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Excision and Extraction Chapter 30 Jan Brooks RN, BSN, CGRN 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 Objectives 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 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 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 Removal 80-90% pass through without incident, usually within 48 hours 10-20% require endoscopic removal 1% require surgical intervention Most involve the esophagus, especially with a benign or malignant stricture, web or ring Foreign Body Removal Most ingested objects that get into the stomach will eventually pass. Conservative management is usual Surgical removal is generally not considered unless a week has gone by Children—size dependent objects Foreign 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 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 Removal Presentation: ◦ ◦ ◦ ◦ ◦ ◦ ◦ Pain Sepsis Mediastinitis Peritonitis Hemorrhage Abscess Abdominal mass Foreign 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 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 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 Removal Patient is sedated Glucagon available to decrease motility Monitoring equipment utilized Protect airway to prevent aspiration Foreign Body Removal Beer cap Bravo Meat impaction Examples Ring Concretion of food or foreign matter that have undergone digestive changes ◦ Trichobezoars—matted hair ◦ Phytobezoars—plant material Treatment: physical disruption –liquid diet, suction and lavage, endoscopic fragmentation Chemical attack with papain, acetycysteine or cellulose Surgical removal Bezoar Removal Types: ◦ Pedunculated—have a stalk ◦ Sessile—attached by broad base to the mucosa Want to remove them to remove the potential of becoming malignant Polypectomy 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 Polypectomy Contraindications ◦ ◦ ◦ ◦ ◦ Use of ASA, NSAIDs, or anticoagulants Coagulopathy Polyps that appear malignant and invasive Inadequate bowel prep Uncooperative patients Polypectomy 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 Polypectomy May require epineprine injected at the base for vasoconstriction • Use of the Polyloop to ligate the stalk ◦ Be careful not to cut through the stalk Snare wire is used to lasso stalk, note blanching prior to cutting May require segmental resection if too large Pedunculated Polyps If less than 8 mm, hot or cold biopsy forceps may be utilized Less than 1 cm, snare wire used May require segmental resection if too large May require Normal saline injected at the base to raise the base of the polyp for resection Sessile Polyps 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 Polypectomy 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 Polypectomy 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 Other Considerations Examples Polyp and post polypectomy Injection Then snaring Tattooing Also known as papillotomy Is 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 ERCP and Sphincterotomy Choledocholithiasis Papillary stenosis Obstruction of the CBD by tumors or lesions Gallstone pancreatitis Cholangitis Sphincter of Oddi dysfunction Choledochocele HIV related hepatobiliary disease—relieves pain Reuces pressure from a bile leak Indications Uncooperative patient Significant coagulopathy Recent MI or severe pulmonary disease Allergy to contrast medium Presence of extremely large stone >20-25 mm Inability to properly position the sphinctertome Increased risk with periampullary diverticula Contraindications Assessment of patient, labs, history NPO Placement of IV catheter and IV fluids Grounding pad placement Positioning of patient Use of safety equipment for patient and staff Medications available—sedation, glucagon, kenivac Prep for ERCP 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 ERCP and Sphincterotomy Ampulla Sludge Sphincterotomy Cholesterol Stones Biliary Stent Double pigtail stent Pancreatic stent 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 Pancreatic Sphincterotomy Bleeding Pancreatitis Retroduodenal perforation Colangitis Entrapment of baskets Complications 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 transhepatic Extracorporeal shock wave Lithotripsy ◦ Utilizes sound waves to fragment stones ◦ Is non invasive Additional 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 Additional Treatments 1. A poylvinyl overtube is useful in removing ◦ ◦ ◦ ◦ A. B. C. D. Foreign bodies from the duodenum Pointed objects Extremely large objects Small, round objects Review Questions 1. A poylvinyl overtube is useful in removing ◦ ◦ ◦ ◦ A. B. C. D. Foreign bodies from the duodenum Pointed objects Extremely large objects Small, round objects Review Questions 2. Endoscopic polypectomy is contraindicated in patients with: ◦ ◦ ◦ ◦ A. B. C. D. Gastric polpys Hyperplastic polyps Sessile polpys more than 2 cm in diameter Coagulopathy 2. Endoscopic polypectomy is contraindicated in patients with: ◦ ◦ ◦ ◦ A. B. C. D. Gastric polpys Hyperplastic polyps Sessile polpys more than 2 cm in diameter 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. B. C. D. A mechanical lithotripter A retrieval basket A balloon catheter Nasobiliary drainage 4. The preferred method of retrieving stones that do not pass spontaneously after endoscopic retrograde sphincterotomy is: ◦ ◦ ◦ ◦ A. B. C. D. A mechanical lithotripter A retrieval basket A balloon catheter Nasobiliary drainage
