137
GastRointestinaL
~ndOscoPY
Editor WILLIAM S. HAUBRICH, M.D. Assistant Editor ELLEN C. SHANNON, M.A. Business Manager DONALD W. TRUMAN, A.B. Editor for Abstracts BERNARD M. SCHUMAN, M.D. Address all correspondence to the Editor Scripps Clinic & Research Foundation 476 Prospect Street La Jolla, California 92037
Editorial Consultants WILLIAM H. MAHOOD, M.D. Philadelphia
G. GORDON McHARDY, M.D. New Orleans
JOHN F. MORRISSEY, M.D. Madison
VERNON M. SMITH, M.D. Baltimore
BENJAMIN H. SULLIVAN, JR, M.D. Cleveland
FRANCISCO VILARDELL, M.D. Barcelona
Advertising Committee HENRY COLCHER, M.D., Chairman 605 Commonwealth Avenue Boston, Massachusetts 02215
FRANCIS J. OWENS, M.D. Cleveland
EUGENE A. GELZAYO, M.D. Southfield
PAUL A. KANTOWITZ, M.D. Cambridge
MARSHALL S. SPARBERG, M.D. Chicago
MURREL H. KAPLAN, M.D. New Orleans
JULIUS WENGER, M.D. Atlanta
ARTHUR P. KLOTZ, M.D. Chairman, NS/G/E Budget and Finance Committee Kansas City, Kansas
Volume 21, No.3, 1975
It's the CP in ERCP that counts Although endoscopic retrograde cholangiopancreatography (ERCP) is a difficult procedure, recent reports indicate that with adequate training and experience, the pancreatic duct and biliary tract can be visualized in most patients. It appears that the diagnostic efficacy or ERCP is limited not by the technical difficulty of cannulation but, rather, by the interpretation of the resulting ductograms. Ductograms, like most radiographs, are not diagnostic of, but are compatible with, a specific diagnosis. The degree of confidence with which we can predict a pathologic process on the basis of a particular radiographic pattern depends primarily on our experience with the radiographic findings of a given disease. In the case of biliary calculi, the diagnostic specificity is high because of the unique radiographic findings in this condition. Unfortunately, the radiographic findings seen in patients with suspected pancreatic and biliary tract neoplasm are not as easy to interpret. This difficulty may result from many factors, including poor quality radiographs and uncertainties in radiograph interpretation. The former difficulty, at least in part, may be a result of the procedure itself. It is not unusual for duodenoscopy and cannulation to take from 30 to 60 minutes, and because of this many radiologists are reluctant to "stand by" during the initial duodenoscopy. As a result, the initial radiography may be performed by the endoscopist or radiology technician. Unfortunately, these initial radiographs and fluoroscopy may be essential in providing diagnostic information. Are the radiolucent defects air bubbles or stones? Was dye in the common hepatic duct long enough for the cystic duct and gallbladder to have filled? Did the right hepatic duct fail to fill because of position or because of obstruction? Was the apparent obstruction ofthe pancreatic duct actually due to a flow artifact caused by the catheter's slipping from the papilla during injection? Was the narrowed area fixed throughout the study, and could it be better visualized at a more oblique angle? These are all questions that may be answered and, sometimes, may only be answered by careful fluoroscopy and correct radiographic technic. The importance of radiographic technic in ERCP cannot be overemphasized and generally requires the services of a radiologist familiar with the procedure. Regardless of the availability of radiology support, the endoscopist must become familiar with the radiographic technics of ERCP. This familiarity will allow optimal cooperation between the endoscopist and radiologist. It is essential in obtaining ducto~ grams when a radiologist is not available. The technic of radiography in ERCP can be learned from gastroenterology-radiology conferences or from courses such as those conducted by the Society, but it is best learned during informal discussions between endoscopist and radiologist. The problem of good quality radiographs is easier to solve than the problems of interpretation. Similar radiographic findings produced by other disease processes (e.g., chronic pancreatitis) and our dependence on ductal deformity for diagnosis make the diagnosis of pancreatic and biliary tract neoplasm difficult. The paper by Zonca et ai, in this issue, and similar reports suggest that, in selected cases, the en-
138
