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Introduction: "Push" or "pull" techniques with the use of snares, forceps, baskets, and grasping devices are conventionally used to manage esophageal food bolus impaction (FBI). A novel cap-assisted technique has recently been advocated to reduce time taken for food bolus (FB) removal. This study aimed to compare the effectiveness of the cap-assisted technique against conventional methods of esophageal FB removal in a randomized controlled trial., Methods: Consecutive patients with esophageal FBI requiring endoscopic removal, from 3 Australian tertiary hospitals between 2017 and 2019, were randomized to either the cap-assisted technique or the conventional technique. Primary outcomes were technical success and FB retrieval time. Secondary outcomes were technical success rate, en bloc removal rate, procedure-related complication, length of hospital stay, and cost of consumables., Results: Over 24 months, 342 patients with esophageal FBI were randomized to a cap-assisted (n = 171) or conventional (n = 171) technique. Compared with the conventional approach, the cap-assisted technique was associated with (i) shorter FB retrieval time (4.5 ± 0.5 minutes vs 21.7 ± 0.9 minutes, P < 0.001), (ii) shorter total procedure time (23.0 ± 0.6 minutes vs 47.0 ± 1.3 minutes, P < 0.0001), (iii) higher technical success rate (170/171 vs 160/171, P < 0.001), (iv) higher rate of en bloc removal (159/171 vs 48/171, P < 0.001), and (v) lower rate of procedure-related mucosal tear and bleeding (0/171 vs 13/171, P < 0.001). There were no major adverse events or deaths within 30 days in either group. The total cost of consumables was higher in the conventional group (A$19,644.90 vs A$6,239.90)., Discussion: This multicenter randomized controlled trial confirmed that the cap-assisted technique is more effective and less costly than the conventional approach and should be first-line treatment for esophageal FBI., (Copyright © 2021 by The American College of Gastroenterology.)

Objective: to evaluate the medical economics and safety of two methods for the endoscopic removal of jujube pits, one with a transparent cap combined with a stone basket and the other with a transparent cap combined with foreign body forceps., Methods: consecutive patients with a suspected jujube pit ingestion in the esophagus between January 2008 and December 2017 were enrolled into the study. Fifty-three patients who met the criteria were divided into two groups. Group A patients were treated by a transparent cap combined with a stone basket and group B patients were treated by a transparent cap combined with foreign body forceps. The following clinical data were collected: age, sex, location of jujube pits, complications, operation time, extraction success and average hospital costs., Results: a total of 53 patients who met the criteria were enrolled into the study; 29 cases in group A and 24 cases in group B. Endoscopic removal was successful in 98.1% (52/53) of the patients and the remaining 1.9% (1/53) required surgery. Severe complications were less frequent in group A than in group B (p = 0.017). Surgery time was not significantly different between the two groups (p = 0.647). The extraction success in group A was higher than in group B (p = 0.001). The medical costs including the total cost, inspection, treatment, radiation and drug cost were not significantly different between the two groups (p > 0.05 in all cases)., Conclusion: endoscopic baskets are suitable for cases of jujube pit ingestion and have a higher extraction success and a lower proportion of severe complications. Surgery time was not significantly extended and the medical costs did not increase.

