Ingested and unremovable dental prostheses, with sharp clasps which catch and stick
in the esophagus, can lead to direct injury, compression ulcer, and perforation or
penetration [1]
[2]. To establish appropriate procedures for removing such objects according to our
strategy for accidentally swallowed esophageal foreign bodies, we examined: (i) the
removal process in cases without esophageal resection, and (ii) the resected specimen
in a case where esophagectomy had been done.
Our strategy for the management of esophageal foreign bodies is removal as follows:
(i) nonsurgically, using a direct forceps or an endoscope, by direct vertical traction
or horizontal rotation, and extracting the foreign body or pushing it into the stomach;
(ii) surgically, using synchronous direct manipulation under surgical exposure with
the assistance of a forceps or an endoscope; or (iii) surgically, with esophagotomy
or esophagectomy. Endoscopic examination is done both pre- and post-removal; in nonsurgical
cases this is to check for any preceding injuries that might have been missed or for
secondary injuries that occurred during removal of the foreign body, and in surgical
cases it is to done to check for preceding injuries invisible from the operative field
and to determine the method of reconstruction [3].
We encountered nine such cases in 6 years (involving the cervical esophagus in five
cases and the thoracic in four). None of these dental prostheses with sharp clasps
could be removed by simple vertical traction, but all except one could be removed
by horizontal rotation ([Fig. 1] and [2]), the remaining one being removed by esophagectomy. Although post-removal endoscopy
revealed ulcers in all cases, 1 or 2 days’ fasting was enough to prevent perforation
or penetration. In the resected specimen, we found longitudinal ulcers and perforation,
indicating that the clasp had moved vertically at first, scratched the mucosa, and
then rotated horizontally and penetrated the esophageal wall ([Fig. 3] -[5]) [3].
Fig. 1 Plain radiograph showing a dental prosthesis with sharp metallic clasps that are sticking
into the cervical esophageal wall. Inset: the removed prosthesis.
Fig. 2 Dental prosthesis with sharp metallic clasps caught in the orifice of the esophagus,
visualized by: a plain radiography, and b upper gastroenterological endoscopy. c The removed dental prosthesis.
Fig. 3 Plain radiograph showing dental prosthesis with sharp metallic clasps penetrating
the esophageal wall. In this case the incarcerated dental prosthesis was removed with
the esophagus during esophagectomy. Inset: the removed dental prosthesis.
Fig. 4 Resected specimen from the patient who underwent thoracic esophagectomy. A deep longitudinal
ulcer can be seen, and a perforation hole at the anal end of the ulcer in which the
clasp of the dental prosthesis had been incarcerated. This indicated that the clasp
of the ingested dental prosthesis had moved vertically at first, scratching the esophageal
mucosa, and had then rotated horizontally and penetrated the esophageal wall, suggesting
that we should attempt horizontal rotation at endoscopic removal
Fig. 5 Incarceration of a sharp clasp. The clasp can turn in any direction according to force
(gravity or peristaltic movement) when it is not sticking into the esophageal wall.
When even only the tip of the clasp has stuck, its main direction of movement is then
restricted: the force that will result in further penetration into or tearing of the
esophageal mucosa has a possible component along the direction of the clasp (penetration)
and a possible component perpendicular to this direction (tearing), and it is difficult
for the lateral surface of the shaft of the clasp to tear the layers of the esophageal
wall, from the mucosal to the muscular layer, simultaneously.
Although there have been many reports concerning procedures for passing foreign bodies
safely through the esophagus, there are few describing methods of extracting a dental
prosthesis with sharp clasps that are sticking into the esophageal wall [3]
[4]
[5]. This study shows the importance of horizontal rotation for extracting such a foreign
body.
Endoscopy_UCTN_Code_TTT_1AO_2AL
