OBJECTIVE:

To report the removal of an ingested clam shell that was firmly impacted in the esophagus.

CLINICAL PRESENTATION AND INTERVENTION:

A 77-year-old man presented at our hospital with acute dysphagia after eating a seafood risotto. An urgent dedicated examination (noncontrast helical multislice computed tomography scan of the neck and flexible esophagoscopy) detected a clam shell lodged in the upper esophagus. After several unsuccessful endoscopic attempts, a lifesaving cervical esophagotomy was performed and the foreign body was retrieved.

CONCLUSION:

This patient who ingested clam shell recovered well following the retrieval of the foreign body by performing a lifesaving cervical esophagotomy

Balducci, Genoveffa

Gasparrini, Marcello

Giuliani, Diletta

Nigro, Alice

Virgilio, Edoardo

Medical Principles and Practice

English

&lt;b&gt;&lt;i&gt;Objective:&lt;/i&gt;&lt;/b&gt; To report the removal of an ingested clam shell that was firmly impacted in the esophagus. &lt;b&gt;&lt;i&gt;Clinical Presentation and Intervention:&lt;/i&gt;&lt;/b&gt; A 77-year-old man presented at our hospital with acute dysphagia after eating a seafood risotto. An urgent dedicated examination (noncontrast helical multislice computed tomography scan of the neck and flexible esophagoscopy) detected a clam shell lodged in the upper esophagus. After several unsuccessful endoscopic attempts, a lifesaving cervical esophagotomy was performed and the foreign body was retrieved. &lt;b&gt;&lt;i&gt;Conclusion:&lt;/i&gt;&lt;/b&gt; This patient who ingested clam shell recovered well following the retrieval of the foreign body by performing a lifesaving cervical esophagotomy.</jats:p

Edoardo Virgilio

Diletta Giuliani

Alice Nigro

Marcello Gasparrini

Genoveffa Balducci

Crossref

Cervical Esophagotomy for Removal of an Ingested Clam Shell: A Very Uncommon Foreign Body Ingestion

OBJECTIVE:
To report the removal of an ingested clam shell that was firmly impacted in the esophagus.
CLINICAL PRESENTATION AND INTERVENTION:
A 77-year-old man presented at our hospital with acute dysphagia after eating a seafood risotto. An urgent dedicated examination (noncontrast helical multislice computed tomography scan of the neck and flexible esophagoscopy) detected a clam shell lodged in the upper esophagus. After several unsuccessful endoscopic attempts, a lifesaving cervical esophagotomy was performed and the foreign body was retrieved.
CONCLUSION:
This patient who ingested clam shell recovered well following the retrieval of the foreign body by performing a lifesaving cervical esophagotomy

