Diagnosis and management of esophageal perforation due to a fishbone: a case report and narrative review
Highlight box
Key findings
• Managing an emergency such as esophageal perforation in a high-volume center allows for a more rapid and accurate diagnostic and therapeutic process. A multidisciplinary approach should be considered the treatment of choice for complex cases.
What is know and what is new?
• Esophageal perforation caused by a foreign body is a clinical emergency. Treatment consists of removing the foreign body and managing the surgical and clinical consequences of the perforation. There are no unequivocal guidelines for managing this emergency.
• Treatment in a high-volume center with a specialized Thoracic Surgery department allows for rapid and more complete case management.
What is the implication, and what should change now?
• There is a need for universal guidelines in managing this emergency.
• A multidisciplinary approach led by a thoracic surgeon is needed for case management.
Introduction
Background
Esophageal perforation is an extremely rare but potentially life-threatening emergency as-sociated with high morbidity and mortality rates. Studies indicate that mortality ranges from 10% to 25% within the first 24 hours after perforation and can increase to 40–60% if treatment is delayed beyond this period (1).
Rationale and knowledge gap
Fishbone ingestion is recognized as one of the most common causes of esophageal perforation, accounting for approximately 12% of cases (2). However, fishbone ingestion does not always lead to frank mediastinal abscess. The treatment method depends on the location, size, configuration, and number of foreign bodies present in the esophagus. To date, the optimal method for removing foreign bodies from the esophagus remains uncertain (3).
Endoscopists’ interventions can sometimes delay the timely management needed to prevent frank mediastinitis and patient sepsis. Nevertheless, when feasible, the endoscopic procedure represents the least invasive approach with minimal impact on the patient’s hospital stay (2).
Objective
This article aims to explore the challenges in managing esophageal perforation caused by fishbones, with particular emphasis on the decision-making process between conservative treatment, endoscopic procedures, and the optimal timing for surgical intervention. It describes how to manage this type of emergency in a high-volume, specialized center, equipped with cutting-edge technologies and surgical techniques, using a multidisciplinary approach.
Furthermore, it discusses the lack of standardized guidelines and the need for improved decision-making tools to manage these rare but potentially catastrophic cases.
Methods
This study consists of two components: a clinical case report and a narrative literature review. The clinical case involves a 28-year-old male who presented to the emergency department with acute retrosternal chest pain following fish consumption. The patient underwent clinical examination, laboratory tests, thoracic computed tomography (CT), and two esophagogastroduodenoscopies (EGDS) performed 24 hours apart. Management included empirical broad-spectrum antibiotic therapy, clinical monitoring, and, ultimately, a right thoracotomy for removal of the foreign body and repair of the esophageal perforation.
For the literature review, a narrative search of major biomedical databases (PubMed, Scopus) was conducted, focusing on articles published within the last 11 years (from April 1993 to May 2024) regarding esophageal perforation due to foreign body ingestion, associated complications, and therapeutic guidelines, particularly the last 4 years. We considered only those in English, case reports where patients were managed in high-volume centers, and retrospective studies. We present this article in accordance with the CARE reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-25/rc).
Case presentation
A 28-year-old man from Bangladesh, with no known comorbidities, presented to the emergency department with right retrosternal chest pain that began shortly after consuming fish at lunch.
Initially, the patient went to another hospital, where he executed a first thoracic CT scan, showing the presence of a foreign body into the proximal esophagus. Given the complexity of the case, he was subsequently transported to the Emergency Room of Policlinico Universitario Agostino Gemelli, which has a specialized department of thoracic surgery. After the consult of the thoracic surgeon, in a first instance, a chest CT scan with and without iodinated contrast and gastrografin, was performed (approximately 12 hours after the patient’s arrival). It confirmed the presence of a 12-mm hyperdense, elongated foreign body located in the proximal esophagus, partially extraluminal, and closely adjacent to the right lateral wall of the trachea. Associated esophageal wall thickening and perivisceral inflammation were also observed.
