Mechanical Lithotripter Research Articles

Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife

Video 1Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife. A 61-year-old man with a 3-decade history of recurrent cholecystitis presented to the community emergency department with severe right upper quadrant pain. A CT scan was performed and revealed gangrenous cholecystitis with likely cholecystoduodenal fistulous communication.After discussion with the patient and the HPB team, the plan was made to attempt endoscopic extraction of the obstructing stone. This would be performed in the operating room, such that if endoscopic extraction was not possible, surgical management would proceed.During the endoscopy, 1 L of liquid material was suctioned and the retained solids were cleared as best as possible. The large obstructing stone was then seen in the duodenal cap. In the cap, we could appreciate the obstructing stone and the fistulous tract.We then passed a guidewire distal to the stone and advanced a 15- to 20-mm extraction balloon over the guidewire. The balloon was passed distal to the stone and inflated to 20mm. We then applied firm, steady traction in an attempt to extract the stone.With the double-channel gastroscope, we passed a second wire and extraction balloon distal to the stone to increase the amount of traction that could be applied. Both balloons were inflated distal to the stone, and steady, firm traction was again applied. Unfortunately, this was not successful either.We then decided to use a regular ERCP needle knife to incise the stone. Because the knife was delicate, it was easily deformable, so we decided to switch to a triangle-tip knife.Using the "PreciseSECT" mode on the electrosurgical unit, the stone was repeatedly incised. Particular care was taken to avoid flinging the knife and damaging the duodenal wall.Saline was used as the irrigation solution to ensure electrosurgical conductivity when the current was applied.At this point, we could appreciate fragmentation of the stones after repeated incision.After about 3 hours of stone incision and fragmentation, the guidewire was passed beyond the stone; the extraction balloon was advanced over the wire; and the balloon was again inflated with steady traction applied. This time, the stone was successfully extracted from the stomach.The duodenum was then examined. There were no remaining large pieces of stone or any significant mucosal damage or perforation.Using a mechanical lithotripter, the remaining larger fragments of stone were fragmented and extracted. However, because the stone had a large diameter, lithotripsy at the center was not initially possible, and the smaller lateral aspects had to be performed until the stone was completely fragmented.This case demonstrates the incision and fragmentation of a massive gallstone with the use of an endoscopic submucosal dissection knife and electrosurgical unit.With cautious application of this technique, successful endoscopic management of a large gallstone causing Bouveret syndrome was achieved. This technique avoided open surgical management and allowed for elective cholecystectomy at a later date with less morbidity.

Use of mechanical lithotripter to assist in the endoscopic removal of an impacted long chicken bone in sigmoid diverticula.

Use of mechanical lithotripter to assist in the endoscopic removal of an impacted long chicken bone in sigmoid diverticula.

Novel elbow basket mechanical lithotripter for large common bile duct stone removal

ABSTRACT Background Large common bile duct (CBD) stones often require lithotripsy. In this study, we aimed to introduce a novel device-elbow basket catheter for mechanical lithotripsy (ML) of CBD stones and assess the efficacy and safety of the novel device. Methods This was a retrospective study. A total of 139 patients with large CBD stones who underwent lithotripsy using the elbow basket mechanical lithotripter (EBML) or conventional basket mechanical lithotripter (CBML) during endoscopic retrograde cholangiopancreatography (ERCP) from June 2016 to September 2021 in our center were enrolled in the study. The stone clearance rate, intubation time, overall procedure time, and adverse event rate were compared between the two groups. Results The stone clearance rate in the first ERCP program in the EBML (n = 71) group was significantly higher than that in the CBML (n = 68) group (98.6% vs. 88.2%; P< 0.05). The intubation time in the EBML group was significantly shorter than that in the CBML group (median time; 12s vs. 78s; P< 0.001). The overall procedure time in the EBML group was significantly shorter than that in the CBML group (median time; 51 min vs. 63 min; P< 0.001). The adverse event rate (7.4% vs. 1.4%: P> 0.05) was similar between the two groups. Conclusions ML using EBML in patients with large CBD stones is feasible and safe. Compared with the CBML, the stone clearance rate of the EBML is higher in a single procedure and decreases the time of intubation and the overall procedure.

