Complications of foreign body impaction are directly related to the retention time in oesophagus. If the foreign bodies are retained for at least 3 days, pus will appear, followed in turn by an abscess cavity wrapped in fibrous tissue, making it more difficult to find the foreign body during open surgery. This increases the possibility of infection and severe haemorrhage. Therefore, the operation should be performed as soon as possible.
The clinical presentations were similar in that the patients commonly complained of dysphagia and odynophagia after mis-swallowing foreign bodies. CT is a useful method for diagnosing foreign body impaction in the oesophagus(4). More clinical information, such as the location of the foreign body in the neck tissues, the thickened of esophagus, extraluminal air in the soft tissue of the neck due to the oesophageal perforation and abscess cavities adjacent to the oesophagus, and even the arterial aneurysmal if present, can be visualized on CT. Information on the relationship between the foreign body and important cervical structures is important for open surgery. However, tenderness was most obvious at the pre-cervical sites,especially above the upper suprasternal fossa. It could be a screening physical sign of cervical oesophageal foreign body impaction.
Perforation of the cervical oesophagus will lead to abscesses in the tissues surrounding the oesophagus and even the upper mediastinum. Infection dissemination is limited because the oesophagus is attached to the prevertebral fascia and the spread of infection to the mediastinum is slow. Regardless, such infections are usually mild (10) and can be treated with sufficient flushing, drainage and broad-spectrum antibiotics. Cervical oesophagus lacerations due to foreign body impaction are always small can heal without suturing after endoscopic removal; whereas in case of open lateral neck incisions, suturing is needed. Sometimes, the mucosa is oedematous and cannot be sutured primarily. It might heal itself after drainage and anti-infection treatment. In the patient no. 1(table 1), the laceration of oesophagus was too long to be sutured. Sufficient drainage and enterostomy were performed to provide nutritional support and the patient still recovered well, starting on an oral diet after two months. Larger laceration should perhaps also be repaired in secondary surgery or with the muscles adjacent to the oesophagus, but no cases of muscle repair were recorded in our cases.
However, the cervical oesophageal perforation would lead to life-threatening complications such as mediastinum abscess and aneurysmal haematoma . The foreign body may perforate the carotid artery and cervical veins and cause massive bleeding. It should first be treated with vascular surgery and cervical open surgery immediately.
The objective of surgical procedure is exploration along the tracheoesophageal sulcus and oesophagus to search for foreign body and any purulent cavities, which can be difficulty because the thick fibrous wall of abscess cavity leads to confusion regarding the structure surrounding the oesophagus, making it difficult to locate the foreign bodies enveloped in the cavity. Early open surgery in the neck within three days of mis-swallowing is necessary because it is unlike that the purulent cavity has formed in that time. If the serious tissue fibrosis confuses the vital structures, the bony structure, such as cervical centrum and thyroid cartilage, is useful to locate the key structures.
Among the 15 cases, 12 underwent incision on the left side of the neck. Foreign bodies appear to easily enter into the left cervical side which may be related to the anatomical characteristics of the cervical oesophagus. Because this organ, passes through the front-left side of the vertebral column, foreign bodies are to penetrate the retroesophageal space from the left side of the oesophagus, and left cervical incisions are more convenient for exposing the oesophagus, the foreign body and the abscess. No severe intra- and postoperative complications occurred in these cases. Although the left recurrent laryngeal nerve is closer to the midline than the right nerve(11), no additional neurological damage was caused due to incision of the left side of the neck.
Some authors that consider posterior incision along the sternocleidomastoid muscle to also be feasible (12); however, we incised the neck along the anterior border of the sternocleidomastoid because it is closer to the oesophageal perforation. The incision is safe and convenient if the anatomy of the thyroid is familiar, and in our study, no complications of the blood vessels or nerves occurred in the cases that underwent the anterior incision.
Adequate flushing and drainage are crucial to accelerate the recovery after surgery. A two-lumen tube is sometimes required to treat abscesses in the superior-mediastinum.one lumen for flushing and the other for drainage. Certain procedures for oral intake were then followed. This procedure is relatively safe, no cases returned to the hospital due to postoperative reinfection around the oesophagus after transition to a normal diet in our cases.
More than 800 cases of oesophageal foreign body impaction were observed in our hospital in one year, most of which involved choking on fish bones, jujube seeds, chicken and duck bones and dentures, which can be removed with gastroscopy. Relatively few cases require surgical incision due to the protrusion of oesophageal foreign bodies into the neck space. But in those cases, an earlier intervention is best. Medical treatment often lasts more than one week, and a period of two to three weeks is ideal. Practical application of high-level antibiotics of sufficient dosage has been shown to be necessary. No recurrent infectious were observed in our series.
Surgery with a lateral neck approach can often be used to treat cases of mis-swallowed foreign bodies that protrude from the oesophagus into the neck, in addition to abscesses of the neck and super mediastinum. The procedure introduced in this study is a safe and feasible method for treating foreign body impaction.