of pancreatic pseudocysts and concluded that it should be agood method of treatment in high risk patients or in casesof previous surgical failure.

Between March 19802 and December 1985, we had theopportunity to perform an endoscopic cystoduodenostomy(ECD) for 13 patients and a cystogastrostomy (ECG) forfive patients, leaving a transnasal drain in the cyst forseveral days. Cystoduodenostomy was performed for painfulpancreatic cysts protruding into the second portion of theduodenum and occurring in patients with chronic pancrea­titis. Disappearance of the cyst was observed in 12 cases(Fig. 1). After a median follow-up of 16 months, we observedtwo cases of relapsing pain and cysts, which were success­fully treated by another ECD.

Endoscopic cystogastrostomy, performed for large retro­gastric pseudocysts, was followed by total regression in threecases without recurrence; in the first case, surgery wasnecessary to achieve complete drainage, and in the last one,which concerned a patient with three communicating cysts,total regression occurred after the addition of percutaneousexternal drainage.

We did not observe any complications in either the ECDsor the ECGs. When the cysts are accessible, this type ofendoscopic management is safe and less invasive than sur­gery. Therefore, this treatment need not be restricted topoor risk patients and, indeed, has become our first step forthe management of pancreatic pseudocysts.

M. Cremer, MDJ. Deviere, MD

Department of GastroenterologyULB Hopital Erasme

Brussels, Belgium

REFERENCES1. Kozarek RA, Brayko CM, Harlan J, Sanowski RA, Cintora I,

Kovac A. Endoscopic drainage of pancreatic pseudocysts. Gas­trointest Endosc 1985;31:322-8.

2. Cremer M. Cystoduodenostomy. Proceedings of the Third Sym­posium of Digestive Endoscopy. Paris, May 29 and 30, 1981.

Ponsky catheter

To the Editor:

Recently, we have had difficulty with the use of a Medi­tech PEJ catheter (Ponsky catheter #324, American Endos­copy Co., Inc., 7150 Hard Street, Mentor, Ohio 44067). Thisinformation will, I suspect, be valuable to those who may beconsidering use of this device.

This new catheter employs a 20 F mushroom catheterwhich contains two 8 F inner catheters. One serves as ajejunostomy tube and the other as a gastrostomy tube. Thedilating stilette used in the placement of this catheter is thestandard 16 F Medicath catheter. When we pulled the 20 Fmushroom catheter through the abdominal puncture site,significant tension was placed on the mushroom catheterand it stretched. As it stretched, the inner plastic catheterswere pulled farther into the mushroom catheter. The tensionwas relaxed, the mushroom catheter contracted to its formersize, but the plastic catheters within it coiled and became

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kinked and obstructed. In our patient, the catheter had tobe removed.

I think that some modification needs to be made in theconstruction of this catheter and the manner in which it isplaced if it is to be used effectively.

Martin S. Kleinman, MDRochester, New York

Response to Dr. Kleinman's letterregarding the PEJ catheter

To the Editor:

The problem described by Dr. Kleinman seems to havebeen produced during the insertion of the catheter ratherthan in the production. In any event, obstruction of thefeeding port should not prove dangerous to the patient. Thissituation, while frustrating, may be remedied in a numberof ways. The tube may be left in place for a week or so andthe tract allowed to mature. It may then be replaced withanother tube.

Tubes for percutaneous gastrostomy and jejunostomy, likethe procedures themselves, are very new and will requireconstant improvement and development. Comments fromthe users to the manufacturers are extremely important andmust be encouraged if we are to arrive at the ideal solution.

Jeffrey L. Ponsky, MD, FACSDepartment of Surgery

Case Western Reserve UniversitySchool of Medicine

Cleveland, Ohio

Comments on endoscopic TV editorial

To the Editor:

The editorial by Graham et al. in the February 1986 issueentitled "Endoscopic Television: Traditional and Video En­doscopy") provides a concise analysis of our newest modalityfor imaging the gastrointestinal tract. With a quick, deftstroke, they have brushed aside the preliminary misconcep­tions engendered by "television" endoscopy and focusedattention upon the essence of video endoscopy: the digitalimage. By utilizing this computer-generated image we havenow transformed our visualization of the gastrointestinaltract into a form of information which offers boundlessopportunity. Because it is digital information (computerdata, if you wish), this new mode of viewing the gastrointes­tinal tract is placed smack in the middle of the vast computerrevolution. Therefore, capabilities enumerated by Grahamet al. represent but a few of the possibilities of this infantsystem.

The following is a partial list of capabilities that videoendoscopy could, with the appropriate software control,perform alone or integrated with any or all of the otherfunctions: (1) video enhancement to intensify and/or subduecertain elements of the image to make subtle differencesreadily apparent; (2) video magnification to "zoom in" ondetails and "blow up" a small area to full screen size; (3)

GASTROINTESTINAL ENDOSCOPY