University Departments of Anaesthesia and SurgeryGlasgow Royal Infirmary

Glasgow, Scotland

REFERENCES1. Berman IR, Fleischer D. Monitoring and patient safety. Gas­

trointest Endosc 1990;36:160-1.2. Murray AM, Morran CG, Kenny GNC, Anderson JR. Arterial

oxygen saturation during upper gastrointestinal endoscopy: theeffects of a midazolam/pethidine combination. Gut 1990;31:270-3.

3. Eichorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH,Seeman RG. Standards for patient monitoring during anes­thesia at Harvard Medical School. JAMA 1986;256:1017-20.

4. Lunn JL, ed. Recommendations for Standards of Monitoringduring Anaesthesia and Recovery. The Association of An­aesthetists of Great Britain and Ireland. 1988;1:1.

Precut papillotomy: primum non nocere

To the Editor:

It was with great interest that we read the paper of Siegelet al. l and the editorial by Cotton2 concerning precut papil­lotomy (PCPT). At the time we applied PCPT, we hadperformed nearly 2000 diagnostic and therapeutic ERCPs.Our ability to cannulate the common bile duct (CBD) wasbetween 85 and 90% comparable to that reported in theliterature.3 To date, we have performed PCPT in 16 patients(age range, 63 to 94 years; median age, 81 years). All werereferred to our unit because of clinical and laboratory evi­dence of obstructive jaundice, and all had dilation of theCBD on ultrasound scanning.

The papilla of Vater and the peripapillary area werenormal in all but one patient, whose bulging papilla con­tained an impacted stone. The PCPT was done accordingto the technique described by Huibregtse et al.4 with aretractable, 5-mm-long needle knife. In 11 (69%)cases, pre­cut was immediately followed by CBD cannulation. Stoneswere present in eight cases and completely removed in all ofthem; pancreatic cancer was diagnosed in three patients,and two were successfully decompressed with stents. Onepatient was cannulated after a second attempt, therebyincreasing the rate of successful cannulation from 69 to 75%.However, extraction of a CBD stone was not possible, andthe patient was referred to surgery. Cannulation failed infour (25%) patients. Of these, two patients elected to havesurgery; one was found to have a CBD stone, and the otherwas found to have pancreatic cancer. Two (12%) otherpatients suffered complications. One with pancreatic cancersuccumbed to gram-negative sepsis 24 hours after PCPT,giving a mortality rate of 6%. The other, with the CBDstone, developed a duodenal perforation and was treatedsurgically.

Our small retrospective study reveals that PCPT can yielda correct diagnosis in 75% of the cases and permits successfultherapeutic intervention in 69%. Although our experiencewas limited to one patient, we found that impacted stoneslend themselves to this type oftherapy because they providea protective surface on which the precut papillotome can bealigned, thereby permitting a more controlled and limitedincision. The high incidence of morbidity and mortality

544

(12%), however, prevents us from endorsing the indiscrimi­nate use of PCPT.

We have found that the anatomy of the intramural cho­ledochus cannot be accurately predicted. Therefore, blindpuncture of the papillary roof with the extension of theprecut incision inferiorly as described by Siegel et al. l is avery risky procedure. We agree that PCPT should only beused in highly selected cases and by endoscopists experi­enced in this technique.

Massimo Conio, MDSebastiano Saccomanno, MD

Hugo Aste, MDVittorio Pugliese, MD

Istituto Nazionale per la Ricerca sui CancroServizio di Gastroentero/ogia et Endoscopia Digestiva

Genova, Italy

REFERENCES1. Siegel JH, Ben-Zvi JS, Pullano W. The needle knife: a valuable

tool in diagnostic and therapeutic ERCP. Gastrointest Endosc1989;35:499-503.

2. Cotton PB. Precut papillotomy-a risky technique for expertsonly. Gastrointest Endosc 1989;35:578-9.

3. Siegel JH. Precut papillotomy: a method to improve success ofERCP and papillotomy. Endoscopy 1981;12:130-3.

4. Huibregtse K, Katon RH, Tytgat GNJ. Precut papillotomy viafine-needle knife papillotome: a safe and effective technique.Gastrointest Endosc 1986;32:403-5.

Endoscopic diagnosis of intestinalmetaplasia

To the Editor:

Intestinal metaplasia is frequently associated with gastricmucosal atrophy. Gastric atrophy may be suggested at thetime of endoscopy, but intestinalization is a diagnosis thatrequires specialized endoscopic staining techniques or path­ologic study. We would like to present the endoscopic find­ings in a patient whose gastric mucosal appearance sug­gested, and pathologic examination confirmed, intestinalmetaplasia.

A 76-year-old woman was referred for evaluation of sev­eral months of anorexia, early satiety, occasional vomiting,and weight loss. She had a remote history of peptic ulcerdisease treated with antacids, without known recurrence.Physical examination was unrevealing as were routine lab­oratory studies.

Esophagogastroduodenoscopy revealed a normal esopha­gus and proximal stomach. The stomach distended well withsoft, pliable mucosal folds. The mucosa of the gastric bodywas characterized by numerous, evenly distributed, small (1­mm) white elevations separated by pale orange mucosa (Fig.1). The antral mucosa was erythematous but otherwisevisually normal. The duodenal bulb and second portion werenormal in appearance.

Multiple biopsies of the gastric body (Fig. 2) revealedmarked loss of gastric glands with widespread intestinalmetaplasia. Small foci of inflammatory cells were notedwithout evidence of dysplasia or carcinoma. Antral biopsiesrevealed regenerative hyperplasia, and a biopsy from theduodenum was normal.

GASTROINTESTINAL ENDOSCOPY