- Email: [email protected]
What is new in tattooing? “Custom tattooing!”
Letters to the Editor
11. Elton E, Hanson BL, Quaseem T, Howell DA. Diagnostic and therapeutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients. Gastrointest Endosc 1998;47:62-7. 12. Schapira L, Falkenstein DB, Zimmon DS. Endoscopy and retrograde cholangiography via gastrostomy. Gastrointest Endosc 1975;22:103-4. 13. Holderman WH, Etzkorn KP, Harig JM, Watkins JL. Endoscopic retrograde cholangiopancreatography and stent placement via gastrostomy: technical aspects and clinical application. Endoscopy 1995;27:135-7. 14. Gray R, Leong S, Marcon N, Haber G. Endoscopic retrograde cholangiography, sphincterotomy, and gallstone extraction via gastrostomy. Gastrointest Endosc 1992;38:731-2.
LETTERS TO THE EDITOR Enhancing endoscopic research To the Editor: I read with interest your editorial ‘‘Endoscopic Research in America.’’1 I believe that in large measure its message is squarely on the mark. The recently published National Institutes of Health (NIH) ‘‘Roadmap’’ clearly indicates recognition by NIH leadership that there are many hurdles that limit translation and clinical research, and attempts will be made to overcome these through new overarching initiatives (see the Web site http://www.nihroadmap.nih.gov/). However, these general initiatives will never supplant the need for physician scientists in specific disciplines who are interested in diseases or technologies to commit themselves to actively participating in the clinical research process. Many problems in our health care delivery system and academic medical centers conspire against clinical investigators in procedural specialties, as your editorial enumerates, but the problems faced by our patients mandate that we must work hard to overcome these hurdles. I believe that professional subspecialty organizations such as the American Society for Gastrointestinal Endoscopy (ASGE) have the potential of playing a critical role in facilitating more and better clinical research. The ASGE can provide a forum for facilitating the creation of new clinical research projects at national meetings and small workshops, and through publication in Gastrointestinal Endoscopy. One of the most important aspects of the clinical research process is to bring together members of the clinical and research community to identify specific areas of highest priority for research and then to develop the needed implementation plan, including clinical study designs, infrastructure requirements, and the cadre of study investigators. For those not familiar with investigator-originated research, this process is far more complicated and time consuming than simply signing on to participate in a pharmaceutical company sponsored trial, but the potential benefits to society are unique and substantial. To facilitate this type of planning, the ASGE 328
GASTROINTESTINAL ENDOSCOPY
can identify and bring together key thought leaders in GI endoscopy, advisers from other successful areas of clinical research, and individuals from NIH and industry. The ASGE can sponsor mentoring sessions that provide needed clinical research skills to interested potential new investigators. These largely intellectual aspects of clinical research are fortunately the relatively low budget items, but they do require time, effort, and dedication of key leaders and some financial support to make the process happen. The leadership stature of the ASGE places the society in a good position to try to step up to this challenge. I am personally available to any interested individual or group who would like to discuss these clinical research ideas and how NIH can help. Stephen P. James, MD, Acting Director Division of Digestive Diseases and Nutrition National Institute of Diabetes and Digestive and Kidney Diseases Bethesda, MD [email protected] REFERENCE 1. Sivak MV Jr. Endoscopic research in America (revisited). Gastrointest Endosc 2003;58:901-7. PII: S0016-5107(03)02690-7
