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Current Management of Esophageal Impactions
Current Management of Esophageal Impactions* Sloa11e R . Blair, M.D .; Geoffrey M . Graeber, M .D . , F.C .C.P.; Jose L. Cru;:;;;:;;avala, M .D.; Robert A. Gustafson, .\I.D .; Ronalcl C . Hill, M . D ., F.C.C .P.; Herbert K \\;l1rden, M .D.; and Gordon F Murray, M .D., F.C.C.P. We analyzed our experience at a university medical center from 1977 to 1990 to assess our success in using esophagoscopy and related treatments for removing esophageal impactions. There were 157 episodes of impaction in 150 patients, consisting of 39 pediatric and Ill adult patients. In the pediatric cases, foreign bodies were most often the cause of impaction, while adult cases were usually caused by food or bones. Esophagoscopy was performed successfully in 32 of 34 pediatric patients in which it was attempted;
there was only one complication. Other forms of therapy that were infrequently tried met with variable results. Esophagoscopy was successful in removing the impaction in 104 of 109 attempts in adults. Two perforations occurred, with one resulting in death. Various other methods achieved success in the remaining patients. The data suggest that esophageal impaction can be treated successfully by endoscopy with very low morbidity and mortality. (Chest 1993; 104:1205-09)
impaction is a relatively uncommon but E sophageal consistently encountered clinical problem. Sev-
the distribution was fairly uniform, with a slightly higher frequency for the 61- to 70-year-old category. In the patients younger than 12 years of age, the male to female ratio was 1.6:1. In the adult patients, the male to female ratio was 1. 7:1. In the pediatric cases more foreign objects were found in the esophagus, most often coins. The adults generally had some type of impacted food, most commonly meat (Table 2). Coins and some of the foreign bodies found in the adult esophagi were often a result of tavern games' and unusual events. Patients with a history of psychiatric illness had some unusual items found in the esophagus. In pediatric cases, foreign bodies were fi.mnd most often in the upper third of the esophagus (84 percent). In the adult patients, esophageal impaction occurred more commonly in the distal esophagus (53 percent) (Table 3). Preexisting distal esophageal disease accounted for the larger number of impactions in the distal esophagus of the adults (Table 4). There were 27 patients that had either a web, a stricture, or a
eral different therapeutic methods exist for treating these impactions, which include direct papain or carbonated fluid treatment, glucagon therapy, Foley catheter removal, and endoscopically guided methods. Since its introduction, the endoscopic approach to resolution has heen very successful; however, the reported incidence of complications has given reason to exercise caution in its employment. This retrospective study was conducted to evaluate our success with all modalities to remove esophageal impactions and to document our complications and mortalities. METHODS Our series evaluated the dini<:al fi.·atures of and treatments f<>r body impadions in patients seen at our institution from 1977 throu~h 1990. The dia~nosis in all eases was t11nnrmed by endoseop)~ radio~raphie proeedures, or both. After treatment, efforts were m;ult• to maintain posthospital snrveillanet• to dt·termine the ellieaey of therapy, to ascertain the ineidenee ofn><:nrrenee, ami to t11rrdate the inddenee with predisposin~ ~astroinll'stinal and systemie disease . f<>rei~n
Table I - Age Distribution of Impactions
RESULTS
There were 150 patients: 39 pediatric cases, each with one episode of impaction, and 111 adult patients, with a total of 118 impactions (7 repeated impactions; none of the patients had more than 2 impactions). In the pediatric patients, there was a uniform distribution among the three age groups (Table I). In the adults, *From the Dt•partments of Sur~ery, Baylor Colle~e of Medidne (Dr. Blair), Houston, and the \Vest \'ir~inia University Sehool of Mt•dicine (Drs. Craeber, Cruzzavala, Custafson, Hill , \Varden, and Murray), Mor~antown . Manuseript received Decembe r 21l. 1992; revision aeeepted Februarv 23 , 1993. Rt•prlut rl'qw•sts: Dr. Grtwbt'l; Dqmrtnwut of Sw·gay, PO Box 92.38 , Uht Virgiuiu Uuivn.•ily HSC.\', Morguutorm, WV 26.50692.'38
Age, yr Pediatric
Adults
0-2 3-6 4-ll 12-20 21-30 31-40 41-50 .'51-60 61-70 71-1!0 lll-90 91-100
No . (%)
17 ll ll 39 14 ll 10 17 17 2.3 ll 12 3
(44)
(21l) (21;) lhtal impadious (12) (9) (ll.5) (14.4) (14.4) (19.5) (9) (10)
(3)
11/l li>tal impactious
CHEST I 104 I 4 I OCTOBER, 1993
1205
Table 2- Types of Foreign Bodies Found*
Table 4- Preexisting Disease- Gastrointestinal Tract*
Foreign Body
Pediatric
Adult
Meat Unspecified food Chicken hone Fish hone Meat/hone <.~>mbination Coins Miscellaneous Wire Barrette Tack Safety pin Beer bottle cap Upper plate Hard candy Fishing line
5 0
70 24
8 3 5 4 5 0 0 0
0 0 29 4 1
0 0 0 0 0
Proximal esophageal atresia Weblstricture/Schatzki's ring Hx impactions Hiatal hernia Nonesophageal GI disease Dysphagia >6 mo beli>re impaction Abnormal motility Neoplasia Esophagitis Ulceration Esophageal pouch
Pediatric
Adult
2
0 27 27 26 20 15 11 5 3 3 3
0 0
0 0 0 0 0
*Five other adults had various <.~nditions not classified in the above groups.
