Ann Thorac Surg 2009;88:1019-1021. doi:10.1016/j.athoracsur.2009.01.061
© 2009 The Society of Thoracic Surgeons
Case Reports
Successful Removal of Indigested Shell Using a Rigid Esophagoscope and a Pneumatic Lithotriptor
Heezoo Kim, MD, PhDa,
Hyun Koo Kim, MD, PhDb,*,
Gi-Run Kang, MDa,
Du-Young Kang, MDb,
Young Ho Choi, MD, PhDb,
Sang-Ho Lim, MD, PhDa
a Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Korea
b Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Korea
Accepted for publication January 21, 2009.
* Address correspondence to Dr Kim, Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, 97 Guro-dongkil, Guro-ku, Seoul, 152-703, Korea (Email: kimhyunkoo{at}korea.ac.kr).
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Abstract
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Foreign body ingestion is a commonly encountered clinical problem in pediatric emergency cases. The authors report a case of an esophageal foreign body caused by the accidental ingestion of a shell in an 8-month-old girl. Endoscopic removal was attempted but failed because of the sharp margin of the shell and caused it to be deeply impacted into the esophageal wall. Accordingly, a pneumatic lithotriptor was inserted through a rigid esophagoscope and used to fragment the shell.
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Introduction
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Foreign body ingestion is a common clinical problem in children, and the upper esophagus is the most common site of foreign body lodgment [1]. The majority of swallowed foreign bodies pass harmlessly and spontaneously through the gastrointestinal tract [1–3], but occasionally they become lodged, and endoscopic or surgical management is required to resolve the situation. In particular, impacted foreign bodies with a sharp margin are dangerous because they can cause esophageal mucosal laceration during retrieval.
The authors reported a patient with a sharp, margined foreign body lodged in the upper esophagus that was removed by fragmenting it with a pneumatic lithotriptor, which is normally used to manage renal and ureteral calculi. Shell fragments were safely removed under direct esophagoscopy without causing any mucosal damage to the upper esophagus.
An 8-month-old baby girl was presented at our pediatric department with a mild fever of 1-month duration, which had become aggravated 4 days prior to admission. A routine chest roentgenogram at admission revealed a 2 x 2 cm sized, crescent-shaped, and sharp-edged foreign body in proximal esophagus from the level of the thoracic inlet to above the level of the aortic arch (Fig 1).
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Fig 1. Chest lateral roentgenogram showing a 2 x 2 sized, high-density foreign body in the proximal esophagus.
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She was referred to the department of gastroenterology, and an esophagoscopy was performed using a flexible endoscope under conscious sedation. The object was identified as a shell with broken, sharp edges (Fig 2). Despite every effort, endoscopic removal failed because the shell had impacted and adhered to an edematous esophageal wall. Furthermore, its sharp margin threatened esophageal tearing during extraction, and if too much force had been applied, it could have scratched or lacerated the esophageal wall. Therefore, under general anesthesia, endoscopic removal was retried through a rigid esophagoscope (Karl Storz, 5 x 30 [Karl Storz GmbH & Co, Tuttlingen, Germany]). The foreign body proved to be too firmly impacted to remove. Thus, we decided to use lithotriptor (Swiss LithoClast pneumatic lithotriptor [EMS Electro Medical Systems, Nyon, Switzerland]) to fragment the shell. A lithoclast 0.8-mm probe (Fig 3) was inserted through the rigid esophagoscope, and a pediatric fibroptic bronchoscope (2.2-mm LF40P [Olympus, Tokyo, Japan]) was used to visualize the foreign body, because the lithoclast probe obstructed the visual field. Several strikes with the lithotriptor were sufficient to fragment the shell without esophageal wall damage, and the fragments produced were easily removed.
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Fig 2. An esophagoscopic examination revealed that the foreign body was a shell that impacted and adhered to the esophageal wall.
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Fig 3. A lithoclast 0.8-mm probe (Swiss LithoClast pneumatic lithotriptor [EMS Electro Medical Systems, Nyon, Switzerland])
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The shell seemed to be that of a type of surf clam (Fig 4). Under suspicious mediastinitis, total parenteral nutrition was administered for a week. On postoperative day 8, an esophagogram revealed no esophageal leak. She was then placed on a soft diet, which was well tolerated. She was discharged on postoperative day 10 without complication.
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Comment
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A randomized, clinical trial found that 25% to 30% of asymptomatic esophageal coins pass spontaneously without complication [4]. However, lodged esophageal foreign bodies usually cause symptoms such as odynophagia, coughing, drooling, irritable crying, or nausea and vomiting [1]. More serious complications of ingested foreign bodies include esophageal laceration, perforation, abscess, and fistula formation. In particular, the ingestion of sharp objects introduces a 35% risk of esophageal, gastric, or duodenum perforation, and thus such objects should be promptly removed by endoscopy [5].
The endoscopic removal of foreign bodies is successful in most cases with a success rate of > 97% [1, 2], but when endoscopic removal failed, surgical intervention should be considered [5].
Pneumatic lithotriptors are highly effective at fragmenting the large bladder and kidney stones [6]. Insertion of the lithotriptor through an esophagoscope prevented adequate visualization of the foreign body, and it is essential when using a lithotriptor to achieve good visualization of the target to avoid damaging the surrounding tissue. Accordingly, to secure a visual field, we used a pediatric fiber bronchoscope. In the described case, open surgical intervention was avoided by applying recently acquired equipment in a novel manner, and by adopting a multi-disciplinary approach. We believe that this is the first report of the combined use of a lithotriptor and a rigid esophagoscope to remove a deeply impacted brittle, large foreign body with a sharp margin.
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References
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- Lin CH, Chen AC, Tsai JD, Wei SH, Hsueh KC, Lin WC. Endoscopic removal of foreign bodies in children Kaohsiung J Med Sci 2007;23:447-452.[Medline]
- Katsinelos P, Kountouras J, Paroutoglou G, Zavos C, Mimidis K, Chatzimavroudis G. Endoscopic techniques and management of foreign body ingestion and food bolus impaction in the upper gastrointestinal tract: a retrospective analysis of 139 cases J Clin Gastroenterol 2006;40:784-789.[Medline]
- Lyons 2nd MF, Tsuchida AM. Foreign bodies of the gastrointestinal tract Med Clin North Am 1993;77:1101-1114.[Medline]
- Waltzman ML, Baskin M, Wypij D, Mooney D, Jones D, Fleisher G. A randomized clinical trial of the management of esophageal coins in children Pediatrics 2005;116:614-619.[Abstract/Free Full Text]
- Pavlidis TE, Marakis GN, Triantafyllou A, Psarras K, Kontoulis TM, Sakantamis AK. Management of ingested foreign bodies. how justifiable is a waiting policy?. Surg Laparosc Endosc Percutan Tech 2008;18:286-287.[Medline]
- Denstedt JD, Eberwein PM, Singh RR. The Swiss lithoclast: a new device for intracorporeal lithotripsy J Urol 1992;148:1088-1090.[Medline]
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Abstract
Introduction