What is new in tattooing? ‘‘Custom tattooing!’’ To the Editor: I read with great interest the report of Sawaki et al.1 on ‘‘A two-step method for marking polypectomy sites in the colon and rectum.’’ I congratulate these investigators for describing a novel technique; the first step being to produce a submucosal bleb by injection of saline solution and the second to fill the bleb with India ink. This effectively creates a custom tattoo in the submucosal plane and thereby avoids injection into the muscularis propria or peritoneal cavity. I routinely have been using a similar technique to custom tattoo the submucosal plane of the colon with India ink for the last 4 years.2,3 Initially, I used a ‘‘double injection technique,’’ similar to the two-step method described by Sawaki et al.,1 except for a slight difference.2 This consisted of injection with two sclerotherapy needles, one attached to a syringe with saline solution and another to a syringe filled with India ink, which are passed separately through the accessory channels of a two-channel colonoscope, making them ready for use, one after the other, quickly. A saline solution submucosal bleb was created and then filled with ink with the second needle, which already was positioned at the end of the colonoscope, ready for injection. I agree with Sawaki et al.1 that maintaining an angle of nearly 08 to the mucosal plane for injection of India ink into the submucosal bleb is critical for the success of this technique. Although this is relatively easy to do in the lower quadrants of the endoscopic visual field, I encountered a problem with transmural injection when creating tattoos in the upper visual quadrants. In my initial experience VOLUME 59, NO. 2, 2004
Letters to the Editor
with this technique, I noted leakage of the ink from the puncture made for saline solution injection, despite use of a small bore needle (23-gauge). In addition, a two-channel colonoscope was not always available. Hence, I changed to a ‘‘sequential injection technique.’’3 This consisted sequentially of creation of a submucosal bleb by injection of 1 mL saline solution, switching the saline solution syringe to one filled with India ink, and injection of ink into the submucosal bleb without removing the needle from the submucosal fluid cushion until a nice tattoo was seen. Then, the needle was withdrawn while maintaining tamponade with the needle sheath at the puncture site. With this sequential injection technique, it was easy to create clean, 4-quadrant tattoos without any leakage of the ink. In addition, with the sequential injection technique, there is no risk of improper injection into the muscularis propria. Microscopic evaluation of the tattooed sites after surgical resection in two of my patients confirmed localization of the India ink to the submucosa. I have not encountered any complication by using this technique during the last 4 years. I agree with the conclusion of Sawaki et al.1 that a two-step method is the easiest and safest technique for endoscopic tattooing. Gottumukkala S. Raju, MD, DM, MRCP (UK) University of Texas Medical Branch at Galveston Galveston, Texas REFERENCES
nately, intra-operative localization can be difficult with this technique because of the spatial positioning and rotation of the sigmoid and transverse colons. We, therefore, marked two points (the most distal sites) with a small amount of India ink. By using this method, we easily found polypectomy sites despite rotation of the colon. We believe that the leakage of India ink through the puncture wound made for saline solution injection along with precise injection of India ink prevent excessive tattooing. However, we consider the sequential injection technique2 attractive and plan to further investigate its use. Akira Sawaki, MD Tsuneya Nakamura, MD Takashi Suzuki, MD Kazuo Hara, MD Tetsuya Kato, MD Tomoyuki Kato, MD Takashi Hirai, MD Yukihide Kanemitsu, MD Kenji Okubo, MD Kyosuke Tanaka, MD Ichiro Moriyama, MD Hiroki Kawai, MD Masaki Katsurahara, MD Kakuya Matsumoto, MD Kenji Yamao, MD Aichi Cancer Center Hospital Nagoya, Japan
1. Sawaki A, Nakamura T, Suzuki T, Hara K, Kato T, Kato T, et al. A two-step method for marking polypectomy sites in the colon and rectum. Gastrointest Endosc 2003;57:735-7. 2. Raju GS. Double injection technique to prevent complications of endoscopic tattooing [letter]. Gastrointest Endosc 2001; 53:697-8. 3. Raju GS, George S, Jones T. Sequential injection technique for controlled endoscopic tattooing (videos) [abstract]. Am J Gastroenterol 2001;96:S322. PII: S0016-5107(03)02554-9
1. Raju GS. Double injection technique to prevent complications of endoscopic tattooing [letter]. Gastrointest Endosc 2001;53: 697-8. 2. Raju GS, George S, Jones T. Sequential injection technique for controlled endscopic tattooing (videos) [abstract]. Am J Gastroenterol 2001;96:S322.