Schatzki's ring. Twenty-seven patients had a persistent history of impaction, and 26 had a history of hiatal hernia. Twenty patients had a history of nonesophageal gastrointestinal disease. Six patients reported experiencing dysphasia in the recent past (close to the time of impaction). Eleven adult patients had a history of some type of abnormal motility, while an addit!onal five had esophageal neoplasia. The sum of this tally (122) exceeds the number of patients (ll1) because of multiple abnormalities and symptoms in some of the patients. In the pediatric patients, two suffered from proximal esophageal atresia. Three other patients had a history of a web or a Schatzki's ring, nonesophageal gastrointestinal disease, and/or dysphasia. Thirty-four of the pediatric patients had no known gastrointestinal tract abnormality. Most of the patients, both pediatric and adult, sought medical attention within 6 h of the time of impaction (Table 5). In the pediatric population, 83 percent of the patients were referred within the first 24 h after impaction, whereas 89 percent of the adults sought care within the first 48 h. A significant minority of the patients in both groups waited beyond 48 h before seeking initial therapy. Although these patients
presented for treatment greater than 48 h after the impaction occurred, there was no difference in their final outcome when compared with those who sought treatment earlier. They also did not suffer a higher Incidence of complications. In both pediatric and adult cases, esophagoscopy was the treatment of choice (Table 6). Of the pediatric patients, 32 of 34 attempts at esophagoscopy were successful. Of the seven patients treated by other means, four had the impaction removed by laryngopharyngoscopy, two patients had resolution with observation alone, and one patient underwent surgery. In the patients who had rigid esophagoscopy, ten attempts were successful. Flexible esophagoscopy was successful in one patient. In our analysis of the remaining 23 patients, esophagoscopy was carried out, but it could not be determined whether it was flexible or rigid . In 21 of these 23 patients, the esophagoscopy was successful. In six children, different types of mechanical procedures were unsuccessfully attempted prior to esophagoscopy. In three patients, there were unsuccessful attempts at dislodgment of the foreign body by use of a Foley catheter. Two patients had undergone the Heimlich maneuver without successful dislodgment of the foreign body. One patient was inverted and shaken, but the foreign body did not dislodge. All six patients were then successfully treated with esophagoscopy.
Table 3-Location of Impaction in the Esophagus When Extracted*
Table 5- Time to Definitive Consultation for Each Episode of Impaction
*The totals are greater than the number of impactions since multiple objects were found' in seven patients.
Loc~tion
in the Esophagus
Upper third Middle third Lower third
Pediatric, No. (%)
Adult, No. (%)
Hours
Pediatric, No. (%)
Adult, No. (%)
31 (84) 4 (11)
47 (39) lO (8)
24 (67) 2 (6)
68 (58)
_g____@ 37
63 (53)
0-6 7-12 13-23 24-36 37-48 49+
120
*Note: The total of 37 li>r impactions in pediatric patients is 2 less than the total number of impactions since one pediatric patient had multiple sites of impaction and another patient had no location specified in the chart. 1n the adult patients, 6 of 114 had 2 sites identified for a total of 120.
