Balloon Extraction of Esophageal Foreign Bodies in Children By Stephen E. Morrow, Stephen W. Bickler, Alfred F! Kennedy, Charles L. Snyder, Ronald J. Sharp, and Keith W. Ashcraft KansasCity, Missouri Background: Whereas esophageal foreign bodies are com- monly removed with rigid esophagoscopy under general anesthesia, selected foreign bodies also can be removed using a Foley catheter balloon under fluoroscopic control without anesthesia. The authors prefer to initially attempt removal of smooth, radiopaque esophageal foreign bodies using the balloon technique and then proceed to rigid esopha- goscopy if unsuccessful. Methods: The authors reviewed their 7-year experience with this approach in 276 children with esophageal foreign bodies. goscopy, and 12 passed into the stomach and were observed. The only complication was one episode of epistaxis that resolved. Success of the balloon method was not related to patient age, foreign body duration, location, or presenting symptoms. The use of more than 5 minutes of fluoroscopy time was associated with a low likelihood of successful extraction. Conclusion: The balloon extraction technique is a safe and effective alternative to rigid esophagoscopy for the removal of selected esophageal foreign bodies in children. J Pediatr Surg 33:.X6-270. Copyright o 1998 by W.B. Saun- Results: One hundred seventy-three children underwent at- ders Company. tempted balloon extraction, and 146 of these underwent successful removal with this method. Fifteen remained lodged INDEX WORDS: Esophagus, foreign body removal, fluoros- in the esophagus and were subsequently removed by esopha- copy, balloon catheters. H ISTORICALLY, most esophageal foreign bodies in children have been removed with rigid esophagos- copy under general endotracheal anesthesia. Although rigid esophagoscopy remains the standard practice for virtually all sharp objects and complicated cases, alterna- tive methods of extraction for smooth objects in an uncomplicated setting have been advocated in recent years. These methods include the use of flexible esopha- goscopy under sedation, foreign body advancement with bougienage, and balloon extraction under fluoroscopy. These management strategies have sparked a heated debate among specialists regarding safety and efficacy. Advocates of each method are often specialists familiar with one particular technique. The purpose of this report is to review the experience of a pediatric surgery group experienced with all methods of foreign body removal. The balloon extraction procedure has become our initial approach for most children with uncomplicated, smooth esophageal foreign bodies. Mercy Hospital over a 7-year period (January 1988 through August 1995) with the diagnosis of esophageal foreign body were reviewed. Data retrieved included patient age, sex, foreign body type, location of the foreign body within the esophagus, elapsed time since ingestion of the foreign body, presenting symptoms, extraction method used, result of extraction attempt, fluoroscopy time for balloon extractions: and complications. The data were entered into a computer database for analysis. Inclusion criteria for balloon extraction were absence of respiratory distress, ability to be restrained without medications, and the presence of a smooth-edged object clearly seen within the esophagus on plain chest x-ray. The majority of such objects were coins. After informed consent was obtained, children meeting the inclusion criteria preferentially underwent balloon extraction; those who did not respond to this method subsequently underwent rigid esophagoscopy. Contrast studies of the esophagus were not obtained, and no deliberate attempts to advance the object into the stomach were made. The influence of additional factors such as a history of esophageal surgery, known esophageal pathology, presenting symptoms, and foreign body duration on the choice of extraction method used varied according to the discretion of the surgeon; hence, not all children meeting the inclusion criteria were taken directly to balloon extraction. MATERIALS AND METHODS The records of 276 children (age range, 2 months to 19 years, 11 months) who were referred to the surgery service at The Children’s From The Children k Mercy Hospital, Kansas City, MO. Presented at the 28th Annual Meeting of the American Pediatric SurgicalAssociation, Naples, Florida, May 18-21, 1997. Address reprint requests to Stephen E. Morrow, MD, Department of Surgery The Children S Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108-4698. Copyright o 1998 by IVB. Saunders Company 0022.3468/98/3302-0022$03.00/O At The Children’s Mercy Hospital, children with foreign bodies of the aerodigestive tract are referred exclusively to the pediatric surgery service. All balloon extractions are performed by pediatric surgeons or fellows in the radiology suite, usually with assistance of a junior surgery resident, nurse, and radiology technician. Equipment for airway manage- ment is kept in the room. The general technique used is as follows: Patients are restrained in the lateral position on the fluoroscopy table with the aid of an Octagon board (Enterprises Octostop, Montreal, Canada). AFoley catheter (12F to 14F) is passed and guided distal to the object under fluoroscopic control. The balloon is then inflated with contrast material and steadily withdrawn under constant fluoroscopic surveillance. If the foreign body resists dislodgment, the procedure is terminated. Just before the object reaches the oropharynx, the child is rotated to the prone position and allowed to expectorate the object. After removal of the foreign body, the patient undergoes reimaging with fluoroscopy to rule out the presence of additional foreign bodies. 266 JournalofPediatric Surgery, Vol33, No 2 (February), 1998: pp 266-270