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Breakage of disposable biopsy forceps: a rare complication during GI endoscopy
Brief Reports 2. Lorenz R. Allergic reaction to contrast medium after endoscopic retrograde pancreatography [letter]. Endoscopy 1990;22:196. 3. Mantin FI, Tress BW, Colman PG, Deam DR. Iodine-induced hyperthyroidism due to nonionic contrast radiography in the elderly. Am J Med 1993;95:78-82. 4. Tombach B, Bremer C, Reimer P, Kisters K, Schaefer RM, Geens V, et al. Renal tolerance of a neutral gadolinium chelate (gadobutrol) in patients with chronic renal failure: results of a randomized study. Radiology 2001;218:651-7. 5. Townsend RR, Cohen DL, Katholi R, Swan SK, Davies BE, Bensel K, et al. Safety of intravenous gadolinium (Gd-Bopta) infusion in patients with renal insufficiency. Am J Kidney Dis 2000;36:1207-12. 6. Nussbaum ES, Casey SO, Sebring LA, Madison MT. Use of gadolinium as an intra-arterial contrast agent in digital subtraction angiography of the cervical carotid arteries and intracranial circulation [technical note]. J Neurosurg 2000;92:881-3. 7. Spinosa DJ, Kaufmann JA, Hartwell GD. Gadolinium chelates in angiography and interventional radiology: a useful alternative to iodinated contrast media for angiography. Radiology 2002;223:319-25.
nonionic contrast media in 7 of 28 patients with hyperthyroidism in a geriatric hospital.3 Hence, ERCP with an iodinated contrast agent was considered to be contraindicated in our patient. Paramagnetic contrast agents, usually administered intravenously, are used for magnetic resonance imaging (MRI) analogous to the use of iodinated contrast agents for CT. Most magnetic resonance contrast agents in clinical use are chelates of gadolinium. The major route of contrast excretion is renal. Unlike iodinated contrast media, however, MRI contrast agents have few side effects and rarely cause idiosyncratic reactions. They also are a good choice for patients with impaired renal function.4,5 For those reasons, magnetic resonance contrast agents have been used for arteriographic studies in unstable patients, in patients with impaired renal function, and in patients with a history of an anaphylactoid reaction to an iodinated contrast medium.6,7 The case presented suggests that these agents also can be used for ERCP when necessary. Further studies of the use of magnetic resonance contrast agents for ERCP in selected patients with a history of severe adverse reactions to iodinated contrast agents are warranted.
Department of Gastroenterology (F.M-F.); Institute of Radiology (M.S.R.); Department of Gastroenterology (P.S.), Sa˜o Paulo University, Sa˜o Paulo, Brazil.
REFERENCES
Reprint requests: Fauze Maluf-Filho, MD, R. Sergipe, 401 cj. 102, Sa˜o Paulo – SP, CEP 01243-906, Brazil.
1. Kimmey MB, Al-Kawas FH, Carr-Locke DL, Edmundowicz SA, Gannan RM, Jamidar PA, et al. Technology assessment: radiographic contrast media used in ERCP. Gastrointest Endosc 1996;43:647-51.
Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/2005/$30.00 + 0 PII: S0016-5107(05)00125-2
Breakage of disposable biopsy forceps: a rare complication during GI endoscopy Ichiro Yoshikawa, MD, PhD, Masahiro Yamasaki, MD, Keiichiro Kume, MD, Akinari Tabaru, MD, PhD, Makoto Otsuki, MD, PhD Kitakyushu, Japan
EGD is one of the most commonly performed procedures in the world. Despite the expanding volume of such procedures, the complication rate for EGD remains low, at 0.25%, with a mortality rate of 0.009%.1 The device most frequently used during GI endoscopy is the biopsy forceps. Several studies have compared the cost, the function, and the safety of reusable vs. disposable biopsy forceps.2,3 The rate of malfunction of reusable forceps is 80% at 21 to 25 uses, whereas disposable forceps invariably functioned well.2 The use of reusable biopsy forceps carries the potential risk of transmission of infectious agents if these devices are not cleaned, disinfected, and reprocessed according to strict standards. From these reasons, the use of disposable endoscopic accessories is growing substantially. 918 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 7 : 2005
CASE REPORT Case 1 A rare complication was encountered while trying to obtain a specimen from a polypoid lesion on the anterior wall of the distal gastric body by using a disposable biopsy forceps (Radial Jaw 3, standard size; Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass). In our unit, a new disposable forceps is used whenever a biopsy specimen is to be obtained. Normally, the forceps is inserted through the accessory channel of the endoscope, in this case a forwardviewing instrument with a 2.8-mm-diameter channel (GIF 230; Olympus Optical Co, Ltd, Tokyo, Japan), when the endoscope tip is in the mid body of the stomach, and it is not angulated or deflected. The jaws of the forceps were www.mosby.com/gie
Brief Reports
oriented perpendicular to the gastric wall, advanced against the target, and closed. Upon closure, however, the forceps were bent at a nearly right angle (Fig. 1) and could not be withdraw into the endoscope. The forceps were pulled back against the accessory channel opening at the tip of the endoscope, whereupon it was possible to safely withdraw the endoscope and the forceps together. The patient was not injured, and there was no damage to the endoscope. The experienced endoscopist had inserted the forceps into the accessory channel smoothly, and the experienced assistant closed the forceps with a slow, steady motion. No unusual force was exerted in attempting to obtain the biopsy specimen.
