Brief Reports L Kao, T Nguyen, J Dominitz, et al Modification of a latex glove for the safe endoscopic removal of a sharp gastric foreign body Lillian S Kao, MD, Toan Nguyen, MD, Jason Dominitz, MD, MHS, Harry L Teicher, MD, David J Kearney, MD The endoscopic removal of sharp foreign objects from the upper GI tract is a challenge A latex protector hood (Ballard Medical Products, Draper, Utah) exists as a commercially available device for retrieving sharp objects The following is a case report of the safe removal of a sharp foreign object by a similar technique using a modification of a widely available latex orthopedic glove (Maxxus, Arlington, Tex.) CASE REPORT A 61-year-old man with a history of T11 paraplegia, chronic pancreatitis, gastroesophageal reflux disease, From the Departments of Surgery and Gastroenterology, University of Washington School of Medicine, Seattle Division of the VA Puget Sound Health System, Seattle, Washington Reprint requests: David J Kearney, MD, Box 111GI, Seattle Division of the VA Puget Sound Health System, 1660 S Columbian Way, Seattle, WA 98108 Copyright © 2000 by the American Society for Gastrointestinal Endoscopy 0016-5107/2000/$12.00 + 37/54/106689 doi:10.1067/mge.2000.106689 VOLUME 52, NO 1, 2000 Figure Endoscopic view of plastic star in stomach hypertension, and recurrent transient ischemic attacks presented with a several-month history of dysphagia that recently had been improving He described dysphagia for solid food and liquids as well as recent weight loss secondary to fear of emesis He denied fever, chills, or odynophagia He denied any knowledge of swallowing a foreign body On physical examination the abdomen was soft and nontender with normally active bowel tones A barium esophagogram demonstrated distal esophageal narrowing over a to cm segment with an eccentric, shelflike protrusion There was a small hiatal hernia, normal GASTROINTESTINAL ENDOSCOPY 127 L Kao, T Nguyen, J Dominitz, et al Brief Reports pharyngeal motility, and moderate cricopharyngeal dysfunction No foreign body was visualized Several weeks later he underwent endoscopy, which revealed no esophageal stricture, mass, or other anatomic abnormalities However, there was a plastic 2.5 × 2.5 cm star-shaped object lodged in the pre-pyloric region with mild inflammation and edema of the surrounding mucosa (Fig 1) Because the star appeared to be too wide to pass distally through the pylorus and was causing mucosal irritation, retrieval was attempted The star was able to be snared without difficulty, but it was thought to be unsafe to attempt to pull it through the esophagus because of a fear that the sharp prongs would injure the mucosa An attempt to retrieve the object using an overtube was made but the size of the object precluded passage into the overtube Retrieval was also attempted with a Roth net, (U.S Endoscopy, Mentor, Ohio), but the sharp points of the star were not encompassed by the net in a manner that would allow safe passage The procedure was aborted leaving the star-shaped object in the stomach Although a latex protector hood has been used safely for removal of sharp objects,8,9 none was immediately available On the following day, a latex orthopedic glove was modified for removal of the star An orthopedic glove was chosen for its thickness compared with a standard surgical glove; the latter is between 6.5 and 10 miL thick (1 miL = 1/1000 inch), whereas an orthopedic glove is at least 10 miL thick by definition The wrist portion was cut off and then attached securely to the end of a dual channel endoscope (GIF2T100; Olympus America, Inc., Melville, N.Y.) using a purse-string silk suture and a rubber band (Fig 2) The device was then inverted and the endoscope with the attached device was passed to the stomach After the object was grasped with a polypectomy snare, withdrawal and torquing of the endoscope at the gastroesophageal junction caused the glove to flip back to its original shape and envelop the sharp prongs of the foreign body The star was then removed within the protective sheath of the glove under direct vision Endoscopy was not repeated to assess mucosal damage The procedure, which took less than 15 minutes, was well tolerated by the patient and he was discharged home on the same day A B DISCUSSION C Figure Procedure for modification of orthotopic glove A, Glove is cut at the wrist B, Glove attached to the end of a dual-channel endoscope with a purse string suture and a rubber band Glove is drawn back over the endoscope for passage C, Position of glove after capture of the foreign body and withdrawal through the esophagus 128 GASTROINTESTINAL ENDOSCOPY The extraction of sharp foreign bodies from the upper GI tract is a difficult problem and can lead to complications that require immediate treatment or surgical intervention if endoscopic management is unsuccessful Commonly encountered objects in this category include toothpicks, bones, nails, screws, razor blades, safety pins, and dentures.1 The potential morbidity and mortality from such objects depends on their location Sharp foreign bodies lodged in the esophagus can lead to esophageal perforation, retroesophageal abscess, mediastinitis, and esophagoaortic fistulae.2 Foreign bodies