Esophageal foreign bodies - Treatment

Goals of treatment for esophageal foreign bodies

It is possible to remove the foreign body earlier using the most gentle method to prevent the development of complications.

Indications for hospitalization

All cases of confirmed foreign bodies in the esophagus and suspected ingestion are subject to immediate hospitalization.

Non-drug treatment of foreign bodies in the esophagus

A gentle diet after removal of foreign bodies, if necessary, physiotherapy treatment in cases of complications.

Drug treatment of foreign bodies in the esophagus

Conducting antibacterial, detoxifying, hyposensitizing therapy, extracorporeal detoxification in complicated foreign bodies of the esophagus.

Surgical treatment of foreign bodies in the esophagus

The method of removal is determined taking into account the nature, localization and duration of stay of the foreign body in the esophagus, accompanying complications and previous endoscopic interventions. Wait-and-see tactics in the hope of spontaneous release and excretion of the foreign body after the introduction of antispasmodics are unacceptable. In children, foreign bodies do not tend to be released and are firmly fixed in the high folds of the cervical spine.

When removing foreign bodies, doctors are guided by the average size of the esophagus and the distance from the edge of the teeth to the physiological narrowing of the esophagus).

Foreign bodies fixed in the first physiological constriction are removed using direct hypopharyngoscopy.

Foreign bodies are removed from the second and third physiological stenosis of the esophagus using esophagoscopy with a Brunings esophagoscope under general anesthesia using muscle relaxation when grasping and removing large, heavy, amagnetic, pointed and complicated foreign bodies, as well as under local anesthesia. Esophagoscopy can be performed with the patient in a sitting position, lying on his back, on his side and in the knee-elbow position. In children, foreign bodies are removed from the esophagus exclusively under general anesthesia.

Rigid endoscopy under anesthesia retains its leading role in childhood. Due to the peculiarities of the anatomical structure of the esophagus, in the overwhelming majority of cases in children, foreign bodies are retained in the cervical part of the esophagus, where their visualization is especially difficult due to high folds of the mucous membrane; the cervical part of the esophagus in children is not only narrower, but also proportionally longer. A rigid endoscope provides a good view of the esophagus, fixes it, and allows the foreign body to be removed with the least risk for the child.

When removing a foreign body from the esophagus, the following rules must be strictly observed:

1. do not use such techniques as inducing vomiting, do not allow the patient to swallow bread crusts and other dense food products with the false goal of pushing a foreign body into the stomach, do not blindly push a foreign body into the stomach using a gastric tube;
2. remove the foreign body only in a natural way, observing the rule - remove the foreign body in the same way it entered the esophagus, i.e. using esophagoscopy; this method is very effective in uncomplicated simple cases, in which there are no local contraindications;
3. Do not repeat esophagoscopy for a new attempt to remove a foreign body if the first attempt fails, is complicated by mucosal edema, submucosal abscess or infected hematoma, or in other cases that make esophagoscopy impossible; in these cases, resort to the surgical method of removing the foreign body by means of external esophagotomy.

When removing a foreign body from the esophagus, the following principles must be observed:

• removal of a foreign body from the esophagus is performed only under visual control;
• Before extracting a foreign body, it must be freed without much effort from the surrounding tissues (swollen mucous membrane) and positioned so that it can be securely grasped and removed without damaging the mucous membrane;
• Before removing a foreign body, the space above it must be cleared to allow the grasping instrument to be easily brought to it;
• The forceps selected for removing a foreign body must match its shape for the most secure grip and atraumatic extraction;
• if a foreign body is placed in the lumen of the tube, then it is removed through the latter and only after that the tube itself is removed;
• if the foreign body does not pass into the tube, it is pressed tightly against the beak of the esophagoscope and removed along with the latter;
• Before esophagoscopy and removal of a foreign body, premedication is performed - 1 hour before the manipulation, atropine, promedol, diphenhydramine are administered; 10 minutes before, application or aerosol anesthesia of the pharynx and laryngopharynx is performed with a solution of cocaine or dicaine.

