during surveillance colonoscopy subsequent to a preceding "normal" follow-up examination. There are a few new techniques which may render piecemeal polypectomy safer for the average endoscopist. One is the injection of saline into the submucosa beneath the polyp which has been assessed visually to require piecemeal removal. This method was developed in Japan and called the "strip biopsy" technique. 3,4 The saline creates a fluid cushion under the polyp to elevate it away from close apposition to the serosa, making it easier to snare and also safer because of the edematous submucosal cushion. Immediate post-transection bleeding may usually be rapidly controlled with an injection of 1:10,000 epinephrine solution via a sclerotherapy needle directly into the bleeding site. Epinephrine may be added to the saline injection solution, but the Japanese authors have not felt it was necessary. In more than 50 consecutive piecemeal polypectomies using this technique, I have not noted any immediate bleeding. In the series from the Massachusetts General Hospital, 2 bleeding was delayed in the three patients who required transfusions, not occurring until 3 to 13 days after the procedure. This late bleeding is due to the excavation of the zone of coagulation necrosis and is not preventable. Twenty-seven percent of the patients in the authors' series had post-polypectomy colon resections. 2 In spite of their plea that "a careful judgment should be made as to the location of the polyp," sometimes endoscopic localization is inaccurate and the surgeon may not be able to find the site at laparoscopy. There are currently two methods to locate the site at surgery: intra-operative colonoscopy and prior India ink injection. It has been noted that location of a previous polypectomy site is the largest indication for intra-operative colonoscopy.5 This can be circumvented by India ink injection around the site pre-operatively.6 Clips may be used as markers,? but spontaneously dislodge. Vital dyes such as indigo carmine or methylene blue are rapidly absorbed from injection sites. The two articles in this issue1,2 which address important safety issues further illuminate the evolution of polypectomy. The one on small polypsl deserves attention and cautious duplication in a randomized fashion. The one on large polyps 2 gives us the fortitude to attempt removal when the polyp looks benign and when it appears that it may eventually be endoscopically resectable. Jerome D. Wave, MD New York, New York
REFERENCES 1. Tappero G, Gaia E, De Giuli P, Martini S, Gubetta L, Emanuelli
G. Cold snare excision of small colorectal polyps. Gastrointest Endosc 1992;38:310-3. 392
2. Walsh RM, Ackroyd FW, Shellito PC. Endoscopic resection of large sessile colorectal polyps. Gastrointest Endosc 1992;38:303-9. 3. Karita~, Tada ~, Okita K. The successive strip biopsy partial resectIon techmque for large early gastric and colon cancers. Gastrointest Endosc 1992;38:174-8. 4. Karita M, Tada M, Okita K, Kodama T. Endoscopic therapy for early colon cancer: the strip biopsy resection technique. Gastrointest Endosc 1991;37:128-32. 5. Cohen JL, Forde KA. Intraoperative colonoscopy. Ann Surg 1988;207:231-3. 6. Hyman N, Waye JD. Endoscopic four quadrant tattoo for the identification of colonic lesions at surgery. Gastrointest Endosc 1991;37:1:56-8. 7. T.abibian N, Michaletz PA, Schwartz JT, et al. Use of endoscopIcally placed clip can avoid diagnostic errors in colonoscopy. Gastrointest Endosc 1988;34:262-5.
