Excision and Extraction Chapter 30

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Excision and ExtractionChapter 30

• Jan Brooks RN, BSN, CGRN

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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

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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

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Foreign Body Removal

• Most occur at an anatomical or physiological
  narrowing
• Cricopharyngeal area
• Lower esophageal sphincter (LES)
• Pylorus
• Duodenal C Loop
• Ligament of Treitzsuspensory muscle from
  diaphragm that follows the duodenum to jejunum
• Ileocecal valve
• Anus

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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

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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

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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
• Childrensize dependent objects

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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

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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

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Foreign Body Removal

• Presentation
• Pain
• Sepsis
• Mediastinitis
• Peritonitis
• Hemorrhage
• Abscess
• Abdominal mass

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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

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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

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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

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Foreign Body Removal

• Patient is sedated
• Glucagon available to decrease motility
• Monitoring equipment utilized
• Protect airway to prevent aspiration

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Examples
Beer cap
Bravo
Ring
Meat impaction
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Bezoar Removal

• Concretion of food or foreign matter that have
  undergone digestive changes
• Trichobezoarsmatted hair
• Phytobezoarsplant material
• Treatment
• physical disruption liquid diet, suction and
  lavage, endoscopic fragmentation
• Chemical attack with papain, acetycysteine or
  cellulose
• Surgical removal

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Polypectomy

• Types
• Pedunculatedhave a stalk
• Sessileattached by broad base to the mucosa
• Want to remove them to remove the potential of
  becoming malignant

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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

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Polypectomy

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

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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

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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

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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

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Polypectomy

• 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

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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

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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

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Examples
Polyp and post polypectomy
Injection Then snaring
Tattooing
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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

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Indications

• Choledocholithiasis
• Papillary stenosis
• Obstruction of the CBD by tumors or lesions
• Gallstone pancreatitis
• Cholangitis
• Sphincter of Oddi dysfunction
• Choledochocele
• HIV related hepatobiliary diseaserelieves pain
• Reuces pressure from a bile leak

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Contraindications

• Uncooperative patient
• Significant coagulopathy
• Recent MI or severe pulmonary disease
• Allergy to contrast medium
• Presence of extremely large stone gt20-25 mm
• Inability to properly position the sphinctertome
• Increased risk with periampullary diverticula

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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 availablesedation, glucagon, kenivac

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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

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Ampulla
Sphincterotomy
Cholesterol Stones
Sludge
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Biliary Stent
Double pigtail stent
Pancreatic stent
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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

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Complications

• Bleeding
• Pancreatitis
• Retroduodenal perforation
• Colangitis
• Entrapment of baskets

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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

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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

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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

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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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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