1206
3 (*) 1 (3) ....§.J!1l 36
19 7 9 4
(16) (6) (8) (3)
!.L..(ill 118
*Note: In the pediatric group, 3 of the 39 did not have sufficient data to document the time interval. Management of Esophageal Impactions {Blair et e/)
Table 6- Treatment of Esophageal Impactions (Successful/Total AUempts)
lhtal t•sopha)!;osmpy Ri)!;id Flexihle Unspecified Laryng<>pharyng<>s<.,>p)· Observation Surgery Glucagon Papain Foley cathe ter Heimlich Shaking
Pediatric
Adult
32134
104/109
10110 111
37137 17122 50150 214 7fi
21123 4/4 212 Ill
Ill
3125 1/3 013
013
012 011
012
In the adult patients, esophagoscopy was conducted successfully in 104 of 109 attempts. Rigid esophagoscopy was successful in all 37 known cases, whereas flexible esophagoscopy was successful in 17 of 22 cases; in 50 episodes, esophagoscopy was conducted, but documentation was not provided about whether a flexible or a rigid instrument was used . Laryngopharyngoscopy was conducted successfully in two of four instances; the impaction was near the esophageal introitus in two of these cases. Other modes of therapy were attempted in some of the adult patients, with differing degrees of success. The impaction passed successfully with observation in seven patients. Surgery was conducted in one patient with successful removal of the foreign body and relief of the impaction. Glucagon therapy was successful in only three of25 attempts. Papain therapy was used in three patients, with one successful treatment. Foley catheter dislodgment was tried in three patients, but was unsuccessful in all. The Heimlich maneuver, performed in two patients, also met with no success. There was a total of seven complications. There was only one pediatric complication, for which reintubation was required when the endotracheal tube became dislodged during esophagoscopy. In the six adult cases, the complications were more significant. In one patient, the equipment malfunctioned and flexible endoscopy could not be completed. In another patient, the impaction was missed during the initial esophagoscopy, and radiographic information provided a false negative . The patient returned in approximately 12 h to undergo successful treatment for an esophageal impaction. Three adult patients required thoracotomies for complications related to the impaction. After an unsuccessful endoscopic attempt created an esophageal perforation, one patient underwent thoracotomy for foreign body removal and repair of esophageal injury. Surgical treatment was successful and the patient was discharged well from the hospital. In another patient, a thoracotomy was required for repair
of a perforation after successful foreign body removal by endoscopy. A third patient required a thoracotomy for perforation after multiple esophageal endoscopies and dilatations were attempted. The patient suffered an acute perioperative myocardial infarction and died of complications of the myocardial infarction ·within 48 h of successful repair of the esophageal perforation. Of the two perforations that occurred at our institution, it could not be determined whether these were caused by the foreign body or the endoscope. DISCUSSION
Material retained in the esophagus generally falls into two categories: foreign bodies and food. Meat and bones generally are the most frequent causes among adults, 1. 2 while pediatric cases are most often from coins and other foreign objects. 1•3 An interesting empirical correlation can be drawn between the frequency of meat or bone impactions and the location of the institution where the series was collected. Those centers in or near coastal cities had higher incidences of bone impactions, often caused by fish bones.u~ In contrast, meat impactions predominated our series as well as series from other inland institutions. 1•3 Thus, it may be that the proportion of foodrelated impactions seen at a given institution correlates with the specific diet of the population in the vicinity of the treating institution. Some series from other countries have reported a relatively high incidence of coins impacted in adult patients. 2 •6 Preexisting physical and mental conditions may predispose patients, particularly adults, toward retaining food and foreign bodies in the esophagus. Dentures are associated with esophageal foreign body impaction.' TaylorH reported that, in patients over the age of 60 years who retain esophageal material, 75 percent had some sort of dental appliance. Conversely, Phillipps and Patel9 found that the use of dentures in an adult population with food impacted in the esophagus was less than the national average. Mental disorders were present in 2.3 percent of patients with esophageal impaction. 9 The location of the impaction in the esophagus reflects the age group and type of ingested material. The majority of pediatric patients had foreign bodies lodged in the upper esophagus; coins and other nonfood items were the most common objects found. In our adult cases, the lower third of the esophagus was the most common site of esophageal impaction. Thus, the most common area for esophageal disease was found to coincide with the area of impaction in most adults. The large number of strictures, hiatal hernias, and dysphagia present before the occurrence of impaction further supports a role of distal esophageal disease in the incidence of esophageal impaction. Others have drawn similar conclusions from an apCHEST I 104 I 4 I OCTOBER, 1993
1207
praisal of their data .9- 11 Most of the foreign bodies found in the pediatric patients of our series were ingested accidentally. Only four pediatric patients had some type of food present, the majority having foreign bodies. Tavern games (in which coins were used) were responsible for many of the adult foreign bodies. A few other patients used their teeth to open bottles, crush hard candy, or to manipulate other items, which found their way to the esophagus and became lodged. This relatively low incidence of foreign bodies in the adult esophagus is quite comparable to other published series from the North American literature. Jackson 10 is credited with one of the first large series demonstrating a high success rate with relatively few complications using esophagoscopy. Although few series report no complications, the entire gamut of possible complications has been reported; perforation, mediastinitis, fistulas, and aspiration pneumonia. Perforation rates are generally low, but reported incidences are variable. Brooks3 reported a high complication rate in a small series, 3 of 26 patients treated with esophagoscopy. In larger series, lower perforation rates of 6 percent have been reported for patients treated with esophagoscopy. '- 9 Although several different modalities of therapy were attempted by physicians at our institution, the vast number of patients were treated by some form of endoscopy. Removal of the esophageal foreign bodies was successful in the majority of cases. Similar results have been reported by other authors. 