Diagnostic laparoscopy in the era of minimally invasive surgery There is no doubt that the explosive development of laparoscopic cholecystectomy, and its acceptance (indeed, its demand) by the general public, has begun a new era of minimally invasive surgery. This was made abundantly clear at a remarkable conference "Laparoscopy in Diagnosis and Therapy" held in Orlando, Florida in January. Experts from the United States, Europe, and Japan met to discuss an expanding list of actual and potential laparoscopic and thoracoscopic operations, while instrument manufacturers and engineers listened in an attempt to balance new concepts with creative solutions. The question, "Therapeutic Laparoscopy: A New Milestone?" was answered with a resounding "Yes"! At the same time, another question was asked. Are there "decreasing needs for diagnostic laparoscopy?" The answer was "No," but I sensed somewhat less enthusiasm and more ambivalence in the response. All gastroenterologists present noted a decrease in the number of diagnostic laparoscopies they had performed in recent years. The fall-off correlated with the growth of diagnostic imaging methods and ultrasound or computed tomography-directed biopsy. 1 Will the tremendous new interest in therapeutic laparoscopy lead to a resurgence in the performance of diagnostic laparoscopy as well? The gastroenterologist-laparoscopists were unequivocal in their belief that diagnostic laparoscopy has much to offer. Decades of experience have shown that careful inspection of the liver surface and visually directed biopsies by a trained observer can significantly improve the diagnosis and staging of chronic liver disease. Imaging methods are of little value here. Hepatologists more often than not rely primarily on histologic evaluation. Yet it has been amply demonstrated that the sampling error of a percutaneous biopsy can be high. For example, the diagnosis of cirrhosis is missed in the 20% range. 2• 3 This may not have been critically important in the past, but recent GASTROINTESTINAL ENDOSCOPY
therapeutic innovations, including anti-viral therapy and liver transplantation, may make the accurate diagnosis and staging of chronic liver disease much more important. The ability to see much smaller lesions on liver and peritoneal surfaces with laparoscopy, in the range of 1 mm compared with the range of 1 em imaged on ultrasound and CT, gives laparoscopy additional clout in cancer staging. In patients with pancreas cancer and CT scans negative for liver and peritoneal metastases, Warshaw et al. 4 have prospectively documented a 40% incidence of metastatic disease at laparoscopy. Similar results have also been demonstrated in other cancers with a high predilection for liver and peritoneal metastases. In this issue of the journal, Kriplani et al. 5 correctly identified 95% of patients with metastases to liver, peritoneum, and omentum from gallbladder cancer at laparoscopy compared with 51% using ultrasonography. The diagnosis and staging of hepatocellular carcinoma can be greatly improved with laparoscopy.6, 7 In two prospective studies, Brady et al. B,9 have shown the increased diagnostic yield of laparoscopy compared with imaging, particularly in the etiology of ascites of unknown origin. Laparoscopy has also been found to add diagnostic information in patients with fever of unknown origin and in patients with Hodgkin's disease and non-Hodgkin's lymphoma. 1O- 12 In fact, as a general rule, whenever a diagnostic laparotomy is contemplated, with little likelihood of therapeutic benefit or where non-operative therapy would serve equally well, an exploratory laparoscopy should be considered as a first step to minimize morbidity. It is ironic that gastroenterologists, who nurtured and refined diagnostic laparoscopy, seem unlikely to participate widely in the current boom. Perhaps this is a pessimistic outlook, but it was certainly the majority opinion of the group meeting in Orlando. Referral patterns for laparoscopy will be primarily to surgeons, and hospital turf restrictions will make it difficult for gastroenterologists to perform enough procedures to maintain competence. There is already a paucity of laparoscopy training available in gastroenterology fellowship programs in the United States. However, several questions remain to be answered. Gastroenterologists have become skilled at performing laparoscopy in an endoscopy room with conscious sedation and local anesthesia, reducing morbidity and expense. Diagnostic laparoscopy is among the most simple and straightforward endoscopic methods. New instruments and techniques may make diagnostic laparoscopy even easier. Gastroenterologists are likely to continue to play the major role in management of patients with chronic liver disease. Will surgeons learn to perform laparoscopy under local anesthesia? Will they be willing to learn the nuances of laparoscopic VOLUME 38, NO.3, 1992