Case 2 In another case, the biopsy forceps (Radial Jaw 3, standard size; Microvasive Endoscopy) broke in the exact same manner as in Case 1. In this second case, however, the forceps was opened and closed several times to ensure that it was functioning correctly before inserting it into the accessory channel of the endoscope. Thus, the defect in this forceps was identified before using it for the procedure. The broken forceps was exchanged for a new one, and the potential for a complication, therefore, was averted.
DISCUSSION In both cases described above, the disposable forceps were brand new and were used before the product expiration date. The explanation for the failure of the forceps was unclear, but it appeared that a fine wire within the forceps was not firmly attached. The forceps malfunction encountered in the first case was immediately reported to the manufacturer. A representative of the company informed us that their biopsy forceps are manufactured by hand by highly experienced workers and that, despite strict quality control, the probability of breakage based on reported instances was only 0.0005%. In our endoscopy unit, however, breakage occurred in two disposable biopsy forceps among 12,000 uses during a 5-year period, a rate of breakage of 0.016%. Breakage of reusable biopsy forceps because of metal fatigue appears to be rare, although it is reported.4 A search of medical publications did not identify any published report pertaining to breakage of disposable biopsy forceps as a complication during GI endoscopy. To reduce the potential for complications, however, endos-
www.mosby.com/gie
Figure 1. Endoscopic image showing broken jaws of disposable biopsy forceps (Radial Jaw 3, standard size; Microvasive Endoscopy).
copists should be aware that disposable biopsy forceps can break during a procedure. REFERENCES 1. Cooper GS, Blades EW. Indications, contraindications, and complications of upper gastrointestinal endoscopy. In: Sivak MV Jr, editor. Gastroenterologic endoscopy. Philadelphia: W.B. Saunders; 2000. p. 438-54. 2. Yang R, Ng S, Nichol M, Laine L. A cost and performance evaluation of disposable and reusable biopsy forceps in GI endoscopy. Gastrointest Endosc 2000;51:266-70. 3. Bourguignon C, Destrumelle AS, Koch S, Grumblat A, Carayon P, Chopard C, et al. Disposable versus reusable biopsy forceps in GI endoscopy: a cost-minimization analysis. Gastrointest Endosc 2003;58: 226-9. 4. Malik SK, Behera D. Breakage of alligator biopsy forceps. An usual complication during fiberoptic bronchoscopy. Chest 1984;85:837-8.
Third Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Iseigaoka, Yahatanishi-ku, Kitakyushu, Japan. Reprint requests: Makoto Otsuki, MD, PhD, The Third Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan. Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/2005/$30.00 + 0 PII: S0016-5107(05)00123-9
Volume 61, No. 7 : 2005 GASTROINTESTINAL ENDOSCOPY 919
nonionic contrast media in 7 of 28 patients with hyperthyroidism in a geriatric hospital.3 Hence, ERCP with an iodinated contrast agent was considered to be contraindicated in our patient. Paramagnetic contrast agents, usually administered intravenously, are used for magnetic resonance imaging (MRI) analogous to the use of iodinated contrast agents for CT. Most magnetic resonance contrast agents in clinical use are chelates of gadolinium. The major route of contrast excretion is renal. Unlike iodinated contrast media, however, MRI contrast agents have few side effects and rarely cause idiosyncratic reactions. They also are a good choice for patients with impaired renal function.4,5 For those reasons, magnetic resonance contrast agents have been used for arteriographic studies in unstable patients, in patients with impaired renal function, and in patients with a history of an anaphylactoid reaction to an iodinated contrast medium.6,7 The case presented suggests that these agents also can be used for ERCP when necessary. Further studies of the use of magnetic resonance contrast agents for ERCP in selected patients with a history of severe adverse reactions to iodinated contrast agents are warranted.
Department of Gastroenterology (F.M-F.); Institute of Radiology (M.S.R.); Department of Gastroenterology (P.S.), Sa˜o Paulo University, Sa˜o Paulo, Brazil.
REFERENCES
Reprint requests: Fauze Maluf-Filho, MD, R. Sergipe, 401 cj. 102, Sa˜o Paulo – SP, CEP 01243-906, Brazil.
1. Kimmey MB, Al-Kawas FH, Carr-Locke DL, Edmundowicz SA, Gannan RM, Jamidar PA, et al. Technology assessment: radiographic contrast media used in ERCP. Gastrointest Endosc 1996;43:647-51.
Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/2005/$30.00 + 0 PII: S0016-5107(05)00125-2
Breakage of disposable biopsy forceps: a rare complication during GI endoscopy Ichiro Yoshikawa, MD, PhD, Masahiro Yamasaki, MD, Keiichiro Kume, MD, Akinari Tabaru, MD, PhD, Makoto Otsuki, MD, PhD Kitakyushu, Japan
EGD is one of the most commonly performed procedures in the world. Despite the expanding volume of such procedures, the complication rate for EGD remains low, at 0.25%, with a mortality rate of 0.009%.1 The device most frequently used during GI endoscopy is the biopsy forceps. Several studies have compared the cost, the function, and the safety of reusable vs. disposable biopsy forceps.2,3 The rate of malfunction of reusable forceps is 80% at 21 to 25 uses, whereas disposable forceps invariably functioned well.2 The use of reusable biopsy forceps carries the potential risk of transmission of infectious agents if these devices are not cleaned, disinfected, and reprocessed according to strict standards. From these reasons, the use of disposable endoscopic accessories is growing substantially. 918 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 7 : 2005
CASE REPORT Case 1 A rare complication was encountered while trying to obtain a specimen from a polypoid lesion on the anterior wall of the distal gastric body by using a disposable biopsy forceps (Radial Jaw 3, standard size; Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass). In our unit, a new disposable forceps is used whenever a biopsy specimen is to be obtained. Normally, the forceps is inserted through the accessory channel of the endoscope, in this case a forwardviewing instrument with a 2.8-mm-diameter channel (GIF 230; Olympus Optical Co, Ltd, Tokyo, Japan), when the endoscope tip is in the mid body of the stomach, and it is not angulated or deflected. The jaws of the forceps were www.mosby.com/gie
Brief Reports
oriented perpendicular to the gastric wall, advanced against the target, and closed. Upon closure, however, the forceps were bent at a nearly right angle (Fig. 1) and could not be withdraw into the endoscope. The forceps were pulled back against the accessory channel opening at the tip of the endoscope, whereupon it was possible to safely withdraw the endoscope and the forceps together. The patient was not injured, and there was no damage to the endoscope. The experienced endoscopist had inserted the forceps into the accessory channel smoothly, and the experienced assistant closed the forceps with a slow, steady motion. No unusual force was exerted in attempting to obtain the biopsy specimen.
Case 2 In another case, the biopsy forceps (Radial Jaw 3, standard size; Microvasive Endoscopy) broke in the exact same manner as in Case 1. In this second case, however, the forceps was opened and closed several times to ensure that it was functioning correctly before inserting it into the accessory channel of the endoscope. Thus, the defect in this forceps was identified before using it for the procedure. The broken forceps was exchanged for a new one, and the potential for a complication, therefore, was averted.
DISCUSSION In both cases described above, the disposable forceps were brand new and were used before the product expiration date. The explanation for the failure of the forceps was unclear, but it appeared that a fine wire within the forceps was not firmly attached. The forceps malfunction encountered in the first case was immediately reported to the manufacturer. A representative of the company informed us that their biopsy forceps are manufactured by hand by highly experienced workers and that, despite strict quality control, the probability of breakage based on reported instances was only 0.0005%. In our endoscopy unit, however, breakage occurred in two disposable biopsy forceps among 12,000 uses during a 5-year period, a rate of breakage of 0.016%. Breakage of reusable biopsy forceps because of metal fatigue appears to be rare, although it is reported.4 A search of medical publications did not identify any published report pertaining to breakage of disposable biopsy forceps as a complication during GI endoscopy. To reduce the potential for complications, however, endos-
www.mosby.com/gie
Figure 1. Endoscopic image showing broken jaws of disposable biopsy forceps (Radial Jaw 3, standard size; Microvasive Endoscopy).
copists should be aware that disposable biopsy forceps can break during a procedure. REFERENCES 1. Cooper GS, Blades EW. Indications, contraindications, and complications of upper gastrointestinal endoscopy. In: Sivak MV Jr, editor. Gastroenterologic endoscopy. Philadelphia: W.B. Saunders; 2000. p. 438-54. 2. Yang R, Ng S, Nichol M, Laine L. A cost and performance evaluation of disposable and reusable biopsy forceps in GI endoscopy. Gastrointest Endosc 2000;51:266-70. 3. Bourguignon C, Destrumelle AS, Koch S, Grumblat A, Carayon P, Chopard C, et al. Disposable versus reusable biopsy forceps in GI endoscopy: a cost-minimization analysis. Gastrointest Endosc 2003;58: 226-9. 4. Malik SK, Behera D. Breakage of alligator biopsy forceps. An usual complication during fiberoptic bronchoscopy. Chest 1984;85:837-8.
Third Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Iseigaoka, Yahatanishi-ku, Kitakyushu, Japan. Reprint requests: Makoto Otsuki, MD, PhD, The Third Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan. Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/2005/$30.00 + 0 PII: S0016-5107(05)00123-9
Volume 61, No. 7 : 2005 GASTROINTESTINAL ENDOSCOPY 919