Response:
Individualized management of bleeding peptic ulcer
We appreciate the comments of Dr. Raju regarding techniques for marking the colon and rectum. We consider our method to differ from previously described methods because it produces a pinpoint tattoo. When tattooing the colon, it is important to provide accurate localization, while ensuring that a minimal amount of India ink is injected so as to avoid complications such as peritonitis. We agree that injecting India ink into the submucosa reduces the likelihood of complications. If the first created bleb is filled with ink, the area of the intestine marked by using the double injection technique1 will be larger and, hence, more intestine may be resected than is necessary. In our experience with using conventional one-point marking, when the sigmoid colon was marked, the descending colon also became dyed, making it necessary to resect a portion of the descending colon, although the lesion to be resected actually was located in the sigmoid colon. To reduce the quantity of ink, we attempted to mark one point of the ventral side of the colon that was identified by water injected into the colon with the patient supine. UnfortuVOLUME 59, NO. 2, 2004
REFERENCES
PII: S0016-5107(03)02555-0
To the Editor: We read with interest the meta-analysis by Marmo et al.1 published in Gastrointestinal Endoscopy, which suggests that systemic second-look endoscopy reduces the risk of recurrent bleeding in patients with bleeding peptic ulcer. This topic is highly relevant because bleeding peptic ulcer is still common and the mortality associated with recurrent bleeding remains high. Systematic endoscopic re-treatment may be attractive as a way to reduce further bleeding and improve prognosis. An exploration of this question should be based mainly on 3 studies that logically can be pooled for meta-analysis because the methodology used in each was similar (systematic endoscopic re-treatment vs. no systematic re-treatment, i.e., repeat endoscopic treatment only in cases of clinically recurrent bleeding).2-5 However, in our opinion, the methodology of one study from Europe differs substantially from those of other trials.5 In this randomized trial of Rutgeerts et al.,5 854 patients with bleeding peptic ulcer initially were GASTROINTESTINAL ENDOSCOPY
329
11. Elton E, Hanson BL, Quaseem T, Howell DA. Diagnostic and therapeutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients. Gastrointest Endosc 1998;47:62-7. 12. Schapira L, Falkenstein DB, Zimmon DS. Endoscopy and retrograde cholangiography via gastrostomy. Gastrointest Endosc 1975;22:103-4. 13. Holderman WH, Etzkorn KP, Harig JM, Watkins JL. Endoscopic retrograde cholangiopancreatography and stent placement via gastrostomy: technical aspects and clinical application. Endoscopy 1995;27:135-7. 14. Gray R, Leong S, Marcon N, Haber G. Endoscopic retrograde cholangiography, sphincterotomy, and gallstone extraction via gastrostomy. Gastrointest Endosc 1992;38:731-2.
