Risk Factors for Post-ERCP Pancreatitis in Pediatric and Young Adult Patients.

OBJECTIVES: Post-ERCP pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Limited existing data suggest that prophylactic pancreatic duct (PD) stenting in pediatric patients may increase the risk of PEP. The aim of this study is to identify factors associated with PEP in pediatric patients. METHODS: Patients at a single institution who underwent ERCP between 2012 and 2020 were retrospectively reviewed. Patient and procedure-related factors were collected. Data were analyzed using Chi-square or Fisher exact tests as appropriate and Mann-Whitney-Wilcoxon tests. RESULTS: Seven hundred thirty-six ERCPs were performed for 402 unique patients. Ninety-four cases were complicated by PEP (12.8%), of which 91 were mild and 3 were moderately severe. Pancreatic indication, native major papilla, PD cannulation and injection, and higher American Society for Gastrointestinal Endoscopy (ASGE) complexity were associated with PEP. A higher proportion of patients who received rectal indomethacin (65% vs 47%, P = 0.002), or who had placement of a prophylactic (31% vs 20%, P = 0.01) or therapeutic PD stent (37% vs 27%, P = 0.04) developed PEP; however, in a subgroup analysis of high-risk patients, this association was not persistent. A smaller proportion of PEP patients had PRSS1 mutation compared to non-PEP patients (22% vs 40%, P = 0.04). CONCLUSIONS: This study evaluates factors associated with developing PEP in a large pediatric cohort. A high rate of PEP was observed, likely secondary to higher rates of pancreatic indication and higher ASGE complexity scores compared to previously reported literature. Randomized prospective trials are needed to better define the utility of various interventions.

Long-Term Survival Outcomes after Operative Management of Chronic Pancreatitis: Two Decades of Experience.

BACKGROUND: Chronic pancreatitis is a debilitating, life-altering disease; however, the long-term outcomes after operative intervention have not been established. STUDY DESIGN: Patients who underwent operative intervention at a single institution between 2000 and 2020 for chronic pancreatitis were included, and survival was assessed using the National Death Index. RESULTS: A total of 493 patients who underwent 555 operative interventions for chronic pancreatitis during 2 decades were included. Of these patients, 48.5% underwent total pancreatectomy ± islet autotransplantation, 21.7% underwent a duodenal preserving pancreatic head resection and/or drainage procedure, 16.2% underwent a pancreaticoduodenectomy, and 12.8% underwent a distal pancreatectomy. The most common etiology of chronic pancreatitis was idiopathic (41.8%), followed by alcohol (28.0%) and known genetic polymorphisms (9.9%). With a median follow-up of 83.9 months, median overall survival was 202.7 months, with a 5- and 10-year overall survival of 81.3% and 63.5%. One hundred sixty-five patients were deceased, and the most common causes of death included infections (16.4%, n=27), cardiovascular disease (12.7%, n=21), and diabetes-related causes (10.9%, n=18). On long-term follow-up, 73.1% (n=331) of patients remained opioid free, but 58.7% (n=266) had insulin-dependent diabetes. On multivariate Cox proportional hazards modeling, only persistent opioid use (hazard ratio 3.91 [95% CI 2.45 to 6.24], p < 0.01) was associated with worse overall survival. CONCLUSIONS: Our results represent the largest series to date evaluating long-term survival outcomes in patients with chronic pancreatitis after operative intervention. Our data give insight into the cause of death and allow for the development of mitigation strategies and long-term monitoring of comorbid conditions.

Predicting endocrine function after total pancreatectomy and islet cell autotransplantation: A novel approach utilizing computed tomography texture analysis.

