Abstract

Background: This study aims to assess the outcomes and prognosis of surgical interventions aimed at removing esophageal foreign bodies in patients with mental retardation.

Methods: Between January 2010 and January 2021, a total of 30 consecutive patients (20 males, 10 females; median age: 29.5 years; range, 2 to 57 years) with mental retardation who were diagnosed with esophageal foreign bodies and underwent surgical treatment were retrospectively analyzed. Age and sex of the patients, symptoms, type of the foreign body, esophageal stricture level, methods used for preoperative diagnosis, type of surgical procedure, postoperative complications, and length of hospital stay were recorded.

Results: Seventeen (56.6%) patients had a foreign body in the first narrowing, 12 (40%) in the second narrowing, and one (3.3%) in the third narrowing. A rigid esophagoscopy was performed in all cases. However, successful removal was not achieved in two (6.6%) cases, and foreign bodies were removed through cervical esophagotomy in one (3.3%) patient and through esophagotomy with right thoracotomy in one (3.3%) patient. Postoperative complications included esophagitis in seven patients (23.3%) and wound infection and pneumonia in two patients (6.6%). The median length of hospital stay after treatment was 1.09 days in patients without complications and 3.3 days in patients with complications. There was a significant correlation between the occurrence of complications and the length of hospital stay (p=0.002). The foreign body was successfully removed in all patients, and no mortality was observed.

Conclusion: Early diagnosis and emergency intervention can reduce complications, particularly considering the possibility of non-food and sharp-edged foreign bodies that pose a higher risk of damaging the digestive system, in patients with mental retardation than those without such conditions.

Esophageal foreign bodies (EFBs) refer to substances, including medications, food items, or inorganic materials, which are ingested accidentally or intentionally and lodged within the esophagus.[1] This common condition requires early diagnosis and immediate intervention, as it has the potential to result in a wide range of complications, including mucosal ulceration, esophageal perforation, mediastinitis, tracheoesophageal fistula, and aortoesophageal fistula, all of which can be fatal.[1,2] Invasive procedures are required in only 10 to 20% of the patients, as foreign bodies are often expelled from the body without complications due to the slippery structure of the digestive tract.[3,4] In the adult age group, foreign body retention in the esophagus usually occurs accidentally.[1] Since patients with intellectual disabilities, who constitute a special group of patients, tend to manipulate objects with their hands and put them into their mouths, non-food objects may also be encountered as EFBs.[5] They are also susceptible to eating disorders and are at risk of experiencing obstruction once incompletely chewed food, nuts, or animal bones are lodged in the esophagus, representing the narrowest segment of the upper gastrointestinal tract.[6]

In the present study, we aimed to evaluate our experience with EFBs in patients with mental retardation who underwent rigid esophagoscopy and esophageal surgery for foreign body retrieval.

Methods

This multi-center, retrospective study was conducted at Department of Thoracic Surgery of three centers between January 2010 and January 2021. Among 1,048 patients who were admitted to our hospital with EFBs, a total of 30 consecutive Caucasian patients (20 males, 10 females; median age: 29.5 years; range, 2 to 57 years) with mental retardation who were diagnosed with EFBs and underwent surgical treatment were included.

The data evaluated included age, sex, symptoms, type of the foreign body, esophageal stricture level where the foreign body stays in the esophagus, methods used for preoperative diagnosis, type of surgical procedure, postoperative complications, and length of hospital stay.

Statistical analysis
Statistical analysis was performed using the IBM SPSS for Windows version 25.0 software (IBM Corp., Armonk, NY, USA). Continuous variables were presented in mean ± standard deviation (SD) or median (min-max), while categorical variables were presented in number and frequency. The chi-square correlation test was used to test whether there was a relationship between two independent classification variables. A p value of <0.05 was considered statistically significant.

Results

Of a total of 30 patients, three (10%) were diagnosed with Down syndrome. The period between foreign body ingestion and treatment was 0-1 day (11 patients presented one day after foreign body ingestion). All cases were symptomatic at presentation. Among these patients, 28 presented with dysphagia, five had hypersalivation, one reported a stinging sensation while swallowing, and one had a cough. In four cases, the diagnosis was established solely through direct radiography, while in the remaining cases, thoracic computed tomography (CT) was additionally used for diagnosis. Figure 1 shows the furniture pieces within the thoracic esophagus on thoracic CT scans (A) and the furniture pieces following their removal through esophagoscopy (B).

