Supraglottic foreign body in a woman with Down's syndrome and congenital heart disease: A case report

Rationale:An impacted foreign body (FB) in the larynx of an adult is a rare but potentially life-threatening occurrence. Patients with Down''s syndrome (DS) are vulnerable to airway FB. However, the anesthesia for FB removal can be challenging. This report describes a case in which a FB was impacted between the vestibular folds in an adult with DS, congenital heart disease, and a difficult airway.Patient concerns:A 41-year-old woman swallowed a piece of sharp-tipped wooden skewer presented with a sudden onset of aphonia, dysphagia, and an acute sore throat without respiratory difficulty. The patient had DS, congenital heart disease, pulmonary arterial hypertension, and severe obstructive sleep apnea–hypopnea syndrome. The airway evaluation indicated that ventilation and intubation would be difficult due to retrognathia, macroglossia, adenotonsillar hypertrophy, and Mallampati''s classification III.Diagnosis:The clinical symptoms and laboratory examination confirmed FB penetrated between the vestibular folds.Interventions:After careful multidisciplinary preoperative assessment and preparation, the FB was removed successfully by direct laryngoscopy under moderate sedation and spontaneous ventilation, with the application of 1% lidocaine as topical anesthesia.Outcomes:The laryngeal FB was removed successfully without any complications. And the patient was discharged home the next day.Lessons:This case report shows the importance of anesthetic depth for laryngeal FB removal. The use of moderate sedation (allowing spontaneous ventilation) and adequate analgesia combined with local anesthesia enabled the patient to withstand the stress of direct laryngoscopy. Appropriate assessment, careful preparation, and multidisciplinary collaboration yielded the smooth removal of a laryngeal FB in an adult with DS.     

Cardiopulmonary bypass as a bridge for bronchial foreign body removal in a child with pulmonary artery sling: A case report

Rationale:Successful removal of an airway foreign body (FB) in some intractable cases can be very challenging, because of tracheal anomalies, unstable respiratory status of the patients, and the location of FB. The use of cardiopulmonary bypass (CPB) support for the treatment of a FB is extremely rare.Patient concerns:We present a case of a 39-month-old previously healthy girl who was admitted to our hospital for suspected FB aspiration (FBA). Initially, the attempt for removal of the FB by conventional bronchoscopy failed because of hypoxic intolerance.Diagnoses:Bronchoscopy revealed tracheal anomalies and subsequent computed tomography angiography demonstrated the presence of a pulmonary artery sling (PAS), which confirmed the diagnosis of PAS accompanied with FBA.Interventions:With the assistance of CPB, multidisciplinary treatment involving the respiratory, cardiothoracic and anesthetic teams were involved and the bronchial FB was removed by flexible bronchoscopy successfully and then PAS was corrected by surgical intervention.Outcomes:The patient remained asymptomatic, without shortness of breath or wheezing during the 15 months follow-up.Lessons:This case highlights that in a complicated case of FBA, bronchoscopy and computed tomography imaging are of great importance to achieve an accurate diagnosis, and a multidisciplinary treatment approach is essential for a satisfactory outcome. If the patient is unstable for bronchoscopy, CPB can be temporarily used in the stabilization of the patient to allow safe removal of the FB.     

Foreign body removal using flexible bronchoscopy in terminal cancer: A case report

Rationale:Pulmonary foreign body aspiration is a serious medical problem. The risk of foreign body aspiration into the airways increases considerably in patients with end stage cancer with reduced consciousness and impaired airway reflexes. However, few studies have reported on foreign body aspiration in the airways in patients with terminal cancer or receiving end-of-life care. Herein, we report the use of flexible bronchoscopy in patients with end-of-life cancer with pulmonary aspiration.Patient concerns:A 71-year-old man with neuroendocrine carcinoma was admitted to a palliative care unit for end-of-life care. He accidentally aspirated implant teeth into the airway with decreased consciousness and death rattle.Diagnosis:On chest x-ray, the foreign material was observed in the left main bronchus.Interventions:Despite concerns regarding the use of bronchoscopy given the deterioration of the overall organ function, flexible bronchoscopy was performed.Outcomes:Eventually, the foreign body was removed using a basket in the nasal cavity without major complications. The patient died comfortably after 7 days.Lessons:The possibility of patients in the palliative care unit with reduced consciousness and death rattle to aspirate foreign bodies into the airways must be carefully considered. Flexible bronchoscopy should be considered to carefully remove aspirated foreign bodies in the airway without any side effects, even in patients with terminal cancer or receiving end-of-life care.     

