Use Of Overtube Research Articles

Novel use of overtube for rectal foreign body to “clean” out the colon: Extraction of large Tide-To-Go pen

The rate of colorectal foreign bodies is increasing. Endoscopists must be creative in order to remove the foreign objects safely in the most minimally invasive manner as these objects could vary greatly in size and shape. We present a case of the novel use of an esophageal overtube to aid in the removal of a difficult-to-remove Tide-To-Go cap.

1868 Novel Use of Overtube for Rectal Foreign Body to “Clean” Out the Colon: Extraction of Large Tide-To-Go Pen

INTRODUCTION: The rate of colorectal foreign bodies is rising. This poses an interesting challenge to endoscopists as there is great variability in object size, shape, and surface characteristics. This heterogeneity requires endoscopists to have a diverse range of techniques at their disposal to safely remove colorectal foreign bodies in a minimally invasive manner. We present a case of the novel use of an esophageal overtube to aid in the removal of a difficult-to-remove Tide To Go cap. CASE DESCRIPTION/METHODS: The patient was a 55-year-old male who presented to the ED about 24 hours after inserting a smooth plastic Tide To go pen into his rectum. When he attempted to remove the pen, the cap was left behind. He denied any pain, hematochezia, fevers or chills. In the ED he underwent a CT scan which showed a well circumscribed air-containing elongated and conelike region occupying the rectum and rectosigmoid with mild thickening of the rectal wall without extraluminal air. We initially gave him 4L of Golytely to flush the object, but he did not pass the object on his own. During flexible sigmoidoscopy we could appreciate a very strictured and erythematous rectum and a smooth, white, plastic object lodged in the rectosigmoid colon. Multiple attempts at pulling the object out with rat-tooth forceps, snare, and Roth net were all futile as we could not pull the object through the narrowed rectum. We then inserted a heavily lubricated esophageal overtube through the rectum and pulled the object into the overtube and removed the cap and overtube together. The overtube helped dilate and straighten the rectum while allowinging the object to be secured into the overtube. DISCUSSION: The incidence of patients presenting to emergency departments with rectal foreign bodies is increasing, particularly in males. Recurrent episodes of rectal foreign body insertion requiring repeat endoscopic and surgical interventions for extraction can lead to anorectal stricturing. The alteration of anatomy may, as in this case, result in difficulty with foreign body extraction despite endoscopic access to the object. Stenting of the overlying mucosa and straightening of the rectum with overtube placement may facilitate successful retrieval of the rectal foreign body.

1798 An Endoscopic Vacuum-Assisted Closure Technique Modified Through the Overtubes for Patients With Esophageal Anastomotic Leaks

INTRODUCTION: Endoscopic vacuum-assisted closure (E-VAC) therapy is safe and effective for esophageal anastomotic leaks. However, the repetitive exchange of sponge tubes is technically demanding. CASE DESCRIPTION/METHODS: We designed an E-VAC technique, modified through the use of overtube, to make E-VAC therapy safer and more comfortable for both endoscopists and patients. Intraluminal E-VAC therapies were used for the treatment of post-operative thoracic esophageal leaks in five cases of esophageal cancer. After overtube insertion, sponge tube was inserted through the overtube, while keeping biopsy forcep inside the nasogastric tube (NGT), and was positioned at intraluminal leakage site under endoscopic guidance. NGT was repositioned from the mouth to the nostrils using carrier tube and a controlled negative pressure was applied. Sponge tube was regularly changed twice a week until the complete closure of leaks. Technical and clinical success rates were analyzed to evaluate the safety and efficacy of this technique. The modified E-VAC therapy was applied in five selected cases for a mean of 13.8 days (range, 7-28 days) with a mean of 3.2 sponge tube changes (2-6 changes) for anastomotic leaks that were, on average, 1.0 cm (0.5-2 cm). The mean procedural time was 14.9 min (12-30 min) and no E-VAC therapy-related complications occurred. All patients were discharged, on average, after 44.4 days (range, 14-95 days) of hospitalization and two cases were treated with additional esophageal metal stents after six and two sponge tube changes, respectively. DISCUSSION: Our E-VAC therapy technique, modified via inserting sponge tubes through overtube, is effective and safe for patients with thoracic esophageal anastomotic leaks.

Laparoscopic Transgastric Endoscopy after Roux-en-Y Gastric Bypass: Case Series and Review of the Literature

Endoscopic access to the gastric remnant and pancreatobiliary tree is technically difficult after Roux-en-Y gastric bypass even when facilitated by the use of specialized techniques such as balloon enteroscopy and the use of overtubes. Furthermore, such techniques are not universally available at all medical centers. We describe a case series of 13 patients with a history of Roux-en-Y gastric bypass for the treatment of morbid obesity who underwent laparoscopic transgastric endoscopy through the gastric remnant to access the duodenum or biliary tree. Charts of these patients were reviewed for demographics, indications for procedure, length of stay, morbidity, and mortality. Four of the patients had failed prior attempts to access the excluded anatomy through traditional transoral endoscopy. Two patients underwent transgastric endoscopy for evaluation of gastrointestinal bleeding. Of the 11 patients for whom endoscopic retrograde cholangiopancreatography was planned, all underwent successful biliary cannulation and sphincterotomy. There were no conversions to an open procedure or complications during the follow-up period. Laparoscopic transgastric endoscopy is a safe and reliable method to access the excluded stomach and biliary tree in patients with a history of Roux-en-Y gastric bypass.

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.

