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Small volume India ink injections
groups is critical to further achievements in the field, for technological advancements, safe introduction and utilization of new technologies in the community, timely and reasonable reimbursement of new procedures, and costeffective application of endoscopy to patient care. To fulfill our goals, communication and cooperation between these groups is essential: people talking together and working together for the good of the patient. I have been impressed by how much can be achieved when people pull together and how little is accomplished when individuals follow their own agenda. The obligation of the President of the A/S/G/E is to encourage interaction between the groups, bring the right people together to confront issues and deal with problems, and try to reconcile individual goals with the ultimate goal of optimal patient care. A great orchestra does not consist solely of fine instruments played by talented musicians. The ability to play in harmony, responsiveness to the maestro's lead, and the leader's ability to stay half a beat ahead are equally essential elements of a great orchestral performance. The field of endoscopy consists of many talented people working together to produce fine instruments and ensure their effective performance. And like an orchestra leader, the president must be half a beat ahead, anticipating needs and calling on the right people to produce harmony in place of discord. A number of issues currently before us demand cooperative efforts. Past and future interaction between the Health Care Financing Administration (HCFA), members of Congress, Hsaio's group at the Harvard School of Public Health, the Physician Payment Review Commission, and members of the A/S/G/E and the sister societies to effect reasonable policies for reimbursement of endoscopy, the cooperative efforts of academic and clinical gastroenterologists and surgical endoscopists to find a solution to the pressing problem of advanced endoscopic training of practicing physicians, application of state of the art technology to education in endoscopy through interaction between the A/S/G/E and industry to provide essential engineering and technical expertise and financial support, and utilization of the Council of Regional Endoscopic Societies to disseminate education to local communities and develop sources for clinical and endoscopic research are a few examples. The introduction of the national fee schedule for Medicare reimbursement is perhaps the greatest example of the need for communication and cooperation. Individual members of A/S/G/E worked closely with Hsaio's group and with members of the PPRC to develop a fair reimbursement system, with the understanding that the end result was to be a budget-neutral fee schedule as mandated by Congress. When HCFA, in their Notice of Proposed Rule Making unilaterally proposed a 16% reduction in the conversion factor and adjusted downward many of Hsaio's carefully calculated relative work values, the response was overwhelming. Thousands of gastroenterologists from around the country, including close to half of the A/S/G/E membership, wrote detailed letters to HCFA and Members of Congress objecting to the proposals that would convert a budget-neutral fee schedule to a budget savings that approached $7 billion. More importantly, however, equally vehement objections came from Members of Congress, who recognized physicians' willingness to work together with government to VOLUME 37, NO.6, 1991
achieve a reasonable system of reimbursement and the administration's failure to act with similar good faith. However, the final rules may read (unknown at the time of submission of this column) HCFA did not have to acknowledge the carloads of letters that their unilateral behavior precipitated and, therefore, may assume a more cooperative approach in the future. Indeed, since that time, members of HCFA have sought the advice of A/S/G/E on relative value units for endoscopy, and A/S/G/E members like Bergein Overholt and James Frakes have given them valuable input. Future interactions on reimbursement and related coding issues will involve both the Government Relations Committee, chaired by James Frakes, and the newly created Ad Hoc Committee on Reimbursement to be chaired by Paul Kantrowitz. At the August 1991 governing board meeting, ad hoc committees were also appointed to deal with the issues of advanced endoscopic training and application of state of the art technology to education, and these have been placed in the expert hands of our two immediate past-presidents, James Borland and Michael Sivak, Jr., respectively. Their early efforts will be apparent in the Learning Center being organized by Blair Lewis for the 1991 Digestive Disease Week and in an exciting innovation planned by A. J. DiMarino, Director for the 1991 Annual Postgraduate Course at Digestive Disease Week. Council of Regional Endoscopic Societies, under the capable leadership of Bennett Roth, is actively opening the lines of communication between the Regional Endoscopic Societies and the national organization. I discussed some of their plans in the September issue of The ASGE News and more concrete information will be available in the near future. In all of these endeavors, the commitment of people makes the difference and of people working together makes an even greater difference. A copy of The ASGE News can be obtained from the American Society of Gastrointestinal Endoscopy, Thirteen Elm Street, Manchester, MA 01944.
