Four strategies for the management of esophageal coins in children

Esophageal Bougienage for Management of Lodged Esophageal Coins: Safe, Effective, Efficient, and Underused

OBJECTIVES

The aims of the study are to evaluate outcomes of esophageal bougienage for management of lodged esophageal coins and to assess the extent of bougienage usage and barriers among emergency providers.

METHODS

We performed a retrospective chart review of pediatric patients with single lodged esophageal coins presenting to our single academic pediatric emergency department between November 2012 and December 2018. We compared procedural outcomes, complications, length of stay (LOS), and cost between those managed with bougienage and with endoscopy. We further surveyed emergency physicians to assess the extent of bougienage usage and barriers to utilization across different institutions.

RESULTS

We identified 205 patients with single lodged esophageal coins presenting during our study window. One hundred forty-seven patients ultimately underwent bougienage with 97% success and no major complications. Fifty-six patients were managed by endoscopy with 100% success and one major complication. Bougienage had significantly lower LOS (median 2.18 vs 11.92 hours, P < 0.001) and hospital charges (median $3533 vs $12,679, P < 0.001) compared with endoscopy. We received 242 completed surveys representing 38 states from primarily academic pediatric emergency physicians. The majority of respondents (90%) used specialist consult with only 4.5% performing bougienage. A total of 36.4% of respondents had never heard of the procedure and only 16.1% had ever performed it. Barriers to usage included lack of provider training (95.6%), perceived risk of complications (94.4%), and perceived lack of success (80.5%).

CONCLUSIONS

Bougienage is safe and effective with significant LOS and cost benefits compared with endoscopy. Despite these advantages, the procedure is underused, because of lack of provider education and concerns regarding safety, efficacy, and both family and specialist preference, which are not supported by current literature. These data support the need for broader education regarding the bougienage technique, as well as larger prospective studies of its safety and outcomes.

30 Years of Flipping the Coin-Heads or Tails?

INTRODUCTION

 Swallowed coins are a frequent cause of pediatric emergency department visits. Removal typically involves endoscopic retrieval under anesthesia. We describe our 30-year experience retrieving coins using a Foley catheter under fluoroscopy ("coin flip").

MATERIALS AND METHODS

 Patients younger than 18 years who underwent the coin flip procedure from 1988 to 2018 were identified. Failure of fluoroscopic retrieval was followed by rigid endoscopic retrieval in the operating room. Detailed subanalysis of patients between 2011 and 2018 was also performed.

RESULTS

 A total of 809 patients underwent the coin flip procedure between 1988 and 2018. Median age was 3.3 years; 51% were male. The mean duration from ingestion to presentation was 19.8 hours. Overall success of removal from the esophagus was 85.5%, with 76.5% of coins retrieved and 9% pushed into the stomach. All remaining coins were retrieved by endoscopy. Complication rate was 1.2% with nine minor and one major complications, a tracheal tear that required repair. In our recent cohort, successful fluoroscopic removal led to shorter hospital lengths of stay (3.2 vs. 18.1 hours, p < 0.001).

CONCLUSION

 Patients who present with a coin in the esophagus can be successfully managed with a coin flip, which can be performed without hospital admission, with rare complications.

History and radiographic findings as predictors for esophageal coins versus button batteries

OBJECTIVE

To determine if clinical history and radiographic findings are reliable predictors for coin versus button battery in children presenting with esophageal foreign bodies to accurately guide decision making regarding the urgency of removal.

METHODS

A retrospective chart review was conducted in a single pediatric tertiary care center of all children who presented with suspected coin or button battery esophageal foreign body ingestion from 2017 to 2019. Patients with documented surgical removal, completed consultation notes, and available radiographic studies were included. Descriptive statistical analysis was performed and predictive characteristics of the diagnostic tests were calculated.