BACKGROUND: Islet cell autotransplantation is an effective method to prevent morbidity associated with type IIIc diabetes after total pancreatectomy. However, there is no valid method to predict long-term endocrine function. Our aim was to assess computed tomography texture analysis as a strategy to predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation. METHODS: All patients undergoing total pancreatectomy and islet cell autotransplantation from 2007 to 2020 who had high-quality preoperative computed tomography imaging available for texture analysis were included. The primary outcome was optimal long-term endocrine function, defined as stable glycemic control with <10 units of insulin/day. RESULTS: Sixty-three patients met inclusion criteria. Median yield was 6,111 islet equivalent/kg body weight. At a median follow-up of 64.2 months, 12.7% (n = 8) of patients were insulin independent and 39.7% (n = 25) demonstrated optimal endocrine function. Neither total islet equivalent nor islet equivalent/kg body weight alone were associated with optimal endocrine function. To improve endocrine function prediction, computed tomography texture analysis parameters were analyzed, identifying an association between kurtosis (odds ratio, 2.32; 95% confidence interval, 1.08-4.80; P = .02) and optimal endocrine function. Sensitivity analysis discovered a cutoff for kurtosis = 0.60, with optimal endocrine function seen in 66.7% with kurtosis ≥0.60, compared with only 26.2% with kurtosis <0.60 (P < .01). On multivariate logistic regression including islet equivalent yield, only kurtosis ≥0.60 (odds ratio, 5.61; 95% confidence interval, 1.56-20.19; P = .01) and fewer small islet equivalent (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .02) were associated with optimal endocrine function, with the whole model demonstrating excellent prediction of long-term endocrine function (area under the curve, 0.775). CONCLUSION: Computed tomography texture analysis can provide qualitative data, that when used in combination with quantitative islet equivalent yield, can accurately predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation.

Total pancreatectomy and islet cell autotransplantation: a 10-year update on outcomes and assessment of long-term durability.

BACKGROUND: Total pancreatectomy and islet cell autotransplantation (TPIAT) offers an effective, lasting solution for the management of chronic pancreatitis up to 5-years post-operatively. Our aim was to assess durability of TPIAT at 10-years. METHODS: Patients undergoing TPIAT for chronic pancreatitis eligible for 10-year follow-up were included. Primary outcomes, including endocrine function and narcotic requirements, were reported at 5-, 7.5-, and 10-years post-operatively. RESULTS: Of the 231 patients who underwent TPIAT, 142 met inclusion criteria. All patients underwent successful TPIAT with an average of 5680.3 islet equivalents per body weight. While insulin independence tended to decrease over time (25.7% vs. 16.0% vs. 10.9%, p = 0.11) with an increase in HbA1C (7.6% vs. 8.2% vs. 8.4%, p = 0.09), partial islet function persisted (64.9% vs. 68.0% vs. 67.4%, p = 0.93). Opioid independence was achieved and remained durable in the majority (73.3% vs. 72.2% vs. 75.5%, p = 0.93). Quality of life improvements persisted, with 85% reporting improvement from baseline at 10-years. Estimated median overall survival was 202.7 months. CONCLUSION: This study represents one of the largest series reporting on long-term outcomes after TPIAT, demonstrating excellent long-term pain control and durable improvements in quality of life. Islet cell function declines over time however stable glycemic control is maintained.

Is There a Benefit to Adjuvant Chemotherapy in Resected, Early Stage Pancreatic Ductal Adenocarcinoma?

BACKGROUND: The role of systemic therapy for Stage IA pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim of our study was to evaluate the impact of adjuvant chemotherapy (AC) on survival in patients with early stage disease. METHODS: The National Cancer Database was queried from 2006 to 2017 for resected pT1N0M0 (Stage 1A) PDAC. Exclusion criteria included neoadjuvant therapy, radiation, or those who suffered a 90-day mortality. RESULTS: Of the 1526 patients included in the study, 42.2% received AC and 57.8% underwent surgery alone. Patients who received AC were younger, had fewer comorbidities, and were more likely to have private insurance, compared with those treated with surgery alone. Patients who received AC had longer median overall survival (OS) compared with those who underwent surgery alone (105.7 months vs 72.0 months, p < 0.01). Subset analyses based on individual "good" prognostic features (size ≤ 1.0 cm, lymphovascular invasion negative, well/moderately differentiated, margin negative resection) demonstrated improved OS with AC. Following propensity score matching based on key clinicopathologic features, AC remained associated with improved median OS (83.7 months vs 59.8 months, p < 0.01). However, in the cohort with body/tail tumors (101.2 months vs 95.0 months, p = 0.19) and those with all "good" prognostic features (95.9 months vs 90.6 months, p = 0.15), AC was not associated with improved survival. CONCLUSIONS: In resected, Stage IA PDAC, AC is associated with improved overall survival in the vast majority of patients; however, in select cohorts the role of AC is unclear. Further study is needed to tailor treatment to individual patients with PDAC.

Systemic Therapy for Resected Pancreatic Adenocarcinoma: How Much is Enough?

