Keywords
Food impaction - esophageal food obstruction - bolus - bolus removal - esophagus -
endoscopy - endoscopic emergency
Schlüsselwörter
Steckengebliebene Nahrung - Verlegung der Speiseröhre durch Nahrung - Bolus - Bolusentfernung
- Ösophagus - Endoskopie - endoskopischer Notfall
Introduction
Food impactions in the esophagus are a known phenomenon in gastroenterology. Although
few studies on their epidemiology exist, many authors suspect a rising incidence,
with current numbers of about 10 to 20 per 100000 per year [1]
[2]
[3]. The risk is considerably higher in individuals with underlying esophageal diseases
such as eosinophilic esophagitis (EoE), pseudodiverticulosis (DEIPD), strictures,
or tumors [4]
[5]
[6]. In these groups, up to 50 percent of all patients may experience single or repeated
food impactions at least once in their lifetime [7]. The type of impacted food will usually be meat [1]
[8].
Clinically, food impactions present as emergencies with the patient unable to swallow
anything including their own saliva. Chest pain can occur but it is not mandatory
and, if present, usually mild [9].
Before the widespread availability of flexible endoscopy, several noninvasive methods
for bolus removal had been tried, but neither nifedipine, nitroglycerin, diazepam,
buscopan, glucagon, nor Coca-Cola proved successful [10]
[11]
[12]
[13]
[14]. Standard therapy since the 1980s is endoscopy, which basically gives us two ways
of removing the bolus: forward into the stomach, or backwards by retrograde extraction
[15]
[16].
In the early days of therapeutic endoscopy, it was believed that pushing the food
forward would pose an unacceptable risk of laceration, penetration, or bleeding. Consequently,
retrograde removal of the impacted bolus was generally recommended, and routinely
performed [17]. By the turn of the century, this dogma had been questioned by a growing number
of endoscopists, and several studies came out showing that the forward-pushing technique
was faster than the retrograde removal, and equally safe [18]
[19]
[20]. Consequently, the American Society for Gastrointestinal Endoscopy (ASGE) allowed
a gentle forward-pushing as early as 2002, and explicitly recommended it in their
updated guidelines in 2011 [21]
[22]. By 2016, the European Society of Gastrointestinal Endoscopy (ESGE) followed suit
and recommended pushing in their clinical guidelines as well [23].
Now in 2023, Heise et al. published a new series of 77 food obstructions in adults
and children, of which only 5 were resolved by pushing the bolus forward. In the remaining
cases, impacted food was removed by suctioning it into an overtube, a technique that
was originally introduced in 1990 [24]. Based on those findings, the authors conclude that pushing forward is unsafe and
recommend a change of the ESGE guidelines [25].
Since this is in contrast with otherwise published data [18]
[19]
[20] as well as with national and international guidelines [22]
[23], we undertook this retrospective, single-center, observational study. Its objectives
were to examine whether the nature of food impactions and way they are treated had
changed in the last two decades, wether pushing can still be considered a safe procedure,
and wether the existing guidelines need to be changed.
Patients and Methods
Brandenburg University Hospital is a tertiary center, serving a population of roughly
100000. In January 2025, we retrospectively searched the hospital’s endoscopic database
(ViewPoint Versions 5 and 6, General Electric Company, USA) for every food or bolus
obstruction from January 1st 2008 to December 31st 2024, thus covering the time span from eight years before the publication of the
European Guidelines in 2016, until eight years after [23].
Inclusion criteria were:
-
Patient 18 years or older
-
Admitted to emergency department for suspected esophageal food impaction
-
Underwent endoscopy for food removal within 24 hours after admission.
Exclusion criteria were:
-
All cases in which the obstruction spontaneously resolved between admission and endoscopy
-
All cases in which the stuck object was other than food (4 times tablets, 3 dislocated
stents, 1 battery, 1 tracheal cannula, 1 bone splinter, 1 razor blade, 1 hemostatic
clip, 1 suture, 1 dislocated Lynx band)
-
All cases in which the documentation regarding type of bolus and / or way of removal
was incomplete.
For patients who had more than one episode of bolus obstructions, each episode was
counted as one case. This resulted in 99 cases that were included in the study.