RESULTS

139 patients met inclusion criteria for the study. Of 5 patients who had esophageal button batteries removed, clinical history was concerning for button battery in 2; accuracy of 12.35%. However, radiology reports suggested a battery in all 5. The negative predictive value for radiology alone for diagnosis of button battery was 97% with 81% accuracy. The clinical history for coin foreign body was accurate in 85.28% while radiography was 87% accurate. Wait time on average for all coin foreign body cases was 6.3 h. Day cases waited on average 5.5 h while after-hours cases waited a statistically significantly longer 7.5 h (p = 0.006).

CONCLUSION

Button batteries, while clinically important emergencies, are rare esophageal ingestions. Radiography has a strong negative predictive value for button battery. Children whose radiographic studies do not demonstrate concern for button battery could be considered for delayed elective removal. This could allow children to complete a period of observation at home, thereby reducing prolonged in-house wait times prior to operative removal.

Novel Bougie for the Management of Esophageal Coins in Children: An Observational Study

OBJECTIVES

To determine the efficacy and safety of a novel bougie for the removal of esophageal coins lodged in the proximal esophagus.

SUBJECTS AND METHODS

This was an observational study. Medical records were reviewed of patients who were confirmed with esophageal coins between July 2015 and October 2016 in our department. Sixty-three patients, upper esophageal coins were confirmed by radiographs, were treated by using this novel bougie to remove esophageal coins.

RESULTS

A total of 63 children were enrolled in this study. Sixty coins (95%) were removed successfully. The coin was extracted on the first attempt in 56 cases (89%), the second attempt in 3 cases (5%), and the third attempt in 1 case (2%). Two coins retained in the esophagus underwent endoscopy. In the remaining patient, the coin passed into the stomach and was confirmed to be passed in the stool within 48 hours. No serious complications occurred in any subject.

CONCLUSIONS

Our novel bougie procedure is likely a safe, highly efficient approach to managing esophageal coins given that no serious complications of the 63 patients were reported. This simple technique may provide another valuable option to physicians.

Endoscopic Management of Foreign Bodies in the Gastrointestinal Tract: A Review of the Literature

Foreign body ingestion is a common diagnosis that presents in emergency departments throughout the world. Distinct foreign bodies predispose to particular locations of impaction in the gastrointestinal tract, commonly meat boluses in the esophagus above a preexisting esophageal stricture or ring in adults and coins in children. Several other groups are at high risk of foreign body impaction, mentally handicapped individuals or those with psychiatric illness, abusers of drugs or alcohol, and the geriatric population. Patients with foreign body ingestion typically present with odynophagia, dysphagia, sensation of having an object stuck, chest pain, and nausea/vomiting. The majority of foreign bodies pass through the digestive system spontaneously without causing any harm, symptoms, or necessitating any further intervention. A well-documented clinical history and thorough physical exam is critical in making the diagnosis, if additional modalities are needed, a CT scan and diagnostic endoscopy are generally the preferred modalities. Various tools can be used to remove foreign bodies, and endoscopic treatment is safe and effective if performed by a skilled endoscopist.

Western view of the management of gastroesophageal foreign bodies

The best modality for foreign body removal has been the subject of much controversy over the years. We have read with great interest the recent article by Souza Aguiar Municipal Hospital, Rio de Janeiro, Brazil, describing their experience with the management of esophageal foreign bodies in children. Non-endoscopic methods of removing foreign bodies (such as a Foley catheter guided or not by fluoroscopy) have been successfully used at this center. These methods could be an attractive option because of the following advantages: Shorter hospitalization time; easy to perform; no need for anesthesia; avoids esophagoscopy; and lower costs. However, the complications of these procedures can be severe and potentially fatal if not performed correctly, such as bronchoaspiration, perforation, and acute airway obstruction. In addition, it has some disadvantages, such as the inability to directly view the esophagus and the inability to always retrieve foreign bodies. Therefore, in Western countries clinical practice usually recommends endoscopic removal of foreign bodies under direct vision and with airway protection whenever possible.

Clinical effectiveness of bougienage for esophageal coins in a pediatric ED

OBJECTIVE

To describe a tertiary care pediatric emergency department (PED) experience with bougienage for esophageal coins.

