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Paper text:
accidentally ingested foreign body is a common emergency , presenting to the otolaryngologists , gastroenterologists , gastrointestinal surgeons , and thoracic surgeons . over 90% of them
we report three patients where endoscopic removal failed or was not attempted ; the resulting delay posed considerable difficulty in treatment and necessitated three different surgical approaches to the oesophagus in the face of life - threatening infection .

 patient 1a 60-year - old malnourished woman presented with dysphagia , fever , and retrosternal pain 7 days after accidental ingestion of a two - tooth denture with metal clasps .
a chest x - ray ( cxr ) showed the metal clasps of the prosthesis in the region of the junction of mid and lower third oesophagus .
a repeat videoendoscopy at our hospital showed an impacted denture at 29 cms ( from the incisor teeth ) with adjacent mucosal sloughing ( figure 1 ) which could not be dislodged .
she was subjected to rigid oesophagoscopy under general anaesthesia ( ga ) which also failed to extract the denture .
there was no option but to proceed to an urgent left thoracotomy through the 7th intercostal space .
an oesophagotomy below the aortic arch revealed the denture with its hooks deeply embedded in an extremely thickened and oedematous oesophageal wall .
a feeding jejunostomy was inserted ( so that early enteral nutrition could be provided and continued in an event of leak ) , in addition to nasogastric tube and chest drains .
on the 7th postoperative day , a cxr revealed moderate left pleural effusion , but a contrast x - ray on the 10th day did not show any leakage from the oesophagotomy repair site . however , oral methylene blue administration resulted in bluish discolouration of the basal chest drain effluent suggesting a leak and was confirmed on a contrast ct scan ( figure 2 ) .
she was fed through the jejunostomy for a further period of two weeks during which the leak resolved and oral feeding was gradually instituted . 
  a 60-year - old malnourished woman presented with dysphagia , fever , and retrosternal pain 7 days after accidental ingestion of a two - tooth denture with metal clasps .
a chest x - ray ( cxr ) showed the metal clasps of the prosthesis in the region of the junction of mid and lower third oesophagus .
a repeat videoendoscopy at our hospital showed an impacted denture at 29 cms ( from the incisor teeth ) with adjacent mucosal sloughing ( figure 1 ) which could not be dislodged .
she was subjected to rigid oesophagoscopy under general anaesthesia ( ga ) which also failed to extract the denture .
there was no option but to proceed to an urgent left thoracotomy through the 7th intercostal space .
an oesophagotomy below the aortic arch revealed the denture with its hooks deeply embedded in an extremely thickened and oedematous oesophageal wall .
a feeding jejunostomy was inserted ( so that early enteral nutrition could be provided and continued in an event of leak ) , in addition to nasogastric tube and chest drains . on the 7th postoperative day ,
a cxr revealed moderate left pleural effusion , but a contrast x - ray on the 10th day did not show any leakage from the oesophagotomy repair site . however , oral methylene blue administration resulted in bluish discolouration of the basal chest drain effluent suggesting a leak and was confirmed on a contrast ct scan ( figure 2 ) .
she was fed through the jejunostomy for a further period of two weeks during which the leak resolved and oral feeding was gradually instituted . 

patient 2a 65-year - old man accidentally swallowed a three - tooth denture ( without clasps ) at work away from his hometown .
flexible endoscopy 24 hours later noted the denture in lower oesophagus , but extraction had to be aborted after it got impacted at a more proximal level .
his symptoms worsened , but he decided to travel to his hometown for further intervention , which delayed treatment for another 2 days . on presentation to us on the 5th day , he had severe chest pain , fever , and leukocytosis , but cxr was unremarkable .
an urgent rigid oesophagoscopic extraction under ga failed as the denture was firmly impacted with one end appearing to have penetrated the oesophageal wall at 23 cms .
the procedure was abandoned , and an urgent water soluble contrast x - ray was arranged .
severe mediastinitis causing extensive induration of the upper and midoesophagus with loss of tissue planes was encountered . despite the large size of the denture , it could not be easily localized , and the site of oesophagotomy for its removal was determined by intraoperative flexible endoscopy .
the silhouetted denture from endoscopic transillumination enabled a precise oesophagotomy ( figures 3 and 4 ) .
he resumed oral feeding after a normal contrast x - ray on the 10th postoperative day . 
 
a 65-year - old man accidentally swallowed a three - tooth denture ( without clasps ) at work away from his hometown .
flexible endoscopy 24 hours later noted the denture in lower oesophagus , but extraction had to be aborted after it got impacted at a more proximal level .
his symptoms worsened , but he decided to travel to his hometown for further intervention , which delayed treatment for another 2 days . on presentation to us on the 5th day , he had severe chest pain , fever , and leukocytosis , but cxr was unremarkable .
an urgent rigid oesophagoscopic extraction under ga failed as the denture was firmly impacted with one end appearing to have penetrated the oesophageal wall at 23 cms .
the procedure was abandoned , and an urgent water soluble contrast x - ray was arranged .
severe mediastinitis causing extensive induration of the upper and midoesophagus with loss of tissue planes was encountered . despite the large size of the denture
, it could not be easily localized , and the site of oesophagotomy for its removal was determined by intraoperative flexible endoscopy .
the silhouetted denture from endoscopic transillumination enabled a precise oesophagotomy ( figures 3 and 4 ) .
he resumed oral feeding after a normal contrast x - ray on the 10th postoperative day .  

