Foreign bodies of the esophagus: treatment

Objectives of treatment of foreign bodies of the esophagus

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

Indications for hospitalization

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

Non-drug treatment of foreign bodies of the esophagus

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

Medicamentous treatment of foreign bodies of the esophagus

Antibacterial, detoxification, hyposensitizing therapy, extracorporeal detoxification with complicated foreign bodies of the esophagus.

Surgical treatment of foreign bodies of the esophagus

The method of removal is determined taking into account the nature, location and duration of stay in the esophagus of the foreign body, concomitant complications and previous endoscopic interventions. It is inadmissible expectant tactics in the calculation of spontaneous release and isolation of a foreign body after the administration of antispasmodics. In children, foreign bodies have no tendency to release and are fixed firmly in the high folds of the cervical region.

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

Fixed in the first physiological constriction, foreign bodies are extracted by direct hypopharyngoscopy.

From the second and third physiological constrictions of the esophagus, foreign bodies are removed by the method of esophagoscopy by the Brunings esophagoscope under anesthesia with the use of muscle relaxation in the capture and removal of large, heavy, magnetized, pointed and complicated foreign bodies, and under local anesthesia. Esophagoscopy can be performed in the sitting position of the patient, lying on the back, on the side and in the knee-elbow position. In children, foreign bodies from the esophagus are removed exclusively under anesthesia.

Hard endoscopy under anesthesia retains its leading importance in childhood. Due to the peculiarities of the anatomical structure of the esophagus, in the vast majority of cases, foreign bodies linger in the cervical esophagus in the children, where their visualization is especially complicated by high folds of the mucous membrane, the neck 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, allows you to extract a foreign body with the least risk of a child's length.

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

1. Do not use such techniques as provoking vomiting, do not give the patient to swallow bread crusts and other dense foods with the false purpose of pushing a foreign body into the stomach, do not push the foreign body into the stomach blindly with a gastric probe;
2. to extract a foreign body only in a natural way, observing the rule - remove the foreign body in the way it entered the esophagus, ie, with the help of esophagoscopy; this method is very effective in uncomplicated simple cases in which there are no local contraindications;
3. do not perform repeated esophagoscopy for a new attempt to remove the foreign body in the case of a failed first, complicated mucosal edema, submucous abscess or infected hematoma, or in other cases that make it impossible to esophagoscopy; in these cases resort to a surgical method of extracting a foreign body through external esophagotomy.

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

• removal of the foreign body of the esophagus is performed only under the control of vision;
• before extraction of a foreign body, it must be released without much effort from surrounding tissues (swollen mucous membrane) and positioned so that it can be reliably captured and removed without damaging the mucosa;
• before removing a foreign body, the space above it must be freed to conveniently guide the gripping tool to it;
• The tongs chosen for removal of a foreign body should correspond to its shape for the most dense capture and atraumatic extraction;
• if the foreign body is placed in the lumen of the tube, then it is removed through the latter and only then the tube itself is removed;
• if the foreign body does not pass into the tube, then it is firmly pressed against the beak of the esophagoscope and removed together with the latter;
• Before esophagoscopy and removal of a foreign body, premedication is performed - atropine, promedol, dimedrol is administered 1 hour before the manipulation; for 10 minutes - produce an application or aerosol anesthetic of the pharynx and the laryngopharynx with a solution of cocaine or dicaine.

Difficulties in esophagoscopy can occur with a thick, short, stiff neck, upper prognathia, pronounced cervical lordosis, high sensitivity of the pharyngeal reflex. In this case, the use of intratracheal anesthesia with muscle relaxation and ventilation is not excluded. In recent years, it is the last type of anesthesia that is becoming more common with the removal of the foreign body of the esophagus due to the fact that it creates the most favorable conditions for esophagoscopy - eliminates the neck and esophagus muscles, removes the swallowing reflex, the muscular wall of the esophagus, undergoing the relaxation action of muscle relaxants Alloferin, Tracryrum, Norcuron, Listenon, etc.), becomes relaxed and supple to the passage of the esophagoscope tube, there is a spasm of the esophagus that can mask foreign matter e body is held, so that it can be easily removed.

The technique of removing the foreign body of the esophagus depends on its consistency (density), shape (spherical, oval, pointed, flat, etc.), the nature of the surface (slippery, rough, with barbs, etc.). Soft and elastic foreign bodies, usually contained in the food lump (chunks of meat, cartilage) or in a swallowed portion of liquid food (bone), the size of which exceeds the diameter of the esophagoscope tube, is captured by finger-shaped forceps, the spikes of which penetrate into the soft foreign body or tightly seize the bone, lead to the tube and on direct contact with the latter is removed together with the esophagoscope. Sometimes such a foreign body is removed by the method of lump (fragmentation), the bitten parts of which are extracted through the tube. To do this, use spoon-shaped forceps with sharp sponges.

Solid foreign bodies of flat form (buttons, coins, paper clips and buttons, fish bones) are difficult to identify because of the reactive edema of the mucous membrane. It is advisable to remove them with special forceps capable of tightly gripping the edge of such a foreign body, or with forceps that allow the foreign body to give a rotational motion, which greatly facilitates the release of the foreign body from the swollen mucosa or spasm of the esophagus.