Upon arrival at the emergency room, where he was managed at first, the patient was clinically stable [vital parameters: heart rate: 102 bpm; blood pressure: 110/70 mmHg; SO2 99% without O2; Glasgow Coma Scale (GCS) 15; arterial blood results: pH 7.36; partial pressure of oxygen (pO2) 95 mmHg; partial pressure of carbon dioxide (pCO2) 40 mmHg] without signs of sepsis. The patient was afebrile (36.1 ℃). Blood tests were within normal limits except for an elevated white blood cell count {15.2×109/L; normal range: [4–11]×109/L}; C-reactive protein (CRP) was anormal more than 15 mg/L (normal range: 0.3–10 mg/L). Given the presence of a foreign body on imaging, esophagogastroduodenoscopy (EGDS) was per-formed, confirming the presence of a fishbone in the mid-esophagus. A first attempt to remove the bone by EGDS was made, but it failed. In fact, it contributed to the displacement of the fishbone into a position that favored the formation of an esophago-tracheal fistula.
Empiric broad-spectrum antibiotic therapy with piperacillin/tazobactam was initiated. A repeat chest CT scan, performed 24 hours after the EGDS, still showed the presence of a linear hyperdense structure (12 mm × 2 mm) in the proximal third of the thoracic esophagus, at the level of the aortic arch, consistent with the retained fishbone. The object was visualized abutting the right anterolateral esophageal wall (Figure 1).
Due to progressive elevation of inflammatory markers (leukocytosis, CRP) and the persistent presence of the foreign body, a multidisciplinary team composed of thoracic surgeons and endoscopists opted for surgical intervention. The surgical procedure was performed under general anesthesia. The patient was intubated with a double-lumen tube to exclude the right lung.
Before proceeding with the incision, an EGDS was performed with the aim of intraoperatively locating the fishbone. Then, a right lateral thoracotomy was performed to extract the foreign body and evaluate the extent of mediastinitis and esophageal injury.
Upon entering the pleural cavity, a small amount of serous, reactive, non-purulent pleural effusion was noted. The posterior mediastinal pleura was incised from 5 cm below the azygos vein to the apex of the pleural dome. After dividing the azygos vein using a mechanical stapler, the anterolateral esophageal wall was dissected from 2 cm below to 5 cm above the azygos vein. Dissection proceeded into the tracheoesophageal groove, the suspected location of the foreign body as per CT imaging. At this level, an ecchymotic area of the esophageal wall was identified, along with a small muscular tear. Gentle pressure on the area released corpuscular material, which was sent for microbiological analysis.
Intraoperatively, an endoscopic ultrasound (EUS) was performed, confirming the presence of a hyperechoic structure suggestive of the fishbone at the site of the muscular defect, ap-proximately 24 cm from the dental arcade. Through careful digital manipulation, the fishbone was extracted via the esophageal muscular breach. The defect was then closed with two interrupted 3-0 Vicryl sutures. An intraoperative methylene blue leak test, performed through a naso-esophageal tube, was negative.
A protective flap was created using the parietal pleura to reinforce the esophageal suture (Figure 2).
We preferred to use the pleura as it was present on site, avoiding having to change the patient’s position on the operating table thus possibly facilitating the patient’s extubation for example.
At the end of the procedure the anesthetist executed erector spinae plane block and the surgeons inserted an antalgic catheter into the serratus muscle. After surgery the patient was transferred to intensive care unit for monitoring. He was then transferred to the thoracic surgery department the following day.
During surgery, a para-esophageal purulent area was identified and sent for microbiological analysis (then positive for Streptococcus mitis/oralis).
Postoperatively, in consideration of the inflammation indices, the paraoesophageal purulent area visible also on the CT scan and awaiting the results of the microbiological test, a broad-spectrum antibiotic and antifungal therapy with piperacillin/tazobactam and fluconazole was administered [scheme: piperacillin/tazobactam 4.5 mg intravenous (IV), 3 per day for 11 days; fluconazole 400 mg/200 mL IV, 1 per day for 11 days]. At the discharge: augmentin 1 g (per os), 3 per day for 7 days.
The inflammatory process was monitored through drain output. Serial chest radiographs and monitoring of the inflammation indices (which progressively decreased after treatment; Table 1). The symptoms progressively disappeared.
