Rat-tooth Forceps Research Articles

Successful Endoscopic Band Ligation of Esophageal Perforation by Fish Bone Ingestion

Acute esophageal perforations by foreign body ingestion result in complications such as mediastinitis and retropharyngeal or parapharyngeal abscesses. Because the mortality of esophageal perforation is up to 22%, immediate treatment is critical. Herein, we report a case of successful endoscopic band ligation of esophageal perforation. A 68-year-old man was admitted complaining of substernal pain and dysphagia after ingesting a fish bone. Immediately emergency endoscopy was performed, and the fish bone was observed lodged in the lower esophagus. Although the fish bone was easily removed by an endoscopic rat-tooth forceps, esophageal perforation was found after the procedure. Endoscopic band ligation for perforation was performed. Initial chest computed tomography (CT) showed pneumomediastinum and local inflammation, but follow-up CT showed improved pneumomediastinum. The patient was given oral nutrition 2 weeks after procedure, and he was discharged without any complications. This case report emphasizes for the first time the availability of immediate endoscopic band ligation for acute esophageal perforation.

Dense calculi formation resulting in impaction of pancreatic stent

A 35-year-old male had pancreatic duct stenting using a 7 F single-pigtail 10-cm stent 11 years back for chronic pancreatitis. He was lost to follow up and presented recently with recurrent pain of 3 months duration. A computed tomography scan revealed a retained stent with dense calcification extending to side brancheswith the stent embeddedwithin the calculi, filling the entire length of the pancreatic duct (Fig. 1a). Attempts to retrieve the stent endoscopically using rat tooth forceps, biliary balloon, a Soehendra dilator, and a stent passed parallel to the stent to fragment the calculi failed due to dense impaction and friability of the stent. He underwent surgery. At operation, there were dense calculi in the pancreatic duct and side branches, and inseparable dense calcifications around the retained stent (Fig. 1b). The stent was completely occluded. The stent and calculi were removed, and he underwent lateral pancreatojejunostomy. Pancreatic duct stents, placed for various indications, are known to produce duct and parenchymal changes in 36 % to 50 % of cases [1]. Calcific intrapancreatic embedding of a pancreatic stent requiring surgical removal 10 years after initial deployment is reported [2]. To our knowledge, retrieval of a stent 11 years after the initial deployment has never been reported.

Esophageal Stent Migration Leading to Pneumothorax and Esophageal-Pleural Fistula: A Rare but Important Complication

Purpose: Esophageal stents are used in the management of malignant dysphagia. Covered self-expanding stents are standard practice in esophageal cancer as either palliation or a bridge to surgical resection. Stent placement carries a risk of complications, including aspiration pneumonia, fistula formation, and stent migration. More severe complications such as stent fracture and jejunal perforations have been reported. Case Report: We report a case of a 63-year-old woman with a history of a malignant esophageal stricture who underwent placement of a fully covered esophageal stent. The procedure was well tolerated with symptom improvement. She was then treated with chemotherapy and radiation with ultimate plans for surgical resection. Over the next six weeks, she presented to the hospital twice for chest pain. Two upper endoscopies during this time revealed a patent esophageal stent in proper position. Eight weeks after initial stent placement, she represented with persistent nausea and dysphagia. An upper endoscopy revealed stent migration with mucosal ulceration in the mid-esophagus from previous stent placement. The stent was pulled back into proper position with a rat-toothed forceps. She returned two weeks later with acute dyspnea and chest pain. A CXR revealed a right-sided tension pneumothorax. A chest tube was placed and immediately drained bilious liquid. A chest CT demonstrated erosion of the proximal end of the stent through the esophagus into a contained posterior mediastinal space which communicated with the right pleural cavity. Emergent upper endoscopy revealed the proximal portion of the stent eroding through the esophagus with an area of visible pleura. Stent removal was attempted but unsuccessful. The stent was then grasped with a rat-toothed forceps and pulled back into the esophagus to seal the visible defect. Twelve hours later, a CXR again showed stent migration. A repeat endoscopy revealed the proximal end of the stent within the pleura. It was pulled back to cover the defect and a second partially covered esophageal self-expanding stent was placed within the previously placed stent. Unfortunately, the patient's respiratory status continued to deteriorate and she passed away a few days later. Discussion: This case describes a rare complication of esophageal stent placement: pneumothorax and esophageal-pleural fistula development. Although esophageal stents can be beneficial in select patients with malignant strictures, stent migration is a common complication. This case highlights the importance of not only recognizing these complications, but also the management dilemmas and endoscopic challenges they bring.

