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Eur J Cardiothorac Surg 1998;13:499
© 1998 Elsevier Science NL

Editorial comment

Foreign bodies in the oesophagus

The Yorkshire Laser Centre, Goole and District Hospital, Woodland Avenue, Goole, DN14 6RX, UK

In this issue of the journal Dr Al-Qudah and colleagues [1] review 23 years experience in the paper Esophageal foreign bodies (FB) seen and treated in their Institution at the University Hospital of Amman, Jordan. Their article draws attention to a number of important points.

First, that geography and cultural factors influence the population at risk and the nature of the ingested FB as well as the pattern of referral. In their cases an overall majority were children with coins, retained in the pharyngo-oesophageal junction and/or cervical oesophagus. In contrast, in Nandi and Ong's [2] series of nearly 2400 cases, fish and other bones formed the bulk of ingested FBs. This article by Al-Qudah et al. brings about the opportunity to debate a number of issues, related to the subject, which concern thoracic surgeons.

Historically, patients with ingested FBs have been referred for management to the otorhinolaryngologist (ORL) or thoracic surgeon either directly or following triage. These specialities are trained not only in pharyngo-oesophagoscopy and tracheobronchoscopy and, therefore, carry out not only oesophageal retrieval of the FB but can also inspect the upper airway if the diagnosis is in doubt, or in the case of negative oesophagoscopy.

Experience shows that differential diagnosis between ingestion or inhalation of a FB may at times be virtually impossible since the diagnosis of ingested FB relies on the triad of clinical history and examination, radiology and endoscopy. Considering that the diagnosis of an inhaled FB relies on this same triad and that clinical history may be unhelpful, to distinguish between ingestion and inhalation in some categories of at risk patients, e.g. psychiatric and children, it would seem prudent to continue the traditional pattern of referral to ORL or thoracic surgeon. This tradition is firmly upheld in some centres such as that of Dr. Al-Qudah, with the result that their patients were diagnosed and treated promptly with no important morbidity or mortality. Similar results have been obtained in other specialised centres [2] [3] [4].

The advent of the flexible, fibre-optic endoscope has placed endoscopy services in the hands of the physician gastroenterologist and, in turn, expansion of interventional endoscopy has altered the pattern of referral of ingested FBs so that in some areas this has become the responsibility of the gastroenterologist.

Whilst uncomplicated, blunt objects may successfully be removed by the physician using a flexible instrument, more complicated cases need still to be referred to the thoracic surgeon. It is not surprising therefore, that weight of published opinion favours the use of a rigid, open ended instrument for the retrieval of a FB with many feeling that the reallocation of this problem area is a retrograde step. In cases where the ingested object is sharp, with the potential for complication, referral directly to the surgeon for management is obviously the sensible approach.

It is important to emphasise that inevitably in a small percentage of cases no object is retrieved. This may be due to the fact that, in spite of the reported history, no object has in fact been ingested. However, failure to identify a FB does not necessarily mean that there has not been one ingested. It therefore follows that full investigation of the alimentary tract must be instigated. In the absence of conclusive findings follow-up arrangements should be made since failure to do so could have important medico-legal implications. Additionally, after successful retrieval of a FB it is important to ensure in consultation with the patient that the FB has been removed in total.

I believe that there should be guidelines in place in Accident and Emergency departments which govern best practice in FB ingestion or inhalation. These should cover primary diagnostic methods which, in cases of an oesophageal FB should include precise clinical history and examination and antero-posterior and lateral views of neck and chest. Following these, referral should be made to an appropriate surgical centre for endoscopy, including pharyngo-oesophagoscopy, using a rigid instrument. If findings are negative upper endoscopy with the flexible instrument should be recommended. In cases of suspected FB inhalation tracheo-bronchoscopy needs to be added. It is worth remembering that FBs can migrate both to a more distal portion of the digestive system and also transmurally into the mediastinum and other intrathoracic structures. Therefore, early diagnosis and treatment is essential if potentially hazardous or life threatening situations are to be avoided.

References

1. Al-Qudah A, Daradkeh S, Abu-Khalaf M. Esophageal foreign bodies. Eur J Cardio-thorac Surg 1998;13;in press.
2. Nandi P., Ong G.B. Foreign body in the esophagus: review of 2394 cases. Br J Surg 1978;65:5-9.[Medline]
3. Hawkins D.B. Removal of blunt foreign bodes from the esophagus. Ann Otol Rhinol Laryngol 1990;99:935-940.[Medline]
4. Lyons M.F., Tsuchida A.M. Foreign bodes of the gastrointestinal tract. Med Clin N Am 1993;5:1101-1114.

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