Anand Dwivedi, MD
Carilion Memorial Hospital
Virginia Tech Carilion School of Medicine
Roanoke
Klaus Mönkemüller, MD, PhD, FASGE, FJGES
Professor of Medicine, Virginia Tech Carilion School of Medicine, Virginia, USA
There is a myriad of instruments to remove swallowed objects greater than 6 cm in length (such as pens, pencils, and toothbrushes) including nets (e.g. Roth net), snares, forceps, tripod prongs, overtubes, and various distal scope attachment caps (soft short, stiff, capuchon). A large transparent distal attachment cap was developed to remove small metal pieces, specifically, clip fragments of the over-the-scope clip (Remove cap, Ovesco, Germany) (1) (Figure 1).
We have also found this cap very useful to remove impacted meat from the esophagus. As this cap is three times larger than traditional “hard” caps (i.e. those used for banding) and has large capacity volume, we refer to it as the “mega cap” (Figures 1A-C). Herein we report on the novel use of the Remove cap for removing a swallowed pen from inside the stomach.
The cap is larger than any existing transparent cap and allows for suctioning most of the impacted meat inside. Its distal diameter is 16 mm with a cap length of 26 mm (effective “catch length of 22 mm) (Figures 1A-C). This results in an inner cap “catch-volume” of approximately 5 ml, which is almost double to that of traditional distal transparent caps. Another big advantage of this cap is its softness (elasticity, figures 1D-E), which allows for smooth introduction into the esophagus (Fig. 1F). Once inside the stomach the cap can be placed against the mucosa, which turns it into oval shape, thus increasing the ability to pull back a sharp end of the foreign body such has the pen tip, inside of the cap (Fig. 1G). Using a Raptor, rat-tooth or alligator forceps is mandatory, was it is important to tightly grab the pen. A snare may be an option, but too often the snares slid off pens and pensils, especially if the object has been inside the stomach for several outs and is now covered by mucus and secretions. Specific tricks to remove a pen from the stomach are (Figure 2):
a) Slowly place the distal part of the cap onto the pen,
b) Move with the cap towards the proximal end of the pen. In this case it was the sharp, painting part (Fig. 1A),
c) Do not grasp the pen on its very tip, but focus on the groove on “neck” (Fig. 1B),
d) Close the forceps slowly, as closing to fast may result in it sliding over the foreign body (Fig. 1C),
e) Once the forceps is tightly closed against the pen tip go ahead and pull the pen into the cap (Fig. 1D),
f) Because this cap is soft it allows for “deformation” while the pen tip is being pulled inside. With hard caps it would be very hard or impossible to get a pen tip into it (Fig. 1E-F),
g) Once the pen tip (or most of it) is inside the cap, commence pulling the scope out. It is very important that the forceps shaft is held with the left hand in place. Hard caps would never allow a tip to get inside,
h) Keep insufflating air (or CO2) to distend the esophageal lumen and gently torque the scope to right and left,
i) Gently pull the scope out, while continuously torquing right and left. The torquing maneuver decreases the chances of the pen tip to get caught or hung up on the esophageal mucosa or any of the esophageal anatomic (physiologic) stenotic areas.
For the final extraction maneuver it is important to have the patient’s neck hyperextended and that the assistant is ready to catch the pen inside of the mouth. Fig. 1G shows the extracted pen. The entire extraction procedure lasted 4 minutes. In sum, this novel cap is a new addition to the armamentarium for remove long, sharp and pointed foreign bodies from inside the GI tract.
References:
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Bauder M, Meier B, Caca K, Schmidt A. Endoscopic removal of over-the-scope clips: Clinical experience with a bipolar cutting device. United European Gastroenterol J. 2017 Jun;5(4):479-484. doi: 10.1177/2050640616671846. Epub 2016 Oct 6. PMID: 28588877; PMCID: PMC5446147.
Images from EndoCollab. See endocollab.com for more information, including videos, quick tips and lectures on these and many other practical endoscopy tricks and techniques.
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