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Endoscopy within the British Society of Gastroenterology
0016-5107/84/3002-0109$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1984 by the American Society for Gastrointestinal Endoscopy
Special Report Endoscopy within the British Society of Gastroenterology The British Society for Digestive Endoscopy amalgamated with the British Society of Gastroenterology in 1980 for reasons detailed in an editorial (Gut 1980;21:1-2). Meetings had always been held in close conjunction and are now completely integrated. There are several differences from the American scene. The BSG has a varied membership: about 30% are surgeons, and 10% are other specialists with gastrointestinal interest (radiologists, pathologists, basic scientists). There are two main meetings each year-in April (3 days) and in September (4 days); there are also numerous workshops and an annual Endoscopy Teaching Course lasting 2 days, with live demonstrations, seminars, and exhibitions. The main meetings attract 800 to 1000 registrants and are usually held on a University campus. The endoscopy content consists of a half day symposium (on a topic chosen by the Endoscopy Committee) and of submitted scientific papers. These are selected by the BSG Program Committee (which includes representatives of the Endoscopy Committee) in direct competition with papers of other specialist interests. There is no quota for endoscopy papers. In practice there is usually one separate session devoted to technical endoscopy papers; the remainder are fitted into sessions with specific organ or disease interest. One presentation at the plenary session of the Spring meeting is reserved for the winner of the Endoscopy Prize Essay (recently named after Harold Hopkins, father of fiberoptics). At the Autumn meeting there is an invited "Endoscopy Foundation Lecture." A Postgraduate course is held on the first day of both Spring and Autumn meetings; endoscopic aspects are included where relevant to the chosen topic. Spring Meeting, London, April 20 to 22, 1983
President, Professor John Lennard-Jones; VicePresident (Endoscopy), Dr. Duncan Colin-Jones. The Postgraduate Teaching Day was devoted to obstructive jaundice, its causes, consequences, diagnosis, and management. Ultrasound diagnosis was discussed by Lees who reported an accuracy of 98% for the recognition of obstructive jaundice, with a precise diagnostic rate of 86% in an experience of more than 500 patients. The endoscopic approach to diagnosis and treatment was outlined by Cotton, and the percutaneous approach by Perieres, who conceded that endoscopic methods of treatment (sphincterotVOLUME 30, NO.2, 1984
omy and stents) should be attempted first whenever possible. The poor results of surgery for cancer were reviewed by Malt, but Blumgart made a plea for operative intervention in patients with hilar tumors. The Endoscopy Symposium was devoted to aspects of endoscopic sphincterotomy, with reviews of indications and results (Cotton), complications (Axon), drainage techniques (Cockel), surgical aspects (Venables), and the radiologist's role (Mason). All speakers emphasized the need for detailed prospective data. Sphincterotomy is now accepted as the treatment of choice in elderly patients, whether or not cholecystectomy has been performed, and randomized trials are in progress in younger patients. Cotton reported an 8% biliary complication rate in 150 patients followed for 3 to 8 years after sphincterotomy. Venables noted that many endoscopic series reported only the complications resulting directly from sphincterotomy, omitting others (such as cardiovascular problems) that would appear in a surgical series. The inadequacy of retrospective data has been highlighted by a computerbased prospective multicenter study in Britain, which shows a complication rate of about 15% for sphincterotomy. Several endoscopic papers dealt with acute gastrointestinal bleeding. Caletti submitted an abstract showing that endoscopic ultrasound could be used to study varices as well as the results of sclerotherapy. McCormack had used an endoscopic Doppler probe to study variceal flow patterns and demonstrated important perforating veins above the cardia; similar conclusions were drawn from a study in which varices were injected with a sclerosant which contained contrast material (Rose). At the preceding Endoscopy Teaching Course, Beckly had described the use of an endoscopic Doppler probe to map blood flow in bleeding ulcers and showed that Doppler results could help predict rebleeding. The Endoscopy Prize lecture was given by Rose, and concerned practical aspects of sclerotherapy. He demonstrated that sclerotherapy was more efficient when performed under fluoroscopy control with contrast material in the sclerosant. The King's group (Westerby) reported a randomized trial comparing sclerotherapy at 1- and 3-week intervals; more frequent treatment resulted in earlier variceal obliteration but a greater incidence of mucosal ulceration. Swain had compared available hemostatic probes (dry monopolar, liquid monopolar, bipolar, and the heater probe) in animal experiments and found the heater probe to be the most promising. He also described a 109
"hot squeeze" electrode that was very effective in animals, but doubts were expressed as to its applicability in humans. Bown reported good results with argon and Nd:YAG laser treatment in six patients with bleeding vascular anomalies. There were only two papers on simple endoscopic diagnosis, but both were of major practical importance. Paoluzi showed for the first time that the recurrence rate of duodenal ulceration was significantly higher if complete healing had not been achieved initially and recommended endoscopic surveillance to healing. By contrast, in an attempt to reduce the load of diagnostic endoscopy in a district hospital, Mann had recorded 77 variables from the clinical history of patients to see which might be used to help in selection for endoscopy; several combinations could be applied to reduce the number of unnecessary endoscopic investigations. There were several papers concerning gastritis, dysplasia, and cancer. The BSG