BACKGROUND: Systemic therapy is an essential part of treatment for pancreatic ductal adenocarcinoma (PDAC). However, not all patients receive every cycle of chemotherapy and even if they do, the impact of reduced dose density (DD) on survival is not known. PATIENTS AND METHODS: A single institutional prospective database was queried for patients with PDAC who underwent curative resection between 2009 and 2018. The primary outcome was DD, defined as the percentage of total planned chemotherapy actually received and associated survival. RESULTS: Of the 126 patients included, 38.9% underwent a neoadjuvant approach, which was associated with a greater median number of completed chemotherapy cycles (5 cycles versus 4 cycles, p < 0.01) and a higher median total DD (93.0% versus 65.0%, p < 0.01), compared with an adjuvant treatment approach. In both groups, adjuvant chemotherapy completion rates were low, with only 55 patients completing all adjuvant cycles. After sequential survival analysis, patients who received a DD ≥ 80% had improved median overall survival (OS) (27.1 months versus 18.6 months, p = 0.01), compared with patients who achieved a DD < 80%. On multivariate Cox proportional-hazards modeling, only the presence of lymphovascular invasion (HR: 1.77, 95% CI: 1.04-2.99, p = 0.04) and DD < 80% (HR: 1.91, 95% CI: 1.23-3.00, p = 0.01) were associated with decreased OS. CONCLUSIONS: In this cohort study, patients who received ≥ 80% DD had significantly better OS. DD should be considered an important prognostic metric in pancreatic cancer, and strategies are needed to improve chemotherapy tolerance to improve patient outcomes.

Radiation therapy in borderline resectable pancreatic cancer: A review.

BACKGROUND: Borderline resectable pancreatic cancer constitutes a complex clinical entity, presenting the clinician with a locally aggressive disease that has a proclivity for distant spread. The benefits of radiation therapy, such as improved local control and improved survival, have been questioned. In this review we seek to summarize the existing evidence on radiation therapy in borderline resectable pancreatic cancer and highlight future areas of research. METHODS: A comprehensive review of PubMed for clinical studies reporting outcomes in borderline resectable pancreatic cancer was performed in June 2021, with an emphasis placed on prospective studies. RESULTS: Radiologic "downstaging" in borderline resectable pancreatic cancer is a rare event, although some evidence shows increased clinical response to neoadjuvant chemotherapy over radiation therapy. Margin status seems to be equivalent between regimens that use neoadjuvant chemotherapy alone and regimens that include neoadjuvant radiation therapy. Local control in borderline resectable pancreatic cancer is likely improved with radiation therapy; however, the benefit of improved local control in a disease marked by systemic failure has been questioned. Although some studies have shown improved survival with radiation therapy, differences in the delivery and tolerance of chemotherapy between the neoadjuvant and adjuvant setting confound these results. When the evidence is evaluated as a whole, there is no clear survival benefit of radiation therapy in borderline resectable pancreatic cancer. CONCLUSION: Once considered a staple of therapy, the role of radiation therapy in borderline resectable pancreatic cancer is evolving as systemic therapy regimens continues to improve. Increased clinical understanding of disease phenotype and response are needed to accurately tailor therapy for individual patients and to improve outcomes in this complex patient population.

The natural history of chronic pancreatitis after operative intervention: The need for revisional operation.

BACKGROUND: For patients with chronic pancreatitis, duodenum-sparing head resections and pancreaticoduodenectomy are effective operations to relieve abdominal pain. For patients who develop recurrent symptoms after their index operation, the long-term management remains controversial. METHODS: Between 2002 and 2014, patients undergoing operative intervention for chronic pancreatitis were identified retrospectively. Patients requiring reoperation after their index operation were reviewed. RESULTS: A total of 121 patients with chronic pancreatitis underwent an index operation. At a median time of 33 months, 85 patients underwent no further operative intervention, while 36 patients underwent reoperation. A reoperative procedure was completed with acceptable perioperative morbidity and blood loss. After a revision operation, 25% of patients became narcotic independent. Narcotic requirements decreased from 143 morphine equivalent milligrams per day (MEQ/d) to 80 MEQ/d, and 58% of patients required less than 50 MEQ/d. Insulin requirements were not increased from preoperative levels. Multivariate analysis demonstrated only narcotic requirement and exocrine insufficiency after the index operation to be predictive for the need for a revision operation. CONCLUSION: Our data demonstrate the following: (1) A significant number of patients undergoing duodenum-sparing head resections (26%) or pancreaticoduodenectomy (29%) required reoperation for recurrent abdominal pain; and (2) a revisional operation can be effective in relieving recurrent abdominal symptoms. Patients with recurrent symptoms should be considered for additional operative intervention.

