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Oesophageal and gastric endoscopic foreign body removal: Complications and

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Article  in  Journal of Small Animal Practice · December 2009

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PAPER
Oesophageal and gastric endoscopic
foreign body removal: complications
and follow-up of 102 dogs
OBJECTIVES: To assess complication rate, risk factors for complica-
tions and outcome in dogs with oesophageal and gastric endoscop-
ic foreign body (FB) removal.
METHODS: Medical records of 102 dogs undergoing endoscopic
removal of oesophageal and/or gastric FBs from March 2001 to
November 2006 were retrospectively reviewed. All owners were
contacted by telephone to provide follow-up information.
RESULTS: West Highland white terriers, Yorkshire terriers and Ber-
nese mountain dogs were over-represented compared to the hos-
pital population. Endoscopy alone was successful in 92/102 dogs
(90·2 per cent), whereas gastrotomy (but no oesophagotomy) was
required in 10 dogs (9·8 per cent). Complications in 13/102 dogs
(12·7 per cent) were perforation (8), oesophageal stricture (1),
oesophageal diverticula (1), perioesophageal abscess (1), pneu-
mothorax and pleural effusion (1) and respiratory arrest (1). Six
dogs (all weighing <10 kg) had complications resulting in death or
euthanasia. Bone FBs, bodyweight of less than 10 kg, and oesoph-
ageal or gastric FB in place for more than three days were signifi-
cant risk factors for complications. Of the dogs available for follow-
up (75/96), 92 per cent had no complications after discharge.
CLINICAL SIGNIFICANCE: Endoscopic FB removal is associated with a
low overall complication rate with bone FBs and bodyweight of less
than 10 kg as significant risk factors.
P. GIANELLA, N. S. PFAMMATTER AND
I. A. BURGENER
Journal of Small Animal Practice (2009)
50, 649–654
DOI: 10.1111/j.1748-5827.2009.00845.x
Accepted: 28 July 2009
Department of Clinical Veterinary Medicine,
Division of Small Animal Internal Medicine, Vet-
suisse Faculty of the University of Bern, 3001
Bern, Switzerland
Journal of Small Animal Practice • Vol 50 • December 2009
INTRODUCTION
Gastrointestinal foreign bodies (FBs) are
relatively common in both canine and
feline practice. Due to their slightly indis-
criminate eating habits, swallowing of
incompletely masticated food, and expo-
sure to toys and dental chews, dogs are
more likely to be presented with gastroin-
testinal FBs than cats. If unresolved, these
FBs can become life threatening. Bone or
cartilage material, fishhooks, needles, chew
treats, balls and toys are reported FBs in
dogs (Spielman and others 1992, Michels
• © 2009 British Small Animal Veterinary Association
and others 1995, Sale and Williams 2006,
Leib and Sartor 2008). Depending on the
localisation, common clinical signs are
salivation, retching, gagging, vomiting,
regurgitation, anorexia, pain, respiratory
distress and restlessness (Gualtieri 2001,
Tams 2003, Willard 2004). The severity
of the clinical signs depends on the type
and size of FB, its location, the dura-
tion of obstruction, and the presence or
absence of a stricture or a wall perfora-
tion with subsequent abscessation, pleu-
ritis, mediastinitis, pneumomediastinum,
pneumothorax, peritonitis and pneumo-
peritoneum (King 2001, Seiler and others
2001). Occasionally, dogs show no clinical
signs. The duration of FB impaction can
vary from hours to days or weeks before
presentation and diagnosis. Oesopha-
geal and gastric FBs can be visualised on
lateral chest or abdominal radiographs.
However, small and non-radiopaque FBs,
especially in the stomach, are sometimes
difficult to see on survey radiographs and
may require positive contrast radiography.
In the oesophagus, FBs tend to lodge in
the narrowest points: the thoracic inlet,
the heart base and just cranial to the lower
oesophageal sphincter. Given the possible
complications, oesophageal FBs should
be promptly removed or gently pushed
into the stomach for dissolution or gas-
trotomy. This can be achieved using rigid
and flexible endoscopes (Houlton and
others 1985, Spielman and others 1992,
Michels and others 1995, Leib and Sar-
tor 2008), fluoroscopic guidance (Moore
2001), thoracoscopy/laparoscopy or sur-
gery (Michels and others 1995, Sale and
Williams 2006). The latter, although
more aggressive, appears to be a necessary
approach if endoscopic removal fails or if
oesophageal or gastric perforation is pres-
ent (Parker and others 1989).