announced the initiation of a computer-based register of patients with early gastric cancer and dysplasia. Complacency about endoscopic definition of ulcers was dispelled by the study of Farini. No fewer than seven of 113 patients were found to have malignancy within 1 year of a careful endoscopic diagnosis of benign gastric ulcer with multiple biopsies. The same group had followed 18 patients with moderate or severe gastric dysplasia; the dysplasia did not regress in any, and two patients were found to have carcinoma within 5 months. Thomas found a correlation between duodenogastric reflux after ulcer surgery (as determined by isotope scanning) and dysplasia. In contrast to most studies, Pickford detected no stump cancers or severe dysplasia among patients endoscoped many years after gastric resection. There were three papers relevant to endoscopic sphincterotomy. Swain reported preliminary results of thermal and photoacoustic fragmentation of biliary calculi in vitro, using continuous wave and giant pulse lasers. Carr-Locke described good results in 82 patients who had undergone endoscopic sphincterotomy for duct stones with gallbladders in situ. Many centers are now performing endoscopic sphincterotomy for patients with acute gallstone-related pancreatitis. Autumn Meeting, York, September 27 to 30, 1983
The postgraduate teaching session concerned a critical evaluation of new tests in gastroenterology, involving the esophagus and stomach, small intestine, liver, and pancreas. There was a parallel meeting of the Endoscopy Assistants' group. The Endoscopy Symposium concerned laparoscopy and was organized by Dr. Paul Brown. Laparoscopy has been little used in Britain in comparison with other European countries, as we heard in an excellent presentation by Dr. 110
Harald Henning. This comprehensive account from Germany was backed up by the views of a surgeon (Cuschieri) and a physician (Cowan). The annual invited Endoscopy Foundation Lecture was given by Professor David Auth from Seattle, Washington, on the subject of endoscopic control of bleeding. He traced the history of endeavor in this field and reviewed the elegant experiments of his group. Gastrointestinal bleeding was also the most popular subject addressed in the scientific papers. Swain gave the final results of the University College-St. James' Hospital YAG laser trial; this provided convincing evidence of benefit in patients with peptic ulcers and active stigmata of recent hemorrhage. Re-bleeding, emergency surgery, and death were all significantly greater in the control group. Storey had been using the Seattle heater probe in Sydney, Australia. This was not a controlled trial; he restricted the method to old or unfit patients who were already anesthetized for an emergency operation because of continued bleeding or rebleeding in hospitaL Treatment with the heater probe avoided surgery in most of the patients with gastric ulcers, but was much less effective (often due to poor access) in duodenal ulcers. Beckly presented preliminary clinical experience with an endoscopic Doppler ultrasound device in bleeding patients. The transducer was passed across the ulcer base in 60 patients who had presented with acute bleeding. The recordings had high predictive values concerning rebleeding, and the technique had potential for choosing the type of therapy and monitoring its success. The two major centers of hepatology in London presented interesting but somewhat contradictory papers about endoscopic sclerotherapy for varices. At the Royal Free, Burroughs had analyzed the natural history of 186 consecutive bleeding cirrhotics over a 5-year period; sclerotherapy was not used. Variceal rebleeding was not inevitable in the initial follow-up period of 1 year, and only 22% of those who survived the initial admission subsequently died of bleeding. Professor Sherlock's group postulated that sclerotherapy could only be proved to be of benefit in very large trials. By contrast, Westerby (from Kings College Hospital) reported the final analysis of a randomized controlled trial of injection sclerotherapy involving 116 patients, entered between 1977 and 1981. Cumulative survival was significantly better in the sclerotherapy group and applied equally to all 3 Child's grades. Other groups are evaluating the use of vasodilators in the management of varices. Dawson showed that portal pressure could be assessed using an endoscopic pneumatic pressure gauge, with good correlation with hepatic wedge pressure. There was a group of papers concerning ERCP and therapeutic procedures. Axon presented a new classification of pancreatograms in chronic pancreatitis, GASTROINTESTINAL ENDOSCOPY
derived from an international workshop held earlier in the year in Cambridge. It was designed to be consistent with ultrasound and computed tomography criteria and to facilitate comparative studies. Cotton reported on a collected series of 105 cases of pancreatic orifice sphincterotomy. The procedure seemed relatively safe, but the indications are still speculative. Pancreatic stone extraction had been successful in about half of the cases attempted; the clinical response to accessory orifice sphincterotomy in patients with pancreas divisum was not predictable. Hatfield compared his results of endoscopic biliary prosthesis with 8 French and 10 French diameter stents; results appear to be better with the larger stents. There is continuing interest in gastritis and premalignant changes. Watt showed that the abnormalities seen after vagotomy and gastrojejunostomy were not present in a control group of patients with ulcers who had not undergone surgical treatment. The same group demonstrated that bile diversion (with Rouxen-Y loop) could reverse gastric dysplasia in the postoperative stomach. The remaining endoscopic papers looked toward the future. Lucas described a plastic pH electrode which could be passed through a standard endoscope for target measurement under visual inspection. Taylor reported the initial Manchester experience with free floating intragastric balloons in patients with morbid obesity. Initial prototypes deflated quickly, but improved silicone balloons appeared to be effective.
