CORRESPONDENCE
there were a more successful method known to said patient. The patient described by Dr. Bromberg would be, by present standards, considered to have inappropriate treatment. One may be quite certain that none of the specialists mentioned "put a finger" on her problem. If this were done, she would have demonstrated muscle trigger point pain or cervical facet pain-most likely both. These people do have weakness of the hand. They are found to have minor to major defects in range of motion in the neck and all have an assortment of the common trigger points so well delineated by Travell, Bonica, Pace and others.'-3 The mere act of touching, identifying and explaining these pains as due to dysfunction puts patients in a different situation where they can involve themselves in their own recovery using exercise and strengthening procedures. Only by bridging the psychological and the physical, by responding to a patient's body language of pain with the body language of palpating, touching and accepting, will we as physicians avoid making casualties of patients such as the one described. I must apologize for raising doubts. Having seen some 5,000 chronic pain patients over the last ten years, my experience tells me that someone should have put a finger-literally put a J. BLAIR PACE, MD finger-on this problem. Santa Ana, California REFERENCES 1. Travell R, Rinzler, SH: The myofacsial genesis of pain. Postgrad Med 2:425-434, 1952 2. Bonica JJ: Management of myofascial pain syndromes in general practice. JAMA 164:732-738, 1957 3. Pace JB: Pain, pharmacology and treatment techniques. JCE Clin Med 86:31-40, 1979
Removal of Retained Gallstones TO THE EDITOR: I read with interest the Specialty Conference' and accompanying editorial comments) concerning treatment of retained gallstones in the May 1979 issue. They were generally informative and current with one glaring exception. The Specialty Conference totally ignored and the editorial comment all but ignored the newest and most promising approach to patients with this problem-transduodenal endoscopic sphincterotomy. This technique is not "considered experimental" in the United States as stated by Dr. White but rather is established and in common practice in many referral centers throughout this country. Although it is currently being done on frail and elderly patients at increased risk from open laparotomy, endoscopic sphincterotomy is 158
AUGUST 1979 * 131
* 2
now achieving a high success rate (90 percent to 95 percent) and sufficiently low morbidity (5 percent to 8 percent) and mortality (1 percent) to be considered preferred treatment in all patients with retained common duct stones if T-tract removal is not feasible or achievable. In the past two years at the University of California, San Francisco, we have carried out 50 successful sphincterotomies in 54 attempts; the major barriers td success being abnormal anatomy of the distal bile duct or duodenum. We have had two complications: one, a moderate blood loss from the sphincterotomy lihcision requiring two units of blood, and the second a case of moderate postsphincterotomy pancreatitis that responded to conservative therapy. None of our patients have died nor have any required emergency operations. In this series we have done five successful sphincterotomies and stone extractions in patients in whom there had been unsuccessful attempts at stone retrieval via the T-tube tract. There is no doubt in my mind that endoscopic sphincterotomy is an established technique for retrieval of retained gallstones, at least at the University of California, San Francisco. HOWARD A. SHAPIRO, MD Clinical Professor of Medicine Director, Gastrointestinal Diagnostic Center University of California, San Francisco School of Medicine San Francisco REFERENCES 1. Longmire JP Jr, Goldstein LI, Sample WF, et al: The treatment of retained gallstones-Interdepartmental Clinic Conference, UCLA School of Medicine (Specialty Conference). West J Med 130:422-434, May 1979 2. White TT: Techniques in treatment of retained gallstones (Editorial Comment). West J Med 130:435-437, May 1979 *
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Dr. Longmire Replies TO THE EDITOR: Dr. Shapiro is indeed correct in pointing out the potential value of transduodenal endoscopic sphincterotomy as an additional approach to the removal of common duct stones. His enthusiastic presentation of a quite respectable, but still somewhat limited, experience with the procedure includes two of the most frequently encountered complications, postsphincterotomy bleeding and pancreatitis, and should be viewed in the perspective that surgeons have recognized for many years-that is, that a retrospective report of outstanding results from a certain technical procedure obtained by a particular group of experts may serve as a goal to be emulated, but can by no means be taken as indicative of the results to be expected in the country at large. The
