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A sphincterotome with variable-length wire
The m a i n purpose of our study was to provide anatomic and histopathologic confirmation t h a t cancer in the h e a d of the pancreas arising from the region of the gland d r a i n e d by the accessory pancreatic duct m a y r e s u l t in obstruction of the common bile duct, b u t spare the m a i n pancreatic duct. Our study is unique in providing histopathologic confirmation of this phenomenon in d e m o n s t r a t i n g the cancer to be of pancreatic ductal cell origin and not of bile duct origin. 1 To our knowledge, the anatomic confirmation of this phenomenon h a s not been previously demonstrated. As described in our paper, F r e e n y et al. 2 described 3% of the cases to have a normal m a i n pancreatogram. As also discussed in our paper, Silvis et al. 3 found t h a t 5 of 40 (12%) p a t i e n t s with pancreatic carcinoma h a d a n o r m a l pancreatic duct, b u t an abnormal common bile duct. The p a p e r by Roberts-Thomson, 4 which is referenced by Dr. Blackstone, describes one case of pancreatic carcinoma t h a t is associated with a n o r m a l pancreatogram. However, the limitation of this report, as in previous reports, is t h a t although the patients were known to have pancreatic cancer, precise anatomic confirmation t h a t common bile duct obstruction was specifically r e l a t e d to a t u m o r arising from the accessory duct distribution was not provided. This was the m a i n i n t e n t of our p a p e r and represents the unique aspect of our report. As discussed by Silvis et al., 3 it h a s only been speculated in the p a s t t h a t t u m o r s arising in the region of the accessory pancreatic duct m a y result in obstructive jaundice b u t m a y leave the m a i n p a n c r e a t o g r a m intact. However, as Silvis et al. 3 pointed out, t h e r e h a s been limited information confirming this fact anatomically and histopathologically. We have not specifically reviewed our experience with regard to the finding of a normal p a n c r e a t o g r a m in patients with obstructive jaundice related to pancreatic cancer; however, as reviewed in our discussion, F r e e n y et al. 2 found t h a t of 530 patients with pancreatic cancer, 3% h a d a n o r m a l pancreatogram. In conclusion, we believe our study is unique in providing anatomic a n d histologic evidence t h a t a t u m o r arising from the accessory duct m a y p r e s e n t with an isolated bile duct stricture and a normal m a i n pancreatogram.
Kris V. Kowdley, MD University of Washington Schoo/ of Medicine Seattle, Washington
REFERENCES 1. Reference 1 above. 2. Freeny PC, Ball TJ. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) in the evaluation of suspected pancreatic carcinoma: diagnostic limitations and contemporary roles. Cancer 1981;47:1666-78. 3. Silos SE, Rohrmann CA, Vennes JA. Diagnostic accuracy of endoscopic retrograde cholangiopancreatography in hepatic biliary and pancreatic malignancy. Ann Intern Med 1976;84: 438-40. 4. Roberts-Thomson IC. Endoscopic retrograde pancreatography: analysis of the normal pancreatogram, and changes which are associated with chronic pancreatitis and pancreatic cancer. Med J Aust 1977;2:793-6.
494 G A S T R O I N T E S T I N A L E N D O S C O P Y
A sphincterotome with variable-length wire To the Editor: U n d e r the h e a d i n g "New Methods-New Materials," you recently published an article by T a n a k a and colleagues t concerning a "new sphincterotome." Effectively, t h e y describe a s t a n d a r d sphincterotome with a plastic s h e a t h covering its whole length up to the wire portion. Changing the position of the s h e a t h alters t h e length of the wire. The authors a p p e a r to be referring to the '%iliary cannulation sleeve" which we described in your j o u r n a l in 1986. 2 We discussed several of the a d v a n t a g e s t h a t they mention, including alteration of cutting wire length, improved sphincterotome orientation, a n d use of the sleeve for repetitive duct cannulation. Use of this technique h a s reduced somewhat since the development of guide wire sphincterotomes, b u t there are still good indications. The authors mention t h a t "commercial availability is anticipated in the n e a r future." The "Cunningham-Cotton sleeve" h a s been featured in the catalog of Wilson-Cook Medical (Winston-Salem, N.C.) for m a n y years.