Background/purpose: In pediatric cases of ingested foreign bodies, gastrointestinal foreign bodies (GIFB) have distinct factors contributing to longer and more costly hospitalizations., Methods: Patients admitted with ingested foreign bodies were identified in the Kids' Inpatient Database (1997-2009)., Results: Overall, 7480 cases were identified. Patients were most commonly <5years of age (44%), male (54%), and Caucasian (57%). A total of 2506 procedures were performed, GI surgical procedures (57%) most frequently, followed by GI endoscopy (24%), esophagoscopy (11%), and bronchoscopy - in cases of inhaled objects (9%). On multivariate analysis, length of stay increased when cases were associated with intestinal obstruction (OR=1.7), esophageal perforation (OR=40.0), intestinal perforation (OR=4.4), exploratory laparotomy (OR=1.9), and gastric (OR=2.9), small bowel (OR=1.5), or colon surgery (OR=2.5), all p<0.02. Higher total charges (TC) were associated with intestinal obstruction (OR=2.0), endoscopy of esophagus (OR=1.8), stomach (OR=2.1), or colon (OR=3.3), and exploratory laparotomy (OR=3.6) or surgery of stomach (OR=5.6), small bowel (OR=6.4), or colon (OR=3.4), all p<0.001., Conclusions: Surgical or endoscopic procedures are performed in approximately one third of GIFB cases. Associated psychiatric disorder or self-inflicted injury is seen in more than 20% of GIFB patients. Resource utilization is determined heavily by associated diagnoses and treatment procedures., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Esophageal foreign body retrieval is typically performed by rigid or flexible esophagoscopy. Despite evidence supporting the efficacy and safety of balloon extraction, it is rarely performed. We sought to establish the financial benefits of this minimally invasive approach., Methods: A retrospective review of 241 children with esophageal coins between 2011 and 2013 was performed. Coins were removed via endoscopy or fluoroscopic-guided balloon retrieval. Timing, symptoms, facility cost, and patient charges were compared., Results: Two hundred patients had attempted balloon retrieval with 80% success. Forty-one patients went directly for operative removal. Patients with respiratory difficulty (p=0.05), wheezing (p<0.01), or fever (p=0.03) were more often taken directly for endoscopic retrieval. The median cost and charges for attempted balloon extraction were $484 and $1647. The median cost and charges for primary endoscopy were $1834 and $6746. The median total cost and charges of attempted balloon extraction including ED, OR, transport, admission, and balloon retrieval were $1231 and $3539 versus $3615 and $12,204 in the primary endoscopy group (p<0.001, p<0.001). Seventeen percent of patients who underwent attempted balloon retrieval were admitted prior to removal compared to 76% who underwent primary endoscopy (p<0.001)., Conclusions: Fluoroscopic guided balloon extraction of esophageal coins is a financially prudent choice which shortens hospital stay., Level of Evidence: III., Type of Study: Retrospective treatment and economic study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Controversy exists about the utility of pharmacologic agents and endoscopic technique used for esophageal food bolus impaction., Aim: To evaluate the utility of glucagon and the technique used for endoscopic removal, including the rate of success and the adverse events of the techniques., Methods: The database of the largest healthcare provider in southeastern Wisconsin was retrospectively reviewed for patients presenting with esophageal food bolus impaction. Data extracted included glucagon administration and its success rate, outcome of radiographic studies, and the endoscopic method of removal and adverse events associated with it, including 30-day mortality., Results: A total of 750 patients were identified with food bolus impaction from 2007 to 2012. Glucagon was administered in 440 patients and was successful in 174 (39.5%). Endoscopic removal was performed in 470 patients and was successful in 469 (99.8%). The push technique was utilized in 209 patients, reduction in the bolus size by piecemeal removal followed by the push technique was utilized in 97 patients, and the pull technique was utilized in 107 patients. There were no perforations with endoscopic removal. Only 4.5% of the X-rays performed reported a possible foreign body within the esophagus. Glucagon was a significantly less-expensive strategy than endoscopic therapy (p < 0.0001)., Conclusion: Glucagon is low cost, is moderately effective, and may be considered as an initial strategy. Endoscopic removal regardless of technique is safe and effective. The yield of radiography is poor in the setting of food bolus impaction.

