Response

Abstract

We would like to thank Dr Cyrany and colleagues for bringing to our attention their case of a bleeding collateral splenic artery. Their video showed that they had a spurting artery, which they occluded with clips and cyanoacrylate. The splenic artery obstruction was caused by a previous glue injection, and their current attempt resulted in splenic embolism because of glue spreading into the spleen. These findings support our conclusions that care should be taken to avoid injecting arterial malformations supplying the spleen. Although they were able to stop the bleeding with glue injection around or into the collateral arteries, their intervention was associated with splenic embolism and supports our suggestion to use imageguided arterial embolism with a solid medium.We read with great interest the recent American Society for Gastrointestinal Endoscopy guideline of "Endoscopy by non-physicians" in which the authors concluded that "there are insufficient data to support non-physician endoscopists to perform colonoscopy and upper endoscopy, level 3 (expert opinion only)." 1 We respectfully disagree with such a recommendation. In 2003, in the pages of the Journal, we reported that nurse endoscopists, using colonoscopes, were able to reach the cecum safely in patients who were scheduled to have only a sigmoidoscopy for colorectal screening. 2 The preamble of the guideline claimed that the medical literature was searched using PubMed; yet, a search using the keywords nurse and colonoscopy yielded a number of studies reporting the outcomes of nurses performing colonoscopy. 2-6 For readers to critically appraise, reproduce, and perhaps update the guidelines, it would be useful if such guidelines included the search details (database, keywords used, and period of search). We are concerned that, in an era of increased need for colorectal cancer screening and subsequent surveillance, the role and potential of nurse colonoscopists might have been minimized by an incorrect level-3 recommendation, instead of being capitalized upon as a precious resource.