Drs. Reisberg and Mabee are commended for their ap­preciation of observations made by past workers and theirapplication of old methods to new techniques.

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our readers respond

The bobbin' polyp

Occasionally the radiologist can identify a lipoma of thecolon because they are radiolucent and may change con­tour during a barium enema examination. 1 More often, thelipoma cannot be differentiated from other polypoid neo­plasms of the large bowel.

The endoscopist may suspect a lipoma when the polypis very smooth and is covered by a normal-appearingmucosa, and when there is a "sliding" sensation with thebiopsy forceps as they tug the mucosa over the submucosalfatty tumor. The biopsy is seldom deep enough to obtainfat and confirm the diagnosis.

Electrosnare removal of the lipoma may be performed.2

I have noticed that a lipoma will float in the fixative (Figure1) because the density of the fat-filled polyp is less thanthat of the fluid. The endoscopist can be certain the"bobbin' polyp" is a lipoma. Malignant degeneration of alipoma might also give the "bobbin' polyp sign," but Ihave not encountered one of these rare tumors.

Robert G. Norfleet, MDMarshfield Clinic

Marshfield, Wisconsin 54449

Figure 1. A lipoma floats onthe surface of fixative solution.

REFERENCES1. BERK RN, WERNER LG: Lipoma of the colon. Am j Gastroenterol

61 :145, 19742. WAVE jD, FRANKEL A: Removal of a pedunculated lipoma by

colonoscopy. Am j. Gastroentero/61:221, 1974

VOLUME 25, NO. 1, 1979

Para-endoscopic snaring

When confronted with the need to remove an acciden­tally ingested pencil from a patient's stomach, I improviseda method of retrieval that may be of further use.

In this instance, the only endoscope available was theOlympus GIF, and the only snare was a colonoscopic snare(Olympus SD1U). After passing the endoscope and visu­alizing the long (12 cm) pencil fragment, I found that thesnare would not fit through the biopsy channel of theendoscope. I found it easy, however, to pass the sheathedsnare perorally along the previously positioned endoscope.

When the tip of the snare was visualized inside thestomach, the snare loop was opened and the wire wasgrasped lightly using forceps passed through the endo­scope's biopsy channel. This enabled easy and accurateplacement of the wire snare over the foreign object. Theendoscope and wire snare with attached pencil were thenwithdrawn simultaneously.

I have since had occasion to remove foreign objects witha snare fitting through the biopsy channel, and I am alsoaware of the "pick-a-back" method of attaching accesso­ries to the endoscope. I am impressed, though, that havingthe snare free of the endoscope offers some advantage inmanipulation of the snare, in visualization of the foreignobject as it is withdrawn, and possibly in better control ofits passage from esophagus through the hypopharynx. Ob­viously, care must be taken not to use force in passing thesnare.

Barton L. Smith, MD301 South 7th Avenue, Suite 330

West Reading, Pennsylvania 19611

book reviews

Endoscopic Sphincterotomy of the Papilla of Vater

edited by Ludwig Demling and Meinhard ClassenGeorg Thieme Publishers, Stuttgart, and PSG Publishing Com­pany, Massachusetts, 1978. 100 pps., 102 i1lus.

In March 1976 a workshop on endoscopic sphincterot­omy of the papilla of Vater was held in Munich, WestGermany. This publication represents a summary of thematerial presented at these meetings, and the editors haveorganized the papers from the 37 contributors into a con­cise but comprehensive review of this new procedure.

The 100-page publication is divided into 17 chapters.The first 4 chapters are concerned with papillary anatomy,pathophysiology, radiography, and manometry. Chapters5 through 7 deal with the surgical approach to diseases ofthe papilla of Vater, and chapters 8 through 12 discuss themulticenter (9) German experience (556 cases) with theindications, technique, results, and complications of en­doscopic papillotomy. The final 5 chapters present aninternational review of the preliminary experience withendoscopic papillotomy in Japan (36 cases), USA (63 cases).Belgium (82 cases), Italy (8 cases), and England (86 cases).The text is supplemented by 84 figures and 18 tables which

29

abstractsof interest

to endoscopists

are of excellent quality. Although there has been a tremen­dous increase in the world experience with endoscopicpapillotomy since 1976, it is interesting that the data pre­sented in this monograph are essentially the same as re­ported at the 1977 conference which reviewed a Germanexperience that had tripled in 1 year.

This publication should be extremely useful to the manyphysicians just beginning to perform endoscopic papillo­tomy and will be of interest to all physicians desiring aclear, concise review of this exciting new procedure.

Otto T. Nebel, MD530 Lomas Santa Fe Drive

Solana Beach, California

Through the Alimentary Canal with Gun and Camera

by George S. ChappellFrederick A. Stokes Company, New York, 1930. 231 pps.