Peter B. Cotton, MD John Cunningham, MD Charleston, S.C. REFERENCES 1. Tanaka M, Ogawa Y, Kimura H, Naritomi G. A sphincterotome with variable-length wire for easier endoscopic sphincterotomy and quicker biliary drainage. Gastrointest Endosc 1995;41: 244-6. 2. Cunningham JT, Cotton PB, Speer AG. Biliary cannulation sleeve. Gastrointest Endosc 1986;32:407-8.
Passing a Crosby capsule into the duodenum using a duodenoscope To the Editor: (~ksiioz~lu I described a technique passing a Crosby capsule into the duodenum using a duodenoscope. He suggested a suture loop tied over the base of the Crosby capsule, which is t h e n grasped by biopsy forceps in the duodenoscope when the capsule is in the stomach; both are t h e n advanced in t a n d e m into the duodenum. Although this technique m a y be successful, I would w a r n t h a t a protruding biopsy forceps does pose a possible r i s k of duodenal wall laceration or even puncture. I would suggest t h a t the biopsy forceps be w i t h d r a w n into the duodenoscope as the capsule a n d scope are advanced.
Robert L. Erickson, MD Montc/air, New Jersey REFERENCE 1. Oksfioz~lu G. Endoscopy-assisted placement of a Crosby capsule [Letter]. Gastrointest Endosc 1995;41:82.
VOLUME 42, NO. 5, 1995
Kris V. Kowdley, MD University of Washington Schoo/ of Medicine Seattle, Washington
REFERENCES 1. Reference 1 above. 2. Freeny PC, Ball TJ. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) in the evaluation of suspected pancreatic carcinoma: diagnostic limitations and contemporary roles. Cancer 1981;47:1666-78. 3. Silos SE, Rohrmann CA, Vennes JA. Diagnostic accuracy of endoscopic retrograde cholangiopancreatography in hepatic biliary and pancreatic malignancy. Ann Intern Med 1976;84: 438-40. 4. Roberts-Thomson IC. Endoscopic retrograde pancreatography: analysis of the normal pancreatogram, and changes which are associated with chronic pancreatitis and pancreatic cancer. Med J Aust 1977;2:793-6.
494 G A S T R O I N T E S T I N A L E N D O S C O P Y
A sphincterotome with variable-length wire To the Editor: U n d e r the h e a d i n g "New Methods-New Materials," you recently published an article by T a n a k a and colleagues t concerning a "new sphincterotome." Effectively, t h e y describe a s t a n d a r d sphincterotome with a plastic s h e a t h covering its whole length up to the wire portion. Changing the position of the s h e a t h alters t h e length of the wire. The authors a p p e a r to be referring to the '%iliary cannulation sleeve" which we described in your j o u r n a l in 1986. 2 We discussed several of the a d v a n t a g e s t h a t they mention, including alteration of cutting wire length, improved sphincterotome orientation, a n d use of the sleeve for repetitive duct cannulation. Use of this technique h a s reduced somewhat since the development of guide wire sphincterotomes, b u t there are still good indications. The authors mention t h a t "commercial availability is anticipated in the n e a r future." The "Cunningham-Cotton sleeve" h a s been featured in the catalog of Wilson-Cook Medical (Winston-Salem, N.C.) for m a n y years.
Peter B. Cotton, MD John Cunningham, MD Charleston, S.C. REFERENCES 1. Tanaka M, Ogawa Y, Kimura H, Naritomi G. A sphincterotome with variable-length wire for easier endoscopic sphincterotomy and quicker biliary drainage. Gastrointest Endosc 1995;41: 244-6. 2. Cunningham JT, Cotton PB, Speer AG. Biliary cannulation sleeve. Gastrointest Endosc 1986;32:407-8.
Passing a Crosby capsule into the duodenum using a duodenoscope To the Editor: (~ksiioz~lu I described a technique passing a Crosby capsule into the duodenum using a duodenoscope. He suggested a suture loop tied over the base of the Crosby capsule, which is t h e n grasped by biopsy forceps in the duodenoscope when the capsule is in the stomach; both are t h e n advanced in t a n d e m into the duodenum. Although this technique m a y be successful, I would w a r n t h a t a protruding biopsy forceps does pose a possible r i s k of duodenal wall laceration or even puncture. I would suggest t h a t the biopsy forceps be w i t h d r a w n into the duodenoscope as the capsule a n d scope are advanced.
Robert L. Erickson, MD Montc/air, New Jersey REFERENCE 1. Oksfioz~lu G. Endoscopy-assisted placement of a Crosby capsule [Letter]. Gastrointest Endosc 1995;41:82.
VOLUME 42, NO. 5, 1995