doscopic ductogram is capable of providing an excellent degree of confidence in the diagnosis of pancreatic and biliary tract neoplasm. Unfortunately, to date we still have not adequately answered many of the essential questions concerning the clinical role of ERCP in the diagnosis of these lesions. How useful is ERCP in evaluating patients with pancreatic and biliary tract neoplasm? With what confidence does a negative ductogram rule out the presence of neoplasm? What are the various radiographic patterns encountered in pancreatic and biliary tract neoplasm, and what degree of specificity does each of these patterns provide? These are just a few of the many questions that remain to be answered. The answer to these and other questions concerning the clinical application of ERCP in the diagnosis of neoplasm will be provided only by careful studies. Retrospective studies should allow us to characterize the various radiographic patterns seen in pancreatic and biliary tract neoplasm, and prospective studies should allow an objective test of the clinical efficacy of these patterns. The relatively small number of patients with pancreatobiliary neoplasm and the need for accurate long-term follow-up, suggest the desirability of cooperative studies. The role of the Society's research committee in the area of cooperative studies has not been defined but could conceivably act as a coordinator for such studies. Whether ductogram alone, or in combination with ductal cytology, will allow the early diagnosis of pancreatic and biliary tract neoplasm; and whether early diagnosis, if possible, will significantly change the morbidity and mortality of these diseases are questions whose answers are eagerly awaited by all clinicians. Otto T. Nebel, MD United States Naval Hospital San Diego, California
our
readers
respond
Ever forget the bite block?! The endoscopes currently in use for esophagogastroduodenoscopy are pliable and subject to indentation, with destruction of the fiber bundles if bitten hard during an endoscopic procedure. To avoid this type of accident, various bite blocks are inserted around the 'scope before pasaage and then are wedged between the supper and lower teeth, thus permitting maneuverability of the 'scope through the mouth and preventing the patient from biting the 'scope. At times, the endoscopist or the technician may forget to apply the bite block before insertion of the 'scope, necessitating removal of the' scope to apply the bite block. In the rare circumstances in which this has occurred in our clinic,
Figure 1. we have utilized a bite block with a longitudinal cut which permits application after the 'scope has been passed. (Figure 1) This device is not as strong as the uncut bite block but has proven more than adequate to protect the endoscope. If this device is used, it should be made from a new bite block and utilized only in those instances which require a bite block after passage ofthe 'scope. Used in this manner, the bite block should retain most of its tensile strength. Robert C. Patton, Maj, MC Marvin Garcia, DAC Department of Medicine Gastroenterology Service William Beaumont Army Medical Center El Paso, Texas 79920
Bronchoscopy: advertent and inadvertent I would like to comment on the article "A case of mistaken identity: inadvertent bronchoscopy" which appeared in Gastrointestinal Endoscopy 20: 167, 1974. One year ago, while performing a gastroscopy with the Olympus GIP Panendoscope, we used an old dental model Water-Pik while examining an elderly man suffering from acute upper gastrointestinal bleeding. Due to inexperience with the Water-Pik, the patient received a large amount of saline which was aspirated into his lungs, and he was in danger of "drowning." The endoscope was removed from the patient's stomach, inserted into the trachea with no difficulty, and aspiration was carried out under direct vision. The patient tolerated all these procedures well with no immediate or late ill effects. I would obviously not recommend the endoscope for routine bronchoscopy, but in emergency there does not seem to be any contra-indication to its use. Paul Rozen, MD Gastroenterology Department Municipal Governmental Medical Center Ichilov Hospital Tel Aviv, Israel
(Editor's Note: Just the other day I had an opportunity of observing a jiberoptic bronchoscopy in our ENT department. Because the patient also had experienced dysphagia, it was a simple matter, on the spot, to drop the Olympus bronchoscope into the esophagus where excellent views ofa normal esophagus were readily obtained.) GASTROINTESTINAL ENDOSCOPY