METHODS

This was a large retrospective case series of children with esophageal coins presenting to a tertiary PED from January 2004 to October 2012. Bougienage eligibility criteria were medically stable, no prior gastro-esophageal surgery or disease, single coin, and witnessed ingestion within 24 hours. Abstracted data were age, signs and symptoms, coin type, management, efficacy, complications, returns, length of stay (LOS), and hospital charges. Main outcomes included procedural success and complications. Secondary outcomes included LOS and hospital charges.

RESULTS

There were 245 patients with esophageal coins with 136/145 (94%) successful bougienage procedures and 109/109 (100%) successful surgical retrievals. There were 18 minor complications and 5 return visits for patients with bougienage. There were 10 minor and 2 major complications with surgical retrieval. Patients undergoing bougienage were 4 years (SD 2) vs 3 years (SD 3) for surgical retrieval (P < 0.001). Mean LOS for successful bougienage was 137 minutes (SD 54) vs 769 (SD 535) for surgical retrieval. The difference in the means was 632, 95% CI for the difference in means of -723 to -541 (P < .001). Mean charges for successful bougienage were $984 (SD $576) vs. $7022 (SD $3132) for surgical retrieval. The difference in means was $6038, 95% CI -$6,580 to -$5,496 (P < .001).

CONCLUSIONS

Esophageal bougienage is safe and highly effective. It is also more time and cost efficient than other treatment options.

Distal esophageal foreign bodies: is it a common occurrence post-fundoplication requiring immediate intervention?

OBJECTIVE

Dysphagia secondary to "tight" distal esophageal wraps are a well-known complication of Nissen fundoplication (NF). However, the literature makes no mention of distal esophageal foreign bodies (DEFB) appearing after NF. This study was undertaken to determine the occurrence of asymptomatic DEFB in children post-fundoplication.

METHODS

A retrospective review and case series of radiographic images of children who underwent NF between 2001 and 2004. Images reviewed include chest and abdominal radiographs, esophagrams, and oropharyngeal motility studies.

MAIN OUTCOME

DEFB on radiology report and image.

RESULTS

Two hundred and thirty-three children (135 males and 98 females) underwent NF at the ages of 15 days to 19.5 years. Two thousand and seven radiographs were reviewed. Five FBs (2.15%) were noted. Four of the five FBs (80%, overall incidence 1.72%) were present in the distal esophagus. Three required rigid esophagoscopy (one marble and one with multiple foreign bodies (FBs) for removal. One who had a distal FB seen on barium swallow 'spontaneously passed' during esophagoscopy.

CONCLUSION

DEFB in children status post-NF is unusual with an incidence 1.72% of our patients. Our review might be underestimating the incidence as translucent foreign bodies may have been missed. DEFB are surprising due to the fact that most of these children are neurologically impaired and gastrostomy-tube fed. The children's NPO status may also result in these DEFB remaining asymptomatic until being 'incidentally' found on radiographic imaging. Thus, NF may predispose to obstruction when a foreign body (FB) is ingested; but because of the population involved, this remains a fairly unusual entity. However, the presence of a DEFB in this population may necessitate prompt endoscopic retrieval as the likelihood of spontaneous passage is less.

[Ingestion of foreign bodies in children. Recommendations of the French-Speaking Group of Pediatric Hepatology, Gastroenterology and Nutrition]

Ingestion of foreign bodies is a common pediatric problem. The majority of ingested foreign bodies pass spontaneously. Management of foreign body ingestions varies based upon the object ingested, its location, and the patient's age and past history. Esophageal foreign bodies should be urgently removed because of their potential to cause complications. Ingested batteries that lodge in the esophagus, sharp or pointed foreign bodies in the esophageal or gastric tract, and ingestion of multiple magnets all require urgent endoscopic removal. Flexible endoscopy is the therapeutic modality of choice for most patients. The use of devices such as a latex protector hood or an overtube may facilitate safer extraction of sharp objects.

Safety and efficacy of a protocol using bougienage or endoscopy for the management of coins acutely lodged in the esophagus: a large case series

STUDY OBJECTIVE

We report our experience using the bougienage procedure in the management of esophageal coins.