Background: Ingested foreign bodies are a frequent presentation in pediatric emergency departments. Although some pass spontaneously through the gastrointestinal tract, the majority of esophageal-ingested foreign bodies (EFB) require removal., Materials and Methods: Kids' Inpatient Database (1997-2009) was used to identify children (aged <20 y) with EFB (International Classification of Diseases, Ninth Revision, Clinical Modification code 935.1). Multivariate logistic regression analyses were constructed to identify predictors of resource utilization., Results: Overall, 14,767 EFB cases were identified. Most patients were <5 y of age (72%), boys (57%), and non-Caucasian (55%), with a median (interquartile range) length of stay (LOS) of 1 (1) d, and total charges of $11,003 (8503). A total of 11,180 procedures were performed, most commonly esophagoscopy (77%), followed by bronchoscopy (20%), gastroscopy (2%), and rarely surgery (0.8%). By multivariate logistic regression, increased total charges were associated with a diagnosis of esophageal ulceration (odds ratio [OR] = 1.57), esophagoscopy (OR = 1.42), and bronchoscopy (OR = 1.62), all P < 0.001. Total charges also increased with admission to urban nonteaching hospitals (OR = 1.51) versus urban teaching hospitals, P < 0.001. Prolonged LOS (≥1 d) was associated with admission to a hospital in the Midwest (OR = 3.18) and with esophageal ulceration (OR = 2.11) and esophagoscopy (OR = 1.13), P < 0.03. Boys had higher odds of longer hospitalization (OR = 1.21), P < 0.001. Overall hospital mortality was 0.1% (n = 16)., Conclusions: Most EFB occur in children <5 y of age. Esophageal ulceration, esophagoscopy, and bronchoscopy are associated with increased total charges. Esophageal ulceration, esophagoscopy, and boys are associated with an increased LOS. Surgery and hospital mortality are both extremely rare in children with EFB., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Coins are the foreign body most commonly ingested in infants and children. Coins retained in the esophagus require intervention to prevent complications. Management of retained esophageal coins remains variable both between and within institutions. We hypothesize that the incorporation of bougienage in the management of pediatric esophageal coins is safe and more cost-effective compared with traditional management strategies that use endoscopy., Methods: We conducted a retrospective review of infants and children diagnosed with an esophageal foreign body managed at Children's Hospital of Wisconsin between January 2003 and June 2012. Pediatric otolaryngologists (ear-nose-throat, ie, ENTs) or pediatric surgeons manage all children with esophageal foreign bodies in a prospective call schedule that alternates weekly., Results: During an 8.5-year period, 1,642 children were diagnosed with esophageal foreign bodies and 518 had a retained coin. For esophageal coins, ENT managed 218 cases and pediatric surgery managed 300. ENTs preferentially used endoscopy for coin removal, whereas pediatric surgeons used either endoscopy or esophageal bougienage for selected children meeting specific criteria. Bougienage was successful at advancing the coin into the stomach in 94% of patients, and endoscopy was successful at removing the coin from the esophagus in 100% of patients. The mean duration of stay was 0.6 days for endoscopy by ENT, 0.6 days for endoscopy by pediatric surgery, and 0.1 days for bougienage (P < .05). The median hospital charge was $4,593 for endoscopy by ENT, $5,379 for endoscopy by pediatric surgery, and $579 for bougienage (P < .05). There were 3 complications each in the endoscopy group for ENT and pediatric surgery. There were no complications in children undergoing bougienage., Conclusion: This is the first case series evaluating the management of children with esophageal coins using a prospective assignment to endoscopy versus endoscopy or bougienage. Our data support bougienage as a safe and cost-effective treatment for managing retained esophageal coins in selected children., (Copyright © 2015 Elsevier Inc. All rights reserved.)

A 57-year-old man presented to the hospital because of swallowing of a small marble precipitated by a hallucination. He subsequently developed chest discomfort. He had a history of psychiatric problem and an esophageal corrosive injury complicated by stricture of the middle esophagus.This report describes the novel idea of endoscopic intervention for the retrieval of an esophageal foreign body. Its inventiveness and the use of limited resources, by adapting a 30-mm aseptic common tubing into an endoscopic retrieving device, make the method novel. This novel low-cost endoscopic cap (NLCEC) was adapted to 25 mm of the front end of the endoscope, with 5 mm maintained for the soft part to prevent esophageal mucosal injury during the retrieval process. An 8-mm green marble was found impacted in the esophagus 32 cm from the incisors. The use of forced suction allowed for the successful retrieval of the marble within minutes. The patient had an uneventful recovery without any serious complications.This NLCEC may be a viable and safe tool for the endoscopic retrieval of esophageal foreign objects without general anesthesia. This innovative design is beneficial in terms of patient safety, easy preparation, and low cost.

Study Objective: We report our experience using the bougienage procedure in the management of esophageal coins., Methods: Observational case series of all patients presenting to our emergency departments with coins acutely lodged in the esophagus between 1994 and 2006. All patients were treated according to our protocol with either endoscopy or bougienage. Patients are eligible for bougienage if they have had a witnessed coin ingestion less than 24 hours before presentation and if esophageal coin position is confirmed by chest radiograph and there is no history of esophageal disease, surgery, or foreign body. Primary outcomes measured were complications, efficacy of procedure, hospital charges, length of stay, and return to the hospital. Length of stay and hospital charges data were gathered for patients presenting in the final 24 months of the study., Results: Six hundred twenty patients were identified as having esophageal coins. Three hundred fifty-five patients had a successful bougienage, and 17 patients had unsuccessful bougienage. By comparison, 248 patients underwent endoscopy, and the coin was successfully removed in all but 1 of these patients. Of patients undergoing endoscopy, 89 were eligible for bougienage, but patient, parent, or physician preference was for endoscopic management. Eleven patients required reevaluation or readmission for complaints related to esophageal coin. The only complication was subglottic edema, causing respiratory distress in a single patient who had undergone endoscopy. Patients undergoing endoscopy had an average length of stay of 6.1 hours and average hospital charges were $6,087. Patients undergoing bougienage had an average length of stay of 2.2 hours and average hospital charges of $1,884., Conclusion: In properly screened patients with coins acutely lodged in the esophagus, bougienage offers a safe and effective alternative to other methods of coin management.