Two new radiological findings to improve the diagnosis of bronchial foreign-body aspiration in children

Our objective was to report on two new chest X-ray signs (hyperinflation or obstructive emphysema with atelectasis in the same hemithorax, and aeration within an area of atelectasis) in children with foreign-body aspiration (FBA). We performed a retrospective review of clinical characteristics and chest X-ray films of 133 children with FBA. Of 133 children, 45% were under 3 years old. History of a choking crisis was present in 101 (75.8%); however, it was only elicited upon follow-up questioning in 33 children (32.7%). Early foreign-body (FB) extraction (<24 hr) was performed in 17.3%; removal took place between 1-7 days in 29.3%. The site of aspirated FBs was bronchial in 78.9%, laryngeal in 6%, and tracheal in 4.5%, with mobile FB in the trachea/bronchi in 4.5%. The chest X-ray was normal in 11.3%. Positive findings included: radiopaque FB (23.3%); hyperinflation or obstructive emphysema (21.8%); hyperinflation or obstructive emphysema with atelectasis in the same hemithorax (18%); lobar atelectasis (12.8%); whole-lung atelectasis (6.8%); shift of mediastinal shadow (11%); and aeration within an area of atelectasis (6%). In conclusion, if a history of choking crisis is not present in a child with suspected FBA, two previously undescribed radiological signs (hyperinflation or obstructive emphysema with atelectasis in the same hemithorax, and aeration within an area of atelectasis) should be sought in order to improve the utility of chest-X ray for early diagnosis of FBA.     

Electric wire as a urethral foreign body: A case report

Rationale:Most self-insertion of urethral foreign bodies is the result of exotic impulses, psychometric problems, sexual curiosity, or sexual practice while intoxicated. Ultrasound has been proven to be an effective tool for determining the presence, location, and characteristics of the urethral foreign body.Patient concerns:A 48-year-old man presented with a mass in the urethra for 2 years. Physical examination suggested swelling and ulcer in the scrotum. The white blood cell count was elevated (12.60 × 10⁹/L). Urinalysis showed an increased white cell count (484.60/μL) and urine occult blood (±).Diagnosis:Ultrasound examination of the genitourinary system identified an 8.3 cm linear hyperechoic object and hyperechoic spots in the urethra. Computed tomography revealed an extremely hyperdense lesion in the penis. Intraoperative findings showed electric wire bending and winding surrounded by fibrous tissues with urethral rupture.Interventions:The patient was treated with urethrotomy as the endoscopic treatment failed. and the electric wire was removed successfully.Outcomes:The patient was followed up for 45 days without discomfort. Ultrasound examination of the genitourinary system suggested that the wound was almost healed, but with a small urethral effusion, with a maximum depth of approximately 1.9 mm.Lessons:A foreign body was inserted into the patient''s urethra for 2 years without any medical treatment. Urethral perforation was found during surgery. In such cases, ultrasound examination can determine the location, shape, and size of the urethral foreign body and play an important role in the diagnosis of foreign bodies.     

Esophageal foreign bodies in adults: systematic review of the literature

Objective: Esophageal Foreign Body (FB) impaction represents a major challenge for healthcare providers. Aim of this systematic review was to analyse the current literature evidence on prevalence, presentation, treatment, and outcomes of impacted esophageal FB.

Materials and methods: Literature search was conducted between 2000 and 30th June 2018 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement.