Esophagoscopy may be difficult in the case of a thick, short, stiff neck, upper prognathism, pronounced cervical lordosis, and high sensitivity of the pharyngeal reflex. In this case, the use of intratracheal anesthesia with muscle relaxation and artificial ventilation is not excluded. In recent years, it is the latter type of anesthesia that has become increasingly widespread in the removal of a foreign body from the esophagus due to the fact that it creates the most favorable conditions for esophagoscopy - contraction of the neck and esophagus muscles is excluded, the swallowing reflex is eliminated, the muscular wall of the esophagus, exposed to the relaxing effect of muscle relaxants (Alloferin, Tracrium, Norcuron, Listenon, etc.), becomes relaxed and pliable to the passage of the esophagoscope tube, the existing spasm of the esophagus, which can mask the foreign body, passes, due to which it is easily removed.

The technique for removing a foreign body from the esophagus depends on its consistency (density), shape (spherical, oval, pointed, flat, etc.), and surface nature (slippery, rough, jagged, etc.). Soft and elastic foreign bodies, usually contained in the food bolus (pieces of meat, cartilage) or in the swallowed portion of liquid food (bone), the size of which exceeds the diameter of the esophagoscope tube, are grasped with stick-shaped forceps, the spikes of which penetrate the soft foreign body or tightly grasp the bone, are brought to the tube and, upon direct contact with the latter, are removed together with the esophagoscope. Sometimes such a foreign body is removed by biting (fragmentation), the bitten parts of which are extracted through the tube. For this, spoon-shaped forceps with sharp jaws are used.

Hard flat foreign bodies (buttons, coins, paper clips and pins, fish bones) are difficult to detect due to reactive mucosal edema. It is advisable to remove them with special forceps capable of tightly grasping the edge of such a foreign body, or with forceps that allow the foreign body to be given a rotational movement, which significantly facilitates the release of the foreign body from the edematous mucosa or esophageal spasm.

Spherical and ovoid bodies (beads, fruit stones) are removed with spoon-shaped or ring-shaped pliers or pliers with spherical teeth. Solid bodies of irregular shape with an atraumatic surface are removed with pliers, the size of the spread and the shape of which allow for a secure grip of such a foreign body. Solid bodies with a traumatic surface (glass fragments, sharp metal objects, bone chips with sharp awl-shaped edges) are removed very carefully, having first given them a position in which their removal does not cause harm to the mucous membrane. Pointed bodies (needles, nails, pins, thin chicken bones, etc.) are very dangerous, since it is during their introduction that perforations of the esophagus most often occur. If the sharp end of such a foreign body is directed towards the stomach, then its removal does not present any particular difficulties. It is only important that when searching and grasping the blunt end, do not push it downwards or cause damage to the esophagus wall. If the sharp end of such a foreign body (for example, a needle) is directed upwards, then special Tucker forceps are required to remove it, with the help of which the sharp end is grasped by these forceps, positioned along the axis of the instrument and inserted into the esophagoscope tube.

There is another way to remove the needle: the beak of the tube is brought to the end of the needle that has penetrated the mucous membrane, pressed against the wall of the esophagus so that its end is deeper than the end of the needle, then the tube in this position is moved forward so that the end of the needle is in the lumen of the tube behind the edge of the beak, in the final phase, cup-shaped forceps are brought to the end of the needle, grasped and removed.

A foreign body in the form of bent nails (V-, U- or L-shaped) is removed together with an esophagoscope. To do this, the sharp end is inserted into the tube, and the blunt end remains in the lumen of the esophagus. When removing such a foreign body, its blunt end slides along the wall of the esophagus without damaging it. This principle is used when removing a safety pin that has been inserted in an open state with the end up.

If the sharp end of the pin is directed towards the coriander, it is grasped with single-toothed forceps by the spring ring and inserted into the lumen of the tube. The situation is much more complicated when the pin is directed with the end up. Attempts to turn it with the end down lead to damage to the wall of the esophagus and often to its perforation. Therefore, such attempts are strictly prohibited. To extract a pin in this position, first of all, its sharp end embedded in the mucous membrane is found and released. Then it is grasped with Tucker forceps and inserted into the tube. Removal is performed together with an esophagoscope, while the smooth rounded surface of the pin retainer slides along the mucous membrane, pushing the wall of the esophagus outward, without causing harm to it.