VIRGILIO, EDOARDO

BALDUCCI, Genoveffa

Archivio della ricerca- Università di Roma La Sapienza

E-Mail karger@karger.com Case Report  Med Princ Pract 2017;26:390–392  DOI: 10.1159/000477403  Cervical Esophagotomy for Removal of an Ingested Clam Shell: A Very Uncommon Foreign Body Ingestion  Edoardo Virgilio    Diletta Giuliani    Alice Nigro    Marcello Gasparrini    Genoveffa Balducci   Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology “Sapienza,” St. Andrea Hospital,  Rome, Italy  Introduction  The ingestion of a foreign body with impaction in the esophagus is a common gastrointestinal emergency  [1, 2] . A myriad of usual as well as infrequent objects have been reported  [1, 2] . Clam shell ingestion represents a very un-usual occurrence; as of 2017, only 6 cases have been de-scribed in the literature. Differently from other materials, the retrieval of this bivalve mollusk can entail very serious medical and surgical problems. We report the successful removal of a clam shell by cervical esophagotomy. Case Report  A 77-year-old man presented with acute dysphagia after eating a seafood risotto. His previous medical history was significant for cervical spine fixation performed 24 years previously because of amyotrophic lateral sclerosis. At the visit, apart from the oropha-ryngeal discomfort, the patient was eupneic and hemodynamical-ly stable. A noncontrast helical multislice computed tomography  Keywords  Foreign body ingestion · Clam shell · Esophagotomy  Abstract  Objective: To report the removal of an ingested clam shell that was firmly impacted in the esophagus.  Clinical Presen-tation and Intervention: A 77-year-old man presented at our hospital with acute dysphagia after eating a seafood ri-sotto. An urgent dedicated examination (noncontrast helical multislice computed tomography scan of the neck and flex-ible esophagoscopy) detected a clam shell lodged in the up-per esophagus. After several unsuccessful endoscopic at-tempts, a lifesaving cervical esophagotomy was performed and the foreign body was retrieved.  Conclusion: This patient who ingested clam shell recovered well following the re-trieval of the foreign body by performing a lifesaving cervical esophagotomy.  © 2017 S. Karger AG, Basel  Received: October 12, 2016  Accepted: May 10, 2017  Published online: May 10, 2017  Edoardo Virgilio, MD, PhD  St. Andrea Hospital  via di Grottarossa 1035–39  IT–00189 Rome (Italy)  E-Mail aresedo1992   @   yahoo.it  © 2017 S. Karger AG, Basel  www.karger.com/mpp  Significance of the Study  • The clam shell was retrieved by performing cervical esophagotomy and the patient recovered well. Clinicians should be aware of this particular type of foreign body ingestion because it necessitates prompt surgery rather than nonoperative management or endoscopy. Th is is an Open Access article licensed under the terms of theCreative Commons Attribution-NonCommercial 3.0 Un-ported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribu-tion permitted for non-commercial purposes only.Downloaded by: 94.160.96.113 - 9/13/2017 11:17:45 PM Cervical Esophagotomy for Removal of an Ingested Clam Shell Med Princ Pract 2017;26:390–392DOI: 10.1159/000477403391(CT) scan of the neck was performed urgently: a radio-opaque for-eign body with a concave morphology and a diameter of 4 cm was seen lodged in the upper esophagus at the subglottis level anteri-orly to C6–C8 ( Fig. 1 a). Imaging sagittal reconstruction outlined a maritime design congruent with the shell of a clam ( Fig. 1 b). An immediate flexible endoscopy was performed that confirmed a whitish clam shell as the foreign body ( Fig. 2 ); however, it failed to retrieve the object due to its particularly milled surface. Three flex-ible esophagoscopies were attempted subsequently but were all un-successful. Thereafter, a rigid endoscopy was carried out but the removal maneuvers also failed. At day 25 after ingestion, the pa-tient developed acute respiratory failure that required lifesaving orotracheal intubation. At this point, surgery was designated as the only feasible treatment to retrieve the object through a left later-al cervicotomy. A longitudinal esophagotomy was accomplished along the Laimer-Killian triangle, permitting the extraction of the clam shell once split in 2 pieces ( Fig. 3 ). The postoperative course was unremarkable, and the patient was discharged home after a few days and advised to maintain a regular oral diet. Discussion  In general, foreign body ingestion with impaction in the esophagus is a common gastrointestinal emergency resulting from accidental or intentional action  [1] . On the other hand, accidental ingestion of a clam shell is an un-usual event. As of 2017, in fact, after burrowing into the world literature, we have found only 2 other cases dealing with clam shell ingested and impacted in the esophagus  [3, 4] . In one case a 4.5-cm clam valve was removed via rigid esophagoscopy (after an unsuccessful flexible en-doscopy), and in the other the successful retrieval (at the third endoscopy) was complicated by esophageal perfora-tion and tension pneumothorax requiring emergency chest tube and repair of the perforation  [3, 4] . Differently from the aforementioned instances, our patient had med-ical history significant for a serious