Bipolar cautery snare capture and removal of esophageal food bolus obstruction

Abstract

An 88-year-old man with a long history of intermittent difficulty with swallowing solids and liquids was referred from another institution where an unsuccessful attempt had been made to remove a completely obstructing distal esophageal food bolus. Several hours before, he had swallowed three dried apricots. He was edentulous and wore poorly fitting dentures. He admitted that because the apricots were so tough, he was unable to chew them and had to swallow them whole. Shortly thereafter, he developed a pressure sensation in his chest and was unable to swallow even his saliva. He attempted to vomit but was unsuccessful in dislodging the obstruction. He went the emergency room of his local hospital where he underwent a barium swallow. This showed a large distal esophageal food bolus along with the characteristic appearance of a diffuse esophageal motility disorder. A prolonged unsuccessful attempt was made to remove the foreign bodies. He was then referred to our institution. On arrival, he complained of continued difficulty with swallowing and still had a pressure sensation in his chest. His physical examination was unremarkable. Under intravenous sedation, endoscopy demonstrated a tightly impacted distal esophageal food bolus. Multiple attempts were made to grasp the mass with grasping forceps and a snare but the food bolus was so tightly impacted and its surface so slippery, that none of these approaches at removal would hold. Attempts to advance the food bolus into the stomach, using the tip of the endoscope guided by a fluoroscopically placed guidewire, even after 1 mg of intravenous glucagon to relax the esophagus,3 were also unsuccessful. After this second prolonged try, further efforts at disimpaction were discontinued. The patient was rehydrated overnight. The following day, prior to undertaking re-endoscopy, we used the dry run technique,3, 4 to simulate various approaches to disimpaction. We obtained samples of fresh and dried apricots. We then evaluated various methods of grasping them so that the snare would hold. The most successful method appeared to be that of using the bipolar snare (Everest Medical, Minneapolis, Minn.)5 with a short burst of cautery current using a Valley Lab SSE 2L generator