diagnosis and staging in the various liver disorders where careful observation can add to histology? Surgeons performing laparoscopic therapeutic procedures will certainly have to perform a standardized diagnostic exploration as part of each procedure, just as is currently done during an elective laparotomy. A good laparoscopic atlas, probably compiled by gastroenterologists,13, 14 should be readily accessible in the operating suite. A possibility that seems remote at the moment is that gastroenterologists will develop laparoscopic therapies that are less likely than cholecystectomy to require immediate laparotomy.15 The work of Frimberger16 in performing laparoscopic cholecystotomy is potentially an example, not quite crossing the dividing line of the cystic artery that separates the medical from surgical specialist in the treatment of gallstones. 17 Finally, it has been suggested that joint surgery and gastroenterology training programs be developed to produce a new type of minimally invasive endoscopic specialist. 1B Technical developments in therapeutic laparoscopy seem certain to dazzle us over the next decade. Sorting out what should be done from what can be done must be a major priority, and the benefits of diagnostic laparoscopy must not be overlooked. Charles J. Lightdale, MD New York, New York
REFERENCES 1. Lightdale CJ. Laparoscopy in the age of imaging [Editorial). Gastrointest Endose 1985;31:47-8. 2. Nord HJ. Biopsy diagnosis of cirrhosis: blind percutaneous versus guided direct vision techniques-a review. Gastrointest Endosc 1982;28:102-4. 3. Pagliari L, Rinaldi F, Craxi A, et al. Percutaneous blind biopsy versus laparoscopy with guided biopsy in diagnosis of cirrhosis. A prospective randomized trial. Dig Dis Sci 1983;28:39-43. 4. Warshaw AL, Fernandez-del Castillo C. Pancreatic carcinoma. N Engl J Med 1992;326:455-65. 5. Kriplani AK, Jayant S, Kapur BML. Laparoscopy in primary carcinoma of the gallbladder. Gastrointest Endosc 1992;38: 326-9. 6. Lightdale CJ. Clinical applications of laparoscopy in patients with malignant neoplasms. Gastrointest Endosc 1982;28:99102. 7. Jeffers L, Spieglman G, Reddy R, et al. Laparoscopically directed fine needle aspiration for the diagnosis of hepatocellular carcinoma: a safe and accurate technique. Gastrointest Endosc 1988;34:235-7. 8. Brady PG, Goldshimid S, Chappel G, Stone FL, Boyd WP. A comparison of biopsy techniques in suspected focal liver disease. Gastrointest Endosc 1987;33:289-92. 9. Brady PG, Pebbles M, Goldschmid S. Role of laparoscopy in the evaluation of patients with suspected hepatic or peritoneal malignancy. Gastrointest Endosc 1991;37:27-30. 10. Coleman M, Lightdale CJ, Vinciguerra VP, et al. Peritoneoscopy in Hodgkin's disease. Confirmation of results by laparotomy. JAMA 1976;236:2634-6. 11. Chabner BA, Johnson RE, Young RC, et al. Sequential nonsurgical and surgical staging of non-Hodgkin's lymphoma. Ann Intern Med 1976;85:149-54. 12. Salky BA, Bauer JJ, Gelernt 1M, Kreel I. The use oflaparoscopy in retroperitoneal pathology. Gastrointest Endosc 1988;34:22730.
393
13. Beck KL. Color atlas of laparoscopy. Philadelphia: WB Saunders, 1984. 14. Henning H, Lightdale CJ, Look D. Laparoscopy atlas and textbook. Stuttgart: Thieme (in press). 15. Salky BA, Bauer JJ, Kreel I, Gelernt 1M, Gorfine SR. Laparoscopic cholecystectomy: an initial report. Gastrointest Endosc 1991;37:1-4. 16. Frimberger E. Operative laparoscopy: cholecystotomy. Endoscopy 1989;21:367-72. 17. Classen M. The cystic artery: borderline between internal medicine and surgery [Editorial]. Gastrointest Endosc 1990;36:5336. 18. Cotton PB, Baillie J, Pappas TN, Meyers WS. Laparoscopic cholecystectomy and the biliary endoscopist [Editorial]. Gastrointest Endosc 1991;37:94-7.
