Ann Thorac Surg 2004;77:2218-2220
© 2004 The Society of Thoracic Surgeons
Case report
Chronic retained foreign bodies in the esophagus
Rishendran R. Naidoo, MBChb*,
Anunathan A. Reddi, FCS Cardio (SA)
Department of Cardiothoracic Surgery, Nelson R. Mandela School of Medicine, Durban, South Africa
Accepted for publication June 6, 2003.
* Address reprint requests to Dr Naidoo, Department of Cardiothoracic Surgery, Nelson R. Mandela School of Medicine, Private Bag Jacobs, Durban, KW 4001, South Africa
e-mail: naidoor21{at}nu.ac.za
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Abstract
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Two cases of esophageal perforations consequent upon chronic retained foreign bodies are presented. In both patients a mediastinal mass associated with the foreign body was noted on chest radiography. Retrieval of the foreign bodies, although feasible by esophagoscopy in 1 patient, was unsuccessful in the second patient, thus necessitating thoracotomy.
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Introduction
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Endoscopic removal of esophageal foreign bodies in patients presenting early is invariably successful, which is a common occurrence in general surgical practice. On the contrary, chronic retained foreign bodies may necessitate thoracotomy for removal to obviate the risk of mediastinal breach and fulminant sepsis.
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Patient 1
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A 3-year-old clinically healthy child presented with a 2-month history of dysphagia for solids, associated with cough, anorexia, and loss of weight.
The chest radiograph (Fig 1)
revealed a coin-shaped foreign body in the upper mediastinum shown outside the esophageal lumen on esophagogram (Fig 2).
Rigid esophagoscopy demonstrated anterior mucosal inflammation and pus emanating from a sinus at 15 cm from the incisor teeth with no foreign body visualized.
Before right posterolateral thoracotomy, aortography was undertaken to exclude the presence of an aorto-esophageal fistula. At surgery, an inflammatory mass containing pus and the metallic casing of a wristwatch, closely related to the esophagus with intact mucosa, was noted. The foreign body was removed, the mediastinum drained, and postoperative care was unremarkable.
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Patient 2
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A 6-year-old clinically healthy child presented with a 2-week history of dysphagia for solids and a dry cough. Contrast esophagogram demonstrated a foreign body immediately adjacent to the esophageal lumen with an associated mediastinal mass. Aortogram excluded the presence of an aorto-esophageal fistula. At rigid esophagoscopy the mucosa was irregular and inflamed with a perforation in the right lateral wall at 18 cm from the incisor teeth. The foreign body, with its edge visible, was grasped and removed. After 3 days of fine-bore naso-gastric tube feeding and antibiotics, a contrast study was made to demonstrate an intact esophagus. Recovery was uneventful.
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Comment
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Foreign bodies tend to impact in the esophagus by virtue of the passive, distensible, and accommodating nature of the organ [1]. Esophageal peristaltic activity may be inadequate to prevent retention of swallowed objects. The brunt of this problem is borne by children who form 83% of such reported cases [2].
Clinical sequelae of retained foreign bodies depend on the characteristics of the foreign bodies and the duration of impaction. The most common site of impaction is at the level of the cricopharyngeus followed by the other areas of anatomical narrowing [3].
Complications of retained foreign bodies range from acute perforations with mediastinal sepsis to delayed esophago-tracheal fistulas. A rare and potentially fatal complication is an aorto-esophageal fistula [1, 4]. Although neither patient had features to suggest such a fistula, we believe it is important to exclude imminent fistulization in the presence of a chronically retained foreign body by aortogram.
In the majority of patients with a history of ingestion of a foreign body, the plain chest radiograph confirms the presence. This diagnosis mandates immediate removal under direct vision to avoid complications. Nonendoscopic management involving the use of a Foley catheter to disimpact the foreign bodies, mainly coins, has also been reported [5].
In contrast to an acute perforation that is detected early, when repair and mediastinal drainage is advised, the presence of a chronic perforation in association with a foreign body and a mediastinal inflammatory mass should be treated by removal of the foreign body, enteric feeding, and antibiotics until healing has occurred as demonstrated by contrast esophagogram. Whether the chronically retained foreign body should be removed endoscopically or by a thoracotomy depends entirely on the feasibility and safety of retrieval at esophagoscopy [6].
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References
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- Nandi I., Ong B.G. Foreign bodies in the esophagus: a review of 2394 cases. Br J Surg 1978;65:5-9.[Medline]
- Baraka A., Bikhazi G. Oesophageal foreign bodies. BMJ 1975;8:561-563.
- Blair S.R., Graeber G.M., Cruzzaval J.L., et al. Current management of oesophageal impactions. Chest 1993;104:1205-1209.[Abstract/Free Full Text]
- Ctercteko G., Mok C.K. Aorto-oesophageal fistula induced by a foreign body: the first recorded survival. J Thorac Cardiovasc Surg 1980;80:233-236.[Abstract]
- Odelowo E.O.O., Komolafe O.F. Diagnosis, management, and complications of oesophageal and airway foreign bodies. Int Surg 1990;75:148-157.[Medline]
- Schwarz G.F., Polsky H.S. Ingested foreign bodies of the gastrointestinal tract. Am Surg 1976;42:236-240.[Medline]
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Abstract
Introduction
