Excision and ExtractionExcision and ExtractionChapter 30Chapter 30

Jan Brooks RN, BSN, CGRN

ObjectivesObjectives

1. Describe techniques and precautions taken when removing foreign bodies.

2. Explain indications, contraindications, procedures and potential complications with polypectomy

3. Describe indications, contraindications and procedure of endoscopic sphincterotomy

Foreign Body RemovalForeign Body Removal

Foreign bodies may be in the esophagus, stomach, duodenum or colon

It may be accidental or deliberately swallowed or introduced into the rectum

Most frequent victims are children 6 months to 4 years, persons with dentures, inebriated or mentally impaired

Foreign Body RemovalForeign Body Removal

Most occur at an anatomical or physiological narrowing◦Cricopharyngeal area◦Lower esophageal sphincter (LES)◦Pylorus ◦Duodenal C Loop◦Ligament of Treitz—suspensory muscle from

diaphragm that follows the duodenum to jejunum◦Ileocecal valve◦Anus

Foreign Body RemovalForeign Body Removal

Types of items ingested:◦Coins, toys, crayons, buttons, other small

objects◦Meats◦Lower GI tract-may be accidental or as a result

of criminal assault◦Iatrogenic (medical or dental) devices◦Small bowel video capsule

Foreign Body RemovalForeign Body Removal

80-90% pass through without incident, usually within 48 hours

10-20% require endoscopic removal1% require surgical intervention

Most involve the esophagus, especially with a benign or malignant stricture, web or ring

Foreign Body RemovalForeign Body Removal

Most ingested objects that get into the stomach will eventually pass.

Conservative management is usualSurgical removal is generally not

considered unless a week has gone byChildren—size dependent objects

Foreign Body RemovalForeign Body Removal

Endoscopic removal considered when:◦Food Boluses◦Lead or mercury containing items such as

batteries◦Sharp pointed objects-needles, pins, toothpicks◦Long narrow objects, such as wires◦Item is greater than 2 cm in diameter◦Ingestion of illicit drugs

Foreign Body RemovalForeign Body Removal

Contraindications:◦Risk of removing the object is greater than the

risk posed by the object◦Uncooperative patient◦Patients with known or suspected perforated

viscus

Foreign Body RemovalForeign Body Removal

Presentation:◦Pain◦Sepsis◦Mediastinitis◦Peritonitis◦Hemorrhage◦Abscess◦Abdominal mass

Foreign Body RemovalForeign Body Removal

Obtain History◦Description of the foreign body◦Length of time lodged◦Type and location of pain◦History of dysphagia◦Radiological examination◦Previous foreign body ingestion and removal

Foreign Body RemovalForeign Body Removal

Tools utilized:◦Laryngoscopes and curved forceps◦Rat tooth, alligator forceps◦Three or four pronged forceps◦Snare wire, biopsy forceps◦Nets◦Baskets◦Overtubes and Endoscopic hoods

Foreign Body RemovalForeign Body Removal

Use of the Overtube◦When object has sharp edges◦Multiple passages are required◦Protection of the airway

◦Sharp objects must be removed with the Pointed end down or covered if both ends are pointed

Foreign Body RemovalForeign Body Removal

Patient is sedatedGlucagon available to decrease motilityMonitoring equipment utilizedProtect airway to prevent aspiration

ExamplesExamples

Beer cap

RingBravo

Meat impaction

Bezoar RemovalBezoar Removal

Concretion of food or foreign matter that have undergone digestive changes◦Trichobezoars—matted hair◦Phytobezoars—plant materialTreatment:

physical disruption –liquid diet, suction and lavage, endoscopic fragmentationChemical attack with papain, acetycysteine or cellulose

Surgical removal

PolypectomyPolypectomy

Types:◦Pedunculated—have a stalk◦Sessile—attached by broad base to the mucosa

Want to remove them to remove the potential of becoming malignant

PolypectomyPolypectomy

Use of Electro surgical Units (Cautery)Requires use of grounding pad

◦Apply to flank or thigh◦Avoid boney prominences◦Avoid Adipose tissue◦Tattoos-especially those with colors, metallic

inks◦No lotions or oils on skin for adequate contact◦Document skin after removal

PolypectomyPolypectomy

Contraindications◦Use of ASA, NSAIDs, or anticoagulants◦Coagulopathy◦Polyps that appear malignant and invasive◦Inadequate bowel prep◦Uncooperative patients

PolypectomyPolypectomy

Can be done with:◦Cold or Hot biopsy forceps◦Cold Snares◦Injection Snare◦Snare wire utilizing cautery◦May require normal saline injection at base for ease

in removal

◦Communication is essential between physician and GI assistants

Pedunculated PolypsPedunculated Polyps

May require epineprine injected at the base for vasoconstriction

• Use of the Polyloop to ligate the stalk◦ Be careful not to cut through the stalkSnare wire is used to lasso stalk, note

blanching prior to cuttingMay require segmental resection if too

large

Sessile PolypsSessile Polyps

If less than 8 mm, hot or cold biopsy forceps may be utilized

Less than 1 cm, snare wire usedMay require segmental resection if too

largeMay require Normal saline injected at the

base to raise the base of the polyp for resection

PolypectomyPolypectomy

Retrieval of polypoid tissue is important so that the specimen may have complete histological determination.◦May be done with removing the tissue from

biopsy forceps◦Caught in specimen trap utilizing suction◦Use of the snare wire or net to bring it to

outside the body◦Direct suction applied to the polyp◦Bolus of water used to dislodge tissue

