Fig. 284.—Denture impacted in Œsophagus.
(Professor F. M. Caird's case.)
It should be borne in mind that drunkards may suffer from a form of spasm of the œsophagus, which simulates the impaction of a foreign body; hospital records also show that the patient may only have dreamt that he has swallowed a foreign body, usually a denture. These possibilities should be always excluded before further procedures are undertaken.
Treatment.—There being no urgency, a careful examination is carried out, not only to confirm the impaction of a foreign body, but its site and its relation to the wall of the gullet. In skilled hands, the safest and most certain means of removing impacted foreign bodies is with the aid of the œsophagoscope. If this apparatus is not available, other measures must be adopted varying with the nature of the body, its site, and the manner of its impaction.
A bolus of food, for example, or a small smooth object that is likely to pass safely along the alimentary canal, if it cannot be extracted with forceps, may be pushed on into the stomach by the aid of a bulbous-headed or sponge probang. This must be done gently, especially if the body has been impacted for any time, as the inflammatory softening of the œsophageal wall may predispose to rupture.
Small, sharp, or irregular objects, such as fish bones, tacks, or pins, may be dislodged by the “umbrella probang”—an instrument which, after being passed beyond the foreign body, is expanded into the form of a circular brush which, on withdrawal, carries the foreign body out among its bristles.
Coins usually lodge edgewise in the œsophagus, and are best removed by means of an instrument known as a “coin-catcher”, which is passed beyond the coin, and on being withdrawn catches it in a hinged flange. In emergencies a loop of stout silver wire bent so as to form a hook makes an excellent substitute for a coin-catcher.
In difficult cases the removal of solid objects is facilitated by carrying out the manipulations in the dark room with the aid of the X-rays and the fluorescent screen.
Irregular bodies with projecting edges or hooks, such as tooth-plates, tend to catch in the mucous membrane, and attempts to withdraw them by forceps or other instruments are liable to cause laceration of the wall. When situated in the cervical part of the œsophagus, these should be removed by the operation of œsophagostomy (Operative Surgery, p. 195).
If the foreign body is lodged near the lower end of the gullet, it may be necessary to perform gastrostomy (Operative Surgery, p. 291), making an opening in the anterior wall of the stomach large enough to admit suitable forceps, or, if necessary, the whole hand, in order that the body may be extracted by this route; experience shows that an impacted body is more easily extracted from below, that is, from the stomach, than from above.
When the surgeon fails to remove the body by either of these routes, gastrostomy must be performed both to feed the patient and to place the gullet at rest. Smooth bodies may lie latent for long periods, but those with points or hooks damage the mucous membrane, cause ulceration and perforation with the risk of erosion of vessels and secondary hæmorrhage or of cellulitis of the neck or mediastinum and empyema.