1·3 •5 •7 • 11 · 13 Our experience with Foley catheter dislodgment of esophageal foreign bodies and papain therapy for ingested meat was rather small. Despite the poor results in achieving foreign body removal, there were no perforations of the esophagus or necrotizing pneumonia due to papain therapy, and no complications from attempts at dislodgment with Foley catheter. Although Foley catheter dislodgment has been championed by some individuals, 14.1 5 our series is too small to compare with these other studies. We have discontinued using papain therapy, since incidences of necrotizing pneumonia and esophageal perforation present too great a risk with papain use . 1 ~>- 1 H Few individuals have reported successful treatment of esophageal foreign bodies with glucagon therapy. 19 ·20 In our experience, glucagon therapy achieved only a 12 percent success rate. Thus in our experience, glucagon administration is not very effective in treating esophageal foreign body impactions. Others advocate some form of gas-forming agent used to expand the esophagus. 21 We have no experience with this therapeutic approach. Observation was successful in allowing two pediatric and seven adult patients to pass their foreign bodies without any intervention. Although observation may 1208
be successful in some instances, we do not suggest this therapy at the current time since our success with endoscopy has heen good. Observation allows the patient's esophagus to continue to contract against the ingested foreign body and offers the potential for further erosion and possible perforation. Our success rate with endoscopic removal was extremely high , with a perforation rate of less than 2 percent. Other complications were relatively inconsequential. Our success rate was greater than 90 percent of those patients who received attempted esophageal foreign body removal by endoscopy. Success rates comparable to this have been published in a number of other reports. 1·4· 7 ·9 A high success rate coupled with low failure and perforation rates suggest that endoscopy should he the preferred method of treatment for esophageal impactions, in both adult and pediatric cases. Endoscopic examination may also allow the identification of underlying pathology that might be responsible for the impaction event. Our preference is to use rigid esophagoscopy since the larger instrument allows removal of most objects without withdrawing the endoscope. Also pieces of food may he removed in parts by large grasping forceps employed through the central lumen. If close inspection is necessary after removal of the foreign body, a flexible instrument with its fiberoptic capabilities may be employed. REFERENCES
1 Giordano A, Adams G, Boies L Jr, Meyerhoff W Current management of esophageal foreign bodies. Arch Otol 1981; 107:249-51 2 Olnwole F. Foreign body impaction in the esophagus: a review of ten years' experience in a teaching hospital. J Natl Med Assoc 1986; 78:987-90 3 Brooks J. Foreign bodies in the air and fond passages. Ann Surg 1972; 175:720-32 4 Selivanov V, Sheldon G, Cello J, Crass R. Management offoreign body ingestion. Ann Surg 1984; 51 :173-79 .'5 Nardi P. Ong GB. Foreign body in the esophagus: review of 2 ,394 cases. Br J Surg 1978; 65:.'5-9 6 Yadov SPS, Kohli GS, Goelll, Gulah SP. Bolder R, Chaula RK . Foreign bodies in the oesophagus. Indian J Chest Dis All Sci 1987; 29:94-7 7 Webb W, McDaniel L, Jones L. Foreign bodies of the upper gastrointestinal tract: current management. South Med J 1984; 77:1083-86 8 Taylor R. Esophageal fcneign bodies. Emerg Med Clin North Am 1987; .'5:301-11 9 Phillips JJ, Patel P. Swallowed fc1reign bodies. J Laryngol Otol 1988; 102:235-41 10 Jackson CL. Foreign bodies of the esophagus. Am J Surg 19.'57; 93:308-12 11 Bloom R, Nakano P. Gray S, Skandalakis J. Foreign bodies of the gastrointestinal tract. Am Snrg 1986; .'52:618-21 12 Chaikhorini A, Kratz J, Crawfc>rd F. Foreign bodies of the esophagus. Am Snrg 198.'5; .'51:173-79 13 Buchin P. Foreign bodies of the esophagus. NY State Med J 1981; 81:10.'57-.'59 14 Bigler FC. The use of a Fc1ley catheter for removal of blunt Management of Esophageal Impactions (Blair et a/J
15 16 17
18
foreign bodies from the esophagns. J Thorac Cardiovasc Sur~ 1966; 51:759-60 Campbell JB, Condon VR. Catheter removal ofhlnnt esopha~eal foreign bodies in children. Pediatr Radio! 1989; 19:361-65 Richardson JR. A new treatment for esophageal obstruction due to meat impaction. Ann Otol RhinoVLaryn~oll945; 54:328-48 Andersen HA, Bernarz PE . Grindloy JH . Perforation of the esophagns after use of digestant agent. Ann Rhinol Pneumo Laryngol 1959; 68:890-96 Holsinger JW, Fuson RL, Sealy WP. Esopha~eal perforation
following meat impaction and papain in~estion . JAMA 204:18889 19 Hall ML, Hosehy JS. Hemorrhagic pulmonary edema associated with meat tenderizer: treatment for esophageal meat impaction. Chest 1988; 94:640-42 20 Ferruci JT, Long JA Jr. Radiologic treatment of esophageal food impaction using intravenous glucagon. Radiology 1983; 149:60102 21 Wehb WA. Management of foreign bodies of the upper gastrointestinal tract. Gastroenterol1988; 94:204-16
Thoracoscopy Society A Thoracoscopy Society is being fonned to provide ongoing discussions regarding the indications, technical aspects and complications associated with thoracoscopy. This society will become a working group to help address ongoing issues related to this procedure. Any individual interested in participating in this group should please contact either of the following: William J. Martin II, M.D . or Praveen Mathur, M.B.B.S., Division of Pulmonary and Critical Care Medicine, Indiana University Medical Center, 1001 West lOth Street OPW 425, Indianapolis, IN 46202-2879; 317-630-8445; fax : 317-630-6386. Both Drs. Martin and Mathur can also be contacted at the ACCP annual meeting in Orlando in October, 1993.