3 clips, 2 Stents, 1 Loop: A Novel Technique to Prevent Stent Migration in Strictures

Purpose: The incidence of gastrojejunal anastomotic stricture after RYGB is reported to be 3-22% and is the most common complication post gastric bypass. Although no formal definition exists, a gastrojejunal anastomotic stricture is loosely defined as a narrowing of the anastomosis that does not allow passage of a standard gastroscope (8.6-9.8 mm). The best nonsurgical treatment for strictures regardless of the underlying cause is stent placement as an alternative to surgery. The most common complication of stent placement is stent migration. Other complications include tissue ingrowth and stent erosions. Migration away from the initial anastomotic site continues to be a major issue and is reported in 12-66% of patients. Anchoring techniques to prevent stent migration have been reported and include endoscopic clips, polypectomy snare applied to the stent's retrieval lasso and fixed externally, and surgical suturing of the lasso. We present a case of endoloop and 3 clips to holster a Bonastent successfully to prevent migration in a patient who already had one previously placed stent migrated. A 48 year-old male with a history of a Roux-en-Y gastric bypass presented with dysphagia, nausea, and vomiting two months after surgery and recent Wallflex stent placement. He was unable to consume solids and was found to have a stricture at the gastrojejunal anastomotic site. He then proceeded to have an upper endoscopy where a post-anastomotic ulcer was also noted. The enteroscope was passed distally into the jejunum where the previously placed Wallflex stent was located and removed with a rat-toothed forceps. No dilation or re-stent was performed given the amount of tissue edema and the presence of the anastomotic ulcer which was not present on the previous endoscopy. A guide wire was advanced through the stricture and then dilated from 6-12 mm with a CRE balloon. After the dilation, the endoscope was easily able to enter the efferent jejunal limb, confirming the location of the wire. Under fluoroscopic guidance a fully-covered esophageal dogbone shaped Bonastent® (18 mm × 60 mm) was deployed. An endoloop was then placed around stent retrieval lasso, and three hemoclips were used to secure the loop to the gastric remnant to help prevent distal migration. Follow-up after 8 weeks, he continues to be asymptomatic, tolerating solids and liquids without any symptoms. To our knowledge this type of success has never been reported before. Stent migration and the need for close surveillance and revision are currently the most marked drawbacks of stents but this will likely be improved as stent manufacturers customize stent's shape for use in bariatric surgery.

Use of the Over-the-Scope-Closure (OTSC) Device: One Year Experience at a U.S. Interventional Endoscopy Center

Purpose: To report our initial U.S. experience and to study the technical success, factors predisposing to failure and complications of OTSC. Methods: Retrospective review of a prospectively collected database of all patients treated with OTSC from January 2011 - April 2012 at a single tertiary care referral center. Results: 24 patients underwent placement of 28 OTSC devices. The mean age was 70 years. 14 (58%) patients were female. Indications for OTSC applications included post surgical enterocutaneous fistula (10), spontaneous perforation (1), anastomotic leak (4), perforation post mucosal resection (3), prophylactic closure of mucosal defect post EMR (1), post-polypectomy bleeding (2), post endoscopy perforation (2), tracheo-esophageal fistula (1) and leakage from a percutaneous jejunostomy site (1). Instruments or modalities used to grasp the tissue were dedicated devices (bidirectional forceps or tripronged anchoring device) in 16 and non dedicated devices (rat tooth/alligator forceps or suction alone) in 15. Successful tissue acquisition with these devices was 2/16 for dedicated and 13/15 for the non-dedicated. The non-dedicated devices were superior to the dedicated devices for tissue acquisition (p=0.0004). OTSC was successful in achieving hemostasis on a bleeding stump of a large lipoma and a hyperplastic polyp post polypectomy. It was also successful in preventing a post EMR crater from the high risk of delayed bleeding or perforation. Overall, the OTSC was effective in 15/27 procedures (53%). It was used in 21 procedures for defect closure resulting in instant and complete closure in 12/21 (57.1%) and partial closure in 9/21 (42.9%). Mean follow up was 2.9 months (range 1-8m). Mean size of defect was 10 mm (range 5-25 mm). A trend towards higher success was noted in defects < 10 mm compared to defects > 10 mm (90% vs. 60%; p=0.36). The duration of the defect ranged from <24h to 2 y. No difference was noted in closure of fresh perforations or fistula (<72 hrs) vs chronic fistula (> 1 month) (75 % vs. 67%). Repeat OTSC placement failed to close the defects in 2/2. There were no complications from OTSC device placement. Conclusion: The OTSC provides a safe endoscopic alternative to manage fistula, perforation and bleeding. Our series shows no significant difference for closure of early fistula or perforations as compared to chronic fistula. Rat-tooth forceps or suction was superior to the dedicated devices for tissue acquisition. Our limited experience with repeat OTSC treatment in failed initial attempts have been disappointing.

