Minimally invasive therapy

Although all visible wavelengths are capable of damaging the retina, blue light with its short wavelength has more energy and is, therefore, more dangerous. The increasing use of video endoscopy should decrease the risk of light damage for gastroenterologists, but if fiberoptic instruments are extensively used, we recommend the use of a blue light absorbance filter. Hedwig J. Kaiser, MD Josef Flammer, MD Gaudenz Miller, MD Universitats-Augenklinik Basel Basel, Switzerland

Figure 1. Videoendoscopic photograph of the stomach revealing a lapel pin flag of the United States which our patient swallowed.

REFERENCES 1. Meyerrarken E. Uber Maculaschadigung durch Beobachtung'

2. 3. 4. 5. 6. 7. 8. 9.

der Sonnenfinsternis vom 30. Juni 1954. Klin Monatsbl Augenheikd 1956;129:78-86. Calkins JL, Hochheimer BF. Retinal light exposure from operating microscopes. Arch OphthalmoI1979;97:2263-7. Robertson DM, Feldman RB. Photic retinopathy from operating room microscope. Am J OphthalmoI1986;101:561-96. Lessel M, Thaler A, Heilig P, et al. Intraoperative retinal light damage reflects in electrophysiologic data. Doc Ophthalmol 1991;76:323-33. Berninger TA, Canning CR, Giindiiz, D et al. Using argon laser blue light reduces ophthalmologists' color contrast sensitivity. Arch Ophthalmol 1989;107:1453-8. Hawerth RS, Sperling HG. Prolonged color blindness induced by intense spectral lights in rhesus monkeys. Science 1971;114:520-3. Octopus 201 Manual. Schlieren, Switzerland: Interzeag, 1986. Lanthiny P. The desaturated panel D15. Doc Ophthalmol 1978;46:185-9. Mittl RN, Lopez R, Zemon V. Contrast sensitivity after successful retinal detachment repair. Invest Ophthalmol 1990;3l(ARVO suppl):129.

Patriotic swallow To the Editor: During the Gulf war, a 25-year-old woman with a seizure disorder, presented to the emergency room after inadvertently swallowing a foreign body with her phenytoin pills. A chest x-ray revealed a safety pin-shaped object at the level of the mid-esophagus. On an emergent upper gastrointestinal endoscopy, a support the troops, lapel flag of the United States was seen in the mid-esophagus, which moved into the stomach during the procedure (Fig. 1). With the help of a foreign body prong and an alligator forceps, the top of the pin was grasped and it was removed in toto. Manoop S. Bhutani, MD Mohammad R. Soleimanpour, MD Wright State University School of Medicine Dayton, Ohio

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Minimally invasive therapy To the Editor: Endoscopic visualization of the fallopian tube (falloposcopy), the popliteal artery, and the internal auditory canal. Expandable stents placed in the prostate, urethra, ureter, coronary artery, and bronchus. Robotic surgery performed at a computer work station removed from the operating room. Extracorporeal sound waves focused to destroy intraabdominal malignancies without surgery. Laparoscopic appendectomy, colectomy, nephrectomy, hysterectomy, lymphadenectomy, and highly selective vagotomy. Aortic valve replacement performed in 15 min via catheter in an antecubital vessel. Exciting stuffl All of the above were reported at the Third International Meeting for the Society for Minimally Invasive Therapy, which was held in Boston on November 10 to 12, 1991. Noticeably absent at the meeting were gastrointestinal endoscopists. Although some surgical endoscopists were present, there were less than 10 gastroenterologists among the 500 participants. I have felt for years that the boundaries between surgeons and physicians have been increasingly blurring. The concerns, the techniques, and even the tools used by a wide variety of cloggologists are similar.! At this meeting of minimally invasive therapists, these facts were even more apparent. The added influence of various new technologies will also impact upon the way that we do business. The management of digestive diseases in the 21st century will be very different than it was a few decades ago. These are exciting times. The Fourth International Meeting for the Society of Minimally Invasive Therapy is scheduled in Dublin next November. For information, contact: Mr. J. E. A. Wickham, The Society for Minimally Invasive Therapy, 25 John Street, London WCIN 2BL, United Kingdom. David E. Fleischer, MD Georgetown University Medical Center Washington, D.C.

GASTROINTESTINAL ENDOSCOPY

REFERENCE cloggology.