Letters to the Ed itor Small volume India ink injections To the Editor: The reports of Caman et al.I and Parks et aF have pointed out the complications that may occur with colonic tattoo. Their experience emphasized the need to standardize India ink preparation, its sterilization, and the quantity to be injected. Since 1984, we have performed colonic tattoos to aid surgeons to identify lesions at laparotomy in 134 patients and have found it a safe, simple technique without significant complications. 3 The injection of only 0.1 ml of India ink in two or three sites has been adequate to guide the surgeon to the lesion to be resected. This smaller volume of injection creates a much smaller "dead space" for bacteria carried on the tip of needle to multiply. The larger the volume of this dead space, the less access 649
the immune defense mechanisms carried by the blood vessels, lymphatics, and macrophages have to the bacteria in the center of this space. This may be one of the factors contributing to abscess formation when larger volumes are injected. Bacterial cultures of abscesses resulting from the colonic tattoos would be helpful in determining whether infection or chemical factors are responsible.
background of 450 ERCPs annually may be downright dangerous in the hands of a solo practitioner performing 25 mainly diagnostic procedures a year. It is tempting to use PP as a substitute for skill at biliary cannulation. This is a temptation well worth resisting.
John Baillie, MB ChB, FRCP(Glasg)
Burton A. Shatz, MD St. Louis, Missouri
Division of Gastroenterology Duke University Medical Center Durham, North Carolina
REFERENCES
REFERENCES
1. Caman E, Brandt LS, Brenner S, Frank M, Sablay D, Bennett
1. Katuscak I, Horakova M, Frlicka P, Straka V, Macko J. Needle
B. Fat necrosis and inflammatory pseudo-tumor due to endoscopic tattooing of the colon with India ink. Gastrointest Endose 1991;37:65-8. 2. Park SI, Genta RS, Romeo DP, Weesner RE. Colonic abscess and focal peritonitis secondary to India ink tattooing of the colon. Gastrointest Endosc 1991;37:68-71. 3. Shatz BA, Thavorides N. Colonic tattoo for follow-up of endoscopic polypectomy. Gastrointest Endosc 1991;37:59-60.
knife sphincterotomy: a necessary tool [Letter]. Gastrointest Endosc 1991;37:495. 2. Dowsett JF, Polydorou AA, Vaira D, et al. Needle knife papillotomy: how safe and how effective? Gut 1990;31:905-8. 3. Cotton PB. Precut papillotomy-a risky technique for experts only [Editorial]. Gastrointest Endosc 1989;35:578-9.
Guidewire-assisted esophageal dilation Needle knife sphincterotomy
To the Editor:
To the Editor:
We read with interest the recent article 1 concerning guidewire-assisted esophageal dilation without fluoroscopy. We believe that both the title of the article and the message are misleading, possibly giving bad advice. In our opinion, there are two safe ways to place a wire for guidewire-assisted esophageal dilation. When it is possible to pass the endoscope into the distal stomach, one can layout the guidewire as one withdraws the instrument. Fluoroscopy must be used for guidewire placement when the stricture diameter is such that the endoscope cannot be passed beyond it. Both techniques are well described and from this perspective the article offers little new information. 2 A guidewire with marks to denote distance certainly has some advantages, but the advantages are minor because there are a number of other equally simple methods of determining that the guidewire has remained where it was placed. The major disagreement we have is the authors' method of dilation when the stricture could not be negotiated with an endoscope. When that occurred, the guidewire was passed blindly and, without any external checks as to where it was located, they proceeded with dilation. The technique violates a number of what we believe are the principles of good patient management, including: "one should not take unnecessary chances" and "there is no right way to do the wrong thing." In our opinion, such truly blind guidewireassisted dilation is almost always a mistake. No matter how smoothly the wire appears to pass, the operator does not have reliable knowledge about its location in the stomach. The wire can just as easily be coiled in a hiatal hernia or in the fundus as being in the proper position. The authors have relied upon the erroneous concept that "I did it a number of times, I did not have a complication, therefore it must be safe." Endoscopists should regularly read the article entitled "If nothing goes wrong, is everything all right"?3 One finds that experience is a poor teacher, and that the actual com-