Endoscopic management of intraluminal gastric band erosion using a laser lithotripsy probe.

Intraluminal erosion of adjustable and non adjustable gastric bands generally occurs years after placement. Different endoscopic techniques have been described for the management of bands that erode the gastric wall, using endoscopic scissors, rigid endoscopic guides wire coupled to a mechanical lithotripter or even less frequently used devices such as the Gastric Band Cutter System to cut it. We present a clinical case in which we used a lithotripsy laser probe to break the band with great effectiveness without complications.

Long-term effects of endoscopic papillary large balloon dilation in patients with challenging bile duct calculi: A retrospective observational study.

Endoscopic papillary large balloon dilation (EPLBD) can be used to treat challenging common bile duct stones. No previous studies have reported intractable cases treated either by EPLBD or mechanical lithotripter use. We aimed to evaluate and compare the long-term effects of EPLBD with mechanical lithotripter use.This retrospective cohort study reviewed data from 153 patients admitted to the Eastern Chiba Medical Center from April 2014 to March 2020, presenting with common bile duct calculi that could not be removed using a basket or balloon catheter. Patients were divided into groups depending on whether the treatment was performed using a mechanical lithotripter or EPLBD. The primary outcome was the recurrence rate of common bile duct calculi, and the secondary outcome was the rate of postoperative adverse events. The Wilcoxon test was used to compare the 2 groups. Statistical significance was set at P < .05.The median age of patients included in the lithotripter and EPLBD groups were 73 years and 83 years, respectively (P = .006), while the sex ratio (male:female) in the groups was 18:13 and 55:67, respectively. The EPLBD group showed a statistically larger median bile duct diameter (13 mm [range: 8–24 mm] vs 11 mm [range: 5–16 mm]; P < .001), larger maximal calculus diameter (median, 13.5 mm [range: 8–25 mm] vs 11 mm [range: 7–16 mm]; P < .001), and shorter median cumulative treatment time after reaching the duodenal papilla (35.5 minutes [range: 10–176 minutes] vs 47 minutes [range: 22–321 minutes]; P = .026) in comparison to the lithotripter group. There was no significant difference in the rate of adverse events between the EPLBD and the mechanical lithotripter groups. The recurrence rate was significantly lower (P = .014) in the EPLBD group.EPLBD increases therapeutic efficacy and reduces treatment duration for patients in whom calculus removal is difficult, without increasing the frequency of adverse events. No serious adverse events were observed. Additionally, EPLBD appears to reduce the risk of long-term recurrence. Future studies are needed to evaluate long-term outcomes in younger patients.

A Simple Method for Endoscopic Treatment of Large Gastric Phytobezoars: "Hand-Made Bezoaratome".

Large gastric phytobezoars are generally resistant to standard chemical or endoscopic treatments. We presented our experience of an alternative endoscopic method using a hand-made tool called a "hand-made bezoaratome" for the treatment of large gastric phytobezoars. Patients who consulted or who were diagnosed with gastric bezoars at an education and research hospital between January 2015 and December 2018 were prospectively included in the study. Patients with phytobezoars of 50 mm and larger were included in the study. Patients with trichobezoars, lactobezoars, pharmacobezoars, under 18 years of age, and pregnant women were excluded. A 0.25 mm diameter guidewire and a mechanical lithotripter sheath were used to prepare the "hand-made bezoaratome." After the first procedure, patients were advised to consume 2500 mL of Coca Cola® or the same amount of pineapple juice per day, until the next procedure. Endoscopic procedures were performed at 5-day intervals until complete reabsorption of the bezoar was achieved. Patients were followed up for 6 weeks. The study group included 37 (21 males, mean age: 57.6 ± 12.5 years) patients. The median size of the phytobezoars was 71 mm (50-90). The median endoscopic procedure time was 853 s (380-1940 s). The success rate for endoscopic fragmentation was found to be 100%. No major complications occurred during the endoscopic procedures, but 1 patient (2.7%) required surgery for ileus due to an obstruction at the distal part of the jejunum, 61 h after the second endoscopic session. The overall success rate of the endoscopic treatment was 97.3%. Using a "hand-made bezoaratome" is effective and reliable for the endoscopic treatment of large gastric bezoars.

