Disclaimer Endoscopy procedures can result in harm to patients and should be performed only by qualified medical professionals This video is intended solely for informational purposes and to supplement not replace proper training and supervision by qualified instructors ID: 640705
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Slide1
Video Case Report
Endoscopic Removal of an Eroded Surgical PledgetSlide2
Disclaimer
Endoscopy procedures can result in harm to patients and should be performed only by qualified medical professionals. This video is intended solely for informational purposes and to supplement, not replace, proper training and supervision by qualified instructors.
Medicine is an ever changing field. Viewers are advised to check the most current information provided by the manufacturer for every device being used and to verify the indications, contraindications, and proper procedural technique. The dose, method of administration, and contraindications for any administered drug should be confirmed before use.
The American Society of Gastrointestinal Endoscopy, publisher of the
VideoGIE
, disclaims all liability arising from damages to persons or property arising from use of the information contained in this video.Slide3
Endoscopic Removal of an Eroded Surgical Pledget Causing Liver abscesses and Hepaticoduodenal Fistula
Jayakrishna Chintanaboina, MD, MPH
Abraham Mathew, MD, MSc
PennState
Health Milton S. Hershey Medical Center
Division of Gastroenterology and Hepatology
Hershey, PA, USASlide4
Disclosures
Funding: None Relationship with industry:
Jayakrishna Chintanaboina
:
None
Abraham Mathew
:
Consultant with Boston ScientificSlide5
Keywords
Organ
Liver, Duodenum
Procedure
EGD
Pathology
Fistula, Foreign body
Diagnosis
Hepaticoduodenal
Fistula
Therapy
Endoscopic
removal of foreign body
Instruments used
Endoscope
Accessory used
Biopsy
forceps
, Rat tooth
forcepsSlide6
Case
A 75-year-old female presented with recurrent liver abscesses of unknown cause.The
abscesses failed to respond to several percutaneous drainage procedures and multiple courses of
antibiotics
Past medical history of benign
hepatic adenoma status post partial hepatectomy 42 years prior and gastric ulcer diagnosed 5 years prior to the
presentationSlide7
Case
On examination, she was afebrile and obese (BMI – 32.9)Percutaneous drain noted
in the epigastrium
A
midline scar and multiple small scars from prior percutaneous drains
Laboratory
data
CBC, CMP – UnremarkableSlide8Slide9Slide10Slide11Slide12Slide13Slide14Slide15Slide16
Case
Esophagogastroduodenoscopy
(EGD)
Duodenal
bulb – a fistula with purulent drainage
A
fistulogram
using a
sphincterotome demonstrated a small tract into the liver
The fistula was closed by ablating the mouth of the fistula with argon plasma coagulation and by clipping as the opening was small. Slide17Slide18Slide19Slide20Slide21
VIDEO – 1 – Repeat EGD demonstrating the surgical pledget and attempted removalSlide22
Case
After discussion with the surgeons, it was determined that an attempt to remove the surgical pledget by endoscopy would be safer than performing
a surgery with potential morbidity and mortalitySlide23
Video 2 – demonstrating the removal of the surgical pledget.Slide24Slide25
Case
At 4-month follow up, patient reported no symptoms and felt more energetic without any
myalgias
and fatigue.
She
did not require any further antibioticsSlide26
Case
Percutaneous drains were removed in couple of weeks as there was no further drainage. As patient remained asymptomatic, a repeat endoscopy was not pursued.
At 5 year follow-up, patient remained asymptomatic and did not require any further interventions. Slide27
Discussion
Surgical
pledgets
made of
teflon
have been reported to erode in to the esophagus [1]
Teflon
pledgets
are commonly used in fundoplication however there is small but significant risks that led to abortion of use of this technique in most institutions [2]
Baladas
H.G. et al.
Esophagogastric
fistula secondary to
teflon
pledget: a rare complication following laparoscopic fundoplication. Dis Esophagus. 2000; 13 (1): 72-4
Teflon
pledget reinforced fundoplication causes symptomatic gastric and esophageal
lumenal
penetration. Am J Surg.
2004 Feb;187(2):226-9
.Slide28
Conclusions
Gastroenterologists and surgeons should be aware of this rare potential complication of surgical pledgets, which may occur even several decades after
surgery
Endoscopic
removal of the surgical pledget should be attempted, if feasible, before considering a major surgical procedure with potential morbidity and mortality