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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 127-129

Transthoracic extraction of impacted denture at mid esophagus in a 75-year-old patient


1 Departments of Cardio-Thoracic and Vascular Surgery, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India
2 Department of Anesthesia, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India
3 Department of Ear-Nose-Throat, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India

Date of Web Publication16-Oct-2014

Correspondence Address:
Vikas D Goyal
Department of Cardio-Thoracic and Vascular Surgery, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda - 176 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.143095

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  Abstract 

A 75-year-old male patient presented with history of dysphagia following inadvertent passage of loose dentures into the esophagus. Patient could only swallow liquids thereafter and had persistent pain in the throat. Upper gastrointestinal endoscopy confirmed the presence of denture in mid esophagus at approximately 22-25 cm from incisors but the denture could not be removed as it had got impacted in the esophagus. Thoracotomy and esophagotomy was planned because repeated endoscopic removal was unsuccessful. Right posterolateral thoracotomy was performed through the fifth intercostal space and longitudinal esophagotomy in the mid esophagus was done to extract the impacted dentures followed by primary repair of the esophagus. The patient recovered well and he was discharged on the eighth postoperative day.

Keywords: Dysphagia, esophagotomy, impacted denture, thoracotomy


How to cite this article:
Goyal VD, Rana S, Sharma S, Gupta VD. Transthoracic extraction of impacted denture at mid esophagus in a 75-year-old patient . Arch Int Surg 2014;4:127-9

How to cite this URL:
Goyal VD, Rana S, Sharma S, Gupta VD. Transthoracic extraction of impacted denture at mid esophagus in a 75-year-old patient . Arch Int Surg [serial online] 2014 [cited 2020 Oct 21];4:127-9. Available from: https://www.archintsurg.org/text.asp?2014/4/2/127/143095


  Introduction Top


Foreign bodies in the esophagus rarely require surgical intervention in the form of open surgery as they are easily removed with endoscopic techniques. In some patients, foreign bodies pass through the gastrointestinal tract with peristalsis and no further intervention is required. Plain radiograph is useful to diagnose and localize the site of radio-opaque foreign bodies but dentures contrary to the general belief are not radio-opaque in most of cases and cannot be localized on plain radiographs. There are few reported series and case reports in literature on surgical management of foreign bodies in the esophagus. On the contrary, there are large number of reported series on endoscopic removal of foreign bodies from esophagus.

Endoscopic extraction of impacted dentures due to sharp edges and rigid structure can lead to esophageal perforation and esophagotomy [1] may be required to extract the impacted foreign body especially when it gets impacted. We present a case of impacted foreign body (denture) in the mid esophagus with delayed presentation, which could not be removed with endoscopic techniques and required surgical removal through right posterolateral thoracotomy and esophagotomy followed by primary repair.

Cervical, [1],[2] thoracic, [3] and abdominal approaches [4] for extraction of the foreign bodies in the esophagus have been used depending upon the site of impaction of foreign body in the esophagus. There is a report in literature where transhiatal esophagectomy [4] was done for impacted denture and poor condition of the esophagus, but it should be considered the last resort. Esophagotomy and primary repair should be the preferred option in cases where endoscopic removal is unsuccessful.


  Case Report Top


A 75-year-old male patient presented with history of dysphagia following inadvertent passage of loose dentures into the esophagus. The patient could only swallow liquids thereafter and had persistent pain in the throat. Earlier, the patient was receiving treatment at a peripheral center where chest radiograph was done, and the denture was thought to have moved down with peristalsis because it was not visible on the chest radiograph [Figure 1]. Barium swallow was not done at that time, although it would have been beneficial by localizing the foreign body as a filling defect. Barium swallow is more useful than plain radiographs for diagnosing radiolucent esophageal foreign bodies whereas plain radiograph is more useful in cases of radio-opaque foreign bodies such as metallic coin, pins, etc. The patient had persistent symptoms of dysphagia and something sticking in the throat, and later, he was referred to our institute. Upper gastrointestinal endoscopy confirmed the presence of denture in the mid esophagus and extraction was not successful since it got impacted in the esophagus. The patient was again taken for endoscopic removal of denture under general anesthesia next day but the denture was firmly stuck up with the esophageal wall and could not be extracted. The patient was then referred to us for surgical removal since there was risk of esophageal perforation with repeated attempts of extraction with endoscopes. The patient was weak and emaciated and was not an ideal candidate for surgery. Investigations revealed severe hypoproteinemia with serum albumin level of 1.5 gm/dl and deranged prothrombin time of 20 seconds. The patient was preoperatively stabilized for 2 days and was given fresh frozen plasma, amino acid infusions, multivitamin injections, and intravenous fluids to improve general condition and bring the laboratory parameters as normal as possible. Thoracotomy and esophagotomy was planned because repeated endoscopic removal was unsuccessful. During surgery, general anesthesia was given using single lumen endotracheal tube. Thoracic epidural catheter could not be inserted as the patient had deranged prothrombin time even after pre-operative stabilization. Right posterolateral thoracotomy was performed through the fifth intercostal space after resecting the fifth rib and harvesting the intercostal muscle pedicle flap. Denture was localized in the esophagus by palpation, and esophagus was mobilized and looped distal to the site of impaction. Longitudinal esophagotomy [Figure 2] of approximately 7 cm in length was done. Denture was held with Alli's forceps and extracted and Ryle's tube previously placed proximal to the denture was guided in to distal esophagus and stomach. There was no transmural perforation at the site of impaction although inflammation was present. After removal of the denture esophagus was repaired in two layers using 3-0 polyglactin suture on the mucosa and silk 3-0 on the muscular layer. Flap of pleura was mobilized and the repair site was covered with pleural flap followed by further reinforcement by the intercostal muscle pedicle flap harvested at the time of thoracotomy to minimize the risk of leak. Two intercostal drains were inserted and standard thoracotomy closure was done. Postoperatively, the patient was given amino acid infusions and fresh frozen plasma. Ryle's tube feeding was also commenced on the second postoperative day to improve patient's nutritional status; oral feeding was started from the sixth postoperative day. Before and after starting oral feeds, chest roentgenogram and leucocyte count was done to rule out any evidence of infection or collection. Barium swallow could have also been done to check for leakage prior to starting oral feeds. The patient recovered well and was discharged on the eighth postoperative day.
Figure 1: Denture not localized on preoperative chest radiograph