Completion pancreatectomy and islet cell autotransplantation as salvage therapy for patients failing previous operative interventions for chronic pancreatitis.

PURPOSE: Traditional decompressive and/or pancreatic resection procedures have been the cornerstone of operative therapy for refractory abdominal pain secondary to chronic pancreatitis. Management of patients that fail these traditional interventions represents a clinical dilemma. Salvage therapy with completion pancreatectomy and islet cell autotransplantation (CPIAT) is an emerging treatment option for this patient population; however, outcomes after this procedure have not been well-studied. METHODS: All patients undergoing CPIAT after previous decompressive and/or pancreatic resection for the treatment of chronic pancreatitis at our institution were identified for inclusion in this single-center observational study. Study end points included islet yield, narcotic requirements, glycemic control, and quality of life (QOL). QOL was assessed using the Short Form (SF)-36 health questionnaire. RESULTS: Sixty-four patients underwent CPIAT as salvage therapy. The median age at time of CPIAT was 38 years (interquartile range [IQR], 14.7-65.4). The most common etiology of chronic pancreatitis was idiopathic pancreatitis (66%; n = 42) followed by genetically linked pancreatitis (9%; n = 6) and alcoholic pancreatitis (8%; n = 5). All of these patients had previously undergone prior limited pancreatic resection or decompressive procedure. The majority of patients (50%; n = 32) underwent prior pancreaticoduodenectomy, whereas the remainder had undergone distal pancreatectomy (17%; n = 11), Frey (13%; n = 8), Puestow (13%; n = 8), or Berne (8%; n = 5) procedures. Median time from initial surgical intervention to CPIAT was 28.1 months (IQR, 13.6-43.0). All of these patients underwent a successful CPIAT. Mean operative time was 502.2 minutes with average hospital duration of stay of 13 days. Islet cell isolation was feasible despite previous procedures with a mean islet yield of 331,304 islet cell equivalents, which totaled an islet cell autotransplantation of 4,737 ± 492 IEQ/kg body weight. Median patient follow-up was 21.2 months (IQR, 7.9-36.8). Before CPIAT, all patients required a mean of 120.8 morphine equivalent milligrams per day (MEQ/d), which improved to 48.5 MEQ (P < .001 compared with preoperative requirements) at most recent follow-up. Of these patients, 44% (n = 28) achieved narcotic independence. All patients were able to achieve stable glycemic control with a mean insulin requirement of 16 units per day. Of these patients, 20% (n = 13) were insulin independent after CPIAT. Mean postoperative glycosylated hemoglobin was 7.8% (range, 4.6-12.5). Islet cell viability was confirmed with endocrine testing and mean C-peptide levels 6 months after CPIAT were 0.91 ng/mL (range, 0.1-3.0). The SF-36 QOL survey administered postoperatively demonstrated improvement in all tested modules. CONCLUSION: This study is the first to examine the results of salvage therapy with CPIAT for patients with refractory chronic pancreatitis. Patients undergoing CPIAT achieved improved postoperative narcotic requirements, stable glycemic control, and improved QOL.

Total pancreatectomy with islet cell autotransplantation as the initial treatment for minimal-change chronic pancreatitis.

OBJECTIVES: Patients with minimal-change chronic pancreatitis (MCCP) are traditionally managed medically with poor results. This study was conducted to review outcomes following total pancreatectomy with islet cell autotransplantation (TP/IAT) as the initial surgical procedure in the treatment of MCCP. METHODS: All patients submitted to TP/IAT for MCCP were identified for inclusion in a single-centre observational study. A retrospective chart review was performed to identify pertinent preoperative, perioperative and postoperative data. RESULTS: A total of 84 patients with a mean age of 36.5 years (range: 15-60 years) underwent TP/IAT as the initial treatment for MCCP. The most common aetiology of chronic pancreatitis in this cohort was idiopathic (69.0%, n = 58), followed by aetiologies associated with genetic mutations (16.7%, n = 14), pancreatic divisum (9.5%, n = 8), and alcohol (4.8%, n = 4). The most common genetic mutations pertained to CFTR (n = 9), SPINK1 (n = 3) and PRSS1 (n = 2). Mean ± standard error of the mean preoperative narcotic requirements were 129.3 ± 18.7 morphine-equivalent milligrams (MEQ)/day. Overall, 58.3% (n = 49) of patients achieved narcotic independence and the remaining patients required 59.4 ± 10.6 MEQ/day (P < 0.05). Postoperative insulin independence was achieved by 36.9% (n = 31) of patients. The Short-Form 36-Item Health Survey administered postoperatively demonstrated improvement in all tested quality of life subscales. CONCLUSIONS: The present report represents one of the largest series demonstrating the benefits of TP/IAT in the subset of patients with MCCP.

