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We report successful removal of a long spoon using alligator forceps and an endoscopic snare inserted simultaneously into a 2-channel endoscope.
A 21-year-old woman with binge-eating/purging–type anorexia nervosa presented after accidentally swallowing a spoon the night before. She had used the spoon habitually to induce vomiting after binge eating. Upon presentation, she was in no apparent distress, and physical examination was noncontributory. Abdominal roentgenogram revealed a radiopaque object measuring 19 cm (Fig. 1).
Urgent esophagogastroduodenoscopy was performed with a 2-channel endoscope (GIF-2TQ260M, Olympus Medical Systems, Tokyo, Japan) (Video 1, available online at www.giejournal.org). An overtube could not be used because the spoon was too large to fit through it. Conscious sedation with midazolam was used without intubation.
The spoon was buried in food residue in the upper body of the stomach (Fig. 2A and B). Rat tooth alligator jaw forceps (model FG-42L-1, Olympus) were inserted through the left channel, and a reusable endoscopic snare (SD-5U-1, Olympus) was inserted through the right channel. The forceps were advanced through the loop of the snare (Fig. 2C). After grasping the spoon with the forceps, followed by the snare, forceps and snare were alternately opened and closed to move toward the edge of the spoon (Fig. 2D). With the snare grasping the edge, the forceps were extended in an open position to push the side of the spoon, rotating it around the edge to become parallel to the esophagus (Fig. 2E). The endoscope was twisted clockwise so that the spoon and snare could pass the esophagogastric junction in the 12 o'clock position. As the endoscope slid along the 6 o’clock position within the esophageal lumen and the snare was passed through the left channel in the 7 o’clock position, this twisting created space for the edge of the spoon handle to pass without touching the mucosa. The endoscope was retracted slowly through the esophagus, ensuring that the rounded end of the spoon did not injure the esophagogastric junction (Fig. 2F). A diagram illustrating the spoon handle passing the esophagogastric junction is presented in Figure 3.
When the spoon reached the mouth, it could not be retracted through the mouthpiece. The endoscope was therefore drawn out of the mouth while advancing the snare, which still grasped the spoon, to prevent reingestion. The mouthpiece was then removed, the patient’s head was tilted back, and the spoon was removed by hand (Fig. 4). The procedure was completed with no adverse effects. The patient reported no pain or tarry stools at her clinic visit 1 week later.
Guidelines recommend use of overtubes or protective hoods to prevent mucosal injury and intubation for patients with high aspiration risk during endoscopic foreign body removal.
Latex rubber hoods are not available in Japan. Although large plastic hoods are used for sharp objects, we did not use them because the hoods themselves can injure the throat and may hinder endoscopic manipulation or view, and the spoon was not sharp. Intubation was not performed because the gag reflex of patients with binge-eating/purging–type anorexia is significantly weakened owing to repeated induction of vomiting. Our patient tolerated the procedure extremely well, without any gag reflex, coughing, or burping.
It is often difficult to grasp long objects at the very edge, which is required to pass them through the esophagogastric junction. Successful spoon removal with a 2-channel endoscope and 2 endoscopic snares has been previously reported.