Cap-assisted large cold snare removal of a giant phytobezoar

A 56-year-old woman presented to our department with a 1-day history of hematemesis and a 2-year history of eating persimmons. After the patient had received an injection of proton pump inhibitor, we found a giant phytobezoar (about 6 × 4 cm) in her stomach on gastroscopy ([Fig. 1 a]). The phytobezoar was turned into an upright position with the endoscope in the inverted position ([Video 1]). A large snare (4 cm in diameter) was used to trap the phytobezoar ([Fig. 1 b]); however, it was hard to crush the phytobezoar when tightening the snare. Therefore, the tightened snare was pulled into the cap to cold-cut the phytobezoar using cap assistance. After repeated snare-trapping and cap-assisted cold-cutting, the phytobezoar was finally cut into several pieces. The larger pieces were pulled out using the snare ([Fig. 2]); the leftover small pieces were washed out of the body using oral polyethylene glycol. A subsequent gastroscopy, 2 days after the cap-assisted cold-cutting snare removal procedure, revealed a clear stomach ([Fig. 3]).

Fig. 1 Endoscopic views showing: a a giant phytobezoar (about 6 × 4 cm) in the stomach; b a large cold snare being used to trap the phytobezoar.

Video 1 A giant phytobezoar is removed using a repeated cap-assisted large cold snare technique to fragment the bezoar, with the larger pieces being removed with the snare, leaving the stomach clear after flushing with oral polyethylene glycol.

Fig. 2 Photograph of the some of the larger pieces of the phytobezoar that were removed with the snare.

Fig. 3 Image from a repeat endoscopy 2 days after the cold snare excision showing a clear stomach.

Gastric bezoars can be removed by drinking coco-cola, or the use of forceps, snare, or DualKnife [1] [2]; however, a giant gastric bezoar is difficult to remove. A previous report described cap-assisted cold snare removal of a small cyanoacrylate glue bezoar [3]. Herein, we show that a cap-assisted cold snare technique can also be used to easily remove giant phytobezoars with large diameters.

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• References

• 1 Iwanuro M, Okada H, Matsueda K. et al. Review of the diagnosis and management of gastrointestinal bezoars. World J Gastrointest Endosc 2015; 7: 336-345
• 2 Tao Z, Yu Y, Zhou X. New application of dual knife: Easier removal of a giant bezoar. Dig Endosc 2019; 31: e62-e63
• 3 Sun M, Pan S, Liang Y. et al. Removal of a duodenal cyanoacrylate glue bezoar with a snare and cap-assisted endoscopy. Endoscopy 2020;