What is the best method for removing an esophageal foreign body, specifically meat, in children?

Esophageal Meat Foreign Body Removal in Children

Flexible endoscopy performed by a gastroenterologist is the best method for removing esophageal foreign bodies, including meat, in children, with success rates up to 90-98% and should be performed urgently within 24 hours or emergently within 2-6 hours if the child is symptomatic. 1, 2

Primary Removal Technique

• Flexible endoscopy is the gold standard first-line intervention for esophageal foreign body removal in children, including meat impactions 1, 2
• The procedure achieves successful removal in 97-98% of cases when performed by experienced operators 3, 2
• Flexible endoscopy can be performed under conscious sedation rather than requiring general anesthesia in many cases, though general anesthesia with endotracheal intubation is recommended for airway protection in children 1, 2
• The procedure takes significantly less time than rigid endoscopy (mean 10.5 minutes vs 16.5 minutes, p=0.04) 4

Retrieval Instruments and Technique

• Grasping forceps, baskets, or snares are the appropriate retrieval devices for meat and other esophageal foreign bodies 1, 5
• An overtube should be used when removing sharp or pointed objects to protect the esophageal mucosa during extraction 2
• Stone retrieval baskets are particularly effective for removing certain types of foreign bodies 5

Timing of Intervention

• Symptomatic children with drooling require emergent endoscopy within 2-6 hours because these symptoms indicate complete or near-complete obstruction with aspiration and perforation risk 1
• All esophageal foreign bodies should be removed within 24 hours to prevent perforation and fistula formation 1, 5
• Delaying intervention with 24-hour observation while fasting is contraindicated as it increases aspiration risk 1

Role of Rigid Endoscopy

• Rigid endoscopy is reserved as a second-line technique when flexible endoscopy fails or is unsuitable 1
• Rigid endoscopy is particularly indicated for upper esophageal foreign bodies when flexible endoscopy is unsuccessful 1
• Both techniques have equivalent safety profiles and success rates (97% overall), but flexible endoscopy is faster and allows better mucosal examination 3, 4

Essential Concurrent Procedures

• Obtain at least 6 biopsies from different esophageal sites during the procedure to evaluate for underlying pathology such as eosinophilic esophagitis, which is found in up to 25% of patients with food impaction 1
• Flexible endoscopy allows more thorough examination and easier biopsy collection compared to rigid endoscopy (19% vs 6% biopsy rate, p=0.04) 4

Common Pitfalls to Avoid

• Do not attempt non-endoscopic removal methods (such as balloon extraction for meat) as these are associated with increased perforation and aspiration risks 2
• Do not delay endoscopy for radiographic confirmation if the child has persistent esophageal symptoms, as plain radiographs have up to 85% false-negative rates for non-radiopaque foreign bodies like meat 1
• Do not discharge the child without ensuring they can tolerate water and providing clear instructions about diet progression and warning signs of complications 6

Backup Plan

• If flexible endoscopy fails, consult ENT for rigid endoscopy 1
• If both endoscopic techniques fail or perforation occurs, immediate surgical consultation (thoracic or general surgery) is required 1
• Training in both flexible and rigid techniques is essential since treatment failures with one method are successfully managed by converting to the other 3