Sp949 Endoscopic Extraction of a Deeply Embedded Denture in Upper Esophagus

A 45 year old female patient was referred to us for extraction of a denture in upper esophagus. On presentation, she had grade III dysphagia and gave history of accidental ingestion of a denture with metal wires 14 days back. Attempts at removal of this failed at other centres. X ray/CT chest revealed the FB in the cervical esophagus. On endoscopy, the denture was seen engrafted into the lateral walls. It couldn't be moved even for a minimal distance with rat tooth forceps. There was no perforation seen on prior imaging.

Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos)

Endoscopic placement of fully covered self-expandable metal stents (FCSEMS) has been attempted to manage benign biliary strictures, but currently available FCSEMSs may be associated with unintended complications, including de novo strictures, in patients with normal life expectancy. To evaluate the feasibility of an intraductally placed modified FCSEMS to minimize stent-induced bile duct injury in patients with benign biliary strictures. Prospective observational clinical feasibility study. Tertiary-care academic center. This study involved 21 patients with symptomatic benign biliary strictures in whom conventional endoscopic management failed. Strictured segments were 15 mm above the ampulla of Vater. The modified FCSEMS has convex margins, a lasso, and an anti-migrating waist on the central portion. Stents were placed entirely above the papilla and removed after 3 to 5 months. Success, complications, removability, midterm outcome. FCSEMSs were successfully placed inside the bile duct in all patients. No episodes of pancreatitis, cholangitis, or sepsis were noted during the stenting period. Stent migration occurred in 4 patients (19.0%), but 3 were asymptomatic during follow-up. All stents were removed successfully with rat-tooth forceps without complications. Post-stenting cholangiograms showed improvement of strictures in 20 of 21 patients, without de novo focal stricture. The clinical success rate was 95.2%, with one recurrent stricture. The small number and lack of comparison with other types of FCSEMSs. Temporary intraductal placement of a newly modified FCSEMS effectively improved strictures and prevented potential stent-induced complications in patients with benign biliary strictures. Controlled large-scale trials are needed to confirm the long-term efficacy.

Endoscopic management for delayed diagnosis of a foreign body penetrating the esophagus into the lung

A 31-year-old male presented with chest pain started after eating chicken about 2 weeks earlier. Upper endoscopy and Computed tomography scan of the chest revealed a sharp chicken bone penetrating the esophageal wall into the right lung. The foreign body was removed endoscopically using a rat-tooth forceps, followed by prophylactic placement of a metal stent across the esophageal perforation site. Foreign body-induced perforation is one of the common etiologies of benign esophageal perforations. Although the primary treatment is surgery, endoscopic therapy may be appropriate in individualized cases like our patient.