From the Rostrum
Intersociety cooperation Men will find that they can prepare with mutual aid far more easily what they need, and avoid far more easily the perils which beset them on all sides, by united forces. Benedict Spinoza
Professional medical societies, unlike most modern commercial corporations, recognize the strengths and advantages of friendly cooperation. Rather than relying solely on individual, often competitive approaches to solving the problems of modern medicine, societies are increasingly joining forces, pooling resources, and attempting to speak with one voice when dealing with major issues. In the past (and occasionally in the present) the medical and surgical gastrointestinal societies often appeared to be more concerned with preserving individual identities and taking credit for successful governmental, clinical, or educational initiatives, than they were for seeking the most effective united approach to common problems. As I begin my term as president of A/S/G/E, I intend to devote special effort to building on 394
the appreciable accomplishments of recent presidents who have successfully pursued greater cooperation with our sister societies. Many may be unaware of the large number of cooperative projects or programs of the past decade. The list is impressive: 1. The three national gastrointestinal medical societies, AGA, ACG, and A/S/G/E, appointed a joint research committee in 1980 for the purpose of addressing issues of the colorectal adenoma and its relationship to colorectal cancer. This committee's deliberations gave birth to the National Polyp Study, a National Cancer Institute funded, multicenter, controlled trial designed to determine the best followup surveillance after resection of colorectal adenomas. This study was completed in 1990, and an impressive number of scientific papers dealing with all aspects of the adenomacancer relationship are currently being published. l 2. The AGA and A/S/G/E conducted the first joint gastrointestinal postgraduate course in the fall of 1985. By joining forces, the two societies provided attendees with a unique blend of basic science, clinically pertinent information, and technical updates. With the confusing myriad of courses currently being offered around the calendar, future combined programs are clearly desirable. 3. The major committees of the medical gastrointestinal societies which deal with clinical, research, training, education, and practice issues have included liaison members from sister societies for many years. This crossover at the committee level is very effective in ensuring that all important interests and concerns are addressed during the development of policies and programs. In addition, A/S/GIE and its sister surgical endoscopic society, SAGES, have frequently interacted over the years in the development of endoscopic training and practice guidelines. 4. In 1988, the A/S/GIE Standards of Training and Practice Committee and the AGA Patient Care Committee collaborated in the writing of the first comprehensive clinical guideline for screening and surveillance of colorectal neoplasms. This guideline, published in JAMA, has been widely accepted and utilized by the general medical community.2 5. The four societies which participated for many y~ars in Digestive Disease Week (AGA, A/S/G/E, SSAT, and AASLD) recently entered into a charter establishing a formal relationship for the government of Digestive Disease Week (DDW). The DDW Council, comprised of officers of each of these societies, now meets biannually to plan and establish policy for this important scientific and educational program. 6. The A/S/GIE and the American Academy of Family Physicians carried out a comprehensive hands-on training program to teach community-based family physicians flexible sigmoidoscopy. A/S/G/E is currently working with the American College of Physicians to develop a similar program for residents in internal medicine. 7. Beginning with DDW 1991, jointly sponsored clinical symposia have been conducted by A/S/G/E and both SSAT and AGA. Topics included colorectal polyps, laparoscopic cholecystectomy, and gastrointestinal bleeding. It is anticipated that these popular programs will lead to an increasing number of collaborative scientific and educational programs in the future, thus reducing the bewildering array of competing sessions during DDW. GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Tappero G, Gaia E, De Giuli P, Martini S, Gubetta L, Emanuelli
G. Cold snare excision of small colorectal polyps. Gastrointest Endosc 1992;38:310-3. 392
2. Walsh RM, Ackroyd FW, Shellito PC. Endoscopic resection of large sessile colorectal polyps. Gastrointest Endosc 1992;38:303-9. 3. Karita~, Tada ~, Okita K. The successive strip biopsy partial resectIon techmque for large early gastric and colon cancers. Gastrointest Endosc 1992;38:174-8. 4. Karita M, Tada M, Okita K, Kodama T. Endoscopic therapy for early colon cancer: the strip biopsy resection technique. Gastrointest Endosc 1991;37:128-32. 5. Cohen JL, Forde KA. Intraoperative colonoscopy. Ann Surg 1988;207:231-3. 6. Hyman N, Waye JD. Endoscopic four quadrant tattoo for the identification of colonic lesions at surgery. Gastrointest Endosc 1991;37:1:56-8. 7. T.abibian N, Michaletz PA, Schwartz JT, et al. Use of endoscopIcally placed clip can avoid diagnostic errors in colonoscopy. Gastrointest Endosc 1988;34:262-5.