Over the time span of 16 years, 12 different endoscopists were involved in treating
food impactions. Endoscopy was generally carried out under nurse administered propofol
sedation (NAPS) and circulatory monitoring. No patient was intubated. Gastroscopes
used were Fujinon EG Series (EG 530CT, EG 530WR, EG 580NW2, EG 600WR; Fujifilm Group,
Japan), and Olympus GIF Series (GIF 1T -140, GIF-160, GIF-G145, GIF-XTQ160, GIF-H190,
GIF-HQ190; Olympus Corp, Japan). If not pushed forward, food was removed by plain
suction, or by the use of forceps, 3- or 5-prong graspers, nets (all: MTW Endoskopie
W. Haag KG, Germany), or loops (Fujinon, Fujifilm Group, Japan). However, we did not
use an overtube as a suction device.
Data were stored in a spreadsheet program (Excel 2016, Microsoft Corp., USA). Statistical
computation was performed using Prism 9.0.0 (GraphPad Software Inc., La Jolla, USA).
Binary and numeric data is presented as count and/or percentage. Differences between
groups were assessed by chi-square (Χ2) test. A p value < 0.05 was considered significant.
This study has been approved by the ethics committee of the Brandenburg Chamber of
Physicians, Ref No. 2024–142-BO-ff. All procedures were in accordance with the standards
of the institutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Results
From January 2018 to December 2024, our clinic performed endoscopy in 99 fully documented
cases of esophageal food impactions. Median age of patients was 65 years, minimum
was one year, maximum was 94 years. Eighty percent of patients were male, 20 % were
female (p < 0.001) ([Fig. 1]). Counting food impactions per year, there was a nearly logarithmic increase, with
zero to four annual impactions prior to 2016, and up to 22 annual impactions afterwards.
Coefficient of correlation (R2) was 0.82 ([Fig. 2]).
Fig. 1 Esophageal food obstructions 2008 to 2024 by sex. p < 0.001.
Fig. 2 Esophageal food obstructions in Brandenburg from 2008 to 2024. Given are absolute
numbers per year and 2nd degree polynomic trend line. R2 = coefficient of correlation.
If one would omit the “corona year” 2020, R2 would be greater than 0.9.
The majority of causes for food impactions were reflux-associated, like peptic strictures,
mucosal scarring, impaired peristalsis, or ulcers within Barret’s mucosa in 26 cases
(25 %, hereinafter referred to as “GERD”), EoE in 16 cases (15 %), and pseudodiverticulosis,
hernia, and unspecific esophagitis in 7 cases respectively (7%); these five making
up almost two thirds of all patients. The rest was due to a much broader spectrum
of diagnoses; in descending order: unspecific esophagitis, achalasia, rings, post-OP
stenosis, candidiasis, esophageal carcinoma, radiation esophagitis, scarring after
caustic injury, metastasis, and ulcer. In 12 cases (11%), no cause for the bolus obstruction
could be identified ([Fig. 3]).
Fig. 3 Causes of esophageal food obstructions in Brandenburg. Given are percentages of 99
cases from 2008 to 2024. GERD = complications of gastro-esophageal reflux disease,
like scarring, strictures, stenoses, or Barrett’s ulcer; EoE = eosinophilc esophagitis;
post OP = anastomotic stricture; Metastasis = compression by lymph note metastases
from bronchial carcinoma or gastric carcinoma.
Seven patients were admitted more than once. One patient had three episodes because
of peptic stricture (PS), three patients had two episodes each, also because of PS.
Two were admitted twice for DEIPD, and one was admitted twice for EoE.
Stuck food was removed by pushing forward in 58 cases (59 %), by pulling it out in
28 cases (28 %), or by a combination of both in 13 cases (13 %). When comparing the
times before and after the introduction of the European guidelines in 2016, there
was an increase of pushing, alone or in combination, from 56 percent to 75 percent
(p < 0.001) ([Fig. 4]).
Fig. 4 After the introduction of the European guidelines in Feb 2016, the pushing method
(solely or in combination with pulling) increased from 56 percent to 75 percent (p
< 0.001). Numbers are percentages; absolute numbers for the time span from 2008 to
2016 are much smaller than from 2017 on (compare [Fig. 2]).
Regardless of the method used, in all cases the food bolus was removed during the
initial emergent endoscopy. This denotes a technical success rate of 100 percent.
Overall, we observed three adverse events: One minor bleeding after pushing forward
which stopped spontaneously and did not require intervention, one equally minor bleeding
after pushing forward and performing bougienage in the same session, and one esophageo-tracheal
fistula after removal with net and grasper which was most likely pre-existing.
