Discussion

Foreign bodies of the gastrointestinal tract are most common in children, peaking between six months and six years of age.^{Reference Al-Faham and Al-Hakkak1} However, adults with underlying oesophageal pathology, psychiatric illness and prisoners are considered high-risk groups.^{Reference Brady2,Reference Al-Qudah, Daradkeh and Abu-Khalaf3}

Approximately 80 per cent of ingested foreign bodies pass naturally through the gastrointestinal tract. However, because of their size or shape, some may become lodged, most commonly at sites of physiological narrowing. In children, this typically occurs at the level of the cricopharyngeus muscle, while in adults, the lower oesophageal sphincter is the most frequent site of impaction.^{Reference Ashraf and Khan4} Around 20 per cent of lodged foreign bodies are removed endoscopically, while open surgery is required in less than 1 per cent of cases.^{Reference Al-Faham and Al-Hakkak1,Reference Dray and Cattan5}

Various removal techniques have been described in the literature. For blunt objects located in the proximal gastrointestinal tract, a Foley catheter can be passed below the object, its balloon inflated, and the foreign body removed while withdrawing the catheter. However, this method is contraindicated in patients with known oesophageal structural abnormalities, and in those with an uncertain or prolonged foreign body ingestion time. Another reported technique involves the use of an oesophageal bougie to advance smooth, round, low-risk objects down to the stomach, from where the foreign body will typically pass spontaneously.^{Reference Bonadio, Emslander, Milner and Johnson6}

The ‘gold standard’ treatment for lodged or high-risk objects remains endoscopic removal, while flexible endoscopy is used primarily used for soft foreign bodies, such as food boluses, as well as objects located lower down in the gastrointestinal tract.^{Reference Lam, Woo and van Hasselt7}

There are reports in the literature of successful removal of large foreign bodies. For instance, a case described by Gulati et al. involved the accidental ingestion of a 19 cm long toothbrush, which was removed with a rigid oesophagoscope and alligator forceps under general anaesthesia.^{Reference Gulati, Wadhera, Singh Gulia and Hooda8} In another case reported by Hyun et al., a large fish bone lodged near the upper oesophageal sphincter was removed using a cap-assisted colonoscope.^{Reference Hyun, Chun, Keum, Seo, Kim and Jeen9}

The uniqueness of such cases lies in the shape and significant size of the foreign bodies, which prevents them from migrating beyond the duodenum. However, endoscopic extraction of such large and complex foreign bodies is not always successful, necessitating open surgery in some cases. In the case reported here, the patient was deemed high risk for laparotomy because of a history of 17 previous laparotomies. Rigid and flexible endoscopic removal was unsuccessful because the knife was firmly lodged low in the oesophagus.

The perforation rates following sharp foreign body ingestion were previously as high as 35 per cent. However, these rates have significantly decreased with the advent of advanced, modern techniques. The location of the foreign body plays an essential role in determining the risk of perforation, with the oesophagus, duodenum and ileocecal valve posing the highest risks.^{Reference Sahn, Mamula and Ford10}

In our case, we managed to avoid oesophageal perforation by innovatively using a cut, size 3 laryngeal mask as a protective port into the oesophagus. This method allowed us to safely utilise multiple instruments in the oesophagus, while simultaneously protecting the organ. This improvised technique could be of significant value in similar complex scenarios, demonstrating the importance of adaptability and innovation in surgical practice.