Endoscopic Removal of an Eroded Surgical Pledget Video Case Report Endoscopic Removal of an Eroded Surgical Pledget

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.

Jayakrishna Chintanaboina, MD, MPH Abraham Mathew, MD, MSc 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, USA

Disclosures Funding: None Relationship with industry: Jayakrishna Chintanaboina: None Abraham Mathew: Consultant with Boston Scientific

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 forceps

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 presentation

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 – Unremarkable

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.

VIDEO – 1 – Repeat EGD demonstrating the surgical pledget and attempted removal

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 mortality

Video 2 – demonstrating the removal of the surgical pledget.

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 antibiotics

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.

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.

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