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Snare extraction of a gastric foreign body
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Duodenoscopic removal of a Brunner's gland adenoma Edward I. Alper, M.D. William S. Haubrich, M.D. Scripps Clinic and Research Foundation 476 Prospect Street La Jolla, California 92037
Endoscopic removal of polypoid lesions from the duodenum is a new technic. I The initial American report came from this clinic 2 and the following is the first reported removal of a Brunner's gland adenoma by duodenoscopy. CASE REPORT A 72 year old man was referred because of discomfort along the right rib margin which had recurred intermittently over the previous 10 years. He gave no history of bleeding. Physical examination was unremarkable. Gastrointestinal radiographs revealed no anatomic or structural disease except for a smooth, round, fixed, 2 cm defect occupying most of the duodenal cap. The lesion was readily encountered, just beyond the pylorus, with the Olympus GIF instrument. Its surface was round, smooth, unabraded, and indistinguishable in texture from the surrounding duodenal mucosa; it was situated on a short, thick pedicle (Figure 1a). A wire snare was easily passed over the lesion and secured around its base. A cutting current (Cameron-Miller unit) was applied, and the pedicle was severed leaving a dry, white base. Attempts to retrieve the tumor were frustrated as it repeatedly slipped beyond our grasp into the descending duodenum. Vigorous saline catharsis was begun (magnesium citrate 200 ml 3 times over 8 hours) and at 4 a.m. the following morning (19 hours after the procedure), the tumor was retrieved in a liquid stool and immediately fixed in formalin. The lesion was intact and easily identifiable as the tumor which had been snared the morning before. The patient
duodenal mucosa. The pathologic diagnosis was Brunner's gland adenoma. One month later, the patient reported feeling entirely well with no gastrointestinal discomfort. A repeated barium meal examination revealed a normal, undistorted, duodenal cap. DISCUSSION Tumors of the duodenum are relatively infrequent. Of 1399 benign small bowel tumors reported by Riveret al.,3 198 (14.2%) were situated in the duodenum. Adenomas derived from Brunner's glands comprised 10 of 21 benign duodenal tumors described by Charles et al. 4 The rather recondite topic of Brunner's gland adenoma has been recently reviewed by Osborne and his Yale associates. 5 We are uncertain that our patient's somewhat nondescript abdominal distress can be rightly attributed to the submucosal tumor of the duodenal bulb. We do believe we have demonstrated that polypoid lesions of the duodenum can be easily and safely removed endoscopically with a minimum of inconvenience to the patient and at a cost far less than that entailed by abdominal laparotomy. We know of no instance in which a Brunner's gland adenoma, once removed, has recurred. We would have preferred to have withdrawn the lesion with our endoscope, but with a 2 cm lesion and a 1 cm pylorus, we found ourselves in much the same position as the fellow who builds a large boat in his basement. We were gratified to learn that a severed duodenal tumor is not much the worse for wear after an extended voyage along the alimentary canal. REFERENCES I. ROESCH W, KOCH H, FRUHMORGEN P, CLASSEN M: Operative endoscopy of the upper gastrointestinal tract (abstract). Gastroenterology 64:849, 1973 2. HAUBRICH WS, JOHNSON RB, FOROOZAN P: Endoscopic removal of a duodenal adenoma. Gastrointestinal Endoscopy 19:201, 1973 3. RIVER L, SILVERSTEIN J, TOPEJW: Collective review: benign neoplasms of the small intestine; critical comprehensive review, with reports of 20 cases. 1m Abstr Surg 102: I, 1956 4. CHARLES RN, KELLEY ML, CAMPETI F: Primary duodenal tumors, a study of 31 cases. Arch Int Med 111:23, 1963 5. OSBORNE R, TOFFLER R, LOWMAN RM: Brunner's gland adenoma of the duodenum. Dig Dis 18:689, 1973
Snare extraction of a gastric foreign body James H. DeGerome
