Gastrointestinal Radiology > Procedures > Foreign Bodies > Foreign Bodies (7)


Treatment of Food Impactions And Foreign Bodies in the Esophagus

I.  Blunt Three-Dimensional Foreign Bodies (cont.)

B.  Fluoroscopically Guided Basket Extraction

  • The materials required are as followed:  
    • Using a Dormia-type wire basket with fluoroscopic guidance is particularly useful for extracting 3-dimensional blunt objects that have become impacted above an esophageal stricture. 
    • A selection of biliary stone baskets (Medi-Tech/Boston Scientific Corp.; Cook, Inc., Bloomington, IN) measuring 13 to 30 mm in diameter will permit extraction of foreign bodies in children.  A 30 mm Dotter Retriever Basket (Cook, Inc.) is usually most effective for adults.  A basket diameter is chosen that matches the size of the esophagus so that there will be no space outside the basket into which the foreign body can escape.  
    • Either a cut-off nasogastric tube or a 7-F angiographic catheter with a slight curve near the tip can be used to introduce and guide the basket into the esophagus.  The working length of the basket must be slightly longer than the guiding catheter.

 

Fig. 1.  (Adapted from Shaffer HA Jr., Alford BA, de Lange EE, et al.  Basket extraction of esophageal foreign bodies.  AJR 147:1010-1013, 1986.  Reproduced by permission.)

  • The protocol is as followed (see above illustration):

    1. A preprocedure barium swallow allows the radiologist to select a basket of proper diameter and tailor a curve at the tip of the catheter to facilitate passage of instruments around the foreign body.  After the posterior pharynx is sprayed with a topical anesthetic, the catheter is passed through the mouth into the esophagus above the impaction.  

    2. If the esophageal wall and foreign body are no longer outlined by barium, coating is reestablished by injecting a small amount of medium density, dilute barium suspension through the catheter (Fig. 1A).  

    3. An 0.038-inch angiographic guidewire is then inserted into the catheter and carefully advanced around the impacted object using fluoroscopic guidance (Fig 1B).

    4. The catheter is then advanced over the guidewire beyond the foreign body.  This usually places the end of the catheter within or below an underlying esophageal stricture (Fig. 1C).

    5. The guidewire is removed from the catheter, and a basket of appropriate size is advanced inside the catheter until it is located beside the foreign body (Fig. 1D).

    6. The midpoint of the basket must be positioned at or below the lower margin of the foreign body in order to capture the object when the basket is unsheathed.  The catheter is withdrawn to unsheathe the basket.  At first, the basket may not open fully because it is deformed by the adjacent foreign body or restricted by an underlying esophageal stricture (Fig. 1E).  

    7. If the basket is withdrawn a short distance at this time, it may dislodge the foreign body upward and away from the stricture where the basket has more room to expand.  The foreign body is then engaged in the basket by twirling the instrument, usually clockwise, until the object is trapped in the wire cage (Fig. 1F).  If the basket must be advanced, this should be done only within the protective cover of the catheter to avoid any risk of penetrating the esophageal wall.

    8. The patient is turned onto his right side, and the X-ray table is tilted approximately 30˚ head-down to reduce the risk of aspiration during the extraction.  With the foreign body trapped by the basket, the catheter and basket are withdrawn as a unit from the esophagus through the mouth in a smooth, continuous motion (Fig. 1G).  Resistance may be encountered during passage of the upper esophageal sphincter (cricopharyngeus muscle), but this is overcome by keeping steady traction on the basket while asking the patient to “retch”.

  • Occasionally, food or a foreign body will be so tightly impacted in an esophageal stricture that passage of the guidewire and catheter cannot be performed.  In these circumstances, it may be necessary to use a hydrophylic guidewire.  If this fails, the catheter suction technique (described next) may be used to disimpact the object a short distance upward from the esophageal stricture.  Then, the guidewire, catheter and basket can be advanced around and beyond the foreign body.

  • We have performed 48 fluoroscopically guided basket extraction procedures in 43 patients ranging in age from 3 months to 84 years and have successfully removed 90% of the impactions, all located above esophageal strictures.  There have been no complications.  Advantages of this foreign body extraction method include:  1) it is an outpatient procedure and relatively inexpensive when compared to endoscopy or inpatient treatment; 2) general anesthesia is not required, nor is sedation needed in most cases; 3) the risk of iatrogenic esophageal perforation is minimized because the basket is advanced within a protective sheath using fluoroscopic guidance; and 4) tracheal aspiration is unlikely because the foreign body is controlled within the basket during withdrawal .

  • For removal of three-dimensional blunt foreign bodies, fluoroscopically guided basket extraction is the procedure of choice, especially when there is an underlying esophageal stricture.  However, this method is not appropriate for removal of coins and other discoid objects from the esophagus.  These flat, two-dimensional foreign bodies may be difficult to secure in the basket during their extraction .



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