VOLUME 30, NO.2, 1984
Swain reported experimental studies in animals undertaken to develop endoscopic methods for performing colostomy and gastrostomy without laparotomy; they also attempted to make entero-enterostomies endoscopically. The annual business meeting of members of the Society is always held at the September meeting. The most controversial item was a proposal to have a new class of "industrial membership" for members of the instrument and pharmaceutical companies. Before it merged with the British Society of Gastroenterology, the British Society for Digestive Endoscopy had such a membership (corporate membership), which facilitated exchange. However, this proposal was rejected at the annual general meeting. The President for 1984 is Dr. Richard McConnell from Liverpool, a distinguished gastroenterologist with a particular interest in genetics. The Vice-President (Endoscopy) is Dr. Klaus Schiller. Meetings will be held in Salford (Manchester) from April 25 to 27, and in Liverpool from September 12 to 14, immediately before the European Society meetings in Lisbon. Visitors are welcome. Further details can be obtained from the BSG Secretariat, Rayne Institute, 5 University Street, London, W.C.1. Peter B. Cotton, MD The Middlesex Hospital London, England
111
Special Report Endoscopy within the British Society of Gastroenterology The British Society for Digestive Endoscopy amalgamated with the British Society of Gastroenterology in 1980 for reasons detailed in an editorial (Gut 1980;21:1-2). Meetings had always been held in close conjunction and are now completely integrated. There are several differences from the American scene. The BSG has a varied membership: about 30% are surgeons, and 10% are other specialists with gastrointestinal interest (radiologists, pathologists, basic scientists). There are two main meetings each year-in April (3 days) and in September (4 days); there are also numerous workshops and an annual Endoscopy Teaching Course lasting 2 days, with live demonstrations, seminars, and exhibitions. The main meetings attract 800 to 1000 registrants and are usually held on a University campus. The endoscopy content consists of a half day symposium (on a topic chosen by the Endoscopy Committee) and of submitted scientific papers. These are selected by the BSG Program Committee (which includes representatives of the Endoscopy Committee) in direct competition with papers of other specialist interests. There is no quota for endoscopy papers. In practice there is usually one separate session devoted to technical endoscopy papers; the remainder are fitted into sessions with specific organ or disease interest. One presentation at the plenary session of the Spring meeting is reserved for the winner of the Endoscopy Prize Essay (recently named after Harold Hopkins, father of fiberoptics). At the Autumn meeting there is an invited "Endoscopy Foundation Lecture." A Postgraduate course is held on the first day of both Spring and Autumn meetings; endoscopic aspects are included where relevant to the chosen topic. Spring Meeting, London, April 20 to 22, 1983
President, Professor John Lennard-Jones; VicePresident (Endoscopy), Dr. Duncan Colin-Jones. The Postgraduate Teaching Day was devoted to obstructive jaundice, its causes, consequences, diagnosis, and management. Ultrasound diagnosis was discussed by Lees who reported an accuracy of 98% for the recognition of obstructive jaundice, with a precise diagnostic rate of 86% in an experience of more than 500 patients. The endoscopic approach to diagnosis and treatment was outlined by Cotton, and the percutaneous approach by Perieres, who conceded that endoscopic methods of treatment (sphincterotVOLUME 30, NO.2, 1984
omy and stents) should be attempted first whenever possible. The poor results of surgery for cancer were reviewed by Malt, but Blumgart made a plea for operative intervention in patients with hilar tumors. The Endoscopy Symposium was devoted to aspects of endoscopic sphincterotomy, with reviews of indications and results (Cotton), complications (Axon), drainage techniques (Cockel), surgical aspects (Venables), and the radiologist's role (Mason). All speakers emphasized the need for detailed prospective data. Sphincterotomy is now accepted as the treatment of choice in elderly patients, whether or not cholecystectomy has been performed, and randomized trials are in progress in younger patients. Cotton reported an 8% biliary complication rate in 150 patients followed for 3 to 8 years after sphincterotomy. Venables noted that many endoscopic series reported only the complications resulting directly from sphincterotomy, omitting others (such as cardiovascular problems) that would appear in a surgical series. The inadequacy of retrospective data has been highlighted by a computerbased prospective multicenter study in Britain, which shows a complication rate of about 