This ASG video tip is sponsored by Braintree, maker of the newly approved Souflave and Soutab. Hi, my name is Aaron Walfish and I will be discussing the management of sharp foreign bodies. I have no financial conflict of interest to report. Foreign body ingestion is a common diagnosis that presents to emergency departments. While most ingested foreign bodies pass spontaneously, approximately 10-20% of foreign bodies require an endoscopic procedure. Sharp and pointy foreign bodies of the upper gastrointestinal tract represent a special therapeutic challenge inasmuch as they may cause significant damage during endoscopic removal resulting in bleeding or even full wall laceration. When removing sharp foreign bodies, one must pay attention to appropriate airway management, sedation type, and retrieval devices. Protective retrieval devices include a cap, an overtube, and a retractable latex rubber hood. With the aid of these devices, sharp foreign bodies can be safely extracted. While the overtube has the advantage of facilitating multiple passes and is especially useful when faced with multiple foreign bodies, objects larger than the overtube cannot be extracted and its use is limited to those objects that will fit into the overtube. When using the retractable hood, the bell portion of the hood is inverted while passing through the lower esophageal sphincter. Then, during withdrawal of the endoscope through the lower esophageal sphincter, the ends of the bell portion are pushed frontward so that the hood is slipped forward to its original shape covering the sharp object and preventing damage to the esophageal mucosa. However, a problem sometimes encountered with this device is that contact of the bell portion with the gastric wall during attempts to grasp the foreign body may cause the hood to flip forward prematurely. A 28-year-old male in good health presented with a 2-week complaint of abdominal pain. He reported that 3 weeks earlier, he swallowed a dental floss stick. CT imaging confirmed a foreign body in the shape of a floss stick in the distal stomach extending toward the pylorus. On endoscopy, we see a dental floss stick impacted at the pylorus. The endoscope was placed through the duodenum, resulting in dislodgement of the floss stick. While examining the impaction site, we see only a superficial ulceration. On retroflexion, we see the floss stick in the body of the stomach. Initially, we attempted to remove the foreign body using just a snare. Our intention was to grab the floss stick at the edge. However, due to the irregular shape, we grabbed it in the center and manipulated the snare to the edge of the floss stick. Because of the asymmetrical shape of the floss stick, we were unable to position it such that the pointed end would be trailing while withdrawing the endoscope. Such a configuration is critical to reduce the risk of trauma and perforation. Because of this problem, we switched to using a cap at the end of the endoscope in order to pull the sharp edge into the cap and in that way protect the esophagus from injury while withdrawing the endoscope. We were successful in pulling the sharp edge of the floss stick into the cap and we began withdrawing the endoscope. At this point, we asked the anesthesiologist to deflate the endotracheal tube cuff. Unfortunately, despite taking down the endotracheal tube cuff, the floss stick was unable to pass through the upper esophageal sphincter. It is precisely because of issues like this that we had decided to intubate the patient prior to the procedure to ensure adequate sedation and airway protection. Due to our inability to remove the foreign body through the upper esophageal sphincter, we reinserted the floss stick back into the stomach. At this point, we considered using an overtube, however, the floss stick diameter was larger than the overtube lumen and thus would not be able to fit through the overtube lumen. At this time, we chose to use a plastic hood to protect the esophageal wall from the foreign body. We continued to use a snare to grab the foreign body. We avoided using a rat tooth because the foreign body was plastic and there was a risk of letting go of the floss stick during withdrawal. We could have also used a basket, but we were concerned of the basket ripping during withdrawal. While manipulating the floss stick, the hood flipped prematurely. This greatly limited our working field of vision. At this time, we could have done one of three things. We could have released the floss stick and inserted the gastroscope into the pylorus to re-invert the hood. We could have withdrawn the gastroscope completely and then re-inverted the hood externally. Or we could have worked with an impaired visual field and tried to maneuver the floss stick into the inverted hood. We chose to work with the impaired visual field and we were successfully able to maneuver the floss stick into the inverted hood. It's important to remember that once the plastic hood is flipped over, visualization is severely impaired. At this time, the sharp edge was covered by the hood and we were able to safely withdraw the floss stick through the esophagus. We once again asked the anesthesiologist to deflate the endotracheal tube cuff so that the floss stick would be able to pass through the upper esophageal sphincter more easily. Despite deflating the cuff, we still had some resistance, but at this time we were able to successfully remove the foreign body. So let's just review the important take-home points. When removing foreign objects that have a sharp edge such as partial dentures, needles, and the like, one should strongly consider using a protective cover such as an overtube, a plastic cap, or a retractable rubber hood. When a protective device is not available, pointed objects should always be removed such that the pointed end is trailing. Remember, advancing sharp points can cause lacerations and puncture, whereas trailing ones are less likely to lead to complications. General anesthesia with endotracheal intubation should be strongly considered to ensure airway protection. Proper orientation of the foreign body is important for successful extraction through sphincter areas such as the lower and upper esophageal sphincters. In addition, you may need to have your anesthesiologist deflate the cuff of the endotracheal tube to successfully extract the foreign body through the upper esophageal sphincter. Careful planning prior to the actual procedure is beneficial to help decide which devices may be necessary. Finally, communication with your anesthesiologist is critical to help to lead to a successful extraction. For further information, below are some references.

management of sharp foreign bodies

ingested

endoscopic removal

upper gastrointestinal tract

protective retrieval devices