3090 Endoscopic Removal of Partially Migrated Gastric Banding

INTRODUCTION: Intragastric band migrations or dysfunctions are common long-term complications of laparoscopic adjustable gastric banding (Lap-Band) that classically require surgical treatment. In this video case we describe the endoscopic removal of partially eroded Lap-Bands. CASE DESCRIPTION/METHODS: We present the case of a 61 years-old female that underwent a Lap-Band in 2002 for morbid obesity (weight 150 Kg, BMI 55.1). In November 2017 she had abdominal pain and an EGD showed erosion of the gastric mucosa and partial intragastric migration of the Lap-Band (&gt;50%). After surgical removal of the subcutaneous reservoir an endoscopic procedure was planned to remove the migrated gastric band. The procedure was performed under general anesthesia, with CO2 insufflation and using a therapeutic gastroscope (GIF-1T 160, Olympus, Japan). The ring was captured with a guidewire (Jagwire, Boston Scientific, Marlborough, MA) under endoscopic control and fluoroscopic control in a "loop shape". The endoscope was then removed, and a mechanical lithotripter (Endobair, London, UK) was placed over the 2 extremities of the wire and a biliary lithotripsy device was used to cut the migrated band. The band was pushed into the stomach, captured with a snare and pulled out. There were no procedure related complications. DISCUSSION: Endoscopic removal of intragastric migrated Lap-Band is safe, repeatable and procedure and is a valide alternative over surgery. Watch the video: http://bit.ly/2LuYDJS

Safety and Efficacy of Endoscopic Removal of Common Bile Duct Stones in Elderly Patients ≥90 Years of Age.

Objective We examined the safety and efficacy of endoscopic stone removal for choledocholithiasis in elderly patients ≥90 years of age with native papilla and compared the outcomes with those in patients 75-89 years of age. Methods This multicenter retrospective study included 569 patients 75-89 years of age and 126 patients ≥90 years of age who had native papilla and underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis at 3 institutions in Japan between April 2012 and March 2018. The main outcomes assessed were the incidence of post-ERCP complications during hospitalization and outcomes of ERCP in patients ≥90 years of age. Results Biliary cannulation and subsequent endoscopic sphincterotomy, endoscopic balloon dilation, and endoscopic large balloon dilation were successful in 97.7% of patients 75-89 years of age and in 98.4% of patients ≥90 years of age. There was no significant difference in the incidence of post-ERCP complications between patients 75-89 years of age and those ≥90 years of age (7.7% vs. 9.5%, respectively; p=0.47). Although the rate of use of mechanical lithotripter was not significantly different, the rate of complete stone removal in patients ≥90 years of age was lower than that in patients 75-89 years of age (81.0% vs. 94.9%, respectively; p<0.001). In all cases with incomplete stone removal in both groups, permanent biliary stent placement was successful. Conclusion ERCP for choledocholithiasis in elderly patients ≥90 years of age is a safe and effective procedure; however, endoscopists should select appropriate strategies after considering each patient's medical condition and background.

Cholangioscopy-guided holmium laser lithotripsy of a stone trapped in a mechanical lithotripter.

Cholangioscopy-guided holmium laser lithotripsy of a stone trapped in a mechanical lithotripter.

