Ann Thorac Surg 2007;84:1854-1857. doi:10.1016/j.athoracsur.2007.07.020
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Foreign Bodies in the Esophagus
Dov Weissberg, MDa,b,*,
Yael Refaely, MDa,b
a Department of Thoracic Surgery, Tel Aviv University Sackler School of Medicine, Tel Aviv
b Department of Thoracic Surgery, E. Wolfson Medical Center, Holon, Israel
Accepted for publication July 9, 2007.
* Address correspondence to Dr Weissberg, 11 Be’eri St, Rehovot, 76352, Israel (Email: dovw{at}post.tau.ac.il).
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Abstract
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Background: One third of foreign bodies retained in the gastrointestinal tract are present in the esophagus. Their management depends on the anatomic location, shape and size of the foreign body, and duration of impaction.
Methods: Between 1971 and 2001, 32 patients with foreign bodies in the esophagus were admitted to our service in the Wolfson Medical Center. Their charts were reviewed for preoperative diagnosis, kind and location of foreign body, length of retention, management of patients, complications, and length of hospitalization.
Results: One patient was admitted with perforation of the esophagus. Thirty of the foreign bodies have been extracted at rigid esophagoscopy and two at thoracotomy. There was one complication (tear of esophageal mucosa) and one death.
Conclusions: The presence of a foreign body in the esophagus is a challenging problem. Perforations may result in death. Impaction mandates immediate extraction. Our experience indicates that the use of a rigid esophagoscope is safe and reliable. Based on this experience and that of other authors, we recommend the use of the rigid endoscope as the instrument of choice for extracting foreign bodies from the esophagus. Surgeons in training should be taught rigid esophagoscopy.
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Introduction
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The presence of a foreign body in the gastrointestinal tract is a challenging problem. Its management depends on a number of factors, such as anatomic location, shape and size of the foreign body, and duration of impaction. Foreign bodies retained in the esophagus are by far the most dangerous. Perforations are common and may result in death [1, 2]. Extraction of the foreign body as soon as diagnosed is, therefore, mandatory. However, the best method of extraction of an esophageal foreign body remains controversial. Over the past decade, the flexible fiberoptic endoscope has gained great popularity, mainly owing to its safety. The rigid esophagoscope is equally safe and effective in the hands of an experienced surgeon [3–5], however, and in most instances, the particular instrument is chosen on the base of the surgeon’s experience. In recent years, there were reports of the flexible instrument adversely affecting outcome of the procedure, until replaced with the rigid endoscope [6, 7].
This study reviews our experience with the management of foreign bodies in the esophagus over a 30-year period.
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Patients and Methods
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Approval for this study was obtained from our Institutional Review Board, and individual consent was waived.
A retrospective chart review was made of all patients hospitalized at the Wolfson Medical Center with a diagnosis of foreign bodies in the gastrointestinal tract between July 1971 and December 2001. Ninety five patients were identified. The charts were reviewed for the following: patient demographics, preoperative diagnosis, kind and location of the foreign body, timing of the procedure (emergency versus elective), type of procedure, complications, intensive care unit length of stay, and the length of hospitalization.
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Results
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Some of these patients were included in our earlier publication on foreign bodies [8]. In 32 instances, the foreign bodies were present in the esophagus (Table 1). Of these, 16 were retained at the cricopharyngeus, 14 in the thoracic esophagus, and 2 at the lower esophageal sphincter. There were 13 male and 19 female patients between 9 months and 73 years of age, among them were 10 children aged from 9 months to 11 years. The mean age of all patients was 23 years, 5 months.
Search for preexisting changes in the esophagus, including strictures, failed to disclose any. Bones, fruit pits, and food were retained in 13 patients; of these, one fruit pit was found and extracted at a thoracotomy, after earlier perforation. There were nine coins, all in children; six fish bones, all in adults; one razor blade; and one spring of a laundry peg (Table 1). The length of retention in the esophagus ranged from 4 hours to 6 days (mean, 16 hours). All patients were managed on the thoracic surgery service, including children, who were boarded on the pediatric service under the responsibility of thoracic surgeons. Thirty of the foreign bodies had been extracted at esophagoscopy, using the rigid instrument, all within 18 hours of admission. The length of retention in the esophagus was considerably longer, however, and lasted from 4 hours to 6 days because of delays in seeking medical help. Two patients had their foreign bodies removed at thoracotomy. Of these, 1 was admitted to the intensive care unit, where she remained 14 days, until her death. There was 1 complication (tear of esophageal mucosa) and 1 death (Table 2).
