Pediatr Surg Int DOI 10.1007/s00383-013-3331-7
ORIGINAL ARTICLE
Predictive factors for successful balloon catheter extraction of esophageal foreign bodies Alessandra C. Gasior • E. Marty Knott Susan W. Sharp • Charles L. Snyder • Shawn D. St. Peter
•
Accepted: 11 June 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction Foreign bodies in the esophagus are common in children. Time from ingestion to presentation is variable, and may not be known. Our center usually performs Foley catheter balloon extraction under fluoroscopy as the first step to attempt removal to prevent all patients from going to the operating room. The efficacy of this procedure has been reported. However, information is lacking about the relationship between presentation variables and the likelihood of success. Methods After IRB approval, we performed a retrospective single-center review from January 1988 to August 2011 of children with an esophageal foreign body. Pearson’s correlation was used to evaluate the relationship between variables and successful balloon extraction for P \ 0.05. A logistic regression was done to evaluate for independence. Results 819 patients presented with esophageal foreign bodies, with a mean age of 3.3 years. 572 patients underwent balloon extraction, 83 % successful. Mean ingestion duration was 16.6 h with fluoroscopy time of 2.3 min and mean number of attempts was 1.5. Successful balloon extraction had a negative correlation with refusal to eat, respiratory distress, cough, wheeze, upper respiratory infection symptoms, stridor, fever, duration of ingestion [1 day, unwitnessed ingestion, fluoroscopy time and number of balloon catheter attempts. There was a positive correlation between success and both age and duration of
A. C. Gasior E. M. Knott S. W. Sharp C. L. Snyder S. D. St. Peter (&) Department of Pediatric Surgery, Children’s Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA e-mail:
[email protected]
ingestion \1 day. Independent predictive factors were number of balloon catheter attempts. Conclusions Patients with longer duration of ingestion, symptoms from the foreign body and increased number of removal attempts have a decreased likelihood of success with balloon catheter extraction and should not undergo prolonged efforts of removal. Keywords Esophageal foreign body Pediatrics Fluoroscopy-guided catheter extraction
Introduction Foreign body ingestion is frequently encountered by pediatric surgeons. In the United States alone, there were over 125,000 cases of esophageal foreign bodies in children reported by the American Poison Control Center in 2007 [1]. The most common ingested foreign body is a coin. Curious toddlers swallow coins that become lodged in the esophagus [2]. Patients frequently present with choking, dysphagia, drooling, refusal to eat, respiratory distress, wheezing, abdominal or chest pain, cough or remain asymptomatic. As complications from foreign body ingestion may cause aspiration or perforation, this requires early removal [3]. In order to avoid routine general anesthesia in these cases, we initially use a Foley balloon catheter to perform an awake extraction under fluoroscopy where success rates approach 90 % [4–7]. Currently, data are lacking on presenting variables that are more likely to be related to success or failure with balloon extraction. In this study, we expanded our previously reported experience and examined the patient’s clinical presentation to evaluate variables that predict successful fluoroscopic guided balloon extraction [5].
123
Pediatr Surg Int
Methods After institutional review board approval (#12070341), a retrospective review from January 1988 to August 2011 was performed for esophageal foreign bodies in children \19 years old. Demographics, presenting symptoms of drooling, refusing to eat, vomiting, cough, respiratory distress, choking, wheezing, upper respiratory infection symptoms, stridor, fever, chest pain, abdominal pain or no symptoms were assessed. Duration of symptoms, as well as witnessed or unwitnessed ingestion was noted. Esophageal position and type of foreign object were recorded. The balloon extraction is usually performed by the pediatric surgery fellow in the radiology fluoroscopy suite with assistance from a radiology technician, 1 or 2 emergency department nurses and possibly a general surgery resident. The pediatric surgery fellow undergoes supervised training of this technique with either a senior pediatric surgery fellow or a pediatric surgery attending until competency is obtained. This set-up is available 24 h/day, 7 days a week. The patient is placed on monitors. No sedation is used for this procedure, as to allow the patient to assist in coughing the object up for extraction. Infants are immobilized on a papoose board restraint. Typically, a 10 or 12 F lubricated Foley catheter is passed through either nare, advanced posterior and distal to the lodged esophageal object, and inflated with 5 mL of dilute barium contrast (3:1, water to barium). The inflated balloon is then carefully removed with constant traction under continuous fluoroscopy. Once the object reaches the posterior pharynx, the patient is turned from a prone position to a right decubitus position and allowed to expectorate the object. This technique prevents aspiration. A bite block is used if the patient has teeth. Occasionally, the object is pushed into the stomach and the object is allowed to complete a safe passage through the intestines. If successful, the patient is observed in the emergency department, given an oral challenge with clear liquids and discharged if well. No follow-up studies or contrast studies are performed if the patient clinically passes the oral challenge test. Typically, the procedure is abandoned after a few attempts if extraction is unsuccessful, and a rigid esophagoscopy is performed in the operating room under general anesthesia. When available, fluoroscopy time, number of attempts and complications were examined. Patients with a history of esophageal anastomosis or associated pathology are not considered for balloon extraction as the patients are usually dilated at the time of removal. Patients with an active respiratory illness are also not considered for fluoroscopy extraction as the balloon can stimulate severe broncho/ laryngospasm. Generally, patients 5 years of age or older are treated directly with endoscopy due to difficulty with restraint and control. Finally, those with a known
123
protracted interval between swallowing the foreign body and presentation may forego attempting balloon extraction. Univariate analysis was performed using Pearson’s correlation to evaluate the relationship between variables and successful balloon extraction for P \ 0.05. Multivariate analysis was performed using logistic regression to evaluate for independence between those variables and successful balloon extraction.
