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Endoscopic removal of an entrapped foreign body from the sigmoid colon using a needle knife
Endoscopic removal of an entrapped foreign body from the sigmoid colon using a needle knife Francisco C. Ramirez, Steven T. Zierer, Michael R. Mills, Robert A. Sanowski,
MD MD MD MD
Ingested foreign bodies usually pass through the digestive system uneventfully. Occasionally, objects become entrapped within the gut lumen or, rarely, become embedded within the gut wall. The latter may be resistant to traditional endoscopic removal techniques and require surgery. We report the first use of a needle knife in the endoscopic removal of a sharp-pointed object entrapped in the sigmoid colon, thus averting the need for surgical intervention.
Figure 1. Foreign body with sharp-pointed ends encircling mucosal bridge.
CASE REPORT A 69-year-old edentulous man with a history ofvagotomy, antrectomy, and Billroth II anastomosis for peptic ulcer disease 16 years ago underwent screening flexible sigmoidoscopy. Examination terminated at 30 cm from the anal verge because of inadequate preparation. There were several polyps and extensive diverticulosis. Two weeks later, a colonoscopy revealed four polyps in the right side of the colon and six polyps in the transverse colon that were successfully removed. At 35 cm from the anal verge, there was a sharppointed foreign body with surrounding diverticula, polypoid lesions, and hyperemic mucosa with punctate hemorrhages. This object was entrapped by a mucosal bridge going through the central portion (Fig. 1). Efforts to remove the foreign body with the polypectomy snare (Bard Optimizer Polypectomy Snare, Bard Interventional Products, Tewksbury, Mass.) and rat-tooth forceps (Olympus America Inc., Melville, N.Y.) failed. The object moved freely around the band of tissue, but would not release with traction. The patient remained in the hospital after the procedure for further evaluation and surgical consultation. After discussing the potential risk of perforation without treatment, the choice of surgery or a more aggressive endoscopic approach was offered to the patient. He chose to have another endoscopic procedure with the support of the surgical service should urgent intervention be required. The following day, 12 and 15 mm through-the-scope esophageal dilation balloons (Microvasive Maxforce TTS High Performance Balloon Dilation Catheter, Boston Scientific Co, Boston, Mass.) placed across the inner aspect of the object stretched but did not release the object from the mu-
From the Department of Medicine, Gastroenterology Section, Carl T. Hayden Veterans Affairs Medical Center, Phoenix, Arizona. Reprint requests: Francisco C. Ramirez, MD, Carl T Hayden VAMC (111G), 650 E. Indian School Rd., Phoenix, AZ 85012. 37/4/67024
84 GASTROINTESTINAL ENDOSCOPY
Figure 2. Completely transected mucosal bridge after endoscopic electroincision, which freed the plastic tab for endoscopic removal.
cosal bridge. Repeated efforts with the rat-tooth forceps and polypectomy snare also failed. Through the biopsy channel of a 60 cm video flexible sigmoidoscope (Olympus America Inc.), three injections of 1:10,000 epinephrine (total 6.5 ml) into the midportion of the mucosal bridge were administered using a retractable injection sclerotherapy needle (Retractable Flexitip Needle, 25 gauge 5 mm, Bard Interventional Products). A needle knife (Wilson-Cook Medical, Inc., Winston-Salem, N.C.) was then passed and the cutting wire exposed. After a few practice passes, the electrocautery unit (Valleylab SSE2L Solid State Electrosurgery, Boulder, Colo.) was set with monopolar blended current (three cut, three coagulation) and short bursts of current delivered using the cut pedal. This resulted in successful transection of the mucosal bridge (Fig. 2). The procedure resulted in no abdominal pain or bleeding. The foreign body was retrieved with rat-tooth forceps and was found to be a plastic tab used for sealing bread bags (2.3 cm by 2.2 cm). The patient stayed in the hospital overnight and received a clear liquid diet and parenteral antibiotics. He experienced no abdominal pain, VOLUME 44, NO. 1, 1996
fever, or bleeding and was discharged the next day on a regular diet. The patient reported no complaints on follow-up, and repeat flexible sigmoidoscopy 4 weeks later showed healing with a residual scar. DISCUSSION