Although reports of endoscopic, fluo-
roscopic or surgical removal of FBs have
been published, there is little information
in recent literature regarding complica-
tions and long-term follow-up of endo-
scopic FB removal in a large case series.
The purpose of this study was to assess the
649

complication rate, risk factors for compli-
cations and outcome in dogs with oesoph-
ageal and gastric endoscopic FB removal.
MATERIALS AND METHODS
Case selection
Medical records of dogs with gastroin-
testinal FBs that underwent endoscopic
removal in the Small Animal Clinic of the
University of Bern, Switzerland, between
March 2001 and November 2006 were
reviewed. Data retrieved included signal-
ment, clinical signs at presentation, dura-
tion of clinical signs, type and location of
FB, degree of macroscopic mucosal dam-
age, technique of FB removal, short-term
complications and length of hospitalisa-
tion. All canine patients entering the hos-
pital during the study period were used as
a control population.
Follow-up
During medical records review, owners
were contacted by telephone to provide
follow-up information. A single investiga-
tor (NSP) interviewed the owners with a
standard questionnaire to ensure that all
owners were asked the same questions.
They were asked if clinical signs related to
the FB removal (vomiting, regurgitation,
respiratory distress, apathy, pain) or diffi-
culties in eating were observed after hos-
pital discharge. Furthermore, information
was gathered about further medical care
sought and, in the case of death, the cause
of death if known.
Statistical analysis
Statistical analyses were performed with
NCSS (Kaysville, Utah, USA). Successful
Table 1. Comparison of breeds between the study (n=102) and the hospital population (n=15147). Only the breeds with at
least 3 cases were included in the calculation
Breed
(n = 102)
West Highland white terrier
Yorkshire terrier
Bernese mountain dog
Labrador retriever
Golden retriever
German shepherd dog
CI = confidence interval.
650
P. Gianella and others
endoscopic FB removal was defined as
removal without gastrotomy or oesoph-
agotomy and did not necessarily implicate
successful outcome. The results were sum-
marised in contingency tables. The impact
of bodyweight, the duration of a FB in
place, as well as type and location of the
FB on complications and death/euthana-
sia was examined with Fisher’s exact test
(P-value of <0·05 considered significant)
and odds ratios with 95 per cent confi-
dence interval (odds ratios with confi-
dence intervals not including 1 considered
significant).
RESULTS
Study population
During the study period 102 dogs under-
went gastrointestinal endoscopic FB
removal (102/15147, this represents a
prevalence of 0·67 per cent of the canine
hospital population). The FB was located
in the oesophagus (n = 57), in the stomach
(n = 36) or both (n = 9). The study popu-
lation consisted of dogs from 50 different
breeds and 10 mixed-breed dogs. Only six
breeds showed at least three cases, with
West Highland white terrier, Yorkshire
terrier and Bernese mountain dog over-
represented compared to the hospital pop-
ulation during the study period (Table 1).
Fifty-two dogs were males (21 neutered)
and 50 were females (29 spayed). The
median age was 4 years, with a range of 3
months to 17 years. Seventeen dogs were
less than 1 year old at presentation, 45
dogs were aged between 1 and 5 years, 32
dogs between 5 and 10 years, and 8 dogs
were more than 10 years old. The median
body weight was 18·9 kg with a range from
Cases Controls
(n = 15, 147)
11 201
9 451
9 508
7 1040
5 629
3 1016
Journal of Small Animal Practice • Vol 50
1·3 to 47·3 kg. Forty-six dogs weighed less
than 10 kg, 14 between 10 and 20 kg, 12
between 20 and 30 kg and 29 less than
30 kg. For one dog, bodyweight was not
recorded.