Sump Syndrome as a Complication of Choledochoduodenostomy

Case Presentation and EvolutionA 71-year-old man initially underwent open cholecystec-tomy for biliary colic in 1990. Since then, he had been welluntil new symptoms began in 2009, when he presented to acommunity hospital reporting intermittent epigastric pain;ultrasound and computed tomography (CT) scans revealedcholedocholithiasis.Because an endoscopic retrograde cholangiopancrea-tography (ERCP) and stone extraction at that hospital wereunsuccessful, the patient underwent exploratory laparot-omy with common bile duct (CBD) exploration, duringwhich a CBD stone was removed and a side-to-side cho-ledochoduodenostomy (CDD) was performed.Several months following temporary postoperative reliefof his symptoms, the patient developed recurrent episodicright upper quadrant and epigastric pain, but withoutassociated jaundice or fever. He was referred to StanfordUniversity Medical Center, where he was seen by a gas-troenterologist for evaluation and further management.His past medical history included atrial fibrillation,hyperlipidemia, diabetes mellitus type II, and vestibularneuritis. Drug history included metoprolol, atorvastatin,metformin, dabigatran, dronedarone, and diltiazem. Thepatient had no known drug allergies. Socially, the patientdid not smoke and enjoyed only occasional alcohol. Therewas no family history of biliary tract disease.On examination, the patient appeared well and com-fortable, was slightly underweight, and had a soft and non-tender abdomen. The subcostal incision from his originalsurgery was visible but appeared well healed. Laboratoryfindings, including liver function tests, were normal (WBC7.9, Hb 13.4, Hct 39.4, Plts 257, Na 139, K 3.9, Cl 104,CO2 23, BUN 12, Cr 0.9, PT 15.4, INR 1.3, PTT 48.5, TBili 0.7, ALT 39, AST 16, Alk P 143, Glu 113, Ca 9.2). Anechocardiogram revealed mild mitral, aortic, and tricuspidvalve regurgitation, with an ejection fraction of 54%.Magnetic resonance cholangiopancreatography (MRCP)revealed a grossly dilated and tortuous CBD, as well asdilated common hepatic and intrahepatic ducts (Fig. 1a). Afluid–debris level was also seen in the CBD (Fig. 1b).Endoscopy revealed a patent side-to-side CDD anasto-mosis that could be entered with the gastroscope (Fig. 2).Moderate amounts of vegetable debris were seen in theCBD, and were removed using a rat-toothed forceps(Fig. 3). Using a duodenoscope, the CBD was also cann-ulated through the ampullary orifice and contrast injectionshowed an 18-mm-wide CBD with contrast extravasationthrough the stoma. Filling defects revealed further debris inthe distal CBD, which were cleared using a balloon cath-eter through the CDD.Following ERCP, the patient was immediately relievedof his symptoms. However, within a few days, the symp-toms recurred, and, again, included epigastric pain withoutjaundice or fever. Multiple further ERCPs were necessary,each revealing similar findings of vegetable debris withinthe CBD. Despite clearing the CBD during each procedure,the debris re-accumulated and symptoms always recurred.

Esophageal Avulsion Following Removal of a Partially Covered Esophageal Stent: Lessons Learned 10 Years Later

S esophageal stents are used for benign and malignant diseases, though no self-expandable metal stent (SEMS) is ood and Drug Administration (FDA)-approved for benign disease. ully covered SEMS and self-expandable plastic stents (SEPS) are emovable due to lack of tissue embedment.1 We describe a patient in whom a partially covered SEMS was placed for benign disease prior to the commercial availability of fully covered SEMS and SEPS. Subsequent removal was complicated by stent avulsion. A 60-year-old man underwent distal esophagectomy with proximal gastric resection of a T3N0M0 adenocarcinoma in early 2001. Two months after surgery, he developed an esophagogastric anastomotic stricture and tracheoesophageal fistula with severe aspiration pneumonia. Neither fully covered SEMS nor SEPS were commercially available then. A 23-mm diameter, partially covered SEMS (Ultraflex; Boston Scientific, Natick, MA) was placed across the esophagogastric anastomosis. He clinically improved with normal swallowing. Serial bronchoscopic examinations were performed (Figure A) until the stula could no longer be identified 6 months later. Endoscopic stent emoval was performed by grasping the proximal portion of the stent ith a rat-toothed forceps and was withdrawn, but the esophagus was till attached (Figure B). Pathology revealed squamous mucosa with ubmucosal fibrosis. The patient was emergently intubated, transerred to intensive care, and upper endoscopy showed completely enuded esophageal mucosa, but no perforation or disruption of the nastomosis was seen. Bronchoscopy showed a 1-mm tracheoesophgeal fistula. Repeat esophagoscopy and bronchoscopy 4 days later howed a hypopharyngeal tear at the upper esophageal sphincter. ollow-up examinations showed healing of the tear and fistula but he patient subsequently developed a refractory proximal cervical sophageal stricture necessitating hypopharyngeal colonic interposiion. Unfortunately, the patient developed chronic aspiration and ied of pneumonia 8.5 years after initial SEMS placement and withut recurrent adenocarcinoma. SEMS and SEPS were developed for palliation of malignant esophgeal disease. Over time they have been used for benign diseases. emoval of partially covered SEMS is feasible despite the fact that the ncovered portion becomes embedded into the esophageal wall. In ases where the distal end of a partially covered SEMS remains in the tomach embedding generally occurs only on the esophageal side. fter this present case and before SEPS and fully covered SEMS were ntroduced, we would remove partially covered SEMS using the inersion technique as described by Low and Kozarek.2 Nevertheless, there have been complications similar to this case.3,4 More recently, removal of partially covered SEMS using a stent-in-stent technique has been described.5 Using this method a fully covered SEMS or SEPS is placed inside the partially covered SEMS to induce tissue necrosis between the esophageal lumen and the embedded stent in order to bring the uncovered portion of the SEMS to the luminal surface. Both stents are then removed during the endoscopic session 7 to 14 days later (Supplementary Video 1). We continue to use partially covered SEMS in patients with benign esophageal disease who have experienced repeated SEMS and/or SEPS migration and have not resolved their underlying disease process with removal of the partially covered SEMS using the stent-in-stent technique as described. To date we have removed 5 partially covered SEMS using this method without technical difficulty or adverse event.

