Over to you

We welcome all contributions to Over to you. We reserve the right to edit submissions.

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Casebook,
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Email: casebook@mps.org.uk.

Understanding vascular anomalies

I read with interest the article “An unwelcome scar” in the previous issue of Casebook 18 (1).

I agree completely with the points made but am very keen to point out several other critical issues raised by the case.

One could argue, if the term cavernous haemangioma does indeed mean a venous malformation in this instance, that this patient received a suboptimal treatment modality, and one could definitely argue that he should have been offered the choice

1. The term “cavernous haemangioma” is an outdated and incorrect term that became obsolete following the classification devised by Mulliken and Glowacki in 1982.¹ Their classification system (in a slightly modified form) was adopted the following year by the International Society for the Study of Vascular Anomalies (ISSVA), which is the leading international research and clinical group representing this field. When people use this term, they usually mean a venous malformation, a lesion which is neither cavernous or a haemangioma. Those of us who work in this fascinating field devote many hours to correcting misleading terminology from the historical literature like this, and treating patients who have suffered for years with an incorrect diagnosis or, worse, incorrect treatment.
2. Most modern clinicians working in this field would agree that the treatment of choice for a venous malformation is not excision but percutaneous injection sclerotherapy. Interestingly, this creates no scar, which is a point particularly pertinent in your case. One could argue, if the term cavernous haemangioma does indeed mean a venous malformation in this instance, that this patient received a suboptimal treatment modality, and one could definitely argue that he should have been offered the choice. 
3. In my opinion, modern clinical practice would demand that a soft tissue mass is imaged radiologically prior to excision biopsy. This lesion could have been diagnosed on a simple five minute ultrasound scan, as there are several clear radiological features that are typical for venous malformations (as there are for true haemangiomas). I am surprised that the surgeon went ahead with surgery without any prior radiological opinion. If the diagnosis had been made pre-surgery, the option of sclerotherapy may have been raised.

The field of vascular anomalies (the umbrella term for venous malformations, haemangiomas and other similar pathologies) is a fascinating one. It is a subject taught very poorly at medical school and rarely covered at all after that. I think most doctors find it confusing and therefore shy away from it, never updating the outdated terminology they once learnt. On a recent audit of my practice, 80% of my referrals in our busy vascular anomalies unit came with an incorrect diagnosis, and many with a history of incorrect, disfiguring treatments. The “new” ISSVA classification is, in fact, simple and straightforward to understand, and helps immensely with the approach to diagnosis and treatment. It would perhaps be an excellent subject for an article in a future edition of your journal.

Dr Alex M Barnacle
Consultant Interventional Radiologist, London, UK

1. Mulliken JB, glowacki J, Haemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics Plast Reconstr Surg 69(3):412-22 (1982).

Scar or lump?

Thirty years ago, I saw a sticker in California that said: “Support a lawyer. Become a doctor”. Funny at the time, but all too true

Thirty years ago, I saw a sticker in California that said: “Support a lawyer. Become a doctor”. Funny at the time, but all too true. The case labelled “An unwelcome scar” (Casebook 18 (1)) is very much a case in point. The case was settled because the surgeon did not inform a ten-year-old boy that he would have a scar after surgery.

Firstly, scars always occur after surgery. In my experience (and I’ve been cutting people for 40 years) it’s very difficult to predict whether scars will be hypertrophic. The report neglects to inform us as to whether the scar resulting from revision surgery was also hypertrophic.

The original lesion was a “pigmented lump” that turned out to be a haemangioma. Surely, had this been left, it would also have been unsightly and caused the patient to become self-conscious in his teens. Additionally, in my experience, very few ten-year-old children are in favour of having procedures done on them, informed or not.

If you really felt that this case was indefensible then the profession is in deep trouble, and I for one am pleased that I am in the twilight of my career.

This emphasis on informed consent draws attention away from the real issues of negligence, which include not examining patients (if you don’t look, you won’t see), not listening to them, and paying little attention to the march of events. If a complaint doesn’t clear up, something’s on the go. Investigate or refer!

Finally, in South Africa we are to an extent protected by the law of prescription. If the same law applied in the same way in the UK, half these cases would not have made it to the courts. In this country, a patient has three years after the event to start proceedings. After that, the claim prescribes.

Dr Henry Martin
GP, South Africa

Damage limitation

Re “An unwelcome scar” (Casebook 18 (1)) – I was surprised to read in the last paragraph that “as neither PT [the boy of ten years old] nor his mother had been warned of either of these known ‘complications’ of the surgery, the case was settled”.

It is not clear when (in which year) this minor operation was performed on the young boy, probably at least a decade ago? It must be acknowledged that the culture of informing patients about possible complications has changed for the better over the last decade or so, involving more explicit explanation of what may be expected with regard to potential complications and side effects.

Yet, in this case, the “unsightly hypertrophic scar” on the antecubital fossa of a boy, and the loss of tactile sensation over a small area (usually expected to be temporary), can hardly be considered to be “damaging complications”.

I would have thought that, if they had gone to the surgeon, Mr W, to complain after x years, a simple explanation to the mother and her son would have been sufficient for them to accept what had followed the original operation. Perhaps the surgeon could then have offered cosmetic surgery to excise the scar.

Instead of “settlement”, an agreement could then have been arrived at that Mr W would attempt to improve the scar. Then MPS would have protected and educated the surgeon and the patient and his mother!

Dr J T Mets
MRCS, LRCP, Artsexamen
Leiden
DOH, MFOM, M.D.
South Africa

A helping handover

An adequate handover takes time and, since there is no formal time dedicated towards it, doctors have to handover during their own (out of hours) time

I was delighted to read your article “Dropping the baton” (Casebook 18 (1)), as it highlighted a very important yet undermined topic. As a sufferer from poor handover myself, I have touched on some of the reasons why many healthcare professionals fail to handover adequately, if at all:

• An adequate handover takes time and, since there is no formal time dedicated towards it, doctors have to handover during their own (out of hours) time. Therefore, many doctors would prefer to either handover informally over the phone or leave without handing over at all. 
• Many juniors seem to think that if there are no jobs to be done for the patient, handing over is not needed – not realising that failure to anticipate the problem is as catastrophic as the problem itself. 
• Many argue that even if the patient is unwell, handing over will not change the management, as there is not much that can be done “overnight” and most things can wait till the morning.

Handover is a team’s responsibility and not just an individual’s job; if the patient is unwell, s/he should be handed over at all levels.

Dr Zina Aboud
FY1 (Anaesthetics & ITU)
London, UK

Pregnancy and chickenpox

I read the article on chickenpox in pregnancy (Casebook 18(1) “Rare and serious complications”) with interest, as the unwary can fail to realise the significance of exposure to or infection with chickenpox during pregnancy.

Perhaps the learning points could have highlighted the risks to the fetus, not just to the mother. Particularly in the first 20 weeks, the fetus may develop congenital varicella syndrome (limb hypoplasia, microcephaly, cataracts, growth retardation and skin scarring), while if infection occurs a week before to a week after delivery there is, as demonstrated in the case, the risk of severe and even fatal neonatal disease.

Zoster Immune globulin (VZIG) should be considered for varicella zoster antibody-negative contacts exposed at any stage of pregnancy, as well as for neonates of women who develop chickenpox in the period seven days before delivery to seven days after delivery. Pregnant women with chickenpox may benefit from oral aciclovir, as can neonates. So we should remain vigilant, and readily seek expert virological advice to minimise the risk to pregnant women and their unborn babies from chickenpox infection.

Dr Nicola Jones
GP, Wales