Objectives: To compare the cost effectiveness of plain film radiography, computed tomography (CT), and endoscopy as initial diagnostic modalities in adult patients complaining of retained ingested foreign bodies., Design: A systematic literature review was conducted to determine key statistics for the analysis, such as prevalence of disease, prevalence of complications, and the sensitivity and specificity of each diagnostic modality. Costs were estimated using 2006 Medicare reimbursement for hospital and professional fees. A deterministic cost-effectiveness analysis was then conducted using decision analysis software and a decision tree model to evaluate the various diagnostic strategies. After identifying initial results, we also performed sensitivity and threshold analysis to assess the strength of the recommendations., Results: We reviewed 316 abstracts, identified 16 pertinent studies that included a total of 7,088 patients with possible foreign bodies, and extracted key statistics from those papers. Decision analysis showed that CT scanning as an initial diagnostic strategy proved more cost effective than plain film or operative endoscopy. The incremental cost of immediate endoscopy for every additional correctly diagnosed patient was $5,238. Plain radiography was more costly and less effective, even with the addition of confirmatory CT scanning after a negative plain film. Sensitivity and threshold analyses demonstrated that these results are robust., Conclusions: Patients presenting with a complaint of a retained ingested foreign body are most cost-effectively managed with CT scan, after history and physical. Immediate endoscopy may be considered if CT is not available, although it adds significant cost. Plain films are dominated by these two diagnostic strategies.

Background: Foreign body ingestion is a common pediatric problem. Coins are by far the most common ingested foreign bodies. When ingested coins become lodged in the esophagus, they may cause serious complications if they are not removed in a timely manner. Endoscopic removal is the preferred treatment in many pediatric centers as its safety and effectiveness are well established., Objectives: We performed this study to evaluate safety and effectiveness of an alternative method of managing esophageal coins, using bougienage technique., Methods: Previously healthy children presenting to the local emergency room with uncomplicated, witnessed coin ingestion of less than 24 hours duration were prospectively recruited with an intent-to-treat analysis. A single oral passage of a Hurst bougie dilator was performed by a gastroenterologist to dislodge the esophageal coin into the stomach. If bougienage was successful (x-ray showing coin in the stomach), patients were discharged and instructions were given for monitoring stools until passage of the coin through anus was confirmed. If bougienage was unsuccessful, the child developed symptoms at any time or if a coin remained intragastric for 4 weeks, endoscopic removal was planned. Children whose parents declined to participate in the bougienage treatment received the standard endoscopic removal and their hospital records were used as controls., Results: A total of 10 children were enrolled in this study, with a mean age of 3.2 years (11 mo to 10 y), 6 boys and 4 girls. All received little or no sedation. Nine children (90%) were successfully treated using bougienage, all of whom spontaneously passed the ingested coins, with a mean duration of 2.6 days (1 to 7 d) without subsequent intervention. A single case failed bougienage and underwent endoscopic removal. Three children declined bougienage treatment and underwent endoscopic removal. There were no reported minor or major adverse events with any of our cases. The mean health care cost for the hospital visit for bougienage treatment was $1210, compared with $3100 for the endoscopic removal (P<0.001). Furthermore, the mean time spent in the hospital from diagnosis to discharge was 2 hours for bougienage-treated patients compared with 8 hours for endoscopic treatment (P<0.001)., Conclusions: Bougienage of impacted esophageal coins is an effective, safe, and more economic treatment modality for selected pediatric patients with uncomplicated coin ingestion. This simple technique may provide a valuable tool to emergency room physicians or primary care doctors especially when endoscopy is not readily available.