Results: Sixty-one studies matched the inclusion criteria. The total number of included patients was 13,092. The cervical esophagus was the most frequent impaction site (67%) and sharp-pointed objects were the most common FB (38.1%). Retrosternal pain (78%), dysphagia (48%), and odynophagia (43.4%) were the most common symptoms. A flexible or rigid endoscopic approach was adopted in 65.1% and 16.8% of patients, respectively. Overall, 17.8% of patients had a complication related to the impacted esophageal FB or to the endoscopic manoeuvers. A surgical approach was required in 3.4% of patients. The overall mortality was 0.85%.

Conclusions: Surgery is the upfront treatment in patients with esophageal perforation or endoscopically irretrievable esophageal FB. A minimally invasive approach can be adopted in selected patients. Effective prevention of FB impaction should focus on accurate diagnostic work-up to search for an underlying motility disorder after a first episode of esophageal impaction, even if transient and self-resolving.     

Esophageal foreign bodies: 177 cases

The aim of this study is to assess patients treated for esophageal foreign bodies. The charts of patients (n = 177), between January 1994 and April 2009, were investigated retrospectively. Patients' age and gender, locations and types of foreign bodies (FBs) and interventions were taken into consideration. Fifty‐seven percent of the patients were male. The youngest patient was 6 months, whereas the oldest was 83 years old. The median age was 9 years. Half of the patients were in their first decade. Treatment took place 11 h (ranging from 1 to 120 h) after impaction of the FB. One hundred fifty‐two FBs were removed in 177 patients. Our negative esophagoscopy (n = 25) rate was 14%. The FBs were radiopaque in 75% (n = 114) and were commonly (71%; n = 109) located in the cervical esophagus. Metallic coins (n = 81–53%) were the most commonly observed inorganic FB while bones and/or meat impaction (n = 54–35%) were the most frequent organic FB. A total of 182 endoscopic interventions were performed on these patients. One hundred eleven of them were esophagoscopy and the remaining 71 were direct laryngoscopy. The FB was pushed into the stomach in 11 patients. Our morbidity rate was 1.6% (n = 3). Iatrogenic perforation occurred in two patients. There was no mortality. Esophageal FBs may vary in type: sharp or round objects, metallic, plastic or organic material. FBs are commonly found at pharyngoesophageal junction and usually removed by McGill forceps. Rigid esophagoscopy is used for children and adults because of its large working channel. Rigid instruments are considered reliable and safe for extracting foreign bodies.     

A rare asymptomatic metallic intraocular foreign body retained in the anterior chamber for 15 years: A case report

Rationale:Intraocular foreign bodies (IOFBs) are common in ocular injuries, but asymptomatic metallic IOFBs retained in the anterior chamber for years are rare.Patient concerns:A 31-year-old female presented with blurred vision in her right eye after lumbar magnetic resonance imaging. Her best-corrected vision acuity was 0.6 in the right eye and 1.0 in the left eye. Slit-lamp examination revealed a brown granular foreign body in the anterior chamber and pigmentation of the limbus. Lens and retina examination indicated ocular siderosis. Corneal endothelioscopy revealed decreased endothelial cell density. A detailed history showed ocular globe injury 15 years earlier.Diagnoses:Anterior chamber IOFB with ocular siderosis.Interventions:Anterior chamber foreign body removal was performed with appropriate incision and forceps.Outcomes:The anterior chamber IOFB was successfully removed and examined as a magnetic metal foreign body. The best-corrected vision acuity was 1.0 at 1 day postoperatively. An abnormal electroretinogram with a 12% decrease in the “b” wave and a 91% decrease in the “a” wave was observed 3 months postoperatively. There were no intraoperative or postoperative complications during a 3-month follow-up.Lessons:Eye trauma should be examined carefully to exclude IOFBs. Asymptomatic anterior chamber foreign bodies can also cause corneal endothelial injury and ocular siderosis. Careful examination and timely management are needed in such cases.     