that pass distally through the intestinal tract can result in perforation, obstruction, or hemorrhage A review by VOLUME 52, NO 1, 2000 Brief Reports Velitchkov et al.3 of 542 patients who ingested foreign bodies revealed that 75% of objects passed uneventfully through the intestinal tract Of the 25% of patients who required intervention, 78% underwent successful endoscopic retrieval of the foreign body and 22% underwent surgical removal Several methods for the safe removal of sharp gastroesophageal foreign bodies have been described One is to use an overtube to protect the esophagus during removal of the sharp object.4,5 However, this technique may be uncomfortable for the patient and the luminal size of the overtube at 11 to 15 mm is a limitation Another technique involves fashioning a protective hood for the endoscope from a variety of devices including the tip of a 32F chest tube6 and a modified rubber urinary catheter.7 There is also a commercially available device that consists of a soft latex protector hood; successful use of this device has been reported.8,9 It maintains an inverted bell shape during introduction of the endoscope into the esophagus and stomach On withdrawal through the gastroesophageal junction, the device flips forward into its original shape and thus protects the esophagus from injury during withdrawal of the foreign object Although technical problems can occasionally occur with premature return of the bell portion to its original orientation, this device has been found by Bertoni et al.9 to be safe and effective in a review of their 5-year experience Although a sharp foreign object was retrieved without complications using a modified latex orthopedic glove in the present case, the adequacy of protection afforded by the glove should be determined in further trials The commercially available equivalent has been used safely to retrieve objects such as razor blades, plastic and metallic forks, dentures, and sharp-edged metal objects.8,9 Although the glove would seem to be a reasonable alternative, the thickness of the glove cuff (0.29 mm, Maxxus) is thinner than that of the latex hood (2 mm, Ballard Medical) Therefore, given the disparity in thickness and our limited experience, we cannot comment on the overall safety of the method described here VOLUME 52, NO 1, 2000 L Kao, T Nguyen, J Dominitz, et al One potentially life-threatening complication to consider is that of severe anaphylaxis secondary to latex exposure There are no reports of latex allergy associated with endoscopy and intraluminal exposure of latex However, severe anaphylaxis is documented in the radiologic literature to be associated with mucosal exposure to the inflatable latex cuffs used for performing barium enemas.10 By extrapolation of these data, it can be concluded that a similarly severe reaction is a potential complication with the use of the latex glove Gloves made of other synthetic material are available, but they are generally thinner than the latex orthopedic gloves and may not be appropriate for use in the manner described in this report Physicians should be aware of this potential complication and seek an alternative solution in patients known to be allergic to latex REFERENCES Webb WA Management of foreign bodies of the upper gastrointestinal tract: update Gastrointest Endosc 1995;41:39-51 Nandi P, Ong GB Foreign bodies in the oesophagus: review of 2394 cases Br J Surg 1978;65:5-9 Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases World J Surg 1996;20:1001-5 Rogers BHG, Kot C, Meiri S, Epstein M An overtube for the flexible fiberoptic esophagogastroduodenoscope Gastrointest Endosc 1982;28:256-7 Spurling TJ, Zaloga GP, Richter JE Fiberendoscopic removal of a gastric foreign body with overtube technique Gastrointest Endosc 1983;29:226-7 Tuen HH, Lai E, Fan ST Endoscopic retrieval of ingested broken glass in the esophagus and stomach by end-hood and suction technique Gastrointest Endosc 1989;35:357-8 Garrido J, Barkin JS Endoscopic modification for safe foreign body removal Am J Gastroenterol 1985;80:957-8 Bertoni G, Pacchione D, Conigliaro R, Sassatelli R, Pedrazzoli C, Bedogni G Endoscopic protector hood for safe removal of sharp-pointed gastroesophageal foreign bodies Surg Endosc 1992;6:255-8 Bertoni G, Sassatelli R, Conigliaro R, Bedogni G A simple latex protector hood for safe endoscopic removal of sharppointed gastroesophageal foreign bodies Gastrointest Endosc 1996; 44:458-61 10 Ownby DR, Tomlanovich M, Sammons N, McCullough J Anaphylaxis associated with latex allergy during barium enema examinations AJR 1991; 156:903-8 GASTROINTESTINAL ENDOSCOPY 129 ... used safely for removal of sharp objects,8,9 none was immediately available On the following day, a latex orthopedic glove was modified for removal of the star An orthopedic glove was chosen for. .. reaction is a potential complication with the use of the latex glove Gloves made of other synthetic material are available, but they are generally thinner than the latex orthopedic gloves and may not... back over the endoscope for passage C, Position of glove after capture of the foreign body and withdrawal through the esophagus 128 GASTROINTESTINAL ENDOSCOPY The extraction of sharp foreign bodies