Kearney, MD The endoscopic removal of sharp foreign objects from the upper GI tract is a challenge.. A latex pro-tector hood Ballard Medical Products, Draper, Utah exists as a commercial
Trang 1Brief Reports L Kao, T Nguyen, J Dominitz, et al.
Modification of a latex glove for the safe
endoscopic removal of a sharp gastric
foreign body
Lillian S Kao, MD, Toan Nguyen, MD, Jason Dominitz,
MD, MHS, Harry L Teicher, MD, David J Kearney, MD
The endoscopic removal of sharp foreign objects
from the upper GI tract is a challenge A latex
pro-tector hood (Ballard Medical Products, Draper,
Utah) exists as a commercially available device for
retrieving sharp objects The following is a case
report of the safe removal of a sharp foreign object
by a similar technique using a modification of a
widely available latex orthopedic glove (Maxxus,
Arlington, Tex.)
CASE REPORT
A 61-year-old man with a history of T11 paraplegia,
chronic pancreatitis, gastroesophageal reflux disease, hypertension, and recurrent transient ischemic attacks
presented with a several-month history of dysphagia that recently had been improving He described dysphagia for solid food and liquids as well as recent weight loss sec-ondary to fear of emesis He denied fever, chills, or odynophagia He denied any knowledge of swallowing a foreign body On physical examination the abdomen was soft and nontender with normally active bowel tones.
A barium esophagogram demonstrated distal esophageal narrowing over a 2 to 3 cm segment with an eccentric, shelf-like protrusion There was a small hiatal hernia, normal
From the Departments of Surgery and Gastroenterology,
University of Washington School of Medicine, Seattle Division of
the VA Puget Sound Health System, Seattle, Washington.
Reprint requests: David J Kearney, MD, Box 111GI, Seattle
Division of the VA Puget Sound Health System, 1660 S.
Columbian Way, Seattle, WA 98108.
Copyright © 2000 by the American Society for Gastrointestinal
Endoscopy 0016-5107/2000/$12.00 + 0 37/54/106689
doi:10.1067/mge.2000.106689
Figure 1 Endoscopic view of plastic star in stomach.
Trang 2pharyngeal motility, and moderate cricopharyngeal dysfunc-tion No foreign body was visualized.
Several weeks later he underwent endoscopy, which revealed no esophageal stricture, mass, or other anatomic abnormalities However, there was a plastic 2.5 × 2.5 cm star-shaped object lodged in the pre-pyloric region with mild inflammation and edema of the surrounding mucosa (Fig 1) Because the star appeared to be too wide to pass distally through the pylorus and was causing mucosal irritation, retrieval was attempted The star was able to be snared without difficulty, but it was thought to be unsafe
to attempt to pull it through the esophagus because of a fear that the sharp prongs would injure the mucosa An attempt to retrieve the object using an overtube was made but the size of the object precluded passage into the over-tube Retrieval was also attempted with a Roth net, (U.S Endoscopy, Mentor, Ohio), but the sharp points of the star were not encompassed by the net in a manner that would allow safe passage The procedure was aborted leaving the star-shaped object in the stomach Although a latex pro-tector hood has been used safely for removal of sharp objects, 8,9 none was immediately available.
On the following day, a latex orthopedic glove was mod-ified for removal of the star An orthopedic glove was cho-sen for its thickness compared with a standard surgical glove; the latter is between 6.5 and 10 miL thick (1 miL = 1/1000 inch), whereas an orthopedic glove is at least 10 miL thick by definition The wrist portion was cut off and then attached securely to the end of a dual channel endo-scope (GIF2T100; Olympus America, Inc., Melville, N.Y.) using a purse-string silk suture and a rubber band (Fig 2) The device was then inverted and the endoscope with the attached device was passed to the stomach After the object was grasped with a polypectomy snare, withdrawal and torquing of the endoscope at the gastroesophageal junction caused the glove to flip back to its original shape and envelop the sharp prongs of the foreign body The star was then removed within the protective sheath of the glove under direct vision Endoscopy was not repeated to assess mucosal damage The procedure, which took less than 15 minutes, was well tolerated by the patient and he was discharged home on the same day.
DISCUSSION
The extraction of sharp foreign bodies from the upper GI tract is a difficult problem and can lead to complications that require immediate treatment or surgical intervention if endoscopic management is unsuccessful Commonly encountered objects in this category include toothpicks, bones, nails, screws, razor blades, safety pins, and dentures.1The poten-tial morbidity and mortality from such objects depends on their location Sharp foreign bodies lodged in the esophagus can lead to esophageal per-foration, retroesophageal abscess, mediastinitis, and esophagoaortic fistulae.2 Foreign bodies that pass distally through the intestinal tract can result in perforation, obstruction, or hemorrhage A review by
Figure 2 Procedure for modification of orthotopic glove.
A, Glove is cut at the wrist B, Glove attached to the end of a
dual-channel endoscope with a purse string suture and a
rubber band Glove is drawn back over the endoscope for
passage C, Position of glove after capture of the foreign
body and withdrawal through the esophagus.
A
B
C
Trang 3Velitchkov et al.3of 542 patients who ingested
for-eign bodies revealed that 75% of objects passed
uneventfully through the intestinal tract Of the
25% of patients who required intervention, 78%
underwent successful endoscopic retrieval of the
for-eign body and 22% underwent surgical removal
Several methods for the safe removal of sharp
gas-troesophageal foreign bodies have been described
One is to use an overtube to protect the esophagus
during removal of the sharp object.4,5However, this
technique may be uncomfortable for the patient and
the luminal size of the overtube at 11 to 15 mm is a
limitation
Another technique involves fashioning a
protec-tive hood for the endoscope from a variety of devices
including the tip of a 32F chest tube6and a modified
rubber urinary catheter.7 There is also a
commer-cially available device that consists of a soft latex
protector hood; successful use of this device has been
reported.8,9It maintains an inverted bell shape
dur-ing introduction of the endoscope into the esophagus
and stomach On withdrawal through the
gastro-esophageal junction, the device flips forward into its
original shape and thus protects the esophagus from
injury during withdrawal of the foreign object
Although technical problems can occasionally occur
with premature return of the bell portion to its
orig-inal orientation, this device has been found by
Bertoni et al.9to be safe and effective in a review of
their 5-year experience
Although a sharp foreign object was retrieved
without complications using a modified latex
ortho-pedic glove in the present case, the adequacy of
pro-tection afforded by the glove should be determined
in further trials The commercially available
equiv-alent has been used safely to retrieve objects such as
razor blades, plastic and metallic forks, dentures,
and sharp-edged metal objects.8,9 Although the
glove would seem to be a reasonable alternative, the
thickness of the glove cuff (0.29 mm, Maxxus) is
thinner than that of the latex hood (2 mm, Ballard
Medical) Therefore, given the disparity in thickness
and our limited experience, we cannot comment on
the overall safety of the method described here
One potentially life-threatening complication to consider is that of severe anaphylaxis secondary to latex exposure There are no reports of latex allergy associated with endoscopy and intraluminal expo-sure of latex However, severe anaphylaxis is docu-mented in the radiologic literature to be associated with mucosal exposure to the inflatable latex cuffs used for performing barium enemas.10By extrapo-lation of these data, it can be concluded that a simi-larly severe reaction is a potential complication with the use of the latex glove Gloves made of other syn-thetic material are available, but they are generally thinner than the latex orthopedic gloves and may not be appropriate for use in the manner described
in this report Physicians should be aware of this potential complication and seek an alternative solu-tion in patients known to be allergic to latex
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