Foreign body ingestion occurs most commonly in adults with mental retardation, psychiatric disorders, alcoholism, imprisonment, and those involved in drug trafficking} The risk of accidental foreign body ingestion also increases in subjects with dentures because of their impaired tactile sensation. 2 Most ingested foreign bodies are found in the esophagus or stomach, but occasionally objects will pass into the small intestine and colon. This is more likely to occur when natural barriers, such as the pylorus or ileocecal valve, have been altered by prior surgery or disease. Foreign bodies in the rectosigmoid colon are usually the result of insertion through the anus. Overall, 80% to 90% of ingested objects pass spontaneously; 10% to 20% need endoscopic removal and 1% require surgery. 3-5 Although less than 1% of all foreign bodies will perforate the gut, 6 for a sharp-pointed object the rate of perforation is as high as 15% to 35% and removal becomes necessary. 79 In the past, removal of foreign bodies from the lower gastrointestinal tract was generally performed with a rigid endoscope or required surgery} ° With the development of flexible endoscopy, successful removal of foreign bodies was later reported in the cecum 11, 12and transverse colon 13using polypectomy snares or biopsy forceps. In our patient, a plastic tab was incidentally found lodged in the sigmoid colon with surrounding diverticular disease. Poor tactile sensation and altered gastric anatomy were the predisposing factors in this unusual case of foreign body ingestion. Most likely, the sharply-pointed object became trapped between saddle-bag diverticula and pierced the adjoining wall, resulting in a mucosal bridge. Cutting the mucosal bridge with a needle knife not only allowed successful endoscopic removal but avoided surgery. Endoscopic electroincision has been used for sphincterotomy, management of Schatzki's ring 14 and benign gastrointestinal strictures, 15-17 and to gain access to pancreatic pseudocysts} s Recently, a hot biopsy forceps was used to cut a mucosal bridge that formed at a colonic anastomosis with relief of constipation} 9 In our patient, a much thicker mucosal bridge made multiple passes with the needle knife a more viable option. This case demonstrates a new application of the needle knife for removal of entrapped foreign bodies
VOLUME 44, NO. 1, 1996
that are resistant to conventional endoscopic methods. We used epinephrine injection to reduce the likelihood of bleeding through local vasoconstriction and tamponade. To ensure proper orientation of the needle knife, multiple sham passes were made prior to the use of cutting current. Although no immediate or delayed complications were encountered, we believe that surgical back-up should always be available. ACKNOWLEDGMENT
We wish to thank the Medical Media Department of the Carl T. Hayden VA Medical Center for assistance with photographic reproduction. REFERENCES 1. Ginsberg GG. Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc 1995;41:33-8. 2. Bunker PG. The role of dentistry in problems of foreign body in the air and food passage. J Am Dent Assoc 1962;64:782-7. 3, Perelman H. Toothpick perforation of the gastrointestinal tract. Journal of Abdominal Surgery 1962;4:51-3. 4. Schwartz GF, Polsky HS. Ingested foreign bodies of the gastrointestinal tract. Am Surg 1976;42:236-8. 5. Bendig DW, Mackie GG. Management of smooth-blunt gastric foreign bodies in asymptomatic patients. Clin Pediatr 1990;29: 642-5. 6. Johnson WE. On ingestion of razor blades. JAMA 1969;208: 2163. 7. Vizcarrondo FJ, Brady PG, Nord HJ. Foreign bodies in the upper gastrointestinaltract. Gastrointest Endosc 1983;29:208-10. 8. Rosh W, Classen M. Fiberendoscopic foreign body removal from the upper gastrointestinal tract. Endoscopy 1972;4:193-7. 9. Carp L. Foreign bodies in the intestine. Ann Surg 1927;85:57591. 10. Barone JE, Yee J, Nealon TF. Management of foreign bodies and trauma of the rectum. Surg Gynecol Obstet 1983;156: 453-7. 11. Vemula NR, Madariaga J, Brand DL, Hershey H. Colonoscopic removal of a foreign body causing colocutaneous fistulas. Gastrointest Endosc 1982;28:195-6. 12. Sorenson RM, Bond JH Jr. Colonoscopic removal of a foreign body from the cecum. Gastrointest Endosc 1975;21:134-5. 13. Oehler JR, Dent TL, Ibrahim MAH, Gracie WA Jr. Endoscopic identification and removal of an unusual symptomatic colonic foreign body. Dig Dis Sci 1979;24:236-9. 14. Guelrud M, VillasmilL, Mendez R. Late results in patients with Schatzki ring treated by endoscopic electrosurgical incision of the ring. Gastrointest Endosc 1987;33:96-8. 15. Thorsen G, RosselandAR. Endoscopic incision ofpostoperative stenoses in the upper gastrointestinal tract. Gastrointest Endosc 1983;29:26-9. 16. Groitl H, Endoscopic treatment of scar stenosis. Endoscopy 1984;6:168-70. 17. Moreto M, Zaballa M, Ibanez S. Endoscopic incision as an alternative to bougienage in the treatment of peptic esophageal stricture. Endoscopy 1990;22:105-9. 18. Lawson JM, Baillie J. Endoscopic therapy for pancreatic pseudocysts. Gastrointestinal Endoscopy Clinics of North America. 1995;5:181-93. 19. Weinstock LB, Shatz BA. Endoscopic treatment of a colonic anastomotic mucosal bridge. Gastrointest Endosc 1994;40: 773-4.