High readmission rates after surgery for chronic pancreatitis.

BACKGROUND: Readmission after complex gastrointestinal surgery is a frequent occurrence that burdens the health care system and leads to increased cost. Recent studies have demonstrated 30- and 90-day readmission rates of 15% and 19%, respectively, following pancreaticoduodenectomy. Given the psychosocial issues often associated with chronic pancreatitis, we hypothesized that readmission rates following surgery for chronic pancreatitis would be higher than previously reported for pancreaticoduodenectomy. METHODS: We retrospectively reviewed patients undergoing surgery for chronic pancreatitis at a single institution between 2001 and 2013. Patients in this cohort underwent pancreaticoduodenectomy, Berne, Beger, or Frey procedures. Readmission to a primary or secondary hospital was evaluated at both 30 and 90 days after discharge. Multivariate logistic regression analysis was performed to identify factors associated with readmission. RESULTS: The records of 111 patients were evaluated, of which 69 (62%) underwent duodenal-preserving pancreatic head resection (Berne, Beger, or Frey), while the remaining 42 (38%) underwent pancreaticoduodenectomy. Within the duodenal-preserving pancreatic head resection arm, readmission rates at 30 and 90 days were 30.4% and 43.5%, respectively. Readmission rates following pancreaticoduodenectomy were similar with 33.3% at 30 days and 40.5% at 90 days. The most common reasons for readmission were pain control, infectious complications, and recurrent pancreatitis. On multivariate analysis, wound infection during the initial hospital stay was a predictor of readmission at both 30 and 90 days (P = .02). CONCLUSION: To our knowledge, our data represent the first report demonstrating very high readmission rates after surgery for chronic pancreatitis, more than double the previous rates reported for pancreaticoduodenectomy. This cohort of patients requires extensive discharge planning focused on pain control, nutritional optimization, and close postoperative monitoring.

Long-term outcomes after total pancreatectomy and islet cell autotransplantation: is it a durable operation?

OBJECTIVE: Total pancreatectomy and islet cell autotransplantation (TPIAT) has been increasingly utilized for the management of chronic pancreatitis (CP) with early success. However, the long-term durability of this operation remains unclear. METHODS: All patients undergoing TPIAT for the treatment of CP with 5-year or greater follow-up were identified for inclusion in this single-center observational study. End points included narcotic requirements, glycemic control, islet function, quality of life (QOL), and survival. RESULTS: Between 2000 and 2013, 166 patients underwent TPIAT; 112 of these patients had 5-year follow-up data to analyze. All patients underwent successful IAT with a mean of 6027 ± 595 islet equivalents per body weight. There was no perioperative mortality and actuarial survival at 5 years was 94.6%. The narcotic independence rate at 1 year was 55% and continued to improve to 73% at 5-year follow-up (P < 0.05). The insulin independence rate declined over time (38% at 1 year vs 27% at more than 5 years), but insulin requirements remained similar (21.4 vs 24.3 units per day, P = 0.6). All patients achieved stable glycemic control with a median hemoglobin A1C (HgA1C) of 6.9% (range: 5.85%-8.3%). The short form 36-item QOL assessment of a subset of patients available for contact demonstrated continued improvements in all tested modules in patients with at least 5-year follow-up. Two patients developed diabetic complications requiring whole organ pancreas transplant for salvage. CONCLUSIONS: This represents one of the largest series examining long-term outcomes after TPIAT. This operation produces durable pain relief and improvement in QOL parameters. Insulin independence rates decline over time, but most patients maintain stable glycemic control.

Surgical outcomes after total pancreatectomy and islet cell autotransplantation in pediatric patients.

