POINT OF VIEW Fibergastroscopy: Fact and Fiction DAVID KATz, M.D.

N THE July issue of T h e American Journal of Digestive Diseases, Drs. Waye, Pittman, and Krueger detailed the lack of necessity for gastric aspiration prior to the performance of fibergastroscopy. I should like to question certain statements which were made and take the opportunity to comment on the present status of fibergastroscopy. I shall make use of a preliminary compilation of statistics from a questionnaire on fibergastroscopy that has been circulated among members of the American Society for Gastrointestinal Endoscopy. The authors contend that "gastric aspiration has traditionally preceded endoscopic procedures" and that "complete evacuation of the normal pool of gastric contents has been necessary because of the nature of the endoscopic instruments." One must concede that tradition initially dictated the use of Ewald tube aspiration prior to gastroscopy. By 1952, my own training experience 2 suggested omission of gastric aspiration. Our present group annually performs more than 400 elective standard gastroscopies (and 100 elective fibergastroscopies) without prior aspiration; we have even handled a group of acute bleeders without using aspiration immediately prior to gastroscopy.3 Our contact with other endoscopic groups suggests that aspiration prior to elective gastroscopy is no longer a universally used procedure. Waye et al. further state that "the advent of fiber optic instrumentation has allowed clearer and more adequate inspection of the stomach." On the contrary, a lens system instrument allows clearer views. Still photographs taken through standard gastroscopes by experts such as Smith and Nelson are far superior to still photographs taken through the fiberscope. The manufacturers of the instrument used by Waye et al. collaborated with me in a similar manner to produce a lens esophageal telescope that--by their own admission--takes clearer still and motion picture#, 5 than does the LoPresti fiberesophagoscope, which they also manufacture. As to the question of "more adequate inspection of the stomach" by the fibergastroscope: of those questionnaire respondents experienced in performing fibergastroscopic examinations, the first 59 individuals answered the question "Does the ffbergastroscope visualize proximal stomach well?" as outlined in Question 1. Thirty answered that it did not 50% or more of the time; 5 claimed it never permitted good visualization of the proximal stomach. (These are the replies of only those individuals who claimed familiarity with

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using the fiherscope.) I,Vould 50c71o of examiners fanfiliar with the Eder-Palmer standard gastroscope claim that the instrument did not visualize the proximal stomach well 50% of the time? \,Vould 5% claim it never visualized the proximal stomach well? In all fairness one must allow that the fiberscope does permit good visualization of the distal stomach, and this question was not posed. Recalling the initial hopes for the instrument as a duodenoscope, we did ask " H o w often have you entered d u o d e n u m with the fibergastroscope?" Of the 59 rel)lies, .t3 indicated no entry at any time, while only 3 individuals suggested entry 50% or more of the time (Question 2). Incidentally, .18 of the 59 individuals responding used the A.C.M.L instrument, the one Waye and his co-workers utilized. Since it seems readily evident that the fibergastroscope has serious failings as a duodenoscope, what were the feelings of our respondents with regard to the use of the fiberscope for routine gastroscopy (Question 3) ? It would seem that there is no agreement. Most of the older endoscopists adhere to the standard instrument while most of the younger workers favor the fiberscope. Only one reply suggested that an examiner used both procedures at every examination! How rational is his approach when one realizes that most individuals utilizing the fiberscope admit it fails badly in visualizing the proximal stomach, while the standard instrument cannot visualize the antrum or pylorus! Indeed, this was the conclusion of the panel held at the recent American Society for Gastrointestinal Endoscopy meeting at Colorado Springs - - n o single gastroscope can be utilized as a complete instrument. G T h e r e is a final question as to the safety of the fibergastroscope in comparison to the standard gastroscope (Question 4). Drs. lVaye, Pittman, and Krueger state that maneuvering the patient "was never attended with any patient discomfort or fish" (italics mine). Of course one does not know for certain whether fibergastroscopic perforations are induced at introduction or during a p r o c e d u r e - - b u t preliminary findings of the questionnaire suggest that in the hands of the expert members of the society the fibergastroscope is less safe than the standard gastroscope. One should mention that the society has 287 O UI'ISTION 1. DOES T H E I;IBERGASTROSCOPE VIS[T.kI,IZE P R O X I M A L S T O M A C H 1VEI,I,?

