Removal of an embedded esophageal fishbone by minimal incision using the gel immersion endoscopic ultrasound-guided technique

Endoscopic removal of ingested esophageal foreign bodies using forceps is a simple procedure [1], but it can become relatively difficult to identify and remove the foreign body when it is completely embedded in the wall [2] [3] [4]. Salvage surgery is highly complex and invasive; however, without intervention, there is a risk of perforation and mediastinal abscess formation [5].

An 82-year-old woman presented to the emergency department with pharyngeal pain on swallowing for 1 day. Computed tomography showed a 25-mm fishbone in the upper esophagus ([Fig. 1]). We performed outpatient gastroscopy and were initially able to detect the fishbone, but it accidentally strayed into the esophageal wall and was completely lost, leaving no penetration point such as a mucosal hole or erosion. With the patient under general anesthesia, we again attempted to remove the fishbone using miniature-probe endoscopic ultrasound (EUS) with a novel gel immersion technique, which clearly revealed the whole embedded fishbone beneath the mucosa without any evidence of muscular infiltration ([Fig. 2]). After the fishbone had been accurately located, we performed a local injection and started a mucosal incision, using a DualKnife (KD-650Q; Olympus Medical Systems, Tokyo, Japan), 3 mm from the tip of the bone, which was identified just under the incision line ([Fig. 3]). The fishbone was removed using a reopenable clip (SureClip; Micro-Tech, Nanjing, China), which enabled precise movement [Fig. 4]). Finally, a synthetic hemostatic material (PuraStat; 3-D Matrix, Tokyo, Japan) was applied to the incision line to prevent bleeding and postoperative stricture formation.

Fig. 1 Computed tomography image showing a 25-mm fishbone (arrowheads) in the upper esophagus.

Fig. 2 Endoscopic ultrasound image using a miniature probe with a novel gel immersion technique clearly showing the whole embedded fishbone beneath the mucosa.

Fig. 3 Endoscopic image showing the edge of the fishbone, which was revealed after the initial mucosal incision.

Fig. 4 Photograph of the extracted fishbone (right), which is seen to be the same shape as on computed tomography image (left).

In this report, we present the first case in which a fishbone was completely identified using EUS guidance with gel immersion and successfully removed with a minimal incision, without any complications ([Video 1]).

Removal of an embedded esophageal fishbone by endoscopic minimal incision with the gel immersion endoscopic ultrasound-guided technique.Video 1

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Artikel online veröffentlicht:
25. September 2024

• References

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