Gastrointestinal Radiology > Procedures > Foreign Bodies > Foreign Bodies (9)


Treatment of Food Impactions And Foreign Bodies in the Esophagus

II.  Foley Catheter Balloon Extraction of Coins and Other Flat Objects

  • With this procedure, a Foley catheter balloon is inflated distal to the foreign body and is withdrawn together with the object under fluoroscopic guidance.  The vast majority of experience has been with coins and other smooth, radiopaque objects, but nonopaque foreign bodies, including food impactions, can also be removed.         

      

  • Special Materials.  1) Several Foley catheters in sizes 10 - 14 French with 5 ml balloons.  2) Kelly surgical clamp.  3) A nonionic, water-soluble contrast agent to opacify the balloon and check the esophagus for perforation after the procedure.  4) Small syringe to inflate Foley catheter balloon with contrast.  5) Medium density barium suspension in a syringe to connect to the Foley catheter so that a nonopaque foreign body can be located and opacified.

  • Method.  The esophageal foreign body is first localized and characterized radiographically.  The Foley balloon is tested prior to catheter insertion into the patient to make sure that it inflates symmetrically.  If not, the catheter is discarded and replaced with a catheter having symmetrical balloon inflation.

    • Before beginning the extraction procedure, the patient must either be cooperative or restrained in a firm but gentle fashion.  If necessary, a bite block is inserted between the teeth to keep the patient from biting the catheter.  

    • The patient is then placed in the right lateral position.  The Foley catheter with the balloon deflated is inserted orally.  Oral insertion appears less traumatic and may avoid complications associated with the transnasal approach, such as displacement of the foreign body into the nasopharynx and epistaxis.  

    • Under fluoroscopic guidance, the catheter is passed beyond the foreign body, and the balloon is inflated with the water-soluble contrast agent.  Overdistention of the balloon should be avoided because it may cause airway compression and respiratory compromise. 

    • At this point, the patient is turned into a semi-prone position, and the fluoroscopy table is tilted 30˚ head down to minimize the chance of the foreign bodyís entering the larynx during the extraction.  The catheter is then withdrawn with moderate, steady traction to deliver the foreign body into the oral pharynx (Fig. 3).  Once the foreign body appears in the oral pharynx, it may be expelled by a cough or grasped with a Kelly clamp.  

    • Moderate resistance to withdrawal of the foreign body and balloon will be encountered at the level of the cricopharyngeal muscle.  At this point, gentle traction for a few moments is usually followed by relaxation of the upper esophageal sphincter and passage of the foreign body.  Significant impedance to withdrawal at any other level should cause the attempt to be terminated.  If the balloon slips past the object, it is reinserted and the procedure is repeated.

 Figure 3.  Diagrammatic sagittal representation of the use of a Foley catheter to extract a coin from the esophagus.  After being passed orally, the Foley catheter is directed distal to the foreign body under fluoroscopic guidance.  Then, the catheter balloon (bold arrow) is inflated with a water-soluble contrast medium.  The Foley catheter and coin are withdrawn together into the patientís mouth under fluoroscopic control.  (From Shaffer HA Jr, de Lange EE.  Diagnosis and treatment of food impactions and foreign bodies in the esophagus.  In Taveras JM, Ferrucci JT (eds).  RADIOLOGY: Diagnosis/Imaging/Intervention.  Philadelphia.  J. B. Lippincott Co., 1994, Volume 4, Chapter 15B, pp 1-11.  Reproduced by permission.)

  • Note.  In some adult cases, a Foley catheter is too short to reach the foreign body; in others, its diameter is too large to pass beyond a tight impaction.  In these circumstances, we have successfully used an angiographic catheter and guidewire to pass beyond the obstruction, followed by exchange for a balloon angioplasty catheter (Medi-tech, Watertown, MA) of an appropriate size for the diameter of the patientís esophagus.  Using the same technique as for a Foley catheter, the angioplasty catheter balloon is inflated distal to the foreign body, and together they are withdrawn from the esophagus into the mouth.

  • Discussion.  Foley catheter balloon extraction is an easily performed, relatively effective, and safe method of removing blunt foreign bodies from the esophagus.  It avoids the morbidity and costs of endoscopy, general anesthesia, and hospitalization.  The procedure is most appropriate for removing flat, two-dimensional foreign bodies, such as coins and discs, because the relatively large Foley catheter can slide easily beside and beyond these objects.  The reported success rate for this procedure in more than 2500 patients is 95%.  The incidence of complications is 0.4%.  Only one death has been well documented and reported with this technique, and that was due to airway occlusion by a coin that was aspirated during its withdrawal.  

  • Generally accepted contraindications to Foley catheter balloon extraction are the presence of:  

    1. sharp or ragged foreign bodies or those of unknown type; 

    2. clinical or radiographic evidence of esophageal perforation; 

    3. complete esophageal obstruction, precluding the passage of the catheter.   Impaction for longer than 72 hours is a relative contraindication.  

  • Originally, radiolucent foreign bodies were considered a contraindication to use of this technique; however, more recent experience has shown that nonopaque objects can be safely and successfully removed with a Foley catheter balloon if the objects are first outlined with a contrast agent.  Another early taboo was the presence of an esophageal stricture because of the fear of esophageal rupture, but this concern has been dismissed by several authors, including us.  If the esophageal anatomy is defined with a small amount of barium, the balloon can be partially inflated in the region of the stricture in order to withdraw the foreign material away from the narrowed area.  After the foreign body has been retracted above the stricture, balloon distention can be increased as needed.

 


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