Results 819 children presented with esophageal foreign bodies. The majority were boys. The mean age of all patients was 3.3 years. The mean age of those who did not have a balloon extraction attempt was 5 years. 89 % of patients were diagnosed by a chest X-ray. The position of the foreign body was upper esophageal in 69 %, 11 % were middle esophagus and 12 % were lower esophagus. 91 % of these objects were coins. Six (0.78 %) of these objects were batteries. 572 patients underwent balloon extraction. With all positions of objects, 83 % were successfully extracted, 6 % (n = 43) were pushed into the stomach (all of which passed without intervention) resulting in an 89 % success rate overall and failure rate of 11 % (n = 43). The success rate for lower esophageal objects was 77 %, 69 % for middle and 79 % for upper foreign bodies. Mean ingestion duration was 15.4 h ± 1.8 days with fluoroscopy time of 2.3 ± 2.6 min. Mean number of attempts was 1.5 with a range of 1–6 attempts. Univariate correlations are displayed in Table 1. Successful balloon extraction had a negative correlation with refusal to eat, respiratory distress, cough, wheeze, upper respiratory infection symptoms, stridor, fever, duration of ingestion [1 day, unwitnessed ingestion, fluoroscopy time and number of balloon catheter attempts. There was a positive correlation between successful extraction and both age and duration of ingestion \1 day. The only independent predictor found in the multivariate regression was number of balloon catheter attempts (P = 0.03; b = -1.33). There were four complications. Two patients had epitaxis. On one patient, the balloon could not be deflated and it lodged in the nasopharynx, requiring balloon removal with direct laryngoscopy and Magill forceps. Another patient had an apneic event with the Foley catheter extraction. The procedure was stopped, no airway intervention was required, and the patient was later taken to the operating room for successful rigid esophagoscopy removal. There were no episodes of aspiration once the foreign body was in the pharynx. Of the battery ingestions, three were successfully removed under fluoroscopy and cleared clinically without further sequelae. One patient had an unsuccessful attempt
Pediatr Surg Int Table 1 Correlation between parameters and outcome measures Parameter
Foley catheter success correlations Correlation (R score)
P value
Vomiting
0.001
0.977
Drooling
0.035
0.361
Chest pain
0.064
0.097
0.028
0.466
Abdominal pain Choking
-0.071
0.063
0.072
0.058
Refusal to eat Respiratory Distress
-0.12 -0.113
0.002 0.003
Cough
-0.155
\0.0001
Wheezing
-0.109
0.004
URI symptoms
-0.241
\0.0001
Stridor
-0.154
\0.0001
Fever
-0.181
\0.0001
Unwitnessed ingestion
-0.509
0.009
Fluoroscopy time
-0.346
\0.0001
Number of Foley attempts
-0.209
0.003
Duration greater than 1 day
-0.164
\0.0001
No symptoms
Age
0.12
0.002
Duration \1 day
0.162
\0.0001
at removal and went to the operating room for rigid esophagoscopy. Another patient went directly to the operating room for rigid esophagoscopy due to duration of ingestion. Another patient had successful removal under fluoroscopy, however, returned 1 week later with worsening respiratory symptoms and he was found to have a tracheoesophageal fistula requiring operative repair. This was the only patient with a missed esophageal injury.
Discussion Children commonly present to the emergency department with ingestion of a foreign object. The peak incidence of foreign body ingestion in other reports is between 6 months and 3 years, similar to what we found here [8]. The incidence has been reported by others to be equal in males and females, although there were more boys in our study [9]. Coins are most often found in the first narrowing of the esophagus at the thoracic inlet as seen in almost 70 % of our patients. Our success rate for esophageal foreign body removal was 83 %. When we include passage into the stomach, our success rate approached 90 %. We had a complication rate of \1 %, and there were no long-term sequelae. Balloon extraction allows the patient to be treated in a relatively short time frame, without the additional time and costs of the operating room and risk of general anesthesia.