CHEST I 104 I 4 I OCTOBER, 1993
1209
there was only one complication. Other forms of therapy that were infrequently tried met with variable results. Esophagoscopy was successful in removing the impaction in 104 of 109 attempts in adults. Two perforations occurred, with one resulting in death. Various other methods achieved success in the remaining patients. The data suggest that esophageal impaction can be treated successfully by endoscopy with very low morbidity and mortality. (Chest 1993; 104:1205-09)
impaction is a relatively uncommon but E sophageal consistently encountered clinical problem. Sev-
the distribution was fairly uniform, with a slightly higher frequency for the 61- to 70-year-old category. In the patients younger than 12 years of age, the male to female ratio was 1.6:1. In the adult patients, the male to female ratio was 1. 7:1. In the pediatric cases more foreign objects were found in the esophagus, most often coins. The adults generally had some type of impacted food, most commonly meat (Table 2). Coins and some of the foreign bodies found in the adult esophagi were often a result of tavern games' and unusual events. Patients with a history of psychiatric illness had some unusual items found in the esophagus. In pediatric cases, foreign bodies were fi.mnd most often in the upper third of the esophagus (84 percent). In the adult patients, esophageal impaction occurred more commonly in the distal esophagus (53 percent) (Table 3). Preexisting distal esophageal disease accounted for the larger number of impactions in the distal esophagus of the adults (Table 4). There were 27 patients that had either a web, a stricture, or a
eral different therapeutic methods exist for treating these impactions, which include direct papain or carbonated fluid treatment, glucagon therapy, Foley catheter removal, and endoscopically guided methods. Since its introduction, the endoscopic approach to resolution has heen very successful; however, the reported incidence of complications has given reason to exercise caution in its employment. This retrospective study was conducted to evaluate our success with all modalities to remove esophageal impactions and to document our complications and mortalities. METHODS Our series evaluated the dini<:al fi.·atures of and treatments f<>r body impadions in patients seen at our institution from 1977 throu~h 1990. The dia~nosis in all eases was t11nnrmed by endoseop)~ radio~raphie proeedures, or both. After treatment, efforts were m;ult• to maintain posthospital snrveillanet• to dt·termine the ellieaey of therapy, to ascertain the ineidenee ofn><:nrrenee, ami to t11rrdate the inddenee with predisposin~ ~astroinll'stinal and systemie disease . f<>rei~n
Table I - Age Distribution of Impactions
RESULTS
There were 150 patients: 39 pediatric cases, each with one episode of impaction, and 111 adult patients, with a total of 118 impactions (7 repeated impactions; none of the patients had more than 2 impactions). In the pediatric patients, there was a uniform distribution among the three age groups (Table I). In the adults, *From the Dt•partments of Sur~ery, Baylor Colle~e of Medidne (Dr. Blair), Houston, and the \Vest \'ir~inia University Sehool of Mt•dicine (Drs. Craeber, Cruzzavala, Custafson, Hill , \Varden, and Murray), Mor~antown . Manuseript received Decembe r 21l. 1992; revision aeeepted Februarv 23 , 1993. Rt•prlut rl'qw•sts: Dr. Grtwbt'l; Dqmrtnwut of Sw·gay, PO Box 92.38 , Uht Virgiuiu Uuivn.•ily HSC.\', Morguutorm, WV 26.50692.'38
Age, yr Pediatric
Adults
0-2 3-6 4-ll 12-20 21-30 31-40 41-50 .'51-60 61-70 71-1!0 lll-90 91-100
No . (%)
17 ll ll 39 14 ll 10 17 17 2.3 ll 12 3
(44)
(21l) (21;) lhtal impadious (12) (9) (ll.5) (14.4) (14.4) (19.5) (9) (10)
(3)
11/l li>tal impactious
CHEST I 104 I 4 I OCTOBER, 1993
1205
Table 2- Types of Foreign Bodies Found*
Table 4- Preexisting Disease- Gastrointestinal Tract*
Foreign Body
Pediatric
Adult
Meat Unspecified food Chicken hone Fish hone Meat/hone <.~>mbination Coins Miscellaneous Wire Barrette Tack Safety pin Beer bottle cap Upper plate Hard candy Fishing line
5 0
70 24
8 3 5 4 5 0 0 0
0 0 29 4 1
0 0 0 0 0
Proximal esophageal atresia Weblstricture/Schatzki's ring Hx impactions Hiatal hernia Nonesophageal GI disease Dysphagia >6 mo beli>re impaction Abnormal motility Neoplasia Esophagitis Ulceration Esophageal pouch
Pediatric
Adult
2
0 27 27 26 20 15 11 5 3 3 3
0 0
0 0 0 0 0
*Five other adults had various <.~nditions not classified in the above groups.
