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during esophagogastroduodenoscopy: a randomized, doubleblind, placebo-controlled, prospective investigation. Gastrointest Endosc 1995;42:45-50. Saunders BP, Elsby B, Boswell AM, Atkin W, Williams CB. Intravenous antispasmodic and patient-controlled analgesia are of benefit for screening flexible sigmoidoscopy. Gastrointest Endosc 1995;42:123-7. Koyama T, Fujimoto K, Iwakiri R, et al. Prevention ofrecurrent bleeding from gastric ulcer with a nonbleeding visible vessel by endoscopic injection of absolute ethanol: a prospective, controlled trial. Gastrointest Endosc 1995;42:128-31. Mavissakalian MR, Jones B, Olson S. Absence of placebo response in obsessive-compulsive disorder. J Nerv Ment Dis 1990;178:268-70. Merikle PM, Skanes HE. Subliminal self-help audiotapes: a search for placebo effects. J Appl Psychol 1992;77:772-6. Quitkin FM, Stewart JW, McGrath PJ, et al. Further evidence that a placebo response to antidepressants can be identified. Am J Psychiatry 1993;150:566-70. Lynoe N. Is the effect of alternative medical treatment only a placebo effect? Scand J Soc Med 1990;18:149-53. Dimond EG, Kittle CF, Crokett JE. Comparison of internal mammary artery ligation and sham operation for angina pectoris. Am J Cardiol 1960;5:484-6. Cobb LA, Thomas GI, Dillard DH, et al. Evaluation of internal mammary artery ligation by a double-blind technic. N Engl J Med 1959;260:1115-8. Thomsen J, Bretlan P, Tos M, Johnsen NJ. Placebo effect in surgery for Meniere's disease: three-year follow-up. Otolaryngo] Head Neck Surg 1983;91:183-6. Beecher HK. The powerful placebo. JAMA 1955;159:1602-6. Shapiro AK, Morris LA. The placebo effect in medical and psychologicaltherapies. In: Garfield SL, Bergin AE, eds. Handbook of psychotherapy and behavior change: an empirical analysis. 2nd ed. New York: Wiley, 1978. GowdeyCW, Hamilton JT, Philp RB. A controlled clinical trial using placebos in normal subjects: a teaching exercise. Can Med Assoc J 1967;96:1317-22. RosenzweigP, BrohierS, ZipfelA. Pharmacoepidemiologyand drug u~lization. The placebo effect in healthy volunteers: influence of experimental conditionson the adverse events profileduring phase I studies. Clin Pharmacol Ther 1993;54:578-83. Blackwell B, Bloomfield SS, Buncher CR. Demonstration to medical students of placebo responses and non-drng factors. Lancet 1972;1:1279-82. Tetreault L, Bordeleau JM. On the usefulness of the placebo and of the double-blind technique in the evaluation of psychotropic drugs. Psychopharmacol Bull 1971;7:44-64. Aznor-RamosR, Giner-VelasquezJ, Lara-Ricaide R, MartinezManautou J. Incidence of side effects with contraceptive placebo. Am J Obstet Gynecol 1969;105:1144-9. Gracely RH, Dubner R, Wolskee PH, Deeter WR. Placebo and naloxone can alter post-surgical pain by separate mechanisms. Nature 1983;306:264-5. WilcoxCS, Cohn JB, Linden RD, et al. Predictors of placebo response: a retrospective analysis. Psychopharmacol Bull 1992; 28:157-62. Brown WA, Johnson MF, Chen MG. Clinical features of depressed patients who do and do not improve with placebo. Psychiatry Res 1992;41:203-14. Silvis SE. Endoscopy in the People's Republic of China. Gastrointest Endosc 1982;28:261-3. Horwitz RI, Viscoli CM, Berkman L, et al. Treatment adherence and risk of death after a myocardial infarction. Lancet 1990;336:542-5. Brody H. The lie that heals: the ethics of giving placebos. Ann Intern Med 1982;97:112-8. Hersh EV, Ochs H, Quinn P, MacAfeeK, Cooper SA. Narcotic receptor blockade and its effect on the analgesic response to placebo and ibuprofen after oral surgery. Oral Surg Oral Med Oral Pathol 1993;75:539-46. GracelyRH, Dubner R, Deeter WR, WolskeePJ. Clinicians'expectations influence placebo analgesia [Abstract].Lancet 1985;1:43.

