Ann Thorac Surg 2003;76:1276-1278
© 2003 The Society of Thoracic Surgeons
Case report
Weerda diverticuloscope: novel use to remove embedded esophageal foreign bodies
John C. Kucharczuk, MDa*,
Larry R. Kaiser, MDa,
M. Blair Marshall, MDa
a Division of Thoracic Surgery, Hospital of the University of Pennsylvania and Philadelphia Veterans Hospital, Philadelphia, Pennsylvania, USA
Accepted for publication March 3, 2003.
* Address reprint requests to Dr Kucharczuk, Division of Thoracic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
e-mail: john.kucharczuk{at}uphs.upenn.edu
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Abstract
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Embedded sharp foreign bodies of the cervical esophagus represent a clinical challenge. Initial attempts at removal are usually undertaken by nonsurgical endoscopists who are often successful with blunt objects. Unsuccessful attempts with sharp objects, however, can result in distal migration, mucosal damage, and frank perforation. Thoracic surgeons are often called on for cervical esophagotomy after endoscopic attempts have failed. This report describes the novel use of a Weerda diverticuloscope for removal of a dental appliance with metallic hooks embedded in the cervical esophagus.
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Introduction
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Foreign body ingestion typically occurs in pediatric, psychiatric, alcoholic, and elderly patients. Most impacted objects remain in the cervical esophagus. Blunt and small sharp objects can usually be removed by traditional flexible or rigid esophagoscopy. Sharp objects such as fish and chicken bones can be "reoriented" and retrieved through a rigid scope. Large, rigid foreign bodies with sharp edges embedded in the mucosa and objects that exceed the diameter of the rigid scope in all orientations present a particularly difficult problem. These patients are often referred for cervical esophagotomy and removal.
This report illustrates the use of a Weerda diverticuloscope (Karl Storz, Tuttlingen, Germany) to remove a large dental plate with metallic hooks embedded in the mucosa. The diverticuloscope (Fig 1)
is a bivalved instrument with fiberoptic illumination designed for transoral stapling of Zenker’s diverticulum. It is, however, an ideal instrument for removal of large, sharp, cervical esophageal foreign bodies.
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Fig 1. Weerda diverticuloscope in both the (A) closed and (B) opened position. Two different length scopes are shown.
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A 27-year-old man presented to an outside community emergency room after an alcohol binge. He was missing his dental bridge and unable to swallow. He was taken to the operating room by a surgical oncologist who reported being "experienced in esophageal surgery" for examination and removal. After 3 hours of attempted removal with flexible and rigid esophagoscopy a transfer was requested to thoracic surgery at the University of Pennsylvania for cervical esophagotomy. On transfer, the patient was in no distress but appeared uncomfortable and was drooling. He was afebrile and had no subcutaneous air. The white blood count was normal and a chest radiograph was obtained (Fig 2)
. He received antibiotics and was taken to the operating room.
Following general endotracheal anesthesia, a flexible esophagoscope was introduced into the cervical esophagus using direct laryngoscopy. At 25 cm, a large dental prosthesis was visualized with metallic hooks embedded into the mucosa. Proximal mucosa injury was present suggesting that the appliance had been pushed distally. The flexible scope was removed and a rigid cervical esophagoscope was introduced; unfortunately due to the embedded nature of the foreign body it was impossible to unhook the mucosa. Furthermore, due to the size of the prosthesis retrieving it through the rigid esophagascope would have been impossible. Removal outside of the scope would risk possible perforation due to the multiple sharp edges of the prosthesis.
The Weerda diverticuloscope was introduced into the cervical esophagus and positioned just proximal to the prosthesis. The instrument was opened slowly to dilate the esophagus. The scope was oriented so that it could slide past the embedded hooks and engulf the prosthesis. The scope was suspended for stabilization in the same manner one performs suspension laryngoscopy. The hooks were cut to release the prosthesis, which was brought back through the Weerda scope with a foreign body forceps (Fig 3). The residual hooks were then easily retrieved by rotating the foreign body forceps in a direction opposite the hook curve. Flexible esophagoscopy demonstrated mucosal injury but no evidence of perforation. After recovery from general anesthesia the patient underwent an esophagogram with gastrograffin followed by thin barium. The thin barium study showed a small 3-mm defect without free extravasation (Fig 4).
The patient was observered for 72 hours, remained afebrile with no leucocytosis, and was discharged home.
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Comment
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Management of embedded sharp esophageal foreign bodies presents significant challenges. The Weerda diverticuloscope offers superior visualization of the cervical esophagus when compared with the standard rigid esophagoscope because it dilates the esophagus as it is opened. Due to its bivalved nature the Weerda instrument provides a larger working channel allowing direct manipulation and retrieval of large foreign bodies that simply will not fit through a rigid esophagoscope under any orientation. Finally, it can be suspended to provide a stable working environment. This allows the surgeon the use of both hands without the need to steady the scope. Operative intervention remains warranted when the foreign body cannot be retrieved or when frank perforation is present.
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Abstract
Introduction