GastRointestinaL
~ndOscoPY
Editor WILLIAM S. HAUBRICH, M.D. Assistant Editor ELLEN C. SHANNON, M.A. Business Manager DONALD W. TRUMAN, A.B. Editor for Abstracts BERNARD M. SCHUMAN, M.D. Address all correspondence to the Editor Scripps Clinic & Research Foundation 476 Prospect Street La Jolla, California 92037
Editorial Consultants WILLIAM H. MAHOOD, M.D. Philadelphia
G. GORDON McHARDY, M.D. New Orleans
JOHN F. MORRISSEY, M.D. Madison
VERNON M. SMITH, M.D. Baltimore
BENJAMIN H. SULLIVAN, JR, M.D. Cleveland
FRANCISCO VILARDELL, M.D. Barcelona
Advertising Committee HENRY COLCHER, M.D., Chairman 605 Commonwealth Avenue Boston, Massachusetts 02215
FRANCIS J. OWENS, M.D. Cleveland
EUGENE A. GELZAYO, M.D. Southfield
PAUL A. KANTOWITZ, M.D. Cambridge
MARSHALL S. SPARBERG, M.D. Chicago
MURREL H. KAPLAN, M.D. New Orleans
JULIUS WENGER, M.D. Atlanta
ARTHUR P. KLOTZ, M.D. Chairman, NS/G/E Budget and Finance Committee Kansas City, Kansas
Volume 21, No.3, 1975
It's the CP in ERCP that counts Although endoscopic retrograde cholangiopancreatography (ERCP) is a difficult procedure, recent reports indicate that with adequate training and experience, the pancreatic duct and biliary tract can be visualized in most patients. It appears that the diagnostic efficacy or ERCP is limited not by the technical difficulty of cannulation but, rather, by the interpretation of the resulting ductograms. Ductograms, like most radiographs, are not diagnostic of, but are compatible with, a specific diagnosis. The degree of confidence with which we can predict a pathologic process on the basis of a particular radiographic pattern depends primarily on our experience with the radiographic findings of a given disease. In the case of biliary calculi, the diagnostic specificity is high because of the unique radiographic findings in this condition. Unfortunately, the radiographic findings seen in patients with suspected pancreatic and biliary tract neoplasm are not as easy to interpret. This difficulty may result from many factors, including poor quality radiographs and uncertainties in radiograph interpretation. The former difficulty, at least in part, may be a result of the procedure itself. It is not unusual for duodenoscopy and cannulation to take from 30 to 60 minutes, and because of this many radiologists are reluctant to "stand by" during the initial duodenoscopy. As a result, the initial radiography may be performed by the endoscopist or radiology technician. Unfortunately, these initial radiographs and fluoroscopy may be essential in providing diagnostic information. Are the radiolucent defects air bubbles or stones? Was dye in the common hepatic duct long enough for the cystic duct and gallbladder to have filled? Did the right hepatic duct fail to fill because of position or because of obstruction? Was the apparent obstruction ofthe pancreatic duct actually due to a flow artifact caused by the catheter's slipping from the papilla during injection? Was the narrowed area fixed throughout the study, and could it be better visualized at a more oblique angle? These are all questions that may be answered and, sometimes, may only be answered by careful fluoroscopy and correct radiographic technic. The importance of radiographic technic in ERCP cannot be overemphasized and generally requires the services of a radiologist familiar with the procedure. Regardless of the availability of radiology support, the endoscopist must become familiar with the radiographic technics of ERCP. This familiarity will allow optimal cooperation between the endoscopist and radiologist. It is essential in obtaining ducto~ grams when a radiologist is not available. The technic of radiography in ERCP can be learned from gastroenterology-radiology conferences or from courses such as those conducted by the Society, but it is best learned during informal discussions between endoscopist and radiologist. The problem of good quality radiographs is easier to solve than the problems of interpretation. Similar radiographic findings produced by other disease processes (e.g., chronic pancreatitis) and our dependence on ductal deformity for diagnosis make the diagnosis of pancreatic and biliary tract neoplasm difficult. The paper by Zonca et ai, in this issue, and similar reports suggest that, in selected cases, the en-
138
