Endoscopic retrieval followed by compression hemostasis using a Sengstaken–Blakemore tube to manage a foreign body with suspected aortic injury

A 44-year-old woman presented with unremitting chest pain after a fish meal. A fishbone had been stuck in her esophagus overnight. A local endoscopist had tried to remove it but had failed.

Contrast-enhanced computed tomography ([Fig. 1]) confirmed that there was a high density line shadow in the esophagus just below the tracheal bifurcation. The fishbone had pierced the esophageal wall and was close to the descending aortic adventitia, and possible aortic injury was strongly suspected. Standard cardiovascular surgery was planned, but was refused by the woman and her relatives because of the potentially massive surgical trauma. With written informed consent, an innovative endoscopic strategy involving multidisciplinary cooperation was successfully employed ([Video 1]).

Fig. 1 Contrast-enhanced computed tomography scan of a 44-year-old woman with a fishbone stuck in her esophagus. The fishbone had pierced the esophageal wall and was close to the descending aorta (arrow).

Endoscopic retrieval of a fishbone followed by compression hemostasis using a Sengstaken–Blakemore tube. Postoperative care and examinations are also presented.

Using endoscopic imaging, only the tip of the fishbone could be observed, 28 cm from the incisors ([Fig. 2]). Grasping forceps were introduced and the 2.2 cm-long fishbone was successfully retrieved ([Fig. 3]). Then fresh blood immediately spurted out. After flushing with normal saline, a Sengstaken–Blakemore tube (SBT) was immediately inserted. The gastric balloon was placed accurately over the mucosal wound, inflated with 100 mL of gas, and adjusted for local compression hemostasis ([Fig. 4]). The SBT was deflated under endoscopy 20 h postoperatively. Only mild mucosal erosion was observed and there was no active bleeding ([Fig. 5]). The patient’s postoperative course was uneventful ([Fig. 6]).

Fig. 2 Endoscopic image of the tip of the fishbone.

Fig. 3 A 2.2 cm long fishbone retrieved endoscopically from the esophageal wall.

Fig. 4 Esophageal compression hemostasis using an inflated gastric balloon.

Fig. 5 Mild mucosal erosion 20 h postoperatively after endoscopic retrieval of a fishbone followed by compression hemostasis using a Sengstaken – Blakemore tube.

Fig. 6 Computed tomography showed no hemorrhage or undesired complications 7 days postoperatively after endoscopic retrieval of a fishbone followed by compression hemostasis using a Sengstaken–Blakemore tube.

Endoscopic management is necessary in only 10 % – 20 % of foreign-body cases, while fewer than 1 % require a standard surgical procedure [1]. For patients with suspected injury of the descending aorta or life-threatening esophagus–aorta fistula, surgical management is commonly recommended. In previous reports, an SBT has been used to control the arterial hemorrhage before unavoidable surgery [2] [3]. In our patient, the inflating gastric balloon was not used as a preoperative intervention, but was effectively applied for local compression hemostasis immediately after an endoscopic procedure. Tailored adjustment of compression and its duration was important for successful treatment. This combined strategy is minimally invasive, feasible, and safe, and could provide an alternative approach to surgical treatment for patients at high risk. Further research is necessary to weigh the clinical benefits against the potential complications of this strategy.

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• References

• 1 Athanassiadi K, Gerazounis M, Metaxas E et al. Management of esophageal foreign bodies: a retrospective review of 400 cases. Eur J Cardiothorac Surg 2002; 21: 653-656
• 2 Yamada T, Sato H, Seki M et al. Successful salvage of aortoesophageal fistula caused by a fish bone. Ann Thorac Surg 1996; 61: 1843-1845
• 3 Assink J, Vierhout BP, Snellen JP et al. Emergency endovascular repair of an aortoesophageal fistula caused by a foreign body. J Endovasc Ther 2005; 12: 129-133