METHODS

Observational case series of all patients presenting to our emergency departments with coins acutely lodged in the esophagus between 1994 and 2006. All patients were treated according to our protocol with either endoscopy or bougienage. Patients are eligible for bougienage if they have had a witnessed coin ingestion less than 24 hours before presentation and if esophageal coin position is confirmed by chest radiograph and there is no history of esophageal disease, surgery, or foreign body. Primary outcomes measured were complications, efficacy of procedure, hospital charges, length of stay, and return to the hospital. Length of stay and hospital charges data were gathered for patients presenting in the final 24 months of the study.

RESULTS

Six hundred twenty patients were identified as having esophageal coins. Three hundred fifty-five patients had a successful bougienage, and 17 patients had unsuccessful bougienage. By comparison, 248 patients underwent endoscopy, and the coin was successfully removed in all but 1 of these patients. Of patients undergoing endoscopy, 89 were eligible for bougienage, but patient, parent, or physician preference was for endoscopic management. Eleven patients required reevaluation or readmission for complaints related to esophageal coin. The only complication was subglottic edema, causing respiratory distress in a single patient who had undergone endoscopy. Patients undergoing endoscopy had an average length of stay of 6.1 hours and average hospital charges were $6,087. Patients undergoing bougienage had an average length of stay of 2.2 hours and average hospital charges of $1,884.

CONCLUSION

In properly screened patients with coins acutely lodged in the esophagus, bougienage offers a safe and effective alternative to other methods of coin management.

Foreign body ingestion in children: an analysis of pediatric surgical practice

Ingestion of a foreign body (FB) is a prevalent condition among children. The type of FB varies according to the feeding habits and sociocultural features of communities. The management modality differs also between disciplines due to use of conventional techniques. We aimed to picture the general characteristics of FB ingestion and treatment alternatives, to mention the indications of open surgery in an advanced pediatric surgical center. The records of patients who were hospitalized for FB ingestion between 1973 and May 2005 were evaluated retrospectively. One hundred and twelve patients were enrolled into the study. The mean age was 2.27 +/- 2.84 years with a M/F ratio of 59/53. The history was suggestive of ingestion in 92% of patients. The age did not differ significantly whether the history was positive or negative (3.6 years vs. 4.8 years and P = 0.19). Most common presenting symptom was vomiting (28.6%). The duration of symptoms was longer in patients with negative history (median 47.7 h vs. 28.1 h and P < 0.002). Physical examination was normal in 89.3% of cases. Most common localization of the FB shown in plain X-ray was the esophagus (67%). Esophagography revealed nonopaque FB in the esophagus in 4.4%. X-ray was normal in 6.3% of the patients. The age of patient did not determine the localization of FB on admission (P = 0.436). Endoscopic removal was attempted in 75% and was successful in 68% of patients in which FB was extracted by using laryngoscope and Magill forceps (12%), rigid esophagoscope with FB forceps (51%), and flexible endoscope with FB forceps (5%). FB could not be found in 32% of patients at initial rigid esophagoscopy or flexible endoscopy. FB was eliminated spontaneously (n = 19) or extracted surgically (n = 8). Follow-up was preferred in 21% of patients on initial admission. FB proceeded uneventfully in 15 patients or was extracted by flexible endoscopy or surgery in one and eight patients, respectively. Surgery was performed in 4% on admission. Surgery or endoscopy were essentially required in cases whose follow-up period exceeded 4 days when compared with patients who eliminated FB spontaneously within 4 days, independent to the location of FB. The metallic objects were the frequently ingested FBs (83.8%) in which the safety pins (SPs) (n = 53) and coins (n = 25) were the most frequent. The type of FB did not affect the FB localization on admission (P = 0.38). The duration of hospitalization was longer in patients with delayed admission; 2.46 +/- 3.51, 3.80 +/- 8.17, and 5.72 +/- 4.24 days for the admissions within first, second-fifth days, and sixth or later days after ingestion, respectively (P = 0.000). Pediatric surgery has the largest spectrum of duty in the treatment of FB ingestion in children. Negative history, normal physical examination findings and absence of symptoms do not exclude the possibility of FB ingestion. Presentation with isolated respiratory symptoms is an enigma that can lead to misdiagnoses. The mode of management should be selected according to the patient's condition, surgeon's experience, and available technical equipment as well as the location and type of ingested FB. Especially, SPs should be treated by experienced surgeons. Simple extraction techniques and both rigid and flexible endoscopies with appropriate forceps as well as surgery can be used for the extraction of FBs lodged in the alimentary tract. Surgery can be expected especially in asymptomatic cases that have been followed up for more than 4 days irrespective of the location of FB.

