- Email: [email protected]
E in action
States Army Medical Corps for 20 years, during which time he held many important positions, including chief of gastroenterology at both Fitzsimmons and Brooke Army Hospitals, chief of the Europe Hepatitis Research Center in Munich, and Army European Consultant in gastroenterology from 1951 to 1953. He subsequently joined the faculty of the University of Texas M.D. Anderson Hospital and Tumor Institute where he was chief of the Section of Gastroenterology for many years. He was also an organizer and first president of the Texas Society for Gastrointestinal Endoscopy. In 1966, he received the William H. Rorer Award for his article on Intragastric Photography and, in 1974, the Seale Harris Award in Nutrition from the Southern Medical Association. In addition to his early work in hepatitis and intragastric photography, he authored many articles on the endoscopic evaluation and biopsy of gastric ulcers and neoplasms. He ran an active Fellowship Program at the M.D. Anderson Hospital and will be fondly remembered by his numerous former students. He will be greatly missed by those of us who worked with him, and knew him well, and also by his loving wife, Mary, and his daughters, Sheila, Patricia, and Roberta. Frank L. Lanza, MD Houston, Texas
From the Rostrum
The A/S/G/E in action The A/S/G/E has assumed a leadership role in many areas of gastroenterology of importance to our members. At the same time, we have strengthened our ties with the other gastrointestinal societies: to speak with one voice, avoid VOLUME 37, NO.3, 1991
duplication of effort, and share the expertise of individuals in all aspects of gastroenterology, hepatology, and gastrointestinal surgery. Our organization is developing new programs, expanding existing ones, and starting projects that we expect to bear fruit in the next few years. To mention just a few, our highly successful A/S/G/E practice guidelines are being expanded into "superguidelines," by Standards of Practice Committee members. These superguidelines, started under Emmet Keeffe and continuing under Katherine O'Connor, utilize wider input and representation from other societies in their preparation to assure wider acceptance. Existing guidelines are also being revised to remain consistent with current consensus, technology, and practice. Through the efforts of David Burnett, A/S/G/E will be offering a new type of research award that provides "seed money" for development of grant proposals for outcome and effectiveness research. A/S/G/E and AGA, in cooperation with PruCare of California, a subsidiary of the Prudential Insurance Company of America, are considering a pilot study of the impact of training-based credentialing and guidelinebased utilization on endoscopic utilization and volume, using A/S/G/E- and AGA-generated credentialing criteria and practice guidelines. Paul Kantrowitz and Martin Brotman, representing the A/S/G/E and AGA, respectively, are participating in the design of the study and, if plans proceed as anticipated, Prudential will provide the study patient population, data collection and collation, and financial support. David Gilbert and Technology Assessment Committee members are looking critically at new technologies, weighing the published data and comparing the safety and efficacy of each new technique with those of existing modalities to produce an up to date assessment of emerging technologies for A/S/G/E members. ACP is planning to utilize the expert guidance of John Bond, A/S/G/E President-Elect, to develop an instructional program in flexible sigmoidoscopy for residents in internal medicine throughout the country. Thomas Fabry is developing an exciting, innovative, state of the art interactive self-assessment program. With only an IBM-PC or compatible and an inexpensive "plug-in" CDROM attachment, physicians will be able to test their endoscopic skills and diagnostic and therapeutic acumen. If you make a mistake or fail to negotiate a curve, you will be told the correct course or technique, either visually or audibly. Yes, the program will even talk back! Although still very much in the planning stages, the A/S/G/E is studying the project with an eye toward offering a "subscription," with additional programs to cover new endoscopic techniques and scientific information. Those of you who have visited the A/ S/G/E Learning Center during Digestive Disease Week know that computer-assisted instruction in endoscopic technique is now a reality. Despite ongoing frustrations, A/S/G/E continues to work hard with the federal government on reimbursement. Ably guided by Randolph Fenninger, our "man in Washington," Donald O'Kieffe, councillor and immediate past-chairman ofthe Government Relations Committee, and James Frakes, current chairman, A/S/G/E, along with our sister societies, AGA and ACG, have and will continue to present our positions, soundly based in facts, to Congress, HealthCare Financing Administration, and the Physician Payment Review Commission. Our own members work with these groups 401
