Snare-assisted precutting and dual-knife fistulotomy performed during difficult biliary cannulation in a patient with an ectopic papilla of Vater

Endoscopic retrograde cholangiopancreatography is widely used in the diagnosis and treatment of pancreatobiliary diseases; however, successful biliary cannulation is a prerequisite for this operation. We herein present a new method in a patient in whom cannulation was difficult. A 56-year-old man was admitted to the hospital with choledocholithiasis. Endoscopic retrograde cholangiopancreatography was performed, and duodenoscopy revealed that the patient’s duodenal papilla was located at the initial part of the horizontal segment of the duodenum. Because of the ectopic location of the duodenal papilla, the guidewire could not be inserted into the biliary and pancreatic duct. Therefore, we performed a new method to resolve the problem of difficult cannulation. A polypectomy snare was used to excise the mucosa covering the surface of the intramural segment of the common bile duct, and a dual knife was used to form a fistula. A guidewire was then inserted through the stoma into the bile duct. After the procedure, the bile duct was successfully cannulated and the stones were removed. No complications occurred. This new method may be an alternative treatment to precutting for difficult biliary cannulation in patients with a protruded papilla of Vater.

Unusual cause of gastric perforation

39-year-old woman was admitted to surgery department for epigastric pain, upper abdomen was tender on palpation without signs of peritoneal irritation. Abdominal plain X-ray and ultrasound showed no significant pathology, there were mild microcytic anemia and leukocytosis, serum amylase was normal, initial C-reactive protein 6 mg/l rose to 142 mg/l during 2 days. Gastroscopy revealed tiny foreign body stabbed into the anterior wall of gastric antrum with submucosal edema around (Figure 1). Sharp fragment was released from the gastric wall by a polypectomy snare and extracted with a forceps (partially pulled into the working channel to avoid esophageal injury), outside verified as plastic shard (Figure 2). CT scans showed single air bubble in the subhepatic space, thus verifying transmural perforation (Figure 3,4). Nevertheless, subsequent course was uneventful with antibiotic and proton pump inhibitor therapy. Retrospectively, patient admitted intake of beverage with ice prepared by smashing of frozen plastic bottle 2 days before hospital admission.

A Novel Bipolar Polypectomy Snare Can Be an Alternative Choice for Endoscopic Resection

Objective: Endoscopic resection (ER) is more difficult and has a higher rate of complications, such as perforation and bleeding. The aim of this study was to evaluate the safety and feasibility of a bipolar polypectomy snare for ER.Methods: Initial ER procedures in live pigs were carried out. Then, a human feasibility study was performed in patients with colorectal polyps. Finally, the finite element method was used to evaluate the safety and effectiveness of the new bipolar snare.Results: In the live animal model, there were no significant differences in wound size and cutting time between monopolar and bipolar groups. The histological results (histological scores) of the two groups in porcine experiments were almost the same except that the incision flatness of bipolar group was better than that of the monopolar group. Incidence of bleeding and perforation was similar between the two groups in pigs' and patients' study. At last, the finite element model showed that the vertical thermal damage depth produced by bipolar snare system was approximately 71–76% of that produced by monopolar snare system at the same power.Conclusions: The novel bipolar snare is feasible in patients with colorectal polyps and can be an alternative choice for ERs.

Upper Gastrointestinal Foreign Body, our Experience in Faridpur Medical College Hospital

Accidental ingestion and impaction of food or non-food foreign body in upper GIT is not uncommon. This retrospective study was undertaken at Gastroenterology department of Faridpur Medical College Hospital, Bangladesh. Data were collected from endoscopy software by computer search among patients with foreign bodies in upper GIT from January 2012 to December 2018. Total 41 patients with endoscopically proved ingested with or without impacted foreign body in the upper GIT were studied. Of them, 28 were male and 13 were female with age ranges from 15 to 85 years with a mean age of 52.66 ± 19.7 years. Meat bolus was the commonest type (12; 29.3%), followed by dental prosthesis (9; 22%). Most of them (24; 58%) were impacted between 20 to 30 cm from incisor teeth. We could successfully remove 38 cases with a success rate of 92.7% with the help of dormia basket, polypectomy snare & rat tooth foreign body grasper. We found few erosions and superficial ulcerations at the impacted site among patients with dental prosthesis, pill with strip and chicken bone. One patient with sharp flat bone of hilsa fish was impacted at esophagus like sharp cutting blade and produced incised looking wound at both esophageal walls. In 19 cases (46.34%) we found definite anatomic abnormalities and 19 cases (46.34%) no abnormalities was found. Rest 3 cases, who were referred to surgeon we failed to know the underlying pathology. Sharp foreign bodies impacted at upper esophagus were difficult to remove endoscopically. Faridpur Med. Coll. J. Jul 2019;14(2): 74-78