Eur J Cardiothorac Surg 2002;21:653-656
© 2002 Elsevier Science NL
Management of esophageal foreign bodies: a retrospective review of 400 cases
Kalliopi Athanassiadi*,
M. Gerazounis,
E. Metaxas,
Nikolitsa Kalantzi
Department of Thoracic Surgery, General Hospital of Nikea, Piraeus, Greece
Received 18 September 2001;
received in revised form 2 January 2002;
accepted 8 January 2002.
* Corresponding author. Konstantinoupoleosstr. 34A, 15562 Holargos, Athens, Greece. Tel.: +30-10-651-0388; fax: +30-10-654-7695
e-mail: kallatha{at}otenet.gr
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Abstract
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Objective: A retrospective study was conducted in 400 patients with esophageal foreign bodies (EFB) to assess characteristics of EFB and methods of treatment. Methods: From 1962 through 1998, 400 patients with EFB were treated in our department on an emergency basis. There were 202 men (50%) and 198 women (49.6%) ranging in age from 1.5 to 95 years. The main symptoms patients complained of were difficulty in swallowing and pain. Detailed anamnesis, oropharynx and hypopharynx examination and finally radiological examination were the diagnostic tools. The location of the FB was in the cervical esophagus in 57% of cases, in the thoracic one in 26% and at the cardioesophageal junction in 17%. The most common objects found were bones, morsels, coins and needles. Results: The treatment consisted of rigid esophagoscopy under general anesthesia in 343 (85.7%) of our cases. In 57 cases (14.3%) other means such as flexible esophagoscopy, Fogarty or Foley catheters and bougienage turned to be very useful. Only 12 patients (3%) were led to surgery because either extraction was impossible or perforation was present. No major complications occurred in the surgical group, whereas in the group of rigid esophagoscopy, there was one iatrogenous esophageal perforation that presented with empyema thoracis successfully treated. Finally, there was a case of an aortoesophageal fistula with mortal outcome perioperatively. Conclusions: (1) Esophagoscopy is a reliable method in the treatment of EFB impaction. (2) Alternative methods such as bougienage, etc., can be used only in selected cases with smooth foreign bodies. (3) Surgical treatment is unavoidable in cases of irretrievable EFB or esophageal perforation.
Key Words: Esophageal foreign bodies • Esophageal obstruction • Esophagoscopy
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1. Introduction
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Ingestion of foreign bodies is common especially among the pediatric age group, whereas in adults occur more commonly among those with psychiatric disorders, or mental retardation, prisoners and alcoholics [1]. Fortunately, most of them pass through the gastrointestinal tract harmlessly [2,3]. However, 10–20% will require nonoperative intervention and only 1% or less surgery [1–4].
A retrospective study was conducted in 400 patients with esophageal foreign bodies (EFB) in order to analyze our experience and assess characteristics of EFB and methods of treatment.
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2. Material and methods
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From 1962 through 1998, 400 consecutive patients with EFB were treated in our department on an emergency basis. There were 202 men (50.5%) and 198 women (49.5%) ranging in age from 1.5 to 95 years. Only 7% belonged to the pediatric age group. The majority of our patients had a clear history and symptoms of foreign body (FB) ingestion. Delayed presentation of symptoms was seen only in 11.7% of cases. The main symptoms patients complained of were difficulty in swallowing, acute onset of pain, dysphagia and excessive salivation. Detailed anamnesis and physical examination including oropharynx, hypopharynx and abdomen examination (for evidence of peritonitis or small bowel obstruction) were the initial diagnostic tools. Radiological examination performed in all our patients included a lateral and a posteroanterior soft-tissue roentgenogram showing the oropharynx, neck, chest and, when indicated, the abdomen. When there were radiolucent objects such as fish or chicken bones or objects of wood, plastic or glass material, a cautious study with an esophagogram with either barium or gastrographin was done. Finally, sometimes a barium impregnated cotton pledged swallow study was used to clarify the presence of a FB or its location. If no FB was identified and the patient remained symptomatic, endoscopy was also performed.
Only in 23 patients of our series (5.8%) was a certain pathology present such as hiatal hernia, esophageal stenosis, Ivor Lewis operation performed for esophageal cancer, esophageal diverticulum or even lung cancer.
The entrapment of the FB was in the cervical esophagus in 57% of cases, in the thoracic one in 26% and at the cardioesophageal junction in 17% (Table 1) and the duration of impaction was less than 24 h in most of our cases.
The treatment of choice consisted of rigid esophagoscopy (by using esophagoscope of Negus type) under general endotracheal anesthesia in the operating room in 343 (85.7%) of our patients. In the remaining 57 cases (14.3%), other means such as flexible esophagoscopy, Fogarty or Foley catheters and bougienage turned to be very useful. Analytically, in eight cases (2%) the FB was extracted with the use of a Fogarty or Foley catheter, whereas in five cases (1.3%) its location was found with direct laryngoscopy and the FB was removed with McGill forceps. In 38 cases (9.5%) the FB was identified as food bolus endoscopically and was pushed to the stomach, whereas in 43 patients (10.7%), despite the radiological signs of the presence of a FB, it was not found. It has been assumed that it was pushed to the stomach accidentally during esophagoscopy, since symptoms disappeared and a negative radiograph was taken.
Only 12 patients (3%) were led to surgery because either extraction was impossible or dangerous (n=10), or perforation was present (n=2). The surgical approaches were cervicotomy, thoracotomy or gastrotomy according to the location of the FB. These along with the extracted FBs are listed in Table 2.
