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Handbook of Laparoscopy Instruments, 2023, 89-101 89
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Basic Endoscopic Accessories
CHAPTER 9
Parmeshwar Ramesh Junare
1
Department of Gastroenterology, Acharya Vinoba Bhave Rural Hospital, Swangi, Wardha, India
Abstract: Early endoscope was developed about 50 years ago. It was initially
developed as a diagnostic tool. Since then, several modifications in endoscopes have
been made with many developments in endoscopic accessories. In the current era,
endoscopy is used for both diagnostic and therapeutic procedures. Endoscopic
accessories are essential tools for therapeutic endoscopic procedures. Endoscopic
accessories are specially designed devices that pass through accessory channel of the
endoscope & therapeutic endoscopic procedures. Routinely encountered endoscopic
endoscopy needs commonly available endoscopic accessories. Common clinical
problems in day to day practice are gastrointestinal tract bleeding, gastrointestinal tract
foreign bodies, gastrointestinal tract strictures and the requirement of enteral access for
enteral feeding. These procedures can be carried out in a day-to-day practice after
gaining adequate experience and knowledge about the procedures. Commonly used
endoscopic accessories can be divided into hemostatic devices, foreign Body (FB)
removal devices, feeding tubes, biopsy forceps and dilators. Hemostatic devices are
endoscopic accessories to control bleeding from the GI tract. Bleeding from the GI
tract may be of variceal or non-variceal origin and accordingly different devices may
be required. Various types of foreign body ingested can be encountered during clinical
practice which can be dealt with different endoscopic accessories. Enteral feeding is a
safe, effective and physiological means of providing enteral nutrition. Depending on
the clinical situation, gastric or naso-jejunal enteral access may be required for enteral
nutrition. Feeding tubes can be placed endoscopically for enteral access. Different
types of feeding tubes are available. Biopsy forceps are tissue acquisition devices for
diagnostic purposes.
1,*
and Vijendra Kirnake
1
Keywords: Achalasia cardia, APC, Dilator, Endoscopy, Endoscopic accessories,
Esophageal stricture, Enteral feeding, Endoscopic band ligation, Feeding tubes,
Epinephrine, Foreign Body, Gold probe, Hemostasis, Hemoclips, Heater probe,
Injection needles, Non-variceal bleed, Pneumatic balloon, Protein coagulation,
Variceal bleed.
*
Corresponding author Parmeshwar Ramesh Junare: Department of Gastroenterology, Acharya Vinoba Bhave
Rural Hospital, Swangi, Wardha; India; E-mail: parmeshwarjunare.717@gmail.com
All rights reserved-© 2023 Bentham Science Publishers
Lamture Yeshwant Ramrao (Ed.)
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INTRODUCTION
The first flexible endoscope was developed about 50 years ago. It was initially
developed as a diagnostic tool. Since then there were several modifications in
endoscope and in the development of endoscopic accessories. In the current era,
endoscopy is used for both diagnostic and therapeutic procedures. Endoscopic
accessories are required tool for therapeutic endoscopic procedures. Endoscopic
accessories are specially designed devices that passes through through the
accessory channel of the endoscope and therapeutic endoscopic overs procedures.
Routinely encountered endoscopic procedures can deal with commonly available
endoscopic accessories. Common clinical problems in a day-to-day practice
include gastrointestinal tract bleeding, gastrointestinal tract foreign bodies,
gastrointestinal tract strictures and the requirement of enteral access for enteral
feeding.
Common Endoscopic Accessories
Endoscopic accessories are specially designed devices that can be passed through
the working channel of the endoscope for various diagnostic and therapeutic
endoscopic procedures.
Commonly used endoscopic accessories are as follows:
1. Hemostatic devices
2. Foreign Body(FB) removal
3. Feeding tubes
4. Biopsy forceps
5. Dilators
Hemostatic Devices
These devices are used for controlling of bleeding from the gastrointestinal tract.
Bleeding from gastrointestinal tract can be of variceal or non-variceal origin. The
control of variceal and non-variceal bleed is achieved by different endoscopic
accessory devices [1, 2] (Chart 1).
Endoscopic Accessories Handbook of Laparoscopy Instruments 91
Gastrointestinal Bleed
Non-variceal Bleed
Injection needles
Thermocoagulation
Hemoclips
APC
Variceal Bleed
Endoscopic Band Ligation (EBL)
Injection needles
Glue Injection
Balloon Tamponade
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Chart. (1). Classification of GI bleeding.
Injection Needles
Needles for injection consist of three parts: an outer coating of plastic or
polytetrafluoroethylene sheath, the inner hollow part of core needle and handle.
The needle core is manipulated through a handle. The Luer lock connector on
handle allows syringe attachment. (Fig. 1) The needle part is kept inside of the
sheath during progression through the working channel of an endoscope.
