Ernest Azzopardi

Hamish Laing

Iain Whitaker

Cronfa at Swansea University

5. Mauer MM, Bartness TJ. Photoperiod-dependent fat pad massand cellularity changes after partial lipectomy in Siberianhamsters. Am J Physiol 1996 Feb;270:R383e92.6. Dark J, Forger NG, Zucker I. Rapid recovery of body mass aftersurgical removal of adipose tissue in ground squirrels. Proc NatlAcad Sci U S A 1984 Apr;81:2270e2.7. Dark J, Forger NG, Stern JS, et al. Recovery of lipid mass afterremoval of adipose tissue in ground squirrels. Am J Physiol 1985Jul;249:R73e8.8. Harris RB, Hausman DB, Bartness TJ. Compensation for partiallipectomy in mice with genetic alterations of leptin and itsreceptor subtypes. Am J Physiol Regul Integr Comp Physiol 2002Nov;283:R1094e103.Soner TatlidedeEmre GonenSemra H. KarsidagSisli Etfal Training and Research Hospital,Department of Plastic and Reconstructive Surgery,Sisli-Istanbul, TurkeyE-mail address: emregonen76@yahoo.comIsmail KuranMaltepe University,Department of Plastic and Reconstructive Surgery,Maltepe-Istanbul, Turkeyª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2008.01.0411418 Correspondence and communicationsPerceptions of correct preoperative storage andtransfer of amputated digits: a national survey ofreferring emergency departmentsThe increasing ability of plastic surgeons to perform hand,trauma and microsurgery has increased both patients’and doctors’ expectations of what we can achieve. This hasresulted in a multitude of ever smaller body parts in a rangeof conditions appearing in front of the on-call plastic surgeryteam for consideration of replantation. With technicaladvances in surgery there is a possibility that the medicalcommunity may have overlooked the more simple issue ofhow a replantable digit should be prepared, stored andtransported. In recent years, our unit has received digitspotentially suitable for replantation, which have beenstored and transported inappropriately, in some casesrendering the tissue unviable.To assess the perception among referring practitionersof how amputated digits should be packaged and trans-ported to the Welsh Centre for Burns and Plastic Surgery,we performed a telephonic survey of all emergencydepartments in Wales (nZ 18) in September 2007. A semi-structured questionnaire consisting of two parts was used.Part A consisted of an open-ended question while part Bhad a structured approach. The best practice adopted forstorage and transport of amputated extremities was thatstated in the Advanced Trauma Life Support for Students(ATLS).1Step 1 Wrap in moist gauzeStep 2 Wrap in towelStep 3 Put in a plastic bagStep 4 All placed in another plastic bag with ice or iceþwater.In addition to this, it was also observed how manyrespondents would label the part with the patient’s detailsin line with the UK Tissue Authority Requirements.QuestionnaireSection A - Open questionA patient walks into your emergency department witha completely severed finger.How would you prepare and pack the digit beforetransferring it to another unit for replantation?Section B e Structured questionsQu 1 Can a finger be stored directly on ice?Qu 2 Can a finger be stored in sealed sterile saline?Qu 3 Do you trim and clean the amputated part?Qu 4 If yes with what would you clean it with?Qu 5 How long is a correctly stored digit viable?NB Record any other storage methods mentionedFrom a total of 72 individuals invited, 50 respondents (70%response rate) were recruited (four were consultants, 20were specialist registrars and 26 were senior house officerlevel). Twenty respondents opted not to answer and beingtoo busy. Only 9/50 (18%) respondents described theprocedure (steps 1e4) sequentially and correctly, excludinglabelling of package. Only 3/50 would routinely attach an IDtag with patient information in line with the Human TissueAuthority Requirements.2 Twenty-one out of 50 (42%)respondents believed that the amputated digit could bestored directly on ice, and 16 (32%) thought that it couldsimply be stored in sterile saline. Nineteen doctors (38%)said they would routinely trim and clean the amputatedpart, using a variety of solutions [saline (7), chlorhexidine inwater (4), iodine (aqueous) (1), iodine (alcohol) (5) andheparin in saline (2)]. The emergency doctors in generalwere unsure of the safe cold ischaemia time for amputateddigits (m 3.42 h: range 1e24 h).Many publications over the years have discussed thecorrect storage and transport of amputated digits and indi-cations for replantation, including a recent meta-analysis ofsuccess rates following digital replantation.3 Despite