Objective: To compare clinical outcomes and costs under 4 strategies for the management of esophageal coins in children., Methods: We developed a decision analysis model of 4 possible strategies for managing esophageal coins: 1) endoscopic removal under general anesthesia; 2) esophageal bougienage, 3) an outpatient 12- to 24-hour observation period to allow spontaneous coin passage; and 4) an inpatient observation period. Probabilities of success and complication rates for endoscopy and esophageal bougienage were obtained from published data. The probability of spontaneous coin passage was derived from chart review data at our institution. Costs were calculated from charges using a cost-to-charge ratio of.72. Hypothetical patients included in the model were those with a single esophageal coin presenting within 24 hours of ingestion, with no respiratory compromise on presentation and with no previous history of esophageal disease. Strategy-specific outcomes were overall complication rate and total cost in dollars per patient. Sensitivity analyses were performed to account for variations in the data., Results: The esophageal bougienage strategy resulted in no complications and a total cost per patient of $382, which represents a marginal advantage of $2915 per patient compared with the endoscopic removal strategy. On sensitivity analysis over the range of success and complication rates of bougienage, this strategy maintained a considerable decrease in both overall complications and total cost per patient compared with all other strategies. Both outpatient and inpatient observation strategies had overall complication rates of 4.2% compared with the complication rate of 5.8% for the endoscopy strategy. The total cost per patient under these strategies was $2439 for the outpatient and $3141 for the inpatient strategy, representing a marginal advantage of $858 and $156 per patient, respectively, compared with the endoscopy strategy. Both observation strategies maintained a lower overall complication rate compared with endoscopy in the sensitivity analysis. The outpatient observation strategy maintained a marginal advantage of $645 to $1257 per patient compared with endoscopy; however, the inpatient observation strategy total cost per patient surpassed that of endoscopy at a spontaneous passage rate <23%., Conclusions: Given the high success and low complication rates reported for esophageal bougienage, substantial savings in overall complications and costs would be expected with the use of this procedure. With spontaneous passage rates >23%, either an outpatient or an inpatient observation strategy would reduce costs and complications, compared with endoscopic removal of all esophageal coins.

Background: The choice among endoscopy, Foley catheter, and bougienage techniques for pediatric esophageal coin removal currently depends on local or personal preferences. This reflects a lack of prospective comparisons of cost and effectiveness in the literature., Methods: A computerized decision analytic model was used to determine the expected costs of each method of esophageal coin removal. Calculations were based on success rates in the recent literature and local patient charges for each method. Complications reported in this recent literature were also tabulated., Main Results: Of 1746 esophageal coin removal attempts reported in 24 papers, 1706 (97.7%) were successful. There were 37 (2.1%) complications, the majority of which were minor. The expected cost of endoscopic coin removal was $2701; of Foley catheter removal, $660; of bougienage removal, $614. The large difference in expected cost of endoscopy and bougienage or Foley catheter removal persisted in sensitivity analyses., Conclusions: In a literature-based decision analytic model, pediatric esophageal coin removal by the Foley catheter or bougienage technique was far more cost-effective than was endoscopy.

Study Objective: To determine the efficacy and safety of bougienage performed by properly trained pediatric emergency medicine physicians to advance a recently ingested coin lodged in the esophagus into the stomach., Methods: We carried out a prospective study of consecutive cases at two university-affiliated pediatric hospitals. Our subjects were 31 children, each with an ingested coin lodged in the esophagus, who met criteria for bougienage: a single coin ingested in the preceding 24 hours, radiographically localized in the esophagus; no history of esophageal disease, esophageal surgery, or foreign body removal; and no sign of respiratory compromise. The bougienage procedure involved a single pass of a Hurst bougie dilator from the mouth to the stomach with the unsedated patient sitting upright., Results: In all cases, the coin was successfully advanced into the stomach with a single pass of the bougie dilator. No patient experienced an acute complication or delayed surgical complication related to the procedure. In one case the coin was vomited after the procedure and recovered without complications. Mild abdominal pain developed in two patients, who were reevaluated 2 weeks after the procedure. In each case the coin was present in the stomach and was removed endoscopically without subsequent complications., Conclusion: When used by trained emergency physicians, esophageal bougienage is a safe, effective, cost-containing treatment for dislodging and advancing ingested coins from the esophagus into the stomach that requires no sedation or general anesthesia.

Foreign bodies of the esophagus are a common problem in children, with the majority of these foreign bodies being coins. Because there are various methods for managing esophageal coins, we retrospectively reviewed our experience of the past 4 years to establish a safe and cost-effective protocol for their management. From January 1987 to December 1990, 57 children were managed for esophageal coins in our institution. Nineteen children were managed endoscopically under general anesthesia, with a mean patient cost of $1,982 (excluding the surgeon and anesthesiologist charge). Thirty-eight children were managed with Foley balloon extraction or esophageal bougienage in the emergency department with a mean patient cost of $149 (excluding surgeon charge). Both methods were 100% effective, and there were no complications in either group. Rigid criteria were used in selecting patients for balloon extraction and bougienage. These were: (1) duration less than 24 hours; (2) no respiratory distress; and (3) no history of esophageal disease or surgery. Using these criteria, 16 of the 19 patients managed endoscopically could have safely and effectively been managed in the emergency department with a net savings of $1,833 per patient. We conclude that Foley balloon extraction and bougienage of esophageal coins in selected children is both safe and cost-effective. A protocol for managing children with esophageal coins is presented, and the techniques of Foley balloon extraction and esophageal bougienage are reviewed.