Endoscopic management of erosion after banded bariatric procedures

BackgroundProsthetic materials wrapped around a portion of the stomach have been used to provide gastric restriction in bariatric surgery for many years. Intraluminal erosion of adjustable and nonadjustable gastric bands typically occurs many years after placement and results in various symptoms. Endoscopic management of gastric band erosion has been described and allows for optimal patient outcomes. ObjectivesWe will describe our methods and experience with endoscopic management of intraluminal gastric band erosions after bariatric procedures. SettingUniversity hospital in the United States. MethodsA retrospective review of our bariatric surgery database identified patients undergoing removal of gastric bands. A chart review was then undertaken to confirm erosion of prosthetic material into the gastrointestinal tract. Baseline characteristics, operative reports, and follow-up data were analyzed. ResultsSixteen patients were identified with an eroded gastric band: 11 after banded gastric bypass, 3 after laparoscopic adjustable gastric band (LAGB), and 2 after vertical banded gastroplasty. All patients were successfully treated with endoscopic removal of the prosthetic materials using either endoscopic scissors or ligation of the banding material with off-label use of a mechanical lithotripter device. Complications included a postoperative gastrointestinal bleed requiring repeat endoscopy, 1 patient with asymptomatic pneumoperitoneum requiring observation, and 1 with seroma at the site of LAGB port removal. ConclusionsEndoscopic management of intraluminal prosthetic erosion after gastric banded bariatric procedures can be safe and effective and should be considered when treating this complication. Erosion of the prosthetic materials inside the gastric lumen allows for potential endoscopic removal without free intraabdominal perforation. Endoscopic devices designed for dividing eroded LAGBs may help standardize and increase utilization of this approach.

V11-10 MINI-PERCUTANEOUS NEPHROLITHOTOMY USING AN INTEGRATED ULTRASONIC AND MECHANICAL LITHOTRIPTER (OLYMPUS SHOCKPULSE-SE LITHOTRIPTER)

You have accessJournal of UrologyUrolithiasis1 Apr 2017V11-10 MINI-PERCUTANEOUS NEPHROLITHOTOMY USING AN INTEGRATED ULTRASONIC AND MECHANICAL LITHOTRIPTER (OLYMPUS SHOCKPULSE-SE LITHOTRIPTER) Joshua Ebel, Nathaly François, and Bodo Knudsen Joshua EbelJoshua Ebel More articles by this author , Nathaly FrançoisNathaly François More articles by this author , and Bodo KnudsenBodo Knudsen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2999AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Mini-percutaneous nephrolithotomy (mini-PCNL) was initially described in the late 1990s. Many variations on the technique have been described since that time focusing on differing access sizes. Lithotripsy through a mini-PCNL tract has traditionally been accomplished through laser or electro-hydraulic/pneumatic energy. We sought to explore the feasibility of lithotripsy through a mini-PCNL tract with the Olympus ShockPulse-SE Lithotripter which combines both ultrasonic and mechanical energy to optimize lithotripsy. METHODS A 58 year male patient with a 2.5 cm left lower pole stone was identified as the initial candidate for our technique. He was positioned in the standard prone position and access was obtained into his lower pole with an 18-gauge Cook LS access needle. We proceeded to dilate a 16-French tract using a one-step dilator with the Storz Modular Minimally Invasive PCNL (MIP) System. With the Storz MIP M nephroscope and a 1.5 mm Olympus ShockPulse-SE probe, we then broke the stone into minute fragments which were initially suctioned and collected with the StoneCatcher (Boston Scientific) system. Remaining fragments were removed with an endoscopic grasper and a nitinol stone basket. The procedure was performed tubeless with a stent. After five days, a follow-up plain film was obtained and the stent removed. RESULTS The dual modality lithotripter was efficient with stone fragmentation and extraction through suction. The total operative time was 110 minutes. The patient was discharged on post-operative day one after an uncomplicated stay of 30 hours total duration. Post-operatively, his hemoglobin declined 2.3 g/dl and his creatinine rose 0.2 mg/dl. On return, his large 2.5 cm stone showed good clearance on KUB though dust like fragments (< 2 mm) remained in his lower pole. CONCLUSIONS This is the first report of using integrated ultrasonic and mechanical energy lithotripsy in a mini-PCNL. The combination of the Olympus ShockPulse-SE Lithotripter with the Storz MIP system proved efficient in terms of operative duration and stone breakdown. It was also effective at clearing a large stone burden through a small 16-French tract. This method is feasible and provides an alternative to laser or pneumatic lithotripsy and offers the benefits of suction. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1285 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Joshua Ebel More articles by this author Nathaly François More articles by this author Bodo Knudsen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Efficacy and safety of novel digital single-operator peroral cholangioscopy-guided laser lithotripsy for complicated biliary stones.

