Surgical removal of esophageal foreign body by gastrotomy followed by retrival through oral cavity and stomach in two dogs

Introduction

The most common emergencies in dogs is an esophageal foreign body (EFB). When EFB is left untreated, it could lead to pressure necrosis, perforation of esophagus and eventually can lead to death (Delligianni et al., 2020) [4] . Dogs of all breeds are susceptible to esophageal foreign bodies, with bones, wooden sticks, and sewing needles being the most frequently encountered. Previous reports have also documented cases involving toys, fish hooks, and various food items (Brisson et al., 2018) [2] . In cases of esophageal foreign bodies, clinical signs commonly observed are difficulty swallowing, salivation, retching, gagging, and regurgitation. Because these animals are often dehydrated and in shock, supportive care with fluids and acid-base correction must precede any other intervention (Fossum, 2018) [6] . Reports suggest that EFBs occur more often in small breeds such as terriers and poodles, and younger dogs appear to be at higher risk (Deroy et al., 2015) [5] . Foreign bodies lodged in the esophagus may cause acute problems including ulcers, esophageal inflammation, wall perforation, entry of air into the chest or mediastinum, and occasionally, damage to the aorta. Broncho-esophageal fistulae and esophageal strictures are considered as the late complications of occlusion (Rousseau et al., 2007) [11] In many referral cases, plain radiography or endoscopy is useful for determining the type of foreign body and its location. However, in rare cases, contrast radiography may also be used. In approximately 50.00 -80.00% of the reported cases, EFBs were located in the distal esophagus (Brisson et al., 2007; Gianella et al., 2009) [2,7] . The objectives of this study was to describe the two approaches to remove the esophageal foreign body through gastrotomy followed by advancement into the oral cavity or into the stomach.

Materials and Methods

An 8-month-old and a 6-year-old shih-tzu were presented to the Department of Veterinary Surgery and Radiology, Veterinary college, Hebbal, Bangalore with the symptoms of pain, regurgitation, anorexia, lethargy and not passing stools (Fig. 1). The history showed that the dog had swallowed a bone several hr before referral, while he was playing. After completing clinical and hematological examinations, the cases were immediately forwarded for diagnostic imaging to localize the foreign body with accuracy. The lateral radiograph revealed the presence of radio-opaque structure (bone) in the base of the heart of thoracic esophagus (Fig. 2A) and at the caudal aspect of esophagus (Fig. 2B). Laboratory findings indicated mild dehydration and increase in packed cell volume in case 1 and normal values in case 2; however, no signs of neutrophilic leukocytosis and hypoglycemia were observed in both cases, which could be associated with esophageal perforation. The dogs received intra-venous (IV) Lactated Ringer's solution before surgical procedure. Postoperative care: Intravenous fluid therapy (DNS, RL) and antibiotic (Ceftriaxone at 25 mg/kg, q12hr, IV) was followed for 5 more days. The owner was advised to keep the dog offfeed for 5 days followed by liquid diet for 2 days followed by semi-solid diet. Sucralfate (1.00 g) was provided to aid in the repair of the esophageal and gastric mucosae. Skin sutures were removed two weeks later. Both the cases recovered uneventfully without any complications.

Results and Discussion

This study reveals the removal of esophageal foeign body per orally and through stomach. In both cases, the esophageal foreign body was removed without any post-operative complications.

One of the emergencies in veterinary medicine is EFB according to Juvet. In dogs and cats, bones represent the most typical oesophageal foreign bodies, but sharp items like needles and fishhooks, along with rawhide toys, balls, string, and other miscellaneous objects, are also commonly reported.

Objects become trapped in the esophagus either due to their size preventing passage or because sharp edges penetrate and anchor into the mucosal lining. Fossum described that the foreign bodies are most commonly found in thoracic inlet, the base of heart and diaphragmatic hiatus because extraoesophageal structures limit the esophageal dialatation at these sites. Sustained esophageal obstruction by a foreign body enhances peristaltic activity; however, excessive or prolonged pressure at a single site may cause necrosis of the mucosa and subsequent perforation. If esophagitis occurs, it might interfere with esophageal motility and lower esophageal high-pressure zone function. Food that doesnot pass the obstruction accumulates and may be regurgitated or might cause proximal esophageal distension. Prolonged distension disrupts normal neuromuscular function and reduces peristalsis. Esophageal perforation and aspiration pneumonia are the major complications. Sharp objects may abrade or lacerate the esophageal mucosa, causing irritation and inflammation of the underlying tissues (esophagitis) or hemorrhage. Perforation of the esophageal wall by sharp items may result in contamination of adjacent tissues with bacteria, ingesta, and bodily secretions.

Occasionally sharp objects perforate the esophageal wall and one of the great vessels at the base of the heart, causing severe hemorrhage into the mediastinum. Foreign bodies might penetrate the esophageal wall and establish a fistula with the trachea, bronchi, pulmonary parenchyma or skin. Various approaches have been described in prior studies for managing esophageal and gastric foreign bodies, but surgical intervention on the esophagus itself is generally avoided. [1,9] . In cases where the foreign body is located in the lower esophagus near the stomach, attempts are made to push it into the stomach for removal by gastrostomy. If this is not feasible, esophagotomy is performed. For cranial thoracic esophageal foreign bodies, surgical entry is via the left 3rd or 4th intercostal space. Objects lodged at the heart base-most often bones-are approached through the right 4th or 5th intercostal space, while the caudal esophagus is accessed through the left 9th intercostal space (Fossum, 2018) [6] . A transdiaphragmatic gastrotomy is an alternative approach for removing foreign bodies lodged in the caudal esophagus. In this gastrotomy method, access to the stomach is provided by an incision in the diaphragm and it is better to access the stomach through an abdominal incision, because the esophagus is visible when the foreign body is removed and it could be checked for leakage and perforations after removal (Orton, 2017) [10] . In the present case, limited access to endoscopy and the elevated risk of complications from esophageal surgery led to the decision to remove the foreign body via gastrotomy.

Conclusion

In summary, esophageal bone foreign body can be dislodged either by advancement into the stomach or per os with gastrotomy depending on its location. Younger age and larger relative total bone size were also associated with the decision to remove a foreign body. Gastric advancement of foreign body should be considered in cases where oral removal is not feasible.

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