Sp699 Pancreatic Necrosectomy via Percutaneous Self-Expandable Metal Stent Placement

gastric wall to adhere to the abdominal wall before proceeding with ERCP. At our institution we have developed a novel way of EUS guided, fluoroscopic assisted access of gastric remnant followed by sutured gastropexy and subsequent ERCP, all in one session. We describe a series of three such cases. Endoscopic methods: The echo-endoscope was inserted trans-orally and advanced to the gastric pouch or the Roux limb. The remnant stomach was identified using sonographic features and was punctured across the pouch or roux limb wall using a 19G needle pre-loaded with 0.025 guidewire. Radioopaque contrast injection and fluoroscopy were used to confirm needle position. After advancing guidewire the remnant stomach was maximally inflated with air injection through the needle and the best point of percutaneous entry on the abdominal wall was chosen. An 18-gauge introducer needle was inserted into the lumen of the gastric remnant and a 0.035 wire advanced. The wire track was serially dilated and a gastroscope inserted into the remnant. The gastric wall was now secured to the anterior abdominal wall using full thickness sutures. The gastroscope was removed and a 15mm laproscopy port inserted for duodenoscope access. Clinical implications: This novel, one setting minimally invasive approach allows access to remnant stomach and upper GI tract for the purposes of diagnostic and therapeutic endoscopy/ERCP. It allows the use of duodenoscope for difficult cannulation and precise therapeutic ERCP manouvers such as bliary and pancreatic sphioncterotomy. As the gastric wall is secured to anterior abdominal wall with full thickness sutures, one does not run into the risk of dehisence and intra-peritoneal leakage of gastric contents. The use of EUS to access gastric remnant and maximal insufflation alllows for identification of the best point of per cutaneous puncture for gastrostomy tube thus reducing post operative complications and pain. This technique allows the gastrostomy placement and ERCP to be done in the same setting thus reducing health care costs and patient visits.

878 Prospective Randomized Comparative Study Using Hemoclip, Endoloop, and Fibrin Sealant for Endoscopic Closure of Iatrogenic Duodenal Perforation in a Porcine Model: HELLP Study

system, interstitial cells of Cajal and related cells are essential to promote our understanding of the pathophysiologic mechanisms. Aims: Determine 1. Technical feasibility, reproducibility and safety of performing a full thickness gastric biopsy (FTGB) using a submucosal endoscopy with mucosal flap (SEMF) technique; 2. Technical feasibility, reproducibility and safety of tissue closure using an endoscopic suturing device; 3. Presence of myenteric ganglia in tissue samples; 4. Long-term safety. Methods: Six 35kg pigs were studied. Each animal underwent a SEMF procedure. This involved a submucosal injection followed by dissection of the submucosal space using a prototype balloon. The unique unfurling of this dilation balloon created a submucosal tunnel revealing MP. A double channel therapeutic endoscope was advanced into the submucosal tunnel and using an endoscopic Doppler probe a suitable site for resection was identified. Rat tooth forceps was used to tent the MP followed by snare resection. The mucosal defect was closed by interrupted sutures using the endoscopic suturing device. Animals were survived for 2 weeks. To study 6 animals, 8 pigs were enrolled. Two were excluded early in the study after one death from anesthesia related complications and the other had a superficial mucosal tear over the tunnel. Therefore a MP resection was not performed and the animal recovered well, in this setting the procedure would normally be repeated after mucosal healing in 4-6 weeks. Results: FTGB was achieved using the SEMF technique, with the peritoneal cavity visualized endoscopically postresection in all 6 animals. The mucosal offset entry site was successfully closed using the suturing device in all animals. Average total procedure time was 77 mins with a range of 2-4 interrupted sutures placed per animal. Mean resected tissue size was 11 mm. Histology showed muscularis propria and serosa confirming full thickness resections. Multiple myenteric ganglia were visualized in all animals. The clinical course was uneventful. Repeat endoscopy and necropsy at 2 weeks showed absence of mucosal ulceration at either the entry sites or overlying the more distal MP resection sites. Retained sutures were present in 5/6 animals. There was complete healing of the serosa in all animals with minimal single band adhesions in 5/6 animals. Conclusions: Based on this study, FTGB using the SEMF technique and endoscopic suturing device are technically feasible, reproducible and safe. The larger tissue specimens allow for improved analysis of multiple cell types. Future studies will include reproducing this data in a pilot clinical study.

