’ consisted of onlyfour patients, half of whom requireda stoma at the planned colonic resec-tion. This is not only too few patientsfor solid conclusions to be drawn aboutthe risks associated with the ‘bridge tosurgery’ approach, but also a relativelyhigh percentage of patients needed astoma compared with data in the litera-ture, ranging from 0 to 17 per cent3 – 5.Thus, the conclusion that the use of self-expanding metallic stents as a ‘bridge tosurgery’ is associated with a higher riskof adverse events is not substantiatedin the present study, especially whenconsidering that this indication shouldbe restricted to patients with malignantcolonic obstruction.

H. ThorlaciusSkane University Hospital, Malmo,

Sweden(e-mail: henrik.thorlacius@med.lu.se)

DOI: 10.1002/bjs.8673

1 Keranen I, Lepisto A, Udd M,Halttunen J, Kylanpaa L. Outcome ofpatients after endoluminal stentplacement for benign colorectalobstruction. Scand J Gastroenterol 2010;45: 725–731.

2 Small AJ, Young-Fadok TM,Baron TH. Expandable metal stentplacement for benign colorectalobstruction: outcomes for 23 cases.Surg Endosc 2008; 22: 454–462.

2012 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2012; 99: 300–302Published by John Wiley & Sons Ltd

302 Your Views

3 Lepsenyi M, Santen S, Syk I, Nielsen J,Nemeth A, Toth E et al.Self-expanding metal stents inmalignant colonic obstruction:experiences from Sweden. BMC ResNotes 2011; 4: 274.

4 Iversen LH, Kratmann M, Bøje M,Laurberg S. Self-expanding metallicstents as bridge to surgery inobstructing colorectal cancer. Br J Surg2011; 98: 275–281.

5 Saida Y, Enomoto T, Takabayashi K,Otsuji A, Nakamura Y, Nagao J, et al.Outcome of 141 cases ofself-expandable metallic stentplacements for malignant and benigncolorectal strictures in a single center.Surg Endosc 2011; 25: 1748–1752.

Author’s reply: Self-expandingmetallic stents for large bowelobstruction (Br J Surg 2011; 98:1625–1629)

SirWe thank Mr Thorlacius for his interestin our article. The point raised is animportant one and, as mentioned, sevenof our patients undergoing stentingas a bridge to surgery had benigndisease. As such, we advised cautionin interpretation of results related toadverse events associated with stentsinserted as a bridge to surgery owingto the inclusion of patients with benignpathology. With regard to time tostent migration, we do not agree thatthis was related to a reduction ininflammatory swelling. Three of thestents migrated within the first few daysand the other two patients experiencedcomplications shortly after the firstweek following stent insertion. In ourcentre we no longer use stents routinelyfor benign obstruction in view ofprevious experience.

We agree that four patients withmalignant disease is too small a numberto allow any solid conclusions to bedrawn regarding utilization of stents asa bridge to surgery in malignant disease.We advised caution in interpreting ourresults here for the reasons outlinedabove. We recognize the absence ofhigh-quality evidence, in particular

randomized trials to clarify the roleof self-expanding metallic stents whenused as a bridge to surgery in malignantdisease.

C. MackayDepartment of General Surgery, Aberdeen

Royal Infirmary, Aberdeen, UK(e-mail: cmackay@doctors.org.uk)

DOI: 10.1002/bjs.8674

Effect of type of alcoholic beveragein causing acute pancreatitis(Br J Surg 2011; 98: 1609–1616)

SirWe read with interest this articleby Sadr Azodi and colleagues. Manyexcellent research reports have beenpublished using the Swedish PatientRegistry. Aspects of this paper areintriguing, such as the cohort size andthe 10-year follow-up achieved. Thereare some important weaknesses. Theauthors indeed show a significant associ-ation between the amount of spirits con-sumed on a single occasion and the riskof acute pancreatitis. This was empha-sized as the ‘headline’ finding. However,it should be realized that this relation-ship becomes non-significant when theanalysis is confined to cases of alco-holic pancreatitis and patients with gall-stone pancreatitis are excluded fromthe analysis. Furthermore, a propor-tion of patients develop recurrent pan-creatitis following definitive treatmentfor gallstones. It may have been inter-esting to identify this group. Finally,the median age of the cohort stud-ied here was over 60 years. However,the peak incidence of alcohol-relatedpancreatitis occurs at a median age of39 years and the incidence decreaseswith age1. The study aim was to inves-tigate the association between typesof alcoholic beverage and the risk ofpancreatitis. Therefore, the age rangeof the study group was not ideal toanswer the main question posed by thisstudy.

R. Vohra and G. MillerYork Teaching Hospitals NHS Foundation

Trust, York, UK(e-mail: ravsvohra@hotmail.com)

DOI: 10.1002/bjs.8675

1 Lindkvist B, Appelros S, Manjer J,Borgstrom A. Trends in incidence ofacute pancreatitis in a Swedishpopulation: is there really an increase?Clin Gastroenterol Hepatol 2004; 2:831–837.

Author’s reply: Effect of type ofalcoholic beverage in causing acutepancreatitis (Br J Surg 2011; 98:1609–1616)

SirThank you for your valuable comments.As you have noticed, the associationbetween spirit consumption and the riskof acute pancreatitis was attenuated afterexclusion of patients with gallstone-related acute pancreatitis. This resulted,as expected, in loss of statistical preci-sion of the analyses resulting in a widerconfidence interval. However, as shownin Fig. 2, the linear trend in the asso-ciation between spirit consumption andacute pancreatitis remained unchanged.This supports the contention that theobserved association was not due tochance. The occurrence of recurrentacute pancreatitis after gallstone surgerywas beyond the scope of the presentstudy and was not assessed. Previousreports have estimated this proportionto about 10 per cent1,2. Although thepeak of incidence of alcohol-relatedacute pancreatitis occurs at the age of39 years, there is no reason to believethat age alters the association betweenspirit consumption and alcohol-relatedacute pancreatitis differently.

O. Sadr-AzodiKarolinska University Hospital,

Stockholm, Sweden(e-mail: omid.sadr-azodi@ki.se)

DOI: 10.1002/bjs.8676

1 Lankisch PG, Breuer N, Bruns A,Weber-Dany B, Lowenfels AB,Maisonneuve P. Natural history ofacute pancreatitis: a long-termpopulation-based study. Am JGastroenterol 2009; 104: 2797–2805.

2 Lund H, Tønnesen H, Tønnesen MH,Olsen O. Long-term recurrence anddeath rates after acute pancreatitis.Scand J Gastroenterol 2006; 41:234–238.

2012 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2012; 99: 300–302Published by John Wiley & Sons Ltd