PTC and ERCP

meetings, but who is kidding whom? With the advance of colonoscopy and the understood interest of surgeons, this practice is even more widespread than the Society would be willing to admit. Incidentally, many of these educational meetings are sponsored by the Society. Is that not so? Our Italian colleagues are also quite frank with reference to the fee schedule used in Italy. When endoscopy is done in the framework of the Public Health Service, 6 to 8 U.S. dollars is the usual fee. However, when endoscopy is done privately, an upper gastrointestinal endoscopy ranges from 300.00 to 600.00 U.s. dollars. Again, this is very similar to charges in the United States. Most interesting was your report from the World Congress of Digestive Endoscopy, particularly with reference to a meeting on the cost of endoscopy. You point out that about 40 people gathered in a room seating 2500 and, by the time the meeting was over, 15 to 20 doctors remained. Yes, this is about the interest that endoscopists show when fees are discussed. I was particularly taken with the comment of one of the editors of the British Medical Journal who called endoscopic practice "an uncontrollable giant" and, if applied to all dyspeptic patients, "would bankrupt the health care system." I felt soqy for Dr. Schiller who ended up giving a pep talk to 15 to 20 doctors of the 4500 registered, when costs and fees with reference to endoscopy were discussed. Is it not about time that a fee schedule be forthcoming from the Society or a group of societies interested in gastroenterology? When one starts talking about fees, one gets a good deal of nonsense about the different costs in different sections of the country. The differences in costs, whether in Boston or Washington or Denver or California, would probably not amount to more than 10% at the most, if that. It is about time that an effort be made to devise a realistic fee schedule for the various endoscopies if endoscopy is going to bloom further. Otherwise, one is going to be dictated by the government with Medicare and Medicaid and third party payers. Comments from your readers on these matters would be appreciated. Irving B. Brick, MD Division of Gastroenterology Georgetown University Hospital Washington, DG

Golytely: preparation of choice for colonoscopy To the Editor: We wish to report our experience with the use of a "Golytely" solution for the past 6 months. We have been using this type of solution as the preparation of choice for colonoscopy at our community hospital. The patient is given clear liquids for one day and then a Golytely solution of 3 to 5 liters the day of the procedure. The solution is drunk at a rate of 1 liter every 1112 hours. We have used this solution on outpatients who come as far as 30 miles away. Our age range has been 12 to 105 years. We have prepared two rectal cancer patients without complications. 256

Our pharmacy prepares a solution according to the following formula: potassium chloride, 0.75 g/liter; sodium chloride, 1.45 g/liter; sodium bicarbonate, 1.68 sodium sulfate (anhydrous), 5.68 g/liter; and PEG 4000, 59.00 g/liter. This is diluted to 1000 ml with sterile water. The solution expires 96 hours after preparation. Refrigeration enhances palatability and retards bacterial growth. The cost of the ingredients is $0.55 per liter. The preparation time for 4 liters is approximately 25 minutes. The solution is available in com- . mercial form. Recently, our radiologists have been using Golytely as a ,. preparation for single contrast barium enemas. It is also used for intravenous pyelograms and computer tomography scans to clear barium. There have been no significant side effects and most patients think the taste is tolerable. Patients who have had laxatives or enema preparations much prefer Golytely. The residual fluid found in the colon has not impaired the diagnostic quality of the study. As an endoscopist, it has been a great pleasure to count on being able to see the right colon free of stool patient after patient.

J. O. Meadows, MD C. T. Conyers, MD Peninsula General Hospital Medical Gente; Salisbury, Maryland

PTC and ERCP To the Editor: In your review of the Stockholm World Congress, in the November issue of Gastrointestinal Endoscopy (28:262, 1982), you were kind enough to mention some of my contributions in the symposium on obstructive jaundice. You misunderstood my message and I seek the opportunity to correct any false impressions. We were discussing the approach to patients with obstructive jaundice and relative roles of ultrasound, percutaneous transhepatic cholangiography (PTC), and ERCP. Your report suggests that I had "just about thrown in the towel" by admitting that ultrasonography and PTC might make ERCP unnecessary. I was simply reflecting real life; PTC is indeed more popular world wide than ERCP and is clearly satisfactory as a diagnostic tool (used after ultrasound). However, I emphasized that we are now looking beyond diagnosis to therapy. Since the most common causes of obstructive jaundice (stones and tumors) can now be managed endoscopically (by sphincterotomy and stents), it is logical and preferable to use ERCP as the primary approach in the jaundiced patient, where facilities and expertise exist. You also report me as suggesting that nasobiliary drainage is essential after ERCP and sphincterotomy. I do believe that this technique is valuable in reducing cholangitis, but only if stones or stasis remain after the procedure, i.e., not after sphincterotomy in which all stones have been extracted. Peter B. Cotton, MD, FRCP The Middlesex Hospital London, England

GASTROINTESTINAL ENDOSCOPY