Background/study aims Laser lithotripsy can effectively fragment complicated biliary stones, but current cholangioscopes are limited by fragility, restricted mobility or moderate visual resolution. The efficacy and safety of a new digital single-operator peroral cholangioscope to guide laser lithotripsy were evaluated. Patients and methods In this prospective single-center series, consecutive patients with complicated biliary stones, defined as impacted stones > 1.5 cm in size and wider than the more distal common bile duct, or stones that failed extraction by basket mechanical lithotripsy, underwent ERCP and SpyGlass DS peroral cholangioscope (Boston Scientific, Marlborough, United States)-guided laser lithotripsy. Stone clearance rate and incidence of adverse events were determined. Results Seventeen patients (10 men, 7 women; median age 76 years) with a median biliary stone size of 2 cm underwent predominantly holmium:yttrium aluminum garnet laser lithotripsy, achieving a 94 % stone clearance rate over 1 median procedure. Lithotripsy was performed in 8 of 17 patients due to an impacted biliary stone. The remaining patients underwent lithotripsy due to prior failure of the basket mechanical lithotripter to capture or crush their stones. Post lithotripsy, 2 patients developed cholangitis and 1 patient with underlying COPD developed respiratory distress, all resolved with conservative management. There were no hemobilia, perforations, pancreatitis nor any deaths. Conclusion SpyGlass DS peroral cholangioscopy-guided laser lithotripsy is an efficient and safe modality for management of complicated biliary stones.

Is endoscopic papillary large balloon dilatation without endoscopic sphincterotomy effective?

To evaluate the safety and efficacy of endoscopic papillary large balloon dilatation (EPLBD) without endoscopic sphincterotomy in a prospective study. From July 2011 to August 2013, we performed EPLBD on 41 patients with naïve papillae prospectively. For sphincteroplasty of EPLBD, endoscopic sphincterotomy (EST) was not performed, and balloon diameter selection was based on the distal common bile duct diameter. The balloon was inflated to the desired pressure. If the balloon waist did not disappear, and the desired pressure was satisfied, we judged the dilatation as complete. We used a retrieval balloon catheter or mechanical lithotripter (ML) to remove stones and assessed the rates of complete stone removal, number of sessions, use of ML and adverse events. Furthermore, we compared the presence or absence of balloon waist disappearance with clinical characteristics and endoscopic outcome. The mean diameters of the distal and maximum common bile duct were 13.5 ± 2.4 mm and 16.4 ± 3.1 mm, respectively. The mean maximum transverse-diameter of the stones was 13.4 ± 3.4 mm, and the mean number of stones was 3.0 ± 2.4. Complete stone removal was achieved in 97.5% (40/41) of cases, and ML was used in 12.2% (5/41) of cases. The mean number of sessions required was 1.2 ± 0.62. Pancreatitis developed in two patients and perforation in one. The rate of balloon waist disappearance was 73.1% (30/41). No significant differences were noted in procedure time, rate of complete stone removal (100% vs 100%), number of sessions (1.1 vs 1.3, P = 0.22), application of ML (13% vs 9%, P = 0.71), or occurrence of pancreatitis (3.3% vs 9.1%, P = 0.45) between cases with and without balloon waist disappearance. EST before sphincteroplasty may be unnecessary in EPLBD. Further investigations are needed to verify the relationship between the presence or absence of balloon waist disappearance.

Results of the open surgery after endoscopic basket impaction during ERCP procedure.