Schatzki's ring. Twenty-seven patients had a persistent history of impaction, and 26 had a history of hiatal hernia. Twenty patients had a history of nonesophageal gastrointestinal disease. Six patients reported experiencing dysphasia in the recent past (close to the time of impaction). Eleven adult patients had a history of some type of abnormal motility, while an addit!onal five had esophageal neoplasia. The sum of this tally (122) exceeds the number of patients (ll1) because of multiple abnormalities and symptoms in some of the patients. In the pediatric patients, two suffered from proximal esophageal atresia. Three other patients had a history of a web or a Schatzki's ring, nonesophageal gastrointestinal disease, and/or dysphasia. Thirty-four of the pediatric patients had no known gastrointestinal tract abnormality. Most of the patients, both pediatric and adult, sought medical attention within 6 h of the time of impaction (Table 5). In the pediatric population, 83 percent of the patients were referred within the first 24 h after impaction, whereas 89 percent of the adults sought care within the first 48 h. A significant minority of the patients in both groups waited beyond 48 h before seeking initial therapy. Although these patients
presented for treatment greater than 48 h after the impaction occurred, there was no difference in their final outcome when compared with those who sought treatment earlier. They also did not suffer a higher Incidence of complications. In both pediatric and adult cases, esophagoscopy was the treatment of choice (Table 6). Of the pediatric patients, 32 of 34 attempts at esophagoscopy were successful. Of the seven patients treated by other means, four had the impaction removed by laryngopharyngoscopy, two patients had resolution with observation alone, and one patient underwent surgery. In the patients who had rigid esophagoscopy, ten attempts were successful. Flexible esophagoscopy was successful in one patient. In our analysis of the remaining 23 patients, esophagoscopy was carried out, but it could not be determined whether it was flexible or rigid . In 21 of these 23 patients, the esophagoscopy was successful. In six children, different types of mechanical procedures were unsuccessfully attempted prior to esophagoscopy. In three patients, there were unsuccessful attempts at dislodgment of the foreign body by use of a Foley catheter. Two patients had undergone the Heimlich maneuver without successful dislodgment of the foreign body. One patient was inverted and shaken, but the foreign body did not dislodge. All six patients were then successfully treated with esophagoscopy.
Table 3-Location of Impaction in the Esophagus When Extracted*
Table 5- Time to Definitive Consultation for Each Episode of Impaction
*The totals are greater than the number of impactions since multiple objects were found' in seven patients.
Loc~tion
in the Esophagus
Upper third Middle third Lower third
Pediatric, No. (%)
Adult, No. (%)
Hours
Pediatric, No. (%)
Adult, No. (%)
31 (84) 4 (11)
47 (39) lO (8)
24 (67) 2 (6)
68 (58)
_g____@ 37
63 (53)
0-6 7-12 13-23 24-36 37-48 49+
120
*Note: The total of 37 li>r impactions in pediatric patients is 2 less than the total number of impactions since one pediatric patient had multiple sites of impaction and another patient had no location specified in the chart. 1n the adult patients, 6 of 114 had 2 sites identified for a total of 120.
1206
3 (*) 1 (3) ....§.J!1l 36
19 7 9 4
(16) (6) (8) (3)
!.L..(ill 118
*Note: In the pediatric group, 3 of the 39 did not have sufficient data to document the time interval. Management of Esophageal Impactions {Blair et e/)
Table 6- Treatment of Esophageal Impactions (Successful/Total AUempts)
lhtal t•sopha)!;osmpy Ri)!;id Flexihle Unspecified Laryng<>pharyng<>s<.,>p)· Observation Surgery Glucagon Papain Foley cathe ter Heimlich Shaking
Pediatric
Adult
32134
104/109
10110 111
37137 17122 50150 214 7fi
21123 4/4 212 Ill
Ill
3125 1/3 013
013
012 011
012
In the adult patients, esophagoscopy was conducted successfully in 104 of 109 attempts. Rigid esophagoscopy was successful in all 37 known cases, whereas flexible esophagoscopy was successful in 17 of 22 cases; in 50 episodes, esophagoscopy was conducted, but documentation was not provided about whether a flexible or a rigid instrument was used . Laryngopharyngoscopy was conducted successfully in two of four instances; the impaction was near the esophageal introitus in two of these cases. Other modes of therapy were attempted in some of the adult patients, with differing degrees of success. The impaction passed successfully with observation in seven patients. Surgery was conducted in one patient with successful removal of the foreign body and relief of the impaction. Glucagon therapy was successful in only three of25 attempts. Papain therapy was used in three patients, with one successful treatment. Foley catheter dislodgment was tried in three patients, but was unsuccessful in all. The Heimlich maneuver, performed in two patients, also met with no success. There was a total of seven complications. There was only one pediatric complication, for which reintubation was required when the endotracheal tube became dislodged during esophagoscopy. In the six adult cases, the complications were more significant. In one patient, the equipment malfunctioned and flexible endoscopy could not be completed. In another patient, the impaction was missed during the initial esophagoscopy, and radiographic information provided a false negative . The patient returned in approximately 12 h to undergo successful treatment for an esophageal impaction. Three adult patients required thoracotomies for complications related to the impaction. After an unsuccessful endoscopic attempt created an esophageal perforation, one patient underwent thoracotomy for foreign body removal and repair of esophageal injury. Surgical treatment was successful and the patient was discharged well from the hospital. In another patient, a thoracotomy was required for repair