The origins of esophageal foreign body removal date back to the seventh century. During the height of the Byzantine period, patients would swallow a small, dry sponge on a string; the sponge would expand in the stomach, and was then pulled out with removal of the obstructing object [10]. Comparable methods are used today with the evolution of Foley catheters and the development of fluoroscopy. Despite the advantages of fluoroscopic-guided balloon catheter removal, endoscopic removal is still widely practiced [11, 12]. Endoscopic advocates criticize the fluoroscopic catheter technique due to lack of direct visualization of the esophagus and the risk of missing underlying pathology, missing concomitantly impacted non-radio-opaque objects, concerns about airway protection with risk of foreign object aspiration and patient discomfort [13–16]. However, many studies have found fluoroscopic-guided balloon catheter removal to be highly successful, cost effective with a reported savings as high as $5027.31 per patient, a complication rate of 0–1 %, and a decreased overall length of stay [5, 17, 18]. The current literature varies in recommended timing exclusion criteria for Foley catheter-guided balloon extraction from 6–12 h to \2 days to \1 week and even \2 weeks [19–21]. Positive predictive factors for success in our study were age and duration of impaction \1 day. This information is important in the pre-procedure counseling phase for anxious parents. Factors potentially indicating unsuccessful removal were ubiquitous, and included refusal to eat, respiratory distress, cough, wheeze, upper respiratory infection symptoms, stridor, fever, duration of ingestion [1 day, unwitnessed ingestion, fluoroscopy time and number of balloon catheter attempts. The predictive variables prior to attempting removal are all associated with duration of impaction, which are associated with increased inflammation, edema and local tissue reaction, making balloon catheter extraction less successful. These variables move in synchrony in multivariate analysis canceling each other out which leaves only number of attempts as a predictor independent of the other variables. Better patient selection criteria may imprint outcomes and increase physical acceptances of balloon extraction.
References 1. Bronstein AC, Spyker DA, Cantilena LR Jr et al, American Association of Poison Control Centers (2008) 2007 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol 46:927–1057 2. Waltzman ML (2006) Management of esophageal coins. Curr Opin Pediatr 18:571–574 3. Janik JS, Bailey WC, Burrington JD (1986) Occult coin perforation of the esophagus. J Pediatr Surg 21:794–797
123
Pediatr Surg Int 4. Schunk JE, Harrison AM, Corneli HM et al (1994) Fluoroscopic Foley catheter removal of esophageal foreign bodies in children: experience with 415 episodes. Pediatrics 94:709–714 5. Little DC, Shah SR, St Peter SD et al (2006) Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr Surg 41:914–918 6. Morrow SE, Bickler SW, Kennedy AP et al (1998) Balloon extraction of esophageal foreign bodies in children. J Pediatr Surg 33:266–270 7. Rubin SZ, Mueller DL (1987) Removal of esophageal foreign bodies with a Foley balloon catheter under fluoroscopic control. CMAJ 137:125–127 8. Alexander W, Kadish JA, Dunbar JS (1969) Ingested foreign bodies in children. In: Kaufmann HJ (ed) Progress in pediatric radiology, 2nd edn. Yearbook Medical Publishers, Chicago, pp 256–285 9. Balci AE, Eren S, Eren MN (2004) Esophageal foreign bodies under cricopharyngeal level in children: an analysis of 1116 cases. Interact Cadiovasc Thorac Surg 3:14–18 10. Chang JH, Burrington JD (1973) Removal of coins from the esophagus: nothing new under the sun. Pediatrics 51:313 11. Rodriguez H, Passali GC, Gregori D et al (2012) Management of foreign bodies in the airway and oesophagus. Int J Pediatr Otorhinolaryngol 76:584–591 12. McNeill MB, Sperry SL, Crockett SD et al (2012) Epidemiology and management of oesophageal coin impaction in children. Dig Liver Dis 44:482–486
123
13. Jackson RM, Hawkins DB (1986) Coins in the esophagus. What is the best management? Int J Pediar Otorhinolaryngol 12:127–135 14. Hawkins DB (1990) Removal of blunt foreign bodies from the esophagus. Ann Otol Rhinol Laryngol 99:935–939 15. Korcok M (1982) No-confidence vote on catheter removal of foreign bodies. JAMA 247:3304 16. Ritter FN (1974) Questionable methods of foreign body treatment. Ann Otorhinolaryngol 83:729–733 17. Mariani PJ, Wagner DK (1986) Foley catheter extraction of blunt esophageal foreign bodies. J Emerg Med 4:301–306 18. Kelley JE, Leech MH, Carr MG (1993) A safe cost-effective protocol for the management of esophageal coins in children. J Pediatr Surg 28:898–900 19. O’Neill JA Jr, Holcomb GW Jr, Neblett WW (1983) Management of tracheobronchial and esophageal foreign bodies in childhood. J Pediatr Surg 18:475–479 20. Kirks DR (1992) Fluoroscopic catheter removal of blunt esophageal foreign bodies, a pediatric radiologist’s perspective. Pediatr Radiol 22:64–65 21. Campbell JB, Foley LC (1983) A safe alternative to endoscopic removal of blunt esophageal foreign bodies. Arch Otolaryngol 109:323–325