Ball-shaped and ovoid bodies (beads, fruit bones) are removed by spoon-shaped or ring-shaped tongs or forceps with teeth of spherical shape. Solid bodies of irregular shape with an atraumatic surface are removed by tongs, the size of the dilution and the shape of which allow it to reliably capture such a foreign body. Solid bodies with a traumatic surface (glass fragments, sharp metal objects, chipped bone with sharp subulate facets) are removed very carefully, giving them a position in which extraction does not harm the mucous membrane. Pointed bodies (needles, nails, pins, thin chicken bones, etc.) pose a great danger, since it is during their introduction that the esophagus perforation usually occurs. If the sharp end of such a foreign body is directed toward the stomach, then its removal is not particularly difficult. It is important only that when searching and grabbing for the blunt end, do not push it downward or cause damage to the esophageal wall. If the sharp end of such a foreign body (for example, a needle) is directed upwards, special Tuker forceps are required to remove it, by means of which the sharp end is grasped by these forceps, located 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 into the mucosa, pressing it 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 advanced forward so that the end of the needle is in the lumen of the tube for edge of the beak, in the final phase, at the end of the needle, cup-shaped forceps are brought in, grasping it and extracting it.

Foreign body in the form of bent nails (V-, U- or L-shaped) is extracted together with the esophagoscope. To do this, the acute end is introduced into the tube, and the blunt end remains in the lumen of the esophagus. When removing such a foreign body, the blunt end of it slides along the wall of the esophagus, without damaging it. This principle is used when removing an English pin that has been implanted in the opened form with the end up.

If the sharp end of the pin is directed to the coriander, then it is grasped with a single-tooth forceps by a spring ring and injected into the lumen of the tube. The situation is much more complicated when the pin is pointed end-to-end. Attempts to deploy it end to bottom lead to damage to the esophagus wall and often to its perforation. Therefore such attempts are categorically forbidden. To extract the pin in this position, first of all, find and release the sharp end that has penetrated into the mucous membrane. Then grab it with Tykkera forceps and put it into the tube. The removal is performed together with the esophagoscope, while the smooth, round surface of the pin fixator slides over the mucous membrane, pushing the esophagus wall outward without causing harm to it.

There are other ways to remove from the esophagus an open English pin, which, not having advantages over the one described above, conceals the danger of perforation of the esophagus wall or loss of the object to be removed. So, the method of pre-closing the pin requires a special tool to implement, and during this procedure there is a danger of slipping the pin from the gripping part of the tool and deeper inserting it into the esophageal wall, down to its perforation. The method of fragmentation of the pin and its removal in parts through the tube also requires special "nippers", besides, loss of the remaining part of the pin that remains for a while, or damage to the wall of the esophagus when the strong steel from which the pin is made, is not ruled out.

To remove a fragment of glass, the surface of which, covered with mucus, becomes particularly slippery, apply forceps with wide jaws, which are worn by pieces of rubber tube or wrapped around them with a sticky plaster to prevent the foreign body from slipping.

If it is impossible to extract the foreign body with an esophagoscopic method, it is resorted to surgical removal, the indications of which are divided into absolute and relative. Absolute indications include the impossibility of removing by the esophagoscopic method of a deeply penetrated foreign body without causing gross damage to the esophagus; Perforation of the esophagus with obvious signs of secondary infection; presence of pereezophageal emphysema, threatening bleeding, esophagus-tracheal fistula. Relative lesions of the surgical removal of a foreign body from the esophagus include extensive damage to the mucosa; the absence of an experienced esophagogoscopist in the given institution and within 24 hours the patient, for objective reasons, will not be delivered to the appropriate medical institution where they will be able to carry out the removal with the help of esophagoscopy.

From surgical interventions that are used to remove a foreign body of appropriate localization, use cervical esophagothia, which allows you to expose the cervical segment of the esophagus, perform a finger or endoscopic examination of its lumen after esophagotomy, and when a foreign body is found, extract it without much difficulty. To do this, use cervical mediastinotomy, which is also used to drain abscesses in the near esophagus. Purulent processes that arise as complications of the foreign body of the esophagus in the spaces between the esophagus, trachea and the pre-invertebral fascia often come from the peropharyngeal lymph nodes, where the infection enters the lymphatic pathways from the area of esophageal damage to the foreign body and causes a severe clinical picture. The perforation of the esophagus wall by a foreign body, as well as the rupture of the instrument during esophagoscopy, leads to the rapid development of the phlegmon of the neck, which propagates freely downward.

The surgical extraction of the foreign body of the cervical esophagus and the treatment of secondary complications in the esophagus perforations follow the general rules. The incision on the neck is made depending on the location of the foreign body or phlegmon, phlegmon and abscesses of the vascular cleft are opened at the anterior or posterior margin of the sternocleidomastoid muscle. Penetration to the abscess or esophagus after dissection of the superficial fascia (along the gaunt probe) is done in a blunt way. The introduction of hard drains into the uncovered purulent cavity is unacceptable, since it threatens to sore the walls of the vessel. The operative extraction of the foreign body of the cervical esophagus and the surgical treatment of their purulent complications are combined with the administration of broad-spectrum antibiotics. If there is a pronounced violation of the respiratory function, tracheostomy is produced. After surgical removal of the 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.