and participate in the expert panels convened by them, and when their leaders have questions related to endoscopy, they turn to the A/S/G/E for the answers. Our views are heard and we, in turn, hear sympathetic clucks of agreement. But when the budget deficit looms, our views remain unheeded in the face of larger concerns. Since Medicare and Defense are among the largest contributors to the deficit, they are also targeted to be the largest contributors to cutting it. Medicare has no multibillion dollar Star Wars Project to give up, and hospitals were the first targets, so now the scuds are aimed at the doctors. And even though our patriots are firing and hitting some scuds (we did get upper endoscopy off the initial lists of "overpriced procedures"), the launchers keep firing new ones, toward targets (like colonscopy) that were hit before as well as new ones. As I write this column, it is late February, one day until Saddam Hussein must unconditionally withdraw from Kuwait or feel the force of allied armies and marines, 1 week before this From the Rostrum column is due, 3 months until Digestive Disease Week and the start of my term as President, and 10 months until HCFA is mandated to have a "budget-neutral" RB-RVS in place and ready to run. Yet Congress has set Medicare Volume Performance Standards and HCFA wants to institute global fee reimbursement for incisional and non-incisional (including "scopies") surgical procedures in advance of the fee schedule. The goal of both seems to be to shift the budget out of neutral and into reverse. PPRC opposes the relegation of endoscopic procedures to surgical global fee reimbursement, and the Hsaio study narrowly limits the endoscopic "bundle" to the immediate pre- and post-procedure care we all provide. HCFA, on the other hand, includes all visits after the initial consultation up to and for 30 days after the procedure that are related to the procedure in the endoscopic global fee. Although unrelated care can be billed separately, the way is wide open for carriers to arbitrarily refuse reimbursement throughout this period for the same diagnosis, even for a critically ill patient requiring intensive medical care. With the help of our allies, not only in AGA and ACG but also in the regional societies that make up the Council of Regional Endoscopic Societies, currently chaired by Bennett Roth, the A/S/G/E will continue to fight for fair reimbursement practices. Hopefully, by the time I have to write my final From the Rostrum, my news about public policy will be as upbeat and optimistic as it is in the areas of research and education.
Letters to the Ed itor
measured on barium swallow) they were able to divide the patient group into mild (>12 mm), moderate (9 to 12 mm), and severe (:~8 mm) categories. They then reported the various types and sizes ofbougies used for the initial dilation, but no correlation was made between the initial ring diameter and the size of the bougie that was used. This may be a critical point. Goyal et al.,2 in their excellent review of the lower esophageal ring, reviewed various techniques of dilating lower esophageal rings and concluded that a single large bore bougie (with a diameter of at least 16 mm) was more likely to forcefully dilate or tear the ring than gradual dilation with bougies of increasing size, and hence result in better long-term efficacy of dilation. Another important point made was that in cases of failure of large bore dilation, the next step would logically be to repeat the procedure with fluoroscopic guidance to ensure that the bougie had actually passed through the area of the ring. In the current study it is unclear whether the dilations performed were of the "large bore" or "gradual" technique, and hence the lack of efficacy may well be due to differences in technique. Furthermore, no mention was made as to whether fluoroscopic guidance was used in either the initial or subsequent dilations. A final point that concerns me is the criteria that were used to determine whether or not a patient truly had a Schatzki's ring (rather than a peptic stricture or muscular ring), as these criteria are not well delineated in Patients and Methods. The authors state, I think correctly, that Schatzki's rings are not associated with esophagitis. No mention is made as to whether esophagitis in study patients was looked for histologically by biopsy obtained at the time of endoscopy, only that patients with obvious peptic strictures and/or esophagitis were excluded. Obviously, inclusion of patients with peptic strictures and/or muscular rings (usually excluded by the appearance on cine-esophogram 2 ) would skew the results, as these lesions may well not be as amenable to treatment with a single dilation as Schatzki's rings may be. Despite these potential flaws, I believe this is an important study that lays the ground work for understanding the natural history of Schatzki's rings after treatment with esophageal bougienage. Future studies should include rigid admission criteria (i.e, characteristic cine-esophagographic appearance, lack of esophagitis by endoscopy, and histology) and randomized method of bougienage (i.e., initial large bore versus gradual dilation). It would also seem wise to use fluoroscopic guidance for all such dilations, as a recent publication 3 has pointed out clearly the potential pitfalls of esophageal dilation without fluoroscopic guidance. Robert E. Smith, MD Veterans Administration Medical Center White River Junction, Vermont
Dilation of Schatzki's ring To the Editor: I read with interest the recently published study by Groskreutz and Kim! retrospectively reviewing the Mayo Clinic experience with esophageal dilation in the treatment of Schatzki's ring, and would like to make a few comments. On the basis of internal ring diameter (presumably as 402
REFERENCES 1. Groskreutz JL, Kim CH. Schatzki's ring. Long-term results following dilation. Gastrointestinal Endosc 1990;36:479-81. 2. Goyal RK, Glancy JJ, Spiro HM. Lower esophageal ring (second of two parts). N Engl J Med 1970;282:1355-62.