Figure 1. (a) The furniture pieces in the esophagus on thoracic computer tomography and (b) images of the pieces removed after esophagoscopy.

A rigid esophagoscopy was performed in all cases. In two (6.6%) patients, the foreign body could not be removed through rigid esophagoscopy. Right thoracotomy and esophagotomy were performed in one patient who swallowed stones and marbles, and cervical esophagotomy was performed in another patient who swallowed whole walnut in shell. The success rate of esophagoscopy was 93.3%. The patient who swallowed a whole walnut in the shell was found to have destroyed a saturation probe during intensive care unit (ICU) follow-up, and the foreign body was removed through rigid esophagoscopy.

The most common foreign bodies included bone (n=17, 56.6%), stone (n=4, 13.3%), and marble (n=3, 10%). The sites of esophageal narrowing where the foreign bodies became lodged were as follows: the first site of narrowing in 17 (56.6%) patients, the second site of narrowing in 12 (40%) patients, and the third narrowing in one (3.3%) patient. Postoperative complications included esophagitis in seven patients (23.3%) a nd w ound i nfection a nd p neumonia i n two patients (6.6%). The median length of hospital stay after treatment was 1.09 days in cases without complications. However, the median length of hospital stay was 3.3 days in cases with complications. There was a significant correlation between the occurrence of complications and the length of hospital stay (p=0.002). The foreign body was successfully removed in all patients, and no mortality was observed. Table 1 shows demographic and clinical data of the patients.

Table 1. Demographic and clinical characteristics

Discussion

Esophageal foreign body ingestion is one of the most frequently encountered emergencies, with patients able to recover successfully through early diagnosis and treatment without complications.[7] While it is frequently observed in childhood, its occurrence in adulthood is relatively low.[8] It can often be caused by psychiatric disorders and intellectual disability/ neurodevelopmental delay in advanced ages.[9] It may occur intentionally in developing children and elderly patients or adults and prisoners, or it may occur unintentionally in patients with mental retardation due to hallucinations.[10] The patients in our study had intellectual disabilities, and most were in the adult age group. Kaazan et al.,[11] in their multi-center study in which they shared their eightyear experience with EFBs, showed that underlying mental problems were present in 21% of EFBs in adults. In a study reporting on a 20-year experience, Çelik et al.[12] found that 18.8% of patients presenting with EFB retention had accompanying mental health problems. In our study, it was observed that four patients were in the pediatric age group and 26 patients were adult patients. And in our study, a rate of 2.4% was observed.

The type of swallowed foreign body can vary. The nature, size, and location of EFB affect the likelihood of having symptoms and/or complications and, as a result, the management of patients. Higher risk of EFB in mentally retarded patients is associated with various reasons, including poor hand-mouth coordination, discovery of objects, prolonged oral phase, and limited control over objects placed in the oral cavity, and dysphagia.[9] While coins are the primary foreign bodies ingested by children, adults most commonly encounter large pieces of food, particularly meat, as the most common foreign bodies.[13] Similar to that observed in children, bone and non-food foreign bodies were predominant in our cases. Meaty foods should be separated from their bones and given as food to mentally retarded patients and their access to any non-food object that can fit into the oral cavity and be swallowed should be prevented. Individuals who take care of them should be careful in this matter.

Details regarding the foreign body and the time of ingestion can be usually obtained from most adult and adolescent age groups. Infants, young children, mentally disabled individuals, or prisoners might face difficulties or be unwilling to provide a medical history.[14] Therefore, in the presence of sudden severe dysphagia in such patients, it is necessary to consider EFB ingestion and to take a detailed anamnesis that allows us to reach the diagnosis.[15] Dysphagia and hypersalivation were the most common symptoms in our patients, all of whom were symptomatic. However, due to the limited ability of this patient group to communicate like individuals without disabilities, some of them were hospitalized a day after the potential ingestion of the foreign body. Therefore, informing the relatives of individuals with intellectual disabilities about the symptoms that may occur due to EFBs may be effective in early presentation and early intervention.

