Surg Endosc (2011) 25:919–922 DOI 10.1007/s00464-010-1299-0
Esophageal foreign body extraction in children: flexible versus rigid endoscopy Jillian Popel • Hamdy El-Hakim • Wael El-Matary
Received: 2 March 2010 / Accepted: 26 July 2010 / Published online: 24 August 2010 Ó Springer Science+Business Media, LLC 2010
Abstract Background Esophageal foreign body (FB) impaction is a common emergency in children. The goal of this study was to compare rigid versus flexible endoscopy in esophageal FB extraction in children. Methods In a retrospective cohort study with consecutive data, children with esophageal FB impaction who were admitted between January 2005 and December 2008 to the Stollery Children’s Hospital, Edmonton, Canada, were included. Nature of the procedure for FB removal (flexible vs. rigid endoscopy), duration of the procedure, complications, and associated pathology were documented. Results A total of 140 children were included (81 boys; mean age, 59.8 ± 48.6 (range, 4–203) months). More than half (54%) of patients were aged 3 years or younger. Coins were the most common foreign body (77.9%). Flexible endoscopy was used in 89 patients, rigid in 49, and both in 2 patients. The mean duration of the endoscopic procedure was 10.50 ± 12.2 minutes for FE (95% confidence interval (CI), 7.94–13.08) and 16.49 ± 21.1 minutes for RE (95% CI, 13.75–22.45; p = 0.04). Biopsies were taken in 19% of patients undergoing FE and in 6% of RE (p = 0.04). Conclusions Both rigid and flexible endoscopy techniques appear to be equally safe and effective in esophageal foreign
J. Popel Faculty of Medicine, University of Alberta, Edmonton, Canada H. El-Hakim Pediatric Otolaryngology & Head and Neck Surgery, Stollery Children’s Hospital, Edmonton, Canada W. El-Matary (&) Division of Pediatric Gastroenterology, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK e-mail:
[email protected]
body extraction. However, performing flexible endoscopy for esophageal foreign body takes a substantial shorter duration compared with rigid endoscopy. Flexible endoscopy would probably allow a better and more thorough examination and, hence, biopsying esophageal mucosa compared with rigid endoscopy. Keywords Children
Esophagus Foreign body Endoscopy
Due to their high level of curiosity, infants and children commonly place various objects in their mouth. These objects usually pass through the entire gastrointestinal tract (GI) with no complications; however, in approximately 20% of cases, intervention by physicians is required to remove these objects due to the size, shape, type of foreign body (FB), or underlying pathology in the patient [1]. According to data from the 2007 Annual Report of the American National Poison Data System, there were 3,908 cases of ingested coins, and 1,222 required treatment in a healthcare facility [2]. This report, along with many other studies, supports the notion that coins are the most common FB ingested by children [3], but virtually any objects that children encounter can become lodged in the esophagus. Retained esophageal foreign bodies can lead to many complications, such as esophageal perforation [4], stricture formation [5], esophageal-aortic fistula [6], tracheoesophageal fistula [7], respiratory distress with or without cyanosis [8], mediastinal infection [9], altered mental status [10], and the potential progression to death [11]. That is why esophageal FB must be removed without delay once the diagnosis is made [11]. Both rigid and flexible endoscopy techniques are used for removal of esophageal FBs, but there remains a great deal of controversy on which
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method is optimal [12]. Rigid endoscopy may be best for objects that are located in the hypopharynx and cricopharyngeus areas [13]. For objects located in other areas along the GI tract, flexible endoscopy is useful because it allows the visualization of the esophagus, stomach, and duodenum [1]. Flexible endoscopy also may be associated with a lower rate of complications, increased patient comfort, and a lack of requirement for general anesthesia [13]. Esophageal FB removal is performed by different subspecialties depending on the center policy. Pediatric surgeons, otolaryngologists, and gastroenterologists can be involved in esophageal FB extraction. At the Stollery Children’s Hospital, Edmonton, Alberta, esophageal FB removal is performed by both pediatric gastroenterologists (using flexible endoscopy) and otolaryngologists (using rigid endoscopy). The goal of this study was to examine our experience with esophageal foreign bodies and compare the two removal methods: flexible and rigid endoscopy.