3. McClure SA, Wright RA, Brady PG. Prospective randomized study of Maloney esophageal dilation-blinded versus fluoroscopic guidance. Gastrointestinal Endosc 1990;36:272-5. GASTROINTESTINAL ENDOSCOPY
From the Rostrum
The A/S/G/E in action The A/S/G/E has assumed a leadership role in many areas of gastroenterology of importance to our members. At the same time, we have strengthened our ties with the other gastrointestinal societies: to speak with one voice, avoid VOLUME 37, NO.3, 1991
duplication of effort, and share the expertise of individuals in all aspects of gastroenterology, hepatology, and gastrointestinal surgery. Our organization is developing new programs, expanding existing ones, and starting projects that we expect to bear fruit in the next few years. To mention just a few, our highly successful A/S/G/E practice guidelines are being expanded into "superguidelines," by Standards of Practice Committee members. These superguidelines, started under Emmet Keeffe and continuing under Katherine O'Connor, utilize wider input and representation from other societies in their preparation to assure wider acceptance. Existing guidelines are also being revised to remain consistent with current consensus, technology, and practice. Through the efforts of David Burnett, A/S/G/E will be offering a new type of research award that provides "seed money" for development of grant proposals for outcome and effectiveness research. A/S/G/E and AGA, in cooperation with PruCare of California, a subsidiary of the Prudential Insurance Company of America, are considering a pilot study of the impact of training-based credentialing and guidelinebased utilization on endoscopic utilization and volume, using A/S/G/E- and AGA-generated credentialing criteria and practice guidelines. Paul Kantrowitz and Martin Brotman, representing the A/S/G/E and AGA, respectively, are participating in the design of the study and, if plans proceed as anticipated, Prudential will provide the study patient population, data collection and collation, and financial support. David Gilbert and Technology Assessment Committee members are looking critically at new technologies, weighing the published data and comparing the safety and efficacy of each new technique with those of existing modalities to produce an up to date assessment of emerging technologies for A/S/G/E members. ACP is planning to utilize the expert guidance of John Bond, A/S/G/E President-Elect, to develop an instructional program in flexible sigmoidoscopy for residents in internal medicine throughout the country. Thomas Fabry is developing an exciting, innovative, state of the art interactive self-assessment program. With only an IBM-PC or compatible and an inexpensive "plug-in" CDROM attachment, physicians will be able to test their endoscopic skills and diagnostic and therapeutic acumen. If you make a mistake or fail to negotiate a curve, you will be told the correct course or technique, either visually or audibly. Yes, the program will even talk back! Although still very much in the planning stages, the A/S/G/E is studying the project with an eye toward offering a "subscription," with additional programs to cover new endoscopic techniques and scientific information. Those of you who have visited the A/ S/G/E Learning Center during Digestive Disease Week know that computer-assisted instruction in endoscopic technique is now a reality. Despite ongoing frustrations, A/S/G/E continues to work hard with the federal government on reimbursement. Ably guided by Randolph Fenninger, our "man in Washington," Donald O'Kieffe, councillor and immediate past-chairman ofthe Government Relations Committee, and James Frakes, current chairman, A/S/G/E, along with our sister societies, AGA and ACG, have and will continue to present our positions, soundly based in facts, to Congress, HealthCare Financing Administration, and the Physician Payment Review Commission. Our own members work with these groups 401
and participate in the expert panels convened by them, and when their leaders have questions related to endoscopy, they turn to the A/S/G/E for the answers. Our views are heard and we, in turn, hear sympathetic clucks of agreement. But when the budget deficit looms, our views remain unheeded in the face of larger concerns. Since Medicare and Defense are among the largest contributors to the deficit, they are also targeted to be the largest contributors to cutting it. Medicare has no multibillion dollar Star Wars Project to give up, and hospitals were the first targets, so now the scuds are aimed at the doctors. And even though our patriots are firing and hitting some scuds (we did get upper endoscopy off the initial lists of "overpriced procedures"), the launchers keep firing new ones, toward targets (like colonscopy) that were hit before as well as new ones. As I write this column, it is late February, one day until Saddam Hussein must unconditionally withdraw from Kuwait or feel the force of allied armies and marines, 1 week before this From the Rostrum column is due, 3 months until Digestive Disease Week and the start of my term as President, and 10 months until HCFA is mandated to have a "budget-neutral" RB-RVS in place and ready to run. Yet Congress has set Medicare Volume Performance Standards and HCFA wants to institute global fee reimbursement for incisional and non-incisional (including "scopies") surgical procedures in advance of the fee schedule. The goal of both seems to be to shift the budget out of neutral and into reverse. PPRC opposes the relegation of endoscopic procedures to surgical global fee reimbursement, and the Hsaio study narrowly limits the endoscopic "bundle" to the immediate pre- and post-procedure care we all provide. HCFA, on the other hand, includes all visits after the initial consultation up to and for 30 days after the procedure that are related to the procedure in the endoscopic global fee. Although unrelated care can be billed separately, the way is wide open for carriers to arbitrarily refuse reimbursement throughout this period for the same diagnosis, even for a critically ill patient requiring intensive medical care. With the help of our allies, not only in AGA and ACG but also in the regional societies that make up the Council of Regional Endoscopic Societies, currently chaired by Bennett Roth, the A/S/G/E will continue to fight for fair reimbursement practices. Hopefully, by the time I have to write my final From the Rostrum, my news about public policy will be as upbeat and optimistic as it is in the areas of research and education.