Figure 1. (a) Endoscopic view of polypoid submucosal tumor in the duodenal cap; (b) high power view oforderly acinar architecture typical of Brunner's gland adenoma; what appears black in this reproduction is actually the magenta ofthe periodic acid-Schifj' stain. well tolerated both the endoscopy and the retrieval, and he was discharged the following day. There was never evidence of bleeding. On section of the lesion, despite its protracted course through the entire intestinal tract, the histologic features were remarkably well preserved as an orderly array of closely packed acinar structures within a dense collagenous stroma (Figure lb). The tumor was covered by only moderately autolysed, otherwise normal VOLUME 20, NO.2, 1973
Gastroenterology Service, Department of Medicine, USAF Medical Center, Scott AFB, ILL 62225
The advent of the 165 cm colonoscope has modernized our approach to surgical lesions of the stomach, colon, and terminal ileum. Biopsy, polypectomy, and foreign body extraction under direct vision through this instrument or with utilization of its components is now possible, sparing the patient the risk and cost of major abdominal surgery. We have recently extracted a 5 cm hatpin from the stomach of a patient utilizing the ACMI colonoscope snare through the ACMI panendoscope, saving him a major abdominal exploration. This method has major advantages over those
74
previously employed 1 ,2,3 for the removal of smooth, hardsurfaced foreign bodies. CASE REPORT: A 21 year old white man accidentally swallowed a 5 cm hatpin while removing a small meat particle from between 2 lower molar teeth. The hatpin was ingested painlessly, and the patient came to the Wilford Hall Medical Center emergency room where x-rays revealed it to be lodged in the stomach. The patient was admitted to the surgery service, started on nasogastric suction, given-intravenous fluids, and prepared for surgical extirpation of the pin. The gastroenterology service was advised of the case and offered to localize and possibly extract the foreign body. Twelve hours after the patient's admission, panendoscopy revealed the pin impaled, tip first, in the wall of the lesser curve of the stomach, just below the angulus (Figure 1). The ACMI colonoscope snare, within its plastic tubing, was passed through the biopsy channel until visualized. The snare was then advanced and looped around the plastic head of the needle, tightened
Figure 1. Hatpin impaled in antral mucosa (arrows indicate head and shaft of pin).
Figure 2. Shaft of hatpin snared to illustrate the manner in which it was safely extracted from the stomach.
REFERENCES I. GELZAYD EA, JETLY K: Fiberendoscopy: removal of a retained sewing needle from the stomach. Gastrointestinal Endoscopy 18: 161, 1972 2. KLECKNER FS: Intragastric magnet for removal offoreign bodies. Gastrointestinal Endoscopy 16:151, 1970 3. GRISWOLD FC, HAISLIP CE, GARDNER RJ: Removal of an intragastric foreign body using the flexible fiberoptic esophagoscope. Gastrointestinal Endoscopy 19:194, 1973
Persimmon bezoar in an epiphrenic esophageal diverticulum with endoscopic removal William P. Munsell, M.D. Department of Internal Medicine
Ethan A. Walker, Jr., M.D. so that the needle's long axis lay in the plane of the long axis of the panendoscope (Figures 2a and 2b). Then the scope, snare, and needle were removed simultaneously under direct vision without injury ofany type to the mucosa. DISCUSSION: The colonoscope snare component of the ACMI colonoscope permitted the safe removal of this 5 cm hatpin without fear of dropping it or producing further mucosal damage in the esophagus or pharynx. Removal of hard, smooth, foreign bodies with the biopsy forceps, as accomplished by Gelzayd and Jetly, 1 or with an intragastric magnet as by Kleckner2 is inherently hazardous. Hard surfaced metallic objects cannot be as firmly gripped with forceps and magnets, and magnets, in addition to being limited to metallic object extraction, cannot be directly visualized. Direct visualization permitted careful timing of the withdrawal coincident with interperistaltic periods so as to limit pin-mucosa contact time and pressure. This method would seem to be warranted in cases of open safety pin extraction, since the sliding of the pin behind the open forceps, as depicted by the method of Griswold et al. 3 might produce laceration or puncture wounds. Therefore, the judicious use of this method of foreign body extraction is recommended. ACKNOWLEDGEMENT The expert assistance of our gastroenterology technicians, SGT Robert Bailey and SGT Allen Batcheller is gratefully acknowledged.