Table 1
| Post-operative days | Hb (g/dL) | WBC (×109/L) | PLT (×109/L) | Na (mmol/L) | K (mmol/L) | CPK (UI/L) | PCT (ng/mL) | LDH (UI/L) | CRP (mg/L) |
|---|---|---|---|---|---|---|---|---|---|
| 1st | 13.3 | 14.27 | 213 | 142 | 3.4 | 1,432 | 0.16 | 192 | 154.7 |
| 2nd | 13.8 | 12.44 | 235 | 137 | 3.2 | 810 | 0.12 | 247 | 105.2 |
| 3rd | 14.9 | 12.68 | 249 | 140 | 3.4 | 433 | – | 217 | 68 |
| 4th | – | – | – | – | – | – | – | – | – |
| 5th | 13.8 | 12.15 | 302 | 140 | 3.4 | 234 | – | 298 | 32.9 |
| 6th | – | – | – | – | – | – | – | – | – |
| 7th | 12.6 | 11.98 | 307 | 139 | 3.3 | 175 | – | 228 | 38.9 |
| 8th | – | – | – | – | – | – | – | – | – |
| 9th | 13.2 | 10.61 | 364 | 143 | 3.5 | – | – | – | 13.6 |
| 10th | – | – | – | – | – | 175 | – | 211 | – |
CPK, creatine phosphokinase; CRP, C-reactive protein; Hb, hemoglobin; K, potassium; LDH, lactic dehydrogenase; Na, sodium; PCT, procalcitonin; PLT, platelets; WBC, white blood cell.
The patient remained nil per os until the eighth postoperative day, when an esophagogram demonstrated no evidence of leakage, confirming the integrity of the repair.
A semi-liquid diet was initiated without complications, and the patient was discharged on postoperative day eleven with oral antibiotic therapy and instructions to undergo a follow-up CT scan after 1 month.
Approximately 30 days after surgery, the patient underwent a chest CT scan with the following findings: results of removal of the previously reported foreign body in the proximal third of the esophagus, via right lateral thoracotomy with access from the fourth intercostal space.
No pneumomediastinum. No evident fluid collections or significant fluid effusion in the periesophageal area. The esophagus mostly collapsed. Fluid imbibition of the soft tissues of the right anterolateral chest wall, at the level of the surgical access, resulting from a recent surgery. After the discharge the patient started to eat and he continues eating without problems.
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Discussion
Over the past thirty years, the mortality rate associated with esophageal perforation has significantly decreased—from approximately 30% to 15%—thanks to advancements in medical technologies such as minimally invasive surgical techniques and interventional radiology (2).
Among the various foreign bodies that can be ingested such as chicken bones, coins, and small plastic objects fishbones are among the most common, particularly in Asian populations (3,4).
Although fishbones are typically removed endoscopically, more invasive approaches may be required in complex cases. Esophageal perforation from fishbones most frequently occurs at the three physiological constrictions of the esophagus: the cricopharyngeal (at the esophageal inlet), bronchoaortic (where the aortic arch and left main bronchus compress the esophagus), and diaphragmatic (where the esophagus passes through the diaphragm). These points are particularly prone to foreign body impaction and injury (5).
In our case, CT imaging showed the fishbone in a plane corresponding to the aortic arch, confirming that the foreign body was indeed lodged in one of the known physio-logical narrowings.
Common complications of esophageal perforation include mediastinitis, pleural or chest wall abscesses, sepsis, and, in severe cases, septic shock. These complications require immediate and appropriate management due to their high mortality risk (2). While traditional management often involved open surgery, recent advancements favor less invasive endoscopic methods such as clip closure (CC), self-expanding metal stents (SEMS), and vacuum therapy (VT), all of which aim to stabilize the esophagus and promote tissue healing (6).
In our case, the CT scan highlighted imbibition of the esophageal wall and partial perivisceritis, indicative of early mediastinitis. The location of the fishbone in the proximal third of the thoracic esophagus—at the level of the aortic arch—necessitated prompt surgical action due to the risk of complications such as full-blown mediastinitis, abscess formation, and particularly aorto-esophageal fistula, which is associated with a mortality rate exceeding 90% (7).
This highlights the importance of an accurate and timely clinical and radiological assessment to determine the urgency of intervention and whether endoscopic management is feasible. In this case, both the radiological evidence and the unsuccessful endoscopic retrieval guided us toward surgical management, preventing further complications.
Surgical intervention is indicated when the foreign body cannot be removed endoscopically, when there is a visible perforation, or when the object is located near vital structures such as the aortic arch. The presence of extensive pleural or mediastinal contamination also warrants immediate surgical treatment (grade 1B) (8). Up to 1–3% of patients with esophageal foreign bodies require surgery due to complications such as perforation, mediastinitis, pleural empyema, or hemorrhage (8).
Although there are no standard guidelines, we have referred to the World Society for Emergency Surgery guidelines for emergency management. It is essential to be able to manage an emergency such as esophageal perforation in a timely manner, minimizing errors for the direct benefit of the patient.
