Keywords
Magill forceps - foreign bodies - methods
Accidental foreign body (FB) ingestion is a common clinical problem.[1] FB ingestion is highly prevalent among the pediatric age group. In adults, it occurs
most frequently in alcoholics, prisoners, and those with mental retardation.[2]
[3] Radiological localization of ingested FB using advanced techniques is mandatory.[4] Esophagoscopy is the main method for the removal of FBs. Rigid esophagoscopy has
been mainly associated with a 5 and 10% risk of perforation during FB removal. The
ideal methods are all of the procedures which have lower perforation rate to quickly
remove the FBs. Foley catheter extraction and the minimally invasive Magill forceps
devices were described for this goal to remove FBs which located in the upper esophagus.
The present study aimed to report our experience retrieving ingested FBs from the
upper esophagus in children using Magill forceps under general anesthesia.
Materials and Methods
In total, 88 patients (45 males [51.1%] and 43 females [48.9%]) presented with suspected
FB ingestion to the School of Medicine Hospital and Konya State Hospital, Selcuk University
between January 1996 and July 2015. FB ingestion was determined via endoscopic analysis,
or lateral and posterior–anterior radiographies, including the oropharynx, neck, chest,
and abdomen. Cases of FB ingestion were classified into seven groups, according to
history, diagnostic method, and postintervention findings, as follows: (1) coins,
(2) toys, (3) metals, (4) bones, (5) battery, (6) glass, and (7) food ([Figs. 1]
[2]
[3]
[4]
[5]
[6]
[7]). None of the patients had a history of esophageal disease. Clinical symptoms, such
as dysphagia, pain when swallowing, and excessive salivation, were recorded. Excessive
salivation that occurred suddenly after ingestion of an FB was the strongest diagnostic
criterion. All cases of FB ingestion were considered emergencies, and interventions
were performed immediately in the surgical suite. The patients were sedated and FBs
were extracted was using Magill forceps, without intubation. A laryngoscope was inserted
into the pharynx to elevate the larynx and to expose the esophageal entrance. Magill
forceps were advanced into the esophagus and opened to observe and extract the FB.
General anesthesia was administered using sevoflurane in a mixture of oxygen/nitrous
oxide (50:50) via mask ventilation. For procedures that exceeded 20 minutes, dexamethasone
was administered to prevent soft tissue edema. Postprocedure each patient underwent
follow-up X-ray and the patients' parents were advised to prohibit their child from
eating and drinking for 8 to 10 hours. The children were generally discharged the
same day as the procedure.
Fig. 1 Lateral view shows a turban pin in the first part of the esophagus.
Fig. 2 Anterior view shows a turban pin in the first part of the esophagus.
Fig. 3 Cervical computed tomography shows a chicken bone in the first narrowing of the esophagus.
Fig. 4 Three-dimensional view shows a bone in the first narrowing of the esophagus (same
patient as in [Fig. 3]).
Fig. 5 X-ray shows a coin in the first part of the esophagus.
Fig. 6 Coin removed from the first narrowing of the esophagus.
Fig. 7 A turban pin removed from the first narrowing of the esophagus via Magill forceps.
Results
Of the 88 patients who underwent endoscopic examination due to suspected FB ingestion,
all were confirmed to have ingested an FB. Median age of the patients was 12 years;
in all, 15 patients were aged < 5 years ([Table 1]). Among the patients, 63 (71.5%) were diagnosed based on routine radiographic findings;
the other 25 were diagnosed based on physical findings and FB history. None of the
patients had esophageal disease, such as esophageal stenosis secondary to corrosive
injury or congenital esophageal atresia. In all, two patients had cerebral palsy and
mental retardation. The most common type of FB ingested was coins (n = 51 [57.9%]) ([Table 2]). Diameter of coins ranged from about from 20 to 26 mm. The length of pins which
had a sharp point at one end and a round plastic head at the other end was ∼30 mm.
The diameters of batteries ranged from 10 to 20 mm. The pieces of food and toy had
different sizes and lengths and especially the one end of bones had sharp point. The
most common symptom of FB ingestion was hypersalivation (n = 61 [69.3%]) due to inability to swallow. The other symptoms of patients included
discomfort in the throat, dysphagia, and difficulty in speaking. Almost all FBs were
removed via a single procedure. Mean surgical duration was 20 minutes (range: 15–45
minutes). In six (6.8%) of the patients who ingested a coin, the coin passed into
the digestive tract while attempting to remove it from the upper region of the esophagus;
none of these patients had any complications and all the coins were recovered from
stool. Especially, if the FB was a coin, we stopped the oral feeding for 24 hours.
Also, we did not see any complications in that patients.
