What is the management approach for a patient with a retained foreign body, specifically a bronze coil?

Management of Retained Bronze Coil Foreign Body

For a retained bronze coil foreign body, immediately obtain anteroposterior and lateral plain X-rays of the chest, abdomen, and pelvis to localize the object and assess for perforation, then proceed with location-specific extraction based on a stepwise algorithm prioritizing transanal/transurethral approaches before surgery. 1

Initial Assessment

Clinical Evaluation

• Obtain a focused medical history and complete physical examination to assess hemodynamic stability and signs of perforation 1
• Delay digital rectal examination until after X-ray acquisition to prevent accidental injury from the sharp metallic coil 1
• Bronze coils are radiopaque and will be clearly visible on plain radiography 2

Imaging Protocol

• Obtain lateral and anteroposterior plain X-ray films of chest, abdomen, and pelvis as the initial imaging study (strong recommendation, 1B evidence) 1
  • This identifies the foreign body position, shape, size, location, and presence of pneumoperitoneum 1
• If perforation is suspected in a hemodynamically stable patient, obtain contrast-enhanced CT scan of the abdomen (strong recommendation, 1B evidence) 1
• Do NOT delay surgical treatment for imaging if the patient is hemodynamically unstable 1

Laboratory Testing

• Avoid routine laboratory tests if there are no signs of perforation 1
• If perforation is suspected, obtain complete blood count, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin, lactate) 1
• Request routine preoperative blood tests only if manual extraction fails or is not feasible 1

Extraction Approach Based on Location

For Low-Lying Anorectal Foreign Bodies (Below Rectosigmoid Junction)

• Attempt bedside extraction as first-line therapy without signs of perforation 1
• If bedside extraction fails, use pudendal nerve block, spinal anesthesia, intravenous conscious sedation, or general anesthesia to improve transanal retrieval success 1
• Do NOT attempt transanal extraction if there are signs of hemodynamic instability or perforation (strong recommendation, 1C evidence) 1

For High-Lying Anorectal Foreign Bodies (Above Rectosigmoid Junction)

• Attempt endoscopic extraction as first-line therapy 1

For Urethral Foreign Bodies

• For bulbar urethral location, attempt bedside extraction initially 3
• If less invasive methods fail, proceed to open surgical approach 3

Post-Extraction Evaluation

• Perform proctoscopy or flexible sigmoidoscopy after foreign body removal to evaluate bowel wall integrity 1
• For urethral cases, perform cystoscopy after removal to assess urethral wall status 3

Surgical Indications and Approach

Without Perforation

• Proceed to surgery only if transanal/transurethral extraction fails 1
• Use a "step-up" surgical approach: start with downward milking, then proceed to colotomy only when milking/transanal extraction fails 1
• Use laparoscopic approach if skills and instrumentation are available 1

With Perforation and Limited Peritoneal Contamination

• Perform primary suture only for small, recent perforations with healthy, well-vascularized colonic tissues that can be approximated without tension 1
• If primary suture is not feasible in clinically stable patients without risk factors for anastomotic leakage, perform resection with primary anastomosis with or without diverting stoma 1

With Perforation in Critically Ill Patients

• Perform Hartmann's procedure in critically ill patients or those with extensive peritoneal contamination and risk factors for anastomotic leakage 1
• For hemodynamically unstable patients, perform emergent laparotomy with damage control surgery approach (strong recommendation, 1B evidence) 1

Antibiotic Therapy

• Do NOT routinely administer antimicrobial therapy for uncomplicated retained foreign bodies 1, 3
• Administer broad-spectrum antibiotic therapy according to intra-abdominal infection guidelines if there are signs of hemodynamic instability or perforation (strong recommendation, 1B evidence) 1, 3

Critical Pitfalls to Avoid

• Never delay surgical intervention for imaging in hemodynamically unstable patients 1, 3
• Never attempt transanal extraction when perforation or hemodynamic instability is present 1, 3
• Never perform digital rectal examination before obtaining X-rays when dealing with metallic foreign bodies 1, 4