Department of Otolaryngology Oklahoma City Clinic 301 NW 12th Street Oklahoma City, Oklahoma 73103
Bezoars are uncommon lesions of the gastrointestinal tract and are usually found in the stomach. Two esophageal bezoars have been reported in the American literature. 1.2 The following case is the first report in which an esophageal bezoar was diagnosed and removed endoscopically. CASE REPORT An 82 year old white man was referred with the chief complaint of difficulty in swallowing food and weight loss for evaluation of a suspected esophageal carcinoma. He had been unable to swallow food for 4 weeks. This nonpainful dysphagia was associated with regurgitation after eating. Clear liquids were retained only if taken in small sips. His weight had declined from 125 pounds to 99 pounds over the previous 4 weeks. A past history of intermittent nonpainful dysphagia for at least 10 years was elicited. Most difficulty was encountered with bread. Choking and regurgitation occurred at the start of most meals after which the patient resumed eating without difficulty. Physical examination revealed a cachectic elderly man who was dehydrated and weak. His voice was inaudible at times. Except for the nutritional status, the physical findings were unremarkable. GASTROINTESTINAL ENDOSCOPY
Duodenoscopic removal of a Brunner's gland adenoma Edward I. Alper, M.D. William S. Haubrich, M.D. Scripps Clinic and Research Foundation 476 Prospect Street La Jolla, California 92037
Endoscopic removal of polypoid lesions from the duodenum is a new technic. I The initial American report came from this clinic 2 and the following is the first reported removal of a Brunner's gland adenoma by duodenoscopy. CASE REPORT A 72 year old man was referred because of discomfort along the right rib margin which had recurred intermittently over the previous 10 years. He gave no history of bleeding. Physical examination was unremarkable. Gastrointestinal radiographs revealed no anatomic or structural disease except for a smooth, round, fixed, 2 cm defect occupying most of the duodenal cap. The lesion was readily encountered, just beyond the pylorus, with the Olympus GIF instrument. Its surface was round, smooth, unabraded, and indistinguishable in texture from the surrounding duodenal mucosa; it was situated on a short, thick pedicle (Figure 1a). A wire snare was easily passed over the lesion and secured around its base. A cutting current (Cameron-Miller unit) was applied, and the pedicle was severed leaving a dry, white base. Attempts to retrieve the tumor were frustrated as it repeatedly slipped beyond our grasp into the descending duodenum. Vigorous saline catharsis was begun (magnesium citrate 200 ml 3 times over 8 hours) and at 4 a.m. the following morning (19 hours after the procedure), the tumor was retrieved in a liquid stool and immediately fixed in formalin. The lesion was intact and easily identifiable as the tumor which had been snared the morning before. The patient
duodenal mucosa. The pathologic diagnosis was Brunner's gland adenoma. One month later, the patient reported feeling entirely well with no gastrointestinal discomfort. A repeated barium meal examination revealed a normal, undistorted, duodenal cap. DISCUSSION Tumors of the duodenum are relatively infrequent. Of 1399 benign small bowel tumors reported by Riveret al.,3 198 (14.2%) were situated in the duodenum. Adenomas derived from Brunner's glands comprised 10 of 21 benign duodenal tumors described by Charles et al. 4 The rather recondite topic of Brunner's gland adenoma has been recently reviewed by Osborne and his Yale associates. 5 We are uncertain that our patient's somewhat nondescript abdominal distress can be rightly attributed to the submucosal tumor of the duodenal bulb. We do believe we have demonstrated that polypoid lesions of the duodenum can be easily and safely removed endoscopically with a minimum of inconvenience to the patient and at a cost far less than that entailed by abdominal laparotomy. We know of no instance in which a Brunner's gland adenoma, once removed, has recurred. We would have preferred to have withdrawn the lesion with our endoscope, but with a 2 cm lesion and a 1 cm pylorus, we found ourselves in much the same position as the fellow who builds a large boat in his basement. We were gratified to learn that a severed duodenal tumor is not much the worse for wear after an extended voyage along the alimentary canal. REFERENCES I. ROESCH W, KOCH H, FRUHMORGEN P, CLASSEN M: Operative endoscopy of the upper gastrointestinal tract (abstract). Gastroenterology 64:849, 1973 2. HAUBRICH WS, JOHNSON RB, FOROOZAN P: Endoscopic removal of a duodenal adenoma. Gastrointestinal Endoscopy 19:201, 1973 3. RIVER L, SILVERSTEIN J, TOPEJW: Collective review: benign neoplasms of the small intestine; critical comprehensive review, with reports of 20 cases. 1m Abstr Surg 102: I, 1956 4. CHARLES RN, KELLEY ML, CAMPETI F: Primary duodenal tumors, a study of 31 cases. Arch Int Med 111:23, 1963 5. OSBORNE R, TOFFLER R, LOWMAN RM: Brunner's gland adenoma of the duodenum. Dig Dis 18:689, 1973
Snare extraction of a gastric foreign body James H. DeGerome
Figure 1. (a) Endoscopic view of polypoid submucosal tumor in the duodenal cap; (b) high power view oforderly acinar architecture typical of Brunner's gland adenoma; what appears black in this reproduction is actually the magenta ofthe periodic acid-Schifj' stain. well tolerated both the endoscopy and the retrieval, and he was discharged the following day. There was never evidence of bleeding. On section of the lesion, despite its protracted course through the entire intestinal tract, the histologic features were remarkably well preserved as an orderly array of closely packed acinar structures within a dense collagenous stroma (Figure lb). The tumor was covered by only moderately autolysed, otherwise normal VOLUME 20, NO.2, 1973