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3. Results
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The most common objects found were bones, morsels, coins and needles. The majority of our patients (n=387, 96.7%) were successfully treated with endoscopy or the alternative methods mentioned above. Only in 3% of our cases, where either extraction was considered risky either perforation or aortoesophageal fistula coexisted, we operated on.
No major complications occurred in the surgical group, whereas we had a serious one (0.25%) in the group treated with rigid esophagoscopy. There was an iatrogenous esophageal perforation after extraction of a chicken bone that presented with empyema thoracis successfully treated. A right thoracotomy was performed, the perforation was sutured in two layers and the thoracic cavity was drained. No perioperative complications were observed. The second serious complication of our series was an aortoesophageal fistula in an 18-year-old patient with mortal outcome during its surgical repair. The patient was brought to our hospital in hypovolemic shock and although he was led directly to the operating room and the fistula was repaired, he did not survive. Hospital stay ranged from 3 to 48 h for the nonsurgical group and from 6 to 12 days for the surgical one. Mortality reached 0.25%.
3.1. Follow-up
Information is available in the majority of our patients (78.2%). Follow up was done on the basis of personal interview. Over a period of 6 months to 12 years it did not reveal any complication.
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4. Discussion
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Material retained in the esophagus generally falls into two categories: FB and food bolus. Children most often ingest coins and toys, whereas adults commonly tend to have problems with meat and bones [5,6]. Preexisting physical or mental conditions predispose patients to esophageal impaction [1,6].
Impacted foreign bodies in the esophagus can easily cause mucosal ulceration, inflammation or even infections and can also result in various fatal complications such as para- or retroesophageal abscess, mediastinitis, empyema, perforation or even aortoesophageal fistula as it was in one of our cases [3,4,7–10]. The latter is a rare and usually fatal cause of upper gastrointestinal hemorrhage [4,9,10]. Prompt and effective bleeding control and left thoracotomy with primary suture of esophageal and aortic defect could be life-saving [10].
Besides anamnesis and physical examination, radiology is a very important diagnostic tool to identify the FB and its location. According to some authors [7], barium studies have a rate of false-negative or false-positive findings that ranges between 6.5 and 30%, and others [11] stressed the risk of aspiration in a contrast study. In our series, there were no false-negative results and no such complications arose. Some investigators [7,12] have also mentioned the efficacy of computed tomography (CT), especially in the detection of fish bones, but the authors cannot support the above opinion, since they have rarely used a CT scan.
Once a FB's ingestion is diagnosed the physician has to decide whether or not intervention is necessary, what is the degree of urgency and what are the best available means. The timing depends on the increased risk of perforation, aspiration or aortoesophageal fistula [5]. For instance, sharp objects or batteries require urgent intervention, since the complication rate can be as high as 35% [1,5,6].
The best modality of FB removal has been a subject of much controversy [3] for years. The choice of treatment is influenced by many factors, such as the patient's age and clinical condition; the size and shape of the ingested FB; the anatomic location and the skills of the physician. The most important consideration especially in children is airway control. Once the airway is controlled, any modality allowing direct visualization of the FB may be used for removal [1,13].
Endoscopy is currently the most commonly used method for removal [1,5,13,14]. The greatest advantage is the one of direct examination and evaluation of the degree of esophageal injury inflicting by the FB and search for multiple ones [1,13,15,16]. Rigid esophagoscopy [17] had been the primary tool up to 1957 when Hirschowitz [18] constructed the first flexible fiber-optic endoscope employed by the gastroenterologists for investigating patients with complaints involving the upper digestive tract. Today, either rigid or flexible endoscopy performed under general anesthesia or conscious sedation respectively, are considered to be safe and effective methods in experienced hands [1]. Of course, for both, there are some advantages and disadvantages. On the one hand, flexible endoscopy can be cost-effective because it is performed on an outpatient basis without general anesthesia, but on the other hand, when sharp or penetrating FBs are in question, rigid endoscopy is required. Our preference is to use rigid endoscopy since the larger instrument allows the security of the airway and removal of most objects under direct vision without withdrawing the endoscope. Morbidity rates reported in the literature are lower than 1% [1,13] which goes along with the percentage of 0.25% in our series. Many alternative therapeutic methods have been described in the literature, such as dislodgment by a Foley catheter, advancement with bougie, papain or carbonated fluid treatment, glucagon therapy, balloon extraction during fluoroscopy, removal using a magnet, etc. [1,5,19–22]. These are all blind methods of extraction providing no control of the FB as it is removed. They can only be used for blunt foreign bodies of short duration and with no preexisting esophageal disease [23–25]. Their major disadvantage is that if pathology is present it cannot be assessed. In addition, any failure of the above methods still requires esophagoscopy.
Finally, surgery is only considered inevitable when perforation or aortoesophageal fistula is present, or the extraction is either dangerous or impossible to be done by the endoscopist. The surgical approach depends on the location of the FB.
In conclusion we would like to stress that:
- For FB at the level of the hypopharynx or cricopharyngeus muscle the open rigid laryngoscope and a grasping clamp should be used.
- In all other cases esophagoscopy is the method of choice.
- Alternative methods such as bougienage can be used only in selected cases with smooth foreign bodies.
- Surgical treatment is unavoidable in cases of irretrievable EFB or esophageal perforation.
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Footnotes
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Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 9th Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, September 16–19, 2001.
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Abstract
1. Introduction