PolypectomyPolypectomy

Complications:◦Bleeding –immediate or up to 21 or more days post

polypectomy ◦Adverse reactions to sedation◦Vasavagal response from pain or abdominal

distention◦Transmural burns ◦Perforation◦Explosion of flammable gases methane and

hydrogen◦Thermal injury from cautery malfunction

Other ConsiderationsOther Considerations

Utilizing tattooing when area is too large to remove or mass

May require resection Gastric Polyps

◦Recommendations depend on pathology◦Glucagon may be used to decrease peristalsis◦Use of H2 blockers and PPI due to ulcer

formation with removal

ExamplesExamplesPolyp and post polypectomy

Injection Thensnaring

Tattooing

ERCP and SphincterotomyERCP and Sphincterotomy

Also known as papillotomyIs the electrosurgical incision of the

papilla of Vatar and fibers of the sphincter of Oddi

Utilized to assist passage of bile and/or common bile duct stones

Utilize both radiological and direct visualization

Communication is essential between physician and assistant

IndicationsIndications

Choledocholithiasis Papillary stenosisObstruction of the CBD by tumors or lesionsGallstone pancreatitisCholangitisSphincter of Oddi dysfunctionCholedochoceleHIV related hepatobiliary disease—relieves

painReuces pressure from a bile leak

ContraindicationsContraindications

Uncooperative patientSignificant coagulopathyRecent MI or severe pulmonary diseaseAllergy to contrast mediumPresence of extremely large stone >20-25

mm Inability to properly position the

sphinctertomeIncreased risk with periampullary

diverticula

Prep for ERCP and Prep for ERCP and SphincterotomySphincterotomy

Assessment of patient, labs, historyNPOPlacement of IV catheter and IV fluidsGrounding pad placementPositioning of patientUse of safety equipment for patient and

staffMedications available—sedation,

glucagon, kenivac

ERCP and SphincterotomyERCP and Sphincterotomy

Successful sphincterotomy is usually signaled by◦Gush of bile, sludge and stones◦Balloons, dilators and baskets may be used for

stone removal◦If stones are too large, may use lithotripsy to

break stones for passage◦Placement of stents

Ampulla Sphincterotomy

Sludge Cholesterol Stones

Biliary Stent Double pigtail stent

Pancreatic stent

Pancreatic SphincterotomyPancreatic Sphincterotomy

Indications:◦Symptomatic pancreatic obstruction◦Pancreatic calculi◦Pancreatic duct strictures, leaks or pseudocysts◦Pancreas divism◦Pain relief for chronic pancreatitis

◦Utilize small specially designed stents and sphincterotomes

ComplicationsComplications

BleedingPancreatitisRetroduodenal perforationColangitisEntrapment of baskets

Additional TreatmentsAdditional Treatments

Dissolving agents—◦Ursodeoxycholic acid orally –stop after 6 months◦Direct contact solutions-

Methyl tert-butyl ether (MTBE) cholesterol dissolution EDTA –enhances calcium solubility N-acetylcysterine –promotes mucin solubility Can be delivered during ERCP with nasobiliary tube or

transhepaticExtracorporeal shock wave Lithotripsy

◦Utilizes sound waves to fragment stones◦Is non invasive

Additional TreatmentsAdditional Treatments

Pulsed-Dye Laser Lithotripsy◦Stones are destroyed with a pulsed-dye laser

beam◦Allows for precise targeting against stone◦Highly effective and safe for fragmentation◦Limited usage due to cost of the laser

lithotriptors◦Can be done at the time of ERCP or

percutaneously

Review QuestionsReview Questions

1. A poylvinyl overtube is useful in removing◦A. Foreign bodies from the duodenum◦B. Pointed objects◦C. Extremely large objects◦D. Small, round objects

Review QuestionsReview Questions

1. A poylvinyl overtube is useful in removing◦A. Foreign bodies from the duodenum◦B. Pointed objects◦C. Extremely large objects◦D. Small, round objects

2. Endoscopic polypectomy is contraindicated in patients with:◦A. Gastric polpys◦B. Hyperplastic polyps◦C. Sessile polpys more than 2 cm in diameter◦D. Coagulopathy

2. Endoscopic polypectomy is contraindicated in patients with:◦A. Gastric polpys◦B. Hyperplastic polyps◦C. Sessile polpys more than 2 cm in diameter◦D. Coagulopathy

3. For endoscopic retrograde shpincterotomy, the ESU is turned on:◦A. Only when the endoscopist indicates that he

or she is ready to begin cutting◦B. As soon as the grounding pad is securely

attached◦C. Once the patient is in position◦D. As soon as fluoroscopy demonstrates proper

placement of the sphinctertome in the CBD

3. For endoscopic retrograde shpincterotomy, the ESU is turned on:◦A. Only when the endoscopist indicates that he

or she is ready to begin cutting◦B. As soon as the grounding pad is securely

attached◦C. Once the patient is in position◦D. As soon as fluoroscopy demonstrates proper

placement of the sphinctertome in the CBD

4. The preferred method of retrieving stones that do not pass spontaneously after endoscopic retrograde sphincterotomy is:◦A. A mechanical lithotripter◦B. A retrieval basket◦C. A balloon catheter◦D. Nasobiliary drainage

4. The preferred method of retrieving stones that do not pass spontaneously after endoscopic retrograde sphincterotomy is:◦A. A mechanical lithotripter◦B. A retrieval basket◦C. A balloon catheter◦D. Nasobiliary drainage