Diagnostic laparoscopy in the era of minimally invasive surgery There is no doubt that the explosive development of laparoscopic cholecystectomy, and its acceptance (indeed, its demand) by the general public, has begun a new era of minimally invasive surgery. This was made abundantly clear at a remarkable conference "Laparoscopy in Diagnosis and Therapy" held in Orlando, Florida in January. Experts from the United States, Europe, and Japan met to discuss an expanding list of actual and potential laparoscopic and thoracoscopic operations, while instrument manufacturers and engineers listened in an attempt to balance new concepts with creative solutions. The question, "Therapeutic Laparoscopy: A New Milestone?" was answered with a resounding "Yes"! At the same time, another question was asked. Are there "decreasing needs for diagnostic laparoscopy?" The answer was "No," but I sensed somewhat less enthusiasm and more ambivalence in the response. All gastroenterologists present noted a decrease in the number of diagnostic laparoscopies they had performed in recent years. The fall-off correlated with the growth of diagnostic imaging methods and ultrasound or computed tomography-directed biopsy. 1 Will the tremendous new interest in therapeutic laparoscopy lead to a resurgence in the performance of diagnostic laparoscopy as well? The gastroenterologist-laparoscopists were unequivocal in their belief that diagnostic laparoscopy has much to offer. Decades of experience have shown that careful inspection of the liver surface and visually directed biopsies by a trained observer can significantly improve the diagnosis and staging of chronic liver disease. Imaging methods are of little value here. Hepatologists more often than not rely primarily on histologic evaluation. Yet it has been amply demonstrated that the sampling error of a percutaneous biopsy can be high. For example, the diagnosis of cirrhosis is missed in the 20% range. 2• 3 This may not have been critically important in the past, but recent GASTROINTESTINAL ENDOSCOPY
therapeutic innovations, including anti-viral therapy and liver transplantation, may make the accurate diagnosis and staging of chronic liver disease much more important. The ability to see much smaller lesions on liver and peritoneal surfaces with laparoscopy, in the range of 1 mm compared with the range of 1 em imaged on ultrasound and CT, gives laparoscopy additional clout in cancer staging. In patients with pancreas cancer and CT scans negative for liver and peritoneal metastases, Warshaw et al. 4 have prospectively documented a 40% incidence of metastatic disease at laparoscopy. Similar results have also been demonstrated in other cancers with a high predilection for liver and peritoneal metastases. In this issue of the journal, Kriplani et al. 5 correctly identified 95% of patients with metastases to liver, peritoneum, and omentum from gallbladder cancer at laparoscopy compared with 51% using ultrasonography. The diagnosis and staging of hepatocellular carcinoma can be greatly improved with laparoscopy.6, 7 In two prospective studies, Brady et al. B,9 have shown the increased diagnostic yield of laparoscopy compared with imaging, particularly in the etiology of ascites of unknown origin. Laparoscopy has also been found to add diagnostic information in patients with fever of unknown origin and in patients with Hodgkin's disease and non-Hodgkin's lymphoma. 