In 1980, Sloof et al.7 reported one fatality, due topancreatitis, among eight precuts. They concludedthat the procedure "should probably be reserved forcases where surgical treatment is strongly contrain­dicated." Two years later a group with experience ofonly 50 sphincterotomies reported three severe epi­sodes of pancreatitis (one patient requiring severaloperations) after 11 precuts.8 A London group hasrecently reviewed more substantial experience.9 Theyreported 12 complications after 85 precuts: bleeding(5), perforation (4), pancreatitis (2), cholangitis (1);two patients died. These rates for complications andmortality (14% and 2.4%) are substantially higherthan those (5% and 0.6%) which the same groupreported for 667 standard sphincterotomies. lO Lastyear, at Digestive Disease Week, a surgical groupreported no fewer than 5 perforations among 56 pre­cuts (8.9%), as well as 4 other serious complications,with 1 death. ll

I recently convened a workshop on sphincterotomycomplications and canvassed opinions from 20 ex­perts. Six stated that they avoided precutting com­pletely, and the remainder used it only sparingly whenthere was a strong indication for sphincterotomy-astance which is reflected in most of the standardendoscopic texts. 12

-16 At the same workshop, Liguory

reported a careful prospective study of 321 standardsphincterotomies and 67 precuts; the complicationrates were 7 and 22%, respectively.

Precutting, by one of the variant techniques, shouldbe used only by experienced endoscopists in patientswith strong evidence of biliary obstruction and theneed for endoscopic therapy and only after consider­ation of the alternatives. These include referral to amore experienced endoscopist, the use of guide wiretechniques, or a percutaneous (or combined) ap­proach. Surgical exploration may be appropriate insome cases. Precutting certainly cannot be recom­mended for diagnostic purposes.

Peter B. Cotton, MD, FRCPDivision of Gastroenterology

Duke University Medical CenterDurham, North Carolina

REFERENCES1. Damling L. Papillotomy indications and technique. Endoscopy

1983;15:162-4.2. Ikeda D, Tanaka M, Itoh H, Tamura R. A newly devised cutting

probe for endoscopic sphincterotomy of the ampulla of Vater.Endoscopy 1977;9:238-41.

3. Siegel JH. Precut papillotomy: a method to improve success ofERCP and papillotomy. Endoscopy 1980;20:130-3.

4. Osnes M, Kahr T. Endoscopic choledochoduodenostomy forcholedocholithiasis through choledochoduodenal fistula. Endos­copy 1977;9:162-5.

5. Huibregtse K, Katon RM, Tytgat GNH. Precut papillotomy viafine-needle knife papillotome: a safe and effective technique.Gastrointest Endoscopy 1986;32:403-5.

6. Siegel JH, Ben-Zvi JS, Pullano W. The needle knife: a valuabletool in diagnostic and therapeutic ERCP. Gastrointest Endosc

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1989; 35:499-503.7. SloofM, Baker R, Lavelle MI, Lendrum R, Venables CWo What

is involved in endoscopic sphincterotomy for gallstones? Br JSurg 1980;67:18-21.

8. Passi RB, Raval B. Endoscopic papillotomy. Surgery 1982;581-8.

9. Polydorou AA, Dowsell JF, Vaira D, et al. Needle knife sphinc­terotomy (N-KS)-an initial experience. Gut 1988;29:A1490.

10. Vaira D, D'Anna LM, Dowsett J, et al. Endoscopic sphincter­otomy: how safe and successful in the 1980's? Cut1988;29:A1489-90.

11. Booth F, Doerr R, Khalafi F, Luchette F, Flint L. Surgicalmanagement of complications of endoscopic sphincterotomy(ESS) with precut papillotomy (PCP). Am J Surg (in press).

12. Waye J, Geenen J, Fleischer D. Techniques in therapeuticendoscopy. Philadelphia: WB Saunders, 1987.

13. Chung RS. Therapeutic endoscopy in gastrointestinal surgery.London: Churchill Livingston, 1987.

14. Silvis SE. Therapeutic gastrointestinal endoscopy. New York:Igaku-Shoin, 1985.

15. Cotton PB, Williams CB. Practical gastrointestinal endoscopy.London: Blackwell Scientific Publications, 1982.

16. Vennes JA, ERCP, diagnostic and therapeutic applications.Amsterdam: Elsevier Publishing Co., 1989.

From the Rostrum

Training in endoscopy

The American Society for Gastrointestinal Endoscopy hasa long established interest in endoscopic training. Virtuallyfrom its inception, the Society has been resolute in itsaffirmation of high standards of training as essential to theexemplary use of endoscopy in clinical practice. There is afundamental relationship between training that is of highquality and excellence in the care of patients. The AjSjGjE is dedicated to the enhancement of this important rela­tionship and has endeavored to assist those who have directresponsibility for the instruction of trainees in endoscopictechnique and practice.