In case of diagnosis delays and misdiagnoses, serious complications and even life-threatening conditions may develop due to the foreign body, and medico legal problems may occur.[9] The possibility of EFB should be considered in patients with mental retardation, even in the absence of a feature in the anamnesis and/or in the absence of a direct witness to the event.

As our study primarily focused on EFBs in people with mental retardation, we could not evaluate the factors affecting the occurrence of complications because of the small number of cases. Many studies in the literature evaluated the factors such as the type of foreign body, its dimensions, and the duration of retention in the esophagus as potential elements influencing the occurrence of complications.[6,12,13,16] Esophageal foreign bodies are an important clinical condition encountered in all age groups. According to the type of EFBs, there may be objects that can lead to life-threatening complications and be difficult to remove.[17] About 10 to 20% of swallowed objects are removed by endoscopy, while less than 1% require surgical intervention. Surgical intervention is indicated in cases of perforation, obstruction, organ injury and foreign body stuck in the surrounding tissues.[10] In cases with mental retardation, early intervention is necessary to prevent complications by remembering that the retention time may be prolonged due to inadequate medical history and the possibility of non-food sharp-edged foreign bodies having been ingested. However, no consensus exists on the most optimal way to remove an EFB. The main goal should be to prevent complications caused by foreign bodies. Gastroenterologists advocate flexible instruments, while surgeons prefer rigid esophagoscopy. However, due to high detection, low complication and high success rates, both can be recommended in treatment.[18] We preferred rigid esophagoscopy under general anesthesia in all of the cases included in our study, as patients with mental retardation were not able to cooperate effectively during the foreign body removal procedure, and we anticipated that sudden movements by patients might lead to complications and our success rate in foreign body removal with rigid esophagoscopy was 93.3%. None of the patients developed major complications such as perforation or mediastinitis, but minor complications prolonged hospitalization. Due to its high success rate and low complication rates, we believe that rigid esophagoscopy under general anesthesia should be preferred for EFB removal in patients with mental retardation.

As the application period of patients increases, they may present with esophageal perforation depending on the shape and size of the foreign body. Additionally, during EFB removal, the risk of perforation may increase depending on the shape and size of the foreign body. Therefore, it is of great importance to remove the foreign body in the first 24 h to prevent the risk of perforation. If there is perforation in the esophagus, primary repair of the esophagus without wasting time is extremely important to prevent morbidity and mortality.

The study has various limitations. First of all, since the study is retrospective, data were extracted from discharge summaries and medical records. Secondly, the sample size in the study is small. Thirdly, the study period covers a long period of time. Fourth and lastly, due to the mental retardation of the cases, anamnesis was taken from kin of the patients and the possibility that these anamnesis were not sufficient is among the limitations of the study.

In conclusion, since patients with mental retardation with esophageal foreign bodies cannot fully express their complaints, both relatives and clinicians should be vigilant in these patients, particularly in the presence of sudden onset of dysphagia and hypersalivation. Considering these objects may be non-food and sharp-edged foreign bodies, early diagnosis and urgent intervention should be made. Rigid esophagoscopy under general anesthesia by experienced physicians can remove foreign bodies with minimal complications.

Ethics Committee Approval: The study protocol was approved by the Karadeniz Technical University Faculty of Medicine Scientific Research Ethics Committee (date: 10.05.2023, no: 2023/82). The study was conducted in accordance with the principles of the Declaration of Helsinki.

Patient Consent for Publication: Written informed consent was obtained from the legally responsible kin of the patients for publication.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Author: O.T., K.N.K., S.K., Y.A., A.T., A.S.T.; Have given substantial contributions to the literature search, data collection, study design, analysis of data, manuscript preparation and review of manuscript, author: O.T., K.N.K., S.K., A.E., A.B.; Analysis interpretation of the data and review of manuscript. All authors have participated to drafting the manuscript, author: O.T., S.K., Y.A.; Revised it critically. All authors read and approved the final version of the manuscript. All authors read and approved the final version of the manuscript.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

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