Usefulness of an algorithm for endoscopic retrieval of proximally migrated 5Fr and 7Fr pancreatic stents

Proximal migration of pancreatic stent (PMPS) is an infrequent event but its management can be technically challenging and there are no standard retrieval methods. This study aimed to determine the results of an endoscopic stent retrieval algorithm in terms of feasibility and efficacy of the endoscopic procedure. During the period from January 2008 to December 2009, 15 patients (8 women and 7 men with a mean age of 51.9 years) with PMPS were included in this study. Stent retrieval was approached initially with balloon extraction followed by rat-tooth forceps and basket. A rescue approach such as using a stent retriever was attempted when other approaches failed. All the PMPSs (six 5Fr, nine 7Fr) were retrieved successfully within one ERCP session. Balloon extraction was successful in 9 (60%) patients. In the 6 failed cases of balloon extraction, wire-guided rat-tooth forceps grasp was successful in 4, and stone extraction basket grasp was successful in 1 in whom forceps grasp failed. One stent was finally rescued with a stent retriever when balloon extraction, forceps and basket grasp all failed. In patients with successful balloon extraction, 44.4% (4/9) developed post-ERCP hyperamylasemia but none of them developed post-procedure pancreatitis. With this algorithm, 5Fr and 7Fr PMPS were successfully retrieved in all of the patients. Most PMPSs can be safely retrieved with the commonly-used approaches in this study. Those less used approaches can be used as a rescue method.

Proximally migrated pancreatic stent successfully removed using needle-knife and forceps: Complication after precut papillotomy assisted by pancreatic stenting

Pancreatic stent-assisted ampullary precut papillotomy is a rescue method for cases with difficult bile duct cannulation during endoscopic retrograde cholangiopancreatography (ERCP). We describe a case in which post-ERCP pancreatitis (PEP) developed due to the proximal migration of pancreatic stent, after precut papillotomy. Removal of the migrated pancreatic stent was achieved after needle-knife incision of the pancreatic duct's orifice followed by retrieval of the stent using rat-tooth forceps, which resulted in rapid resolution of the PEP. Caution is needed when pancreatic stent is placed after papillary incision. Needle-knife incision of the pancreatic duct orifice followed by forceps removal is an effective technique for rescuing pancreatic stent migration.

Unusual Gastrointestinal Foreign Bodies: Report of 18 Cases

Purpose: We report 18 cases with unusual GI foreign bodies at our institution between 01/2000 and 04/2010. Esophageal: E1. 69 y/F with quarter coin in the lower esophagus retrieved by roth net. E2. 75 y/F with metallic foreign body (FB) wedged at distal esophagus, deeply inserted into esophageal wall at both ends. Argon plasma coagulator used but failed. Successfully removed using rattooth forceps and biopsy forceps. 2 small perforations occurred which were sealed using 2 endoclips. E3. 63 y/F with pills overlying food bolus completely occluding lumen at level of middle third; could not be dislodged. Gastric: G1. 19 y/F with metal bolt in gastric fundus, successfully removed with snare. G2. 20 y/F with ‘Lipitor’ pen in gastric fundus and body retrieved using ERCP web basket. G3. 25 y/F with toothbrush in antrum removed with snare. G4. 19 y/F with food wrapper in gastric body. Multiple endoscopic attempts failed. G5. 85 y/F with 3 bobby pins in gastric body retrieved with snare and overtube to protect airway. G6. 45 y/F with 2 metallic screws in antrum retrieved using roth net. G7. 46 y/F with silastic tubing with suture from banded gastric bypass eroding into the lumen, successfully retrieved using scissors and large biopsy forceps. Duodenal: D1. 30 y/M with aluminum soda can top in bulb, removed using roth net. D2. 19 y/F with pen insert in second part of duodenum (D2) and AA battery in third part, retrieved with snare. D3. 21 y/M with orthodontic brace in D2, removed successfully with snare. D4. 20 y/F with eye glasses in D2, removed with rat-tooth forceps using overtube. Colonic: C1. 24 y/F with 2 hair pins in ascending colon (AC) removed using roth net and biopsy forceps. C2. 41 y/M with headphone metal piece in AC, removed with snare. C3. 49 y/F with crown of tooth in cecum, removed with roth net. C4. 20 y/F with multiple FBs (nuts, toothpaste cap, metal clip), all removed successfully using roth net and snare.FigureFigure