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Progress in endoscopic ultrasonography The s u p p l e m e n t t h a t will a c c o m p a n y the next issue of the J o u r n a l highlights a r e m a r k a b l e period in the d e v e l o p m e n t of endoscopic u l t r a s o n o g r a p h y . Most of the m a t e r i a l in the s u p p l e m e n t h a s been selected from p r e s e n t a t i o n s at the 10th I n t e r n a t i o n a l S y m p o s i u m on Endoscopic U l t r a s o n o g r a p h y , w h i c h took place 4 m o n t h s ago, sponsored by Case W e s t e r n U n i v e r s i t y a n d t h e U n i v e r s i t y Hospitals of Cleveland. The symp o s i u m was notable not only for being the t e n t h of its kind, r e p r e s e n t i n g a certain m a t u r i t y , b u t also for being the first to be held in cooperation with the ASGE, a n d the first to be i n t e g r a t e d w i t h a m e e t i n g of the A m e r i c a n E n d o s o n o g r a p h y Club (AEC). T h e r e w a s a clear m e s s a g e r i n g i n g like a bell over this meeting: endoscopic u l t r a s o n o g r a p h y is m o v i n g ahead. I f t h e r e w a s a sense a few y e a r s ago t h a t the field h a d r e a c h e d a plateau, this t h o u g h t h a s been s h a t t e r e d by the introduction of n e w i n s t r u m e n t s a n d n e w applications. I n a b r o a d sense, endoscopic ultras o n o g r a p h y is following a v e r y classic progression w i t h i n g a s t r o i n t e s t i n a l endoscopy: First, the developm e n t of i m a g i n g w i t h visualization of n o r m a l a n d abn o r m a l a n a t o m y ; second, the obtaining of tissue via directed biopsy for pathologic analysis; a n d third, the introduction of endoscopy-guided t h e r a p y . T h e r e is no doubt t h a t endoscopic u l t r a s o n o g r a p h y r e p r e s e n t s a m a j o r a d v a n c e in g a s t r o i n t e s t i n a l imaging. Its u n i q u e s t r e n g t h lies in its depiction of the g u t wall as a series of layers correlating w i t h histology a n d in its v e r y detailed images of s t r u c t u r e s adjacent to the g a s t r o i n t e s t i n a l lumen, such as l y m p h nodes, the bile duct, a n d the pancreas. New i n s t r u m e n t s h a v e been developed for i m p r o v e d imaging, including cathetersize probes t h a t can be used via the o p e r a t i n g c h a n n e l of s t a n d a r d endoscopes. Fine-needle a s p i r a t i o n for cytology u n d e r E U S guidance h a s now been accomplished. Therapy, u s i n g precision EUS-controlled injection, is j u s t g e t t i n g started, b u t initial results are v e r y encouraging. The excitement of the y o u n g investigators at the m e e t i n g was palpable. T h e i r ability to m a s t e r new t e c h n i q u e s a n d i n s t r u m e n t s was m a n i f e s t by the 61 a b s t r a c t s received for consideration for p r e s e n t a t i o n at t h e scientific session of the AEC. These a b s t r a c t s will also be published in the supplement. The d e v e l o p m e n t of the A E C itself h a s been quite extraordinary. The idea 0 f f o r m i n g a club for A m e r i c a n gastroenterologists interested in e n d o s o n o g r a p h y occ u r r e d to m e in 1991, w h e n we were celebrating the 0016-5107/96/4301-007955.00 + 0 GASTROINTESTINAL ENDOSCOPY Copyright © 1996 by the American Society for Gastrointestinal Endoscopy 37/70/69920

