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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

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excision and extraction chapter 30

Excision and ExtractionChapter 30

Jan Brooks RN, BSN, CGRN

objectives

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 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 Removal
foreign body removal1

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
foreign body removal2

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
foreign body removal3

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
foreign body removal4

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
foreign body removal5

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
foreign body removal6

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
foreign body removal7

Presentation:

    • Pain
    • Sepsis
    • Mediastinitis
    • Peritonitis
    • Hemorrhage
    • Abscess
    • Abdominal mass
Foreign Body Removal
foreign body removal8

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
foreign body removal9

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
foreign body removal10

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
foreign body removal11

Patient is sedated

  • Glucagon available to decrease motility
  • Monitoring equipment utilized
  • Protect airway to prevent aspiration
Foreign Body Removal
examples

Beer cap

Bravo

Ring

Examples

Meat impaction

bezoar removal

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
polypectomy

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
polypectomy1

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
polypectomy2

Contraindications

    • Use of ASA, NSAIDs, or anticoagulants
    • Coagulopathy
    • Polyps that appear malignant and invasive
    • Inadequate bowel prep
    • Uncooperative patients
Polypectomy
polypectomy3

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
pedunculated 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 stalk
  • Snare wire is used to lasso stalk, note blanching prior to cutting
  • May require segmental resection if too large
Pedunculated Polyps
sessile 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
polypectomy4

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
polypectomy5

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
other 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
Other Considerations
examples1

Polyp and post polypectomy

Injection

Then

snaring

Examples

Tattooing

ercp and sphincterotomy

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
indications

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
  • Reucespressure from a bile leak
Indications
contraindications

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 periampullarydiverticula
Contraindications
prep for ercp and sphincterotomy

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
ercp and sphincterotomy1

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
slide32

Ampulla

Sphincterotomy

Cholesterol Stones

Sludge

slide33

Biliary Stent

Double pigtail stent

Pancreatic stent

pancreatic 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
Pancreatic Sphincterotomy
complications

Bleeding

  • Pancreatitis
  • Retroduodenal perforation
  • Colangitis
  • Entrapment of baskets
Complications
additional 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 transhepatic
  • Extracorporeal shock wave Lithotripsy
    • Utilizes sound waves to fragment stones
    • Is non invasive
Additional Treatments
additional treatments1

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
review 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 Questions
review questions1

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 Questions
slide40

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
slide41

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
slide42

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
slide43

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
slide44

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
slide45

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