Flexible versus rigid endoscopy in the management ...

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Associated Data

Data Availability Statement

The authors declare that all data generated or analyzed during this study are included in this published article.

Abstract

Background

Foreign body (FB) impaction accounts for 4% of emergency endoscopies in clinical practice. Flexible endoscopy (FE) is recommended as the first-line therapeutic option because it can be performed under sedation, is cost-effective, and is well tolerated. Rigid endoscopy (RE) under general anesthesia is less utilized but may be advantageous in certain situations. The goal of this study was to compare the effectiveness and safety of FE and RE in the removal of esophageal FBs.

Methods

The authors consulted the PubMed, MEDLINE, Embase, and Cochrane databases, searching for the terms 'Rigid endoscopy AND Flexible endoscopy AND foreign bod*'. Pooled effect measures were computed using an inverse-variance weighted or Mantel-Haenszel method in a random effects meta-analysis, and heterogeneity was assessed via the I2 index and the Cochrane Q test.

Results

Five observational cohort studies published between certain years met the inclusion criteria, involving a total of 1,402 patients; FE was conducted in 736 cases while RE was utilized in 666 instances. The overall complication rate was 7.2%, with common complications including mucosal erosion (26.7%), mucosal edema (18.8%), and iatrogenic esophageal perforations (10.9%). When compared with FE, the pooled success odds ratio (OR) for RE was 1.00 (95% CI 0.48–2.06; p=1.00). The pooled ORs for iatrogenic perforation and other complications were 2.87 (95% CI 0.96–8.61; p=0.06), 1.09 (95% CI 0.38–3.18; p=0.87), and 1.50 (95% CI 0.53–4.25; p=0.44). There were no recorded fatalities.

Conclusions

Both FE and RE are comparably safe and effective for esophageal FB removal. To achieve an individualized or crossover treatment strategy, management should occur in multidisciplinary centers where expertise in RE is present. Re-evaluation of training and certification for RE may be necessary.

Keywords:

Esophageal foreign body, Flexible endoscopy, Rigid endoscopy, Iatrogenic esophageal perforation, Foreign body impaction

Background

Esophageal foreign body (FB) impaction contributes to approximately 4% of emergency endoscopies in clinical scenarios [1, 2], with 60% of adult presentations tied to food bolus issues [3]. The occurrence of foreign body ingestion is notably prevalent in the USA, revealing more than 100,000 documented cases annually [4], leading to an estimated annual mortality count. [5] The incidence of FB-induced perforations accounts for 12% of all esophageal perforations, marked by a mortality rate of 2.1% [6]. Cases of esophageal FB impaction in adults frequently correlate with underlying esophageal conditions [7–10] or psychiatric issues [11–14].

In a retrospective study, it was observed that 57% of instance involved the cervical esophagus, while 26% were in the thoracic section and 17% at the esophago-gastric juncture [15]. The physiological changeover from striated muscle to smooth muscle elucidates why the upper esophagus is the predominant site of impaction. About 50% of sharp objects are found lodged in the upper esophagus, leading to perforations, especially when multiple endoscopic retrieval attempts are made. Ultimately, rigid endoscopic intervention or surgical approaches such as cervical esophagotomy/thoracotomy might be necessitated [16].

Currently, endoscopic procedures are generally viewed as the primary therapeutic approach [17, 18], while surgical intervention is designated as appropriate upfront treatment for patients exhibiting evident perforation or as a rescue measure in the scenario of irretrievable FB [19–22]. Flexible endoscopy (FE) can be conducted under local anesthesia alongside sedation, proving to be cost-effective since hospitalization is not mandatory [23–25]; however, its efficacy may be restricted in the context of sharp FB impaction [15, 26].

Rigid endoscopy (RE) offers a broader operational lumen, substantially aiding in the manipulation of sharp FBs lodged in the upper esophagus. Furthermore, it facilitates the extraction of FBs using various instruments while ensuring that the airway is protected owing to its administration under general anesthesia. Interestingly, the competency required for executing rigid endoscopy remains confined among non-ear-nose-throat (ENT) specialists, which has led to its omission in the latest European guidelines [18].

Should RE be phased out, or does it still hold value? This systematic review and meta-analysis aimed to evaluate the efficacy and complications associated with both RE and FE in the management of esophageal FBs.