There are other methods of removing an open safety pin from the esophagus, which, while not having any advantages over the above, carry the risk of perforating the esophageal wall or losing the object being removed. Thus, the method of preliminary closing of the pin requires a special instrument for implementation, and during this procedure there is a risk of the pin slipping out of the gripping part of the instrument and being inserted deeper into the wall of the esophagus, up to its perforation. The method of fragmenting the pin and removing it in parts through the tube also requires special "nippers", and in addition, the loss of the part of the pin that remains unremoved for a while or damage to the wall of the esophagus when biting through the strong steel from which the pin is made cannot be ruled out.

To remove a glass fragment, the surface of which, covered with mucus, becomes especially slippery, use tweezers with wide jaws, onto which pieces of rubber tubing are placed or wrapped with adhesive tape to prevent the foreign body from slipping off.

If it is impossible to extract a foreign body by esophagoscopy, it is removed surgically, the indications for which are divided into absolute and relative. Absolute indications include the impossibility of removing a deeply embedded foreign body by esophagoscopy without causing gross damage to the esophagus; esophageal perforation with obvious signs of secondary infection; the presence of periesophageal emphysema, threatening bleeding, or an esophageal-tracheal fistula. Relative indications for surgical removal of a foreign body from the esophagus include extensive damage to the mucous membrane; the absence of an experienced esophagoscopist in the given medical institution and the patient, for objective reasons, will not be delivered to the appropriate medical institution within 24 hours, where removal can be performed by esophagoscopy.

Of the surgical interventions used to remove a foreign body of the corresponding localization, cervical esophagotomy is used, which allows for the exposure of the cervical segment of the esophagus, digital or endoscopic examination of its lumen after esophagotomy, and, if a foreign body is detected, its extraction without any particular difficulties. Cervical mediastinotomy is used for this purpose, which is also used to drain abscesses in the periesophageal space. Purulent processes that arise as complications of a foreign body in the esophagus in the spaces between the esophagus, trachea, and prevertebral fascia often originate from the retropharyngeal lymph nodes, where the infection enters through the lymphatic pathways from the area of damage to the esophagus by a foreign body, and cause a severe clinical picture. Perforation of the esophageal wall by a foreign body, as well as rupture by an instrument during esophagoscopy, leads to the rapid development of phlegmon of the neck, spreading downwards without hindrance.

Surgical removal of a foreign body from the cervical esophagus and treatment of secondary complications in esophageal perforations are performed according to general rules. An incision on the neck is made depending on the location of the foreign body or phlegmon. Phlegmons and abscesses of the vascular fissure are opened along the anterior or posterior edge of the sternocleidomastoid muscle. Penetration to the abscess or esophagus after dissection of the superficial fascia (along the grooved probe) is performed by blunt means. The introduction of rigid drains into the opened purulent cavity is unacceptable, since this threatens to cause a pressure ulcer of the vessel wall. Surgical removal of a foreign body from the cervical esophagus and surgical treatment of their purulent complications are combined with the prescription of broad-spectrum antibiotics. In case of severe impairment of respiratory function, a tracheostomy is performed. After surgical removal of a foreign body from the area of both the cervical and thoracic esophagus, the patient is fed through a thin elastic gastric tube; in rare cases, a temporary gastrostomy is applied.

If it is impossible to use the esophagoscopic method, a foreign body in the thoracic and abdominal sections of the esophagus is removed, respectively, using thoracic mediastotomy and laparotomy with opening of the esophagus at the level at which the foreign body was detected during a preliminary examination of the patient.

Indications for fibroendoscopy for foreign bodies in the esophagus:

• large foreign bodies that tightly obstruct the lumen of the esophagus and are inaccessible due to their size for capture and extraction with forceps during rigid endoscopy (in these cases, it is possible to use a polypectomy loop or a grasping basket, placed under the distal section of the foreign body);
• small and especially sharp foreign bodies that have penetrated the wall of the esophagus and are inaccessible for visualization and removal during rigid endoscopy;
• foreign bodies in the pathologically altered stenotic esophagus (high risk of esophageal wall perforation during rigid endoscopy); the controlled distal end of the fibroscope allowed it to be passed through the stenotic section to determine the condition of the esophageal wall in the area of localization of the foreign body or after removal of a foreign body with sharp edges; the ability to pass a fibroesophagoscope through the stenotic opening of the esophagus due to the controlled distal end of the device is of great importance for determining the degree of severity, length and lower level of stenosis, which is of decisive importance in the choice of subsequent reconstructive surgical or conservative treatment, bougienage;
• unfavorable constitutional conditions that do not allow the insertion of a rigid endoscope (short neck, long teeth, rigidity of the cervical spine, etc.);
• control endoscopic examination after removal of complicated foreign bodies from the esophagus to identify damage to the esophageal wall after removal of sharp foreign bodies that have been in the esophagus for a long time;
• foreign bodies that have descended into the stomach during esophagoscopy, remain in the stomach for a long time, or pose a danger during their subsequent movement through the gastrointestinal tract.

