Foregion Body Esophagus

Dr R S Dhaliwal MBBS,MS,DNB(Surgery),M.Ch,DNB(CTVSurgery)

FACS,FCCP,FICA,FNCCP,FIACS Former Prof &

HOD , CTV Surgery, PGIMER,Chandigarh,India

Introduction:

• Esophageal foreign bodies are not so dangerous as air way foreign bodies. But this is a very common problem among children and elderly.

• Anatomically these foreign bodies are commonly found at the various natural constrictions of oesophagus (i.e.at cricopharynx, the cross over of the aortic arch at the level of mid esophagus, and at the lower end of esophagus).

Common F.B. in Esophagus

• Metalic - Coins, Pins, Safety pins, Buttons, Button batteries, Pieces of metal object, blades, broken spoons

• Non metallic – Glass beads, Marbles, Plastic toys or pieces of plastic object, Impacted food bolus, pencil piece

• Dentures partial , Teeth –artificial or natural, Fish Bone, meat or chicken bone

• Any small thing

Patients with Esophageal foreign bodies:

• 1. Pediatric patients• 2. Psychiatric patients• 3. Patients with underlying esophageal

disorders like malignancy,strictures,aclasia• 4. Edentulous patients (elderly)

Clinical presentation:• This depends on whether the patient is a child or adult. Adults usually

describe the event clearly and acknowledge the possibility of the presence of foreign body in the food passage

• In children symptoms include:1. Irritability2. Poor feeding3. Drooling4. Chest pain5. Coughing

• Respiratory symptoms due to esophageal foreign body is common in children because of their small and compressible tracheal lumen. These symptoms include stridor, coughing, and labored breathing.

• Physical examination:This does not play an important role in establishing the diagnosis. Children with oesophageal foreign body tends to drool. Clinical examination is usually unremarkable in most of these patients

Role of radiography:• Main diagnostic tool in oesophageal foreign bodies is

radiography. Commonly these foreign bodies tend to be radio opaque. coins are commonly ingested by children. Food products are the other commonly encountered foreign body. Plain radiographs in these patients may demonstrate bone / cartilage present in the food elements.Both antero posterior and lateral views must necessarily be performed to localize the foreign body. CT Scan gives better information If plain films are not diagnostic then barium swallow should be performed

*Caution: Gastrograffin should not be used because it may cause severe chemical pneumonitis if aspirated.

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Radiology

Radiology

Glass Marble

Denture with hook

Treatment:• Following factors should be considered in the management

of foreign body oesophagus - a. Type / location of the ingested foreign bodyb. Interval between ingestion and presentationc. Age of the patient – Child, Old person Ingestion of caustic foreign bodies like button batteries should be considered as an emergency. Delay in these patients may lead to esophageal perforation.

Sharp metallic objects like pins, needles, razor blades, and nails should always be removed under controlled operating room conditions.Danger of perforation is significant

Endoscopic removal of foreign bodies:• Foreign bodies impacted at the level of cricopharynx should

be removed using an upper esophageal speculum. This can be performedeither under local / general anesthesia.

• Foreign bodies of esophagus can be removed using an oesophagoscope. General anesthesia is preferred in children .It provides adequate relaxation making the passage of oesophagoscope smooth and atraumatic. Local anesthesia can be used if flexible oesophagoscope is used.

• Types of Esophagus- - a. Rigid Esophagoscope – Made of metal .G.A is needed in most of patients. - Lumen is large so forceps can be used easily. - Needs more expertise. – Perforation rate more b. Fiberoptic Esophagoscope - Flexible structure, Can be done under L.A. in OPD or bedside. - Small lumen forceps manipulations not easy. Lower perforation rate.

Endoscopic removal of F.B

• Balloon catheters can be used to extract impacted foreign body in the oesophagus. This method can be used only if the foreign body ingested is single, smooth and radio opaque. These patients should have no history of esophageal disorder / injury.This procedure is performed by placing the patient in head down position. The catheter is passed nasally or orally under fluoroscopic guidance past the foreign body. The balloon is inflated with a radio opaque solution and is slowly pulled out along with the foreign body under fluoroscopic guidance.

Esophagoscopes

Complications of oesophagoscopy

• 1. Oesophageal trauma2. Mediastinitis3 Pneumothorax 4 Surgical emphysema5 Tracheo oesophageal fistula 6 Aorto esophageal fistula

Surgery for F.B. Esophagus

• Indications- a. F.B. Impacted in wall of esophagus-

dentures, metal nails or screws b. Sharp F.B. – blade, knife, needles, c. Suspected perforation d. F.B. along with esophageal pathology - Carcinoma, cardiac achalasia, stricture

Surgical procedures

• Depending upon where the F.B. is lodged in esophagus the procedure is planned a. In neck left side cervical esophagostomy is done and F.B. is removed

b. If it is in the thoracic esophagus a right side postolateral thoracotomy is approach of choice to remove F.B. Whole thoracic esophagus can be approached from RT PLT

C.F.B. impacted near cardiac end (lower end) is removed by a upper laparotomy.