Discussion
We initially undertook this study to compare different endoscopic methods of removing
esophageal food impactions. However, before we could come to this comparison, one
incidental finding caught our attention: The steep and significant increase of esophageal
bolus impactions over the last sixteen years. Although this increase has been assumed
by many, our study is the first to actually prove it for a larger European collective
[26]
[27]. Looking at the curve, there is only one true outlier in 2020, and this is likely
due to the German corona lockdown in that year, with closed restaurants and restrictions
on private barbecue parties [28]. If we omitted 2020 from the analysis, the formal correlation would be even stronger
with a coefficient greater than 0.9 ([Fig. 2]). Another finding is the vast majority of male patients. Also, this is not unexpected,
but we did not think it would be so pronounced [29] ([Fig. 1]).
Of note, less than one third of these obstructions were caused by common diagnoses
like GERD or hernia.
The rest were due to a variety of “rare” diseases like EoE, pseudodioverticulosis
(DEIPD), achalasia, esophageal carcinoma, chemical or radiation esophagitis, scarring,
and others ([Fig. 3]). So even if these diseases are rare, they are diagnoses on the rise, and their
rising incidence combined would explain the exponential increase in bolus obstructions
we observed [30]
[31]. This is especially true for EoE with its worldwide increasing incidence [32]
[33]
[34]
[35]
[36]
[37]
[38], and for DEIPD, a disease that has long been underestimated and has only recently
come to the attention of the gastroenterological community [7]
[39]
[40].
Of note, seven patients had more than one episode of food impaction. This may be astounding
at first, but given the fact that most of the underlying diseases are chronic by nature,
it is easily explained. (We had one patient suffering from DEIPD who had five episodes
in four years but was excluded from the study because of incomplete documentation
[41]).
Regarding the method of removal, we took a pragmatic approach: With the patient sedated,
we first gave the bolus a gentle push with the endoscope. If this gentle pushing did
not work we did not force it but changed our strategy and now tried to remove it with
various tools in one piece. If that also failed, we broke it up into fragments until
the remains could either be pushed forward, or pulled out completely ([Fig. 4]). However, this sequence was not due to a written standard operation procedure (SOP),
but due to the individual decisions of 12 endoscopists over a time span of 16 years.
Against this background, we find two aspects remarkable: First, a success rate of
100 percent, and secondly, the negligible number of three minor adverse events, two
of them probably unrelated to the procedure. This suggests that the individual decisions
were right, and that all methods applied were vastly, and equally, safe.
These results are not extraordinary. Even the first series on forward-pushing from
the beginning of the century showed success rates between 40 and 97 percent, with
minor adverse events between zero and 3 percent [18]
[19]
[20]. This trend continued, so that in 2023, a meta-analysis of 18 studies with 3528
participants could calculate a technical success rate of 97.5% for pushing vs. 88.4%
pulling, with adverse event rates of 4.03% vs. 2.22%. None of these differences where
significant [42].
Insofar, our data are in concordance with the international literature for more than
two decades, but in stark contrast to the aforementioned results of Heise et al. [25].
Regarding retrograde extraction, some endoscopists suspected this technique to be
the more dangerous one because pulling food through the pharynx of a sedated but not
intubated patient would carry the risk of aspiration. Although this is theoretically
possible it has rarely been observed in clinical studies, and all authors came to
the conclusion that an intubation is not necessary. [43]
[44]
[45]. Our own data, with 41 uncomplicated extractions in non-intubated patients, support
these findings and in this case we are in concordance with Heise at al. Whether special
devices such as caps and hoods or the new OTSG Xcavator (Ovesco Endoscopy) would further
improve these already excellent results remains to be seen [46].
As a conclusion, we see no reason to alter the existing guidelines or to restrict
the use of gentle forward-pushing in the management of food obstructions [22]
[23]. On the other hand, we see no reason to restrict the use of retrograde extraction
devices either. Rather, we suggest sticking with the proven pragmatic approach based
on the experience and preference of the performing endoscopist.
Abbreviations
ASGE:
American Society for Gastrointestinal Endoscopy
DEIPD:
Diffuse Esophageal Intramural Pseudo-diverticulosis
EoE:
Eosinophilic Esophagitis
ESGE:
European Society for Gastrointestinal Endoscopy
NAPS:
Nurse administered Propofol Sedation
Compliance with Ethical Standards
Compliance with Ethical Standards
This study has been approved by the ethics committee of the Brandenburg Chamber of
Physicians, Ref No. 2024–142-BO-ff. All procedures were in accordance with the standards
of the institutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Contributions
FH planned the study, performed endoscopy and wrote the manuscript. IEH and JEW cared
for patients, researched data and literature, performed statistic computation and
co-wrote the manuscript. GM, TB, and SL cared for patients, performed endoscopy, researched
literature, and edited the manuscript.
Data Availability
All relevant data are within the paper.