Endoscopic removal of accidental aspirated and ingested dental foreign bodies: A cross-sectional study

The incidence of accidental ingestion and aspiration of foreign body (FB) is likely to occur. Many FBs are discharged spontaneously, but many dental FBs are often sharp and may remain in the pharynx, esophagus, and stomach, causing serious complications such as hemorrhage, asphyxia, perforation of the digestive tract, mediastinal emphysema, peritonitis, and ileus. We aimed to examine which type of dental foreign bodies can be removed by endoscope.In this study, we enrolled 32 patients who were evaluated at the Emergency and Critical Center between January 2014 and December 2019 and who accidentally ingested or aspirated dental FBs. Medical records were reviewed to determine the patients’ sex, age, medical history, time from accidental ingestion of a FB to consultation, cause, location, occurrence status, nature of the FB, location of retained FB, treatment, complications, and outcome.We enrolled 32 patients (14 men, 18 women), with a mean age of 74.5 ± 12.8 years. Accidental ingestion at treatment was common. The most frequent site where the FB was retained was upper gastrointestinal tract (26 cases, 81.3%). In this study, endoscopic removal was indicated for dentures under the size of 43.3 mm, for dental FB (except dentures) more than 13.6 mm. In dentures, between the number of missing teeth, clasp, type, and endoscopic removal was not statistically significant.Dentures under the size of 43.3 mm was likely to be removed by endoscope. Dental FB (except dentures) more than the size of 13.6 mm was likely to be removed by endoscope. There were no indications for endoscopic removal except for size.     

Ampullary gangliocytic paraganglioma with lymph node metastasis: A case report with literature review

Rationale:Gangliocytic paraganglioma (GP) is a rare tumor that mostly develops in the duodenum and is composed of the following 3 cell types: epithelioid endocrine, spindle-like, and ganglion-like cells. It manifests as symptoms such as abdominal pain, gastrointestinal bleeding, and weight loss; however, occasionally, it is incidentally detected on endoscopic or radiologic examinations. Although GP is usually benign, it can metastasize to the lymph nodes, and distant metastases have been reported in some cases.Patient concerns:A 46-year-old woman presented with anemia on health surveillance examination. She had no other specific symptoms, and her physical examination did not reveal any abnormal finding.Diagnosis:Endoscopic ultrasound-guided fine-needle aspiration biopsy was performed, and the endoscopist obtained samples from the inner side of the ampullary mass. Pathological examination suggested GP or a neuroendocrine tumor.Interventions:Initially, we planned transduodenal ampullectomy with lymph node excision. However, there was severe fibrosis around the duodenum, and an examination of a frozen biopsy sample from the periduodenal lymph node showed atypical cells in the lymph node. Therefore, we performed pylorus-preserving pancreaticoduodenectomy with lymph node dissection.Outcomes:The final pathological diagnosis was GP located in the ampulla of Vater. The GP showed lymphovascular and perineural invasion and invaded the duodenal wall. Furthermore, 4 out of 18 harvested lymph nodes showed metastasis.Lessons:We described a case of GP confined to the ampulla with regional lymph node metastasis and reviewed published literature on ampullary GP with lymph node metastasis.     

Calcified shadow of hilus pulmonis followed with finger‐in‐glove sign of lingular bronchus on the left side

Tracheobronchial aspiration of foreign body (FB) in adults is not as common as in children. The clinical manifestations are highly variable under different circumstances, considering the state of the patient, the influence of the FB and incipient medical intervention, etc. The lodgement of FB in adults, as in almost all the reports around the world, is dominantly in the right bronchial tree, especially the intermediate and the basal bronchus, because of anatomical reasons. In this case, we reported, a 75‐year‐old woman with a dental piece in her lingular bronchus, not the right side as usual, for at least 10 years had no symptoms or any notice of the aspiration. Surgery and biopsy helped to make definite diagnosis and eventually removal.     