of a perforation after successful foreign body removal by endoscopy. A third patient required a thoracotomy for perforation after multiple esophageal endoscopies and dilatations were attempted. The patient suffered an acute perioperative myocardial infarction and died of complications of the myocardial infarction ·within 48 h of successful repair of the esophageal perforation. Of the two perforations that occurred at our institution, it could not be determined whether these were caused by the foreign body or the endoscope. DISCUSSION
Material retained in the esophagus generally falls into two categories: foreign bodies and food. Meat and bones generally are the most frequent causes among adults, 1. 2 while pediatric cases are most often from coins and other foreign objects. 1•3 An interesting empirical correlation can be drawn between the frequency of meat or bone impactions and the location of the institution where the series was collected. Those centers in or near coastal cities had higher incidences of bone impactions, often caused by fish bones.u~ In contrast, meat impactions predominated our series as well as series from other inland institutions. 1•3 Thus, it may be that the proportion of foodrelated impactions seen at a given institution correlates with the specific diet of the population in the vicinity of the treating institution. Some series from other countries have reported a relatively high incidence of coins impacted in adult patients. 2 •6 Preexisting physical and mental conditions may predispose patients, particularly adults, toward retaining food and foreign bodies in the esophagus. Dentures are associated with esophageal foreign body impaction.' TaylorH reported that, in patients over the age of 60 years who retain esophageal material, 75 percent had some sort of dental appliance. Conversely, Phillipps and Patel9 found that the use of dentures in an adult population with food impacted in the esophagus was less than the national average. Mental disorders were present in 2.3 percent of patients with esophageal impaction. 9 The location of the impaction in the esophagus reflects the age group and type of ingested material. The majority of pediatric patients had foreign bodies lodged in the upper esophagus; coins and other nonfood items were the most common objects found. In our adult cases, the lower third of the esophagus was the most common site of esophageal impaction. Thus, the most common area for esophageal disease was found to coincide with the area of impaction in most adults. The large number of strictures, hiatal hernias, and dysphagia present before the occurrence of impaction further supports a role of distal esophageal disease in the incidence of esophageal impaction. Others have drawn similar conclusions from an apCHEST I 104 I 4 I OCTOBER, 1993
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praisal of their data .9- 11 Most of the foreign bodies found in the pediatric patients of our series were ingested accidentally. Only four pediatric patients had some type of food present, the majority having foreign bodies. Tavern games (in which coins were used) were responsible for many of the adult foreign bodies. A few other patients used their teeth to open bottles, crush hard candy, or to manipulate other items, which found their way to the esophagus and became lodged. This relatively low incidence of foreign bodies in the adult esophagus is quite comparable to other published series from the North American literature. Jackson 10 is credited with one of the first large series demonstrating a high success rate with relatively few complications using esophagoscopy. Although few series report no complications, the entire gamut of possible complications has been reported; perforation, mediastinitis, fistulas, and aspiration pneumonia. Perforation rates are generally low, but reported incidences are variable. Brooks3 reported a high complication rate in a small series, 3 of 26 patients treated with esophagoscopy. In larger series, lower perforation rates of 6 percent have been reported for patients treated with esophagoscopy. '- 9 Although several different modalities of therapy were attempted by physicians at our institution, the vast number of patients were treated by some form of endoscopy. Removal of the esophageal foreign bodies was successful in the majority of cases. Similar results have been reported by other authors. 1·3 •5 •7 • 11 · 13 Our experience with Foley catheter dislodgment of esophageal foreign bodies and papain therapy for ingested meat was rather small. Despite the poor results in achieving foreign body removal, there were no perforations of the esophagus or necrotizing pneumonia due to papain therapy, and no complications from attempts at dislodgment with Foley catheter. Although Foley catheter dislodgment has been championed by some individuals, 14.1 5 our series is too small to compare with these other studies. We have discontinued using papain therapy, since incidences of necrotizing pneumonia and esophageal perforation present too great a risk with papain use . 1 ~>- 1 H Few individuals have reported successful treatment of esophageal foreign bodies with glucagon therapy. 19 ·20 In our experience, glucagon therapy achieved only a 12 percent success rate. Thus in our experience, glucagon administration is not very effective in treating esophageal foreign body impactions. Others advocate some form of gas-forming agent used to expand the esophagus. 21 We have no experience with this therapeutic approach. Observation was successful in allowing two pediatric and seven adult patients to pass their foreign bodies without any intervention. Although observation may 1208
