LETTERS & COMMENTS
patients with oesophageal cancer would be to improve cooperation between the upper GI tract and thoracic surgeons particularly in areas of research. The second reason for my delight is that we have some tertiary centre specialists who recognize a down-side to centralization, direct and perhaps more importantly indirect. They also say that centres 'collaborating', whether or not they offer oesophageal surgery, would be ideal. With regards to training, I think that any 'budding' oesophago-gastric surgeon, should not only train in UK hospitals (DGH and tertiary centre) but also become a resident abroad in a tertiary centre where the condition is common. This applies to many other areas including major trauma, breast re-construction, malignant melanoma, advanced laparoscopic procedures to mention only a few.
jaundiced before and after cholecystectomy, had a 'slightly dilated bile duct' without stones on ERCP and no apparent cause for gallstones - being non-haemolytic and male. Persisting dilatation alrnost certainly implies the presence of a fusiform choledochal malformation, which probably requires more than an endoscopic sphincterotomy as definitive treatment.
Correspondence to: Mr GH Dickson, Consultant Surgeon, Upper Gastro-Intestinal Unit, Worthing and Southlands Hospitals NHS Trust, Lyndhurst Road, Worthing, West Sussex BN11 2DH, UK. E-mail: [email protected]
Correspondence to: Mr Mark Davenport, Consultant Paediatric Hepatobiliary Surgeon, Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London SE5 9RS, UK Tel: +44 207 346 3350; Fax: +44 207 346 3564; E-mail: [email protected]
Responise to paper by R Sutton & S Chieslyn-Curtis
Acute gallstone pancreatitis in childhood Ann R Coll Surg Engl 2001; 83: 406-8
Mark Davenport Departmenit of Paediatric Surgery, Kinig's College Hospital, Lontdont, UK M ay I congratulate the authors on the expeditious management of their three cases of gallstone-induced pancreatitis. All these children underwent entirely appropriate minimally invasive procedures (ERCP and laparoscopic cholecystectomy) in a district general hospital without ever once seeing a paediatric surgeon. In most paediatric centres in the UK, access to, and experience of, such techniques would be very limited indeed. I would, however, point out that, in the discussion that followed, the authors have ignored some important and correctable causes of pancreatitis in children. Central among these are choledochal malformations, particularly the fusiform variants, which in our experience are the commonest causes of pancreatitis in this age group.' Pancreatitis is due to the presence of the associated common pancreatobiliary channel that allows free bile reflux into the pancreatic duct. The dilatation in the common bile duct need not be large and in some cases is barely discernible from normal.2 In this context, it may be important to re-look at case 2 who was 296
References 1. Davenport M, Stringer MD, Howard ER. Biliary amylase and congenital choledochal dilatation. J Pediatr Surg 1995; 30: 474-7. 2. Lilly JR, Stellin GP, Karrer FM. Forme fruste choledochal cyst. J Pediatr Surg 1985; 20: 449-51.
Responisefrom the authors
Richard Sutton, Sarah Cheslyn-Curtis Department of Surgery, The Luton and Dunstable Hospital, Luton, UK C holedochal malformations may be the commonest cause of pancreatitis in children in a tertiary referral
centre that deals with paediatric hepatobiliary problems, but they are exceedingly rare in the general population served by a DGH. The patient in case 2 had a history of jaundice and because of a slightly raised bilirubin after cholecystectomy underwent ERCP. The liver enzymes were normal. The extrahepatic bile duct was marginally dilated, but the pancreato-biliary junction appeared normal and there was no long common channel. In Lilly et al," quoted by Davenport, all four patients bad an abnormal pancreato-biliary channel. This patient had gallstone-induced jaundice and pancreatitis which have not recurred since cholecystectomy was performed. There was no evidence to support a choledochal malformation aetiology. References 1. Lilly JR, Stellin GP, Karrer FM. Forme fruste choledochal cyst.
J Pediatr Surg 1985; 20: 449-51. Correspondence to: Ms Sarah Cheslyn-Curtis, Consultant Surgeon, The Luton and Dunstable Hospital, Lewsey Road, Luton LU4 ODZ, UK. Tel: +44 1582 491122; Fax: +44 1582 598990 Ann R Coll Surg Engl 2002; 84