Extraction of Open Safety-pins from the Esophagus.—An open safety pin with the point down offers no particular mechanical difficulty in removal. Great care must be exercised, however, that it be not overridden or pushed upon, as either accident might result in perforation of the esophagus by the pin point. The coiled spring is to be sought, and when found, seized with the rotation forceps and the pin thus drawn into the esophagoscope to effect closure. An open safety-pin lodged point upward in the esophagus is one of the most difficult and dangerous problems. A roentgenogram should always be made in the plane showing the widest spread of the pin. It is to be remembered that the endoscopist can see but one portion of the pin at a time (except in cases of very small safety-pins) and that if he grasps the part first showing, which is almost invariably the keeper, fatal trauma will surely be inflicted when traction is made. It may be best to close the safety pin with the safety-pin closer, as illustrated in Fig. 37. For this purpose Arrowsmith's closer is excellent. In other cases it may prove best to disengage the point of the pin and to bring the pointed shaft into the esophagoscope with the Tucker forceps and withdraw the pin, forceps, and esophagoscope, with the keeper and its shaft sliding alongside the tube. The rounded end of the keeper lying outside the tube allows it to slip along the esophageal walls during withdrawal without inflicting trauma; however, should resistance be felt, withdrawal must immediately cease and the pin must be rotated into a different plane to release the keeper from the fold in which it has probably caught. The sense of touch will aid the sense of sight in the execution of this maneuver (Fig. 87). When the pin reaches the cricopharyngeal level the esophagoscope, forceps, and pin should be turned so that the keeper will be to the right, not so much because of the cricopharyngeal muscle as to escape the posteriorly protuberant cricoid cartilage. In certain cases in which it is found that the pointed shaft of a small safety pin has penetrated the esophageal wall, the pin has been successfully removed by working the keeper into the tube mouth, grasping the keeper with the rotation forceps or side-curved forceps, and pulling the whole pin into the tube by straightening it. This, however, is a dangerous method and applicable in but few cases. It is better to disengage the point by downward and inward rotation with the Tucker forceps.
Version of a Safety Pin.—A safety pin of very small size may be turned over in a direction that will cause the point to trail. An advancing point will puncture. This is a dangerous procedure with a large safety pin.
Endogastric Version.—A very useful and comparatively safe method is illustrated in Figs. 94 and 95. In the execution of this maneuver the pin is seized by the spring with a rotation forceps, and thus passed along with the esophagoscope into the stomach where it is rotated so that the spring is uppermost. It can then be drawn into the tube mouth so as to protect the tissues during withdrawal of the pin, forceps, and esophagoscope as one piece. Only very small safety-pins can be withdrawn through the esophagoscope.
Spatula-protected Method.—Safety-pins in children, point upward, when lodged high in the cervical esophagus may be readily removed with the aid of the laryngoscope, or esophageal speculum. The keeper end is grasped with the alligator forceps, while the spatular tip of the laryngoscope is worked under the point. Instruments and foreign body are then removed together. Often the pin point will catch in the light-chamber where it is very safely lodged. If the pin be then pulled upon it will straighten out and may be withdrawn through the tube.
[FIG. 94.—Endogastric version. One of the author's methods of removal of upward pointed esophageally lodged open safety-pins by passing them into stomach, where they are turned and removed. The first illustration (A) shows the rotation forceps before seizing pin by the ring of the spring end. (Forceps jaws are shown opening in the wrong diameter.) At B is shown the pin seized in the ring by the points of the forceps. At C is shown the pin carried into the stomach and about to be rotated by withdrawal. D, the withdrawal of the pin into the esophagoscope which will thereby close it. If withdrawn by flat-jawed forceps as at F, the esophageal wall would be fatally lacerated.]
Double pointed tacks and staples, when lodged point upward, must be turned so that the points trail on removal. This may be done by carrying them into the stomach and turning them, as described under safety-pins.
The extraction of foreign bodies of very large size from the esophagus is greatly facilitated by the use of general anesthesia, which relaxes the spasmodic contractions of the esophagus often occurring when attempt is made to withdraw the foreign body. General anesthesia, though entirely unnecessary for introduction of the esophagoscope, in any case may be used if the body is large, sharp, and rough, in order to prevent laceration through the muscular contractions otherwise incident to withdrawal.* In exceptional cases it may be necessary to comminute a large foreign body such as a tooth plate. A large smooth foreign body may be difficult to seize with forceps. In this case the mechanical spoon or the author's safety-pin closer may be used.
* It must always be remembered that large foreign bodies are very prone to cause dyspnea that renders general anesthesia exceedingly dangerous especially in children.
[FIG. 95.—Lateral roentgenogram of a safety-pin in a child aged 11 months, demonstrating the esophageal location of the pin in this case and the great value of the lateral roentgenogram in the localization of foreign bodies. The pin was removed by the author's method of endogastric version. (Plate made by George C. Johnston )]
The extraction of meat and other foods from the esophagus at the level of the upper thoracic aperture is usually readily accomplished with the esophageal speculum and forceps. In certain cases the mechanical spoon will be found useful. Should the bolus of food be lodged at the lower level the esophagoscope will be required.