The practice of medicine and surgery has entered a newera. The future of the profession, indeed of health care, isdifficult to forecast, although the present course is beinginfluenced by many forces seemingly beyond the control of

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physicians. Some aspects of these changing circumstancesare clearly detrimental, but other trends will improve thedelivery of health care. The growing emphasis on quality isone of the latter. This is a critical issue, and it is imperativethat physicians take a leadership position in defining stand­ards in health care. Given the inextricable relationshipbetwen training and practice, it is appropriate to ponder thequality of instruction in endoscopy. Unfortunately, this isalmost impossible to assess as there is no accurate measureof the overall level of proficiency in procedures for physi­cians upon completion of training for most if not all spe­cialties.

Gastrointestinal endoscopy is an important component ofvarious medical and surgical specialties, the foremost ofthese being gastroenterology and general surgery. Accord­ingly, certification in either area of clinical practice is pre­sumed to include a certain minimal level of competence inendoscopy. However, the methods used to assess competenceare at best uneven. Many aspects of proper endoscopicpractice can be evaluated with the question-answer formatof certifying examinations as, for example, good judgmentin the use of endoscopy which incorporates knowledge ofthe correct indications for procedures. However, the vener­able paper and pencil examination cannot adequately testproficiency in the use of an endoscope and a few endoscopicphotographs of dubious quality are doubtless a poor measureof the mastery of endoscopic diagnosis. However, validationof procedural competence is readily acknowledged as diffi­cult and imprecise, and these observations are not intendedas criticism of the certifying process.

The lack of a practical and objective method for assess­ment of endoscopic proficiency has made it necessary todelegate this responsibility to the training program. Forpractical purposes, procedural competence is authenticatedby those who also provide the training. Presumably, stand­ards and measures of minimal proficiency have been estab­lished by every training program and the ability of eachtrainee who sits for a certifying examination has been gaugedin an objective an systematic fashion against recognizedindicators of competence. A major problem with this ap­proach is the lack of absolute criteria for competence. Thatwhich one program regards as excellent training might bemediocre or even substandard by comparison with anotherprogram. It is difficult, in fact, to refute the impression thatmethods, quality, and standards of training are highly vari­able. Despite this concern, the training program is pivotalto the establishment of competence as well as quality inendoscopic practice.

The absence of a suitable method for the objective assess­ment of competence leads to an inordinate emphasis onnumbers of procedures as a measure of proficiency. In the­ory, for every type of procedure there is a critical minimumlevel of experience that must be attained before competencecan become a consideration. This can be related to anabsolute number of procedures which must be performedbefore even the gifted student of endoscopy attains a reason­able level of proficiency. At best, this is a crude estimate ofability. At worst, it can be so misleading that procedurecounts should never be accepted as a priori evidence ofcompetence. Although requirements for minimum numbersof procedures are undoubtedly necessary, an accent on thelowest acceptable level of proficiency is a reflection of a low

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standard of training which ultimately translates to poorquality in endoscopic practice. There would be considerablegain if greater stress were given to the concept of excellencein endoscopic training.

If the focus of endoscopic training should be excellencerather than a minimal standard, what then is the definitionof an ideal program of instruction? Unfortunately, infor­mation on the characteristics of a model training programis negligible. This is unaccountable in view of the magnitudeof endoscopy in clinical practice and the undeniable rela­tionship between quality of care and standards of training.There is perhaps a certain desire to avoid potentially difficultconsequences of such a definition. Perhaps there is compla­cency with respect to the adequacy of endoscopic training,or a bias against endoscopy as unworthy of true intellectualeffort and the commitment of time and resources. This isundoubtedly an overstatement of fact since there is a newfound awareness of the importance of endoscopic training,but there is nonetheless an uneasy concern that the greaterexperience with endoscopic teaching is not to be foundamong many highly regarded academic training programs.

A concise and complete exposition of an ideal for trainingin endoscopy cannot be developed by one individual or statedin a few paragraphs. However, one absolute requirement forthe model program is the endoscopy instructor. The bestform of instruction is that which one receives in a one toone relation with an expert endoscopist who has the innateability and patience to train others. The technical masteryof endoscopy does not automatically confer the ability toteach others to perform procedures. This is a special art thatmust be developed by dedicated individuals with the innatetalents for this form of teaching. The instructor must protectthe patient's right to a safe, accurate, and expeditious pro­cedure while addressing the needs of the student, a balancethat must be maintained for the most part through judicioususe of the spoken word. If taken seriously, this can be aninteresting emotional experience, something that is com­parable to teaching a teenage son or daughter to drive. It isthe transfer of skill and judgment to an inexperienced indi­vidual whose major contribution to the process is enthusi­asm. There is no school for endoscopy instructors, no certi­fication process, not even a manual with suggestions orlesson plans. Those most adept at teaching endoscopy havelearned the art by trial and error, or in the case of the morefortunate, by emulating the methods of a revered teacher.

The A/S/G/E has summarized its position on endoscopictraining in its "Statement on Endoscopic Training."! Theessential principles of endoscopic instruction are outlined inthis document with emphasis on the role and responsibilitiesof the endoscopy instructors.