Patient history and clinical signs
Clinical signs described by the owner
or noted during physical examination
included retching/gagging (31/102; 25/57
with oesophageal FB, 5/9 with oesopha-
geal and gastric FB, 1/36 with gastric
FB), vomiting (27/102; 0/0/27), cough/
dyspnea (19/102; 17/2/0), anorexia
(15/102; 9/1/5), regurgitation (14/102;
10/4/0), lethargy (11/102; 7/0/4), rest-
lessness (8/102; 5/2/1), hematemesis
(6/102; 1/0/5), hypersalivation (5/102;
4/1/0), weight loss and pain (4/102 each;
0/0/4) and fever (2/102; 1/0/1). No clini-
cal signs were reported by the owner or
were observed during physical examina-
tion in 18/102 dogs. These dogs had been
observed to have ingested foreign material
(7 oesophageal and 11 gastric FBs) right
before the hospital admission. In the 84
patients with FB-related clinical signs, the
duration of the clinical signs before pre-
sentation ranged from 2 hours to 40 days.
The duration was less than one day in 38
dogs, one to three days in 18 dogs, and
greater than three days in 28 dogs.
Location and type of FB
A single lateral thoracic radiograph was
diagnostic for oesophageal FB in all 63
cases performed, whereas three of the
patients observed to have ingested for-
eign material underwent direct endo-
scopic evaluation without radiographs.
Abdominal radiographs (two standard
views) were diagnostic for gastric FB in all
Odds ratio 95% CI P-value
8.93 5.25-15.17 <0.001
3.13 1.63-6.03 0.004
2.77 1.43-5.36 0.008
0.99 0.46-2.14 1.000
1.18 0.48-2.91 0.619
0.42 0.14-1.28 0.162
• December 2009 • © 2009 British Small Animal Veterinary Association

but two cases (43/45), in which the defini-
tive diagnosis was only made at endoscopy
(1 wood, 1 organic material). A concur-
rent presence of oesophageal and gastric
FBs was found in nine dogs, where the
same material was removed from oesopha-
gus and stomach. The location and type of
FB is summarised in Table 2.
Removal
Flexible oesophagoscopy and gastroscopy
were performed within two hours after
radiographs were taken (GIF-XP160
or GIF-Q165, Olympus, Volketswil,
Switzerland). A retrieval using a large rigid
grasping forceps (85 cm, Eickemeyer,
Tuttlingen, Germany) alongside the
endoscope was attempted in most cases,
whereas endoscopic grasping forceps or
baskets (Olympus) were used for smaller
FBs. Endoscopy alone was successful in
92/102 dogs: in 83 dogs, the FB was orally
removed, whereas in nine, the oesophageal
FB was pushed into the stomach for dis-
solution without gastrotomy required
(6× bone, 3× organic material). Gas-
trotomy was necessary only in 10 dogs
with primary gastric FB for definitive FB
removal after an unsuccessful endoscopic
event. Oesophagotomy was not required
in any case.
In 22/57 cases with oesophageal FBs,
oesophagitis was subjectively considered
mild to moderate, with generalised hyper-
emia and single or confluent erosions,
whereas in 23/57 animals, oesophagitis
was judged to be severe with ulcerations
and focal necrosis. In 12/57 cases treated
during emergency duties, this information
Table 2. Site of lodgement of FB and type of material
Localisation Bone Plastic
Oesophagus
thoracic inlet 4 –
heart base 12 1 –
distal 25
not reported 3 –
Stomach 2 15
Oesophagus and 4 1
stomach
Total 50 17
For the nine dogs with FBs in the oesophagus and the stomach, the material retrieved was the same in both localisations. The sharp objects include five fishhooks, two pieces of aluminium,
and two needles, whereas the organic material includes dried pig’s ears, chestnuts, nuts, and fruits.
Journal of Small Animal Practice • Vol 50 • December 2009
Endoscopic foreign body removal
was missing. Superficial erosions and
small ulcerations of the gastric mucosa
were noted in only five dogs with gastric
FBs. In the remaining animals, the gastric
mucosa was either judged to be normal or
not completely evaluated because of gas-
tric repletion.
Post-procedural thoracic radiographs
were obtained in 46 dogs with an oesoph-
ageal FB. Patients with a smooth FB
lodged in the oesophagus only for a few
hours and patients without any visible
mucosal damage and a fast and uneventful
retrieval were not always radiographically
evaluated.