According to the WSES guidelines, our case meets the criteria for a grade 1B indication: an irretrievable foreign body associated with signs of early complications. Thus, surgical intervention with an invasive approach was appropriate and guideline-compliant (8).
Surgical access should be chosen based on the foreign body’s location and the patient’s condition. Options include left cervicotomy, right or left thoracotomy, minimally invasive thoracoscopy (right or left), prone thoracoscopy, laparoscopy, and laparotomy (8).
In cases with limited mediastinal contamination, open or minimally invasive esophagotomy followed by primary repair is considered appropriate. For extensive contamination, esophagectomy—either primary or delayed—should be considered (WSES guidelines) (8).
In our case, we opted for a right thoracotomy, which is a standard approach in esophageal surgery. This was chosen both for its broad exposure and due to the urgent need to localize and safely remove the fishbone. The thoracotomy provided a wide surgical field, which was necessary to manage both the extraction and the repair.
Two EGDS procedures were performed 24 hours apart, with a CT scan conducted between them. While the patient remained clinically stable, continuous monitoring of laboratory and imaging data allowed for timely escalation to surgery, both to remove the fishbone and to prevent the progression to sepsis.
Regardless of the therapeutic approach, literature consistently supports the early use of contrast-enhanced chest CT in suspected esophageal perforation. This helps determine whether the foreign body has migrated toward vascular structures and guides the therapeutic decision-making process. In patients with atypical symptoms, CT also enables better characterization of extraluminal findings (9). In some complex cases, including ours, intraoperative eco-endoscopy can be valuable in localizing the echogenic shadow corresponding to the retained foreign body (7).
The current literature on esophageal perforation due to fishbone ingestion (Table 2) illustrates the heterogeneity of clinical practice and the lack of standardized guidelines. This variability—particularly in follow-up imaging protocols and the balance between conservative and surgical approaches—emphasizes the need for unified clinical recommendations.
Table 2
| Study | Year | Day of extraction | Procedure | Fishbone location | Size of foreign body | Complications |
|---|---|---|---|---|---|---|
| Lu et al. (10) | 2021 | 15 | ESD | T8 | 2 cm | None |
| Rustemov et al. (5) | 2024 | 3 | EGDS | Descending thoracic aorta | 1.5–2.0 cm | Post-traumatic saccular pseudoaneurysm of the descending thoracic aorta |
| Zhong et al. (11) | 2023 | 8 | Thoracotomy | T2 | N/A | Perforation, empyema, mediastinal abscess, sepsis |
| Han et al. (12) | 2023 | 8 | VATS (right mediastinotomy and left exploration) | Not available | N/A | Esophagitis with a 1.2-cm paraesophageal abscess |
| Zhang et al. (7) | 2021 | 9 | Thoracic endovascular procedure | Not available | N/A | Aorto-esophageal fistula, pneumomediastinum |
| This case | 2024 | 2 | Thoracotomy | Proximal third of the thoracic esophagus | 1.5 cm | None |
EGDS, esophagogastroduodenoscopy; ESD, endoscopic submucosal dissection; N/A, not applicable; VATS, video-assisted thoracoscopic surgery.
Strengths and limitations
This article recognizes weaknesses, such as monocentricity, the description of a single clinical case, and the lack of more precise patient information (due to the language barrier).
Among the strengths, we highlight: the availability of a specialized thoracic surgery unit, the resources, and the professionals present in a high-volume center.
Conclusions
Esophageal perforation caused by foreign body ingestion is a rare but potentially life-threatening condition requiring early diagnosis and prompt intervention. Our case illustrates that when the foreign body is located near critical vascular structures and initial signs of mediastinitis are present, early surgical intervention is justified, particularly if endoscopic removal fails. Despite recent advances in endoscopic and minimally invasive techniques, conventional surgical approaches remain essential in complex cases. The literature review highlights the lack of standardized guidelines for managing fish-bone-induced esophageal perforations, underscoring the need for the development of unified clinical protocols to support decision-making in emergency settings.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-25/rc
Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-25/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-25/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Nocera A, Napolitano AG, Gallo A, Scognamiglio C, Petracca-Ciavarella L, Margaritora S, Meacci E. Diagnosis and management of esophageal perforation due to a fishbone: a case report and narrative review. Curr Chall Thorac Surg 2025;7:36.