G A S T R O I N T E S T I N A L E N D O S C O P Y 85
MD MD MD MD
Ingested foreign bodies usually pass through the digestive system uneventfully. Occasionally, objects become entrapped within the gut lumen or, rarely, become embedded within the gut wall. The latter may be resistant to traditional endoscopic removal techniques and require surgery. We report the first use of a needle knife in the endoscopic removal of a sharp-pointed object entrapped in the sigmoid colon, thus averting the need for surgical intervention.
Figure 1. Foreign body with sharp-pointed ends encircling mucosal bridge.
CASE REPORT A 69-year-old edentulous man with a history ofvagotomy, antrectomy, and Billroth II anastomosis for peptic ulcer disease 16 years ago underwent screening flexible sigmoidoscopy. Examination terminated at 30 cm from the anal verge because of inadequate preparation. There were several polyps and extensive diverticulosis. Two weeks later, a colonoscopy revealed four polyps in the right side of the colon and six polyps in the transverse colon that were successfully removed. At 35 cm from the anal verge, there was a sharppointed foreign body with surrounding diverticula, polypoid lesions, and hyperemic mucosa with punctate hemorrhages. This object was entrapped by a mucosal bridge going through the central portion (Fig. 1). Efforts to remove the foreign body with the polypectomy snare (Bard Optimizer Polypectomy Snare, Bard Interventional Products, Tewksbury, Mass.) and rat-tooth forceps (Olympus America Inc., Melville, N.Y.) failed. The object moved freely around the band of tissue, but would not release with traction. The patient remained in the hospital after the procedure for further evaluation and surgical consultation. After discussing the potential risk of perforation without treatment, the choice of surgery or a more aggressive endoscopic approach was offered to the patient. He chose to have another endoscopic procedure with the support of the surgical service should urgent intervention be required. The following day, 12 and 15 mm through-the-scope esophageal dilation balloons (Microvasive Maxforce TTS High Performance Balloon Dilation Catheter, Boston Scientific Co, Boston, Mass.) placed across the inner aspect of the object stretched but did not release the object from the mu-
From the Department of Medicine, Gastroenterology Section, Carl T. Hayden Veterans Affairs Medical Center, Phoenix, Arizona. Reprint requests: Francisco C. Ramirez, MD, Carl T Hayden VAMC (111G), 650 E. Indian School Rd., Phoenix, AZ 85012. 37/4/67024
84 GASTROINTESTINAL ENDOSCOPY
Figure 2. Completely transected mucosal bridge after endoscopic electroincision, which freed the plastic tab for endoscopic removal.
cosal bridge. Repeated efforts with the rat-tooth forceps and polypectomy snare also failed. Through the biopsy channel of a 60 cm video flexible sigmoidoscope (Olympus America Inc.), three injections of 1:10,000 epinephrine (total 6.5 ml) into the midportion of the mucosal bridge were administered using a retractable injection sclerotherapy needle (Retractable Flexitip Needle, 25 gauge 5 mm, Bard Interventional Products). A needle knife (Wilson-Cook Medical, Inc., Winston-Salem, N.C.) was then passed and the cutting wire exposed. After a few practice passes, the electrocautery unit (Valleylab SSE2L Solid State Electrosurgery, Boulder, Colo.) was set with monopolar blended current (three cut, three coagulation) and short bursts of current delivered using the cut pedal. This resulted in successful transection of the mucosal bridge (Fig. 2). The procedure resulted in no abdominal pain or bleeding. The foreign body was retrieved with rat-tooth forceps and was found to be a plastic tab used for sealing bread bags (2.3 cm by 2.2 cm). The patient stayed in the hospital overnight and received a clear liquid diet and parenteral antibiotics. He experienced no abdominal pain, VOLUME 44, NO. 1, 1996
fever, or bleeding and was discharged the next day on a regular diet. The patient reported no complaints on follow-up, and repeat flexible sigmoidoscopy 4 weeks later showed healing with a residual scar. DISCUSSION
