Polypectomy on multiple polyps

REFERENCES

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1. Rutledge RH, Alexander JW. Primary appendiceal malignancies: rare but important. Surgery 1992;111:244-50.

2. Moertel CG, Dockerty MB, Judd ES. Carcinoid tumors of the vermiform appendix. Cancer 1968;21:270-8.

3. MacGillivray DC, Heaton RB, Rushin JM, Cruess DF. Distant metastasis from a carcinoid tumor of the appendix less than one centimeter in size. Surgery 1992;111:466-71. 4. Syracuse DC, Perzin KH, Price JB, Wiedel PD, Mesa-Tejada R. Carcinoid tumors of the appendix. Mesoappendiceal extension and nodal metastases. Ann Surg 1979;190:58-63. 5. Burke AP, Sobin LH, Federspiel BH, Shekitka KM, Helwig EB. Goblet cell carcinoids and related tumors of the vermiform appendix. Am J Clin Pathol 1990;94:27-35. 6. Bak M, Asschenfeldt P. Adenocarcinoid of the vermiform appendix: a clinicopathologic study of 20 cases. Dis Colon Rectum 1988;31:605-12.

Polypectomy on multiple polyps To the Editor: When polypectomy on multiple polyps in the ascending colon or transverse colon is performed, the endoscope must be repeatedly reinserted, and this requires much more time than the polypectomy of a single polyp. To solve this problem, Banez et aLl reported a double endoscope method in 1986. According to this method, the first endoscope (examining endoscope) is inserted using normal technique. After the "question mark" configuration is attained, the second endoscope (retrieving endoscope), i.e., duodenoscope or gastroscope, is inserted, and the polyps removed by the first endoscope are retrieved by the second endoscope one after another. Banez et aLl describe that the removal of multiple polyps by this method is easier and less time consuming compared with the single endoscope technique. However, there was no definite description as to how much time was actually saved. There are also the following problems: Doesn't the insertion of two endoscopes cause anal pain? When a large polyp is removed, is it possible to pass the second endoscope through the narrow lumen beside the indwelling first endoscope? In this respect, we have performed double endoscope method endoscopy in three patients with multiple polyps to compare the time required for insertion of two endoscopes and to ascertain whether there is anal pain or not. To insert the endoscope, 5 mg of diazepam and 25 mg of meperidine were given as premedication according to the method by Banez et aI., and a single skilled endoscopist performed the examination. As a result, the second endoscope did not reach the cecum in all three cases, and the time required to reach the sigmoid colon was longer than that of the first endoscope (Fig. I). The reason for the failure of insertion was that the enteric wall twined around the first endoscope and the lumen could not be visualized (Fig. 2). This entangling occurred when the intestine was straightened, contracted, and folded at the insertion of the first endoscope. When the second endoscope was advanced to the site where the first endoscope was entangled, the second endoscope retroflexed, and it could not be inserted further. Banez et a1. 1 reported that they successfully inserted the 526

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Fig. 1. Difference of the time required for reinsertion of the first and the second endoscopes. In all three cases, the first endoscope was inserted to the cecum within 5 minutes, but the second endoscope could not be inserted beyond the splenic flexure. The time required for reinsertion of the second endoscope to the descending colon was more than twice as long as that of the first endoscope. CD, First endoscope; ® second endoscope; R, rectum; S, sigmoid colon; D, descending colon; SF, splenic flexure; T, transverse colon; A, ascending colon; C, cecum.

Fig. 2. Enteric mucosa is entangled around the first endoscope. In all three cases, the second endoscope could not be inserted beyond this site.

second instrument in all of over 50 cases. What is the difference between their results and our three cases? The first endoscope was inserted into the cecum within 5 minutes, and our problem does not seem to be caused by the length or bending of the intestine. Although the average Japanese is physically smaller than Europeans and Americans, there was no anal injury or pain in these three cases. Thus, if there is a method for insertion of a second endoscope within a short time, it could be useful to facilitate multiple polypectomy. Yoshiharu Uno, MD Department of Internal Medicine Hirosaki, Japan

GASTROINTESTINAL ENDOSCOPY

REFERENCE 1. Banez AV, Bozek SA, Simon RF. A double endoscope method for multiple colonic polypectomy. Gastrointest Endosc 1987;33: 30-2.

