Removal of strange foreign bodies (coins) from the oesophagus with Foley catheters
Ricardo R. Figueiredo 1, Célio Costa 2, Otávio Mocellin Selles 3, Andréia Azevedo 4
Foreign bodies in the esophagus, specially coins, are common accidents in children. Diagnostic is confirmed by radiology, and treatment made with rigid esophagoscopy, under general anesthesia. Aim: Evaluate seccurity and efficacy of the use of Foley catheters in removing coins from the esophagus. Study design: Clinical retrospective. Materials and method: 25 children with coins in the esophagus went under a removal trial with Foley catheters. Parameters like sex, age, localization of the coin, number of trials and results were signed. Results: We found a high index of success, either by removing the coin, or pushing it to the stomach (about 96% of the cases), with a low index of complications (about 4%). Conclusion: The use of Foley catheters to remove coins from the esophagus, under the adequated parameters, is a sucessful and safe method.INTRODUCTION
Accidents with foreign bodies in children, including the esophagus, are observed daily in ENT emergency rooms. Among them, coins are the most common foreign bodies, amounting to about 70% of the cases, most of them in the cervical esophagus1, 2, 3, 4.
The clinical picture is very variable. About 20% are symptomatic1, 4, and they may manifest gastrointestinal symptoms (dysphasia and vomiting) and respiratory symptoms (cough and dyspnea). The latter can be caused by compression of the foreign body or secondary esophageal dilation over the trachea, as well as edema of paraesophageal soft tissues in case of prolonged retention of the foreign body1. In most cases, parents observe the intake of the foreign body or are advised by the child about it. In other occasions, the foreign body is a radiological finding in chest or abdominal x-rays.
The diagnosis is confirmed by radiological exam, requiring mentalis-xipho-pubic incidence, which enables visualization of the whole digestive tract. In most cases, the removal is made by rigid esophagoscopy under general anesthesia.
Complications are rare and noticed in cases of prolonged foreign body retention1, 5, including esophageal perforation, mediastinitis, tracheoesophageal fistula, vascular fistula, extra-luminal migration of foreign body and formation of false diverticulum 1, 5, 11, 12. There may be also cases of iatrogenia, such as perforations during esophagoscopy. If early diagnosed, before they evolve to mediastinitis, they have good prognosis after the surgical procedure. In cases of mediastinitis, prognosis is more reserved. Congenital abnormalities of the esophagus can also predispose to complications10.
We intended to analyze an alternative to the removal by esophagoscopy under general anesthesia: the removal with Foley catheter under local anesthesia, in the hospital setting. We assessed efficacy, safety and cost of the method compared to esophagoscopy under general anesthesia.
MATERIAL AND METHOD
We included 25 children with esophageal foreign body (coins) seen by the service of ENT, Hospital Municipal Souza Aguiar, a reference center for ENT foreign body in the state of Rio de Janeiro, between September 1996 and April 1998.
They were submitted to placement of urinary catheters (Foley) to try to remove the foreign body and we did not use any type of anesthesia to perform the procedures; in some cases, we lubricated the catheter with xilocaine gel, but it seemed to hinder the placement, since the catheter became slippery.
The following parameters were observed before the procedure:
• only coins and telephone tokens can be removed by this method, because they do not have cutting surfaces;
• the foreign body should be single;
• the foreign body should be located maximum at the middle third of the thoracic esophagus;
• there should be a maximum of 36 hours between ingestion and the procedure;
• radiological findings should not be removed with this method, because they are normally associated with inflammatory phenomena, since we do not know how long the foreign body has been there;
• absence of disease or previous esophageal surgery;
• the procedures can only be performed in the hospital, with the presence of the pediatrician and the anesthesiologist.
The procedure was explained in details to the child and the accompanying person. The catheters were introduced through the nose, the child was restrained by the escort (seating on his/her lap) supported by the licensed practical nurse (LPN).
After the introduction of the catheter, the balloon was inflated with air up to two thirds of its total capacity, and then it was pulled upwards to the oropharynx. The LPN flexed slightly the head of the patient and the physician introduced a gloved finger in the child’s oral cavity to help expel the foreign body, which eventually led to marks of bite in the gloved finger. After removal of the foreign body, the child remained in observation for 30 minutes and was then discharged.
When the foreign body was not eliminated, we performed up to three attempts. If there was no elimination yet, new x-rays were ordered to check the position of the foreign body. If the foreign body had regressed to the abdominal cavity, we sent the patient to the pediatrician. If it remained in the same site, we decided for esophagoscopy under general anesthesia.
We collected data such as age, gender, value of the coin, number of catheters used, interval between ingestion of coin and its removal, number of attempts (to pass the catheter), duration of procedure, complications and location of foreign body.
Out of 25 cases, 15 (60%) were male and 10 (40%) were female subjects. Ages ranged from 1 to 13 years (mean of 5.1 years). The most frequent age range was 2 to 5 years (48%), followed by 6 to 10 years (32%).
As to location, 16 (64%) of the foreign bodies were in the inferior third of the cervical esophagus and 9 (36%) in the middle third of the thoracic esophagus. The most frequently found coins were, in order of frequency, R$0.01 (24%), R$0.05 (20%), R$0.10 (20%), R$0.25 (8%), R$0.50 (8%), old coins (8%) and R$1.00 (4%), curiously in decreasing order (the least valuable are also the smallest ones). In two cases (8%) we did not know the value because the coins progressed to the abdomen. The most frequently used catheters were No.10 and 12 (36% each), followed by No.14 (16%) and 16 (4%). In two cases, two catheters of different size were used. In 12 cases (48%), only one attempt was enough, seven cases (28%) required two attempts, and 6 cases (24%) three. As to interval between ingestion and removal, 9 cases (36%) were solved within the first 6 hours, 10 cases (40%) between 6 and 12 hours, 3 cases (12%) between 12 and 24 hours and 3 cases (12%) between 24 and 36 hours. The duration of the procedure ranged from 30 seconds to 10 minutes, in approximate values.
The foreign body was orally expelled in 20 cases (80%). In 4 (16%), it progressed to the abdominal cavity and in only one case (4%) the patient underwent esophagoscopy under general anesthesia.
In only one case (4%) there was a complication: mild bleeding through the oral cavity, and the patient was observed for 24 hours and remained uneventful.