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