Complications
Overall, a total of 13 dogs suffered compli-
cations as summarised in Table 3. Of these,
eight had perforations. In 2/5 oesophageal
perforations, pneumomediastinum was
only evident after endoscopy, whereas
only 1/5 perforation was visible at endos-
copy. Two of the three gastric perforations
were identified at laparotomy, whereas a
pneumoperitoneum was clearly identified
on abdominal radiographs before laparot-
omy in the third. All five oesophageal per-
forations were associated with oesophageal
FBs and not with retrieval of gastric FBs.
In 75 per cent (6/8) of the dogs with per-
foration, the FB was a bone.
One dog with aspiration pneumonia
diagnosed on initial presentation devel-
oped a perioesophageal abscess after the
FB removal. In this dog, the oesopha-
geal FB was pushed into the stomach
and removed by gastrotomy. No signs of
perforation were detected either during
Sharp Chew Tissue Wood
objects treats
3 – – –
2 – – –
– 3 – –
– – – –
6 – 4 3
– 3 – –
9 8 4 3
• © 2009 British Small Animal Veterinary Association
endoscopy or on radiographs thereafter.
A soft-tissue opacity in the caudal medi-
astinum was suspected at presentation, but
only confirmed after radiographic signs of
aspiration pneumonia had resolved two
weeks later. An endoscopic ultrasonogra-
phy of the caudal mediastinum was per-
formed to better define this opacity in the
region of the caudal oesophagus. Due to
the suspicion of a perioesophageal abscess,
a thoracotomy was performed and the
abscess removed.
Six dogs had complications resulting in
death (four) or euthanasia (two). The first
dog had a respiratory arrest after oesopha-
goscopy was initiated and died. Blood was
recovered from the tracheal tube and a
traumatic tracheal rupture was suspected
secondary to the bone itself and its removal.
The second dog with a severe oesophagitis
and multiple diverticula suddenly died at
home two days after discharge. Dogs 3
and 4 had an oesophageal perforation and
died due to cardiac arrest and pneumo-
thorax following FB removal. Dogs 5 and
6 were euthanased upon owner request.
Dog 5 had an oesophageal perforation,
pleural effusion and mediastinitis and was
euthanased after endoscopy, whereas dog
6 developed pneumothorax and pleural
effusion one week after the initial oesoph-
agoscopy. Unfortunately, necropsy was not
available for any of the six dogs.
Endoscopic oesophageal re-evaluation
due to regurgitation was deemed necessary
in only one dog seven days after discharge.
An oesophageal stricture was identified
and endoscopic balloon dilation was suc-
cessfully performed.
Stones Organic Unknown Total
material
– – – 7
– – 15
– 4 – 32
– – – 3
1 2 3 36
– 1 – 9
1 7 3 102
651
 P. Gianella and others

Table 3. Data from 13 dogs with complications (10 with oesophageal FB, 3 with gastric FB, none with FB in both localisations)
Dog number FB type FB localisation Duration of Type of complication Length of Death or
clinical signs hospitalisation euthanasia
1 Plastic Stomach >3 days Perforation/pneumoperitoneum >3 days –
2 Bone Oesophagus heart base >3 days Perioesophageal abscess >3 days –
3 Bone Distal oesophagus >3 days Stricture >3 days –
4 Bone Distal oesophagus >3 days Perforation/pleural effusion /mediastini- – Euthanasia
tis/pneumomediastinum
5 Fishhook Stomach <1 day Perforation 1–3 days –
6 Bone Stomach >3 days Perforation >3 days –
7 Bone Distal oesophagus >3 days Perforation/pneumothorax/cardiac arrest – Death
8 Bone Distal oesophagus Unknown Severe oesophagitis/diverticula – Death
9 Bone Oesophagus thoracic <1 day Perforation / pneumomediastinum >3 days –
inlet
10 Bone Distal oesophagus >3 days Perforation / pneumothorax/cardiac arrest -– Death
11 Bone Oesophagus heart base 1 day Respiratory arrest /traumatic tracheal – Death
rupture
12 Bone Distal oesophagus Unknown Perforation / pneumothorax / pneumome- >3 days –
diastinum
13 Chew treat Oesophagus heart base >3 days pneumothorax / pleural effusion – Euthanasia
after one
week

Of the 96 dogs that survived, 62 were
hospitalised less than one day, 18 between
one and three days, and 16 for more than
three days. Of the seven surviving patients
with complications, all but one were hos-
pitalised for more than three days.
