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Endoscopic Removal of Esophageal Foreign Bodies Using the Tripod Grasper
Diana L. Dougherty, MD and Klaus Mönkemüller, MD, PhD
Virginia Tech Carilion Hospital, Virginia, USA
The tripod grasper was originally developed to retrieve colon polyps (Figure 1). Given its versatile design, it soon became evident that this device was also useful for removing other types of objects.
The tripod grasper consists of a three-pronged wire inside a catheter. Once the prongs are extended out the cannula, they open like a bird claw (Figure 1A and B). Importantly, in contrast to real claws, the tips are rounded, to avoid damage to the mucosa or grasping unwanted tissue. The objective is to get the object inside of the claws and remove it, without pulling off any adjacent tissue.
Whenever there is a food impaction our main device to remove impacted meat or vegetables is the distal transparent cap attached to the scope (Figure 2, Caps in GI Endoscopy). But there are situations when the tripod grasper comes into play.
Brief case report:
Elderly patient with history of previous lye ingestion and complex esophageal strictures presented with food impaction lasting 24 hours. The patient had known esophageal strictures since childhood and was on a regular dilation program. In this patient, however, using a cap was not possible, as the esophagus was stenosed due to previous lye injury. Indeed, in any patient with fibrotic esophagus due to radiation esophagitis, old lye injury or tight anastomosis using caps is difficult or impossible as the lumen is narrowed down.
Therefore, we used tripod grasper.
Herein we present some, tips and tricks on using the tripod grasper (Figure 1).
First, inspect the motility of the esophagus and the interplay of the foreign body with the stenosis and the stricture. Is the esophagus elastic or stiff? Is the foreign body impacted or does it move up and down? Using some water is useful to further determine the interplay of the foreign body and the stricture.
Second, evaluate the mucosa. We want to prevent further damage during manipulation during the extraction maneuvers. Is it macerated due to long-standing pressure damage from the foreign body? Has the patient developed and laceration due to previous nausea, vomiting or retching?
Third, proceed to remove the foreign body. It is important not to open or expose the entire tripod grasper (Fig. 3C), as it may get entangled against the walls of stenotic esophagus. With the open grasper advance the scope towards the foreign body and slowly expose the grasper’s legs. Then close the grasper, while simultaneously pushing towards the foreign body (Fig. 3D). Closing with pushing will result in inefficient grasp and the foreign body may fall off the grasper.
Fourth, once the foreign body is tightly grasped proceed to pull the foreign body towards the tip of the scope, to avoid a gap between the scope tip and grasped foreign body (Figure 3G and 3H). This is called the pathfinder trick, as the scope will serve as guide and “clear the way” for the foreign body on its tip.
If there is a distance between the scope and the tripod grasper with the foreign body (Fig. 3F, yellow arrow showing the gap), the foreign body may fall off at areas of stenosis such as the upper esophageal sphincter or additional esophageal stenosis or fibrotic rings (Fig 3E).
One last trick: while removing the scope with the foreign body, try to do gently twisting of the scope, in a corkscrew-type way, to adapt to esophageal tortuosity and thus, avoid for the foreign body to bounce of the wall or mucosal strictures.
A Quick Tip Video depicting the entire process will be available on endocollab.com