Guidewire slippage into the peritoneal cavity during clinical operations is extremely rare. Therefore, this paper aims to report a successful case of guidewire removal using transgastric natural orifice transluminal endoscopic surgery (NOTES). The goal is to enhance physicians' understanding of the management plan for this unique scenario and provide a valuable reference for clinical practice.

A 64-year-old man presented with abdominal distension and was diagnosed with cirrhosis combined with massive ascites. To proceed with treatment, the patient underwent ultrasound-guided peritoneal puncture and underwent catheterization and drainage. Unfortunately, a 0.035-inch guidewire slipped into the abdominal cavity during the procedure. Following a comprehensive evaluation and consultation by a multidisciplinary team, the guidewire was successfully removed using NOTES.

This case highlights the potential consideration of transgastric NOTES removal when encountering a foreign body, such as a guidewire, within the abdominal cavity.

Guidewires are pivotal in various clinical procedures, encompassing guidance, support, and exchange. While the retention of guidewires within the body is typically deemed uncommon, recent estimates suggest that, on average, two instances of guidewire retention during central venous catheter insertion arise each month[1]. Nevertheless, only one case involving the retention of guidewires within the abdominal cavity has been previously documented[2]. This article presents the pioneering retrieval of abdominal guidewires utilizing a gastrointestinal natural-tunnel endoscopic procedure (natural orifice transluminal endoscopic surgery, NOTES), thus providing clinicians with a valuable point of reference.

The object found within the abdominal cavity was identified as a guidewire, which was presumed to have inadvertently entered during peritoneal puncture placement.

Considering the patient's advanced age and deteriorating health condition, the decision was made to remove the guidewire through transgastric NOTES. The procedure was conducted under anesthesia and involved the following steps (Figure 2 and Video): (1) An incision was created in the anterior wall of the gastric antrum using a DualKnife and IT-knife; (2) Exploration of the abdominal cavity allowed for the identification and extraction of the guidewire with the assistance of foreign body forceps through the gastric wall incision; and (3) The wound was treated using thermocoagulation forceps, and the gastric wall incision was subsequently closed with endoclips.

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Figure 2 The sequential steps of the endoscopic treatment procedures. A: Incision of the gastric wall; B: The abdominal cavity was explored; C: Discovery of the guidewire; D: Removal of the guidewire.

Following the procedure, the patient did not experience any episodes of abdominal pain, fever, or other discomfort. A subsequent abdomen X-ray displayed no dense shadows within the abdominal cavity (Figure 3). The patient was discharged after one-week post-procedure, and during the one-year follow-up period, the patient remained in good health with no complaints of recurrent abdominal discomfort.

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Figure 3 The abdominal stereotaxic plain film revealed a prominent, irregularly shaped hyperdense shadow within the abdominal cavity, accompanied by minimal intestinal gas.

The concept of endoscopic laparotomy utilizing the natural lumen was initially introduced by Kalloo et al[3] in the United States in 1998. Subsequently, in 2004, successful transgastric endoscopic cholecystectomy procedures were performed on pigs. In 2005, the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal Endoscopic Surgeons collaborated to propose the notion of NOTES, which has gained widespread adoption since its inception[4]. NOTES represents an evolving minimally invasive technique aimed at mitigating abdominal trauma and its associated complications[5]. When compared to conventional and laparoscopic surgeries, NOTES offers several advantages, including minimal scarring, reduced trauma, diminished pain, shorter surgical pathways, and accelerated healing[4,6].

With the advancement of various interventional therapies, adverse events caused by auxiliary devices like guide wires, guide catheters, and PEG tubes have become increasingly evident. The safe and swift removal of foreign bodies assumes particular significance. Previous reports of guidewire retention predominantly arise from instances where a broken guidewire inadvertently slipped into the bloodstream during procedures such as coronary angiography[1,7]. Unlike those reported cases, the guidewire in the present study was inadvertently left within the abdominal cavity, with only one similar case reported in the literature[2]. In that previous case, the guidewire was retrieved using ultrasound-guided gastroscopic foreign body forceps via a transcutaneous route, which proved to be relatively challenging and unsuitable for patients with extensive ascites or complex guidewire locations. Given the patient's advanced age and weakened state, traditional approaches involving laparoscopy or open surgery were deemed inappropriate. Taking into account the patient's favorable coagulation function and platelet count, the multidisciplinary team ultimately decided on the transgastric NOTES approach. This well-established surgical method may serve as a valuable reference for clinical practice.

Guidewire slippage into the abdominal cavity is a rare occurrence in clinical practice. When faced with such circumstances, the safe and efficient extraction of the guidewire becomes a pertinent consideration. This study advocates for the utilization of the transgastric NOTES technique as an advantageous approach for guidewire removal from the abdominal cavity.