Materials and Methods

This investigation was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A thorough literature search was performed by two independent authors aimed at identifying published English studies that compared RE and FE in the handling of esophageal FBs. The PubMed, MEDLINE, Embase, and Cochrane databases were utilized, searching with the terms 'Rigid endoscopy AND Flexible endoscopy AND foreign bod*'. The search was complemented by reviewing references from each article. Studies were included if they detailed success rates regarding flexible and rigid endoscopy in extracting foreign bodies lodged within the esophagus. Both adult and pediatric studies were accepted. Studies were excluded if they failed to differentiate between the FE and RE groups or if they compared methodologies outside the context of FB management.

Two authors (AA, DF) independently reviewed 200 abstracts acquired through the literature search, omitting 15 duplicates. Of the 185 records assessed, 178 abstracts were excluded as they did not satisfy inclusion criteria. Seven abstracts were assessed for eligibility and underwent full-text review. Two additional articles were discarded; one focused on diagnosing esophageal pathologies, and the other did not provide requisite data.

All articles comparing RE and FE in the context of foreign body management were included within this systematic review (Fig. ). Three authors (DF, AA, CGR) independently extracted data from the qualifying studies. Relevant data included study characteristics (name of first author, year, and publication journal), patient count within the series, foreign body localization, characteristics of the lodged FB, endoscopic success rates, overall complication rates, and rates of esophageal perforation. The endoscopy was deemed successful if the foreign body was extracted; if conversion to a different endoscopic modality or surgical intervention was required, it was not counted as successful. Any discrepancies among authors were settled by consensus; if consensus could not be reached, a fourth senior author (LB) made the final determination. The methodological quality of the papers was independently evaluated by three investigators using the Newcastle-Ottawa Scale (NOS) [27], where each study was rated on a star system based on selected study groups and the ascertainment of the intended outcome. Each work could achieve a maximum of nine stars.

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Statistical Analysis

The outcomes from the systematic review were qualitatively summarized into a frequentist meta-analysis. For pooled measures of effect size, an inverse-variance weighted or Mantel-Haenszel random effects meta-analysis was carried out accordingly. The DerSimonian-Laird estimator was applied to evaluate the variance between studies (τ2) [28]. Zero cell counts were accounted for as per the methods outlined by Yusuf et al. [29]. Study heterogeneity was assessed using the I2 index and the Cochran Q test [30]. Statistical significance for heterogeneity was determined at p < 0.10 or when the I2 index exceeded 50% [31]. Wald-type 95% confidence intervals were computed for the pooled measure; otherwise, 95% confidence intervals for the I2 index were calculated according to Higgins and Thompson [32]. The small study and publication bias effects were evaluated using the trim and fill method [33], and Egger tests were applied [34]. The prediction interval for the effect of new studies was calculated based on Borenstein [30]. Given the variability in sample sizes across studies, we conducted a sensitivity analysis by excluding one study at a time and re-running the analysis for overall result consistency. Z-score tests were executed. A two-tailed p-value was deemed statistically significant when < 0.05. All analyses and figures were performed using R version 3.2.2 software [35].

Results

Systematic Review

Five studies published within a certain timeframe met the inclusion criteria. The total patient tally was ; individual study sample sizes ranged from 118 to 657, with no randomized controlled trials included. All reports were observational cohort studies, achieving solitary NOS scores of 6 or 7 (median 6.9), indicating a commendable quality level.

Demographic, clinical, and operative details of the patient sample are displayed in Table . Every patient underwent endoscopy for the extraction of FBs lodged in the esophagus. FE was carried out on 736 patients under local anesthesia and sedation, while 666 underwent RE under general anesthesia. The average age of patients varied from 3.5 to 64 years, with more than half being females.

Table 1

Author, year, countryStudy design#PtsMean ageMale (%)ProcedureForeign body type (n)Procedures attempted (n)Successful procedures (n)Overall complications (n)Perforations (n)Esophageal localization (n)BluntSharpLongFoodUpperMiddleLowerBergreen, , USARetrospective.5nrFEREGmeiner, , AustriaRetrospective.6FERERussell,
, USARetrospective.555FEnrnrnrnrRETseng,
, TaiwanRetrospective.741.4FEnrnrnrnrnrnrnrREnrnrnrWang,
, ChinaRetrospective.642.0FEREOpen in a separate window

Using intention to treat, FE proved successful in 714 (97.0%) of patients while RE achieved a success rate of 648 (97.3%). The classification of ingested FBs, aligned with recent guidelines [18], was depicted across three studies (472 patients). Food bolus represented the most frequent occurrence (n=190, 41.3%), and the majority (71%) of these patients underwent FE. Blunt objects and sharp-pointed ones constituted 31.7% and 27.0%, respectively; the latter primarily necessitated RE intervention (n=85, 68.5%). Location of esophageal impaction was reported in four studies (patients). In total, 806 patients (72.6%) experienced upper esophageal FB impaction; 378 (46.9%) were treated with FE, while 428 (53.1%) received RE. One hundred twenty-three impactions occurred in the middle esophagus (11.1%); of these, 60.2% were treated with FE while 39.8% received RE. Finally, 181 patients (16.3%) had lower esophageal impaction, with a significant majority treated using FE (n=133, 73.5%).