The report by Katuscak et aLl raises, but fails to address, a number of important issues surrounding the use of pre-cut papillotomy (PP): 1. The authors do not tell us what percentage of their cases required (PP). However, a little arithmetic allows us to guess: if they performed an average of 450 cases each year between 1984 and the end of 1990 (assuming a 6-month delay in publication of their letter), the PP rate would have been 62 of 6 X 450 = 62 of 2700 = 2.3%. The first important point is that PP was used in a very small percentage of their ERCP cases. 2. PP afforded immediate access in only 34 of 62 patients (55%), which mirrors the failure rate of 54% (40 of 74) reported by Dowsett et a1. 2 Of the initial failures (45%) in the series of Katuscak et a1./ 19 of 28 patients (68%) had to wait 7 days for a successful second procedure. 3. A third (32%) of PP patients did not require therapeutic intervention when access was gained to the biliary tree, the remainder had (almost exclusively) choledocholithiasis. 4. The use of interventional radiology as an alternative when ERCP fails is never mentioned nor is surgery. To critically assess the authors' use of PP, we should know whether or not these alternatives were available and considered. The data presented do not confirm the hypothesis that "PP performed with a needle knife is a necessary accessory technique in ERCP." As Cotton3 pointed out in a 1989 editorial on the subject, some well-known exponents of ERCP avoid precutting altogether. Katuscak et aLl have clearly refined their use of PP and become skilled at the technique, as judged by a very low complication rate. However, is this evidence, as the authors state, that "PP is a safe method" and "not...a very risky procedure"? What are the implications for endoscopists in training and practice? Patients suffer when endoscopists with limited experience of therapeutic ERCP uncritically accept cavalier statements that PP is safe and easy. What is "safe and easy" against a 650
The opinions or assertions herein are the private views of the authors and are not to be construed as reflecting the views of the Army or the Department of Defense. GASTROINTESTINAL ENDOSCOPY
achieve a reasonable system of reimbursement and the administration's failure to act with similar good faith. However, the final rules may read (unknown at the time of submission of this column) HCFA did not have to acknowledge the carloads of letters that their unilateral behavior precipitated and, therefore, may assume a more cooperative approach in the future. Indeed, since that time, members of HCFA have sought the advice of A/S/G/E on relative value units for endoscopy, and A/S/G/E members like Bergein Overholt and James Frakes have given them valuable input. Future interactions on reimbursement and related coding issues will involve both the Government Relations Committee, chaired by James Frakes, and the newly created Ad Hoc Committee on Reimbursement to be chaired by Paul Kantrowitz. At the August 1991 governing board meeting, ad hoc committees were also appointed to deal with the issues of advanced endoscopic training and application of state of the art technology to education, and these have been placed in the expert hands of our two immediate past-presidents, James Borland and Michael Sivak, Jr., respectively. Their early efforts will be apparent in the Learning Center being organized by Blair Lewis for the 1991 Digestive Disease Week and in an exciting innovation planned by A. J. DiMarino, Director for the 1991 Annual Postgraduate Course at Digestive Disease Week. Council of Regional Endoscopic Societies, under the capable leadership of Bennett Roth, is actively opening the lines of communication between the Regional Endoscopic Societies and the national organization. I discussed some of their plans in the September issue of The ASGE News and more concrete information will be available in the near future. In all of these endeavors, the commitment of people makes the difference and of people working together makes an even greater difference. A copy of The ASGE News can be obtained from the American Society of Gastrointestinal Endoscopy, Thirteen Elm Street, Manchester, MA 01944.
Letters to the Ed itor Small volume India ink injections To the Editor: The reports of Caman et al.I and Parks et aF have pointed out the complications that may occur with colonic tattoo. Their experience emphasized the need to standardize India ink preparation, its sterilization, and the quantity to be injected. Since 1984, we have performed colonic tattoos to aid surgeons to identify lesions at laparotomy in 134 patients and have found it a safe, simple technique without significant complications. 3 The injection of only 0.1 ml of India ink in two or three sites has been adequate to guide the surgeon to the lesion to be resected. This smaller volume of injection creates a much smaller "dead space" for bacteria carried on the tip of needle to multiply. The larger the volume of this dead space, the less access 649
the immune defense mechanisms carried by the blood vessels, lymphatics, and macrophages have to the bacteria in the center of this space. This may be one of the factors contributing to abscess formation when larger volumes are injected. Bacterial cultures of abscesses resulting from the colonic tattoos would be helpful in determining whether infection or chemical factors are responsible.
background of 450 ERCPs annually may be downright dangerous in the hands of a solo practitioner performing 25 mainly diagnostic procedures a year. It is tempting to use PP as a substitute for skill at biliary cannulation. This is a temptation well worth resisting.