( ) U E S T I O N 2. H O W O F T E N HAVE YOU I.;NTEREI) D U O D E N I I M 1VITH T H E FIBERGASTROSCOPE?

c~- of the time

No.

% of the time

No.

100% q0-99 75-89 50-74 25-49 10-24 5-9 0

5 2 22 8" 9

76-1 O0 75 ,'5O 2~ 10 5 1-4 0

0 2 1 1 6 2 4 43

8 0 5

*All 8 hi(floated 50%.

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Fibergas÷roscopy QUESTION 3. IN W H A T PERC E N T A G E OF G A S T R O SCOPIES DO YOU NOW USE T H E FIBERGASTROSCOPE?

% 0

1-4 5-9 10-24 25~9 50-74 75-89 90-99 100

QUESTION 4, W H A T HAS BEEN T H E AMOUNT OF GASTROSCOPIC MORBIDITY AND MORTALITY?*

Fiber Gaslro.scol)y No. %

No. 24 2 4 5 0 6* 7 17 20

*All 6 indicated 50%,

No. per formed Perforations Deaths (from perforations) Other accidents Other deaths Over-all morbidity Over-all mortality

21,939 17 6 2 0

.077 .027 .0091 .0861 .027

Standard Gaslroscopy No. % 107,255 51 4 10 I

.048 .0037 .0093 ,0009 .0573 .00 t63

*There was a total of 90 responses.

rnembers but tllat t h o u s a n d s o[ fiberscopes have been s o l d - - t h e exact a m o u n t has not been obtained from company sources. It raay be that tile true morbidity and mortality statistics for tile bullet-nosed fiberscope are higher in tile hands or n o n e x p e r t examiners, i am personally aware o[ deaths caused by fiberscopic t)erforations which occmred as instruments were being used by practitioners not affiliated with the Society. None of these deaths has been reported. In conclusion, I should like to emphasize the following: 1. Gastric aspiration is probably unnecessary as a preliminary to the performance of gastroscopy, be it standard gastroscopy or fibergastroscopy. 2. T h e view obtained through the standard gastroscope is clearer than that obtained through the fiberscope. A lens instrument gives a clearer view than a fiber instrument. 3. T h e fibergastroscope, in the consensus of those using it, allows imperfect visualization of the proximal stomach. T h e same group suggests it rarely (i[ ever) visualizes the d u o d e n u m . 4. T h e fibergastroscope, though relatively safe in the hands of experts, may be more dangerous than tim standard gastroscope. 5. T h e r e is no gastroscope that can be used to inspect the whole stomach. If one does not utilize b o t h standard and fibergastroscopes in the same individual, one cannot he reasonably certain that a complete examination of the stomach has been doue. If one is interested only in the proximal stomach, the standard gastroscope should be used. Conversely, the fibergastroscope rei,,ns supreme in the examination of a n t r u m and prepyloric regions. A practical duodeuoscope has not as yet been developed. 120 E. Prospect St. Mr. Vernon, N. Y. 10550

REFERENCES I. KATZ, D. "Preliminary Report of a Questionnaire on Eiberendoscopy." Presented at the Annual Meeting of the American Society for Gastrointestinal Endoscopy, Colorado Springs, Colo., May 24, 1967.

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Ka~ 2. SELESNICK,S., and KATZ, D. A clinical appraisal of gastroscopy. Conn Med 58:31; 351, 1958. 3. KATZ, D., SIrGEL, H., and SUSSMAN, H. Gastric biopsy in acute upper gastrointestinal hemorrhage and controls: Histological confirmation of erosive gastritis seen gastroscopically (Abst.). Gastroenterology 50:852, June 1966. 4. KATZ, D. "A New Telescope for Esophagoscopic Cinematography." Presented at the Annual Meeting of the American Society for Gastrointestinal Endoscopy, Chicago, Ill., 1966. 5. KAax, D. "Cinematography as an Aid in the Diagnosis of Peptic Esophagitis." Presented at the Annual Meeting of the American Society for Gastrointestinal Endoscopy, Colorado Springs, Colo., May 24, 1967. 6. BROWN,C. H., PALMrR, E. D.. COLCHEa, H., LO PRESTI, P., RmER, J. A., and MORR~SEY,J. F. "Panel on Endoscopic Instrumentation." Presented at the Annual Meeting of the American Society for Gastrointestinal Endoscopy, Colorado Springs, Colo., May 24, 1967.

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