Sterility of India ink

From the Rostrum

LA's the place On October 2,1994, the world of gastroenterology is coming to Los Angeles. The occassion is the celebration of the 10th anniversary of the World Congress of Gastroenterology, and it will be held in conjunction with the 8th World Congress of Digestive Endoscopy and the 5th World Congress of Coloproctology. It is befitting that the United States will be hosting this quadrennial event, since the first such World Congress was held in this country 40 years ago. The Congress will be held under the auspices of the OMGE and is being sponsored by the American Association for the Study of Liver Disease, the American College of Gastroenterology, the American Gastroenterological Association, the American Society for Gastrointestinal Endoscopy, the American Society of Colon and Rectal Surgeons, and the Society for Surgery of the Alimentary Tract. Each of these organizations has provided seed monies and the services of its members to facilitate the development of the programs and organization of the agenda. In addition, there has been overwhelming support from industry to aid in financing the meeting. This includes a substantial contribution toward underwriting the cost of attendance for over 300 young clinicians from around the world. The presence of these representatives, many from underdeveloped nations, will be not only an exceptional educational experience for them, but also an equally exhilirating opportunity for all attendees to benefit from their enthusiasm and interest. Weare all very proud of the lofty standards of DDW here in this country; however, the World Congress brings a truly international flavor to a conference dedicated to providing new insights, state-of-the-art updates, and research in progress in the entire spectrum of digestive disease. The faculty includes the most highly respected experts from around the world. In addition to the presentation of original research, there will be six minicourses presented in genetics, epithelial cell biology, new pharmacologic approaches to gastrointestinal disease, aids, techniques in endoscopy, and new aspects of molecular biology for the ciinician. There will be thirteen quadrennial reviews on such topics as liver transplantation, H pylori, inflammatory bowel disease, and hepatitis C, among others. 0016-5107/94/4004-0519$3.00 + 0 GASTROINTESTINAL ENDOSCOPY Copyright @ 1994 by the American Society of Gastrointestinal Endoscopy

VOLUME 40, NO.4, 1994

An especially enjoyable feature will be the clinical challenge sessions in which the audience will have the opportunity to deal with case presentations, along with a panel of experts, utilizing an interactive computer touch pad network. A separately designated educational center will provide young clinicians from around the world with an opportunity to present their research as well as special lectures covering practice management, ethics, and socioeconomic issues. It is anticipated that this uniquely designated area will be a focal point for intermingling and exchange of ideas among these young physicians. There will be over 75 symposia covering virtually every aspect of the practice of gastroenterology and gastrointestinal endoscopy and surgery. More than 50 Stateof-the-Art lectures from international experts will be presented. Finally, as an extra added attraction, postgraduate courses in endoscopy and laparascopic surgery with extensive use of video and interactive audience participation will be offered just prior to and after the Congress. The scientific and educational merits of the Congress are evident. Never before, in this country, has such a varied and comprehensive program been presented under one roof, by such a distinguished faculty. This is not simply a research meeting, but a multitude of review courses in digestive disease. As such, the registration fee is not only appropriate but, in reality, a bargain. The participation of physicians from American medicine is essential to the success of the Congress. We will have the opportunity not only to learn but also to interact with our colleagues from all over the globe. As we get to know each other, the benefits of this interchange will foster better insight into the nature of digestive diseases and will enhance our understanding of and appreciation for the similarities and differences that exist in other nations both medically and culturally. The personal interchange and dialogue that will be achieved will be of benefit not only to us as physicians but also as citizens of the world! I can assure you that Los Angeles is intact. The streets will be safe, the facilities are outstanding, and the ground will remain solid! Please plan on attending. I cannot end this column without offering a special tribute and thanks to Dr. Melvin Schapiro, a past president of the ASGE, who spearheaded the task force that successfully brought the World Congress to this country and through whose tireless efforts the success of this meeting is virtually guaranteed.

