Clinical characteristics
From 2009 to 2020, there were entirely 1152 cases of foreign body endoscopic extraction in the upper GI tract. Among them, 7 cases were found no foreign body during the process. There were 4 cases that failed to remove the foreign object. The success rate was 99.7%. 2 cases had fish bones impacted in the level of arcus aortae of the upper thoracic esophagus and the patients were referred to surgery.1 case was because of denture incarceration. 1case was a child who ingested slithery global part of toys and the object dropped off into the nasal cavity.
988 cases belonged to food FoBIs (fish bones, animal bones, food bolus, jujube pits and well-shaped undigested food) and 157 cases belonged to nonfood FoBIs (toiletries, utensils, metals, dentures, etc.).
Of those cases reported, food FoBIs accounted for 86.3%. In this group, the ratio of females was slightly higher (50.6%, n = 500) and the average age was 52.31 ± 15.60 years old. 698 of them were outpatients (70.6%). Cervical esophagus was the most often impacted area (40.1%, n = 396) and upper thoracic esophagus was the next (23.5%, n = 232). Fish bone was the dominating type (54.9%, n = 543) and then was the food bolus (16.6%, n = 164). The proportion of animal bones(n = 124) was 12.6%. Jujube pits(n = 56) consisted 5.7% of all food FoBIs.165 patients (16.7%) were found concomitant GI disease, including esophageal diseases like carcinoma (n = 40), stenosis(n = 30) and anastomotic stricture (n = 65) and gastric diseases such as carcinoma(n = 5), pyloric stenosis(n = 3), etc. Figure 1 exhibits three cases of bones and jujube pits impaction among the enrolled cases.(Fig. 1 Endoscopic images showing: (A) the sharp fish bone impacted in the esophagus (20cm from the incisors) and extracted by the forceps, causing perforation (B) the jujube pits impacted in the esophagus (15cm from the incisors) and extracted by the forceps, causing perforation (C) the jujube pits impacted in the gastric antrum and extracted by the basket.)
Nonfood FoBIs(n = 157) made up 13.7% of all the cases reported. Different from the food FoBIs, the majority of nonfood FoBIs occurred in males (66.9%, n = 105, p < 0.001) and stomach was the most frequent impacted location (56.1%, n = 88, p < 0.001). Similar to the food kind group, most of them were outpatients (74.5%, n = 117, p = 0.344). The average age was 41.16 ± 19.78 years old, younger than the other group(p < 0.001). Most of the patients were not diagnosed suspected GI disease. Mental diseases were not described in the records. There had been coins, dentures, diverse parts from metallic materials or toys, toiletries, utensils, accessories, magnets and batteries, etc. Totally, 172 patients were found associated GI diseases during the extraction (15%). Table 1 demonstrated the characteristics of food and nonfood FoBIs respectively. Table 2 showed the numbers of different type of foreign bodies.
Table 1
Clinical characteristics of patients
|
Food FoBI
|
Nonfood FoBI
|
P
|
Gender
|
|
|
< 0.001
|
male
|
488(49.4%)
|
105(66.9%)
|
female
|
500(50.6%)
|
52(33.1%)
|
Average age(years old)
|
52.31 ± 15.60
|
41.16 ± 19.78
|
< 0.001
|
Visit approach
|
|
|
0.344
|
outpatient
|
698(70.6%)
|
117(74.5%)
|
|
Inpatient
|
290(29.4%)
|
40(25.5%)
|
|
Location
|
|
|
< 0.001
|
Epiglottis
|
25(2.5%)
|
5(3.2%)
|
Cervical esophagus
|
396(40.1%)
|
19(12.1%)
|
Upper thoracic esophagus
|
232(23.5%)
|
18(11.5%)
|
Middle thoracic esophagus
|
125(12.7%)
|
4(2.5%)
|
Lower thoracic esophagus
|
78(7.9%)
|
7(4.4%)
|
Stomach
|
92(9.3%)
|
88(56.1%)
|
Duodenum
|
40(4.0%)
|
16(10.2%)
|
Underlying GI disease
|
165(16.7%)
|
7(4.5%)
|
< 0.001
|
Table 2
Foreign body types and numbers
|
Foreign body type
|
No.
