NON-SURGICAL TREATMENT OF BILIARY OBSTRUCTION

1301 cases

the levels of the

gluconeogenic

aminoacids

It is not clear whether these changes in the pattern of aminoacids in the blood are due to some intrinsic defect of muscle metabolism, which is common to Duchenne muscular dystrophy and to the congenital muscle disease of mice, or whether they merely reflect a reduction in muscle mass. However, our work makes it clear that any metabolic stress, and especially fasting, will aggravate the process of muscle wasting, by calling upon the muscles to release aminoacids, a process which cannot be long sustained without a loss of structural protein from the muscles. Department of Neuropathology, Institute of Psychiatry, London SE5 8AF

Department of Applied Physiology and Surgical Science, Royal College of Surgeons,

AMNIOCENTESIS RATES IN OLDER WOMEN

(alanine, gly-

cine, threonine, and serine) are reduced while the branchedchain aminoacids (valine, leucine, and isoleucine) are raised.

SIR,-Alberman et al.l suggested that in the South East Thames Regional Health Authority during 1977 there may have been a referral rate as high as 48% for amniocentesis for pregnant women over 40 years of age who are at high risk for Down syndrome. Since they did not expect more than 68-77% of these patients to want amniocentesis, assuming that dissemination of knowledge does not change booking habits, they felt that they had almost reached saturation point in the long struggle towards full use of the available service.

E. SPARGO O. E. PRATT

London WC2A 3PN

P. M. DANIEL

Department of Child Health, Hammersmith Hospital, London W12

HEATHER STEPHENS

NON-SURGICAL TREATMENT OF BILIARY OBSTRUCTION

SiR,-We share the Royal Free Hospital workers’ enthusiasm for the percutaneous insertion of biliary drainage tubes in patients with malignant obstruction (Nov. 17, p. 1040), but differ in our approach to patients with bileduct stones. Dr Dooley and his colleagues imply that endoscopic retrograde cholangiography (ERC) carries a greater risk of cholangitis than does percutaneous transhepatic cholangiography (PTC) in patients with dilated bileducts. Both procedures can cause cholangitis,I,2 but the risk is very small in experienced hands;3 we have not caused cholangitis during our last 1000 ERCP examinations. Our main disagreement with the Royal Free group concerns the treatment of patients with acute cholangitis due to bileduct stones. Endoscopic diathermy sphincterotomy provides adequate drainage and removal of the cause. If the patient has already undergone cholecystectomy, no further treatment is required. If the gallbladder is still in place, the patient needs only a simple cholecystectomy when the acute illness has subsided. Drainage can certainly be effective percutaneously, but this route is less attractive for the patient who will still require operative duct exploration and, possibly, a sphincteroplasty (as in one of the Royal Free cases). Follow-up studies indicate that endoscopic sphincterotomy provides adequate drainage even in patients with dilated ducts; the orifice is often as large as a sur-

gical sphincteroplasty. When necessary, the endoscopic approach also allows temporary placement of a drainage tube brought out through the patient’s nose,’ and even the insertion of an endoprosthesis

(unpublished). Gastrointestinal Unit, Middlesex Hospital, London W1N 8AA

PETER B. COTTON BERNARD H. LAURENCE

Department of Radiology, Middlesex Hospital

RICHARD MASON

<

a

a

e

112: 954-58. 3. Ohio M, Ono T,

Tsuchiya Y, Saisho H.

u

d

is

s

years of age

giving

over 40 birth in 1977 who received amniocentesis.

Axes proportional to distance (miles).

This is not true, however, of the West Midlands. During 1977, only 16% of mothers over 40 years received amniocentesis. There is also tremendous variation within the region (see figure). The radius of each circle is proportional to the number of births in each major centre to women of 40 or more at the time of the birth; the shaded area shows the proportion of these who received amniocentesis. Even after allowing-for the referral of difficult cases to other hospitals, the regional variation is much la-ger than should be anticipated, and only 26% of patients over 40 received amniocentesis even -in the major centres. It seems that, with some exceptions, metropolitan connurbations are once more advantaged. The major cause of this variation, the absence of ultrasound in some centres, is now largely remedied and, given the facilities available, we would hesitate to imply any criticism at the clinical level.

Summerly for

of Clinical Genetics,

Department Birmingham Maternity Hospital, Birmingham B15 2TG

*Present address: Genetics Laboratory, of Oxford, Oxford OX13QU.

the

use

of their data.

J. H. EDWARDS* TESSA WEBB Department

of Biochemistry,

University

and pancreatogra-

Cholangiography phy. Tokyo: Igaku Shoin, 1978. Mason RR. Trans-nasal bile duct PB, Burney PGJ, after endoscopic sphincterotomy. Gut 1979; 20: 285-87.

4. Cotton

12

Map of West Midlands showing proportions of mothers

We thank M. Ward and Dr M.

CT, Lee TG, Katon RM. Complications of endoscopic retrograde cholangio-pancreatography (ERCP): A study of 10 000 cases. Gastroenterology 1976; 70: 314-20. 2. Juler GL, Conroy RM, Fuelleman RW. Bile leakage following percutaneous trans-hepatic cholangiography with the Chiba needle. Arch Surg 1977; 1. Bilbao MK, Dotter

10

catheterisation

1. Alberman E, et al. Amniocentesis service for Down i: 50.

syndrome.

Lancet

1979;