1O- 12 In fact, as a general rule, whenever a diagnostic laparotomy is contemplated, with little likelihood of therapeutic benefit or where non-operative therapy would serve equally well, an exploratory laparoscopy should be considered as a first step to minimize morbidity. It is ironic that gastroenterologists, who nurtured and refined diagnostic laparoscopy, seem unlikely to participate widely in the current boom. Perhaps this is a pessimistic outlook, but it was certainly the majority opinion of the group meeting in Orlando. Referral patterns for laparoscopy will be primarily to surgeons, and hospital turf restrictions will make it difficult for gastroenterologists to perform enough procedures to maintain competence. There is already a paucity of laparoscopy training available in gastroenterology fellowship programs in the United States. However, several questions remain to be answered. Gastroenterologists have become skilled at performing laparoscopy in an endoscopy room with conscious sedation and local anesthesia, reducing morbidity and expense. Diagnostic laparoscopy is among the most simple and straightforward endoscopic methods. New instruments and techniques may make diagnostic laparoscopy even easier. Gastroenterologists are likely to continue to play the major role in management of patients with chronic liver disease. Will surgeons learn to perform laparoscopy under local anesthesia? Will they be willing to learn the nuances of laparoscopic VOLUME 38, NO.3, 1992
diagnosis and staging in the various liver disorders where careful observation can add to histology? Surgeons performing laparoscopic therapeutic procedures will certainly have to perform a standardized diagnostic exploration as part of each procedure, just as is currently done during an elective laparotomy. A good laparoscopic atlas, probably compiled by gastroenterologists,13, 14 should be readily accessible in the operating suite. A possibility that seems remote at the moment is that gastroenterologists will develop laparoscopic therapies that are less likely than cholecystectomy to require immediate laparotomy.15 The work of Frimberger16 in performing laparoscopic cholecystotomy is potentially an example, not quite crossing the dividing line of the cystic artery that separates the medical from surgical specialist in the treatment of gallstones. 17 Finally, it has been suggested that joint surgery and gastroenterology training programs be developed to produce a new type of minimally invasive endoscopic specialist. 1B Technical developments in therapeutic laparoscopy seem certain to dazzle us over the next decade. Sorting out what should be done from what can be done must be a major priority, and the benefits of diagnostic laparoscopy must not be overlooked. Charles J. Lightdale, MD New York, New York
REFERENCES 1. Lightdale CJ. Laparoscopy in the age of imaging [Editorial). Gastrointest Endose 1985;31:47-8. 2. Nord HJ. Biopsy diagnosis of cirrhosis: blind percutaneous versus guided direct vision techniques-a review. Gastrointest Endosc 1982;28:102-4. 3. Pagliari L, Rinaldi F, Craxi A, et al. Percutaneous blind biopsy versus laparoscopy with guided biopsy in diagnosis of cirrhosis. A prospective randomized trial. Dig Dis Sci 1983;28:39-43. 4. Warshaw AL, Fernandez-del Castillo C. Pancreatic carcinoma. N Engl J Med 1992;326:455-65. 5. Kriplani AK, Jayant S, Kapur BML. Laparoscopy in primary carcinoma of the gallbladder. Gastrointest Endosc 1992;38: 326-9. 6. Lightdale CJ. Clinical applications of laparoscopy in patients with malignant neoplasms. Gastrointest Endosc 1982;28:99102. 7. Jeffers L, Spieglman G, Reddy R, et al. Laparoscopically directed fine needle aspiration for the diagnosis of hepatocellular carcinoma: a safe and accurate technique. Gastrointest Endosc 1988;34:235-7. 8. Brady PG, Goldshimid S, Chappel G, Stone FL, Boyd WP. A comparison of biopsy techniques in suspected focal liver disease. Gastrointest Endosc 1987;33:289-92. 9. Brady PG, Pebbles M, Goldschmid S. Role of laparoscopy in the evaluation of patients with suspected hepatic or peritoneal malignancy. Gastrointest Endosc 1991;37:27-30. 10. Coleman M, Lightdale CJ, Vinciguerra VP, et al. Peritoneoscopy in Hodgkin's disease. Confirmation of results by laparotomy. JAMA 1976;236:2634-6. 11. Chabner BA, Johnson RE, Young RC, et al. Sequential nonsurgical and surgical staging of non-Hodgkin's lymphoma. Ann Intern Med 1976;85:149-54. 12. Salky BA, Bauer JJ, Gelernt 1M, Kreel I. The use oflaparoscopy in retroperitoneal pathology. Gastrointest Endosc 1988;34:22730.