Risk factors for complications
All six dogs that died or were euthanased
weighed less than 10 kg and only one dog
with greater than 20 kg showed complica-
tions. Besides the increased risk for death/
euthanasia (P = 0·007), dogs weighing less
than 10 kg had a significantly increased
risk for complications (P = 0·018; OR
4·82, 95 per cent CI 1·35 to 17·18). An
oesophageal or gastric FB in place for
more than three days was also associated
with a significantly increased risk for com-
plications (P = 0·006; OR 5·52, 95 per
cent CI 1·69 to 17·93) and death/eutha-
nasia (P = 0·047; OR 6·00, 95 per cent CI
1·19 to 29·74), whereas a FB in place for
less than one day yielded a reduced risk
for complications (P = 0·015; OR 0·20,
95 per cent CI 0·06 to 0·74). Five of the
six dogs that died or were euthanased
and 10/13 that developed complications
had a bone FB. Even though bone FBs
yielded significantly more complications
(P = 0·039; OR 3·83, 95 per cent CI 1·05
to 13·78) than other types of foreign
material, there was no statistically signifi-
cant association observed between bone
FB and death/euthanasia (P = 0·107).
Finally, the localisation of the FB was not
a risk factor neither for complications nor
for death/euthanasia, even though all six
dogs that died or were euthanased only
had oesophageal FBs (two heart base, four
distal oesophagus).
Follow-up
A follow-up was available for 75/96 dogs
discharged from the hospital after the
procedure (41/57 oesophageal, 28/36
gastric and 6/9 gastric and oesophageal
FBs). Of these, 69 recovered unevent-
fully (eight died of unrelated cause), four
with oesophageal FB suffered coughing
or retching only for a few days after dis-
charge, and two with oesophageal FB were
presented for a second oesophageal FB 1
to 2 months later (second endoscopic FB
removal without complications).
DISCUSSION
The value of endoscopic FB removal has
been emphasised in several studies (Houl-
ton and others 1985, Spielman and others
1992, Kaiser and others 2003), where suc-
cessful endoscopic removal ranged from
26 to 63 per cent. In the study presented
here, endoscopic removal of oesophageal
FBs was successful in 86 per cent (57/66),
with only 14 per cent of FBs pushed
into the stomach compared with 29 to
52 per cent in the aforementioned stud-
ies. In a recent study about oesophageal
obstruction caused by dental chew treats
(Leib and Sartor 2008), oral removal was
uncommon (26 per cent) and most of the
FBs were pushed into the stomach. How-
ever, it was speculated by the authors, that
the low oral retrieval rate could be likely
attributable to the smooth surfaces that
do not easily lend themselves to grasping
instruments. However, there is no proof in
literature that endoscopic removal is supe-
rior to pushing the FB into the stomach.
Thoracic and abdominal radiographs
were diagnostic or highly suggestive for
oesophageal and gastric FBs in 100 and
95·6 per cent, respectively. For oesopha-
geal FBs, similar rates have been found
before ranging from 75·9 to 100 per cent
(Spielman and others 1992, Sale and
Williams 2006, Rousseau and others 2007,
Leib and Sartor 2008). However, there is
no data available for gastric FBs.
The complication rate of oesophageal
FB removal varies between authors and
methods of retrieval from 8 to 38 per cent
in the aforementioned studies, but no

652 Journal of Small Animal Practice • Vol 50 • December 2009 • © 2009 British Small Animal Veterinary Association

studies on complication rates of gastric FB
removal were found. This study revealed
an overall complication rate of 12·7 per
cent (13/102), with 10/66 (15·2 per cent)
and 3/45 (6·7 per cent) dogs revealing
complications with oesophageal or gas-
tric FBs, respectively. The most common
complication was oesophageal or gastric
perforation (6/8 with bone FB). Second-
ary pneumomediastinum, pneumothorax
or pneumoperitoneum were only visible
in 4/8 dogs with perforation before endos-
copy or gastrotomy, which underscores
the importance of post-procedural radio-
graphs. Two small oesophageal perfora-
tions (only one visible at endoscopy) were
allowed to close spontaneously with good
success according to previous literature
(Ryan and Greene 1975, Parker and oth-
ers 1989). Due to the nature of the gastric
FBs (fishhook, plastic and bone) and/or
the presence of pneumoperitoneum, the
gastric perforations could potentially be
attributed to the FB itself and not to the
endoscopic removal.