Abstracts ENDOSCOPY AROUND THE WORLD Editor for Abstracts, Gregory A. Boyce, MD Panel of Reviewers

Response:

Reading through Dr. Uno's letter, it seems that he was doing both endoscopies alternately by himself. I believe this is the main reason why he was having difficulty. The procedure we described was done by two endoscopists working together. In the later stage of the study, while the second endoscopist was retrieving the polyp, the first endoscopist was already preparing to snare the next polyp. As I reviewed the data, I did not find any considerable delay in the passage of the second scope, although I must admit this time factor was not actually measured in the study. Renata F. Simon, MD Youngstown, Ohio

John Baillie James S. Barkin Stanley B. Benjamin lawrence J. Brandt David R. Cave Masayuki A. Fujino Lionello Gandolfi Christopher J. Gostout David Y. Graham

Seibi Kobayashi Glen A. lehman Zdenek Maratka Steven A. McClave Giorgio Minoli Ben Novis John f. Reinus Walter l. Trudeau Richard A. Wright

Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents DEVIERE J, CREMER B, BAIZE M, ET AL. Gut 1994;35:122-6

Endoscopic nomenclature To the Editor: Endoscopic nomenclature should be clarified. For example, in their recent paper, Young et aP discuss esophageal variceal sclerotherapy (EVS). In the next article, Hashizume et al. 2 refer to endoscopic injection sclerotherapy (EIS). Not only has esophageal variceal sclerotherapy (EVS) been referred to as esophageal injection sclerotherapy (EIS), it has also been called endoscopic sclerotherapy (ES), which should not be confused with endoscopic sphincterotomy (ES), which has also been referred to as endoscopic retrograde sphincterotomy (ERS). Because this confusion in nomenclature has a greater than 5-year history and involves many aspects of gastroenterology and endoscopic procedures, I would propose forming a commission to retrospectively clarify terminology of all endoscopic procedures that have come into vogue over the last 10 years, with a prospective agenda for future procedures as well. Larry R. Leichter, MD Hollywood, Florida

REFERENCES 1. Young MF, Sanowski RA, Rasche R. Comparison and characterization of ulcerations induced by endoscopic ligation of esophageal varices versus endoscopic sclerotherapy. Gastrointest Endose 1993;39:119-22. 2. Hashizume M, Masayuki 0, Kiichiro U, Kazuo T, Seigo K, Keizo S. Endoscopic ligation of esophageal varices compared with injection sclerotherapy: a prospective randomized trial. Gastrointest Endose 1993;39:123-6.

VOLUME 40, NO.4, 1994

Twenty patients with chronic pancreatitis and signs of persistent biliary obstruction associated with common bile duct (CBD) stricture were treated by endoscopic placement of self-expandable metallic stents (Wallstent); of these patients 19 were alcoholics. Persistent biliary obstruction was defined as persistent cholestasis evidenced by alkaline phosphatase concentrations greater than twice the normal values for more than 3 months that had not decreased for more than 2 weeks. Cholestasis was associated with jaundice in seven of these patients, and overt cholangitis in three. These patients each had a 34 mm Wallstent placed over a guide wire into the CBD, covering the entire length of the stricture. There were two technical complications as follows: (1) one stent was improperly placed and immediately replaced, (2) after 6 months, another stent became impacted at the site of a sharp angulation and although there were no clinical problems, a second overlapping stent was placed proximally. There were no problems of early clogging or migration with these metallic stents. Cholestasis, cholangitis, and jaundice resolved quickly. Patients were observed for a mean of33 months (range 24 to 42 months) and 18 of the patients had no biliary problems. Follow-up studies showed the metal mesh to be embedded in the bile duct wall with thickened mucosa growing between the struts of the stent. At 6 months, the struts were burled by the mucosa, giving the impression of a continuous "membrane" lining the stent. Its thickness measured about 2 mm, and the CBD lumen remained patent. However, two patients developed epithelial hyperplasia within the stent, resulting in recurrent cholestasis in one and jaundice in the other. The latter required placement of a second 527