Fig. 3.1.
Chest X-ray showing radiopaque foreign body in the upper esophagus in the region of the cricopharyngeus muscle.
Surgical Indications
The presence of foreign body in the esophagus on imaging is an indication for retrieval. A child with a convincing history of ingestion of a radiolucent object is also an indication. As well, foreign bodies in the esophagus, stomach, or distal intestine require urgent removal if they have potential to cause damage such as batteries or multiple magnets [1].
Special Considerations
Foreign body removal from the airway is almost always performed with rigid endoscopic tools due to improved grasping ability. Esophageal or gastric foreign bodies may be removed using either rigid or flexible endoscopic tools. Larger children or adolescents may require flexible endoscopy for distal esophageal or gastric foreign bodies due to the length restrictions of rigid instruments.
The usual locations of esophageal foreign bodies, depending upon the child’s age, requiring extraction are near the cricopharyngeal sphincter (over 90 %), distal esophagus, or at prior anastomotic sites [2].
Technique
The patient is positioned supine with a shoulder roll. General anesthesia is typically used, and a bite block is placed. Rigid endoscopic equipment appropriate for size/age or flexible endoscopic equipment is required. Among flexible endoscopes , the Olympus GIF 180 (9.3 mm OD) or GIF XP 160 (4.9 mm OD) (Olympus America, Center Valley, PA) are used depending on the size of the patient (Figs. 3.2 and 3.3). Optical grasping forceps (Fig. 3.4) or flexible graspers, snares, or basket should be available (Fig. 3.5).
Fig. 3.2.
Rigid endoscope.
Fig. 3.3.
Flexible endoscope.
Fig. 3.4.
Optical grasping forceps.
Fig. 3.5.
Snare and basket for flexible endoscopy.
For rigid endoscopy, the scope is inserted posteriorly until the esophageal lumen is visualized.
Once the foreign body is visualized, the telescope is exchanged for optical grasping forceps.
The object is grasped, and the entire scope and grasper is removed in a single motion.
The optical grasper is exchanged for the visualizing scope and reintroduced to inspect the mucosa for trauma or injury. For flexible endoscopy, there is no need for instrument exchange. Objects may be removed by introducing grasping forceps, snare, or basket through the working channel of the scope. Similarly, when the object is grasped, the scope and grasping device are removed in a single motion.
Pearls/Pitfalls
It is essential to have all of the necessary equipment prepared and sorted out prior to starting the procedure since instrument or scope exchange is frequently necessary. Any delay in this exchange process can lead to loss of visualization of the object.
With esophageal foreign body removal using rigid scopes, it is sometimes helpful to attach the insufflation tubing of a sigmoidoscope (Fig. 3.6) to the esophagoscope to inflate air to distend the esophageal lumen and prevent the walls from collapsing in to obscure the view.
Fig. 3.6.
Insufflation tubing (from rigid sigmoidoscopy scope).
After grasping the object, one must pull the scope and grasper out simultaneously otherwise the object will be knocked off back into the esophagus by the scope if only the grasper is pulled out.
Postoperative Care
Esophageal foreign bodies can be removed by either rigid or flexible endoscopy with good results and minimal complications. It has been shown that if one approach is unsuccessful, then the alternative approach may be utilized with success [2].
Majority of patients may be discharged from the postanesthesia recovery unit. Exceptions to this include patients with perforation or significant erosion, ongoing respiratory symptoms, or comorbidities.
The overall rate of complications after endoscopic esophageal foreign body removal is low (1–2 %) and may include esophageal perforation, mucosal erosion, mediastinitis, pneumothorax, and pulmonary edema [2].
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Preoperative Evaluation
Commonly, there is a diagnosis of choledocholithiasis, cholangitis, pancreatitis, or right upper-quadrant cystic mass. These diagnoses may be supported by jaundice and right upper-quadrant or epigastric pain on physical exam.
Laboratory evaluation may reveal elevated liver function tests such as hyperbilirubinemia or transaminitis, elevated amylase/lipase, or leukocytosis on complete blood count. A metabolic panel may show electrolyte disturbances.
Right upper-quadrant ultrasound, plain abdominal films (may show gallstones), abdominal computed tomography (common bile duct dilation), and/or magnetic resonance cholangiopancreatography (MRCP) may be useful in the workup of jaundice [3].
Surgical Indications
Surgical indications for ERCP include common bile duct (CBD) obstruction with dilation, CBD stones (before or after cholecystectomy), resolved gallstone pancreatitis with persistent CBD dilation, equivocal MRCP findings requiring definition of pancreaticobiliary anatomy, and internal drainage of biliary tree or pancreatic duct [4].
Special Considerations
The indications for ERCP are similar to those utilized for adult patients although smaller patient size conditions need to be considered. The smallest side-viewing duodenoscope for ERCP has an outer diameter (OD) of 7.3 mm. It is possible to use this therapeutic endoscope in infants as small as 10 kg. ERCP should not be performed in the setting of active pancreatitis. For difficult cases, if the endoscopist is not a surgeon, then surgical backup should be available.
The relevant anatomy includes the duodenum, ampulla of Vater, common bile duct, and the pancreatic ducts of Wirsung and Santorini. It is important to consider the possibility of pancreatic divisum.
Surgical Technique
The patient is placed in supine position. Instruments that are required include a side-viewing endoscope (Fig. 3.7), cannulating catheter, guide wire, sphincterotome, biliary stents (Fig. 3.8), and electrocautery attachment.
Fig. 3.7.
Flexible endoscope for ERCP with side-viewing end.
Fig. 3.8.
Cannulation catheter, sphincterotome, and stent.
For diagnostic purposes, ERCP is performed by cannulating the ampulla of Vater and injecting contrast into the orifice of the pancreatic and common bile ducts. Diagnosis of a choledochal cyst is seen in Fig. 3.9.
Fig. 3.9.
ERCP with cholangiogram demonstrating type I choledochal cyst.
For stone removal/retrieval, the ampulla is cannulated, and then a sphincterotomy is performed to open the ampulla.
Either balloon extraction and/or flushing of the CBD are performed to remove stones.
Pearls/Pitfalls
Smaller patients are more challenging with respect to cannulating the ampulla and performing sphincterotomy.
Postoperative Care
The postprocedural management after ERCP is dictated by the disease process that was the indication for ERCP.
The results of ERCP in children are generally good with limited complications. In an experienced center, bile duct cannulation success as well as therapeutic duct clearance success rates are high [5, 6]. Complications after ERCP include pancreatitis (3–8 %), post-sphincterotomy bleed (rare), duodenal perforation (rare), and bile duct perforation (rare) [5, 6].
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