Materials and methods Between January 2005 and December 2008, 140 children underwent foreign body removal from the esophagus at the Stollery Children’s Hospital in Edmonton, Alberta, Canada. At this center, the service of esophageal body removal is provided by both the Pediatric Gastroenterology Division and Pediatric Otolaryngology Unit. Each unit takes the responsibility of esophageal FB removal in children for 6 months per year. Patients’ medical records were reviewed for patient’s demographics, clinical presentation, duration of FB impaction, and location of foreign body. The initial intervention was flexible endoscopy (n = 87) performed by a pediatric gastroenterologist or rigid endoscopy (n = 51) performed by a pediatric otolaryngologist. Both methods were used in two patients. Data regarding duration of procedure, duration of hospitalization, success or failure of FB removal, complications, biopsies obtained, and any underlying pathology were examined. A ‘‘complication’’ was defined as any event with a negative impact on the subsequent course of the patient, including occurrence of esophageal strictures and/or tears.
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Data were analyzed using Stata 9.1TM (Data Analysis and Statistical Software, Texas, USA). Ethics The protocol of the study was approved by the Heath Ethics Research Board of the University of Alberta.
Results A total of 140 children (81 boys) were included to the study. The mean age was 59.8 ± 48.6 (range, 4–203) months. More than half (54%) of patients were aged 3 years or younger. In most patients (71%), the duration of FB impaction was B24 h (median, 14.5 (range, 2–504) h). In seven patients (5%), the duration of impaction was [7 days. The children presented with a wide variety of symptoms; however, 25 patients (17.7%) were asymptomatic. Drooling was the most common symptom (41.8%), followed by vomiting (27.7%; Fig. 1). FB nature Coins were the most common foreign body (77.9%), followed by food bolus impaction (12.9%). Other impacted foreign bodies included jewelry, safety pins, school supplies, batteries, and stones (9.2%). The size of foreign object was indicated in 109 (77.9%) patient records. Most objects (60.0%) were 16–24 mm in diameter. FB location in the esophagus The majority of foreign bodies were located in the upper third of the esophagus; 34 (24.2%) were located
Statistics Summaries (means, medians, ranges, and standard deviations (SDs)) were obtained for continuous variables, and frequency distributions were provided for categorical variables. For normally distributed data, unpaired t test was used to compare continuous variables. A two-sample proportion test was used to compare dichotomous variables. A significance level of 0.05 was used for all tests performed.
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Fig. 1 Presenting symptoms in 140 children with esophageal FB impaction
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specifically at the level of the cricopharyngeus, and 58 (41.4%) were located elsewhere in the upper esophagus. The lower esophagus was the next most common site of impaction with 27 (19.3%) foreign bodies identified in this location. The least number of foreign bodies was located in the middle third of the esophagus (14.3%). Flexible endoscopy (FE) was used in 87 (62.1%) patients, rigid endoscopy (RE) in 51 (36.4%) patients, and both methods were used in 2 (1.4%) patients. Successful foreign body removal was accomplished in 125 patients, 13 foreign bodies were pushed into the stomach, and 2 foreign bodies were not amenable to removal. In these two patients, rigid endoscopy was initially attempted followed by flexible endoscopy with no success. Both patients needed surgical intervention to remove FB. Duration of procedure and hospitalization The mean duration of the endoscopic procedure was 10.5 ± 16.2 min for FE (95% confidence interval (CI), 7.94–13.08) and 16.4 ± 21.1 min for RE (95% CI, 13.75–22.45; p = 0.04). The duration of hospital stay was 12 h or less in 65% of patients. Most patients (92%) were discharged within 24 h. The mean duration of hospitalization was 13.6 ± 27.9 h for FE (95% CI, 7.72–19.48) and 15.0 ± 28.9 h for RE patients (95% CI, 6.7–23.3; p = 0.39). Associated pathology Biopsies were taken in 17 (95% CI, 13–21) of the 89 (19%) children who had FE, and 3 (95% CI, 1.28–4.72) of the 49 (6%) patients who had RE. These results are statistically significant (p = 0.04). Biopsies were taken if the endoscopists felt that there was an abnormality in esophageal appearance during endoscopy. This is probably a reflection of easier and more thorough examination in flexible endoscopy compared with rigid endoscopy. In total, biopsies were taken in 20 patients. Eosinophilic esophagitis was diagnosed on histological examination in 12 of 20 patients (60%) who had biopsies taken. Of those, eight (66.7%) had food impaction and four (33.3%) had coins. Of the patients with normal histology, three (37.5%) had food impaction and five (62.5%) had coins. Complications Three patients had esophageal strictures at the time of endoscopy. Interestingly, these patients had FB impaction greater than 48 h (49, 147 h, and 168 h). It was difficult to know whether the stricture was there and had lead to FB impaction or had developed as a complication of FB impaction. However, the relative short time of FB
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impaction suggested that stricture was probably there before FB ingestion. One FB was removed using flexible endoscopy, and the other two were removed using the rigid one.