393
13. Beck KL. Color atlas of laparoscopy. Philadelphia: WB Saunders, 1984. 14. Henning H, Lightdale CJ, Look D. Laparoscopy atlas and textbook. Stuttgart: Thieme (in press). 15. Salky BA, Bauer JJ, Kreel I, Gelernt 1M, Gorfine SR. Laparoscopic cholecystectomy: an initial report. Gastrointest Endosc 1991;37:1-4. 16. Frimberger E. Operative laparoscopy: cholecystotomy. Endoscopy 1989;21:367-72. 17. Classen M. The cystic artery: borderline between internal medicine and surgery [Editorial]. Gastrointest Endosc 1990;36:5336. 18. Cotton PB, Baillie J, Pappas TN, Meyers WS. Laparoscopic cholecystectomy and the biliary endoscopist [Editorial]. Gastrointest Endosc 1991;37:94-7.
From the Rostrum
Intersociety cooperation Men will find that they can prepare with mutual aid far more easily what they need, and avoid far more easily the perils which beset them on all sides, by united forces. Benedict Spinoza
Professional medical societies, unlike most modern commercial corporations, recognize the strengths and advantages of friendly cooperation. Rather than relying solely on individual, often competitive approaches to solving the problems of modern medicine, societies are increasingly joining forces, pooling resources, and attempting to speak with one voice when dealing with major issues. In the past (and occasionally in the present) the medical and surgical gastrointestinal societies often appeared to be more concerned with preserving individual identities and taking credit for successful governmental, clinical, or educational initiatives, than they were for seeking the most effective united approach to common problems. As I begin my term as president of A/S/G/E, I intend to devote special effort to building on 394
the appreciable accomplishments of recent presidents who have successfully pursued greater cooperation with our sister societies. Many may be unaware of the large number of cooperative projects or programs of the past decade. The list is impressive: 1. The three national gastrointestinal medical societies, AGA, ACG, and A/S/G/E, appointed a joint research committee in 1980 for the purpose of addressing issues of the colorectal adenoma and its relationship to colorectal cancer. This committee's deliberations gave birth to the National Polyp Study, a National Cancer Institute funded, multicenter, controlled trial designed to determine the best followup surveillance after resection of colorectal adenomas. This study was completed in 1990, and an impressive number of scientific papers dealing with all aspects of the adenomacancer relationship are currently being published. l 2. The AGA and A/S/G/E conducted the first joint gastrointestinal postgraduate course in the fall of 1985. By joining forces, the two societies provided attendees with a unique blend of basic science, clinically pertinent information, and technical updates. With the confusing myriad of courses currently being offered around the calendar, future combined programs are clearly desirable. 3. The major committees of the medical gastrointestinal societies which deal with clinical, research, training, education, and practice issues have included liaison members from sister societies for many years. This crossover at the committee level is very effective in ensuring that all important interests and concerns are addressed during the development of policies and programs. In addition, A/S/GIE and its sister surgical endoscopic society, SAGES, have frequently interacted over the years in the development of endoscopic training and practice guidelines. 4. In 1988, the A/S/GIE Standards of Training and Practice Committee and the AGA Patient Care Committee collaborated in the writing of the first comprehensive clinical guideline for screening and surveillance of colorectal neoplasms. This guideline, published in JAMA, has been widely accepted and utilized by the general medical community.2 5. The four societies which participated for many y~ars in Digestive Disease Week (AGA, A/S/G/E, SSAT, and AASLD) recently entered into a charter establishing a formal relationship for the government of Digestive Disease Week (DDW). The DDW Council, comprised of officers of each of these societies, now meets biannually to plan and establish policy for this important scientific and educational program. 6. The A/S/GIE and the American Academy of Family Physicians carried out a comprehensive hands-on training program to teach community-based family physicians flexible sigmoidoscopy. A/S/G/E is currently working with the American College of Physicians to develop a similar program for residents in internal medicine. 7. Beginning with DDW 1991, jointly sponsored clinical symposia have been conducted by A/S/G/E and both SSAT and AGA. Topics included colorectal polyps, laparoscopic cholecystectomy, and gastrointestinal bleeding. It is anticipated that these popular programs will lead to an increasing number of collaborative scientific and educational programs in the future, thus reducing the bewildering array of competing sessions during DDW. GASTROINTESTINAL ENDOSCOPY