Hemostasis is achieved by mechanical tamponade and cytochemical reaction with
injecting agents. Injection needles are available in various sizes ranging from 2125 G. The length is between 200-240 cm. Injection needles deliver the hemostatic
agent at the bleeding site. For glue injection, a 21G needle is used while for
sclerotherapy, a 23 G needle is preferred. Injection needles are also used for the
elevation of sessile polyps during polypectomy and tattooing of the polypectomy
site for future reorganization. Commonly used agents during injection are as
below (Table. 9.1).
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Fig. (1). Connecters.
Table 9.1. Commonly used agents for injection needle therapy.
Injection Therapy Agent
Variceal haemorrhage Ethanolamine, sodium tetradecyl sulphate, cyanoacrylate
Non-variceal hemorrahge
Achalasia Cardia Botulinum toxin
Refractory structure Triamcinolone
Tattoo India Ink
Cancer Palliation Cisplatin, 5-FU
Saline, epinephrine, polidocanol, sodium tetradecyl sulphate, Ethanol,
Fibrinogen, Thrombin
Hemoclips
Hemoclip application is a mechanical method of haemostasis. It is useful for nonvariceal bleeding. It achieves hemostasis by approximating two folds and clips
them together. Hemoclip application is effective, fast, and achieves immediate
haemostasis [3]. Apart from haemostasis, hemoclips application is useful for the
closure of gastrointestinal tract luminal perforations, closure of mucosal incision
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during per-oral endoscopic myotomy (POEM), and anchoring jejunal feeding
tubes and endoscopic markings.
Types of Hemoclips
Regular Clip
Rotatable: It allows alignment of clip arms to the tissue by rotating the handle.
Reopenable: It can be opened and closed few times before final deployment until
the endoscopist is satisfied with the grasp of the tissue.
Multi-firing Clip: Allows the application of four clips without reloading.
Specifications of some of the commonly available hemoclips are given in (Table.
9.2) and (Fig. 2).
Table 9.2. Specifications of hemoclips.
Clip Company Jaw Size Rotatable
Resolution Boston Scientific 11 N
Instinct
Quick Clip Pro Olympus
Viper Diagmed 11,13,16 Y
Duraclip Conmed 11 Y
Cook
16
11
Y
Y
Fig. (2). Connecters.
Thermocoagulation Devices
Thermocoagulation devices achieve hemostasis by the application of heat at the
bleeding site. The thermal application causes vasoconstriction, protein
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coagulation, and activation of the coagulation pathway to control bleeding.
Thermocoagulation devices are of two types, contact coagulation devices (Bipolar
cautery, heater probe, gold probe, hemostatic forceps, etc.) and noncontact
coagulation devices such as APC [2].
Bipolar Probes
Current passes through an electrocoagulation probe and generates heat at tissue
application sites. It is coaptive coagulation where pressure is used to compress
and seal the walls of the bleeding vessel. A probe can be applied perpendicular or
tangential at the bleeding vessel.
Heater Probes
Heater probe consists of a PTFE-covered aluminium cylinder heating coil and a
distal end with an irrigation port. Catheter diameter ranges from 7F to 10 F. Heat
is transferred from ends and or sides which results in tissue coagulation. Probes
can be placed perpendicularly or tangentially at the bleeding vessel site (Fig. 3).
Fig. (3). Connecting wire.
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Gold Probes
Gold probe taken from Boston Scientific has a unique integrated injection and
thermal hemostasis capabilities to achieve hemostasis. It helps to reduce catheter
exchanges and procedural time. Integrated irrigation facilitates manual or
mechanical irrigation. Its rounded gold distal tip provides conductivity and
effective coagulation (Fig. 4) [3].
Fig. (4). Gold probe.
Hemostatic Forceps
Were developed to prevent and treat bleeding during the endoscopic resection
procedure. Jaws of the forceps grasp the bleeding site while electrocoagulation
causes coagulation of the bleeding vessel. Retraction of tissue during
electrocoagulation limits the depth of tissue injury.
Argon Plasma Coagulation (APC)
It is non-coaptive thermal coagulation method to achieve hemostasis. The system
of APC consists of a probe (monopolar), an electrosurgical unit and an APC
cylinder. Argon gas flows through the probe and is converted into ionized plasma
by the electrode at the distal tip of the probe. Distal tip is placed near the bleeding
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area with a distance of 2 to 6 mm. Current is then applied which gets conducted
through the plasma gas to cause tissue coagulation. APC setting includes power
(increased power produces rapid devitalization and deeper penetration), gas flow
rate (should be kept low to avoid gas embolization and argon pneumoperitoneum)
and mode of delivery (the forced mode- continuous delivery of energy with rapid
tissue devitalization and hemostasis, forced mode-intermittent delivery of energy
with a more superficial effect.) APC is more suited for superficial lesions such as
in gastric antral vascular ectasia (GAVE), and radiation proctitis as the depth of
penetration is only a few millimetres [4].
Endoscopic Band Ligation (EBL)
EBL is a known endoscopic treatment of esophageal varices. However it can be
used for non-variceal bleeding like Dieulofoy lesion, Mallory Weiss tear. It has
handle, connecting a string or a wire that passes through the working channel of
the endoscope and connects with trasleucent distal cap. The terminal cap is preloaded with 4-10 rubber bands. During banding, varices are suctioned into the
distal cap by applying suction, then a handle is rotated to deploy the it.