be successful in some instances, we do not suggest this therapy at the current time since our success with endoscopy has heen good. Observation allows the patient's esophagus to continue to contract against the ingested foreign body and offers the potential for further erosion and possible perforation. Our success rate with endoscopic removal was extremely high , with a perforation rate of less than 2 percent. Other complications were relatively inconsequential. Our success rate was greater than 90 percent of those patients who received attempted esophageal foreign body removal by endoscopy. Success rates comparable to this have been published in a number of other reports. 1·4· 7 ·9 A high success rate coupled with low failure and perforation rates suggest that endoscopy should he the preferred method of treatment for esophageal impactions, in both adult and pediatric cases. Endoscopic examination may also allow the identification of underlying pathology that might be responsible for the impaction event. Our preference is to use rigid esophagoscopy since the larger instrument allows removal of most objects without withdrawing the endoscope. Also pieces of food may he removed in parts by large grasping forceps employed through the central lumen. If close inspection is necessary after removal of the foreign body, a flexible instrument with its fiberoptic capabilities may be employed. REFERENCES
1 Giordano A, Adams G, Boies L Jr, Meyerhoff W Current management of esophageal foreign bodies. Arch Otol 1981; 107:249-51 2 Olnwole F. Foreign body impaction in the esophagus: a review of ten years' experience in a teaching hospital. J Natl Med Assoc 1986; 78:987-90 3 Brooks J. Foreign bodies in the air and fond passages. Ann Surg 1972; 175:720-32 4 Selivanov V, Sheldon G, Cello J, Crass R. Management offoreign body ingestion. Ann Surg 1984; 51 :173-79 .'5 Nardi P. Ong GB. Foreign body in the esophagus: review of 2 ,394 cases. Br J Surg 1978; 65:.'5-9 6 Yadov SPS, Kohli GS, Goelll, Gulah SP. Bolder R, Chaula RK . Foreign bodies in the oesophagus. Indian J Chest Dis All Sci 1987; 29:94-7 7 Webb W, McDaniel L, Jones L. Foreign bodies of the upper gastrointestinal tract: current management. South Med J 1984; 77:1083-86 8 Taylor R. Esophageal fcneign bodies. Emerg Med Clin North Am 1987; .'5:301-11 9 Phillips JJ, Patel P. Swallowed fc1reign bodies. J Laryngol Otol 1988; 102:235-41 10 Jackson CL. Foreign bodies of the esophagus. Am J Surg 19.'57; 93:308-12 11 Bloom R, Nakano P. Gray S, Skandalakis J. Foreign bodies of the gastrointestinal tract. Am Snrg 1986; .'52:618-21 12 Chaikhorini A, Kratz J, Crawfc>rd F. Foreign bodies of the esophagus. Am Snrg 198.'5; .'51:173-79 13 Buchin P. Foreign bodies of the esophagus. NY State Med J 1981; 81:10.'57-.'59 14 Bigler FC. The use of a Fc1ley catheter for removal of blunt Management of Esophageal Impactions (Blair et a/J
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foreign bodies from the esophagns. J Thorac Cardiovasc Sur~ 1966; 51:759-60 Campbell JB, Condon VR. Catheter removal ofhlnnt esopha~eal foreign bodies in children. Pediatr Radio! 1989; 19:361-65 Richardson JR. A new treatment for esophageal obstruction due to meat impaction. Ann Otol RhinoVLaryn~oll945; 54:328-48 Andersen HA, Bernarz PE . Grindloy JH . Perforation of the esophagns after use of digestant agent. Ann Rhinol Pneumo Laryngol 1959; 68:890-96 Holsinger JW, Fuson RL, Sealy WP. Esopha~eal perforation
following meat impaction and papain in~estion . JAMA 204:18889 19 Hall ML, Hosehy JS. Hemorrhagic pulmonary edema associated with meat tenderizer: treatment for esophageal meat impaction. Chest 1988; 94:640-42 20 Ferruci JT, Long JA Jr. Radiologic treatment of esophageal food impaction using intravenous glucagon. Radiology 1983; 149:60102 21 Wehb WA. Management of foreign bodies of the upper gastrointestinal tract. Gastroenterol1988; 94:204-16
Thoracoscopy Society A Thoracoscopy Society is being fonned to provide ongoing discussions regarding the indications, technical aspects and complications associated with thoracoscopy. This society will become a working group to help address ongoing issues related to this procedure. Any individual interested in participating in this group should please contact either of the following: William J. Martin II, M.D . or Praveen Mathur, M.B.B.S., Division of Pulmonary and Critical Care Medicine, Indiana University Medical Center, 1001 West lOth Street OPW 425, Indianapolis, IN 46202-2879; 317-630-8445; fax : 317-630-6386. Both Drs. Martin and Mathur can also be contacted at the ACCP annual meeting in Orlando in October, 1993.
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