|
Food related foreign body
|
Fish bone
|
543(54.9%)
|
|
Other animal bones
|
124(12.6%)
|
|
Food bolus
|
164(16.6%)
|
|
Shaped undigested food
|
101(10.2%)
|
|
Jujube pits
|
56(5.7%)
|
Nonfood foreign body
|
coins
|
10
|
|
denture
|
14
|
|
Medical supply
|
3
|
|
details
|
29
|
|
Packaged tablet
|
7
|
|
key
|
4
|
|
lighter
|
19
|
|
toothpick
|
7
|
|
toothbrush
|
8
|
|
razer
|
2
|
|
stationery
|
3
|
|
accessory
|
6
|
|
battery
|
2
|
|
utensils
|
3
|
|
metal
|
18
|
|
magnets
|
3
|
|
glass
|
4
|
|
scissor
|
1
|
|
needle
|
10
|
|
Coat hanger
|
1
|
|
hair
|
3
|
Time trend and seasonal variation
In total, there were 2.5 cases of food FoBI endoscopic extraction per 1000 patients of EGD investigations. For nonfood FoBI extraction, the frequency was 0.4 per 1000 patients of EGD. There was an uptrend in the annual frequency of food FoBI endoscopic extraction per 1000 patients of EGD during the study period. (r = 0.902, P < 0.001) Over the 12-year time frame of the study, the annual frequency of food foreign body endoscopic extraction increased from 0.65 in 2009 to 8.86 per 1000 patients of EGD in 2020. By contrast, there was no significant change in the annual frequency of nonfood FoBI endoscopic extraction(P = 0.111) (Fig. 2).(Fig. 2 Food foreign body ingestions(FoBIs) versus nonfood foreign body ingestions, 2009 to 2020; the annual frequency of foreign body endoscopic extraction per 1000 patients of esophagogastroduodenoscopy (EGD) over the study years. While food FoBIs was demonstrated by Spearman Correlation test to have a significant uptrend (r = 0.902, P < 0.001), nonfood FoBIs did not demonstrate a significant trend (P = 0.111)).
For seasonal variation, the frequency of food FoBI endoscopic extraction per 1000 patients of EGD had a significant increase in winter (P < 0.001), while there was no significant difference among the other three seasons(P = 0.840). By contrast, there was no seasonal variation in nonfood FoBI endoscopic extraction(p = 0.451) (Fig. 3) (Fig. 3 Food foreign body ingestions versus nonfood foreign body ingestions, 2009 to 2020; seasonal variation of the frequency of foreign body endoscopic extraction per 1000 patients of esophagogastroduodenoscopy (EGD).\({\text{X}}^{2}\) test showed a significant increase during the winter(P < .001) and no significant change in the other three seasons(P = 0.840) in food FoBIs. There was no significant seasonal variation in nonfood FoBIs (P = 0.451)).
And the proportion of different types of food foreign body changed with the season. (P = 0.046) (Fig. 4) The ratios of bones and well-shaped undigested food (distinguished from food bolus) were higher in the winter (bones:69.7% versus 65.0%,66.0%,68.2%; well-shaped undigested food:13.3% versus 8.4%,7.1%,10.5%). The proportion of jujube pits was higher in the spring (8.4% versus 5.7%,4.5%,4.5%). (Fig. 4 Food foreign body and seasons, 2009 to 2020; The proportion of different kinds of food foreign body changed with seasons. \({\text{X}}^{2}\) test showed that the ratios of bones and well-shaped undigested food were higher in the winter than the other three seasons. (P = 0.046)).
Impact of Chinese New Year
In the January and February of the study period, there were totally 213 cases of upper GI foreign body endoscopic extraction. 76 cases were in the Chinese New Year celebratory seasons (totally 180 days) and 137 cases occurred in the other days of these months (totally 531 days). The frequency of foreign body endoscopic extraction demonstrated a significant increase in the 15-day block surrounding Chinese New Year than the other days of January and February by Mann-Whitney U test (P = 0.003).
Risk factors for complications
There were 6 cases leading to a fistula due to the sharp objects including animal bones(n = 2), fish bones(n = 2) and jujube pits(n = 2). 5 cases involved esophagus and 1 case was in the stomach. Meanwhile, 22 cases were diagnosed perforation and treated with titanium clip and drainage tube. The reason included fish bones(n = 15), jujube pits(n = 4), animal bones(n = 2) and toothbrush(n = 1). Most of them influenced the esophagus (n = 19). The overall ratio of adverse events was 2.4%. Major complications included fistula (0.5%) and perforation (1.9%). Inpatient(OR = 5.656, P < 0.001), jujube pits(OR = 18.306, P = 0.009) and age ≥ 60 years(OR = 2.979, P = 0.007) indicated the high risk of severe complications. Results are presented in Table 3.
Table 3
Factors that were associated with increased risk of perforation and fistula
Variables
|
OR
|
95%CI
|
P
|
Inpatient(vs. outpatient)
|
5.565
|
2.500-12.392
|
< 0.001
|
Jujube pits(vs. other objects)
|
18.306
|
2.062-162.526
|
0.009
|
Age ≥ 60years(vs.<60 years)
|
2.979
|
1.348–6.584
|
0.007
|