he ignored the slight dysphagia that followed , but 5 days later , had a bout of vomiting resulting in spontaneous expulsion of the meat bone .
a few days later , he developed fever and neck pain for which he sought medical attention at the local hospital .
a rigid oesophagoscopy under ga noted pus draining into the lumen from the retropharyngeal space .
he was treated with intravenous antibiotics and fluids and nasogastric tube feeding over the next 7 days .
the only imaging he underwent during this admission was a cxr which showed slight widening of the superior mediastinum .
he was referred to our hospital 16 days after the accident , when he remained persistently febrile and developed neck tenderness .
he proceeded to an urgent exploration through an oblique left neck incision , protecting the recurrent laryngeal nerve .
the abscess was drained , but no perforation could be identified in the cervical oesophagus .
oral feeding was instituted without problems after three weeks during which enteral nutrition was maintained through a nasogastric tube . 
 
he ignored the slight dysphagia that followed , but 5 days later , had a bout of vomiting resulting in spontaneous expulsion of the meat bone .
a few days later , he developed fever and neck pain for which he sought medical attention at the local hospital .
a rigid oesophagoscopy under ga noted pus draining into the lumen from the retropharyngeal space . he was treated with intravenous antibiotics and fluids and nasogastric tube feeding over the next 7 days .
the only imaging he underwent during this admission was a cxr which showed slight widening of the superior mediastinum .
he was referred to our hospital 16 days after the accident , when he remained persistently febrile and developed neck tenderness .
he proceeded to an urgent exploration through an oblique left neck incision , protecting the recurrent laryngeal nerve .
the abscess was drained , but no perforation could be identified in the cervical oesophagus .
oral feeding was instituted without problems after three weeks during which enteral nutrition was maintained through a nasogastric tube .
irregular oesophageal - impacted fbs mandate immediate extraction , and most are removed at fibreoptic or videoendoscopy . a clear plan of action is required in the uncommon event of failure to extract the fb .
videoendoscopy is the first therapeutic modality attempted in our hospital if it has lodged beyond the cricopharyngeus .
radiolucent acrylic dentures can be localized by fluoroscopy after asking the patient to swallow a barium - soaked cotton wool which gets caught at the site of oesophageal impaction .
even if extraction at videoendoscopy fails , its magnified view accurately determines the degree of impaction which increases with passage of time . a vigorous attempt at removal is not warranted in the presence of pus , slough , or bleeding , which indicates significant impaction or intramural perforation .
rigid oesophagoscopy under general anaesthesia should be the logical next step . however , disimpaction may be impossible even with the greater mechanical advantage of rigid tools particularly when treatment has been delayed .  
specially designed shears to divide dental plates or bones into smaller pieces and aid its maneuverability have been described .
however , passage of such a robust shear through the rigid oesophagoscope may almost completely obliterate the lumen and the view , limiting its efficacy and safety . in both the patients
where endoscopic removal failed , a thoracotomy had to be performed in the presence of inhospitable mediastinitis , perioesophageal induration with loss of natural tissue planes , and even requiring intraoperative flexible endoscopy in one patient to localize the fb .
the tenuous vascularity due to prolonged impingement and inflammation makes oesophagotomy closure susceptible to leakage postoperatively and stricture formation in the long term , and it is imperative that a precise and short oesophagotomy is made . both patients requiring thoracotomy had to be ventilated for short periods of 1224 hours postoperatively to optimize oxygenation , adding to the costs of an already expensive and lengthy operation .
injudicious and multiple attempts at flexible endoscopic removal of large dentures , particularly with metal clasps , may cause perforation as it is difficult to align the irregular - shaped denture favourably in relation to the lumen .
the exceptional course of spontaneous expulsion after a few days may herald delayed perforation from ischaemic necrosis as was seen in one patient .
the open surgical access ( cervical approach , right or left thoracotomy ) to the oesophageal - impacted fb and their complications must be individualized and guided by endoscopic findings ( distance of fb from incisor teeth ) and imaging [ 5 , 6 ] .
while flexible endoscopy is widely available , the expertise of rigid oesophagoscopy , cervical exploration , thoracotomy , oesophageal surgery , and intensive care is often not available in a single unit or a peripheral hospital .
. it would be prudent to refer these patients early to centres where prompt multidisciplinary input from the otolaryngologist / head and neck surgeon and oesophageal / thoracic surgeon is available .
this is especially so when prolonged impaction beyond 12 hours decreases the chances of endoscopic removal and increases the hazards of open surgical removal .
ill - conceived effort at removal of impacted foreign bodies ( fbs ) in oesophagus vies with delay in removal as the causes of morbidity and mortality . 
 most oesophageal fbs are safely removed endoscopically when attempted early . 
 however , large sharp fbs like dentures and meat bones can get deeply embedded in the wall with prolonged impaction or injudicious attempts at removal leading to life - threatening mediastinitis . 
 open surgery to access the oesophageal - impacted fb in such an event is hazardous . 
 this report emphasizes the need for early site - specific surgical approaches that may be required , albeit rarely , for oesophageal - impacted fbs , where attempts at endoscopic removal have failed or complications have ensued .