LETTERS TO THE EDITOR Enhancing endoscopic research To the Editor: I read with interest your editorial ‘‘Endoscopic Research in America.’’1 I believe that in large measure its message is squarely on the mark. The recently published National Institutes of Health (NIH) ‘‘Roadmap’’ clearly indicates recognition by NIH leadership that there are many hurdles that limit translation and clinical research, and attempts will be made to overcome these through new overarching initiatives (see the Web site http://www.nihroadmap.nih.gov/). However, these general initiatives will never supplant the need for physician scientists in specific disciplines who are interested in diseases or technologies to commit themselves to actively participating in the clinical research process. Many problems in our health care delivery system and academic medical centers conspire against clinical investigators in procedural specialties, as your editorial enumerates, but the problems faced by our patients mandate that we must work hard to overcome these hurdles. I believe that professional subspecialty organizations such as the American Society for Gastrointestinal Endoscopy (ASGE) have the potential of playing a critical role in facilitating more and better clinical research. The ASGE can provide a forum for facilitating the creation of new clinical research projects at national meetings and small workshops, and through publication in Gastrointestinal Endoscopy. One of the most important aspects of the clinical research process is to bring together members of the clinical and research community to identify specific areas of highest priority for research and then to develop the needed implementation plan, including clinical study designs, infrastructure requirements, and the cadre of study investigators. For those not familiar with investigator-originated research, this process is far more complicated and time consuming than simply signing on to participate in a pharmaceutical company sponsored trial, but the potential benefits to society are unique and substantial. To facilitate this type of planning, the ASGE 328
GASTROINTESTINAL ENDOSCOPY
can identify and bring together key thought leaders in GI endoscopy, advisers from other successful areas of clinical research, and individuals from NIH and industry. The ASGE can sponsor mentoring sessions that provide needed clinical research skills to interested potential new investigators. These largely intellectual aspects of clinical research are fortunately the relatively low budget items, but they do require time, effort, and dedication of key leaders and some financial support to make the process happen. The leadership stature of the ASGE places the society in a good position to try to step up to this challenge. I am personally available to any interested individual or group who would like to discuss these clinical research ideas and how NIH can help. Stephen P. James, MD, Acting Director Division of Digestive Diseases and Nutrition National Institute of Diabetes and Digestive and Kidney Diseases Bethesda, MD [email protected] REFERENCE 1. Sivak MV Jr. Endoscopic research in America (revisited). Gastrointest Endosc 2003;58:901-7. PII: S0016-5107(03)02690-7
What is new in tattooing? ‘‘Custom tattooing!’’ To the Editor: I read with great interest the report of Sawaki et al.1 on ‘‘A two-step method for marking polypectomy sites in the colon and rectum.’’ I congratulate these investigators for describing a novel technique; the first step being to produce a submucosal bleb by injection of saline solution and the second to fill the bleb with India ink. This effectively creates a custom tattoo in the submucosal plane and thereby avoids injection into the muscularis propria or peritoneal cavity. I routinely have been using a similar technique to custom tattoo the submucosal plane of the colon with India ink for the last 4 years.2,3 Initially, I used a ‘‘double injection technique,’’ similar to the two-step method described by Sawaki et al.,1 except for a slight difference.2 This consisted of injection with two sclerotherapy needles, one attached to a syringe with saline solution and another to a syringe filled with India ink, which are passed separately through the accessory channels of a two-channel colonoscope, making them ready for use, one after the other, quickly. A saline solution submucosal bleb was created and then filled with ink with the second needle, which already was positioned at the end of the colonoscope, ready for injection. I agree with Sawaki et al.1 that maintaining an angle of nearly 08 to the mucosal plane for injection of India ink into the submucosal bleb is critical for the success of this technique. Although this is relatively easy to do in the lower quadrants of the endoscopic visual field, I encountered a problem with transmural injection when creating tattoos in the upper visual quadrants. In my initial experience VOLUME 59, NO. 2, 2004
Letters to the Editor
