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B.
Fluoroscopically
Guided Basket Extraction
- The
materials required are as followed:
- Using
a Dormia-type wire basket with fluoroscopic guidance is
particularly useful for extracting 3-dimensional blunt objects
that have become impacted above an esophageal stricture.
- A
selection of biliary stone baskets (Medi-Tech/Boston
Scientific Corp.; Cook, Inc., Bloomington, IN) measuring 13 to
30 mm in diameter will permit extraction of foreign bodies in
children. A 30 mm
Dotter Retriever Basket (Cook, Inc.) is usually most effective
for adults. A
basket diameter is chosen that matches the size of the
esophagus so that there will be no space outside the basket
into which the foreign body can escape.
- Either
a cut-off nasogastric tube or a 7-F angiographic catheter with
a slight curve near the tip can be used to introduce and guide
the basket into the esophagus.
The working length of the basket must be slightly
longer than the guiding catheter.
Fig.
1. (Adapted from Shaffer HA Jr., Alford BA, de
Lange EE, et al. Basket
extraction of esophageal foreign bodies.
AJR
147:1010-1013, 1986. Reproduced
by permission.)
-
The
protocol is as followed (see above illustration):
-
A
preprocedure barium swallow allows the radiologist to select a
basket of proper diameter and tailor a curve at the tip of the
catheter to facilitate passage of instruments around the
foreign body. After
the posterior pharynx is sprayed with a topical anesthetic,
the catheter is passed through the mouth into the esophagus
above the impaction.
-
If
the esophageal wall and foreign body are no longer outlined by
barium, coating is reestablished by injecting a small amount
of medium density, dilute barium suspension through the
catheter (Fig. 1A).
-
An
0.038-inch angiographic guidewire is then inserted into the
catheter and carefully advanced around the impacted object
using fluoroscopic guidance (Fig 1B).
-
The
catheter is then advanced over the guidewire beyond the
foreign body. This
usually places the end of the catheter within or below an
underlying esophageal stricture (Fig. 1C).
-
The
guidewire is removed from the catheter, and a basket of
appropriate size is advanced inside the catheter until it is
located beside the foreign body (Fig. 1D).
-
The
midpoint of the basket must be positioned at or below the
lower margin of the foreign body in order to capture the
object when the basket is unsheathed.
The catheter is withdrawn to unsheathe the basket.
At first, the basket may not open fully because it is
deformed by the adjacent foreign body or restricted by an
underlying esophageal stricture (Fig. 1E).
-
If
the basket is withdrawn a short distance at this time, it may
dislodge the foreign body upward and away from the stricture
where the basket has more room to expand.
The foreign body is then engaged in the basket by
twirling the instrument, usually clockwise, until the object
is trapped in the wire cage (Fig. 1F).
If the basket must be advanced, this should be done
only within the protective cover of the catheter to avoid any
risk of penetrating the esophageal wall.
-
The
patient is turned onto his right side, and the X-ray table is
tilted approximately 30˚ head-down to reduce the risk of
aspiration during the extraction.
With the foreign body trapped by the basket, the
catheter and basket are withdrawn as a unit from the esophagus
through the mouth in a smooth, continuous motion (Fig. 1G).
Resistance may be encountered during passage of the upper
esophageal sphincter (cricopharyngeus muscle), but this is
overcome by keeping steady traction on the basket while asking
the patient to "retch".
-
Occasionally,
food or a foreign body will be so tightly impacted in an
esophageal stricture that passage of the guidewire and catheter
cannot be performed. In
these circumstances, it may be necessary to use a hydrophylic
guidewire. If this
fails, the catheter suction technique (described next) may be used
to disimpact the object a short distance upward from the
esophageal stricture. Then,
the guidewire, catheter and basket can be advanced around and
beyond the foreign body.
-
We
have performed 48 fluoroscopically guided basket extraction
procedures in 43 patients ranging in age from 3 months to 84 years
and have successfully removed 90% of the impactions, all located
above esophageal strictures.
There have been no complications.
Advantages of this foreign body extraction method include:
1) it is an outpatient procedure and relatively inexpensive
when compared to endoscopy or inpatient treatment; 2) general
anesthesia is not required, nor is sedation needed in most cases;
3) the risk of iatrogenic esophageal perforation is minimized
because the basket is advanced within a protective sheath using
fluoroscopic guidance; and 4) tracheal aspiration is unlikely
because the foreign body is controlled within the basket during
withdrawal .
-
For
removal of three-dimensional blunt foreign bodies,
fluoroscopically guided basket extraction is the procedure of
choice, especially when there is an underlying esophageal
stricture. However,
this method is not appropriate for removal of coins and other
discoid objects from the esophagus.
These flat, two-dimensional foreign bodies may be difficult
to secure in the basket during their extraction .
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