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EDUCATION AND DEBATE: Jonathan Mitchell, Hyder Hussaini, Dermot McGovern, Richard Farrow, Giles Maskell, and Harry Dalton Quality improvement report: The "jaundice hotline" for the rapid assessment of patients with jaundice BMJ 2002; 325: 213-215 [Abstract] [Full text]

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Where was the surgical input?

Iain G Martin   (26 July 2002)

FINDINGS UNSUPRISING

Joseph I. Yikona   (27 July 2002)

Re: Where was the surgical input?

Jonathan D Mitchell   (29 July 2002)

Where was the surgical input? 26 July 2002
Iain G Martin, Professor of Surgery University of Auckland, New Zealand Send response to journal: Re: Where was the surgical input?	This article showed the value of moving away from traditional referal pathways in the interest of improving patient care. I do however have major concerns that there was no input in the pathway from upper gastro-intestinal / hepatobiliary surgeons. In 2002, with the widespread availability of magnetic resonance imaging, it is far more appropriate to fully investigate patients non-invasively prior to performing an invasive procedure with not inappreciable morbidity: a younger patient with common bile duct stones may be best managed with a one stop laparoscopic approach to both the gallbladder and the bile duct; a patient with a malignant stricture may be best served by operating early as there is little if any evidence to support the use of routine preoperative biliary drainage (indeed it may be detrimental to do so). Whilst ERCP may have been the appropriate therapeutic intervention it is difficult to believe that not involving a surgeon in the pathway always results in the best outcome for the patient. Upper gastrointestinal and hepatobilairy disease demands multidisciplinary care and that team must include a specialist surgeon.
FINDINGS UNSUPRISING 27 July 2002
Joseph I. Yikona, Staff Physician Gosport War Memorial Hospital, Gosport,UK. PO12 3TX Send response to journal: Re: FINDINGS UNSUPRISING	Iain Martin's concerns are noted and unclear in Mitchell et al'S paper. Having done general porfessional training at the Royal Cornwall Trust(RCHT) 1995-1998 I would like to believe that no patient was compromised by this study. The Gastro-service had an excellent liaison between physicians,surgeons and radiologists offering a fast diagnostic service. As far as am aware deterioration of service has not occurred. I remain unsurprised by Mitchell's findings as it reconfirms that RCHT has continued to maintain excellent minimum standards despite the hiccups of NHS politics and funding.
Re: Where was the surgical input? 29 July 2002
Jonathan D Mitchell, Clinical fellow Institute of Liver Studies, Kings College Hospital, London SE5 9RS Send response to journal: Re: Re: Where was the surgical input?	Professor Martin is, of course, entirely correct. Hepatobiliary and upper gastrointestinal surgeons are intregral to the successful workings of the service.This was not clear from our paper. Following the initial clinical, laboratory and radiological assessments decisions as to further non-invasive radiological interventions (CT, MR, MRCP etc) and early surgery were made after discussion with all disciplines usually at our GI radiological meetings.