there were a more successful method known to said patient. The patient described by Dr. Bromberg would be, by present standards, considered to have inappropriate treatment. One may be quite certain that none of the specialists mentioned "put a finger" on her problem. If this were done, she would have demonstrated muscle trigger point pain or cervical facet pain-most likely both. These people do have weakness of the hand. They are found to have minor to major defects in range of motion in the neck and all have an assortment of the common trigger points so well delineated by Travell, Bonica, Pace and others.'-3 The mere act of touching, identifying and explaining these pains as due to dysfunction puts patients in a different situation where they can involve themselves in their own recovery using exercise and strengthening procedures. Only by bridging the psychological and the physical, by responding to a patient's body language of pain with the body language of palpating, touching and accepting, will we as physicians avoid making casualties of patients such as the one described. I must apologize for raising doubts. Having seen some 5,000 chronic pain patients over the last ten years, my experience tells me that someone should have put a finger-literally put a J. BLAIR PACE, MD finger-on this problem. Santa Ana, California REFERENCES 1. Travell R, Rinzler, SH: The myofacsial genesis of pain. Postgrad Med 2:425-434, 1952 2. Bonica JJ: Management of myofascial pain syndromes in general practice. JAMA 164:732-738, 1957 3. Pace JB: Pain, pharmacology and treatment techniques. JCE Clin Med 86:31-40, 1979
Removal of Retained Gallstones TO THE EDITOR: I read with interest the Specialty Conference' and accompanying editorial comments) concerning treatment of retained gallstones in the May 1979 issue. They were generally informative and current with one glaring exception. The Specialty Conference totally ignored and the editorial comment all but ignored the newest and most promising approach to patients with this problem-transduodenal endoscopic sphincterotomy. This technique is not "considered experimental" in the United States as stated by Dr. White but rather is established and in common practice in many referral centers throughout this country. Although it is currently being done on frail and elderly patients at increased risk from open laparotomy, endoscopic sphincterotomy is 158
AUGUST 1979 * 131
* 2
now achieving a high success rate (90 percent to 95 percent) and sufficiently low morbidity (5 percent to 8 percent) and mortality (1 percent) to be considered preferred treatment in all patients with retained common duct stones if T-tract removal is not feasible or achievable. In the past two years at the University of California, San Francisco, we have carried out 50 successful sphincterotomies in 54 attempts; the major barriers td success being abnormal anatomy of the distal bile duct or duodenum. We have had two complications: one, a moderate blood loss from the sphincterotomy lihcision requiring two units of blood, and the second a case of moderate postsphincterotomy pancreatitis that responded to conservative therapy. None of our patients have died nor have any required emergency operations. In this series we have done five successful sphincterotomies and stone extractions in patients in whom there had been unsuccessful attempts at stone retrieval via the T-tube tract. There is no doubt in my mind that endoscopic sphincterotomy is an established technique for retrieval of retained gallstones, at least at the University of California, San Francisco. HOWARD A. SHAPIRO, MD Clinical Professor of Medicine Director, Gastrointestinal Diagnostic Center University of California, San Francisco School of Medicine San Francisco REFERENCES 1. Longmire JP Jr, Goldstein LI, Sample WF, et al: The treatment of retained gallstones-Interdepartmental Clinic Conference, UCLA School of Medicine (Specialty Conference). West J Med 130:422-434, May 1979 2. White TT: Techniques in treatment of retained gallstones (Editorial Comment). West J Med 130:435-437, May 1979 *
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*
Dr. Longmire Replies TO THE EDITOR: Dr. Shapiro is indeed correct in pointing out the potential value of transduodenal endoscopic sphincterotomy as an additional approach to the removal of common duct stones. His enthusiastic presentation of a quite respectable, but still somewhat limited, experience with the procedure includes two of the most frequently encountered complications, postsphincterotomy bleeding and pancreatitis, and should be viewed in the perspective that surgeons have recognized for many years-that is, that a retrospective report of outstanding results from a certain technical procedure obtained by a particular group of experts may serve as a goal to be emulated, but can by no means be taken as indicative of the results to be expected in the country at large. The