Bougienage versus endoscopy for esophageal coin removal in children

BACKGROUND

Foreign body ingestion is a common pediatric problem. Coins are by far the most common ingested foreign bodies. When ingested coins become lodged in the esophagus, they may cause serious complications if they are not removed in a timely manner. Endoscopic removal is the preferred treatment in many pediatric centers as its safety and effectiveness are well established.

OBJECTIVES

We performed this study to evaluate safety and effectiveness of an alternative method of managing esophageal coins, using bougienage technique.

METHODS

Previously healthy children presenting to the local emergency room with uncomplicated, witnessed coin ingestion of less than 24 hours duration were prospectively recruited with an intent-to-treat analysis. A single oral passage of a Hurst bougie dilator was performed by a gastroenterologist to dislodge the esophageal coin into the stomach. If bougienage was successful (x-ray showing coin in the stomach), patients were discharged and instructions were given for monitoring stools until passage of the coin through anus was confirmed. If bougienage was unsuccessful, the child developed symptoms at any time or if a coin remained intragastric for 4 weeks, endoscopic removal was planned. Children whose parents declined to participate in the bougienage treatment received the standard endoscopic removal and their hospital records were used as controls.

RESULTS

A total of 10 children were enrolled in this study, with a mean age of 3.2 years (11 mo to 10 y), 6 boys and 4 girls. All received little or no sedation. Nine children (90%) were successfully treated using bougienage, all of whom spontaneously passed the ingested coins, with a mean duration of 2.6 days (1 to 7 d) without subsequent intervention. A single case failed bougienage and underwent endoscopic removal. Three children declined bougienage treatment and underwent endoscopic removal. There were no reported minor or major adverse events with any of our cases. The mean health care cost for the hospital visit for bougienage treatment was $1210, compared with $3100 for the endoscopic removal (P<0.001). Furthermore, the mean time spent in the hospital from diagnosis to discharge was 2 hours for bougienage-treated patients compared with 8 hours for endoscopic treatment (P<0.001).

CONCLUSIONS

Bougienage of impacted esophageal coins is an effective, safe, and more economic treatment modality for selected pediatric patients with uncomplicated coin ingestion. This simple technique may provide a valuable tool to emergency room physicians or primary care doctors especially when endoscopy is not readily available.

Foreign body in the esophagus: a review

Foreign body in the esophagus is a common emergency presentation. The approach towards a patient with a foreign body in the esophagus comprises a thorough history and systematic examination followed by relevant investigations. However, there is considerable debate over the most appropriate treatment option for such patients. This review aims to develop a comprehensive approach towards patients presenting with foreign body ingestion by developing clinical practice guidelines. These guidelines address not only the initial evaluation of the patient but also the various management alternatives and their advantages, limitations and applicability in various scenarios, based upon a review of the literature.

Safe removal of upper esophageal coins by using Magill forceps: two centers' experience

Coin ingestion with subsequent esophageal coin impaction is common in children. Considerable debate surrounds the choice of technique for the removal of esophageal coins. This study demonstrates a minimally invasive technique for upper esophageal coin extraction. A retrospective review was conducted of 165 children who had upper esophageal coins extracted by using a Magill forceps. One hundred fifty-six coins (96.4%) were successfully removed without any complications. The average time taken to remove the coin was 33 seconds. Use of the Magill forceps technique minimizes instrumentation of the esophagus and is an easy, safe technique for removing coins from the upper end of the esophagus.

