1893 Non-Surgical Endoscopic Management of a Sealed Nail Perforation in the Gastric Antrum

Abstract

INTRODUCTION: Foreign body ingestions are most commonly seen in children, elderly adults, and patients with psychiatric conditions. Perforation is a feared complication, often requiring surgical intervention. We present a case of endoscopic removal of a sealed nail perforation with an over-the-scope clip closure in a patient who was a high-risk surgical candidate. CASE DESCRIPTION/METHODS: A 48-year-old homeless male with a history of multiple abdominal surgeries due to gunshots and stab wounds complicated by abdominal hernias presented with 1 week of abdominal pain after drinking an open bottle of soda. Vital signs were stable on presentation. Labs were unremarkable. Computed tomography (CT) revealed a needle-like foreign body in the antrum of the stomach that appeared to project beyond the lumen without signs of pneumoperitoneum free perforation or fluid (Figure 1). An upper endoscopy was performed to further characterize the foreign body. Upon entering the stomach, a 2mm round metallic circular object (Figure 2) was visualized along the lesser curvature of the antrum, suggestive of a nail embedded into the gastric antrum. General surgery was consulted given concern for perforation, however, the patient was deemed a high-risk surgical candidate due to hostile abdominal scarring. The decision was made for endoscopic repair of the nail perforation. On repeat endoscopy, the nail was again visualized in the lesser curve of the antrum; rat-tooth forceps were used to remove a 2.8cm rusty nail (Figure 3) which was safely pulled through an overtube. The scope was reinserted with an over-the-scope clip attached, which was then successfully deployed at the site of perforation. Patient tolerated the procedure well with no signs of peritonitis and follow-up CT four days post-procedure showed the clip in place. DISCUSSION: Complications such as perforations and abscesses occur in less than 1% of foreign body ingestions. The most common sites of perforation are the ileocecal valve and other points of intestinal angulations. There are limited cases in the literature of endoscopic intervention in a sealed nail perforation in the stomach in an adult. We found that an over-the-scope clip was effective in sealing a small perforation without evidence of peritonitis on follow-up examinations. Coordination with the surgical service is important in endoscopic repair of perforations. Overall, endoscopic removal of a sealed nail perforation is a viable option for high-risk patients.