What is the best course of treatment for a patient with a foreign body, specifically a mutton bone, lodged in the esophagus?

Management of Mutton Bone Lodged in the Esophagus

Proceed immediately to emergent flexible endoscopy within 2-6 hours for removal of the mutton bone, as sharp-pointed and bony foreign bodies in the esophagus carry high risk of perforation, mediastinitis, and mortality. 1, 2, 3

Immediate Diagnostic Workup

Laboratory Studies

• Obtain complete blood count, C-reactive protein, blood gas analysis, and lactate to assess for early complications and systemic inflammation 4, 2

Imaging Strategy

• Perform CT scan immediately if there is any suspicion of perforation (neck pain, fever, subcutaneous emphysema, hemodynamic instability), as CT has 90-100% sensitivity compared to only 32% for plain radiographs 4, 2
• Plain radiographs of neck, chest, and abdomen can identify the bone's location and assess for free air, but have false-negative rates up to 85% for bony foreign bodies 4, 2, 3
• Do NOT perform barium or contrast swallow studies as they increase aspiration risk and impair subsequent endoscopic visualization 4, 2, 3

Endoscopic Management (First-Line Treatment)

Timing and Approach

• Emergent endoscopy within 2-6 hours is mandatory because bone fragments are sharp-pointed objects with high perforation risk 1, 2, 3, 5
• Use a protective device (overtube or hood) during extraction to prevent esophagogastric/pharyngeal damage and aspiration 3
• Consider endotracheal intubation if aspiration risk is high 3

Extraction Technique

• Use appropriate retrieval devices such as rat-tooth forceps, grasping forceps, baskets, or snares depending on bone size and configuration 2, 3, 6
• If the bone is embedded in the esophageal wall, do not force extraction endoscopically as this increases perforation risk 7

Diagnostic Biopsies

• Obtain at least 6 biopsies from different esophageal sites during the index endoscopy to evaluate for underlying pathology (strictures, eosinophilic esophagitis, webs, tumors) that predisposed to impaction 4, 2, 8
• Up to 25% of patients with food/bone impaction have underlying esophageal disorders 4, 2

Surgical Management (When Endoscopy Fails or Complications Present)

Indications for Surgery

• Perforation with free mediastinal or pleural contamination 1
• Foreign body irretrievable endoscopically or positioned dangerously close to vital structures (aorta, azygos vein, trachea) 1, 2, 7
• Bone transfixing the esophageal wall approaching major vessels 7

Surgical Approach

• Esophagotomy with foreign body extraction and primary repair is the preferred technique 1, 2
• Consider combined endoscopic-surgical approach: endoscopy helps locate the perforation precisely, allows safe bone removal under direct vision, enables double-layer repair (internal and external), and facilitates nasogastric tube placement 7
• If primary repair is not feasible due to extensive tissue damage or delayed presentation, perform external drainage, esophageal exclusion, or resection 1

Management of Perforation

If Perforation Occurs During Endoscopy

• Immediate endoscopic band ligation can be attempted for small perforations detected immediately after bone removal 6
• Mortality from esophageal perforation can reach 22%, making immediate treatment critical 6

Operative Repair for Established Perforation

• Operative repair is the treatment of choice for free perforation of the thoracic esophagus with direct repair and adequate drainage 1
• Buttress repairs with viable tissue and ensure proper drainage 1

Post-Procedure Management

Immediate Post-Endoscopy

• If uncomplicated removal without perforation, patient may be discharged after observation 3
• If perforation suspected or confirmed, admit for IV antibiotics, NPO status, and serial imaging 6

Follow-Up

• Schedule outpatient endoscopy if adequate biopsies were not obtained initially 4, 2
• Arrange outpatient review to confirm underlying cause, educate patient about dietary modifications, and institute treatment for any identified esophageal pathology 4, 2

Critical Pitfalls to Avoid

• Never delay endoscopy for pharmacologic interventions (glucagon, benzodiazepines, fizzy drinks) as these have limited evidence and bone fragments require mechanical removal 4, 8
• Never attempt to push a sharp bone distally into the stomach as this dramatically increases perforation risk; only retrieval is appropriate 2, 3
• Do not rely on negative plain radiographs to exclude complications when clinical suspicion exists 4, 2
• Failure to obtain diagnostic biopsies leads to missed underlying pathology and recurrent impactions 4, 2
• Do not lose patients to follow-up; schedule outpatient appointments before discharge 4, 2