Endoscopic protector hood for safe removal of sharp-pointed gastroesophageal foreign bodies

To Pull or to Scope: A Prospective Safety and Cost-effectiveness of Percutaneous Endoscopic Gastrostomy Tube Replacement Methods

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes are routinely used as an effective method for providing enteral nutrition. The need for their exchange is common.

GOALS

We aimed to examine the comparative safety and cost-effectiveness of PEG percutaneous counter-traction "pulling" approach or by endoscopically guided retrieval.

STUDY

A prospective 215 consecutive patients undergoing PEG tube insertion were included. Fifty patients in total were excluded. The patients were examined for demographics, indications for PEG replacement, as well as procedure-related complications and procedural costs.

RESULTS

Group A included 70 patients (42%) with PEG tubes replaced endoscopically, whereas group B included 95 patients (58%) with PEG tubes replaced percutaneously. Baselines characteristics were similar between the 2 groups (P=NS). Group A and group B had similar immediate complication rates including 4 patients in group B (4.2%), and 2 patients in group A (2.8%) (P=0.24). Complications included a conservatively managed esophageal perforation, and self-limited mild bleeding groups A and group B, respectively. The mean procedure cost was significantly higher in the endoscopic PEG replacement group compared with the percutaneous PEG replacement group ($650 vs. $350, respectively).

CONCLUSION

Percutaneous PEG replacement appears as safe as endoscopic PEG replacement, however, percutaneous tube exchange is less costly.

Video endoscopy: removal of retained sewing needles from the duodenum

We report an interesting case of a 21-year-old unmarried girl who swallowed six sewing needles. Her complaints were pain in the epigastrium, associated with nausea and vomiting. On examination, there was mild tenderness in the epigastrium. X-ray of the abdomen and endoscopy confirmed the presence of six needles in the duodenum, with tips lodged in the duodenal wall. Psychiatric opinion was sought which was normal. Under video endoscope (Pentax 2.8, EG 27708) guidance with Captura biopsy forceps without spikes (Cook DBF-2.4-160-S), six sewing needles were removed successfully from the duodenum through the endoscope channel without any complications. However, a video endoscopic removal of the retained six needles from duodenum is probably being reported for the first time.

Comparison of complications between endoscopic and percutaneous replacement of percutaneous endoscopic gastrostomy tubes

When replacing percutaneous endoscopic gastrostomy (PEG) tubes, an internal bolster may be retrieved either percutaneously or endoscopically. The aim of this study was to compare the complications of percutaneous and endoscopic method during PEG tube replacement. The medical records of 330 patients who received PEG tube replacement were retrospectively analyzed. According to the removal method of internal bolster, we categorized as endoscopic group and percutaneous group. Demographic data, procedure-related complications and risk factors were investigated. There were 176 cases (53.3%) in endoscopic group and 154 cases (46.7%) in percutaneous group. The overall immediate complication rate during PEG tube replacement was 4.8%. Bleeding from the stoma (1.3%) occurred in percutaneous group, whereas esophageal mucosal laceration (7.4%) and microperforation (0.6%) occurred in endoscopic group. The immediate complication rate was significantly lower in the percutaneous method (OR, 6.57; 95% CI, 1.47-29.38, P=0.014). In multivariate analysis, old age was a significant risk factor of esophageal laceration and microperforation during PEG tube replacement (OR, 3.83; 95% CI, 1.04-14.07, P=0.043). The percutaneous method may be more safe and feasible for replacing PEG tubes than the endoscopic method in old patients.

[Foreign bodies in the upper gastrointestinal tract]

Foreign bodies in the upper GI tract are an important medical problem and cause about 5% of emergency endoscopies. Endoscopic removal is the method of the choice and is successful in 99% of cases. Nevertheless, endoscopic removal is not necessary in every case because most foreign bodies can pass through the digestive tract and be evacuated in the natural way. An immediate emergency endoscopy is indicated for foreign bodies in the esophagus with signs of obstruction, which is present in more than 75% of cases, because the risk of complications increases with retention time. The endoscopist has myriad possibilities for finding the best and safest way to extract the foreign body.

Removal of press-through-packs impacted in the upper esophagus using an overtube

Foreign bodies in the upper esophagus should be removed as soon as possible to avoid serious complications. However, removals of foreign bodies in the upper esophagus are very difficult, especially if they have sharp edges, such as press-through-packs (PTPs). We experienced four cases of the impacted PTPs in the upper esophagus which was successfully extracted endoscopically with the overtube. Because two edges of PTPs were so firmly impacted in the esophageal wall in all cases, the PTPs were not movable in the upper esophagus. However, after insertion of the overtube, PTPs became movable and were successfully extracted and no serious complications occurred after extraction of PTPs. In one case, insertion of the overtube rapidly expanded the upper esophagus and PTP progressed to the gastric cavity and it could be extracted with the endoscopic protector hood. The endoscopic removal with the overtube was a simple, safe and effective technique for the removal of the impacted PTPs in upper esophagus.

Esophageal emergencies: things that will wake you from a sound sleep

Esophageal emergencies are a common problem facing practicing gastroenterologists and it is important to know what therapies are indicated for different situations. Patients ingesting caustic agents should be monitored intensively for signs of perforation and ultimately for signs of stricture development. Foreign bodies impacted in the esophagus should be removed promptly to prevent perforation. Although esophageal perforations are generally managed surgically, conservative management of localized perforations has become more common especially with improved antibiotics and the use of nonsurgical interventional drainage techniques. In either elected course the gastroenterologist should work closely with the surgical team.