The complication rate overall was recorded at 7.2%. Notably, the most commonly observed complications included mucosal erosion (n=27, 26.7%), mucosal edema (n=19, 18.8%), and iatrogenic esophageal perforation (n=15, 10.9%) (Table ). There were no instances of mortality.

Table 2

Complication%Total (n)Erosion26.727Mucosal edema18.819Others13.914Perforation10.911Ulcer10.911Hemorrhage8.99Post-extraction dilation5.05Mucosa denudation3.03Infection2.02Open in a separate window

Meta-analysis

Beyond a conventional systematic review, we undertook a frequentist random effect model meta-analysis that encompassed five studies with an aggregate patient total.

The pooled odds ratio regarding procedural success was estimated at 1.00 (95% CI 0.48–2.06; p=1.00). The confidence prediction parameters were 0.22 and 4.49, respectively. There was no significant heterogeneity (I2=12%, 95% CI 0.0–81.7%; p=0.34) and τ2=0.. Examination of the funnel plot indicated that neither publication effects nor small study biases could be dismissed, per the Egger test (p<0.001). The adjusted trim and fill odds ratio was calculated at 0.82 (95% CI 0.35–1.88) (Fig. ). The findings from the sensitivity analysis revealed result robustness.

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For the pooled odds ratio concerning perforation rates, an estimated 2.87 (95% CI 0.96–8.61; p=0.06) was established, with prediction limits set at 0.48 and 17.09. Heterogeneity was non-significant (I2=0%, 95% CI 0.0–0.1%; p=0.97) and τ2=0. Visual assessment of the funnel plot showed that publication and small study bias could similarly not be dismissed via the Egger test (p=0.32). An adjustment for the trim and fill odds ratio yielded 3.1 (95% CI 1.06–8.87) (Fig. ). The results of the sensitivity analysis affirmed overall robustness.

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Estimated pooled odds for other complications was calculated at 1.09 (95% CI 0.38–3.18; p=0.87). The predictive lower and upper limits were 0.04 and 28.25, respectively, displaying moderate heterogeneity (I2=60%, 95% CI 0.0–85.0%; p=0.04) and τ2=0.. Funnel plot evaluation indicated that publication and small study biases were also statistically significant according to the Egger test (p=0.03). Adjustments led to a trim and fill odds ratio of 0.40 (95% CI 0.14–1.14) (Fig. a). Results showed variability, particularly influenced by Wang. [48]; expelling this study led to reduced heterogeneity (I2=0.0%, 95% CI 0.0–0.3%), consequently giving pooled odds ratios of 1.86 (95% CI 0.79–4.39; p=0.16) (Fig. b).

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An overall complication pooled odds ratio was estimated at 1.50 (95% CI 0.53–4.25; p=0.44). The prediction limits were set between 0.06 and 40.41, exhibiting moderate heterogeneity (I2=64%, 95% CI 4.3–86.2%; p=0.03) and τ2=0.. A visual inspection of the funnel plot revealed that publication and small study biases were significant as noted by the Egger test (p=0.004). The adjusted trim and fill odds ratio was registered at 0.64 (95% CI 0.24–1.72) (Fig. ). Results upheld robustness after sensitivity analysis.

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Discussion

Findings from the analysis indicate that RE retains a pertinent role in the therapeutic management of patients with upper esophageal FB impaction, particularly for ingestion of sharp objects or in scenarios where general anesthesia is warranted (i.e., in pediatric cases or patients demonstrating respiratory concerns). In instances of large blunt FB impaction, the favorable access to the upper esophagus afforded by rigid endoscopes is crucial for both safe and successful extraction.