Letters to the Editor Sterility of India Ink To the Editor: Recently Salomon et al. l published a paper on the steps they use to produce an ink used in intracolonic tattooing. There is concern in the literature, cited by the authors, that this practice can cause infectious complications, and the authors should be applauded in their efforts at producing a safer ink. Although the authors assert that their sterilization procedure is adequate, there was no confirmatory testing by culturing the ink. The autoclave I use for sterilizing media 519

develops a chamber temperature of 121°C at a chamber pressure of 18 to 25 psi, and I am concerned that a temperature of only 110°C for 20 minutes might not be enough to sufficiently heat aIL volume as was used. Also, assessment of a sterilization protocol would be most convincing if the solution used to confirm the efficacy of the sterilization protocol was contaminated with a typical plumbing pathogen such as a Pseudomonas species. I also note that the authors assert that routine sterilization is effective at eliminating lipopolysaccharide (LPS) from media. Protocols for producing LPS-free media generally call for sterilization times of 12 to 24 hours. Although a filter as used would sterilize the fluid, it would not eliminate endotoxin that would form if the solution supported the growth of bacteria for a time before it was used. Additionally, the need for the use of a filter to ensure sterility is not as reliable as if the solution were sterilized in the first place. A limulus assay or a pyrogen response test in a rabbit should be done to confirm that the preparation is LPS free. A call to a national supplier of tattoo ink disclosed that India ink is used for tattoos, but that another preparation of iron oxide in 70 % isopropanol and glycerin is also available. Apparently tattoo inks for dermal use are not sterilized beyond the inherent antibacterial properties of the vehicle. Perhaps the relatively large volumes of fluid injected into the colonic submucosa compared to the small amounts brought intradermally during cutaneous tattooing is responsible for the infectious complications that have been reported. Stephen Holland, MD University of Alabama Birmingham, Alabama

REFERENCE 1. Salomon S, Berner JS, Waye JD. Endoscopic India ink injection: a method for preparation, sterilization, and administration. Gastrointest Endosc 1993;39:803-5.

Lipiodal as a reliable marker for stenting in malignant esophageal stricture To the Editor: Endoscopic stenting provides rapid relief of dysphagia in patients with malignant esophageal stricture. Most commercially available intubation sets rely on an external marker taped onto the patient's trunk or a marker on the rammer to guide the prosthesis into correct position; these are unreliable and may change position with the patient's movement. Our unit has used submucosal injection of 0.5 ml of 60% meglumine iothalamate (Conray) (May & Baker Ltd., Dagenham, UK) as a radiologic marker for insertion of esophageal prosthesis, which was reported by Ismael et al. l Currently, we have refined our technique and use Lipiodal (iodised poppy seed oil, Guerbet, France) for submucosal injection into the proximal end of the tumor as a marker for prosthesis insertion. Under local anesthesia patients underwent endoscopy with fluoroscopic screening. The position and extent of the stricture were noted. Sequential dilation was carried out before insertion of the prosthesis. The endoscope was reintroduced to inspect the stricture after dilation and a suitable endoprosthesis was then chosen. Lipiodal 0.5 ml was injected into the submucosa at the upper limit of the stricture using a Marcon-Haber injector via the biopsy channel of the endoscope. The Lipiodal contrast can be clearly shown on the fluoroscopy screen (Fig. lA). No external marker was necessary. The endoprosthesis was then inserted under fluoroscopic control and pushing was stopped when the proximal funnel "shoulder" was just above the Lipiodal contrast (Fig. IB). Patency and position were again checked with the endoscope. Lipiodol injections have been used as markers in five pa-

Response:

We thank Dr. Stephen Holland for his remarks on our paper concerning India ink intracolonic tattooing. The points made by Dr. Holland are interesting and credible. We ha~\e endotoxiu not been impressed with any clinical evidence of endotoxm in India ink, and one of the authors (JDW) routinely uses nonautoclaved, but dilute (1:100), India ink solutions for endoscopic tattooing. The current technique, is to use two Millipore filters in tandem (of 0.45 and 0.22 ~m, so that large particles will be trapped by the larger filter and bacteria will be stopped by the 0.22 ~m filter). It is true that one would not need a filter if the solution were sterilized to begin with. Unfortunately, in most endoscopy units, an autoclave is not available, and in most gastrointestinal offices where endoscopy is performed, there is no possibility for autoclaving the solution. We have not found the use of a nonautoclaved solution to be at all detrimental in the last 55 cases injected in this fashion. Jerome D. Wave, MD New York, New York

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Figure 1. A, Lipiodal was injected into the upper end of tumor after dilation. B, The esophageal prosthesis was in position with the funnel "shoulder" at the Lipiodal mark. GASTROINTESTINAL ENDOSCOPY