Magnetic compression anastomosis for rectal atresia following necrotizing enterocolitis: A case report

Rationale:Rectal atresia caused by necrotizing enterocolitis (NEC) is a serious and rare complication in children. Magnetic compression anastomosis (MCA) has been effectively applied in children with congenital oesophageal atresia and biliary atresia. Herein, we reported a case of successfully application of MCA in an infant with rectal atresia following NEC.Patient concerns:A 30⁺⁶ weeks premature birth female fetal infant was transferred to our neonatal intensive care unit due to premature delivery, low birth weight, and neonatal respiratory distress. On postpartum day 11, the infant developed abdominal distension and mucosanguineous feces. This infant was then clinically diagnosed as NEC. She underwent anesthesia and intestinal fistula operation on postpartum day 11 because of NEC.Diagnosis:After 3 months, radiographic examination revealed rectal atresia and stricture.Interventions:This infant was successfully treated with MCA following a cecum-rectal anastomosis and ileocecal valve was reserved.Outcomes:On postoperative day 9, she passed the 2 magnets per rectum. In addition, there were no difficult defecation or fecal incontinence or other short-term complications. After the 7-month follow-up, the patient had an excellent clinical outcome.Lessons:MCA is a feasible and effective method for treating rectal atresia in infants.     

Airway foreign bodies: what's new?

Tracheobronchial foreign body (FB) aspiration is a common problem in children and adults. The medical history is the single most predictive factor in the clinical suspicion of FB aspiration. The "penetration syndrome" defined by the sudden onset of choking and coughing with or without vomiting should prompt concerns for FB aspiration. Findings on radiographic imaging include visualization of a radiopaque FB, atelectasis, postobstructive changes, mediastinal shift, and pneumomediastinum. In the presence of a high clinical suspicion even with normal imaging studies, bronchoscopy should be performed for a thorough evaluation of the airways. Bronchoscopic extraction of airway FBs can be safely accomplished with both the rigid as well as the flexible bronchoscope in adults and children. Rigid bronchoscopy allows for control of the airway and provides excellent visualization with a variety of ancillary instruments available. Increasingly, both the adult and pediatric flexible bronchoscopes have been used successfully in the extraction of airway FBs utilizing urologic or bronchoscopic instruments. Airway control can be achieved with an endotracheal tube or a laryngeal mask airway. A delay in diagnosis increases morbidity including cough, wheeze, edema, and granulation tissue formation. Bronchoscopic evaluation and removal should be performed as soon as the diagnosis is suspected.     

A rare intraocular lens surface foreign body during phacoemulsification surgery: A case report

Rationale:Only a few cases of intraocular lens (IOL) opacification during phacoemulsification surgery have been reported in the literature; intraoperative emergency due to IOL surface foreign body is even rarer.Patient concerns:A 76-year-old woman underwent uncomplicated cataract surgery in her right eye. A triangular transparent seemingly foreign body tightly attached to the posterior surface of the IOL was found during IOL implantation; the IOL surface foreign body prevented the patient from obtaining satisfactory visual acuity after surgery.Diagnosis:IOL surface foreign body.Interventions:After confirmation of the surface foreign body by swept-source optical coherence tomography (IOL Master 700), the surface foreign body was removed in a second surgery. After surgery, the IOL was still well centered.Outcomes:Fortunately, the patient achieved distinctly improved vision without any visual disturbances in her right eye. To identify the material of the foreign body, it was examined by Fourier-transform infrared spectroscopy (FTIR).Lessons:This case suggests that surgeons should carefully observe IOLs before implantation. In addition, effective preoperative planning and skillful surgery can remove foreign bodies smoothly and improve patient vision.     

Successful management of the hepatocellular carcinoma with inferior vena cava tumor thrombus: A case report

Rationale:Hepatocellular carcinoma (HCC) with inferior vena cava tumor thrombus (IVCTT) is traditionally considered an advanced-stage cancer with a poor prognosis. There is no standard treatment for patients diagnosed as HCC with IVCTT.Patient concerns:A 52-year-old man was admitted to our hospital because of suspected hepatic mass during a health examination.Diagnoses:Computed tomography (CT) showed a hepatic mass approximately 4.3 cm × 6.3 cm in size located in segment VII of the liver, with thrombus in the inferior vena cava. The mass exhibited a pattern of early enhancement and washout on contrast-enhanced CT. Alpha-fetoprotein was 614.1 ng/mL (normal value, <8 ng/mL). The preoperative diagnosis was HCC with IVCTT.Interventions:Two months after stereotactic body radiotherapy combined with sorafenib therapy, a planned open anatomical resection of the right posterior lobe of the liver was performed.Outcomes:The patient is alive without disease 12 months after surgery, and the level of alpha-fetoprotein is normal.Lessons:The patient diagnosed as HCC with IVCTT was successfully treated by stereotactic body radiotherapy combined with molecularly targeted drugs followed by surgical treatment. If confirmed in future studies, this would suggest a promising strategy for the management of HCC with IVCTT.     