The foreign body of the thoracic and abdominal parts of the esophagus, with the impossibility of using the esophagoscopic method, is removed, respectively, by thoracic mediastiomyotomy and laparotomy with opening the esophagus at the level at which a foreign body was detected during preliminary examination of the patient.

Indications for fibroendoscopy for foreign bodies of the esophagus:

• large foreign bodies tightly obturating the lumen of the esophagus and inaccessible due to their size for grasping and extracting by forceps with rigid endoscopy (in these cases, it is possible to use a poly-pectoric loop or an entraining basket fed to the distal part of the foreign body);
• small and especially acute foreign bodies embedded in the esophagus wall and inaccessible for visualization and removal with rigid endoscopy;
• foreign bodies in pathologically altered stenosed esophagus (high risk of perforation of the esophageal wall in rigid endoscopy); the controlled distal end of the fibroscope made it possible to conduct it through the stenosed department to determine the condition of the esophageal wall in the area of localization of the foreign body or after extractions of the foreign body with sharp edges; the possibility of conducting a fibro-esophagoscope through a stenosed esophagus orifice due to the controlled distal end of the device is of great importance for determining the severity, extent and lower stenosis level, which is crucial in the choice of subsequent reconstructive surgical or conservative treatment, bougieing;
• unfavorable constitutional conditions that do not allow the introduction of a rigid endoscope (short neck, long teeth, rigidity of the cervical spine, etc.);
• control endoscopic examination after removal of complicated foreign bodies of the esophagus to detect damage to the esophagus wall after removal of foreign bodies that were acute and persistent in the esophagus;
• The foreign bodies that have descended into the stomach during esophagoscopy are long-lasting in the stomach or are dangerous when they subsequently move along the gastrointestinal tract.

Contraindications for fibroesophagoscopy:

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

After any surgical intervention, a fluoroscopy to exclude multiple foreign bodies is performed while removing the foreign body, as well as radiopaque studies with iodolipol or iodine-soluble contrast to exclude the perforation of the esophagus.

After removal of the foreign body from the stenosed esophagus, the patient transfers to the thoracic compartment to continue treatment to restore the lumen of the esophagus.

Foreign bodies penetrating through the esophagus wall are removed by side pharyngotomy, cervical esophagotomy and mediastinotomy. When the testimony is simultaneously opened peri-esophageal phlegmon.

Complications when removing foreign bodies from the esophagus are different - from small injuries of the oral cavity and the esophagus wall to life-threatening patients.

Inflammatory postoperative changes in the esophagus and the perisophageal region develop rapidly and occur severely, accompanied by sepsis, toxicosis and exsicosis.

A severe complication is perforation of the esophagus (up to 4% of cases) with the development of ulcersophageal abscesses (43%) and purulent mediastinitis (16%). In this regard, foreign bodies in the esophageal stenosis are the most dangerous. Perforation in these cases occurs above the stricture in the area of the thin wall of the suprastenotic sac. The clinical picture of perforation in the first hours is due to the development of emphysema of the mediastinum, pneumothorax and irritation of the powerful reflexogenic zones of the mediastinum, which causes severe spontaneous pain behind the sternum, radiating to the back and abdomen, which increases with swallowing. Irradiation of pain in the abdomen is typical for perforation of the thoracic esophagus and for young children, regardless of the level of perforation. Mediastinitis develops rapidly already in the first 6 hours after the formation of perforation. Among the age-related differences in the clinical picture of perforation of the esophagus, attention is drawn to its phase in older children and adults: shock. A false calm and an increase in the symptoms of mediastinitis; in young children suddenly deteriorates state, there is anxiety, which then gives way to lethargy and indifference, the skin assumes an earthy shade. There are signs of a disorder of breathing and cardiac activity, the temperature rises.

On the roentgenogram with perforation of the esophagus in the first hours after surgery, the air cavity is visible, more often in the lower third of the mediastinum, and the penetration of contrast medium into the near-esophageal cellulose, mediastinum and bronchi.

With a small perforation in the cervical esophagus without symptoms of mediastinitis conservative treatment is carried out: probe feeding, parenteral nutrition, massive antibacterial and detoxifying therapy. With a relatively large perforation, superimposition of the gastrostomy, early surgical drainage of the cortex and mediastinum by colotomy and cervical mediastinotomy are shown, 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 the diagnosis of the presence of a foreign body of the esophagus and its qualified removal possible at an earlier time to prevent the development of complications. The ingestion of foreign bodies by infants is of great danger due to the development of severe, life-threatening complications and the greatest difficulties in removing these items due to the small diameter of the esophagus. Lethality in foreign bodies of the esophagus remains quite high and is 2-8%. More often death comes from vascular complications and sepsis caused by local suppuration, especially when penetrating and migrating foreign bodies.

Prevention of foreign bodies of the esophagus

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

[1], [2], [3], [4], [5]