Deeply embedded esophageal fishbone removed by endoscopic submucosal dissection. Foreign body ingestion is encountered frequently in clinical practice. Most foreign bodies pass spontaneously, however, sharp objects, most commonly bony fragments in adults, can become lodged in the esophagus and sharp angulations in the GI tract. Deeply embedded foreign objects are rarely encountered, but they can carry significant morbidity, sometimes mortality, and often require surgical intervention. There is little literature regarding use of endoscopic techniques to remove these foreign bodies. We present a case of a 50 year old gentleman who presented to the emergency department with several hours of dysphagia and odynophagia after consuming fish. He had no burden in medical history. An x-ray of the neck was negative for foreign body. CT chest was subsequently ordered. The CT demonstrated a linear opacity deeply embedded into the esophagus at the GE junction. The likely fishbone appeared to be penetrating through the muscularis propria, shy of the adventitia. Endoscopic ultrasound confirmed a linear hyperdensity projecting through the muscularis propria consistent with the fishbone. After consultation with thoracic surgery, the decision was made to pursue endoscopic removal in an attempt to avoid thoroscopic surgery. The patient was taken emergently to the OR for attempt at endoscopic removal using endoscopic submucosal dissection. In the distal esophagus, a long linear ulcer was identified. The ulcer was followed to just above the GE junction. After careful inspection and irrigation, a small piece of the fishbone could be seen embedded in a transverse orientation deeply in the esophageal tissue. A mixture of methylene blue and normal saline was injected into the defect to expand the submucosal space and help mobilize the fishbone. Using an ESD needle knife, an initial cut was made carefully along the right lateral margin of the defect to expose the bone. The partially exposed bone can now be seen situated between the longitudinal and circular muscular layers of the esophagus. Subsequent dissection was performed laterally using the bone as a scaffold to help prevent deeper injury. Subsequent dissection was performed laterally using the bone as a scaffold to help prevent deeper injury. As the dissection progresses, the extent of the bone penetration becomes more evident. Again, the bone can be seen embedded between the circular and longitudinal muscular layers of the esophagus. Here, we continue to dissect along the bone in an attempt to mobilize one of the free ends. Submucosal injection is again used to try to expand the submucosal space. Here a free end of the bone can be seen mobilized from the tissue. The mobilized bone was then grasped with a rat tooth forceps. It was extracted using an overtube to help prevent esophageal injury. Given the size, depth, and irregular margins of the defect, it was not amenable to closure by through-the-scope clips. A fully covered metal stent was deployed to close the defect. It was secured in place with four through-the-scope clips. The patient did well post-operatively with no immediate complications. He underwent repeat OGD in two weeks' time for stent removal, which demonstrated well-healed mucosa. This case highlights the importance of clinical history in prompt diagnosis of foreign body ingestion. It is important to understand the radiographic character of possibly ingested foreign bodies and which imaging modalities are most appropriate. For instance, plain x-rays can have a sensitivity as low as 50% for certain types of fish bones. Endoscopic ultrasonography can be useful in localizing deeply embedded foreign bodies which are not visible intraluminally. Endoscopic needle-knife dissection is a viable and safe technique which can be employed to remove penetrating foreign bodies and may avoid the need for invasive thoroscopic surgery.

Endoscopic submucosal dissection

Foreign body ingestion

Fishbone removal

Esophagus

Imaging techniques