BACKGROUND: This study aims to review surgical outcomes of pediatric patients undergoing total pancreatectomy with islet cell autotransplantation (TP/IAT) for the treatment of chronic pancreatitis (CP). METHODS: All pediatric patients (≤18 years old) undergoing TP/IAT over a 10-year period (December 2002-June 2012) were identified for inclusion in a single-center, observational cohort study. Retrospective chart review was performed to identify pertinent preoperative, perioperative, and postoperative data, including narcotic usage, insulin requirements, etiology of pancreatitis, previous operative interventions, operative times, islet cell yields, duration of hospital stay, and overall quality of life. Quality of life was assessed using the Short Form-36 health questionnaire. RESULTS: Fourteen pediatric patients underwent TP/IAT for the treatment of CP at the University of Cincinnati with a mean age of 15.9 years (range, 14-18) and a mean body mass index of 21.8 kg/m(2) (range, 14-37). Of the patients, 50% (n = 7) were male and 29% had undergone previous pancreatic operations (1 each of Whipple, Puestow, Frey, and Berne procedures). Etiology of pancreatitis was idiopathic for 57% (n = 8); the remainder had identified genetic mutations predisposing to pancreatitis (CFTR, n = 4; SPINK1, n = 1; PRSS1, n = 1). Mean operative time was 532 minutes (range, 360-674) with an average hospital duration of stay of 16 days (range, 7-37). Islet cell isolation resulted in mean islet cell equivalents (IEQ) of 500,443 in patients without previous pancreatic surgery versus 413,671 IEQ in patients with prior pancreatic surgery (P = .12). Median patient follow-up was 9 months from surgery (range, 1-78). Preoperatively, patients required on average 32.7 morphine equivalent mg per day (MEQ), which improved to 13.9 MEQ at most recent follow-up. Eleven patients (79%) were narcotic independent. None of the patients were diabetic preoperatively. All of the patients were discharged after the operation with scheduled insulin requirements (mean, 17 U/d). This requirement decreased to a mean of 10.1 U/d at most recent follow-up visit. Four patients (29%) progressed to insulin independence. All patients in this series achieved stable glycemic control postoperatively and there was no incidence of "brittle" diabetes. Quality-of-life surveys showed improvement in all tested modules. CONCLUSION: This study represents one of the largest series examining TP/IAT in the pediatric population. Pediatric patients benefitted from TP/IAT with a decrease in postoperative narcotic requirements, stable glycemic control, and improved quality of life.

An unusual presentation of primary sclerosing cholangitis.

This case report describes the unusual presentation of a patient who had findings which were initially suggestive of a type IV choledochal cyst. Her liver biopsy demonstrated biliary cirrhosis. She was treated with endoscopic retrograde cholangiopancreatography and biliary stent exchanges over one year. Her cholangiogram one year later demonstrated resolution of the biliary cystic dilation which led to her initial diagnosis, with beading and stricturing of the hepatic ducts consistent with primary sclerosing cholangitis. Liver-associated enzymes and physical findings also improved. A liver biopsy one year later demonstrated a marked improvement in hepatic fibrosis with no evidence of cirrhosis.

Foreign bodies.

The spectrum of gastrointestinal (GI) foreign bodies includes food bolus impaction in the esophagus, nonfood objects that are swallowed, and various objects that may be inserted into the rectum. The risk depends upon the type of object and its location. Fortunately, 80% to 90% of ingested foreign bodies will pass without intervention. Objects with sharp edges or pointed tips have the highest risk of complications, up to 35%. All objects impacted in the esophagus require urgent or emergent treatment. Rectal foreign bodies are usually removable transanally, although general anesthesia and operative intervention sometimes are required.

Esophageal foreign bodies: types and techniques for removal.

Patients with esophageal foreign bodies require prompt diagnosis and therapy. The first tasks are to determine the type of object, time since ingestion, location of the object, and the likelihood of associated complications. Patients who have evidence of complete esophageal occlusion or who have ingested a sharp or pointed object require urgent treatment due to the increased risk of complications. Button batteries are particularly injurious in the esophagus and should be removed immediately. Coins in the esophagus should also be removed; however, a brief period of observation is appropriate for coins in the distal esophagus, as some will pass spontaneously. Flexible endoscopy is the therapeutic modality of choice for most patients. The key principles for endoscopic management of esophageal foreign bodies are to protect the airway, to maintain control of the object during extraction, and to avoid causing additional damage. Endotracheal intubation is sometimes necessary, especially in younger children and those at higher risk for aspiration. The use of devices such as an esophageal overtube and a latex protector hood may facilitate safer extraction of sharp/pointed objects. Patients with food impactions usually require treatment of an associated structural lesion of the esophagus.