Nd:YAG laser for diminutive polyps

Nd:YAG laser for diminutive polyps To the Editor: We have used the Nd:YAG laser with an attached flat fulgurating tip for the coagulation of polyps 5 mm in size or less. The contact tip allows for minimal depth of penetration in contrast to the Nd:YAG laser used with the open fiber. As with the heat probe and bipolar probe, no ground plate is necessary. The potential for serosal injury should be less than with the commonly used monopolar forceps. We have treated over 25 polyps without complication utilizing this method. When a polyp is encountered, a cold forceps biopsy is taken. The Nd:YAG laser fiber tip is introduced through the biopsy channel of the instrument and the contact tip is placed directly on the lesion. Several 10-watt laser pulses are applied. Laser application continues until visible coagulation (whitening) of the lesion is observed. An average of three to four pulses per lesion is used. To date this method has been both safe and effective. In addition, given the small size of the laser fiber with contact tip, we have been able to use this even in endoscopes with relatively small channel sizes. Elliott N. Fraiberg, MD Margie Wiedemann, RN, CGC Kathy Dean, RN Endoscopy Unit St. Joseph Mercy Hospital Pontiac, Michigan

Removal of colonic medium size sessile polyps without diathermy

to tent the polyp toward the lumen while the assistant continues to close the loop to produce the desired guillotine effect. After transection has been accomplished, the base of the polyp is observed for 1 to 2 min to verify that there is no residual bleeding. If bleeding occurs either electrocoagulation with the ball-point electrode or an infusion of dilute epinephrine can be used to stop it. Bleeding stopped spontaneously without need for further intervention in all 25 cases. Recovery of the resected polyp was postponed until the operator was satisfied that there was no residual bleeding; then the resected polyp was recovered by aspiration. Although the experience with this method is still limited, there is ground for its use as a routine technique. The risk of hemorrhage appears to be low and the risk of perforation negligible while the advantages include economy, quickness, and simplification of the polypectomy procedure. J. C. Meeroff, MD Riviera Beach VA

ope, Florida

REFERENCES 1. Cohen LB, Waye JD. Treatment of colonic polyps. Practical consideration. Clin Gastroenterol 1986;15:359-76. 2. Tedesco FJ. Colonoscopic polypectomy. In: Silvia SE, ed. Therapeutic gastrointestinal endoscopy. New York: Igaku-Shoin, 1984:Chapter 12, 269-88. 3. Waye JD, Bishop D. Endoscopic polypectomy snares. A comparative evaluation. Endosc Rev 1984;1:6-12.

Bacteremia following sclerotherapy in portal hypertension To the Editor:

To the Editor: Sessile polyps of approximately 0.5 to 1.0 em in diameter are among the most common polyps identified at colonoscopy. These medium size polyps are too large to be destroyed using the hot biopsy forceps technique. Irrespective of their configuration which can be spherical or irregularly shaped with small or large areas of attachment to the intestinal wall, l these polyps are usually taken out using the snarecauthery technique. The only precondition to attempt this procedure is that the base of the polyp is not too wide and allows the formation of a pseudostalk. Transection of these polyps using "mixed" electrical current produces very little hemorrhage if any. Nevertheless, there is an increased risk of burning the wall of the colon or causing transmural perforation from excessive electrical energy.2 An innovative method for the removal of such polyps consists in transecting the polyp at the level of the pseudostalk by strangulation using the polypectomy snare but without applying any electrical current. To this date we have used the technique in 25 patients with normal coagulation laboratory values and no history of bleeding disorders. In all cases transection was obtained in a matter of seconds while bleeding from the base of the polyp was negligible. The technique requires a snare with sufficient "guillotine force," that is, a large wire loop, that can be retracted into the sheath at least 1 cm. 3 The snare is placed around the polyp and slowly closed in order to form a pseudostalk. Once the loop is tightened around the pseudostalk, the snare is pulled 136

There are a number of reports in the literature on the incidence of bacteremia following sclerotherapy in cirrhotic patients. 1- 5 We would like to report our experience in cirrhotic and noncirrhotic portal hypertension. We compared the incidence of bacteremia following sclerotherapy in 25 patients, each of cirrhotic and noncirrhotic portal hypertension (20 had extrahepatic portal venous obstruction and 5 had noncirrhotic portal fibrosis/idiopathic portal hypertension). Sclerotherapy was performed after cleaning the fibroptic flexible endoscope and the needle with 2% glutaraldehyde and clean water. Blood cultures were taken at 5 and 30 min after sclerotherapy. If the patient developed fever or had bacteremia in the earlier samples, a repeat sample was taken at 24 hours. We found bacteremia in 4 (16%) of the 25 patients with cirrhosis (pneumococcus in 2 patients at 5 min only, Streptococcus faecalis and Klebsiella pneumoniae in 1 patient at 5 and 30 min, Staphylococcus epidermidis in 1 patient at 5 and 30 min). None grew these organisms at 24 hours after sclerotherapy. In contrast, none of the 25 patients with noncirrhotic portal hypertension developed bacteremia. This incidence of 16% bacteremia following sclerotherapy in cirrhotics is in accordance with the incidence reported in the literature. 1- 5 This is higher when compared with the incidence of 3 to 4% reported in patients without any liver disease or portal hypertension after routine endoscopy. Failure to detect bacteremia in noncirrhotic patients with portal hypertension following sclerotherapy may suggest a good GASTROINTESTINAL ENDOSCOPY