Inadvertent removal of a needle foreign body via endoscopic suctioning in a dog

Abstract

A 6-month-old intact female English bulldog was presented following witnessed ingestion of a sewing needle. The dog underwent attempted endoscopic retrieval under general anesthesia. The needle foreign body was visualized but could not be removed due to orientation, and subsequent attempts at visualization were unsuccessful. Due to the unsuccessful removal, radiographs were obtained before intended surgical exploration, and no sewing needle was identified. The needle was subsequently identified in the working channel of the endoscope, and the dog recovered uneventfully. This is the first report to describe inadvertent endoscopic suctioning of a sharp, needle foreign body.

Key clinical message:

Endoscopy is a key tool in the management and treatment of sharp gastric foreign bodies. Complications are uncommon and typically patient-focused, including gastric perforation or irritation. However, this case report identifies an additional complication that should be considered when endoscopy is not successful.

Foreign-body ingestion is a common presenting complaint at primary care and emergency hospitals. Gastric foreign bodies may cause variable morbidity and mortality ranging from asymptomatic passage through the gastrointestinal tract to gastric ulceration, pyloric obstruction, or gastric perforation (1,2). Treatment recommendations for gastric foreign bodies often depend on foreign-body characteristics including shape, material, and sharpness of borders (3). These recommendations may include benign neglect, induction of emesis, or interventions such as endoscopic or surgical removal (3). Endoscopy is often preferred over surgical intervention for sharp-object ingestion due to its high success, low complication rate, and short length of hospitalization (4–6). Recommendations in humans with sharp foreign-body ingestion include emergent endoscopic removal, within 2 h, when present within the esophagus; or urgent endoscopic removal, within 24 h, when present in the stomach (4,7,8). The success of endoscopic retrieval of sharp foreign bodies is 95% in humans and 92.9% in dogs and cats with sewing-needle ingestion (9,10). Despite high success rates, the reported risks and complications associated with sharp foreign-body endoscopic retrieval include soft tissue trauma, gastric perforation, pneumomediastinum, pneumothorax, and conversion to surgical gastrotomy due to failure of retrieval (9).

To the authors’ knowledge, there are no reported cases of inadvertent retrieval of a sharp foreign body via endoscopic suctioning in either veterinary or human medicine. This case report describes the inadvertent retrieval of a sharp needle foreign body via endoscopic suctioning. This complication may prompt further investigation of sharp needle foreign bodies before surgical intervention, to avoid unnecessary surgical procedures.

CASE DESCRIPTION

A 6-month-old intact female English bulldog weighing 11.8 kg was presented to the emergency department of an emergency hospital because of witnessed ingestion of a sewing needle. The dog had a history of non-cardiogenic pulmonary edema 1 mo earlier from a suspected choking event, but otherwise no prior medical history and no current medications. The dog was clinically normal before needle ingestion. Abdominal radiographs were obtained at an emergency hospital (Figure 1 A, B), confirming the presence of a sewing needle and a large amount of heterogeneous material within the gastric lumen. The dog was referred to a large, private-practice specialty hospital for further evaluation and endoscopy.

FIGURE 1.

A — Right lateral view of abdominal radiograph in an English bulldog. Note the radiopaque, needle-shaped foreign body surrounded by soft-tissue opacity in the ventral aspect of the stomach. B — Ventrodorsal view of abdominal radiograph. Note the metallic needle-shaped foreign body superimposed with the L2 vertebrae.

Physical examination at the time of presentation did not reveal any overt, non-breed-specific abnormalities other than mild hyperthermia (39.2°C, reference range: 37.2 to 39.2°C). On venous blood gas, a mild hyperkalemia (4.66 mmol/L, reference range: 3.62 to 4.60 mmol/L) and a mild hypochloremia (112.2 mmol/L, reference range: 113.0 to 118.0 mmol/L) were noted. Packed cell volume (40%, reference range: 30 to 45%) and total solids (6 mg/dL, reference range: 5.4 to 7 mg/dL) were within normal limits.

Endoscopic retrieval of the sewing needle was recommended. The dog was given maropitant, 1 mg/kg, IV, and premedicated with dexmedetomidine, 2 μg/kg; midazolam, 0.2 mg/kg; and hydromorphone, 0.05 mg/kg; all given IV before induction of general anesthesia with ketamine, 2 mg/kg; and propofol, 2 mg/kg (IV). Following tracheal intubation, anesthesia was maintained with isoflurane, and a balanced isotonic crystalloid fluid was administered at 5 mL/kg per hour throughout the duration of anesthesia.

Once under general anesthesia, the dog was placed in left lateral recumbency. A 7.9-millimeter Karl Storz large flexible videoendoscope (60714NKS; Karl Storz Endoscopy, El Segundo, California, USA) was used for the procedure, which was performed by a Board-certified internal medicine specialist with 5 y of endoscopic experience. The esophagus was grossly normal on visual examination. The stomach had a large amount of food material present and a needle with a black string attached was visualized. The needle was identified in the body of the stomach. The needle was grasped with pelican-type grasping forceps; however, the needle was grabbed at a perpendicular angle and could not be removed due to its orientation. The forceps were chosen due to the size and shape of the needle foreign body.

