EFFECTIVE REMOVAL OF A PEDIATRIC EMBEDDED ESOPHAGEAL FOREIGN BODY

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Author: Amanda Munoz
Published:
Specialties: Endoscopy, Pediatric Surgery
Schools: Loma Linda University Medical Center
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Basic Info

Authors: Amanda Munoz, MD; Ian Vannix, BA; Victoria Pepper, MD; Joanne Baerg, MD

OVERVIEW:

A three-year old girl had an unwitnessed ingestion of a radiolucent foreign body that became embedded in the esophagus with formation of a symptomatic stricture. The foreign body was not visible on initial chest radiograph or at flexible endoscopy.  Pediatric surgery was consulted for removal.

Advanced

Procedure

A combined endoscopic and fluoroscopic approach was planned for removal. We hypothesized that gentle dilation of the stricture would allow visualization of the foreign body.
The child was brought to the operating room and underwent flexible upper endoscopy under general anesthesia. The stricture was identified, but the foreign body was not initially visualized. Under endoscopic guidance, a straight tip, high performance 450 cm guidewire was successfully passed through the stricture. Intraoperative fluoroscopy confirmed the position of the wire. The 180 cm esophageal/pyloric balloon dilation catheter was passed over the wire and intraoperative fluoroscopy confirmed its position.
With intraoperative fluoroscopic visualization, pneumatic dilation of the stricture was performed for two five-minute intervals at 4 atmospheres of pressure. After the procedure was completed, the wire was removed. A small amount of contrast was passed through the balloon dilation catheter. This intraoperative esophagram confirmed that no perforation had occurred.
The flexible endoscopy was repeated and the embedded foreign body was now visible. It was grasped with a three-pronged coin grasper and removed. The child had ingested a plastic squirt gun cap, measuring 2.5 cm in length. The esophagus was inflamed but intact. The intra-operative esophagram was repeated and again revealed no esophageal perforation.
A laparoscopic gastrostomy tube was placed to augment nutrition. The child continued her previous anti-acid medication for GERD and returned six weeks later for follow-up evaluation. During this time-period, she had minimal symptoms. A repeat endoscopy revealed the stricture was easily dilated, and the esophageal inflammation was improved. By eight weeks she had resumed normal oral intake and was asymptomatic.

Indications

This technique is amenable for an ingested non-radiolucent esophageal foreign body that is embedded and has caused a stricture to form. The foreign body may not be easily visualized on endoscopy or routine radiographs.

Contraindications

Relative contraindications include active pneumonia or severe esophagitis. The patient’s overall nutritional and respiratory status should be optimized before proceeding.

Instrumentation

Setup

The procedure should be planned in the operating room.
Intubation and general anesthesia are required for airway protection.
A shoulder roll allows optimal visualization and easy passage of instruments.
The fluoroscopy C-arm and monitor are required as well as the pediatric endoscopy equipment with the pediatric gastroscope and suction.
The listed instruments should be assembled.

Preoperative Workup

A three-year old ex-premature girl presented with a 4-month history of dysphagia, choking and coughing with eating and weight loss. Because she had a previous history of gastroesophageal reflux disease, there was a normal upper gastrointestinal (UGI) contrast study, obtained six months prior to presentation, available for comparison. Her initial chest radiograph was normal.
An UGI study at presentation revealed a tight stricture at the level of the cricopharyngeus, and the upper esophagus was dilated. This study raised the suspicion of a radiolucent, embedded foreign body. Her gastroenterologist performed an upper endoscopy, however, only the stricture was visualized. A computed tomography scan of the chest confirmed the presence of an embedded esophageal foreign body. Pediatric surgery was consulted for removal.

Anatomy and Landmarks

Advantages/Disadvantages

An unwitnessed, radiolucent, ingested esophageal foreign body may become embedded. Children with esophageal foreign body ingestions have varied presentations but most are symptomatic. The majority of esophageal foreign bodies are radiopaque, but a normal chest radiograph cannot rule out a radiolucent foreign body ingestion.
A stricture may develop which renders the foreign body difficult to visualize and not easily amenable to endoscopic removal. A combined endoscopic and fluoroscopic approach, with endoscopic wire placement, followed by balloon stricture dilation under fluoroscopic guidance, allows visualization of the foreign body, and uncomplicated, endoscopic removal.

Complications/Risks

The main risk of the procedure is esophageal perforation and this should be excluded with an esophagram.

Disclosure of Conflicts

We have nothing to disclose.

Acknowledgements

References

Bhat VS, Al-Saadi KA, Bessiouni IE, Tuffaha AS. Embedded esophageal foreign body. A diagnostic challenge. Saudi Med J. 2009; 30: 433–435. PMID: 19271078

Sink JR, Kitsko DJ, Mehta DK, Georg MW, Simons JP. Diagnosis of Pediatric Foreign Body Ingestion. Annals of Otology, Rhinology & Laryngology. 2015;125(4):342-350. doi:10.1177/0003489415611128.

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