Removal of gastrointestinal foreign body

Abstract

The minireview titled “Modern endoscopist’s toolbox: Innovations in foreign body removal” by Shahid and published in the World Journal of Gastrointestinal Endoscopy provided a clear and comprehensive overview of endoscopic management of gastrointestinal foreign bodies. It will serve as a valuable resource for endoscopists involved in the diagnosis and treatment of such cases. Several key and controversial aspects of patient management were highlighted in a meaningful way, including the importance of thorough medical history-taking, appropriate use of radiological imaging, and the selection of suitable endoscopic extraction techniques. An individualized, multidisciplinary approach is essential for diagnosis and treatment. While current guidelines offer significant support, they cannot replace the judgment of an experienced endoscopist working with a well-trained team.

Key Words: Foreign body removal; Endoscopy; Upper endoscopy; Forceps; Snare; Anesthesia

Core Tip: The effective management of gastrointestinal foreign bodies relies on individualized clinical judgment as well as established guidelines. While current guidelines offer significant support, they cannot replace the judgment of an experienced endoscopist working with a well-trained team. Thorough pre-endoscopic assessment, appropriate imaging, skilled endoscopic technique, and multidisciplinary coordination, especially in high-risk cases, are essential for safe and successful outcomes.

TO THE EDITOR

I read with great interest the minireview “Modern endoscopist’s toolbox: Innovations in foreign body removal” by Shahid[1]. The manuscript addressed the topic of endoscopic management of gastrointestinal (GI) foreign bodies in a clear and comprehensive manner. It was highly informative and beneficial for all endoscopists involved in the diagnosis and treatment of GI foreign bodies. As an endoscopist with many years of experience and expertise in the extraction of GI foreign bodies, I would like to offer a few observations and comments regarding the aforementioned manuscript.

Pre-endoscopic preparation

As Shahid[1] rightly noted, a detailed patient history and physical examination are essential prior to endoscopy to characterize the foreign body and to assess the risk of potential complications. This is the most crucial step in the pre-endoscopic evaluation. It is challenging to diagnose patients with altered consciousness or cognitive impairment because the clinical history may not suggest foreign body ingestion. Additionally, symptoms like dysphagia may be attributed to neurological conditions instead. Endoscopy often provides a definitive diagnosis in these types of cases.

Radiography is recommended as the initial imaging modality to evaluate foreign body ingestion[1]. However, the European Society of Gastrointestinal Endoscopy guidelines state that radiography is advised only if the foreign body is radiopaque or if its composition is unknown[2]. While the diagnostic utility is higher for radiopaque objects, I recommend that each case should be assessed individually. Radiographic findings can still be informative even when the foreign body is not radiopaque by revealing partial or complete obstruction, the level of impaction, or signs of complications. Computed tomography is particularly important in suspected perforation cases, although I have found it to be valuable in all cases with an uncertain diagnosis. An interesting and underutilized method for detecting metallic foreign bodies is the use of metal detectors. Their application has been primarily documented in pediatric populations[3]. While current guidelines do not recommend their routine use, further research may clarify their potential utility.

Endoscopy

Endoscopic extraction of food bolus impaction and high-risk foreign bodies is typically performed under general anesthesia with airway protection[1]. I concur with this protocol, particularly in high-risk cases. However, if the patient is cooperative and the procedure is performed by an experienced endoscopist supported by skilled staff, impacted food boluses may be removed safely without general anesthesia. This method should be determined on an individual basis. Prior to the extraction of high-risk foreign bodies, the endoscopist must ensure that a responsible surgeon and anesthesiologist are in place for emergency surgical intervention should complications arise. Ideally, the surgeon should be physically present in the endoscopy unit during the procedure.

The choice of endoscopic accessory is determined by the characteristics of the foreign body and the endoscopist’s experience and preference[1]. In my opinion, the endoscopist’s personal proficiency with specific tools plays the most decisive role. Commonly used instruments include tripod forceps, alligator forceps, and retrieval nets. Tripod forceps are highly effective for extracting impacted food boluses from the esophagus. A useful technique involves opening the tripod two-thirds of the way before grasping the bolus and then closing it while performing continuous suction during extraction. The use of a polypectomy snare in the esophagus is technically challenging and generally less effective. The “push technique” has been proposed as an endoscopic method for relieving impacted boluses[1,2]. Although it has been effective, it carries certain risks as the nature of the distal pathology is often unknown prior to extraction. Therefore, endoscopists should use this method with caution.

Following the removal of a food bolus impaction, particularly in younger patients or when eosinophilic esophagitis is suspected based on endoscopic findings, it is essential to obtain esophageal biopsies. At least six biopsies should be taken from the distal and mid/proximal esophagus[2,4]. The European Society of Gastrointestinal Endoscopy guidelines recommend concurrently obtaining biopsies during the initial endoscopy with the foreign body extraction[4]. If the biopsy is deferred to a later elective procedure, patients may be less likely to return for follow-up.

Conclusion

An individualized, multidisciplinary approach is essential for diagnosis and treatment of GI foreign bodies. While current guidelines offer significant support, they cannot replace the judgment of an experienced endoscopist working with a well-trained team.