Discussion The majority of foreign body ingestions occur in the pediatric population with a peak incidence between ages 6 months and 6 years. In adults, true foreign object ingestion occurs more commonly among those with psychiatric disorders or severe developmental delay [1, 14]. The symptoms of foreign body ingestion in our series were similar to those reported in other series [15]; the most frequent signs and symptoms were drooling, vomiting, chest discomfort, and dysphagia. Similar to many largescale case reports/series was the predominance of coins as esophageal foreign bodies [15]. The location of the coin is an important factor for both management and overall outcome. The majority of the coins in our patients were found to be located in the upper esophagus (65.6%). This is in agreement with other series showing that 60–70% will impact at the upper esophageal sphincter region [13]. Several methods have been described for esophageal FB removal, including esophageal bougienage, the use of Foley catheter, and the use of flexible and rigid endoscopy [16]. At the Stollery Children’s Hospital, Edmonton, Alberta, both rigid and flexible endoscopy techniques are used for esophageal FB extraction. Gmeiner et al. examined 139 patients (median age, 64 years) with esophageal FB impaction during a period of 6 years [12]. Flexible endoscopy was used in 76 patients, whereas the rest had their FB removed with rigid endoscopy. Both techniques were equally successful; however, 3.2% of those who had rigid endoscopy experienced esophageal rupture that needed surgical intervention. On the other hand, none of those who had flexible endoscopy experienced any major complications [12]. Patients who had flexible endoscopy were more comfortable and experienced less postoperative dysphagia compared with those who had rigid endoscopy. It is difficult to know whether this finding was due to the difference in the scope used or the difference in anesthesia, because rigid endoscopy, contrary to the majority of flexible endoscopy, was undertaken using general anesthesia [12]. Based on these results, the authors recommend flexible endoscopy as the first choice for esophageal FB extraction [12]. In the present study, none of our patients suffered major complications secondary to the therapeutic procedure itself. Moreover, surgical skills can be a significant confounder that may affect the complication rate. Age difference between the two series should be taken into
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consideration when the results of both studies are compared. Similar to our study, Berggreen et al. reviewed 192 cases of FB in children and adults where both the FE and RE were used. Success rates between the two methods were not significantly different [17]. Cheng and Tam published their experience in children with FB ingestion. Similar to our series, coins were the most commonly ingested FB [13]. Flexible endoscopy allows better examination of esophageal mucosa [14, 18]. This was reflected on our study as there was a substantial difference in the number of patients who had esophageal biopsies between the two groups. This may reflect the different expertise involved; gastroenterologists will by virtue of training be more adept at inspecting the mucosa and identifying abnormalities, thereby contemplating the performance of biopsies. Normally biopsies would not be taken unless there was an esophageal abnormality that was seen by the endoscopists. Because one third of patients with eosinophilic esophagitis would have no esophageal morphological abnormality [19], one can assume that these patients would have been missed. Limitations of our study include the retrospective nature of data collection and the basis for choice of the procedure. However, the choice of the procedure was purely made on the timing of the presentation according to the protocol of our center. Patients, who present on the days when pediatric otolaryngologists are responsible for esophageal FB removal will receive RE, whereas those who present when pediatric gastroenterologists are responsible for esophageal FB removal will receive FE. Sample size can be another limitation of the present study. However, for a singlecenter pediatric study, the sample size seemed reasonable, although proper sample size and power analysis is lacking.
Conclusions Both rigid and flexible endoscopy techniques are equally effective and safe for esophageal FB extraction. However, performing flexible endoscopy for esophageal foreign body takes a significantly shorter duration compared with rigid endoscopy. Flexible endoscopy would probably allow a better and more thorough examination of the esophageal mucosa compared with rigid endoscopy. Acknowledgments This work was supported by a grant (summer studentship) from the Women’s and Children’s Health Research Institute (WCHRI) of Alberta, Edmonton, Canada.
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Surg Endosc (2011) 25:919–922 Disclosure Authors Jillian Popel, Hamdy El-Hakim, and Wael El-Matary have nothing to disclose.
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