A Risky Case of Esophageal Foreign Body Retrieval

• the 3cm long spine from patient’s esophagus

Tips: Esophageal foreign body incarceration is common. It is often caused by the patient's passive (improper eating) or active reasons (intentional swallowing of mental illness patients and criminal suspects, etc.). 

For foreign bodies caused by improper eating, many people believe that they can be swallowed by drinking vinegar or swallowing rice balls.

However, important organs and tissues are dispersed around the esophagus, such as trachea, large blood vessels, heart, connective tissue, nerve, mediastinum, etc. If a foreign body is forcibly swallowed, it will cause fatal risks such as esophageal perforation, mediastinal infection, large blood vessel bleeding, puncture into the heart, etc. In children, high esophagotracheal fistula can be caused.

For the treatment of esophageal foreign body, there are three main methods: conservative treatment, endoscopic treatment and surgical treatment. Conservative treatment is generally applicable to small blunt foreign bodies below the duodenum. If conservative treatment fails, surgical treatment is required. Compared with traditional thoracotomy for esophageal foreign body removal, endoscopic esophageal foreign body removal has the advantages of less trauma, no thoracotomy, rapid recovery, low cost and fewer complications, and has the dual value of diagnosis and treatment. Most of the esophageal foreign bodies can be removed by endoscopy, but for the foreign bodies without infection in the great vessels that can be removed by endoscopy, CT re-examination should be conducted after foreign bodies discharge to prevent the occurrence of traumatic pseudoaneurysm. 

The foreign body of large blood vessels that cannot be removed by endoscope alone still needs endoscopic combined surgery, so as to avoid the complications of postoperative fistula and stenosis. In the case of patients with infection or even abscess caused by foreign body puncture into the great vessels, endoscopic intervention combined with total covered great vessels stenting is required for treatment.

In this case, the shortest distance between the esophageal foreign body and the aortic arch was only about 2.4mm, but the perforation of the esophagus had not yet been caused. The endoscopic removal was made through the full evaluation and the accurate endoscopic technique, so as to avoid the open-chest surgery.

Chest CTA showed the foreign body is about 2.4mm from the aortic arch.

The patient was firstly admitted in the department of thoracic surgery. After the consultation of digestive endoscopy division, the physicians concluded that the esophageal foreign body could be retrieved through gastroscope.

Prof. Fan Zhining, director of the endoscopic department proposed the operation with the cooperation of doctors for thoracic surgery. As the foreign body was close to the aortic arch, it is a risky case. If there were any urgent situation during operation, thoracic surgery should be carried out immediately.

Ms. Liu, deputy chief physician of the department of digestive endoscopy, performed endoscopic removal of esophageal foreign body for the patient at about 8:00 PM on March 20. The transparent cap was placed at the end of the lens, it entered the esophagus smoothly. The foreign body was incarcerated into the left side wall, 25cm from the incisor, with one end penetrating into the wall of the esophagus. Director Liu used foreign body forceps to clamp the end of the foreign body and got it into the esophageal cavity. Then, the foreign body was rotated with the endoscope and pulled out of the esophagus. Further microscopic observation showed a little mucosal damage on the left side of the esophagus without obvious bleeding. The foreign body was about 3cm long. The patient underwent conservative treatment including fasting, anti-inflammatory and hemostasis treatment, and left hospital on March 21st.

If there are signs of infection after fish bone enters the blood vessel. 

Endoscopic removal of foreign body requires combined intervention with aortic stent implantation.