disengages the barb from the esophageal wall. Maintaining firm tension on the line to seat the hook within the tip of the disgorger leaves little opportunity for the barbs to protrude and reengage the esophageal wall. The hook, line, and disgorger are withdrawn as one unit.
The proximal esophagus may prove difficult to inflate, as insufflated air readily exits via the esophageal aditus, rendering visualization difficult. The author has occasionally used long Rochester Pean artery forceps alongside a rigid esophagoscope to retrieve very proximally located hooks.
Figure 4.14 (a) Endoscopic view (looking distally) of a fishhook within the esophagus. The tip of the fishhook is engaging the esophageal wall. (b) A disgorger (narrow‐bore stomach tube) can be advanced over the fishing line to rest against the hook. The operator will thrust the disgorger to disengage the barb of the hook from the esophageal wall.
The most common complication associated with endoscopic retrieval is mild mucosal laceration and this seldom requires further treatment. Reports of fatal pulmonary vein laceration during endoscopic hook retrieval exist [19].
Surgical retrieval is indicated where endoscopic retrieval attempts fail or where gross esophageal tearing is identified. The surgeon adopts a ventral midline cervical approach or a lateral intercostal thoracotomy centered over an appropriate intercostal space. An esophagotomy is then often required, although some hooks may be retrieved endoscopically once the surgeon has snipped off a barb that penetrates the esophageal wall [19].
Figure 4.15 Radiograph demonstrating a needle embedded in the esophageal wall of a dog.
Figure 4.16 (a) Marked soft‐tissue swelling and subcutaneous emphysema commonly affect the head and neck of dogs that are presented following stick penetration injury. (b) Cervical emphysema is evident on this survey radiograph. The cause in this patient was a stick penetration of the pharyngeal or esophageal wall. (c) A 5‐cm long piece of wood (W) is visible within the cervical tissues on this magnetic resonance image. The dog had suffered an oropharyngeal stick penetration injury two days previously.
Needles
Needles may also lodge in the esophageal wall (Figure 4.15). Endoscopic removal of needles that protrude into the esophageal lumen is readily achievable. Needles that migrate through the esophageal wall to rest in the periesophageal tissues may prove very difficult to locate during surgical exploration. These difficulties are compounded by large body size. Intraoperative fluoroscopy is invaluable in these situations; increasing the chance of successfully finding the needle and limiting the extent of dissection required. Resolution of clinical signs is frequently very rapid. The author does not routinely administer antibacterial agents either in these cases or after retrieval of fishhooks.
Esophageal Stick Injuries
Esophageal puncture may occur as part of an oropharyngeal stick injury. Acutely affected dogs display oral and cervical pain. Marked soft tissue swelling and subcutaneous emphysema are often identified (Figure 4.16a, b), together with drooling of sanguineous saliva. Pharyngeal puncture is very seldom life threatening, even when associated with an underlying track of traumatized tissue, but may evolve into a chronic abscess or discharging sinus [6]. In addition, foreign material is more difficult to surgically locate, once an abscess or suinus has developed, in comparison with exploration of the acute case, even with the assistance of advanced imaging. Esophageal wall breach may lead to a syndrome of descending fasciitis and mediastinitis, which may prove fatal [6]. Endoscopic assessment of esophageal integrity, after foreign body retrieval, may provide a useful complement to other imaging modalities, although hemorrhage and mucosal swelling may impair visualization. Survey radiographs appear to be a sensitive modality with which to identify perforation [6] via the presence of emphysema within the cervical tissues (Figure 4.16b), although this does not distinguish between pharyngeal and esophageal perforation. A careful oral and pharyngeal examination using two long‐bladed, brightly illuminated laryngoscopes may reveal a site of injury. This inspection alone does not rule out additional puncture sites arising from a stick entering the esophageal aditus and perforating the esophageal wall more distally. Endoscopic examination of the esophagus is well suited to further characterize the extent of the patients' injuries. Advanced imaging techniques are also very useful for identifying foreign bodies in the tissues of the neck (Figure 4.16c).
Figure 4.17 A splinter of wood being retrieved during a ventral midline exploration of a dog's neck.
It is not understood why esophageal perforation may foster such a fulminant course. Investigators of descending necrotizing mediastinitis following dental abscess rupture or foreign body impalement injuries in humans speculate on the presence of corridors for infection within tissue planes of the neck [20, 21]. Dogs with this condition require aggressive stabilization followed by early cervical exploration for repair of esophageal perforations, retrieval of foreign material (Figure 4.17), debridement and lavage of the affected tissues, and endoscopic placement of a gastrostomy tube. A ventral midline cervical approach affords good access to the entire cervical esophagus.
5 Gastrointestinal Foreign Bodies
Amie Koenig and Mandy L. Wallace
College of Veterinary Medicine, University of Georgia, Athens, GA, USA
Introduction
Gastrointestinal (GI) foreign bodies are common in dogs and cats; therefore, the need for surgical removal of foreign bodies is frequent in veterinary practice. In a pet insurance company report, $3.4 million in claims related to foreign body ingestion in dogs and cats were made in 2014 [1]. Discrete foreign bodies have been reported in all areas of the GI tract, with reports of the most common location being inconsistent [2–4]. Some authors hypothesize that location of the foreign body at the time of required intervention is correlated with owner awareness of ingestion. Lacking owner awareness, intervention occurs when the foreign body moves into a location that results in clinical signs.
Classification of Foreign Bodies
GI foreign bodies