Table 1
Age distribution of foreign body
|
Age (y)
|
Coin
|
Toys
|
Metal
|
Battery
|
Bone
|
Glass
|
Food
|
Total
|
|
0–3
|
7
|
–
|
1
|
2
|
–
|
–
|
–
|
10
|
|
4–7
|
22
|
5
|
1
|
–
|
–
|
–
|
1
|
29
|
|
8–11
|
16
|
3
|
1
|
1
|
3
|
–
|
–
|
24
|
|
12–22
|
6
|
–
|
11
|
–
|
5
|
–
|
–
|
22
|
|
More than 22
|
–
|
–
|
–
|
–
|
1
|
1
|
1
|
3
|
|
Total
|
51
|
8
|
14
|
3
|
9
|
1
|
2
|
88
|
Table 2
Nature and frequency of foreign bodies ingested
|
Type of foreign bodies
|
Number of patients (n, %)
|
|
Coin
|
51 (57.9)
|
|
Food bolus
|
2 (2.3)
|
|
Fish bones
|
2 (2.3)
|
|
Chicken bones
|
7 (8)
|
|
Turban pins
|
13 (14.8)
|
|
Toys
|
9 (10.2)
|
|
Glass
|
1 (1.1)
|
|
Battery
|
3 (3.4)
|
|
Total
|
88 (100)
|
Discussion
Esophageal FB is an emergency clinical condition that occurs in all age groups (most
commonly in children) that can cause serious morbidity or mortality. FBs retained
in the esophagus generally fall into two categories: FB and food bolus. Children most
often ingest coins, toys, and metal objects, whereas adults commonly present with
meat bolus and bones.[4] More importantly, physical and mental conditions predispose patients to esophageal
impaction. FBs located near the cervical esophageal level are usually the most difficult
to remove, and based on our clinical experience, Magill forceps should be used before
resorting to other methods. Rapid diagnosis and treatment are important to minimize
morbidity and complications associated with FB ingestion.[5] Impacted FBs in the esophagus can easily cause mucosal ulceration and even infection,
and can also result in various fatal complications, including retroesophageal abscess,
mediastinitis, and empyema.[6] The aim of initial patient evaluation is to identify the type of FB and its location,
and to determine if there are any underlying esophageal conditions. Radiographic evaluation
is helpful for confirming the location of an FB and associated complications. Plain
radiography of the neck and chest commonly show the location of radiopaque objects,
such as coins, turban pins, and metallic objects. Both anterior–posterior and lateral
views are necessary for the diagnosis.[7] Nonradiopaque FBs must be removed with great caution; however, there is a lack of
consensus regarding the best method for doing so. The choice of treatment is determined
based on many factors, including patient age and clinical condition, the level of
emergency, and the size of the ingested FB and its anatomic location. Esophageal FBs
account for 7 to 14% of all esophageal perforations, and fish and chicken bones are
the most common FBs in adults.[8] Sharp objects and batteries should be removed as soon as possible to prevent esophageal
erosion or necrosis of the mucosa;[2] however, Eisen et al suggest that small batteries (< 20 mm in diameter) that have
passed beyond the esophagus need not be retrieved unless patients have gastrointestinal
(GI) tract symptoms and signs, such as abdominal pain, abdominal distension, or vomiting.[3] Patients may be symptomatic immediately following ingestion of an FB or as late
as 2 weeks after esophageal perforation.[9] Symptoms of FB ingestion include dysphagia, odynophagia, and chest pain. If an FB
forms a complete obstruction, patients exhibit sialorrhea and regurgitation. Up to
5% of patients can present with airway obstruction when a bolus is impacted near the
upper esophageal sphincter because there is compression of the trachea that causes
symptoms of stridor and coughing.[10] The most common symptoms in the present study's patients were odynophagia and chest
pains. Chest X-rays may show perforation-related complications, such as air and fluid
collection, or abscess in the pleural space, pericardium, or mediastinum; however,
a chest X-ray can show normal findings in some cases and alone is not adequate for
detecting an FB retained in the esophagus. The most important consideration, especially
in children, is airway control.[2] Endoscopy is currently the most widely used method of FB removal;[11] its advantages are direct observation and evaluation of the degree of esophageal
injury caused by an FB. Rigid esophagoscopy had been the primary tool for the removal
of FBs until 1957, when Hirschowitz constructed the first flexible fiber-optic endoscope
employed by gastroenterologists for investigating patients with complaints involving
the upper digestive tract.[12] Today, rigid and flexible endoscopy are performed under general anesthesia and conscious
sedation, respectively. Magill forceps are considered safe and effective in experienced
hands. In the present study, coins and other FBs were extracted from the upper esophagus
using Magill forceps, and we recommend this technique for easy removal of FBs without
the need for deep general anesthesia and/or intubation. This method was used to extract
coins that passed down to the first constriction of the esophagus, as well as to extract
food and other FBs. In cases in which the FB passed into the stomach, we recommended
the patient wait for its passage in stool;[11] however, abdominal pain may be an indication for surgical removal. Children's natural
curiosity and propensity to ingest objects are well known and supported by X-rays
and a history of FB ingestion. Also, it is very important that parents should be aware
of complications of esophageal FBs.[13]
In conclusion, the presence of an FB in the esophagus is a challenging problem, as
perforations may result in death. Rapid diagnosis and treatment of FBs in the esophagus
will decrease the morbidity rate and duration of hospitalization.[14] There are many options available for the management of esophageal FBs. Our clinical
experience indicates that FBs located in the upper esophagus should be removed using
Magill forceps. This approach is the preferable method for extraction of upper-GI
FBs because of its high success rate without complications. Early diagnosis and detection
of FBs are essential for easy removal. Coins and other radiopaque items can be diagnosed
via X-ray and safely removed using direct vision via Magill forceps while patients
are sedated.
