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Rapid Responses: Rapid Responses published:
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Surgical management of metastatic inguinal lymphadenopathy
- Simon C Gibson, Dominique S. Byrne, Alan J. McKay (16 December 2004)
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Cost Implication of Sentinel Node Biopsy for the NHS
- Negin Shamsian, Stephen Hamilton Specialist Registrar , Apul Parikh Registrar , Peter EM Butler Consultant Plastic and Reconstructive Surgeon (14 January 2005)
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Simon C Gibson, SHO 3 in surgery Department of General and Vascular Surgery, Gartnavel General Hospital, Glasgow, G12 OYN, Dominique S. Byrne, Alan J. McKay
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Editor- Swan et al presented an interesting clinical review of the surgical management of metastatic inguinal lymphadenopathy. Attempting to review such a major topic is never easy and some of their technical recommendations are inconsistent with our large experience of treating patients with melanoma over the last 20 years. The authors state that the straight oblique incision is superior to the S- shaped incision, yet their evidence for the preferential use of the straight oblique incision is minimal. In the cited reference Tonouchi et al1 studied only 25 procedures- their first 8 used an S-shaped incision and the following 17 a straight oblique. The small numbers, the effect of experience and lack of information about the case-mix of the two groups mean no firm conclusions can be drawn from this study. The other reference given to justify the incision type is a review article with only anecdotal support for the conclusions. 95 groin dissections have been performed in our department, all using a “lazy S” incision with only 1 case of wound ischaemia, 1 wound dehiscence and 5 post-operative infections. All wounds had healed adequately at 6 weeks. These results compare favourably with those studies in which the straight oblique incision has been employed. Whilst the straight oblique incision can be effective we feel that an appropriately placed lazy S incision allows excellent access to the apex of the femoral triangle with a good cosmetic result and without undue risk of skin ischaemia. The authors state that preserving the long saphenous vein can reduce lymphoedema without increasing recurrence rate. The results of the retrospective study by Zhang et al2 showed a significant decrease in complications in those patients whose long saphenous vein was preserved, however the 70% incidence of lymphoedema in the vein ligation group at 6 months is surprisingly high. Baas et al3 performed 151 groin dissections sacrificing saphenous vein on each occasion and noted lymphoedema in only 20% of cases. Vascular surgeons have used long saphenous vein as a conduit for over 30 years with no evidence that its removal contributes to lymphoedema. We are disappointed to note that the justification for sartorius transposition is based on a reference to work by Paley et al4. This same group have conducted a prospective randomised study5 showing that sartorius transposition does not reduce postoperative wound morbidity. We have never employed sartorius transposition and have not experienced any femoral vessel complications in our series. Sartorius transposition is a technique dating from the time when inguinal node lymphadenectomy was performed as a wide excision and closed with split skin grafting. It is not required with modern techniques. Together with many anatomists, surgeons who regularly perform inguinal node clearance dispute the presence of deep inguinal nodes. Our experience over the last ten years leads us to conclude that clearance to the epimysium of sartorius and adductor longus, skeletalising the femoral vessels clears the femoral triangle completely. The term deep inguinal nodes should be abandoned. 1. Tonouchi H, Ohmori Y, Kobayashi M, Konishi N, Tanaka K, Mohri Y, et al. Operative morbidity associated with groin dissections. Surg Today 2004;34: 413-8. 2. Zhang SH, Sood AK, Sorosky JI, Anderson B, Buller RE. Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva. Cancer 2000;89: 1520-5 3. Baas PC, Koops HS, Hoekstra HJ, van Bruggen JJ, van der Weele LT, Oldhoff J. Groin dissection in the treatment of lower-extremity melanoma. Arch Surg 1992; 127: 281-6 4. Paley PJ, Johnson PR, Adcock LL, Cosin JA, Chen MD, Fowler JM, et al. The effect of sartorius transposition on wound morbidity following inguinal-femoral lymphadenectomy. Gynecol Oncol 1997;64: 237-41. 5. Judson PL. Jonson AL. Paley PJ. Bliss RL. Murray KP. Downs Jr LS. Boente MP. Argenta PA. Carson LF. Gynecologic Oncology. Vol. 95(1)(pp 226- 230), 2004. A prospective, randomized study analyzing sartorius transposition following inguinal-femoral lymphadenectomy Competing interests: None declared |
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Negin Shamsian, Registrar Plastic Surgery Royal Free Hospital, NW2, Stephen Hamilton Specialist Registrar , Apul Parikh Registrar , Peter EM Butler Consultant Plastic and Reconstructive Surgeon
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COST IMPLICATIONS OF SENTINEL NODE BIOPSY FOR THE NHS Dear Sir, We read with interest the Clinical Review of surgical management of metastatic inguinal lymphadenopathy by Swan et al in your November 27th issue. Swan et al describe sentinel lymph node biopsy as a promising technique which may refine the indications for inguinal lymphadenectomy and provide better prognostic information, and reduce morbidity. The current UK melanoma guidelines are inadequate in dealing with the role of sentinel node in melanoma 1. However sentinel node biopsy is still a contentious issue with current guidelines generally recommending that patients be offered it in the context of a clinical trial. Despite this sentinel node biopsy is being increasingly applied in the staging of cutaneous melanoma. To assess the cost to the NHS for sentinel node biopsy for cutaneous melanoma we reviewed one hundred consecutive patients in our plastic surgical unit undergoing this procedure. We assessed the costs of inpatient stay, theatre time, histology, nuclear medicine, follow up, completion lymphadenectomies and the management of complications. We calculated the total cost of sentinel node biopsy in our study as £1550 per patient and £2915 per completion lymphadenectomy. Approximately 6000 new melanomas occur in the UK per annum approximately 3000 patients are intermediate thickness and 600 patients are thick melanomas 2. This means offering sentinel node biopsy to 3600 patients per annum if intermediate and thick melanomas are included. The estimated annual cost to the NHS would be £7.6M if sentinel node biopsy were offered to all patients with intermediate and thick melanomas. Sentinel node biopsy is becoming an integral part of the management of primary melanoma although it there has been no proven survival benefit. The impact of surgical time and the availability of nuclear medicine in units treating melanoma have not been assessed. There will need to be increased provision made in every centre managing melanoma or rationalising the service into centres with existing facilities and allocating resources appropriately for increased activity. There is a significant cost in setting up a sentinel node service, including nuclear medicine staffing and probe costs. Units offering sentinel node studies require easy access to on-site nuclear medicine facilities which may not be available in smaller institutions. The financial implications for the NHS of sentinel node biopsy in malignant melanoma management warrant its inclusion in the service guidance for the management of skin tumours including melanoma being prepared by the National Institute for Clinical Excellence.3 Yours Faithfully, Miss Negin Shamsian
Mr Stephen Hamilton
Mr Apul Parikh
Mr Peter EM Butler,
The Royal Free Hospital, Pond Street, London, NW3 2QG REFERENCES 1. Bishop JA et al. UK guidelines for the management of cutaneous melanoma. Br J Plast Surg 2002; 55: 46-54. 2. Cancer Registration Statistics, England 2000. Office for National Statistics. London. 2003. 3. National Institute for Clinical Excellence. Clinical Guidelines in Progress : Skin Cancer Including Melanoma. http://www.nice.org.uk 2004. Competing interests: None declared |
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