Letters
LETTERS TO THE EDITOR
The Barium Enema in the High Risk Carcinoma Patient In summary, I wish to state that after doing multiple examinations utilizing various techniques, I conclude that the combined study is superior to the air contrast study alone. The recognition of tiny carcinomas presenting as contour defects is easier with a combined method than with the air study alone. My opinion should be of significance to Dr. Miller, not the testimony of those who have little or no experience in technique.
Editor: I disagree with the thrust of Dr. Roscoe Miller's dogmatic approach to the question of air contrast barium enema studies. His letter to RADIOLOGY (1) concerning barium enema technique is threatening to those radiologists who do not follow this procedure. Furthermore, some of his references are from nonradiologic sources (2). For example, to quote Ackerman and del Regato (an eminent pathologist and eminent radiotherapist, respectively) as experts in barium enema technique is ingenuous. Dr. Sidney Winawer (3) is a fine gastroenterologist who is interested in colon carcinoma clinically, but can hardly be considered an expert in barium enema technique. On the other hand, I have personally performed more than 75,000 barium enemas in my career and have utilized a variety of techniques. I prefer the conventional full column barium enema study with compression spot films, high kV, followed by evacuation and air studies at the same time. This approach yields an accuracy close to 100%. Citing Williams' article (4) detailing a 43% error rate on barium enema examinations is insulting to any competent radiologist. The statistics at his hospital are regrettable. Rather than dwell on the dogma of air contrast studies, one should emphasize the most important element of the examination,i.e., only a radiologist should perform the examination, not a gastroenterologist or a general practitioner. The clean colon and the method of fluoroscopy are also of vital significance. Villous adenomas and other lesions can easily be missed on air studies alone. I believe Dr. Margulis (5) is correct in his statements concerning the medicolegal aspects of this controversy.
RICHARD H. MARSHAK, M.D. 1075 Park Ave. New York, N.Y. 10028
REFERENCES 1. Miller RE: The barium enema in the high risk carcinoma patient (letter). Radiology 123:813-815, Jun 1977 2. Ackerman LV, del Regato JA: Cancer Diagnosis: Treatment and Prognosis. St. Louis, Mosby, 4th ed, 1970, p 502 3. Winawer SJ, Sherlock P, Schottenfeld 0, et al: Screening for colon cancer. Gastroenterology 70:783-789, May 1976 4. Williams CS, Hunt RH, Loose H, et al: Colonoscopy in the management of colon polyps. Sr J Surg 61:773-782, Sep 1974 5. Margulis AR: Is double contrast examination of the colon the only acceptable radiographic examination? Radiology 119:741-742, Jun 1976
Reuse of Disposable Catheters and Guide Wires The end result is that part of the catheter can be left in the patient. From a mechanical standpoint only, torque type catheters should not be reused. With regard to Teflon, polyethylene, and polyurethane nonbraided catheters, there is no reason why these cannot be reused providing adequate safeguards are taken for cleaning and hospital protocol includes inspection of critical parts such as the catheter tip and body. These catheters can be used several times when properly cleaned. The terms "Intended for One-Time Use" and "Use Once and Discard" are also employed to provide some product liability relief when catheter failure may be caused by the user. The legal implications of reuse jeopardize the manufacturer since he must depend solely upon the user to clean and inspect before each use.
Editor: With regard to Dr. Ravin and Dr. Koehler's paper "Reuse of Disposable Catheters and Guide Wires" and Dr. Charles Dotter's "Opinion" concerning this subject in the March 1977 issue of RADIOLOGY, I would appreciate commenting as a manufacturer.
REUSE OF CATHETERS Cook Incorporated, along with other companies, pioneered the concept of disposable cardiovascular catheters. Two distinct benefits are derived from disposing of catheters. First, the disposable concept increases volume and volume permits lower prices. At our company price reductions have been passed on to the customer which in turn encourages higher use the product. (For example, even with inflation, a Teflon catheter which cost $20.00 in 1962 is $3.25 today. A guide wire which cost $7.50 in 1965 is $5.25 today.) Secondly, disposability affords the user the option to discard a product before it can develop mechanical defects. With the exception of the torque type catheters which our company markets under the brand of Torcon, there really is no apparent reason why cardiovascular catheters cannot be reused. I cannot speak for other manufacturers; however, I feel that the USCI Posi-Trolll and the Cordis Ducor torque control braided catheters should also be disposed of after one use. These types of catheters are constructed of a braided shaft and nonbraided tip; the two plastic components are bonded together at the distal portion of the catheter. Because the catheter undergoes a high degree of rotation creating tortional stresses on the bond, the bond or the plastic around the bond can fail upon repeated rotations.
REUSE OF GUIDE WIRES Under no condition should any angiographer reuse wire guides unless it is in an absolute emergency. After 13 years of experience with the product, I can categorically state that repeated usage creates mechanical flaws which are not easily detected by superficial inspection, and that, contrary to the above-mentioned paper, guides cannot be satisfactorily cleaned even with ultrasonic cleaners. When a guide wire is used for the first time the coils are stretched and sometimes permanently deformed. This deformation can also easily go undetected. With regard to Teflon coating on guide wires, Cook Incorporated applies as thin a coat as possible to reduce the chance that Teflon can be sloughed into the vessel through abrasion with the catheter or with the needle. There is no question that the Teflon coat is disturbed by abrasion. Loss of Teflon in the vessel is increased with each reuse.
