Endoscopic ultrasound-guided NOTES for fishbone removal near the pancreas

Natural orifice transluminal endoscopic surgery (NOTES) is a minimally invasive technique that accesses internal organs through natural orifices, eliminating external incisions. With advancements in endoscopic technology, NOTES is increasingly applied in clinical practice [1]. Here, we report a case of endoscopic ultrasound (EUS)-guided NOTES for removing a fishbone near the pancreas.

A 59-year-old man who presented with a 10-day history of epigastric pain was admitted. Physical examination showed mild tenderness in the right upper abdomen. Laboratory tests revealed elevated white blood cell count and C-reactive protein levels. He had accidentally swallowed a fishbone 2 months prior but was asymptomatic at that time.

A computed tomography scan identified pancreatic exudation and a high-density strip near the pancreatic head, indicating the presence of a foreign body. However, traditional gastroscopy and EUS with a mini-probe failed to detect it ([Fig. 1]).

Fig. 1 Abdominal computed tomography (CT) and gastroscopy images before the endoscopic procedure. a, b Abdominal plain (a) and contrast-enhanced (b) CT scans suggested a high-density foreign object in front of the pancreatic head. c, d Gastroscopy did not reveal any foreign body or ulcer in the antrum (c) or duodenum (d).

A linear-array echoendoscope (GF-UCT260; Olympus, Tokyo, Japan) was employed, revealing a hyperechoic foreign body adjacent to the pancreatic head. Given the foreign body’s penetration through the gastric wall and the patient’s pain, intervention was necessary. Conventional surgery posed significant trauma and difficulty in locating the object, so we opted for endoscopic full-thickness resection under EUS guidance ([Video 1]).

Endoscopic ultrasound-guided natural orifice transluminal endoscopic surgery for fishbone removal near the pancreas.Video 1

The gastric wall was incised to the serosal layer with a HybridKnife (I-Type I-Jet; Erbe Elektromedizin GmbH, Tübingen, Germany). After relocating under EUS guidance and carefully separating the surrounding tissue, the fishbone (3 cm) was successfully removed ([Fig. 2]). Post-procedure, the patient received anti-inflammatory treatment and recovered uneventfully. He was discharged 5 days later and showed no complications at follow-up ([Fig. 3]).

Fig. 2 Endoscopic ultrasound (EUS)-guided endoscopic full-thickness resection to remove the foreign body. a Linear-array EUS scan revealed a hyperechoic, strip-shaped foreign body near the pancreatic head. b Following careful incision under ultrasound guidance, the foreign body was successfully exposed. c A fishbone approximately 3 cm long was removed successfully.

Fig. 3 Computed tomography (CT) and gastroscopy images at the 3-month follow-up. a CT showed no obvious abnormalities. b, c Gastroscopy showed that the surgical region had mostly healed, with a residual superficial ulcer and a titanium clip.

Accidental ingestion of foreign bodies is common, but migration into the abdominal cavity, particularly near the pancreas, is rare and serious [2]. This case indicates the utility of EUS-guided NOTES for safely removing intra-abdominal foreign bodies, reducing the need for conventional surgery, and minimizing postoperative complications.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Chen S, Ying S, Xian C. et al. Removal of an embedded gastric fishbone by traction-assisted endoscopic full-thickness resection. Endoscopy 2024; 56 (Suppl. 01) E232-E233
• 2 Sugawa C, Ono H, Taleb M. et al. Endoscopic management of foreign bodies in the upper gastrointestinal tract: a review. World J Gastrointest Endosc 2014; 6: 475-481

Publication History

Article published online:
29 April 2025