High-flow nasal cannula application in an infant patient with laryngomalacia during general anesthesia: A case report

Rationale:Laryngomalacia is defined as the collapse of supraglottic structures and can cause not only strider but also trigger difficulties with ventilation and endotracheal intubation during anesthesia management. High-flow nasal cannula (HFNC) has been used to manage patients at high risk of hypoxemia in the intensive care unit; however, limited literature information is available for the application of HFNC to infant patients with laryngomalacia during anesthesia practice.Patient concerns:A 2-month-old male infant was scheduled to undergo surgery for inguinal hernia and undescended testis with general anesthesia.Diagnosis:The patient had subcostal retraction while breathing and frequent oxygen desaturation events and was diagnosed laryngomalacia.Interventions:After the patient was supplied oxygen via HFNC and then given general anesthesia, the initial 2 attempts of endotracheal intubation with a rigid laryngoscope were unsuccessful because the vocal cords were obscured by the epiglottis. A third intubation attempt was performed and successful with a 3.0-sized, uncuffed endotracheal tube within 20 minutes of the initial attempt.Outcomes:No airway complications emerged and oxygen saturation remained at greater than 98% during general anesthesia. The patient was discharged 5 days after surgery without any adverse side effects.Lessons:Continuous oxygenation via HFNC is a good choice to prevent desaturation during difficult tracheal intubations in infant patients with laryngomalacia. This device is expected to be useful for intubation not only in patients with laryngomalacia, but also in infant patients with a predicted high risk of oxygen desaturation events during general anesthesia.     

Foreign body aspiration

The clinical manifestations of foreign body (FB) aspiration can range from an asymptomatic presentation to a life-threatening emergency. Patients may present with acute onset cough, chest pain, breathlessness or sub-acutely with unexplained hemoptysis, non-resolving pneumonia and at times, as an incidental finding on imaging. Patients with iatrogenic FB such as an aspirated broken tooth during difficult intubation or a broken instrument are more common scenarios in the intensive care unit (ICU). Patients with post-obstructive pneumonia with or without sepsis, or variable degree of hemoptysis often require ICU level of care and bronchoscopic interventions. Rigid bronchoscopy has traditionally been the modality of choice; however, with the innovation in instrumentation and wider availability of flexible bronchoscopes, most of the FB removal is now successfully performed using flexible bronchoscopy. Proceduralists choose instruments in accordance with their training and expertise. We describe the use of most common instruments including forceps, balloon catheters, and baskets. Role of cryoprobe and LASER in FB removal is reviewed as well. In general, larger working channel bronchoscopes are preferred; however, smaller working channel bronchoscopes may be used in situations when the patients are intubated with a smaller diameter endotracheal or tracheostomy tubes. Large size FB are removed en bloc with the grasping tool, bronchoscope, and endotracheal or tracheostomy tube, requiring preparation to safely re-establish the airway. After FB removal, bronchoscopy is re-performed to identify any residual FB, assess any injury to the airway, suction post-obstructive secretions or pus, control any active bleeding and remove granulation tissue that may be obstructing the airway. Additional interventions like balloon dilatation may be required to dislodge an impacted FB or to maintain patency of bronchial lumen. If bronchoscopic methods fail, surgery may be required for retrieval of FB in symptomatic patients or to resect suppurative or necrotizing lung process. Multidisciplinary approach involving intensivists, surgeons, and anesthesiologists is the key to optimal patient outcomes.     