Gastroenterology Service, Department of Medicine, USAF Medical Center, Scott AFB, ILL 62225
The advent of the 165 cm colonoscope has modernized our approach to surgical lesions of the stomach, colon, and terminal ileum. Biopsy, polypectomy, and foreign body extraction under direct vision through this instrument or with utilization of its components is now possible, sparing the patient the risk and cost of major abdominal surgery. We have recently extracted a 5 cm hatpin from the stomach of a patient utilizing the ACMI colonoscope snare through the ACMI panendoscope, saving him a major abdominal exploration. This method has major advantages over those
74
previously employed 1 ,2,3 for the removal of smooth, hardsurfaced foreign bodies. CASE REPORT: A 21 year old white man accidentally swallowed a 5 cm hatpin while removing a small meat particle from between 2 lower molar teeth. The hatpin was ingested painlessly, and the patient came to the Wilford Hall Medical Center emergency room where x-rays revealed it to be lodged in the stomach. The patient was admitted to the surgery service, started on nasogastric suction, given-intravenous fluids, and prepared for surgical extirpation of the pin. The gastroenterology service was advised of the case and offered to localize and possibly extract the foreign body. Twelve hours after the patient's admission, panendoscopy revealed the pin impaled, tip first, in the wall of the lesser curve of the stomach, just below the angulus (Figure 1). The ACMI colonoscope snare, within its plastic tubing, was passed through the biopsy channel until visualized. The snare was then advanced and looped around the plastic head of the needle, tightened
Figure 1. Hatpin impaled in antral mucosa (arrows indicate head and shaft of pin).
Figure 2. Shaft of hatpin snared to illustrate the manner in which it was safely extracted from the stomach.
REFERENCES I. GELZAYD EA, JETLY K: Fiberendoscopy: removal of a retained sewing needle from the stomach. Gastrointestinal Endoscopy 18: 161, 1972 2. KLECKNER FS: Intragastric magnet for removal offoreign bodies. Gastrointestinal Endoscopy 16:151, 1970 3. GRISWOLD FC, HAISLIP CE, GARDNER RJ: Removal of an intragastric foreign body using the flexible fiberoptic esophagoscope. Gastrointestinal Endoscopy 19:194, 1973
Persimmon bezoar in an epiphrenic esophageal diverticulum with endoscopic removal William P. Munsell, M.D. Department of Internal Medicine
Ethan A. Walker, Jr., M.D. so that the needle's long axis lay in the plane of the long axis of the panendoscope (Figures 2a and 2b). Then the scope, snare, and needle were removed simultaneously under direct vision without injury ofany type to the mucosa. DISCUSSION: The colonoscope snare component of the ACMI colonoscope permitted the safe removal of this 5 cm hatpin without fear of dropping it or producing further mucosal damage in the esophagus or pharynx. Removal of hard, smooth, foreign bodies with the biopsy forceps, as accomplished by Gelzayd and Jetly, 1 or with an intragastric magnet as by Kleckner2 is inherently hazardous. Hard surfaced metallic objects cannot be as firmly gripped with forceps and magnets, and magnets, in addition to being limited to metallic object extraction, cannot be directly visualized. Direct visualization permitted careful timing of the withdrawal coincident with interperistaltic periods so as to limit pin-mucosa contact time and pressure. This method would seem to be warranted in cases of open safety pin extraction, since the sliding of the pin behind the open forceps, as depicted by the method of Griswold et al. 3 might produce laceration or puncture wounds. Therefore, the judicious use of this method of foreign body extraction is recommended. ACKNOWLEDGEMENT The expert assistance of our gastroenterology technicians, SGT Robert Bailey and SGT Allen Batcheller is gratefully acknowledged.
Department of Otolaryngology Oklahoma City Clinic 301 NW 12th Street Oklahoma City, Oklahoma 73103
Bezoars are uncommon lesions of the gastrointestinal tract and are usually found in the stomach. Two esophageal bezoars have been reported in the American literature. 1.2 The following case is the first report in which an esophageal bezoar was diagnosed and removed endoscopically. CASE REPORT An 82 year old white man was referred with the chief complaint of difficulty in swallowing food and weight loss for evaluation of a suspected esophageal carcinoma. He had been unable to swallow food for 4 weeks. This nonpainful dysphagia was associated with regurgitation after eating. Clear liquids were retained only if taken in small sips. His weight had declined from 125 pounds to 99 pounds over the previous 4 weeks. A past history of intermittent nonpainful dysphagia for at least 10 years was elicited. Most difficulty was encountered with bread. Choking and regurgitation occurred at the start of most meals after which the patient resumed eating without difficulty. Physical examination revealed a cachectic elderly man who was dehydrated and weak. His voice was inaudible at times. Except for the nutritional status, the physical findings were unremarkable. GASTROINTESTINAL ENDOSCOPY