Contraindications for fibroesophagoscopy:

• extremely serious condition of patients;
• hemophilia, leukemia;
• esophageal bleeding;
• signs of perforation of the esophageal wall;
• pronounced inflammatory changes in the mucous membrane around the foreign body.

After any surgical intervention to remove a foreign body, a control fluoroscopy is performed to exclude multiple foreign bodies, as well as a radiocontrast study with iodolipol or iodine-soluble contrast to exclude perforation of the esophagus.

After removal of the foreign body from the stenotic esophagus, the patient is transferred to the thoracic department to continue treatment to restore the lumen of the esophagus.

Foreign bodies that have penetrated the esophageal wall are removed by lateral pharyngotomy, cervical esophagotomy and mediastinotomy. If indicated, periesophageal phlegmon is simultaneously opened.

Complications during removal of foreign bodies from the esophagus vary from minor injuries to the oral cavity and esophageal wall to life-threatening injuries to the patient.

Inflammatory postoperative changes in the esophagus and periesophageal region develop rapidly and are severe, accompanied by sepsis, toxicosis and exsicosis.

A severe complication is esophageal perforation (up to 4% of cases) with the development of paraesophageal abscesses (in 43%) and purulent mediastinitis (16%). In this regard, the greatest danger is posed by foreign bodies in the esophagus stenotic with scars. In these cases, perforation occurs above the stricture in the area of the thinned wall of the suprastenotic sac. The clinical picture of perforation in the first hours is due to the development of mediastinal emphysema, pneumothorax and irritation of powerful reflexogenic zones of the mediastinum, which causes sharp spontaneous pain behind the sternum, radiating to the back and abdomen, increasing with swallowing. Irradiation of pain to the abdomen is characteristic of perforation of the thoracic esophagus and for small children, regardless of the level of perforation. Mediastinitis develops rapidly already in the first 6 hours after the formation of perforation. Among the age differences in the clinical picture of esophageal perforation, attention is drawn to its phasing in older children and adults: shock. false calm and increase in mediastinitis symptoms; in young children, the condition suddenly worsens, anxiety arises, which is then replaced by lethargy and indifference, the skin takes on an earthy hue. Signs of respiratory distress and cardiac activity appear, the temperature rises.

On an X-ray of esophageal perforation in the first hours after surgery, an air cavity is visible, most often in the lower third of the mediastinum, and penetration of the contrast agent into the periesophageal tissue, mediastinum and bronchi.

In case of a small perforation in the cervical esophagus without symptoms of mediastinitis, conservative treatment is carried out: tube feeding, parenteral nutrition, massive antibacterial and detoxifying therapy. In case of a relatively large perforation, the application of a gastrostomy, early surgical drainage of the periesophageal space and mediastinum by colotomy and cervical mediastinotomy are indicated, and, if possible, primary suturing of the defect in the esophageal wall in combination with local and parenteral administration of antibiotics.

Forecast

Depends on the timeliness of diagnosis of the presence of a foreign body in the esophagus and its qualified removal, possibly at an earlier stage, to prevent the development of complications. Swallowing foreign bodies by infants is very dangerous due to the development of severe, life-threatening complications and the greatest difficulties in removing these objects due to the small diameter of the esophagus. Mortality with foreign bodies in the esophagus remains quite high and is 2-8%. More often, death occurs from vascular complications and sepsis caused by local suppurative processes, especially with penetrating and migrating foreign bodies.

Prevention of foreign bodies in the esophagus

Proper organization of children's leisure, parental supervision of young children. In terms of preventing complications, timely diagnostics with optimal use of modern examination methods, removal of foreign bodies by gentle methods, careful examination and observation of patients after removal of the foreign body are of primary importance.

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