with this technique, I noted leakage of the ink from the puncture made for saline solution injection, despite use of a small bore needle (23-gauge). In addition, a two-channel colonoscope was not always available. Hence, I changed to a ‘‘sequential injection technique.’’3 This consisted sequentially of creation of a submucosal bleb by injection of 1 mL saline solution, switching the saline solution syringe to one filled with India ink, and injection of ink into the submucosal bleb without removing the needle from the submucosal fluid cushion until a nice tattoo was seen. Then, the needle was withdrawn while maintaining tamponade with the needle sheath at the puncture site. With this sequential injection technique, it was easy to create clean, 4-quadrant tattoos without any leakage of the ink. In addition, with the sequential injection technique, there is no risk of improper injection into the muscularis propria. Microscopic evaluation of the tattooed sites after surgical resection in two of my patients confirmed localization of the India ink to the submucosa. I have not encountered any complication by using this technique during the last 4 years. I agree with the conclusion of Sawaki et al.1 that a two-step method is the easiest and safest technique for endoscopic tattooing. Gottumukkala S. Raju, MD, DM, MRCP (UK) University of Texas Medical Branch at Galveston Galveston, Texas REFERENCES
nately, intra-operative localization can be difficult with this technique because of the spatial positioning and rotation of the sigmoid and transverse colons. We, therefore, marked two points (the most distal sites) with a small amount of India ink. By using this method, we easily found polypectomy sites despite rotation of the colon. We believe that the leakage of India ink through the puncture wound made for saline solution injection along with precise injection of India ink prevent excessive tattooing. However, we consider the sequential injection technique2 attractive and plan to further investigate its use. Akira Sawaki, MD Tsuneya Nakamura, MD Takashi Suzuki, MD Kazuo Hara, MD Tetsuya Kato, MD Tomoyuki Kato, MD Takashi Hirai, MD Yukihide Kanemitsu, MD Kenji Okubo, MD Kyosuke Tanaka, MD Ichiro Moriyama, MD Hiroki Kawai, MD Masaki Katsurahara, MD Kakuya Matsumoto, MD Kenji Yamao, MD Aichi Cancer Center Hospital Nagoya, Japan
1. Sawaki A, Nakamura T, Suzuki T, Hara K, Kato T, Kato T, et al. A two-step method for marking polypectomy sites in the colon and rectum. Gastrointest Endosc 2003;57:735-7. 2. Raju GS. Double injection technique to prevent complications of endoscopic tattooing [letter]. Gastrointest Endosc 2001; 53:697-8. 3. Raju GS, George S, Jones T. Sequential injection technique for controlled endoscopic tattooing (videos) [abstract]. Am J Gastroenterol 2001;96:S322. PII: S0016-5107(03)02554-9
1. Raju GS. Double injection technique to prevent complications of endoscopic tattooing [letter]. Gastrointest Endosc 2001;53: 697-8. 2. Raju GS, George S, Jones T. Sequential injection technique for controlled endscopic tattooing (videos) [abstract]. Am J Gastroenterol 2001;96:S322.
Response:
Individualized management of bleeding peptic ulcer
We appreciate the comments of Dr. Raju regarding techniques for marking the colon and rectum. We consider our method to differ from previously described methods because it produces a pinpoint tattoo. When tattooing the colon, it is important to provide accurate localization, while ensuring that a minimal amount of India ink is injected so as to avoid complications such as peritonitis. We agree that injecting India ink into the submucosa reduces the likelihood of complications. If the first created bleb is filled with ink, the area of the intestine marked by using the double injection technique1 will be larger and, hence, more intestine may be resected than is necessary. In our experience with using conventional one-point marking, when the sigmoid colon was marked, the descending colon also became dyed, making it necessary to resect a portion of the descending colon, although the lesion to be resected actually was located in the sigmoid colon. To reduce the quantity of ink, we attempted to mark one point of the ventral side of the colon that was identified by water injected into the colon with the patient supine. UnfortuVOLUME 59, NO. 2, 2004
REFERENCES
PII: S0016-5107(03)02555-0
To the Editor: We read with interest the meta-analysis by Marmo et al.1 published in Gastrointestinal Endoscopy, which suggests that systemic second-look endoscopy reduces the risk of recurrent bleeding in patients with bleeding peptic ulcer. This topic is highly relevant because bleeding peptic ulcer is still common and the mortality associated with recurrent bleeding remains high. Systematic endoscopic re-treatment may be attractive as a way to reduce further bleeding and improve prognosis. An exploration of this question should be based mainly on 3 studies that logically can be pooled for meta-analysis because the methodology used in each was similar (systematic endoscopic re-treatment vs. no systematic re-treatment, i.e., repeat endoscopic treatment only in cases of clinically recurrent bleeding).2-5 However, in our opinion, the methodology of one study from Europe differs substantially from those of other trials.5 In this randomized trial of Rutgeerts et al.,5 854 patients with bleeding peptic ulcer initially were GASTROINTESTINAL ENDOSCOPY
329