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50th Anniversary of the ASGE, and I was reminded of how the Society started as The American Gastroscopic Club. I suggested the concept to a small group of American endosonographers who had been meeting informally since the mid-1980s. Led by Mike Sivak, the group included Worth Boyce, Rob Hawes and me, and later Lok Tio. We decided to send a letter to those we thought might be interested, inviting them to an open meeting in October in Boston. There was a uniformly enthusiastic response, and the AEC was under way, climbing recently to 215 members. Accomplishments of the AEC have included educational and informational symposia, the formation of committees on research and education, publication of a slide teaching atlas, multicenter studies and surveys, and an e-mail communication network (eus @acpub.duke.edu) and World Wide Web page (URL, http://www.duke.edu/eus/) via the Internet. The first scientific meeting of the AEC in Cleveland with submitted abstracts, scored and selected by a program committee for oral and poster presentation, has taken the Club to a new level. Most members of the AEC are also members of the ASGE, which assumed responsibility in dealing with the American Medical Association and the Health Care Financing Administration on endoscopic ultrasonography coding and reimbursement issues. While the future of the AEC is not clear, it will likely continue to function in close cooperation with the ASGE. There are strong deterrents to the widespread dissemination of endoscopic ultrasonography. Ultrasound imaging is new for most gastrointestinal endoscopists, and the learning curve is steep. The devices are relatively costly in an environment that is arguably more hostile to expensive new technology than ever before in American medicine. Yet the Cleveland meeting has provided ample evidence that endoscopic ultrasonography can often achieve greater diagnostic accuracy than other imaging methods, and it offers new therapeutic opportunities. It seems likely that endoscopic ultrasonography will occupy a firm niche in clinical gastroenterology for the foreseeable future.

Charles J. Lightdale, MD New York, New York

Modification of common bile duct pre-cut sphincterotomy To the Editor: We found Goffs pre-cut sphincterotomy method 1 recently reported in the journal to be a very interesting modification of pre-cut technique. The complication rate reported was comparable to other pre-cutting methods. Did complications occur during the "learning phase" of this technique prior to November 1, 1991? One or two serious complications in the first 100 patients mAght change the perspective on this new technique. We are aware of life-threatening complications occurring with this technique. The liberal application of pre-cutting (35% in Goffs experience) confuses the issue as to the safety of pre-cutting. As previously noted, Freeman and colleagues2 reported that patients with difficult cannulation had higher complication rates than those with easy cannulation. If pre-cutting is applied very liberally in patients with relatively easy cannulation, such lower-risk patients may have a complication rate that is intermediate in frequency. A small difference in complication rates would require several hundred patients to prove statistically significant. Alternatively, if early use of pre-cutting avoids papillary trauma from guide wires, pre-cutting (in experienced hands) may well be safer. We would encourage the performance of a randomized study in patients in whom initial caimulation is failing. Such a study could randomize to (1) persistence with standard catheters, guide wires, or sphincterotomes and ultimately stopping or using percutaneous methods for failures versus (2) early use of pre-cutting versus (3) late use ofpre-cutting (i.e., all standard techniques were exhausted).

Glen A. Lehman, MD Stuart Sherman, MD /ndiana University Medical Center Indianapolis, Indiana

REFERENCES 1. GoffJS. Common bile duct pre-cut sphincterotomy: transpancreatic sphincter approach. Gastrointest Endosc 1995;41:502-5. 2. Freeman M, Nelson D, Sherman S, et al. Pancreatitis from endoscopicsphincterotomy (ES): a prospective multicenter 30-day study. [Abstract] Gastrointest Endosc 1994;40:P108.

Response: Lehman and Sherman raise a number of interesting and important issues about pre-cut sphincterotomy and in particular my modification. Unfortunately, I am currently unable to provide exact data on the complication rate of the transpancreatic approach prior to November 1991. I started using this method many years before the reported series. I found it to be increasingly useful and thus used it more and more as time went by. I have not substantially modified the 80 G A S T R O I N T E S T I N A L E N D O S C O P Y

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