To report the results of open surgery for patients with basket impaction during endoscopic retrograde cholangiopancreatography (ERCP) procedure. Basket impaction of either classical Dormia basket or mechanical lithotripter basket with an entrapped stone occurred in six patients. These patients were immediately operated for removal of stone(s) and impacted basket. The postoperative course, length of hospital stay, diameter of the stone, complication and the surgical procedure of the patients were reported retrospectively. Six patients (M/F, 0/6) were operated due to impacted basket during ERCP procedure. The mean age of the patients was 64.33 ± 14.41 years. In all cases the surgery was performed immediately after the failed ERCP procedure by making a right subcostal incision. The baskets containing the stone were removed through longitudinal choledochotomy with the stone. The choledochotomy incisions were closed by primary closure in four patients and T tube placement in two patients. All patients were also performed cholecystectomy additionally since they had cholelithiasis. In patients with T-tube placement it was removed on the 13(th) day after a normal T-tube cholangiogram. The patients remained stable at postoperative period and discharged without any complication at median 7 d. Open surgical procedures can be applied in patients with basket impaction during ERCP procedure in selected cases.

Technique for Retrieving Basket and Lithotripter During Endoscopic Retrograde Cholangiopancreatography

A 27-year-old woman with a prior cholecystectomy underwent endoscopic retrograde cholangio pancreatography (ERCP) for abdominal pain and choledocholithiasis. After biliary sphincterotomy, a flower basket was used to grasp and retrieve a 15-mm mid–common bile duct (CBD) stone. However, the flower basket became impacted in the CBD (Figure A). Then, the distal CBD was dilated using a 15-mm CRE balloon dilator (Boston Scientific, Natick, MA). Despite this, the basket could not be pulled out. The outer plastic sheath of the basket was removed and a Soehendra mechanical lithotripter then was inserted alongside the basket wires into the CBD and mechanical lithotripsy (Cook Medical, Winston-Salem, NC) of the stone was attempted.

A novel method to remove an impacted sharp foreign body in the esophagus of an infant

Irregular and sharp foreign bodies in the esophagus are difficult to remove and carry a significantly high morbidity especially if a pointed object is lodged in the esophagus. Improper extraction technique may result in complications including bleeding and perforation. We describe a case of successful removal of an impacted earring where the earring post was lodged in the esophagus. A 19-month girl was noted by her parents that she cried on swallowing and complained of retrosternal chest pain and odynophagia on swallowing. She did not have any coughing, shortness of breath, or fever. Her mother reported that the baby had accidentally swallowed an earring some 15 hours earlier. The baby’s clinical condition was stable on admission. A chest X-ray revealed a metal foreign object (earring) in the esophagus and with the post seen lodged against the esophageal wall (Fig. 1). Computed tomography (CT) chest showed no mediastinal free air (Fig. 2). An upper endoscopy was performed under general anesthesia with endotracheal intubation. This revealed the presence of an earring in the upper esophagus with its post lodged and embedded in the esophageal wall at 19 cm from the incisor (Fig. 3). There was localized mucosal edema and punctate erosions in the esophagus. An attempt made to extract the earring using grasping forceps failed and there was concern over laceration of the esophageal wall because of the sharp post. We pushed the earring forward into the fundus of the stomach (Fig. 4) using a pair of forceps and the endoscope (GIF-Q260; Olympus, Tokyo, Japan). Repeated attempts at removal of the foreign body from the stomach using grasping forceps failed because of the size and the pointed post on the earring. Finally, a mechanical lithotripter (BML-V437QR-30; Olympus), normally used for fragmenting and removing biliary stones, was inserted into the stomach through scope. The basket was opened to engage the stopper on the post and the earring, and traction was applied to the basket wires to break off the post and stopper from the main body of the earring (Fig. 5). These were then removed separately using forceps. The main part of the earring measured 2.0 cm × 1.2 cm Figure 2. computed tomography (cT) chest showing no mediastinal free air

Endoscopic papillary large‐balloon dilation versus endoscopic papillary regular‐balloon dilation for removal of large bile‐duct stones