pub-lished ATLS guideline for the storage and transfer of poten-tially replantable digits, our unit has increasingly beenexposed to incorrectly prepared and stored body parts. Thisin itself is worrying, as the ATLS course is a pre-requisite forsurgical training in the UK and promoted by accident andemergency departments. From our national study, it is clearthat a minority of referring practitioners know how bodyparts should be safely transported. A small number ofworrying storage methods were put forward from qualifiedcancer patients, and 16e20% of these are positive.1,2 Manypatients avoid biopsy because of the invasive nature ofsampling these nodes. However, the involvement of thesenodes not only gives important prognostic information butalso can alter the management offered to the patient.In a subset of breast cancer patients undergoing autolo-gous breast reconstruction with the deep inferior epigastricartery perforator (DIEP), transverse rectus abdominismyocutaneous (TRAM) or gluteal flap, sampling these nodesis possible whilst preparing the internal mammary recipientvessels for anastamosis. Indeed, Arnez et al.3 sampled 11consecutive DIEP reconstructions and found one chain to bepositive for tumour. In another series at Sloane KetteringCancer Center, where IMN is routinely biopsied, Mehrarafound positive chains in almost 3% of patients.4 In all of thesecases, irradiation was added to the management of cancer.In the UK, sampling of IMN at the time of breast recon-struction (either delayed or immediate) is not a routineprocedure unless thought to be clinically suspicious.Following several unexpected positive results, we nowroutinely consent and biopsy IMN in all our patientsundergoing autologous breast reconstruction. We alsoadvocate this policy to the readers.References1. Paredes P, Vidal-Sicart S, Zano´n G. Clinical relevance of sentinellymph nodes in the internal mammary chain in breast cancerpatients. Eur J Nucl Med Mol Imaging 2005;32:1283e7.2. Carcoforo P, Sortini D, Feggi L, et al. Clinical and therapeuticimportance of sentinel node biopsy of the internal mammarychain in patients with breast cancer: a single centre study withlong term follow up. Ann Surg Oncol 2006;13:1338e43.3. Arnez ZM, Snoj M. Sampling of internal mammary chain lymphnodes during breast reconstruction by free flaps from theabdomen. Tumori 2005;91:415e7.4. Mehrara B, et al. (unpublished).Correspondence and communications 1419medical staff including: placing the amputated part in a glassand freezing it, putting it in a pot of formalin, covering with asimple jelonet wrap and wrapping in paper bag and placing ina cool box. It is of note that such surprising responses havebeen noted in a previous UK study.4Although the limitations on inference from a smalldescriptive study are recognised, our results clearly high-light the misperceptions of referring medical practitioners,the onus on plastic surgeons to educate and advise referringemergency departments, and not to presume that theamputated parts will be stored and transferred correctly.With the increasing ‘turn over’ of casualty officers in thenew NHS training pathways, the need for experiencedplastic surgeons to educate junior trainees and supervisereferrals has never been so acute.References1. Advanced trauma life support for doctors. 7th ed. Chicago:American College of Surgeons; 2004.2. Available from: http://www.hta.gov.uk/_db/_documents/2007-05-10_Code_of_Practice_8_Import_and_export_of_human_bodies,_body_parts_and_tissue.pdf [accessed 11. 07].3. Dec W. A meta-analysis of success rates for digit replantation.Tech Hand Up Extrem Surg 2006;10:124e9.4. Lloyd MS, Teo TC, Pickford MA, et al. Preoperative managementof the amputated limb. Emerg Med J 2005;22:478e80.Ernest A. AzzopardiIain Stuart WhitakerHamish LaingWelsh Centre for Burns and Plastic Surgery, MorristonHospital, Swansea, UKE-mail address: iainwhitaker@fastmail.fmª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2008.02.017The routine sampling of internal mammary nodes aspart of breast reconstructionDear Sir,Sentinel lymph node studies have shown that internalmammary nodes (IMNs) can be involved in 10e15% of breastFaisal SalimBabak MehraraAfshin MosahebiPlastic and Reconstructive Surgery, The Royal FreeHospital, Pond Street, London NW3 2QG, UKE-mail address: ms983734@doctors.org.ukª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2008.03.050

Perceptions of correct preoperative storage and transfer of amputated digits: a national survey of referring emergency departments

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