Su1843 Lodged Foreign Bodies in the Small Bowel -Proceed to Surgery or Perform Double Balloon Enteroscopy First?

Abstract

Background: Double Balloon Enteroscopy (DBE) is a surgery sparing procedure to remove ingested foreign bodies which pass beyond the duodenum but have prolonged small bowel passage or get lodged in the small bowel. Aim: To investigate the outcome and safety of DBE for removal of ingested foreign bodies from the small bowel. Methods: 1296 patients underwent 1747 DBE between February 2009 and September 2013 at a single tertiary center of which 22 patients underwent 20 upper DBE and 13 lower DBE for removal of ingested foreign bodies. Data was abstracted by retrospective chart review. Primary outcome was the retrieval success and secondary outcome the complication rate. Results: 22 patients (mean age 54.3 years, SD 19.1) underwent DBE for retrieval of a pill camera (n=12), distal migrated biliary or pancreatic stents (n=5) and accidently or in suicidal attempt ingested foreign bodies (spoon, nail, fish hook) (n=5). 12 patients (57%) underwent a CT scan prior DBE to localize the foreign body (pill camera n=2, stent n=5, ingested foreign body n=5). Only 7 patients had known underlying medical conditions affecting the small bowel (Crohn's disease n=3, previous bowel surgery n=4). In addition to 3 patients with known Crohn's disease DBE diagnosed 4 additional patients with small bowel Crohn's disease, 7 nonsteroidal anti-inflammatory drug (NSAID) inducing strictures and 1 anastomotic stricture. Retrieval of the foreign body was successful in 19 patients (86%) using Roth net (50%), snare (30%) or forceps (20%). 6 patients required small bowel balloon dilation prior removal of the foreign body. 3 patients (13%) (2 pill camera and 1 nail) failed retrieval of the foreign body. Two underwent surgery and 1 patient (ingested nail) who was not a surgical candidate due to frozen abdomen passed the nail spontaneously at a later point. Of 33 DBE 1 procedure (3%) was complicated by small bowel perforation following a successful removal of the pill camera lodged at a Crohn's stricture requiring emergent surgical intervention. Limitations: Single center, retrospective study, heterogeneous patient population. Conclusion: To our knowledge this is the largest cohort study of patients with lodged foreign bodies in the small bowel who underwent DBE. DBE has a high success rate of foreign body retrieval in light of a relative low complication rate. Discussion: A success rate of 86%with a complication rate of 3% justifies patient transfer to a high expertise DBE center for removal of lodged foreign bodies in the small bowel prior attempting a surgical intervention as long as the patient remains stable.