The Traction that Broke the Anti-reflux Stentʼs Back - A Rare but Important Complication

Purpose: The Cook Dua Esophageal Stent with Anti-Reflux Valve was developed to reduce reflux of stomach contents in patients with cancers of the esophagus. We report a case of a spontaneously torn anti-reflux flap previously noted to be in working order. Methods: The patient was a 55-year-old male with metastatic distal esophageal adenocarcinoma with progressive dysphagia. Previous placement of a partially covered esophageal Wallflex stent had allowed oral intake, but resulted in significant reflux symptoms secondary to the stent traversing the gastroesophageal junction. Decision to attempt placement of a Dua Anti Reflux Stent within the previously placed stent in order to curb the reflux of gastric contents. A gastroscope was advanced to the stomach traversing the previously placed Wallstent, retroflexion revealed the stent to be well situated beneath the lower esopohageal sphincter. A 12 cm Cook esophageal Z-stent with Dua anti-reflux valve was then passed over a Savory guide-wire with the distal most radio-opaue marker positioned over the distal margin of the previous stent. The stent was deployed into excellent position under fluroscopic guidance. The gastroscope was then advanced with no resistance and verification of positioning of both stents was confirmed. Post placement x-ray showed no evidence of perforation or migration and the patient was discharged with symptomatic improvement in reflux related discomfort. Results: Two weeks post placement, the patient returned with unbearable chest pain secondary to progressive reflux symptoms. The patient had severe dysphagia to both liquids and solids and had no chest wall tenderness and crepitis. Repeat Esophagogastroduodenoscopy (EGD) with fluroscopy revealed the two stents to be in good position. The scope was passed through the center of the stents into the stomach. The anti-reflux flaps of the Dua stent appeared to be partially torn along the distal edge of the stent with prolapse into the esophagus. A rat tooth forceps was used to grasp the proximal edge of the Z- stent and under fluroscopic guidance the stent was removed. The endoscope was passed again through the previous Wallflex stent which remained in good position without migration and tissue in-growth. The patient was medically managed for reflux and will be considered for repeat stent placement. Conclusion: Previous reports have noted overstrain or defective materials as the reason for the rupture. We believe the etiology of the tear of the anti-reflux valve in this instance to be from direct contact injury from the distal edge of the previously placed Wallflex esophageal stent. We recommend that post-placement tear with consequent dysphagia and recurrent reflux symptoms be cited as a potential complication.

Thyme and Again: One Surprise after Another in an Otherwise Healthy Man

Purpose: A 42-year-old male with no known medical history presented to the emergency department with mild right upper quadrant pain that was constant for three weeks. He denied nausea, vomiting, diarrhea, fever, anorexia or recent travel. PPIs and over the counter antacids offered minimal relief. Physical exam and lab data were unremarkable. CT of the abdomen showed a 3.3 cm lesion in the left lobe of the liver. An EGD was performed and a Y-shaped yellowish foreign body measuring 3.5 cm in maximal diameter was seen in a transverse orientation within the second portion of the duodenum (figure). There were 5 mm nodules near each edge with some heme and ulceration seen within the nodules. After insertion of an overtube to protect the esophagus, the foreign body was grasped with rat-tooth forceps and successfully withdrawn from the patient. On follow up two weeks later, the patient remarked that he was completely pain free. On further questioning, he recalled having eaten a dish containing fresh thyme sprigs a few weeks prior, which roughly coincided with the onset of pain. During that visit, a repeat CT scan with triple phase imaging was obtained for further evaluation of the previously seen liver lesion. Review of the CT showed a 3.6 × 3.4 cm hypodense lesion in the left lobe of the liver, with a pattern of enhancement that was consistent with focal nodular hyperplasia. Conclusion: We report here a case of an ingested thyme sprig causing gastrointestinal symptoms in an otherwise healthy patient. This clinical scenario is likely rare, though a case of cholangitis due to a branch of thyme that had migrated into the bile duct in a patient with a surgical choledochoduodenostomy has been reported. Furthermore, had it not been for the initial CT scan we might never have diagnosed the patient with focal nodular hyperplasia - a benign condition - but one that is rarely seen in men, with up to a 9:1 female predominance.Figure: [1034] Thyme sprig in the duodenum.