15% for sphincterotomy. Several endoscopic papers dealt with acute gastrointestinal bleeding. Caletti submitted an abstract showing that endoscopic ultrasound could be used to study varices as well as the results of sclerotherapy. McCormack had used an endoscopic Doppler probe to study variceal flow patterns and demonstrated important perforating veins above the cardia; similar conclusions were drawn from a study in which varices were injected with a sclerosant which contained contrast material (Rose). At the preceding Endoscopy Teaching Course, Beckly had described the use of an endoscopic Doppler probe to map blood flow in bleeding ulcers and showed that Doppler results could help predict rebleeding. The Endoscopy Prize lecture was given by Rose, and concerned practical aspects of sclerotherapy. He demonstrated that sclerotherapy was more efficient when performed under fluoroscopy control with contrast material in the sclerosant. The King's group (Westerby) reported a randomized trial comparing sclerotherapy at 1- and 3-week intervals; more frequent treatment resulted in earlier variceal obliteration but a greater incidence of mucosal ulceration. Swain had compared available hemostatic probes (dry monopolar, liquid monopolar, bipolar, and the heater probe) in animal experiments and found the heater probe to be the most promising. He also described a 109
"hot squeeze" electrode that was very effective in animals, but doubts were expressed as to its applicability in humans. Bown reported good results with argon and Nd:YAG laser treatment in six patients with bleeding vascular anomalies. There were only two papers on simple endoscopic diagnosis, but both were of major practical importance. Paoluzi showed for the first time that the recurrence rate of duodenal ulceration was significantly higher if complete healing had not been achieved initially and recommended endoscopic surveillance to healing. By contrast, in an attempt to reduce the load of diagnostic endoscopy in a district hospital, Mann had recorded 77 variables from the clinical history of patients to see which might be used to help in selection for endoscopy; several combinations could be applied to reduce the number of unnecessary endoscopic investigations. There were several papers concerning gastritis, dysplasia, and cancer. The BSG announced the initiation of a computer-based register of patients with early gastric cancer and dysplasia. Complacency about endoscopic definition of ulcers was dispelled by the study of Farini. No fewer than seven of 113 patients were found to have malignancy within 1 year of a careful endoscopic diagnosis of benign gastric ulcer with multiple biopsies. The same group had followed 18 patients with moderate or severe gastric dysplasia; the dysplasia did not regress in any, and two patients were found to have carcinoma within 5 months. Thomas found a correlation between duodenogastric reflux after ulcer surgery (as determined by isotope scanning) and dysplasia. In contrast to most studies, Pickford detected no stump cancers or severe dysplasia among patients endoscoped many years after gastric resection. There were three papers relevant to endoscopic sphincterotomy. Swain reported preliminary results of thermal and photoacoustic fragmentation of biliary calculi in vitro, using continuous wave and giant pulse lasers. Carr-Locke described good results in 82 patients who had undergone endoscopic sphincterotomy for duct stones with gallbladders in situ. Many centers are now performing endoscopic sphincterotomy for patients with acute gallstone-related pancreatitis. Autumn Meeting, York, September 27 to 30, 1983
The postgraduate teaching session concerned a critical evaluation of new tests in gastroenterology, involving the esophagus and stomach, small intestine, liver, and pancreas. There was a parallel meeting of the Endoscopy Assistants' group. The Endoscopy Symposium concerned laparoscopy and was organized by Dr. Paul Brown. Laparoscopy has been little used in Britain in comparison with other European countries, as we heard in an excellent presentation by Dr. 110
Harald Henning. This comprehensive account from Germany was backed up by the views of a surgeon (Cuschieri) and a physician (Cowan). The annual invited Endoscopy Foundation Lecture was given by Professor David Auth from Seattle, Washington, on the subject of endoscopic control of bleeding. He traced the history of endeavor in this field and reviewed the elegant experiments of his group. Gastrointestinal bleeding was also the most popular subject addressed in the scientific papers. Swain gave the final results of the University College-St. James' Hospital YAG laser trial; this provided convincing evidence of benefit in patients with peptic ulcers and active stigmata of recent hemorrhage. Re-bleeding, emergency surgery, and death were all significantly greater in the control group. Storey