Drs. Reisberg and Mabee are commended for their appreciation of observations made by past workers and their application of old methods to new techniques.
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The bobbin' polyp Occasionally the radiologist can identify a lipoma of the colon because they are radiolucent and may change contour during a barium enema examination. 1 More often, the lipoma cannot be differentiated from other polypoid neoplasms of the large bowel. The endoscopist may suspect a lipoma when the polyp is very smooth and is covered by a normal-appearing mucosa, and when there is a "sliding" sensation with the biopsy forceps as they tug the mucosa over the submucosal fatty tumor. The biopsy is seldom deep enough to obtain fat and confirm the diagnosis. Electrosnare removal of the lipoma may be performed. 2 I have noticed that a lipoma will float in the fixative (Figure 1) because the density of the fat-filled polyp is less than that of the fluid. The endoscopist can be certain the "bobbin' polyp" is a lipoma. Malignant degeneration of a lipoma might also give the "bobbin' polyp sign," but I have not encountered one of these rare tumors. Robert G. Norfleet, MD Marshfield Clinic Marshfield, Wisconsin 54449
Para-endoscopic snaring When confronted with the need to remove an accidentally ingested pencil from a patient's stomach, I improvised a method of retrieval that may be of further use. In this instance, the only endoscope available was the Olympus 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 the snare would not fit through the biopsy channel of the endoscope. I found it easy, however, to pass the sheathed snare perorally along the previously positioned endoscope. When the tip of the snare was visualized inside the stomach, the snare loop was opened and the wire was grasped lightly using forceps passed through the endoscope's biopsy channel. This enabled easy and accurate placement of the wire snare over the foreign object. The endoscope and wire snare with attached pencil were then withdrawn simultaneously. I have since had occasion to remove foreign objects with a snare fitting through the biopsy channel, and I am also aware of the "pick-a-back" method of attaching accessories to the endoscope. I am impressed, though, that having the snare free of the endoscope offers some advantage in manipulation of the snare, in visualization of the foreign object as it is withdrawn, and possibly in better control of its passage from esophagus through the hypopharynx. Obviously, care must be taken not to use force in passing the snare. Barton L. Smith, MD 301 South 7th Avenue, Suite 330 West Reading, Pennsylvania 19611
book reviews Endoscopic Sphincterotomy of the Papilla of Vater edited by Ludwig Demling and Meinhard Classen Georg Thieme Publishers, Stuttgart, and PSG Publishing Company, Massachusetts, 1978. 100 pps., 102 i1lus.
Figure 1. A lipoma floats on the surface of fixative solution.
REFERENCES 1. BERK RN, WERNER LG: Lipoma of the colon. Am j Gastroenterol 61 :145, 1974 2. WAVE jD, FRANKEL A: Removal of a pedunculated lipoma by colonoscopy. Am j. Gastroentero/61:221, 1974 VOLUME 25, NO. 1, 1979
In March 1976 a workshop on endoscopic sphincterotomy of the papilla of Vater was held in Munich, West Germany. This publication represents a summary of the material presented at these meetings, and the editors have organized 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. Chapters 5 through 7 deal with the surgical approach to diseases of the papilla of Vater, and chapters 8 through 12 discuss the multicenter (9) German experience (556 cases) with the indications, technique, results, and complications of endoscopic papillotomy. The final 5 chapters present an international review of the preliminary experience with endoscopic 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
,
/' /Je f lexe,s ,-
/,-/ /"./
,,"
J'
/'
our
'\
,-
, " " ,,,'-,,,"
"""./ ,-/
./
readers
,/'
,\"
respond
The bobbin' polyp Occasionally the radiologist can identify a lipoma of the colon because they are radiolucent and may change contour during a barium enema examination. 1 More often, the lipoma cannot be differentiated from other polypoid neoplasms of the large bowel. The endoscopist may suspect a lipoma when the polyp is very smooth and is covered by a normal-appearing mucosa, and when there is a "sliding" sensation with the biopsy forceps as they tug the mucosa over the submucosal fatty tumor. The biopsy is seldom deep enough to obtain fat and confirm the diagnosis. Electrosnare removal of the lipoma may be performed. 2 I have noticed that a lipoma will float in the fixative (Figure 1) because the density of the fat-filled polyp is less than that of the fluid. The endoscopist can be certain the "bobbin' polyp" is a lipoma. Malignant degeneration of a lipoma might also give the "bobbin' polyp sign," but I have not encountered one of these rare tumors. Robert G. Norfleet, MD Marshfield Clinic Marshfield, Wisconsin 54449
Para-endoscopic snaring When confronted with the need to remove an accidentally ingested pencil from a patient's stomach, I improvised a method of retrieval that may be of further use. In this instance, the only endoscope available was the Olympus 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 the snare would not fit through the biopsy channel of the endoscope. I found it easy, however, to pass the sheathed snare perorally along the previously positioned endoscope. When the tip of the snare was visualized inside the stomach, the snare loop was opened and the wire was grasped lightly using forceps passed through the endoscope's biopsy channel. This enabled easy and accurate placement of the wire snare over the foreign object. The endoscope and wire snare with attached pencil were then withdrawn simultaneously. I have since had occasion to remove foreign objects with a snare fitting through the biopsy channel, and I am also aware of the "pick-a-back" method of attaching accessories to the endoscope. I am impressed, though, that having the snare free of the endoscope offers some advantage in manipulation of the snare, in visualization of the foreign object as it is withdrawn, and possibly in better control of its passage from esophagus through the hypopharynx. Obviously, care must be taken not to use force in passing the snare. Barton L. Smith, MD 301 South 7th Avenue, Suite 330 West Reading, Pennsylvania 19611
book reviews Endoscopic Sphincterotomy of the Papilla of Vater edited by Ludwig Demling and Meinhard Classen Georg Thieme Publishers, Stuttgart, and PSG Publishing Company, Massachusetts, 1978. 100 pps., 102 i1lus.
Figure 1. A lipoma floats on the surface of fixative solution.
REFERENCES 1. BERK RN, WERNER LG: Lipoma of the colon. Am j Gastroenterol 61 :145, 1974 2. WAVE jD, FRANKEL A: Removal of a pedunculated lipoma by colonoscopy. Am j. Gastroentero/61:221, 1974 VOLUME 25, NO. 1, 1979
In March 1976 a workshop on endoscopic sphincterotomy of the papilla of Vater was held in Munich, West Germany. This publication represents a summary of the material presented at these meetings, and the editors have organized 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. Chapters 5 through 7 deal with the surgical approach to diseases of the papilla of Vater, and chapters 8 through 12 discuss the multicenter (9) German experience (556 cases) with the indications, technique, results, and complications of endoscopic papillotomy. The final 5 chapters present an international review of the preliminary experience with endoscopic 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
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