Case of the missing penny: thoracoscopic removal of a mediastinal coin

Complications of coin ingestion in children, although rare, include esophageal perforation, tracheoesophageal fistula, esophago-aortic fistula, and death. The authors describe thoracoscopic removal of a mediastinal coin that migrated extraluminally from the esophagus in a 23-month-old girl. Right-sided thoracoscopic exploration using a 3-trocar technique in a modified prone position was used. Coin location was assisted by manipulation of a transorally placed Foley catheter and intraoperative fluoroscopy. The coin was retrieved successfully with no intraoperative or postoperative complications and minimal postoperative pain. This is the first report of successful thoracoscopic removal of a mediastinal coin. Thoracoscopy may be a valuable approach for mediastinal foreign body removal in children.

Cecal retention of a swallowed penny mimicking appendicitis in a healthy 2 year old

Toddlers commonly ingest coins. Studies of the evaluation and management of such ingestions have focused on the risk of complications from impaction in the esophagus. It is commonly assumed that coins that have passed through the esophagus present little or no risk for distal complications. We present the first report of cecal retention of a penny in a previously healthy 2 year old, ultimately resulting in surgical intervention.

[Esophageal foreign bodies. Our ten years of experience]

OBJECTIVE

To study the management of esophageal foreign bodies.

MATERIAL AND METHODS

A retrospective study was made of all rigid esophagoscopies performed for suspected foreign bodies in the esophagus by an otolaryngology department for ten years.

RESULTS

Rigid esophagoscopy was performed for suspected foreign bodies in 46 patients (27 females, 19 males); age range 22 months to 88 years. In 40 cases an impacted foreign body was found. The most frequent location was the upper third of the esophagus (33/82.5%). The most common type of foreign body was chicken bones in adults (17/42) and coins in children (2/4). Nine patients (all adults) had complications.

CONCLUSIONS

Due to its low cost and morbility, flexible endoscopy is the first choice for managing esophageal foreign bodies. Rigid esophagoscopy is still an appropriate technique when flexible endoscopy fails or it is not possible.

Removal of esophageal foreign bodies in the pediatric ED: is ketamine an option?

The objective of the study was to evaluate our experience with esophageal foreign body (EFB) removal comparing the use of ketamine-midazolam (K-M) and fentanyl-midazolam (F-M) in the emergency department (ED), to admission and general anesthesia (GA) in the operating room (OR). A retrospective review of all children undergoing EFB removal at our institution during a 2-year period was conducted. A total of 93 patients were identified: K-M 57/93 (61.2%), F-M 28/93 (30.1%), GA 5/93 (5.4%), and 3/93 (3.2%) by other means. Mean procedure durations were 4.8 min for K-M and 7.0 min for F-M. Mean lengths of stay (LOS) for ED procedures were 3.6 hrs for K-M and 5.7 hrs for F-M, versus 17.7 hrs if admitted. Transient hypoxemia occurred in 10.7% of K-M and 15.4% of F-M. Removal of EFBs in the ED may obviate the need for admission. In our experience, the use of K-M is associated with fewer airway complications, shorter removal times, and an overall shorter LOS.

Decision analysis: a basic overview for the pediatric surgeon

Decision making in medicine requires choosing the option that best maximizes benefit while minimizing risk and cost. Even though uncertainty is an inherent feature of any clinical issue, clinicians and policy makers frequently are required to evaluate the best evidence and make therapeutic or policy decisions based on that evidence. Decision analysis is a quantitative approach to decision making under conditions of uncertainty that can be applied to specific types of clinical problems. This method disaggregates a complex clinical problem into its most important components that then can be understood more easily and analyzed quantitatively. Decision analysis has many potential applications in medicine and can be applied to solve specific clinical problems, analyze health care costs, or develop health care policies. In this review, the basic methods for constructing and analyzing decision analyses will be presented, and specific applications of this method to pediatric surgery will be discussed.