Deeply embedded esophageal fishbone removed by endoscopic submucosal dissection

A 50-year-old man presented to the emergency department with chest pain and odynophagia after eating fish. Physical examination and X-ray of the neck were unremarkable. Computed tomography (CT) of the chest showed a fishbone embedded within the muscularis propria of the esophagus ([Fig. 1] a). We then performed an endoscopic ultrasonography (EUS), which localized the fishbone to the posterior wall ([Fig. 2]). A small mucosal defect was also noted.

Fig. 1 a Coronal slice of computed tomography showed a fishbone (arrow) lodged in the distal esophagus, that appeared to penetrate through the submucosa and muscularis propria. b Endoscopically a small portion of fishbone can seen embedded in the distal esophagus through the small mucosal defect.

Fig. 2 Endoscopic ultrasound showed a linear hyperdensity projecting through the muscularis propria.

We proceeded with endoscopic submucosal dissection (ESD) to remove the fishbone ([Video 1]). After normal saline and methylene blue had been injected to expand the submucosal space, a Dual-J knife (Olympus, Center Valley, PA) was used to create a mucosal incision, laterally extending the mucosal defect ([Fig. 1] b). The fishbone was exposed; it was positioned perpendicularly to the esophagus, between the circular and longitudinal muscle layers. Using the fishbone as a scaffold, the overlying circular muscle layer was progressively dissected until the right lateral tip of the bone was freed ([Fig. 3]). The exposed tip was grasped with forceps and removed through the overtube ([Fig. 4]). Examination of the defect revealed incised circular muscle fibers, with intact longitudinal fibers ([Fig. 5]). Attempted closure with through-the-scope clips was unsuccessful because of the orientation of the defect. We placed a 10.5 cm × 23 mm fully covered metal stent (Wallflex; Boston Scientific, Marlborough, Massachusetts, USA). Subsequent CT 48 hours later showed appropriate positioning of the stent with no complications. The stent was removed 2 weeks later, and healed mucosa was observed.

Endoscopic submucosal dissection performed to remove a fishbone deeply embedded into the wall of the distal esophagus.Video 1

Fig. 3 Endoscopic submucosal dissection was done along the fishbone to free the right lateral edge from the circular muscle layer.

Fig. 4 The fishbone was grasped with a rat-toothed forceps and removed via the overtube.

Fig. 5 The remaining muscle defect and exposed submucosa and muscle fibers.

Foreign body ingestion is frequently encountered [1]. In adults, bony fragments are most common, and tend to become lodged at sharp angulations in the gastrointestinal tract [2]. While guidelines recommend emergent endoscopy in esophageal impaction [3] [4], surgical intervention is typically required for deeply embedded nonvisible foreign bodies [5]. As we have demonstrated, in selected patients, EUS may localize the foreign body and facilitate ESD for safe and effective extraction.

Endoscopy_UCTN_Code_TTT_1AO_2AL

Publication History

Article published online:
08 November 2024

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