A novel approach to retrieve a retained wireless video capsule in an unknown location, which has been asymptomatic for 21months and review of the literature.

Abstract

Dear Editor: Video capsule endoscopy (CE) is a safe, innovative tool, and its indications are continuing to expand in examining and diagnosing gastrointestinal (GI) system pathologies especially small bowel disease. It was first introduced by Iddan in 1999 [1] and was approved by the US Food and Drug administration in 2001 for evaluation of occult GI bleeding, overt bleeding without a cause, or chronic unexplained GI blood loss [2]. Since then, the indications are broadening, and it’s use include evaluation of Crohn’s disease (CD) as well as the response to treatment, surveillance of inherited polyposis syndromes, unexplained abdominal pain, malabsorption syndromes, abnormal small bowel imaging, suspected tumor recurrence, and even evaluation of strictures [3]. Capsule retention is one of the most common complications of CE. There is no consensus as to how to best retrieve a retained capsule. If the retained capsule can be localized by imaging studies, retrieval can be attempted using standard endoscopy, push enteroscopy, double-balloon endoscopy or spiral endoscopy. If these approaches fail, surgical retrieval via laparoscopy or open surgery may be required. However, if the capsule’s site cannot be localized, retrieval can be challenging and we hereby describe a case where fluoroscopic assistance was utilized during a laparoscopic approach. This approach has not been described before. A 67-year-old female underwent a video capsule endoscopy on July 24th 2013, for evaluation of iron deficiency anemia. Prior to this, she had an esophagogastroduodenoscopy (EGD) on October 2007, which revealed chronic gastritis and a colonoscopy on February 2008, which was unremarkable. The capsule did not pass, and multiple radiographic examinations including plain films and computerized topography (CT) scan demonstrated the capsule to be located in the small bowel. A CT enterography suggested that the capsule was localized in a mid-ileal loop on July 2nd 2014. On October 30th 2014, the patient underwent an antegrade double-balloon enteroscopy but the capsule could not be reached. Throughout this time, the patient has been asymptomatic. The patient requested the capsule to be retrieved as she was concerned about leakage from the contents. On April 2015, about 21 months after her study, she underwent a laparoscopy. During the laparoscopy, the whole small bowel was examined using laparoscopic nontraumatic intestinal graspers; however, the capsule could not be seen or felt. Thus, fluoroscopy was performed, and loops of small intestine were grasped with intestinal graspers and under fluoroscopy the capsule and impaction site were found. This loop of intestine was exteriorized, an enterotomy was performed proximal to the capsule which could be felt and the capsule was removed. No small bowel pathology was present; thus, the enterotomy was closed, and the bowel segment was reinserted into the abdominal cavity. The patient made an uneventful recovery. Capsule endoscopy is a simple, reliable procedure which is increasingly being used for evaluation of gastrointestinal pathology. It is safe, well tolerated, does not require radiation exposure or sedation. The most common complication is capsule retention, which varies from 0 % in healthy volunteers to 21 % in patients with intestinal obstruction [4]. A pooled retention rate of 1.4 % is reported [5]. It is defined by the International Conference on Capsule Endoscopy (ICCE) in * Gokhan Ozuner gozuner@gmail.com