Point blank, endoscopic retrieval of an extraluminal bullet. We have nothing to disclose. The objectives are to demonstrate the feasibility of safely removing extraluminal foreign bodies or bullets, understand the angle of approach, and utilize multiple endoscopic potential skill sets, and appreciate the different types of exercises needed to remove the foreign body. In 2016, more than 250,000 deaths worldwide were associated with gunshot-related violence. 90% of the mortality was associated from abdominal trauma. The severity of the colon injury dictates the type of surgery, and if non-disruptive colon injury is present, treatment with diverting colostomy and prior repair is a dream of option. If diverting colostomy is performed, then closure may be performed if the injury is vague. Depending on the location, closure of the defect can pose a surgical challenge. We demonstrate an endoscopic technique of foreign body retrieval and closure of defects that are especially useful to prevent recurrent surgery or the original surgery at all. A 36-year-old male with no past medical history presented with multiple gunshot wounds to the right neck, left axilla, and pelvis. He was adequately resuscitated and found to have a bullet entry in the right buttocks with no exit wound. A CT was subsequently performed and demonstrated a bullet in close proximity to the rectum. A barium enema was subsequently performed and demonstrated a leak adjacent to the bullet location. Since there was a leak on the barium enema, a laparoscopic diverting colostomy was performed. Since the bullet was deep in the pelvis, GEO was consulted to remove the bullet for ballistics, as well as close the rectal defect as it was in close proximity to the rectum. A gentamicin wash was performed as in those procedures. An EGD scope with a cap was utilized to identify the bullet and location to the lumen. The perforated site was identified, and a stone extraction balloon with contrast was injected to identify the lumen and the distance it was from the bullet. A pinpoint perforated site was identified, and using a stone extraction balloon, a wire was guided through the perforated site. This wire will help get other accessories for further therapeutic procedures. Balloon dilation was performed sequentially up to 10 millimeters. After dilation, we had a good visualization of the area, and the bullet was nowhere to be found. A fluoroscopic imaging also shows that the trajectory of the approach was not ONFOS. We had to make a decision at that time to continue the same approach or try a different approach. We felt that the ONFOS is better, as it's a smaller hole, easier to close, and less incision, therefore less chance of complication. But this means a new opening as well. A linear EUS scope was utilized to assess the bullet. As you can see, a hyperechoic bullet is visualized outside of the lumen. A 19-gauge FNA needle was utilized to puncture the wall into the perirectal area, and as you can see, we're in close proximity to the bullet. As you can see, the needle is able to blot the bullet, which tells you we're in direct apposition to the bullet. A fluoroscopic imagery also demonstrates the same thing. A 0.025 guide wire was placed in the tract, and a 3.9 French sphincter tone was utilized to dilate the tract. Once initial dilation occurred, sequential balloon dilation was performed from 4 millimeters to 10 millimeters. Although we had good dilation of the tract, the bullet wasn't able to be visualized. We used the insulated tip knife 2 to extend the opening so we have better visualization. We slowly started dissecting the opening layer by layer. Since the rectum is quite thick, it is very important to slowly dissect layer by layer and to assess for vasculature as well. After dissecting 10 to 15 minutes, we were able to get a large enough opening where we can visualize the bullet. As you can see from the on-foss approach, the bullet is directly in front of us. This was what we were always trying to achieve. Since the peri-rectal area and pelvic area is very narrow, we felt the safest thing would be to use a rothnet to try to capture it. Unfortunately, we realized that the rothnet was unable to expand very much due to the narrowness in the pelvis. At the same time, it was not fluoroscopically visualized. We also used a basket to try to capture the bullet, but because of the narrowness of the pelvis, we were unable to expand it enough to capture the bullet. We later followed this up with a retrieval forceps and was able to rotate it and fluoroscopically visualize it to grasp the bullet and bring it out. The next important thing is to identify how to close a defect. We use the distal end of our cap to measure the defect to see if an over-the-scope clip could be placed versus endoscopic suturing. Since this was able to be fully opposed by the cap, we felt the over-the-scope clip would be a better option. We therefore utilized a twin grasper to grasp one end of the defect and opening up the other side of the grasper to grasp the other side of the defect. Once this is closed, we pulled it into our cap and deployed the over-the-scope clip. The original defect was also closed in a similar fashion. As you can see, there's good approximation of the defect with the over-the-scope clip, and you can go proximally into the lumen as well. A stone extraction balloon was utilized to inject contrast in the lumen with no leakage of contrast as seen by this fluoroscopy. The bullet was retrieved and given to police for ballistics. The importance of having on-pos approach is paramount. Eoscatted approach's advantage is forming a track while directly visualizing the vessel with dopplers. Sequential dilation is essential. Utilization of multiple accessories may be necessary to remove foreign bodies. You have to understand how to do over-the-scope clips and suturing prior to taking these types of procedures. And remember, if things do not work as planned, continue to modify technique until the goal is achieved. Thank you.

endoscopic retrieval

extraluminal bullet

closure of defect

foreign body removal

endoscopic techniques