1. Fleischer DE. Therapeutic 1990;65:600-2.

Mayo Clin

Proc

Abstracts ENDOSCOPY AROUND THE WORLD

Editor for Abstracts, James Barthel, MD Panel of Reviewers Seibi Kobayashi Glen A. Lehman Zdenek Maratka Steven A. McClave Giorgio Minoli Ben Novis John F. Reinus Richard A. Wright

John Baillie Jamie S. Barkin Stanley B. Benjamin Lawrence J. Brandt David R. Cave Masayuki A. Fujino Lionello Gandolfi David Y. Graham

Occult microlithiasis in idiopathic acute pancreatitis ROB

E,

NAVARRO

S, BRU C,

ET AL.

Gastroenterology 1991;101:1701-9

The authors reviewed 51 patients who were hospitalized with acute pancreatitis without obvious etiology by laboratory testing, history, or gallbladder evaluation. All patients had a negative transcutaneous ultrasound test on two occasions and a negative oral cholecystogram. Seventy percent of patients were female. The mean age of the patients was 62 years. The authors looked for subtle gallstone disease by performing duodenal drainage of bile stimulated by cholecystokinin and evaluating the bile microscopically for cholesterol, calcium bilirubinate, and calcium carbonate crystals. Also, all patients had follow-up ultrasonography at 3 to 12 months. Eventually, 76% of patients were found to have evidence of calculus disease, by ultrasonography 73%, or microscopic bile examination 67% or both. Eventually, 18 of the patients underwent cholecystectomy, again confirming their stones. Although gallstones were not seen during the initial phase of evaluation in these patients, 67% did have abnormal liver tests during the index episode of acute pancreatitis (92% of these were eventually found to have gallstones). Seventeen patients with positive ultrasound or duodenal bile positive for microlithiasis were treated with full therapeutic doses of ursodeoxycholic acid for 3 to 6 months and then placed on 300 mg of ursodeoxycholic acid per day as maintenance. All but one patient had dissolution of stones, sludge, or microlithiasis on follow-up. Eight patients who complied with ursodeoxycholic acid maintenance therapy remained stone free, but other patients who discontinued their drug experienced stone recurrence and VOLUME 38, NO.3, 1992

recurrent episodes of acute pancreatitis. Cholesterol gallstones were more common in women (68%) than in men (42%). Of 14 patients with no final evidence of gallstones, none had a recurrent attack of pain over a 45-month follow-up period. Sixteen percent of patients who had cholecystectomy or stone dissolution by bile salt therapy (plus maintenance therapy) had recurrent pancreatitis (one from retained common duct stone). Of patients failing to have cholecystectomy or maintenance of ursodeoxycholic acid, 67% had recurrent attacks. Overall, the authors emphasize that microcalculus disease is still a very common cause of idiopathic pancreatitis. This report nicely serves to again emphasize that uncommon manifestations of common disease (gallstones) are still much more common than common manifestations of uncommon disease. Pancreatitis, which is labeled "idiopathic" after preliminary history, laboratory tests, and ultrasound, may be due to a variety of disease including gallstones, tumors, pancreatic duct strictures, pancreas divisum, choledochocele, sphincter of Oddi dysfunction, and so forth. In an elderly predominantly female population, this study emphasizes that gallstones still remain the main primary culprit. While the authors looked for stones by duodenal bile chemical and microscopic analysis, simple transcutaneous ultrasound detected essentially all stones at follow-up examination. The message appears to be, follow your patient carefully and repeat the ultrasound test. The role of ERCP in this group remains uncertain. ERCP was performed in 15 of the patients and was non-diagnostic. No other ERCP details were given. It would be interesting to know whether these patients had evidence of a lacerated papilla (suggesting stone passage), common duct dilation, or evidence of gallbladder sludge by contrast injection. Sphincter of Oddi manometry was apparently not done. For patients with recurrent pancreatitis, who have abnormal liver tests during pain episodes and negative ERCP, we generally do an empiric biliary sphincterotomy under the assumption that they are passing small stones. This approach seems rational in the patient who is already post-cholecystectomy. In patients with the gallbladder in situ, control trials are needed to determine whether long-term bile salt therapy, cholecystectomy, endoscopic sphincterotomy, or combination therapy is the most efficacious in preventing recurrent attacks. PRIYA JAMIDAR GLEN

A.

LEHMAN

Indianapolis. Indiana

Long term results of choledochoduodenostomy in the treatment of choledocholithiasis PARRILLA

P, RAMIREZ P, BUENO FS, ET AL.

Br J Surg 1991;78:470-2

With endoscopic methods now widely accepted as the preferred management for choledocholithiasis (CDL), is there still a role for choledochoduodenostomy (CDD)? Supraduodenal CDD has been used for over a century as a biliary bypass procedure following surgical exploration for bile duct stones. Controversy 403