The needle was released from the forceps for repositioning; however, the needle could not be visualized again despite thorough endoscopic evaluation of the gastric contents. After 1 h of attempts at endoscopic removal, the recommendation for surgical exploration was made. Due to the after-hours nature of the case presentation and endoscopy procedure, 8 h had passed since initial radiography by the time the dog was prepped for surgical exploration and the surgeon was present in the hospital. Based on this time frame, repeat radiographs were obtained due to the concern of the needle foreign body migrating into the small intestine. Full-body radiographs failed to identify the presence of a needle foreign body within the gastrointestinal tract (Figure 2 A, B).

FIGURE 2.

A — Right lateral abdominal radiograph in an English bulldog, with no evidence of a foreign body within the stomach or intestine. B — Right lateral cervical radiograph, with no evidence of a foreign body.

Without evidence of a needle within the gastrointestinal tract, the dog recovered from anesthesia without complication and received flumazenil, 0.01 mg/kg, IV, to aid in recovery. While the dog recovered from anesthesia, radiographs of the endoscope were obtained and revealed the needle within the working channel of the endoscope (Figure 3). The dog was discharged later that day and had no noted complications following discharge. The endoscope sustained major damage from this inadvertent complication and required manufacturer repair.

FIGURE 3.

Radiograph showing the metallic needle-shaped foreign body located within the endoscope.

DISCUSSION

The ingestion of sharp foreign bodies, most commonly sewing needles, has been described in veterinary medicine and is associated with an excellent prognosis (10). The overall prevalence of foreign-body ingestion requiring endoscopic removal has been reported at between 0.47 to 0.67% in a canine hospital population (11,12). Treatment of humans who have ingested sharp foreign bodies includes endoscopic removal, as the incidence of gastrointestinal perforation associated with sharp foreign bodies is up to 15 to 35% (9,10). If endoscopic retrieval is unsuccessful or the sharp foreign body migrates within the intestine, the recommendation is to conduct frequent radiographic follow-ups and pursue surgery if the patient develops clinical signs or the foreign body fails to move within 72 h (10).

In veterinary medicine, endoscopic retrieval is the most recommended treatment modality for sharp foreign-body ingestion and is associated with a high success rate (9,10). Endoscopic retrieval is minimally invasive; however, the procedure can be complicated by gastric ingesta, debris, or fluid (10). In addition, endoscopic retrieval may fail if the sharp foreign body moves from the stomach into the small intestines (10). In a recent study, 12% of animals undergoing endoscopy for gastric or esophageal foreign bodies required surgical intervention due to unsuccessful endoscopy (12). When performed, the overall complication rate associated with endoscopic foreign-body retrieval in dogs is low (12.7%) (9). More specifically, esophageal or gastric perforations associated with endoscopic foreign-body retrieval occur in 7.8% of all cases and 17.2% of cases with sharp foreign bodies (9,10). Other, less-commonly reported complications include esophageal stricture, esophageal diverticulum, periesophageal abscess, and pneumothorax or pleural effusion (9,12). The success of endoscopy has previously been correlated with patient size, age, and operator experience, with greater success associated with younger animals and more experienced operators (12). Previous studies noted a mean time of endoscopic extraction of 54.8 min, ranging from 10 to 120 min, which was not associated with risk of complications (12).

Although various patient complications associated with sharp foreign-body ingestion have been reported in veterinary medicine, this is the first report of inadvertent retrieval of a sharp foreign body via endoscopic suctioning. Surgical intervention for sharp foreign bodies is often pursued when endoscopic retrieval is unsuccessful or when the foreign body is identified in the small intestines (1,10). Up to 5.3% of humans with upper gastrointestinal foreign bodies require conversion from attempted endoscopic retrieval to surgical removal (10). Conversion from endoscopic retrieval to gastrotomy has been reported in 9% of dogs with gastric fishhook foreign bodies, 18% of dogs with esophageal fishhook foreign bodies, and 12% of dogs and cats with various types of gastric or esophageal foreign bodies (12,13). The decision to convert is often rapid and additional imaging may not be done before surgical intervention. In the case described here, the retrieval via endoscopic suctioning was unintentional and, if imaging had not been done before conversion to surgical intervention, this dog may have undergone an unnecessary surgical procedure. Although conversion from endoscopy to surgical intervention should be considered in cases with endoscopic retrieval attempts > 120 min, consideration for repeat imaging exists if the foreign body is no longer visualized. In this case, no washing was done; however, aspirations and suctioning were done due to the large amount of food material and fluid present in the stomach. It was suspected that the needle was inadvertently aspirated during the course of suctioning fluid in the stomach. Caution should be exercised when suctioning the stomach contents in cases of sharp needle foreign bodies, as the orientation may allow for inadvertent removal through the working channel.

In conclusion, this case highlighted the potential complication of unnoticed and inadvertent endoscopic suction retrieval of a sharp needle foreign body, suggesting it may be pertinent to obtain additional imaging before conversion from endoscopic retrieval of sharp foreign bodies to surgical intervention. CVJ