Application of band causes mechanical compression, thrombosis and necrosis
along with subsequent sloughing and scarring. For variceal ligation, band
placement should be started at the gastro-esophageal region and proceeding
spirally upward for a distance of 5-8 cm upward. Bands are usually applied 2 cm
away from the varix. EBL is repeated every 2-4 weeks till complete obliteration
of varices occurs [5] (Fig. 5).
Fig. (5). Endoscopic band ligation (EBL).
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Glue
Glue injection therapy is commonly used for gastric varices. Tissue glue is a
liquid monomer substance such as N-butyl cyanoacrylate which gets polymerized
and solidified into hard substance when comes in contact with blood. Solidification occurs within 20 seconds once come contact with the blood. During glue
injection procedure, the injection needle catheter (21 G, 7 Fr and 240 cm) is
passed through the working channel of the endoscope. Needle checked in the
retroflex position. One to 2 ml of glue is injected at one site followed by flushing
with distilled water (Not saline). It removed immediately after injection [6]. All
personnel need to wear goggles along with routine gloves during glue injection
procedures.
Foreign Body Retrieval Devices
Devices for foreign body retrieval include forceps, retrievers and snares, and
mucosal protection devices. Forceps devices include grasping forceps, alligator
forceps and rat-tooth forceps. Grasping forceps may be of 2, 3 or 4 prongs. Their
use is based on the shape and orientation of objects. The number of prongs
required is determined case by case in order to provide a firm grasp while the
removal of foreign bodies. Rat-tooth forceps have ground distal spiral end and
wide opening jaws which provide an extra strong grip during the removal of
foreign bodies. Alligator jaw forceps have dual features of rat tooth forceps and an
alligator jaw for better grasping. Retriever devices include polypectomy snares,
basket retrievers and Roth-net. Polypectomy snares are available in various sizes
and utilized for removal of smooth round objects. Retrieval basket is are useful
for retrieving long or oddly shaped objects. Rothnet octagonal net that is designed
to open to maximum capacity while maintaining its form within the oesopgagus.
It is also useful for the removal of round or difficult-to-grasp objects such as
coins. Mucosal protection devices include over tubes and foreign body hoods.
Over tubes are passed over the endoscope and protect mucosa by encasing a sharp
object removal. It also protects accidental slippage of foreign bodies into the
airway tract during removal. Foreign body hoods fit over the distal aspect of
endoscopes and protect mucosa while the removal of sharp objects [7].
Biopsy Forceps
Biopsy forceps are required for endoscopic tissue sampling. There are various
designs of biopsy forceps. Biopsy cup jaws’ design is variable and can be oval or
round, serrated or smooth, non-fenestrated or fenestrated. Single-bite biopsy
forceps are useful for the sampling of single tissue at a time while multi-bite
biopsy forceps allow more specimens on a single pass. Double-bite biopsy forceps
have a needle-spike in between the two biopsy cusps. These biopsy forceps allow
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deeper tissue sampling and provide better directed tissue sampling. Jumbo biopsy
forceps (Large-capacity forceps) provide large tissue samples as they cover more
surface area than standard biopsy forceps. Length of upper gastrointestinal tract
biopsy forceps is 155 cm while the length of lower gastrointestinal tract biopsy
forceps is 230 cm [8] (Fig. 6).
Dilators
Strictures are narrowing of the gastrointestinal tract lumen due to benign or
malignant causes. Stricture dilatation is required when there is clinical impairment
due to narrowing or when is required to pass the narrowed segment for diagnostic
or therapeutic purposes. Dilators are devices that carry out stricture dilatations.
Dilators are of two types: 1. Push-type, fixed diameter dilators (Bougie dilators) 2.
Balloon dilators (radially expansible dilators). Bougie dilators exert longitudinal
force and come in various sizes. They are useful for esophageal strictures
dilatations. Hurst and Maloney’s dilators do not accommodate guide wire in it and
self-dilatation by patient is possible. Savary-Gilliard (SG) dilator is a wire-guided
bougie dilator which fit in a guidewire within the central channel of the
cylindrical solid tube. These dilators are flexible, made up of polyvinyl chloride
material and have a distal tapered end. The total length is 70 cm with the length of
the tapered part of around 20 cm. Set of of 7 (5, 7, 9, 12.8, 14 and 15) is usually
required for routine endoscopic practices. “Rule of 3” should be followed during
stricture dilatations [9].
Fig. (6). Biopsy forceps.
Balloon Dilators
Balloon dilators are available in varieties of diameters and lengths. They are
passed through the accessory channel of the endoscope over a guide-wire or
without a guidewire. They exert radial expanding force to carry out stricture
dilatation. Balloons expanded by the pressure of liquid injection (e.g., water,
radiopaque contrast) and balloon pressure monitored manometrically.
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