Endoscopic Diagnosis and Treatment of a Chicken Bone Perforating the Stomach and Penetrating into the Liver

Purpose: A 54-year-old male was admitted with a 3-day history of sharp epigastric pain and recurrent episodes of vomiting. Physical examination revealed mild tenderness in the mid-epigastric area without surgical signs of guarding or rebound tenderness. Routine laboratory studies were unremarkable. CT scan of the abdomen showed a 4 cm discrete linear radio-opaque object penetrating through the stomach and extending into the left lobe of the liver with adjacent pneumoperitoneum (A). Upper endoscopy revealed a chicken bone that penetrating into the gastric antrum (B). The bone, measuring 4 cm in length, was removed using rattooth forceps (C). Three endoscopic clips were applied at the site of removal to close the defect in the stomach. The patient's abdominal pain resolved soon after the procedure. The patient was treated conservatively (no oral intake, intravenous fluids and parental antibiotics) and a repeat CT scan 4 days later showed interval resolution of free air in the abdomen and no signs of gut perforation. The patient tolerated oral intake and was discharged home without problems. Upon questioning, the patient recalled swallowing several pieces of poorly chewed chicken one week before admission. A repeat endoscopy 4 weeks later showed complete closure of the perforation site and the patient was asymptomatic.Figure

Intentional Swallowing of Foreign Bodies Is a Recurrent and Costly Problem That Rarely Causes Endoscopy Complications

Guidelines support endoscopic removal of certain gastric foreign bodies (FBs) and all FBs lodged in the esophagus. We studied the poorly understood group of patients who intentionally ingest FBs. Cases of intentional ingestion of FBs (n = 305) were identified, retrospectively, from an electronic endoscopy database and followed. Cases occurred among 33 different patients, who underwent endoscopy from October 1, 2001, to July 31, 2009 (39.0 cases/year); 79% were diagnosed with a psychiatric disorder. Financial cost analysis was performed using hospital billing and cost systems. Commonly ingested FBs included pens (23.6%), batteries (9.2%), knives (7.2%), and razor blades (6.9%). Most endoscopic procedures were performed under general anesthesia. FBs were commonly retrieved by snares (58.0%), rat-toothed forceps (14.4%), and nets (11.5%), assisted sometimes by use of overtubes (10.8%), and hoods (4.6%). FB extraction was unsuccessful at the initial endoscopy in only 20 cases; 2 cases eventually required surgical extraction. Minor complications occurred in 11 endoscopies. There were no deaths or perforations. The total estimated costs were $2,018,073 ($1,500,627 in hospital costs, $240,640 in physician fees, and $276,806 for security services). Costs were significantly higher for inpatients. Major payers were Medicare (48%) and Medicaid (31%). Intentional FB ingestion occurs among a relatively small number of patients with psychiatric disorders and is costly. Endoscopic retrieval is relatively effective and safe, but often requires general anesthesia. These cases utilize significant hospital and fiscal resources. Attention should be focused on preventing these recurrent and costly episodes.

SUCCESSFUL RETRIEVAL OF AN IMPACTED MECHANICAL LITHOTRIPSY BASKET: A CASE REPORT

We report the successful retrieval of an impacted mechanical lithotripsy basket. In a patient with two large common bile duct stones, the basket with the entrapped stone was impacted within the mid-common bile duct. We then attempted to use another mechanical lithotripter; however the central wire of the basket fractured at the handle portion. Grasping a few wires of the impacted basket with rat-tooth forceps allowed the wires of the basket to slip away from the stone. The present report describes the safe and effective use of rat-tooth forceps in the management of an impacted lithotripter basket.