neurodegenerative disease (amyotrophic lateral sclerosis) which required an operation of cervical spine fixation 24 years previously. In addition to the considerable diameter of the bivalve (4 cm), which could probably entail problems even for healthy people, we do think that both of these compo-nents (long-standing Lou Gehrig disease and former neu-rosurgical intervention) could have participated in this adverse clinical phenomenon. The former, in fact, could have caused discoordinated swallowing leading to the bi-valve ingestion, whereas the latter could have created some fibrotic sequelae involving the cervical esophagus (extraluminal anatomic distortion and/or mucosal stric-ture) contributing to the endoluminal impaction. For our patient, 4 consecutive flexible esophagoscopies and 1 rig-id upper endoscopy were attempted in a very short period a b Fig. 1.  a Noncontrast cervical computed tomography (CT) scan showed a hyperdense object with a concave mor-phology and a diameter of 4 cm lying in the upper esophagus at the subglottis level anteriorly to C6–C8 (red ar-row).  b The CT sagittal reconstruction outlined a maritime design congruent with a clam shell (red arrow).  Fig. 2. At esophagoscopy, a whitish clam shell impacted in the cer-vical esophagus was confirmed as the foreign body. Color version available onlineColor version available onlineDownloaded by: 94.160.96.113 - 9/13/2017 11:17:45 PM Virgilio/Giuliani/Nigro/Gasparrini/Balducci Med Princ Pract 2017;26:390–392DOI: 10.1159/000477403392of time; however, all practices were unsuccessful. Hence, considering the patient’s poor health condition (acute re-spiratory insufficiency requiring orotracheal intubation), surgery appeared to be the only possible curative option. And so it was. Indeed, cervical esophagotomy accom-plished at day 25 permitted retrieval of the shell and, sec-ondarily, amelioration of the general healthy status. Our treatment strategy was conducted in keeping with the American Society of Gastrointestinal Endoscopy Guide-lines which indicate surgery for those initially asymptom-atic cases of immobile blunt foreign bodies complicated by clinical deterioration, perforation, and sepsis  [2, 5] . There are also other circumstances describing a clam shell passing in the small bowel and causing intestinal perforation or subocclusion. In the first event open sur-gery is mandatory, while in the latter extracorporeal shock wave lithotripsy has been successfully described twice  [6–8] . Furthermore, evidence exists that the inges-tion of a clam shell should dictate immediate retrieval rather than simple clinical or radiological observation due to the ascertained risk of developing the food protein-induced enterocolitis syndrome  [9] .  Conclusion  This was a case of successful retrieval of an ingested clan shell by lifesaving cervical esophagotomy. Such in-gestion requires prompt surgery rather than nonopera-tive management or endoscopy. a bColor version available online Fig. 3.  a Through a left lateral cervicotomy, a longitudinal esophagotomy was accomplished along the Laimer-Killian triangle permitting the extraction of the clam shell split in 2 pieces.  b The periostracum of the shell mea-sured 4 cm in diameter.  References  1 Triadafilopoulos G, Roorda A, Akiyama J: Update on foreign bodies in the esophagus: diagnosis and management. Curr Gastroen-terol Rep 2013; 15: 317.  2 Tseng HJ, Hanna TK, Shuaib W, et al: Imag-ing foreign bodies: ingested, aspirated, and in-serted. Ann Emerg Med 2015; 66: 570–582.  3 Pelucchi S, Bianchini C, Ciorba A, et al: Un-usual foreign body in the upper cervical oe-sophagus: case report. Acta Otorhinolaryngol Ital 2007; 27: 38–40.  4 Mato Ponce M, Muñoz Alcántara M, Pérez Pérez A, et al: Tension pneumothorax during removal of a foreign body from the esophagus (in Spanish). Rev Esp Anestesiol Reanim 2001; 48: 151–154.  5 Syrakos T, Zacharakis E, Antonitsis P, et al: Surgical intervention for gastrointestinal for-eign bodies in adults: a case series. Med Princ Pract 2008; 17: 276–279.  6 Tomas X, Alos L, Cores E, et al: Small bowel perforation due to ingested clam valve: imag-ing findings. Eur Radiol 2005; 15: 189–190.  7 Ramón Dalmau M, Ibarz Servio L, Mauri Cunill A, et al: Extracorporeal shockwave lithotripsy on a clam shell fragment lodged in the ileocecal valve. Arch Esp Urol 1994; 47: 159–161.  8 Vicens C, Nadal A, Ponseti JM, et al: Applica-tion of extracorporeal lithotripsy in intestinal subocclusion caused by a clam shell (in Span-ish). Rev Esp Enferm Dig 1994; 86: 612–614.  9 Hayashi D, Aoki T, Shibata R, et al: Case of food protein-induced enterocolitis syndrome caused by short-neck clam ingestion (in Japa-nese). Arerugi 2010; 59: 1628–1633.  Downloaded by: 94.160.96.113 - 9/13/2017 11:17:45 PM

Cervical esophagotomy for removal of an ingested clam shell: a very uncommon foreign body ingestion

Archivio istituzionale della Ricerca -  Università degli Studi di Parma

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Cervical esophagotomy for removal of an ingested clam shell: a very uncommon foreign body ingestion

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Archivio della ricerca- Università di Roma La Sapienza

Archivio istituzionale della Ricerca - Università degli Studi di Parma