Suture technique for endoscopic removal of unusual foreign bodies

LETTERS TO THE EDITOR Suture technique for endoscopic removal of unusual foreign bodies To the Editor: We read with interest the article by Christie et al1 in which the authors describe a novel method to remove an ingested wrench by using a hydrostatic balloon advanced through the ratchet end of the wrench with subsequent withdrawal of the balloon, wrench, and endoscope. In 2002 we reported a new technique, known as the ‘‘suture technique’’ for removal of unusual foreign bodies, that could also have been used with this patient.2 We developed this technique in response to the unusual foreign bodies pediatric patients may ingest that are not amenable to removal by using standard foreign body–removal forceps. The technique can be used for any object with a hole in it, and it has been applied to foreign bodies such as large washers and barrettes. A long surgical suture is preloaded on the biopsy forceps, which are retracted into the endoscope. A portion of the suture is held outside of the endoscope. The endoscope is subsequently passed to the area of the foreign body to be removed. The suture is threaded through the hole of the foreign body, the forceps are opened to release the suture, and the suture is retrieved with the forceps on the other side of the hole (Fig. 1) This in effect puts a loop of suture through the foreign body. The suture is then tightened by withdrawing the forceps into the endoscope channel, and the forceps, suture, foreign body, and endoscope are withdrawn as a single unit. In the case of the wrench above, a heavy suture or several sutures may have been required due to the weight of the foreign body. Marsha Kay, MD Robert Wyllie, MD Department of Pediatric Gastroenterology and Nutrition Cleveland Clinic Cleveland, Ohio, USA REFERENCES 1. Christie DB III, Luke WD, Sedghi S. Ingested foreign-body retrieval: a novel new method. Gastrointest Endosc 2007;65:169-71. 2. Kay M, Wyllie R. Techniques of foreign body removal in infants and children. Tech Gastrointest Endosc 2002;4:188-95. doi:10.1016/j.gie.2007.04.002

Figure 1. Endoscopic suture technique. Reprinted with permission from: Kay M, Wyllie R. Techniques of foreign body removal in infants and children. Tech Gastrointest Endosc 2002;4:188-95.

management. We compliment the authors on their ingenuity. We agree that the suture technique may have had a technical application in our scenario of wrench retrieval1 but believe that the hydrostatic balloon provided for quicker extraction and more intraluminal control than that which we could have accomplished with the suture technique. The balloon also provided us with the benefit of dilating the lower esophageal sphincter during retrieval, helping to facilitate the passage of the wrench while protecting the gastroesophageal junction from injury. We do not feel that the hydrostatic balloon is ideal for smaller objects. However, when confronted with a large, hollow foreign body, the balloon, the wrench, and the scope can be quickly and easily removed as a system, decreasing the amount of sedation and lessening the effort required to successfully retrieve a foreign body of this nature. Dudley Benjamin Christie III, MD William Douglas Luke, MD Shahriar Sedghi, MD Mercer University School of Medicine Medical Center of Central Georgia Departments of Surgery and Gastroenterology Macon, Georgia, USA REFERENCE 1. Christie DB III, Luke WD, Sedghi S. Ingested foreign-body retrieval: a novel new method. Gastrointest Endosc 2007;65:169-71. doi:10.1016/j.gie.2007.06.054

EUS-guided suprapapillary puncture for safe selective biliary access To the Editor:

Response: We appreciate Drs Kay and Wyllie for their review of our article and suggestions for hollow foreign body

We read with interest the article by Artifon et al1 on a novel technique of suprapapillary puncture to gain selective biliary access. After 2 patients with a peripapillary

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Volume 66, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 865