doscopic ductogram is capable of providing an excellent degree of confidence in the diagnosis of pancreatic and biliary tract neoplasm. Unfortunately, to date we still have not adequately answered many of the essential questions concerning the clinical role of ERCP in the diagnosis of these lesions. How useful is ERCP in evaluating patients with pancreatic and biliary tract neoplasm? With what confidence does a negative ductogram rule out the presence of neoplasm? What are the various radiographic patterns encountered in pancreatic and biliary tract neoplasm, and what degree of specificity does each of these patterns provide? These are just a few of the many questions that remain to be answered. The answer to these and other questions concerning the clinical application of ERCP in the diagnosis of neoplasm will be provided only by careful studies. Retrospective studies should allow us to characterize the various radiographic patterns seen in pancreatic and biliary tract neoplasm, and prospective studies should allow an objective test of the clinical efficacy of these patterns. The relatively small number of patients with pancreatobiliary neoplasm and the need for accurate long-term follow-up, suggest the desirability of cooperative studies. The role of the Society's research committee in the area of cooperative studies has not been defined but could conceivably act as a coordinator for such studies. Whether ductogram alone, or in combination with ductal cytology, will allow the early diagnosis of pancreatic and biliary tract neoplasm; and whether early diagnosis, if possible, will significantly change the morbidity and mortality of these diseases are questions whose answers are eagerly awaited by all clinicians. Otto T. Nebel, MD United States Naval Hospital San Diego, California
our
readers
respond
Ever forget the bite block?! The endoscopes currently in use for esophagogastroduodenoscopy are pliable and subject to indentation, with destruction of the fiber bundles if bitten hard during an endoscopic procedure. To avoid this type of accident, various bite blocks are inserted around the 'scope before pasaage and then are wedged between the supper and lower teeth, thus permitting maneuverability of the 'scope through the mouth and preventing the patient from biting the 'scope. At times, the endoscopist or the technician may forget to apply the bite block before insertion of the 'scope, necessitating removal of the' scope to apply the bite block. In the rare circumstances in which this has occurred in our clinic,
Figure 1. we have utilized a bite block with a longitudinal cut which permits application after the 'scope has been passed. (Figure 1) This device is not as strong as the uncut bite block but has proven more than adequate to protect the endoscope. If this device is used, it should be made from a new bite block and utilized only in those instances which require a bite block after passage ofthe 'scope. Used in this manner, the bite block should retain most of its tensile strength. Robert C. Patton, Maj, MC Marvin Garcia, DAC Department of Medicine Gastroenterology Service William Beaumont Army Medical Center El Paso, Texas 79920
Bronchoscopy: advertent and inadvertent I would like to comment on the article "A case of mistaken identity: inadvertent bronchoscopy" which appeared in Gastrointestinal Endoscopy 20: 167, 1974. One year ago, while performing a gastroscopy with the Olympus GIP Panendoscope, we used an old dental model Water-Pik while examining an elderly man suffering from acute upper gastrointestinal bleeding. Due to inexperience with the Water-Pik, the patient received a large amount of saline which was aspirated into his lungs, and he was in danger of "drowning." The endoscope was removed from the patient's stomach, inserted into the trachea with no difficulty, and aspiration was carried out under direct vision. The patient tolerated all these procedures well with no immediate or late ill effects. I would obviously not recommend the endoscope for routine bronchoscopy, but in emergency there does not seem to be any contra-indication to its use. Paul Rozen, MD Gastroenterology Department Municipal Governmental Medical Center Ichilov Hospital Tel Aviv, Israel
(Editor's Note: Just the other day I had an opportunity of observing a jiberoptic bronchoscopy in our ENT department. Because the patient also had experienced dysphagia, it was a simple matter, on the spot, to drop the Olympus bronchoscope into the esophagus where excellent views ofa normal esophagus were readily obtained.) GASTROINTESTINAL ENDOSCOPY