Six dogs had complications resulting
in death (four) or euthanasia (two). In
three of these, oesophagoscopy was fol-
lowed by cardiac or respiratory arrest. For
the remaining three, one died suddenly
two days after the FB removal and the
other two were euthanased upon owner’s
request. It therefore seems that the most
serious complications result from oesoph-
ageal perforation or secondary to efforts
associated with FB removal.
Benign oesophageal strictures in dogs
are complications of severe oesophagi-
tis and are usually associated with gas-
tric reflux during anaesthesia, vomiting
of gastric content, ingestion of a caustic
substance and FB trauma (Sellon and
Willard 2003). In this study, only one
dog presented with an obvious oesopha-
geal stricture. Strictures are more com-
mon secondary to oesophageal impaction
with dental chew treats (Leib and Sartor
2008). The reason for this is unclear, and
the authors only speculated about the
unique characteristics of the dental chew
treats causing severe diffuse oesophageal
damage.
Overall, this study revealed a signifi-
cant association between complications
and bone FBs, bodyweight less than 10
kg, and duration of FB presence. Bones
Journal of Small Animal Practice • Vol 50
Endoscopic foreign body removal
are the most common cause of oesopha-
geal obstruction with reported incidences
as high as 94 per cent (Houlton and others
1985). The lower incidence of 49 per cent
reported here may reflect a wider range of
chewable objects encountered nowadays,
or the increased awareness of the owners
about possible complications with bones.
In a smaller study performed in the same
hospital between 1992 and 1997 (Lüthi
and Neiger 1998), the percentage of bones
was still much higher with 77 per cent.
Dental chew treats, another commonly
reported cause of oesophageal obstruction
(Leib and Sartor 2008), were rarely found
in our patients.
In regard to bodyweight, all six dogs
that died or were euthanased weighed less
than 10 kg. This association has not been
clearly documented, but could be extrap-
olated from previous studies considering
that most of the dogs were of small breed.
Part of this could be explained by the size
of the FBs compared to the body size (that
is, the same piece of FB is potentially more
dangerous for smaller dogs). Nevertheless,
not only small breeds such as West High-
land white terrier and Yorkshire terrier
were over-represented in our study, but
also Bernese mountain dogs. No previous
report indicated an increased risk for large
breed dogs, but unlike the terriers, none of
the Bernese mountain dogs showed com-
plications after FB removal.
A negative correlation between dura-
tion of clinical signs and complications
has been reported elsewhere (Rousseau
and others 2007). Similarly, this study
revealed a significant association between
FB of more than three days duration and
complications. The present study also
confirmed that the majority of oesopha-
geal FBs are found in the caudal portion
of the oesophagus (Houlton and others
1985, Parker and others 1989, Moore
2001, Leib and Sartor 2008).
It should be reminded that this study
has some limitations due to its retrospec-
tive character. Particularly, the degree
of mucosal damage was not objectively
evaluated in all cases (not all emergency
endoscopies fully documented). Further-
more, no attempt was made to relate the
therapy after FB removal to the outcome.
Another limitation was the different level
of experience of the clinicians performing
• December 2009 • © 2009 British Small Animal Veterinary Association
the endoscopies, and its possible effect on
the outcome. It should be noted, how-
ever, that only faculty members or senior
residents were allowed to performed the
FB removals. Unfortunately, 21 patients
were lost to follow-up, which could have
impacted the follow-up results.
In conclusion, the present study docu-
ments that oesophageal and gastric FBs are
still a common cause of referral to teach-
ing hospitals. Even though the overall
complication rate is low, potentially life-
threatening complications may develop
especially in small breed dogs and dogs
with bone FBs. The risk for complications,
and especially perforation, increases when
the FB has been in place for more than
three days. The overall outcome appears
to be very good.
Acknowledgements
The authors would like to thank all cli-
nicians from the Small Animal Hospital
of the University of Bern involved in the
patient management of the cases described
herein.
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