Among the guidelines from the American Society for Gastrointestinal Endoscopy, the determination to utilize RE or FE was left to the discretion of the clinician [17]. Rigid esophagoscopy was recognized as beneficial for proximal FBs located at the upper esophageal sphincter. In contrast, modern European guidelines have entirely left out RE from any recommendations [18]. This discrepancy may stem from the lessee proficiencies of non-ENT experts in performing RE procedures [26] alongside the historically reported theoretical advantages associated with FE over RE as per prior retrospective studies and expert perspectives. Gmeiner et al. [25] claimed that FE enhances patient comfort and exhibits lower complication rates, subsequently proposing a crossover methodology wherein the treatment could shift from FE to RE and vice versa in instances of initial management failure. Given that enduring FB impaction surpassing a 24-hour period elevates the risks of perforation [1, 3, 36–40], a comprehensive approach in tertiary care settings, featuring both FE and RE modalities, may constitute the safest treatment strategy for these patients [41].

The selection of the optimal method for managing impacted esophageal FBs is contingent upon several patient-centric factors (age, clinical state, compliance, American Society of Anesthesiologists (ASA) score), types and sizes of the FB, the anatomical area of impaction, timing of the incidence, and the expertise of the medical practitioners [18]. Surgery should be considered as the primary treatment option for those with evident esophageal perforation or as a supplemental measure where endoscopic retrieval proves impossible. Recently, advancements in less invasive surgical techniques have enabled a thoracoscopic approach for selected patients [42]. Both open and minimally invasive esophagectomy [43], concurrent with immediate or delayed reconstructive options, ought to be viewed as last-resort surgical approaches. Given the persistent challenge posed by esophageal perforations, particularly in developing countries [26], reassessing the function of RE training and certification may yield reductions in surgery-associated morbidity and mortality rates down the line. The transition from open surgical strategies to the endo-surgical management of Zenker diverticulum within specialized centers has led to a renewed interest and heightened usage of the Weerda diverticuloscope [44–46]; this device allows for the introduction of a video endoscope or rigid 5-mm telescope via the operative channel along with multiple instruments (linear endo-staplers, grasping forceps, etc.).

The analyses conducted in our study demonstrate that both FE and RE were effective and safe, with comparable success metrics and overall complication rates (Table ). Although the pooled odds ratio concerning perforations was not statistically significant (p=0.06), the estimated value for RE was 2.87, indicating potential clinical implications. This may be attributable to RE frequently serving as secondary treatment following FE failure or first-line therapy in more demanding circumstances (such as with sharp or large foreign bodies) [16]. Notably, the research conducted by Russell et al. [47] on a pediatric population recorded no perforations within the RE treatment group [47]. This observation is particularly noteworthy since children with FB ingestions typically undergo initial RE intervention under general anesthesia due to compliance issues, necessitating airway protection.

While studies encompassed both pediatric and adult populations, the sensitivity analysis indicated minimal heterogeneity. Furthermore, exclusion of Wang's article [48] revealed complete consistency (I2=0.0%, τ2=0.0%), implying that minor complication instances, such as mucosal edema and erosions, were deemed trivial in these other studies.

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This meta-analysis is subject to limitations. Only retrospective comparative research was included, due to the topic's inherent nature; randomized clinical trials or prospective studies were, unfortunately, unavailable. However, the general quality of the included studies was satisfactory. Additionally, data concerning the timing of endoscopic intervention, patients' ASA scoring, and the reasoning behind the initial choice of FE versus RE were not reported.

Conclusions

In summary, FE and RE appear to demonstrate equivalent effectiveness in the removal of esophageal FBs, with no significantly distinct overall complication or perforation rates. In specific cases, the two methodologies may serve as complementary treatments. Hence, patients should receive management in centers where RE proficiency is available, allowing for tailored or cross-over approaches aimed at minimizing surgical intervention and its associated morbidity. Reevaluation of formal training and certification for RE is likely warranted.

Funding

This study is supported by the AIRES (Associazione Italiana Ricerca Esofago).

Availability of Data and Materials

The authors affirm that all data generated or analyzed during this study can be found within this published article.

Abbreviations

ASAAmerican Society of AnesthesiologistsENTEar-nose-throatFBForeign bodiesFEFlexible endoscopyNNumberOROdds ratioPtsPatientsRERigid endoscopy

Authors' Contributions

DF, AA, and LB made significant contributions to the conceptualization and design of the study. DF, AA, CGR, SS, ER, and FT provided help in the data acquisition phase. DF, AA, GB, LB, and CGR contributed meaningfully to the analysis, data interpretation, and draft of the manuscript. Each author reviewed and approved the final version of the manuscript.

Notes

Ethics Approval and Consent to Participate

There was no requirement for ethical approval or consent to participate in this review.

Consent for Publication

Not applicable

Competing Interests

The authors declare no competing interests.

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