John Baillie, MB ChB, FRCP(Glasg)
Burton A. Shatz, MD St. Louis, Missouri
Division of Gastroenterology Duke University Medical Center Durham, North Carolina
REFERENCES
REFERENCES
1. Caman E, Brandt LS, Brenner S, Frank M, Sablay D, Bennett
1. Katuscak I, Horakova M, Frlicka P, Straka V, Macko J. Needle
B. Fat necrosis and inflammatory pseudo-tumor due to endoscopic tattooing of the colon with India ink. Gastrointest Endose 1991;37:65-8. 2. Park SI, Genta RS, Romeo DP, Weesner RE. Colonic abscess and focal peritonitis secondary to India ink tattooing of the colon. Gastrointest Endosc 1991;37:68-71. 3. Shatz BA, Thavorides N. Colonic tattoo for follow-up of endoscopic polypectomy. Gastrointest Endosc 1991;37:59-60.
knife sphincterotomy: a necessary tool [Letter]. Gastrointest Endosc 1991;37:495. 2. Dowsett JF, Polydorou AA, Vaira D, et al. Needle knife papillotomy: how safe and how effective? Gut 1990;31:905-8. 3. Cotton PB. Precut papillotomy-a risky technique for experts only [Editorial]. Gastrointest Endosc 1989;35:578-9.
Guidewire-assisted esophageal dilation Needle knife sphincterotomy
To the Editor:
To the Editor:
We read with interest the recent article 1 concerning guidewire-assisted esophageal dilation without fluoroscopy. We believe that both the title of the article and the message are misleading, possibly giving bad advice. In our opinion, there are two safe ways to place a wire for guidewire-assisted esophageal dilation. When it is possible to pass the endoscope into the distal stomach, one can layout the guidewire as one withdraws the instrument. Fluoroscopy must be used for guidewire placement when the stricture diameter is such that the endoscope cannot be passed beyond it. Both techniques are well described and from this perspective the article offers little new information. 2 A guidewire with marks to denote distance certainly has some advantages, but the advantages are minor because there are a number of other equally simple methods of determining that the guidewire has remained where it was placed. The major disagreement we have is the authors' method of dilation when the stricture could not be negotiated with an endoscope. When that occurred, the guidewire was passed blindly and, without any external checks as to where it was located, they proceeded with dilation. The technique violates a number of what we believe are the principles of good patient management, including: "one should not take unnecessary chances" and "there is no right way to do the wrong thing." In our opinion, such truly blind guidewireassisted dilation is almost always a mistake. No matter how smoothly the wire appears to pass, the operator does not have reliable knowledge about its location in the stomach. The wire can just as easily be coiled in a hiatal hernia or in the fundus as being in the proper position. The authors have relied upon the erroneous concept that "I did it a number of times, I did not have a complication, therefore it must be safe." Endoscopists should regularly read the article entitled "If nothing goes wrong, is everything all right"?3 One finds that experience is a poor teacher, and that the actual com-
The report by Katuscak et aLl raises, but fails to address, a number of important issues surrounding the use of pre-cut papillotomy (PP): 1. The authors do not tell us what percentage of their cases required (PP). However, a little arithmetic allows us to guess: if they performed an average of 450 cases each year between 1984 and the end of 1990 (assuming a 6-month delay in publication of their letter), the PP rate would have been 62 of 6 X 450 = 62 of 2700 = 2.3%. The first important point is that PP was used in a very small percentage of their ERCP cases. 2. PP afforded immediate access in only 34 of 62 patients (55%), which mirrors the failure rate of 54% (40 of 74) reported by Dowsett et a1. 2 Of the initial failures (45%) in the series of Katuscak et a1./ 19 of 28 patients (68%) had to wait 7 days for a successful second procedure. 3. A third (32%) of PP patients did not require therapeutic intervention when access was gained to the biliary tree, the remainder had (almost exclusively) choledocholithiasis. 4. The use of interventional radiology as an alternative when ERCP fails is never mentioned nor is surgery. To critically assess the authors' use of PP, we should know whether or not these alternatives were available and considered. The data presented do not confirm the hypothesis that "PP performed with a needle knife is a necessary accessory technique in ERCP." As Cotton3 pointed out in a 1989 editorial on the subject, some well-known exponents of ERCP avoid precutting altogether. Katuscak et aLl have clearly refined their use of PP and become skilled at the technique, as judged by a very low complication rate. However, is this evidence, as the authors state, that "PP is a safe method" and "not...a very risky procedure"? What are the implications for endoscopists in training and practice? Patients suffer when endoscopists with limited experience of therapeutic ERCP uncritically accept cavalier statements that PP is safe and easy. What is "safe and easy" against a 650
The opinions or assertions herein are the private views of the authors and are not to be construed as reflecting the views of the Army or the Department of Defense. GASTROINTESTINAL ENDOSCOPY