One patient, a woman 73 years old, accidentally swallowed an apricot pit. Unaware of the accident, she did not seek medical attention for 3 days. At that time, because of pain in the upper chest and inability to swallow any food or liquids, she was referred by her family physician to the hospital. A barium swallow study showed filling defect and obstruction at the upper third of the thoracic esophagus with only a trickle of barium bypassing the obstruction (Fig 1). Because of the 3-day impaction, there was high likelihood of damage to the mucosa, and a trial of esophagoscopic extraction of the foreign body was deemed inadvisable. Therefore, through a right-sided muscle-sparing thoracotomy, an incision was made in the esophagus and the pit was removed. The esophageal incision was closed transversely and a pleural drain was placed close by. The recovery was uneventful.
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Fig 1. Contrast study shows obstruction of the esophagus with only a trickle of barium bypassing the foreign body.
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A woman, 39 years old, swallowed a peach pit, which caused perforation of the esophagus into the right pleural cavity. The patient was unaware of having swallowed the pit and for the first 4 days did not seek medical attention. Then, because of chest pain and fever of 39°C, she was admitted to the medical service for observation, still without suspicion of esophageal perforation. While on the medical service, she had right pleural empyema and sepsis. Cultures of pus aspirated from the right pleura grew a mixture of microorganisms with a predominance of Pseudomonas sp, and she was treated with gentamicin and cephalosporin. Seven days after the perforation she was transferred, septic and moribund, to the thoracic surgery service. At this time her body temperature was 40.5°C; her blood pressure, 125/75 mm Hg; hemoglobin 12.3 g; white blood cell count 18,200; and blood urea nitrogen 45 mg/100 mL. Chest roentgenogram showed inflammatory changes and liquid (pus) in the right pleural cavity. Barium swallow study demonstrated perforation in the lower third of the esophagus. The patient was transferred to the intensive care unit. Amoxycillin was added to the treatment, and an exploratory thoracotomy was done. All pus was aspirated, the pit was removed, and necrotic tissue around the perforation was debrided. Closure of the perforation could not be done at this time. The pleural cavity was lavaged, and two large-bore drains were placed near the perforation. The patient continued to deteriorate, however, and died of sepsis with multiple organ failure on the 25th day after swallowing the pit (Table 2).
Denture impaction occurred in 2 female patients, 52 and 57 years old. One was impacted at the lower end of the esophagus, just above the cardia, the other in the thoracic esophagus. Both were removed at esophagoscopy under general anesthesia. The denture above the cardia had been impacted there for more than 12 hours. Its extraction resulted in a minuscule mucosal injury that healed uneventfully. The second patient was psychotic and had swallowed her denture intentionally. It remained impacted in the thoracic esophagus for 6 days (Fig 2). Extraction at esophagoscopy was probably ill advised, as it resulted in laceration of the esophageal mucosa. There was no complete perforation, however, and the mucosal tear healed well.
A prisoner swallowed a razor blade wrapped in toilet paper. Because of increased friction, the blade became retained in the middle third of the esophagus (Fig 3). It was extracted at esophagoscopy without causing injury.
The spring of a laundry peg was impacted at the cricopharyngeal constrictor of a 9-month-old male infant. It was extracted, uneventfully, at esophagoscopy.
Sixteen patients were discharged on the day of the procedure, after 3 to 4 hours of observation. Twelve patients were kept for observation for 24 hours. Three patients were discharged after 2, 3, and 6 days. One patient died in the intensive care unit after 21 days of hospitalization. The 15 patients who were kept for observation for 24 hours or longer were requested to return for a follow-up visit, but only 10, all adults, complied. At 1 year, all were asymptomatic and well.