Letters to the Ed itor
measured on barium swallow) they were able to divide the patient group into mild (>12 mm), moderate (9 to 12 mm), and severe (:~8 mm) categories. They then reported the various types and sizes ofbougies used for the initial dilation, but no correlation was made between the initial ring diameter and the size of the bougie that was used. This may be a critical point. Goyal et al.,2 in their excellent review of the lower esophageal ring, reviewed various techniques of dilating lower esophageal rings and concluded that a single large bore bougie (with a diameter of at least 16 mm) was more likely to forcefully dilate or tear the ring than gradual dilation with bougies of increasing size, and hence result in better long-term efficacy of dilation. Another important point made was that in cases of failure of large bore dilation, the next step would logically be to repeat the procedure with fluoroscopic guidance to ensure that the bougie had actually passed through the area of the ring. In the current study it is unclear whether the dilations performed were of the "large bore" or "gradual" technique, and hence the lack of efficacy may well be due to differences in technique. Furthermore, no mention was made as to whether fluoroscopic guidance was used in either the initial or subsequent dilations. A final point that concerns me is the criteria that were used to determine whether or not a patient truly had a Schatzki's ring (rather than a peptic stricture or muscular ring), as these criteria are not well delineated in Patients and Methods. The authors state, I think correctly, that Schatzki's rings are not associated with esophagitis. No mention is made as to whether esophagitis in study patients was looked for histologically by biopsy obtained at the time of endoscopy, only that patients with obvious peptic strictures and/or esophagitis were excluded. Obviously, inclusion of patients with peptic strictures and/or muscular rings (usually excluded by the appearance on cine-esophogram 2 ) would skew the results, as these lesions may well not be as amenable to treatment with a single dilation as Schatzki's rings may be. Despite these potential flaws, I believe this is an important study that lays the ground work for understanding the natural history of Schatzki's rings after treatment with esophageal bougienage. Future studies should include rigid admission criteria (i.e, characteristic cine-esophagographic appearance, lack of esophagitis by endoscopy, and histology) and randomized method of bougienage (i.e., initial large bore versus gradual dilation). It would also seem wise to use fluoroscopic guidance for all such dilations, as a recent publication 3 has pointed out clearly the potential pitfalls of esophageal dilation without fluoroscopic guidance. Robert E. Smith, MD Veterans Administration Medical Center White River Junction, Vermont
Dilation of Schatzki's ring To the Editor: I read with interest the recently published study by Groskreutz and Kim! retrospectively reviewing the Mayo Clinic experience with esophageal dilation in the treatment of Schatzki's ring, and would like to make a few comments. On the basis of internal ring diameter (presumably as 402
REFERENCES 1. Groskreutz JL, Kim CH. Schatzki's ring. Long-term results following dilation. Gastrointestinal Endosc 1990;36:479-81. 2. Goyal RK, Glancy JJ, Spiro HM. Lower esophageal ring (second of two parts). N Engl J Med 1970;282:1355-62.
3. McClure SA, Wright RA, Brady PG. Prospective randomized study of Maloney esophageal dilation-blinded versus fluoroscopic guidance. Gastrointestinal Endosc 1990;36:272-5. GASTROINTESTINAL ENDOSCOPY