Acute Pancreatitis and Hyperamylasemia After Double Balloon Enteroscopy: Evaluation of 6720 Procedures with Qualitative Meta-analysis

Purpose: Until recently, the small bowel was beyond the reach of GI endoscopists. However, with the introduction of double balloon (DBE) and single balloon enteroscopy using both antegrade and retrograde approaches, this last frontier in endoscopy has been conquered. It is generally considered a safe although time consuming procedure. A few cases of acute pancreatitis (AP) and hyperamylasemia (HA) after antegrade DBE have been reported. We evaluated the incidence of AP and HA after antegrade DBE in the published literature and performed qualitative meta-analysis (QMA) on the available information. Methods: PubMed search for AP and HA after antegrade DBE with no language or time barrier was carried out. More publications were manually added from the reference lists in key articles. To facilitate QMA, summary sheets of publications were created. QMA was performed using the well established methods of qualitative research such as Diagramming, Theme Repetition without serious contradiction, Theme Saturation, and Investigator Reflexivity (Eval Rev 1985; 9:627-643; The Lancet, 2001; 358:483-488). Quantitative data can be used to do QMA. Results: The literature search provided 6720 DBE procedures for evaluation and QMA.AP as a complication of DBE was found to occur in 1.7% (range 0.3 to 17) of cases. HA was reported in 49% cases after DBE. Information about gender of patients was available in 734 cases; there were 342 women (46.5%). Information about the age was available in 738 patients; mean age was 67.4 (range 17-92)years. Information about the duration of procedure was available in 460 cases; the mean duration was 99 (range 20-400) minutes. The mechanism of HA and AP after DBE is not known but production of closed duodenal loop (Am J Dig Dis 1977; 22:182-188), occlusion of the ampulla or damage to the ampulla by the overtube have been mentioned. There is no consensus about the relationship between duration of procedure & occurrence of AP and HA. Conclusion: HA and AP have been reported after DBE; HA in 49% and AP in 1.7% of cases. Damage caused by the overtube seems to be important. Mann's balloon technique for deep enteroscopy (MBTDE) without the use of overtube has been reported (Am J Gastro 2009; 104: Sept 2009).

A possible method of decreasing bleeding and infection risk in the course of transgastric surgery

Introduction: During the last years many people expressed their doubts whether the rapid development of minimal invasive transgastric surgery increased the risk of bleeding and infection. To solve the problem the literature recommends the use of antibiotic washout, sterile instruments and overtube. So far there has been no specially designed overtube for the transgastric technique. Aim: To design and produce an overtube which overcomes the challenges. Method: Our device was tested on the gastrointestinal tract of a slaughtered pig. The length of the tube was 70cm, the diameter was 3cm, and the thickness of its wall was 0.5mm. It was made of silicon. The overtube was compressed parallel to the longitudinal axis and put into a cover. On the gastric end of the overtube there were two separately inflatable ring-formed balloons to fix the tube to the stomach wall. With a needle knife an incision was made on the gastric wall, through which we managed the compressed end of the overtube into the abdominal cavity. The cover was pulled back and the distal balloon was blown up. With minor force the overtube was moved back while the distal balloon stretched to the outer surface of the gastric wall. From the proximal balloon the cover was removed and it was also blown up. With the help of the overtube a Fallopian tube ligation was performed. Result: Using the overtube we led two flexible endoscopes quickly and safely into the abdominal cavity, moreover, other instruments could also be used and exchanged without any difficulties. The injury of the esophagus could be avoided. With the use of the overtube as a consequence of the compression and closure between the two balloons the risk of bleeding and infection can be reduced. An insufflator can be attached to the overtube so the abdominal pressure becomes measurable. An unexpected result was that as the overtube gave greater rigidity to the instruments the performance of the tube ligation was easier and faster. Conclusion: To lower the risks even further besides the use of specially designed surgical instruments other subsidiary devices are also needed.

Endoscopic band ligation in the treatment of portal hypertension

The evidence that endoscopic band ligation (EBL) has greater efficacy and fewer side effects than endoscopic injection sclerotherapy has renewed interest in endoscopic treatments for portal hypertension. The introduction of multishot band devices, which allow the placement of 5-10 bands at a time, has made the technique much easier to perform, avoiding the use of overtubes and their related complications. EBL sessions are usually repeated at 2 week intervals until varices are obliterated, which is achieved in about 90% of patients after 2-4 sessions. Variceal recurrence is frequent, with 20-75% of patients requiring repeated EBL sessions. According to current evidence, nonselective beta-blockers are the preferred treatment option for prevention of a first variceal bleed, whereas EBL should be reserved for patients with contraindications or intolerance to beta-blockers. Nonselective beta-blockers, probably in association with the vasodilator isosorbide mononitrate, and EBL are good treatment options to prevent recurrent variceal rebleeding. The efficacy of EBL might be increased by combining it with beta-blocker therapy. Patients who are intolerant, have contraindications or bled while receiving primary prophylaxis with beta-blockers must be treated with EBL. In the latter situation, EBL should be added to rather than replace beta-blocker therapy. EBL, in combination with vasoactive drugs, is the recommended form of therapy for acute esophageal variceal bleeding; however, endoscopic injection sclerotherapy can be used in the acute setting if EBL is technically difficult.

Foreign body ingestion: review and suggested guidelines for management.

Eighty percent of ingested foreign bodies which reach to stomach will pass uneventfully through the gastrointestinal tract. The remainder may cause obstruction, perforation or hemorrhage. The risk of complications is increased with long sharp metal objects and animal bones, and may be higher in patients with adhesions due to prior abdominal surgery. Pre-existing intestinal disease such as Crohn's or intestinal stenosis may predispose to complications. The use of overtubes has made endoscopic removal of sharp objects safer. In patients at increased risk for complications, we recommended early endoscopic retrieval of ingested foreign objects.