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Figure 2: Intra-operative photograph showing longitudinal esophagotomy with denture in the esophagus

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  Discussion Top


Dentures are an important cause of foreign bodies in the esophagus in elderly patients. Foreign bodies can be easily removed with endoscopic techniques when the patient present early. However, sharp and impacted foreign bodies with delayed presentation sometimes require surgical removal, as in this case. Although dentures are generally believed to be radio-opaque [5] but they are mostly radiolucent. [6] This incorrect belief might delay the diagnosis and consequently the treatment. Moreover, the required mode of treatment gets changed and the risk increases with the delay in diagnosis.

Athanassiadi K et al . [7] have reported one of the largest series on management of esophageal foreign bodies with 400 cases over a period of 36 years; surgical intervention was required in only 12 cases, and others were managed with endoscopic techniques. Miyazaki T et al . [8] in their study on 90 cases over a period of 5 years reported surgical intervention in 2 patients. Weissberg D et al. [9] reported thoracotomy for 2 patients out of 32 patients with foreign bodies in esophagus, over a period of 30 years.

Patients with a relatively longer duration of dysphagia get malnourished and require pre- and postoperative nutritional supplementation. Management of hypoproteinemia is an important factor determining the patient outcome after esophageal surgery along with other factors.

Thoracoscopic procedures [10] have been used to remove foreign bodies in the esophagus. They have advantages of small incision, reduced postoperative pain, and shorter hospital stay, but open surgery might be beneficial in providing more secure closure of the esophagus and coverage with pleural and or intercostal muscle flaps, with lesser chances of leak from the repair site.


  Conclusion Top


Surgical treatment in the form of esophagotomy may be necessary in some cases of impacted foreign bodies in the esophagus where endoscopic removal is unsuccessful. Dentures are radiolucent most of the times and Roentgenograms are not useful in their detection.

 
  References Top

1.
Nwaorgu OG, Onakoya PA, Sogebi OA, Kokong DD, Dosumu OO. Esophageal impacted dentures. J Natl Med Assoc 2004;96:1350-3.  Back to cited text no. 1
    
2.
Chua YK, See JY, Ti TK. Oesophageal - impacted denture requiring open surgery. Singapore Med J 2006;47:820-1.  Back to cited text no. 2
    
3.
Dalvi AN, Thapar VK, Jagtap S, Barve DJ, Savarkar DP, Garle MN, et al. Thoracoscopic removal of impacted denture: Report of a case with review of literature. J Minim Access Surg 2010;6:119-21.  Back to cited text no. 3
    
4.
Singh P, Singh A, Kant P, Zonunsanga B, Kuka AS. An impacted denture in the esophagus-An endoscopic or a surgical emergency- A case report. J Clin Diagn Res 2013;7:919-20.  Back to cited text no. 4
    
5.
Kumar S, Srinivasan S, Peh WC. Clinics in diagnostic imaging (142). Cervical oesophagus impacted partial denture. Singapore Med J 2012;53:690-3.  Back to cited text no. 5
    
6.
Firth AL, Moor J, Goodyear PW, Strachan DR. Dentures may be radiolucent. Emerg Med J 2003;20:562-3.  Back to cited text no. 6
    
7.
Athanassiadi K, Gerazounis M, Metaxas E, Kalantzi N. Management of esophageal foreign bodies: A retrospective review of 400 cases. Eur J Cardiothorac Surg 2002;21: 653-6.  Back to cited text no. 7
    
8.
Miyazaki T, Hokama N, Kubo N, Ishiguro T, Sakimoto T, Ishibashi K, et al. Management of esophageal foreign bodies: Experience of 90 cases. Esophagus 2009;6:155-9.  Back to cited text no. 8
    
9.
Weisberg D, Refaely Y. Foreign bodies in the esophagus. Ann Thorac Surg 2007;84:1854-7.  Back to cited text no. 9
    
10.
Ruckbeil O, Burghardt J, Gellert K. Thoracoscopic removal of a transesophageal ingested mediastinal foreign body. Interact Cardiovasc Thorac Surg 2009;9:556-7.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2]



 

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