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Comment
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There is an apparent predominance of certain types of foreign bodies in specific groups of patients. Coins and toys are a relatively common finding in children [9, 10]. Razor blades and cutlery are typical for prisoners who swallow these objects deliberately to be hospitalized [8]. Often characterized by a psychopathic personality, these patients are not usually deterred by prospects of possible complications. One patient in this series swallowed a razor blade. In an attempt to minimize damage to the gastrointestinal tract, he wrapped the blade in toilet paper. However, this resulted in increased friction, and the blade was retained in the esophagus. It is attractive to assume that emergence of typical groups predisposed to swallowing certain types of foreign bodies might help prevent such accidents. Unfortunately, it is not easy to prevent psychotics and jail inmates from ingesting any object that can be swallowed. No logic will convince a prisoner that a shaving blade or a fork should not be swallowed if he wants to spend some time in the hospital. It is likely, therefore, that the problem of foreign bodies will remain in the realm of treatment rather than prevention.
Impaction of a foreign body in the esophagus causes edema of the mucosa, and the esophageal wall becomes weakened. Fruit pits are particularly dangerous because of the sharp tip that tends to become engaged in the mucosa. Retention leads to perforation, which is only a matter of time [1, 2, 11]. Therefore, all foreign bodies retained in the esophagus should be removed as soon as diagnosed. The choice of extraction at esophagoscopy or at thoracotomy depends on the feasibility and safety of retrieval at esophagoscopy. We faced this dilemma on two occasions. One was the female patient whose denture remained impacted in the esophagus for 6 days. She was under our care early in our experience. At that time, overconfidence of the senior author led to the ill-advised decision to extract the denture at esophagoscopy, resulting in laceration of esophageal mucosa. Based on that experience, we made a more careful decision in a later patient, who had an apricot pit impacted in the upper esophagus with near-total obstruction for 3 days; that time, the pit was extracted at operation, without complications. Impaction for several days is not by itself an indication for thoracotomy, but an apricot pit has a sharp tip that during the days of impaction could have caused injury to the esophagus, and served as a warning.
The presence of a perforation in association with a foreign body and a mediastinal inflammatory mass should be treated by extraction of the foreign body, enteric but no oral feeding, and antibiotics until healing has occurred as demonstrated by contrast esophagogram [12].
In planning the extraction, one of the important points to considered is the proper choice of the instruments. This is particularly important in the case of sharp and pointed foreign bodies, such as denture with protruding hooks, shaving blades, and open safety pins, which increase the danger of perforation. Extraction of these objects requires special attention and experience. Some may have to be drawn, sometimes only partially, into the lumen of the rigid esophagoscope, to enable their manipulation and extraction while protecting the esophageal mucosa [6]. This protection is not possible with the flexible instrument.
Historically, the initial method of management of esophageal foreign bodies was extraction through the rigid esophagoscope. In 1966 Bigler [13] reported on a new technique, using a Foley catheter, and in the 1970s and 1980s, the flexible fiberoptic instrument became an option. The Foley catheter has been used for extraction of large, radioopaque foreign bodies, but is of no use in the majority of instances. At present, the flexible and rigid endoscopy remain the two universally applicable methods. The success rate with the use of rigid instrument ranges between 94% and 100% [5, 15, 16]. The estimated incidence of esophageal perforation is 0.34% with a 0.05% mortality rate [4]. The success rate with the flexible esophagoscopy ranges between 76% and 98.5% [15, 17, 18], and the morbidity (perforation) rate between 0% and 0.5% [15, 17, 19, 20]. While these success and morbidity rates are similar, the flexible endoscope is newer, and thus more attractive, particularly to those physicians trained in its use, but with no training or experience in the rigid esophagoscopy.
We always use the rigid esophagoscope and a variety of forceps. The wide lumen of the rigid instrument is of great help in manipulating the foreign body and extracting it, and we believe that this should be the instrument of choice [8]. This idea is not isolated and has been suggested by several authors [14, 21, 22]. Unfortunately, the art of rigid esophagoscopy is rapidly disappearing. Already in our days, many gastroenterologists, thoracic surgeons, and laryngologists in training are sometimes surprised when told that an instrument such as rigid esophagoscope could ever have been inserted into the lumen of the esophagagus. To us, this is a source of worry and a reason to reintroduce rigid esophagoscopy in the training curricula of those disciplines involved in the investigation and treatment of esophageal disorders.
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References
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Abstract
Introduction