Since the relevance and importance of the endoscopyinstructor to the objective of high quality training cannot beoverstated, the Society has endeavored to provide theseindividuals with reSOurces and assistance. Most educationalprograms of the Society are suitable for trainees, includingth Audiovisual Resource Center, the Gastrointestinal En­doscopy Self-Assessment Program (GESAP), and the yearlypostgraduate courses. However, the Society also offers otherdirect assistance to the endoscopy instructor. The TrainingDirectors Workshop (1984 and 1988) is a valuable forum forthe interchange of ideas and discussion of issues and prob­lems. This program will be offered again in 1991. This year,

GASTROINTESTINAL ENDOSCOPY

the Society, with the generous support of the OlympusCorporation, awarded its first scholarship for third tiertraining. One of the major objectives of this progam is anexpansion of the cadre of skilled endoscopy instructors. TheSociety expects that scholarship recipients will eventuallyassume roles that emphasize endoscopic training, research,and treatment of difficult and complex gastrointestinal dis­orders. Two scholarships for advanced training in endoscopywill be awarded in each of the next 2 years.

The Standards of Training and Practice Committee wasdivided into two committees in 1988. One of the majorreasons for this change was a desire to devote more resourcesand expertise to the goal of enhanced training in endoscopy.Chaired by Dr. Jack Vennes, the Standards of TrainingCommittee is now addressing many of the complex issuesdiscussed above. There is a large nucleus of individualswithin the Society who have substantial experience in en­doscopic training, and this newly established committeeprovides an organized framework for the effective use of thiscollective expertise. In this regard, the Society is also work­ing to establish contact with the specific individuals withintraining programs who are responsible for endoscopic in­struction in an effort to create a productive interchange ofknowledge and ideas. In these, and its many other activities,the A/S/G/E will remain steadfast in its commitment to theadvancement of endoscopic training and education.

REFERENCE1. Statement on endoscopic training. Gastrointest Endosc 1988;34

(suppl):12S-3S.

Letters to the Editor

Upper gastrointestinal endoscopy withoutsedation

To the Editor:

We read with interest the recent article by AI-Atrakchi'about upper gastrointestinal endoscopy without sedation.We have been performing upper gastrointestinal endoscopywithout prior sedation in our clinic since December 1986. Atotal of 13,282 upper gastrointestinal endoscopic examina­tions have been performed without prior sedation since then.The possible complications of sedation are well known.Reactions may arise from idiosyncracy or overdose. Medi­cation problems may occur after patients leave the unit;prolonged effects of various sedatives may color judgmentand patients must not drive or operate machinery the sameday. Superficial thrombosis occasionally occurs at injectionsites.2 Gastroscope insertion was performed in our patientswithout difficulty or complication and with good tolerance.The average time needed for each procedure was approxi­mately 10 min.

Although we also use topical pharyngeal anesthesia withlidocaine spray, we do not use atropine or any similar agent,that may affect gastric motility3 and may aggravate glau­coma and cause urinary retention.

We also recommend that upper gastrointestinal endos-

VOLUME 35, NO.6, 1989

copy be performed without sedation and with topical pha­ryngeal anesthesia only. This method is safe, well tolerated,and time saving.

Sedat Boyacioglu, MDBahri Ate~, MD

Fatih Hilmioglu, MDYtJkses ihtisas Hospital

Gastroenterology DepartmentAnkara, Turkey

REFERENCES1. AI-Atrakchi HA. Upper gastrointestinal endoscopy without se­

dation: a prospective study of 2000 examinations. GastrointestEndosc 1989;35:79-81.

2. Cotton PB, Williams CB. Practical gastrointestinal endoscopy,2nd ed. Oxford, UK: Blackwell Scientific, 1981:42.

3. Sleisenger MH, Fordtran JS. Gastrointestinal disease. 4th ed.WB Saunders: 1989:675-709.

Upper gastrointestinal endoscopy withoutprior sedation

To the Editor:

In his recently published article,' Dr. AI-Atrakchi reportsthe results of a prospective study of 2000 examinations andconcludes that upper gastrointestinal endoscopy can besafely performed without prior sedation. We agree with thisconclusion but strongly object to the design of the studyregarding assessment of patient anxiety and tolerance. Al­though the study was planned prospectively, a control groupis lacking. Patient anxiety and tolerance were not assessedby an independent investigator or by the patient, but wereevaluated by the examiner. Basic criteria to obtain unbiasedresults were therefore not met. This study at best repeatsknown empirical facts without adding scientifically ensureddata.

S. Sahm, MDH. Dancygier, MDOffenbach am Main

Federal Republic of Germany

REFERENCE1. AI-Atrakchi HA. Upper gastrointestinal endoscopy without se­

dation: a prospective study of 2000 examinations. GastrointestEndosc 1989;35:79-81.

The "snow white" sign

To the Editor:

In a recent issue, Waring et al.' reported on four asymp­tomatic patients undergoing follow-up colonoscopy for co­lonic neoplasms. They were surprised to find multiple, white,slightly raised adherent lesions in various areas of the colon.Close inspection of their color endophotographs reveals the"snow white" sign, and we speculate their series representsadditional cases of the peroxide (or chemical) colitis that wehave described. 2

Additionally, their photomicrographs depicting intramu­cosal cystic spaces strongly resemble the prominent vacuoles

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