Deeply embedded esophageal fishbone removed by endoscopic submucosal dissection

A 50-year-old man presented to the emergency department with chest pain and odynophagia after eating fish. Physical examination and X-ray of the neck were unremarkable. Computed tomography (CT) of the chest showed a fishbone embedded within the muscularis propria of the esophagus ([ Fig. 1 ] a ). We then performed an endoscopic ultrasonography (EUS), which localized the fishbone to the posterior wall ([ Fig. 2 ]). A small mucosal defect was also noted. Fig. 1 a Coronal slice of computed tomography showed a fishbone (arrow) lodged in the distal esophagus, that appeared to penetrate through the submucosa and muscularis propria. b Endoscopically a small portion of fishbone can seen embedded in the distal esophagus through the small mucosal defect. Fig. 2 Endoscopic ultrasound showed a linear hyperdensity projecting through the muscularis propria. We proceeded with endoscopic submucosal dissection (ESD) to remove the fishbone ([ Video 1 ]). After normal saline and methylene blue had been injected to expand the submucosal space, a Dual-J knife (Olympus, Center Valley, PA) was used to create a mucosal incision, laterally extending the mucosal defect ([ Fig. 1 ] b ). The fishbone was exposed; it was positioned perpendicularly to the esophagus, between the circular and longitudinal muscle layers. Using the fishbone as a scaffold, the overlying circular muscle layer was progressively dissected until the right lateral tip of the bone was freed ([ Fig. 3 ]). The exposed tip was grasped with forceps and removed through the overtube ([ Fig. 4 ]). Examination of the defect revealed incised circular muscle fibers, with intact longitudinal fibers ([ Fig. 5 ]). Attempted closure with through-the-scope clips was unsuccessful because of the orientation of the defect. We placed a 10.5 cm × 23 mm fully covered metal stent (Wallflex; Boston Scientific, Marlborough, Massachusetts, USA). Subsequent CT 48 hours later showed appropriate positioning of the stent with no complications. The stent was removed 2 weeks later, and healed mucosa was observed. Quality: mobile 360 480 720 Download Endoscopic submucosal dissection performed to remove a fishbone deeply embedded into the wall of the distal esophagus.Video 1 Fig. 3 Endoscopic submucosal dissection was done along the fishbone to free the right lateral edge from the circular muscle layer. Fig. 4 The fishbone was grasped with a rat-toothed forceps and removed via the overtube. Fig. 5 The remaining muscle defect and exposed submucosa and muscle fibers. Foreign body ingestion is frequently encountered [ 1 ]. In adults, bony fragments are most common, and tend to become lodged at sharp angulations in the gastrointestinal tract [ 2 ]. While guidelines recommend emergent endoscopy in esophageal impaction [ 3 ] [ 4 ], surgical intervention is typically required for deeply embedded nonvisible foreign bodies [ 5 ]. As we have demonstrated, in selected patients, EUS may localize the foreign body and facilitate ESD for safe and effective extraction. Endoscopy_UCTN_Code_TTT_1AO_2AL Endoscopy E-Videos https://eref.thieme.de/e-videos E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos . Publication History Article published online: 08 November 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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