The importance of preparation and innovation in the endoscopic management of esophageal foreign bodies

Both accidental and intentional ingestion of foreign bodies are common. The majority of these cases occur in the pediatric population, mostly in children under 3 years of age. Coins are the most common ingested foreign bodies in children in the United States. In adults, foreign body ingestion is more commonly seen in patients with psychiatric disorders, mental retardation, or impaired cognitive function due to alcohol and/or drugs, or in individuals seeking secondary gain. Edentulous adults are also at a greater risk for foreign body ingestion.1–3 In adults without psychiatric disorders, meat impaction is the most common cause of foreign body obstruction in the United States. Foreign bodies tend to become impacted at areas of anatomic or pathologic narrowing in the gastrointestinal tract, and food impactions tend to occur in adults with underlying esophageal pathology. The majority of foreign bodies that reach the gastrointestinal tract (80–90%) will pass spontaneously. However, 10–20% will require endoscopic intervention; less than 1% will require surgery.4 Signs and symptoms related to foreign body inges-tion vary based upon the size, nature, and number of ingested objects; impaction site; time since ingestion; mental status of the patient; and presence of complications such as obstruction, bleeding, or perforation.5 The initial evaluation should include a detailed description of the most recent ingestion and any history of foreign body ingestions, dysphagia, psychiatric disorders, or significant comorbidities. In addition, symptoms suggestive of high-grade obstruction such as pain or the inability to swallow saliva are important. A physical examination is essential to exclude findings suggestive of perforation such as crepitus or peritoneal signs. Plain radiographs of the neck, chest, and abdomen are helpful for locating radiopaque foreign bodies as well as identifying the presence of free air in the neck, mediastinum, or peritoneum. Computed tomography is highly sensitive for the presence of free air and is superior to plain radiographs when perforation is suspected.6,7 Barium contrast studies are generally not performed in these cases, due to the high risk of aspiration and poor visualization on subsequent endoscopy as a result of mucosal coating. Once a diagnosis of foreign body ingestion is made, the endoscopist must decide whether an immediate intervention is required based upon the perceived risks of aspiration and/or perforation. Prior to attempting removal of the foreign body, the endoscopist and assisting staff should place all accessories within reach, including over-tubes, foreign body graspers, retrieval baskets, and snares, as these items may be helpful for foreign body retrieval. Flexible endoscopy is the preferred retrieval method and allows a thorough examination of the esophagus, stomach, and proximal duodenum. Guidelines from the American Society for Gastrointestinal Endoscopy recommend immediate endoscopic intervention in the presence of high-grade esophageal obstruction or impaction of a sharp object or disk battery within the esophagus.8 Endo-scopic intervention should not be delayed for more than 24 hours for other objects in the esophagus or long, sharp objects in the stomach because of the increased risk of complications. Blunt objects more than 25 mm in diameter are less likely to pass through the pylorus and should also be endoscopically removed. Elective endotracheal intubation should be considered in patients with a high risk of aspiration. Successful capture of the foreign object is the first priority and may present a serious challenge because of the shape or consistency of the object. Foreign body retrieval forceps (eg, rat tooth, alligator type) or Roth net retrievers (US Endoscopy) are commonly used. Some endoscopists have used biliary stone retrieval baskets to firmly grasp objects. In the case reported by Swaminath and associates, the successful use of a trapezoid, wire, rotatable retrieval basket (Boston Scientific) allowed for a firm grasp and reorientation of the bone.9 Other devices that have been used include snares, sutures for objects with holes (eg, washers, rings, earrings), graspers, and balloons.10,11 The risk of mucosal injury during foreign body retrieval can be minimized by orienting the object with its sharp end trailing the extraction, thereby fulfilling Jackson's axiom that advancing points cause perforations, in contrast to trailing points.12 The use of a hood or transparent cap has also been described to help orient small, sharp objects and protect the esophagus.13 However, in general, the use of overtubes is preferred. Overtubes allow repeated introduction of the endoscope, as needed, reduce the risk of mucosal trauma during extraction, and protect the airway. Since 1974, when Witzel and colleagues reported the use of a 80-cm clear plastic tube for the safe removal of 6 razor blades using a snare, a variety of over-tubes have been used in adults.14 In the past, concerns have arisen regarding mucosal pinching and esophageal tears.15 This issue was resolved with the creation of over-tubes that tightly fit endoscopes, thereby minimizing mucosal pinching. The overtube used by Swaminath and colleagues (Guardus, US Endoscopy) is 1 of the 2 overtubes currently available and has a diameter of 16.7 mm.9 Because of the overtube's pliable nature, larger foreign bodies can be retracted into the distal end of the overtube, as described in the case report by Swaminath and colleagues, and the endoscope and overtube can be simultaneously withdrawn.9 In another recent report, an incision was made in the distal 2 mm of the overtube to flatten the distal end and provide a wider oval shape that allowed a razor blade to be pulled into the overtube.16 A rigid esophagoscopy by our otolaryngology colleagues may allow the use of other accessories such as cutting forceps or a lithotriptor. Kim and coworkers reported the successful removal of a shell from the esophageal wall of an infant using a rigid esophagoscope and pneumatic lithotriptor.17 In summary, the management of ingested foreign bodies can be challenging and requires the availability of an experienced endoscopist and technical staff. In addition, access to a variety of endoscopic accessories may be required. Endoscopists should have an open mind regarding the types of accessories that can be used to grasp different objects and the potential value of accessories used in other settings such as endoscopic retrograde chol-angiopancreatography. In some instances, the assistance of other disciplines such as otolaryngology or thoracic surgery may be needed.