Ingesta de cuerpo extraño en pacientes pediátricos en un hospital de tercer nivel y factores asociados

Introduction and aimsForeign body (FB) ingestion is a common problem in children under 5 years of age and is one of the main indications for endoscopy. The aim of the present study was to describe the clinical, radiographic, and endoscopic characteristics of patients with FB ingestion, as well as the factors associated with the anatomic location and the type of object ingested.Materials and methodsAn analytic cross-sectional study was conducted on all patients with FB ingestion seen at the gastroenterology service from January 2013 to December 2018. The data were analyzed using the SPSS program, obtaining frequencies, percentages, medians, and interquartile ranges. Associations were assessed through the chi-square test.ResultsEighty-five patients (52 males and 33 females) were included, with a median age of 4 years. The most common symptom was vomiting (29.4%). Two radiographic projections were carried out in 72.9% of the cases and the stomach was the site where the FB was most frequently visualized (32.9%). The objects most commonly ingested were coins (36%), with esophageal location (p < 0.05), as well as objects with a diameter larger than 2 cm (p < 0.05). An endoscopic procedure was performed on 76 patients (89.4%) for FB extraction, with findings of erythema (28.9%), erosion (48.6%), ulcer (10.5%) and perforation (1.3%).ConclusionsNumerous factors should be taken into account in the approach to FB ingestion in pediatric patients, including type and size of the FB, time interval from ingestion to hospital arrival, and patient clinical status and age.     

A sewing needle in the liver in children: A case report and literature review

Rationale:In clinical practice, foreign bodies (FBs) in the digestive tract are more common in children, but intrahepatic FBs are rare, especially those that can cause infection, bleeding, bile leakage, and other complications. However, there is no consensus on its diagnosis and treatment due to the lack of large-scale cohort studies.Patient concerns:Case 1 is a 4-years 8-months-old girl, who at the age of 10 months, showed an X-ray finding of a striped FB in her liver, with no symptoms. However, the patient’s parents refused surgery. After nearly 4 years of active surveillance, the patient visited our hospital for surgery. Case 2, a 2-year-old male, reported a sewing needle that completely pierced into the right upper abdomen due to an accidental fall that took place half-a-day before admission. He only had right upper abdominal pain. CT showed a striped FB in the liver.Diagnosis:FB in the liver (sewing needle).Interventions:Both the patients were injected with human tetanus immunoglobulin and underwent surgical removal.Outcomes:Both patients recovered smoothly and had no complications during follow-up.Lessons:Active surveillance might be considered for cases with no symptoms or complications and no displacement of the FB, but surgery should be the first choice. If the patient’s condition is complicated, it is recommended to use ultrasound or X-ray to help decision-making during the operation. Additionally, tetanus, child safety, and family education are important supportive measures.     

Intraductal oncocytic papillary neoplasm of the pancreas: A systematic review

BackgroundIntraductal oncocytic papillary neoplasm of the pancreas (IOPN–P) is a rare subtype of intraductal papillary mucinous neoplasm (IPMN). This study was performed to summarize the clinicopathological features and management of IOPN-P.MethodsEnglish-language articles were searched from MEDLINE and EMBASE from the first report of IOPN-P in 1996 until 1 May 2019 following the methodology in the PRISMA guidelines.ResultsIn total, 66 patients from 24 full articles were included in the final data analysis. The patients’ average age was 61 years, and the male/female ratio was 1. Most lesions were large (average size, 5.50 cm), located in the pancreatic head, and found either incidentally or by uncharacteristic abdominal symptoms. IOPN-P was usually a cystic and solid lesion with or without mural nodules on radiological examination. A definitive diagnosis was often acquired from fine needle aspiration biopsy or postoperative pathology. All tumors were diagnosed as carcinoma in situ or minimally invasive carcinoma, necessitating surgical resection. The prognosis of IOPN-P was better than that of other IPMN subtypes, even when metastasis occurred. Recurrence after surgical resection of IOPN-P was rare.ConclusionsIOPN-P is rare among IPMN subtypes with unique pathological characteristics. Because of the nontypical symptoms and radiological findings, a definitive preoperative diagnosis usually depends on multimodal examinations. Management and surveillance of IOPN-P after surgical resection should be differentiated from those of other pancreatic benign cystic lesions because of its relative malignancy, but IOPN-P should also be differentiated from other IPMN subtypes and malignant cystic tumors because of its favorable prognosis.