Foreign body ingestion occurs most commonly in adults with mental retardation, psychiatric disorders, alcoholism, imprisonment, and those involved in drug trafficking} The risk of accidental foreign body ingestion also increases in subjects with dentures because of their impaired tactile sensation. 2 Most ingested foreign bodies are found in the esophagus or stomach, but occasionally objects will pass into the small intestine and colon. This is more likely to occur when natural barriers, such as the pylorus or ileocecal valve, have been altered by prior surgery or disease. Foreign bodies in the rectosigmoid colon are usually the result of insertion through the anus. Overall, 80% to 90% of ingested objects pass spontaneously; 10% to 20% need endoscopic removal and 1% require surgery. 3-5 Although less than 1% of all foreign bodies will perforate the gut, 6 for a sharp-pointed object the rate of perforation is as high as 15% to 35% and removal becomes necessary. 79 In the past, removal of foreign bodies from the lower gastrointestinal tract was generally performed with a rigid endoscope or required surgery} ° With the development of flexible endoscopy, successful removal of foreign bodies was later reported in the cecum 11, 12and transverse colon 13using polypectomy snares or biopsy forceps. In our patient, a plastic tab was incidentally found lodged in the sigmoid colon with surrounding diverticular disease. Poor tactile sensation and altered gastric anatomy were the predisposing factors in this unusual case of foreign body ingestion. Most likely, the sharply-pointed object became trapped between saddle-bag diverticula and pierced the adjoining wall, resulting in a mucosal bridge. Cutting the mucosal bridge with a needle knife not only allowed successful endoscopic removal but avoided surgery. Endoscopic electroincision has been used for sphincterotomy, management of Schatzki's ring 14 and benign gastrointestinal strictures, 15-17 and to gain access to pancreatic pseudocysts} s Recently, a hot biopsy forceps was used to cut a mucosal bridge that formed at a colonic anastomosis with relief of constipation} 9 In our patient, a much thicker mucosal bridge made multiple passes with the needle knife a more viable option. This case demonstrates a new application of the needle knife for removal of entrapped foreign bodies
VOLUME 44, NO. 1, 1996
that are resistant to conventional endoscopic methods. We used epinephrine injection to reduce the likelihood of bleeding through local vasoconstriction and tamponade. To ensure proper orientation of the needle knife, multiple sham passes were made prior to the use of cutting current. Although no immediate or delayed complications were encountered, we believe that surgical back-up should always be available. ACKNOWLEDGMENT
We wish to thank the Medical Media Department of the Carl T. Hayden VA Medical Center for assistance with photographic reproduction. REFERENCES 1. Ginsberg GG. Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc 1995;41:33-8. 2. Bunker PG. The role of dentistry in problems of foreign body in the air and food passage. J Am Dent Assoc 1962;64:782-7. 3, Perelman H. Toothpick perforation of the gastrointestinal tract. Journal of Abdominal Surgery 1962;4:51-3. 4. Schwartz GF, Polsky HS. Ingested foreign bodies of the gastrointestinal tract. Am Surg 1976;42:236-8. 5. Bendig DW, Mackie GG. Management of smooth-blunt gastric foreign bodies in asymptomatic patients. Clin Pediatr 1990;29: 642-5. 6. Johnson WE. On ingestion of razor blades. JAMA 1969;208: 2163. 7. Vizcarrondo FJ, Brady PG, Nord HJ. Foreign bodies in the upper gastrointestinaltract. Gastrointest Endosc 1983;29:208-10. 8. Rosh W, Classen M. Fiberendoscopic foreign body removal from the upper gastrointestinal tract. Endoscopy 1972;4:193-7. 9. Carp L. Foreign bodies in the intestine. Ann Surg 1927;85:57591. 10. Barone JE, Yee J, Nealon TF. Management of foreign bodies and trauma of the rectum. Surg Gynecol Obstet 1983;156: 453-7. 11. Vemula NR, Madariaga J, Brand DL, Hershey H. Colonoscopic removal of a foreign body causing colocutaneous fistulas. Gastrointest Endosc 1982;28:195-6. 12. Sorenson RM, Bond JH Jr. Colonoscopic removal of a foreign body from the cecum. Gastrointest Endosc 1975;21:134-5. 13. Oehler JR, Dent TL, Ibrahim MAH, Gracie WA Jr. Endoscopic identification and removal of an unusual symptomatic colonic foreign body. Dig Dis Sci 1979;24:236-9. 14. Guelrud M, VillasmilL, Mendez R. Late results in patients with Schatzki ring treated by endoscopic electrosurgical incision of the ring. Gastrointest Endosc 1987;33:96-8. 15. Thorsen G, RosselandAR. Endoscopic incision ofpostoperative stenoses in the upper gastrointestinal tract. Gastrointest Endosc 1983;29:26-9. 16. Groitl H, Endoscopic treatment of scar stenosis. Endoscopy 1984;6:168-70. 17. Moreto M, Zaballa M, Ibanez S. Endoscopic incision as an alternative to bougienage in the treatment of peptic esophageal stricture. Endoscopy 1990;22:105-9. 18. Lawson JM, Baillie J. Endoscopic therapy for pancreatic pseudocysts. Gastrointestinal Endoscopy Clinics of North America. 1995;5:181-93. 19. Weinstock LB, Shatz BA. Endoscopic treatment of a colonic anastomotic mucosal bridge. Gastrointest Endosc 1994;40: 773-4.
G A S T R O I N T E S T I N A L E N D O S C O P Y 85