had been using the Seattle heater probe in Sydney, Australia. This was not a controlled trial; he restricted the method to old or unfit patients who were already anesthetized for an emergency operation because of continued bleeding or rebleeding in hospitaL Treatment with the heater probe avoided surgery in most of the patients with gastric ulcers, but was much less effective (often due to poor access) in duodenal ulcers. Beckly presented preliminary clinical experience with an endoscopic Doppler ultrasound device in bleeding patients. The transducer was passed across the ulcer base in 60 patients who had presented with acute bleeding. The recordings had high predictive values concerning rebleeding, and the technique had potential for choosing the type of therapy and monitoring its success. The two major centers of hepatology in London presented interesting but somewhat contradictory papers about endoscopic sclerotherapy for varices. At the Royal Free, Burroughs had analyzed the natural history of 186 consecutive bleeding cirrhotics over a 5-year period; sclerotherapy was not used. Variceal rebleeding was not inevitable in the initial follow-up period of 1 year, and only 22% of those who survived the initial admission subsequently died of bleeding. Professor Sherlock's group postulated that sclerotherapy could only be proved to be of benefit in very large trials. By contrast, Westerby (from Kings College Hospital) reported the final analysis of a randomized controlled trial of injection sclerotherapy involving 116 patients, entered between 1977 and 1981. Cumulative survival was significantly better in the sclerotherapy group and applied equally to all 3 Child's grades. Other groups are evaluating the use of vasodilators in the management of varices. Dawson showed that portal pressure could be assessed using an endoscopic pneumatic pressure gauge, with good correlation with hepatic wedge pressure. There was a group of papers concerning ERCP and therapeutic procedures. Axon presented a new classification of pancreatograms in chronic pancreatitis, GASTROINTESTINAL ENDOSCOPY
derived from an international workshop held earlier in the year in Cambridge. It was designed to be consistent with ultrasound and computed tomography criteria and to facilitate comparative studies. Cotton reported on a collected series of 105 cases of pancreatic orifice sphincterotomy. The procedure seemed relatively safe, but the indications are still speculative. Pancreatic stone extraction had been successful in about half of the cases attempted; the clinical response to accessory orifice sphincterotomy in patients with pancreas divisum was not predictable. Hatfield compared his results of endoscopic biliary prosthesis with 8 French and 10 French diameter stents; results appear to be better with the larger stents. There is continuing interest in gastritis and premalignant changes. Watt showed that the abnormalities seen after vagotomy and gastrojejunostomy were not present in a control group of patients with ulcers who had not undergone surgical treatment. The same group demonstrated that bile diversion (with Rouxen-Y loop) could reverse gastric dysplasia in the postoperative stomach. The remaining endoscopic papers looked toward the future. Lucas described a plastic pH electrode which could be passed through a standard endoscope for target measurement under visual inspection. Taylor reported the initial Manchester experience with free floating intragastric balloons in patients with morbid obesity. Initial prototypes deflated quickly, but improved silicone balloons appeared to be effective.
VOLUME 30, NO.2, 1984
Swain reported experimental studies in animals undertaken to develop endoscopic methods for performing colostomy and gastrostomy without laparotomy; they also attempted to make entero-enterostomies endoscopically. The annual business meeting of members of the Society is always held at the September meeting. The most controversial item was a proposal to have a new class of "industrial membership" for members of the instrument and pharmaceutical companies. Before it merged with the British Society of Gastroenterology, the British Society for Digestive Endoscopy had such a membership (corporate membership), which facilitated exchange. However, this proposal was rejected at the annual general meeting. The President for 1984 is Dr. Richard McConnell from Liverpool, a distinguished gastroenterologist with a particular interest in genetics. The Vice-President (Endoscopy) is Dr. Klaus Schiller. Meetings will be held in Salford (Manchester) from April 25 to 27, and in Liverpool from September 12 to 14, immediately before the European Society meetings in Lisbon. Visitors are welcome. Further details can be obtained from the BSG Secretariat, Rayne Institute, 5 University Street, London, W.C.1. Peter B. Cotton, MD The Middlesex Hospital London, England
111