Endoscopic papillary large-balloon dilation (EPLBD) became popular for the treatment of large common bile-duct stones (CBDS), and its feasibility has been reported in comparison to endoscopic sphincterotomy. However, the comparison between EPLBD and endoscopic papillary regular-balloon dilation (EPBD) has not been reported. In the present study, the efficacy and complications of EPLBD were compared with those of EPBD. We retrospectively assessed 334 consecutive patients with CBDS of any size that were treated by either EPLBD or EPBD between January 2008 and December 2012. In cases with large CBDS (>10 mm), EPLBD and EPBD had similar results in terms of the success rate of stone removal in the first (65% vs. 84%) and total attempts (100% vs. 95%), use of mechanical lithotripter (64% vs. 80%), and procedure time (48.0 ± 17.8 min vs. 44.1 ± 17.1 min). The necessity for crushing stones with a mechanical lithotripter was significantly decreased in EPLBD compared to EPBD (25% vs. 80%). In all cases with CBDS, there was no significant difference in complication rates between EPLBD and EPBD (3.3% vs. 4.7%). Compared to EPBD, EPLBD appears safe and effective for removing large CBDS and decreases the necessity of lithotripsy.

Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography

To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy. Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth II gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing, selectively applying contrast medium, and CO₂ insufflations. The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth II reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth II reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth II reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth II anastomosis. Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.

Use of a mechanical lithotripter to aid in the removal of an impacted razor blade in the esophagus

Sharp foreign bodies in the esophagus are dangerous and carry a high morbidity. Improper technique can cause complications such as perforation or bleeding. We describe a case with an impacted razor blade in the esophagus that was successfully removed by using a lithotripsy basket.

Upper Gastrointestinal Foreign Bodies - A Five Year Experience from a Cosmopolitan Hospital in UAE

Purpose: UGI Endoscopy is a useful tool to manage the extraction of inadvertent ingestion of foreign bodies from upper gastrointestinal tract. We report the cases from NMC Specialty Hospital, UAE over a span of five years from 2003-2008. Methods: All patients who underwent endoscopy for attempted extraction of ingested foreign bodies were reviewed. In cases where endoscopy was not indicated patients/parents were counseled for the same and those cases where extraction was not attempted, were excluded. Endoscopies were performed under GA in children and conscious sedation in adults. Accessories were chosen after testing their grip on similar objects before the procedure. Fluoroscopy was employed to facilitate localization during procedure. Results: The summary of all cases is shown in the table below. Swallowed coins and lead batteries were the most common foreign bodies found in the pediatric population. Fluoroscopy was utilized in locating the objects buried in the luminal food residue. The Rat Tooth Forcep simplified the extraction of coins while Polypectomy Snare secured firm grip on the slippery button batteries. Custom pins were 1.5 inch long with ball shaped plastic heads and sharp tips. Women use them to secure head scarf in gulf countries. In all cases accidental swallowing happened when patients were holding them between teeth while adjusting their scarf. Partial mucosal penetration by the pin was observed in one patient. She was initially sent back from emergency as an erect AXR was negative. But later on a supine AXR showed the pin when patient returned because of persistent discomfort. Pins were easily extracted by holding the sharp end with simple biopsy forceps. Polypectomy snare was also useful in doubling up of sharp edges of a swallowed prescription medicine with intact wrapper which was stuck across on both sides of the esophagus. Another potentially hazardous extraction of a 5 cm long denture, because of larger size and hard nature was safely achieved with the use of an over-tube. Extraction of a large and hard gastric bezoar partially imbedded in gastric mucosa after failed attempts to crush with a mechanical lithotripter, was achieved with surgery.Table: [1406] Types of foreign bodiesConclusion: A supine AXR is important to diagnose ingested radio-opaque foreign bodies. Fluoroscopy helps in locating non-visualized foreign bodies buried in luminal content. Thoughtful pre-procedure selection of endoscopic accessories simplifies the extraction of various upper GI foreign bodies. Over-tube facilitates safe extraction of large objects by diffusing the shear force over the esophageal wall. Non-crushable hard and large objects require surgical removal.