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Case 388

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64-year-old smoker male who underwent subtotal esophagectomy in 2016 due to squamous cell carcinoma (SCC) in the middle thoracic esophagus. Thoracoscopic approach was performed, with esophageal reconstruction with gastric tube through laparotomy and cervicotomy. There were no per or postoperative complications. Three years later, he returned to the service complaining of odynophagia and a feeling of “getting stuck” in the esophagus for about 24 hours. Upper digestive endoscopy was performed for evaluation.

Among the options below, what is the most likely diagnosis for this patient, considering the clinical data and the images presented?

a) Foreign body in the esophagus

25%

b) Idiopathic achalasia of the esophagus

25%

c) Esophageal SCC recurrence

25%

d) Zenker's diverticulum

25%
   

Image Analysis

Image 1: Endoscopic view of the esophagus, 25 cm away from the dental arch. Presence of a foreign body penetrating the gastric tube wall, with a shape suggestive of a surgical clip (blue arrow).


Image 2: Endoscopic view of the esophagus, 25 cm away from the dental arch. A foreign body is seen penetrating the gastric tube wall, with a suggestive shape of a surgical clip (blue arrow), being pulled by an endoscopic forceps (green arrow).

Highlights

-       The esophagus is the gastrointestinal organ most affected by foreign bodies, the main ones being: coins, small toys and bones / meat;

-       The migration of surgical clips after subtotal esophagectomy and gastric tube esophagogastroplasty is a rare complication, but it can be the cause of postoperative dysphagia and odynophagia;

-       The mechanisms of the clip's migration, not yet fully elucidated, may be related to technical error, rejection or inflammatory reaction;

-       The diagnosis can be made by upper digestive endoscopy, with observation of the object in the light, transfixing the organ wall;

-       Treatment is the removal by endoscopy, in general, with good evolution of patients.

References

-       Kordzadeh A, Charalabopoulos A, Lorenzi B. Transmural migration of azygous vein Hem-O-lok clip causing food bolus 3 months following uneventful minimally invasive oesophagectomy. Acta Chirurgica Belgica. 2018;118(4):270-271.

-       Qu J, Wang G, Yuan Z, Li K. Hem-o-lok Clips Migration: An Easily Neglected Complication after Laparoscopic Biliary Surgery. Case Reports in Surgery. 2017;2017:1-4.

-       Adhikari P, Shrestha BL, Baskota DK, Sinha BK. Accidental Foreign Body Ingestion: Analysis of 163 Cases. Int. Arch. Otorhinolaryngol. 2007;11(3):267-270.

-       Arantes V, Forero Piñeros E, Yoshimura K, Toyonaga T. Avanços na abordagem do carcinoma precoce de esôfago. Revista do Colégio Brasileiro de Cirurgiões. 2012;39(6):534-543.

-       Aurino-Neto R, Herbella F, Schlottmann F, Patti M. Evaluation of esophageal achalasia: From symptoms to the Chicago classification. ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 2018;31(2).

-       Senaga C, Corralo G, Lopes A, Chojniak R. Divertículo de Zenker. Revista da Associação Médica Brasileira. 2007;53(2):108-108.

Author

André Luís Vieira Drumond, 4th year medical student at Universidade Federal de Minas Gerais (UFMG).
E-mail: avieiradrumond[at]gmail.com

Supervisor

Marco Antônio Gonçalves Rodrigues, General Surgeon, Associate Professor and Head of the Surgery Department at UFMG.

Email: magro.mg[at]terra.com.br

Reviewers

Leandra Diniz, Mateus Nardelli, Lara Hemerly De Mori, Flávio Augusto Paes, Mariana Alcantara Nascimento, Prof. Júlio Guerra Domingues.

Translated by

Luan Salvador M. Barbalho, 5th year medical student at UFMG.

E-mail: luansmb[at]gmail.com

Test question

(Endoscopist Medical Exam 2011 - City Hall of Betim / MG) In the case of foreign bodies in the esophagus, it is INCORRECT to state:

a) In children, the most frequent are coins and, in adults, bone and meat

25%

b) The presence of batteries in the esophagus is practically an emergency due to the severity of the injuries that can cause its components

25%

c) Cocaine is the most commonly found drug, usually packaged in plastic packages or in condoms, and its immediate removal is advisable

25%

d) The greatest indication for endoscopic treatment is the appearance of symptoms soon after the ingestion of a foreign body

25%

e)

25%
   

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