Breathes there an endoscopist with wit so dull that hehas not jocularly referred to his craft as venturing "throughthe alimentary canal with gun and camera"? More likelyhe has added, "with rod, gun, and camera." Yes, friends,there actually is a book by this title, an almost forgottencopy of which was resurrected and presented to me re­cently by a thoughtful patient. I knew that such a treatisehad been published, but I had not seen or read an actualcopy. Although it was written in the era of Dr. RudolfSchindler's epochal efforts, the book contains no referenceto endoscopy. Rather, it is a fanciful account of miniatur­ized men exploring the marvels of the human interior. It isintended as a blatant spoof, and it succeeds hilariously.

Nevertheless, the book provides insight for the endos­copist. The patient's point of view is suggested by theauthor when he points out, "It is true; one never feelsquite the same towards a person who has looked one'sliver squarely in the eye." Laparoscopists, take note.

The author's esthetic sensitivity is evident in his lament:"Would that I could convey to my readers the disarmingbeauty of that stately temple, the Esophagus, which standsin all its grandiose majesty at the headwaters of the Ali­mentary Canal." Then we are given what might be adescription of traumatic esophagitis: "Terrible they are, incolor and texture, like rubescent liver splotched with grayfungoids, the vertical ridges and serrations being deeplyscarred by horizontal grooves where some clumsily han­dled bolus has scraped the sides." Medical records wouldbe richer if we waxed as rhapsodic when composing theprotocols of our own peroral peregrinations.

The reader is rewarded by perceptive accounts of sys­tems other than digestive. In Cardiac County, the authorhas the good fortune to meet "Systole and Diastole, con­tracting and expanding engineers at the pumping stationat Hartsdale, who have been running it, man and boy, eversince it was built." Farther along, our narrator tells us ofhis explorations in the nerve forests of the Lumbar Regionand observes, "It is necessary to keep nerve forests in trim(nerves should never be allowed to run wild)." He findsthat "order is kept by lumbarjacks who tie the loose nervetwigs with short lengths of spinal cord." This is the author'scontorted explanation of the frequently heard complaint,''I'm just a bundle of nerves!" Not neglected is a visit toEast and West Kidney, "the country being magnificently

30

watered with many fine streams of which the most impor­tant is the Hilus, which feeds the enormous reservoir ofBladivostock." The author concludes with a faithful reportof a gathering of the glandsmen of the Pancreatic leaguewhere the entertainment featured a performance by Mlle.Trypsin, danseuse-du-ventre, and a sailors' chorus singing,"Oh Stimuli, Oh Stimula."

Aside from outrageous plays on place names, not a bitof the anatomy described would be recognized by Gray,and the liberty taken with physiology would get the Bestof Taylor. But, then, who worries about actualities whenbeing regaled by an account such as this?

W. S. Haubrich, MDDivision of Gastroenterology

Scripps Clinic and Research FoundationLa lolla, California

l'im p ses

EdItor for Abstracts

BERNARD M. SCHUMAN, MD

Influence of age and previous use on diazepam dosagerequired for endoscopy.

GILES HF, MACLEOD SM, WRIGHT JR, SELLERS EMCan Med Assoc 1118:513-523, 1978

In 19 patients, a 22-fold variation was observed in theintravenous dose of diazepam necessary as preparation forendoscopy (median dose, 20 mg; range 5 to 110 mg).Analysis of plasma samples for diazepam and N-desme­thyldiazepam revealed that the clinical response did notrelate to the rate or character of initial drug distribution.There was a high correlation between the dose and theplasma concentration 10 minutes after administration.Users of diazepam displayed tolerance to its pharmacologiceffects, requiring a significantly larger dose than nonusers(median doses, 35.0 mg and 14.5 mg, respectively). Olderpatients required less than younger patients.

X-ray examination or endoscopyl A blind prospectivestudy including barium meal, double contrast examination,and endoscopy of esophagus, stomach, and duodenum.

HEDEMAND N, KRUSE A, MADSEN EH, MATHIASEN MSGastrointest RadioI1:331-334, 1977

One hundred-and-one consecutive patients with upperabdominal dyspepsia were examined by conventional bar­ium meal, double-contrast examination, and endoscopy ofthe stomach and the duodenum in a blind prospectiveinvestigation. Only small differences between the sensitiv­ity and the specificity of the methods were found, but thefalse-positive and the false-negative errors of the 3 meth­ods of examination were not the same. The sensitivity ofthe barium meal examination was sufficiently high forprimary screening, but supplementary gastroscopy is nec­essary to increase diagnostic specificity in the stomach.

GASTROINTESTINAL ENDOSCOPY