549
LETTERS TO THE EDITOR
The Barium Enema in the High Risk Carcinoma Patient In summary, I wish to state that after doing multiple examinations utilizing various techniques, I conclude that the combined study is superior to the air contrast study alone. The recognition of tiny carcinomas presenting as contour defects is easier with a combined method than with the air study alone. My opinion should be of significance to Dr. Miller, not the testimony of those who have little or no experience in technique.
Editor: I disagree with the thrust of Dr. Roscoe Miller's dogmatic approach to the question of air contrast barium enema studies. His letter to RADIOLOGY (1) concerning barium enema technique is threatening to those radiologists who do not follow this procedure. Furthermore, some of his references are from nonradiologic sources (2). For example, to quote Ackerman and del Regato (an eminent pathologist and eminent radiotherapist, respectively) as experts in barium enema technique is ingenuous. Dr. Sidney Winawer (3) is a fine gastroenterologist who is interested in colon carcinoma clinically, but can hardly be considered an expert in barium enema technique. On the other hand, I have personally performed more than 75,000 barium enemas in my career and have utilized a variety of techniques. I prefer the conventional full column barium enema study with compression spot films, high kV, followed by evacuation and air studies at the same time. This approach yields an accuracy close to 100%. Citing Williams' article (4) detailing a 43% error rate on barium enema examinations is insulting to any competent radiologist. The statistics at his hospital are regrettable. Rather than dwell on the dogma of air contrast studies, one should emphasize the most important element of the examination,i.e., only a radiologist should perform the examination, not a gastroenterologist or a general practitioner. The clean colon and the method of fluoroscopy are also of vital significance. Villous adenomas and other lesions can easily be missed on air studies alone. I believe Dr. Margulis (5) is correct in his statements concerning the medicolegal aspects of this controversy.
RICHARD H. MARSHAK, M.D. 1075 Park Ave. New York, N.Y. 10028
REFERENCES 1. Miller RE: The barium enema in the high risk carcinoma patient (letter). Radiology 123:813-815, Jun 1977 2. Ackerman LV, del Regato JA: Cancer Diagnosis: Treatment and Prognosis. St. Louis, Mosby, 4th ed, 1970, p 502 3. Winawer SJ, Sherlock P, Schottenfeld 0, et al: Screening for colon cancer. Gastroenterology 70:783-789, May 1976 4. Williams CS, Hunt RH, Loose H, et al: Colonoscopy in the management of colon polyps. Sr J Surg 61:773-782, Sep 1974 5. Margulis AR: Is double contrast examination of the colon the only acceptable radiographic examination? Radiology 119:741-742, Jun 1976
Reuse of Disposable Catheters and Guide Wires The end result is that part of the catheter can be left in the patient. From a mechanical standpoint only, torque type catheters should not be reused. With regard to Teflon, polyethylene, and polyurethane nonbraided catheters, there is no reason why these cannot be reused providing adequate safeguards are taken for cleaning and hospital protocol includes inspection of critical parts such as the catheter tip and body. These catheters can be used several times when properly cleaned. The terms "Intended for One-Time Use" and "Use Once and Discard" are also employed to provide some product liability relief when catheter failure may be caused by the user. The legal implications of reuse jeopardize the manufacturer since he must depend solely upon the user to clean and inspect before each use.
Editor: With regard to Dr. Ravin and Dr. Koehler's paper "Reuse of Disposable Catheters and Guide Wires" and Dr. Charles Dotter's "Opinion" concerning this subject in the March 1977 issue of RADIOLOGY, I would appreciate commenting as a manufacturer.
REUSE OF CATHETERS Cook Incorporated, along with other companies, pioneered the concept of disposable cardiovascular catheters. Two distinct benefits are derived from disposing of catheters. First, the disposable concept increases volume and volume permits lower prices. At our company price reductions have been passed on to the customer which in turn encourages higher use the product. (For example, even with inflation, a Teflon catheter which cost $20.00 in 1962 is $3.25 today. A guide wire which cost $7.50 in 1965 is $5.25 today.) Secondly, disposability affords the user the option to discard a product before it can develop mechanical defects. With the exception of the torque type catheters which our company markets under the brand of Torcon, there really is no apparent reason why cardiovascular catheters cannot be reused. I cannot speak for other manufacturers; however, I feel that the USCI Posi-Trolll and the Cordis Ducor torque control braided catheters should also be disposed of after one use. These types of catheters are constructed of a braided shaft and nonbraided tip; the two plastic components are bonded together at the distal portion of the catheter. Because the catheter undergoes a high degree of rotation creating tortional stresses on the bond, the bond or the plastic around the bond can fail upon repeated rotations.
REUSE OF GUIDE WIRES Under no condition should any angiographer reuse wire guides unless it is in an absolute emergency. After 13 years of experience with the product, I can categorically state that repeated usage creates mechanical flaws which are not easily detected by superficial inspection, and that, contrary to the above-mentioned paper, guides cannot be satisfactorily cleaned even with ultrasonic cleaners. When a guide wire is used for the first time the coils are stretched and sometimes permanently deformed. This deformation can also easily go undetected. With regard to Teflon coating on guide wires, Cook Incorporated applies as thin a coat as possible to reduce the chance that Teflon can be sloughed into the vessel through abrasion with the catheter or with the needle. There is no question that the Teflon coat is disturbed by abrasion. Loss of Teflon in the vessel is increased with each reuse.
549
