Case 1

A 1.5 yr old spayed female mixed-breed dog was presented to the Randall B. Terry, Jr. Companion Animal Veterinary Medical Center at North Carolina State University College of Veterinary Medicine for a suspected esophageal fishhook foreign body. Prior to presentation, the dog ingested a fishing line. Excess fishing line was cut, and the dog was sent for immediate medical attention. Radiographs at a local emergency clinic revealed a single barbed fishhook foreign body caudal to the cardiac silhouette. The hook measured 4.5 × 1.7 cm. The fishhook was positioned so that the curved portion was cranial within the caudal mediastinum and the eye of the hook and barb were pointing caudally. The barbed point was facing rightward and dorsal on thoracic radiographs, but the entirety of the hook was within the left side of the thorax on the ventrodorsal projection. Upon arrival to the referral hospital, general physical examination was within normal limits. Presurgical serum chemistries and complete blood count were within normal limits. A three-view thoracic radiographic study was performed to assess the current location of the foreign body, which appeared unchanged from the radiographic study performed 4 hr earlier by the referring veterinarian (Figure 1). Mild pneumothorax and pneumomediastinum were noted on both sets of radiographs, consistent with esophageal perforation.

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The patient was premedicated with intravenous fentanyl^a and anesthetized with propofol^b. Preendoscopic antibiotics were not administered. The dog was endotracheally intubated and anesthesia was maintained with isoflurane^c in 100% oxygen. Mechanical ventilation was used intermittently during both endoscopy and surgery at the discretion of the anesthesiologist. A continuous rate infusion of fentanyl^a was continued during the perioperative period for pain control. Upper gastrointestinal endoscopy^d was performed; however, due to the proximity of the fishhook to the lower esophageal sphincter, and the inability to visualize the entirety of the hook (only the eyelet of the hook and attached fishing line were visible within the lumen of the esophagus), endoscopy was aborted. In preparation for surgery, cefazolin^e was administered (22 mg/g IV) and redosed once every 90 min perioperatively.

The dog was placed in right lateral recumbency, and a standard surgical preparation was performed using standard surgical scrub^f. Based on the leftward positioning of the barb of the fishhook on the radiographs and endoscopic visualization of the fishing line exiting the left esophageal wall, a left eighth intercostal thoracotomy was performed. The eighth intercostal space was selected based on the craniocaudal position of the fishhook. Following gentle cranial retraction of the left caudal lung lobe, the fishhook was palpated exiting the esophagus ∼1 cm cranial to the diaphragm within the caudal mediastinum. A small volume of hemorrhagic fluid was released upon incision into the mediastinum overlying the fishhook. The hook was visualized to be exiting the esophagus and penetrating the left caudal pulmonary artery. The hook was held immobile using two needle drivers while the center was cut using pin cutters. This maneuver allowed the straight portion of the fishhook with the incorporated eyelet and fishing line to fall into the esophageal lumen for endoscopic retrieval following surgery. The esophageal wall was inspected, and no defects large enough to warrant closure could be identified; therefore, no sutures were placed over the area of perforation. The barbed end was gently released. A Satinsky clamp was placed tangentially across the pulmonary artery, ensuring both continuing vessel patency and hemostasis, and the hook was gently extracted from the artery and removed. The resulting defect in the pulmonary artery was over-sewn using 5-0 polypropylene^g in a simple continuous pattern. The Satinsky clamp was slowly released, and minor hemorrhaging was noted. The clamp was replaced, and an additional simple interrupted suture was placed at the site of hemorrhage using 5-0 polypropylene. The clamp was again released, and no further hemorrhage was noted. Following placement of a 14-French chest tube^h, the thoracotomy was closed routinely. Endoscopic retrieval of the remainder of the fishhook was uneventful, and the dog recovered in the intensive care unit uneventfully. The chest tube remained in place for 18 hr postoperatively to monitor for hemorrhage and pneumothorax, and the dog was discharged from the hospital 36 hr later with a transdermal fentanyl patchⁱ (25 µg) and carprofen^j (2.2 mg/kg per os [PO] q 12 hr). At the 2 wk suture removal appointment, physical examination was unremarkable, and the dog was returned to normal activity.

Case 2

A 3 yr old spayed female Labrador retriever was presented to the Randall B. Terry, Jr. Companion Animal Veterinary Medical Center at North Carolina State University College of Veterinary Medicine for a suspected esophageal fishhook foreign body. The owner initially witnessed the dog pawing at the face while on a walk, then found fishing line extending from the mouth. The line was cut, and the dog taken to a local emergency clinic, where radiographs revealed a single barb fishhook caudal to the cardiac silhouette. The hook measured 4.5 × 1.7 cm. The hook was positioned so that the curved portion was positioned cranially, and the eye of the hook and barb were positioned caudally within the caudal mediastinum. The barbed end was facing slightly leftward and ventral on thoracic radiographs. No pneumomediastinum or pneumothorax was noted. On presentation to the referral hospital, general physical examination was within normal limits. Presurgical serum chemistries and complete blood count were within normal limits. A three-view thoracic radiographic study was performed to assess the current location of the foreign body, which appeared unchanged from the radiographic study performed 6 hr before by the referring veterinarian.

The dog was premedicated with intravenous hydromorphone^k and anesthetized with propofol^b. The dog was endotracheally intubated and anesthesia was maintained with isoflurane^c in 100% oxygen. Mechanical ventilation was used intermittently during both endoscopy and surgery at the discretion of the anesthesiologist. A continuous rate infusion of fentanyl^a was used in the perioperative period for pain control. Based on the location of the fishhook on the radiographs and history of swallowing the fishhook prior to presentation, endoscopy^d was performed to confirm the location of the fishhook within the esophagus and attempt extraction. The fishing line could be seen exiting the esophageal mucosa, but the fishhook could not be visualized endoscopically, so extraction of the fishhook was not attempted. Due to the inability to visualize the fishhook within the esophageal lumen, and based on its radiographic location towards the left side of the mediastinum, the dog underwent a left eighth intercostal space thoracotomy following routine surgical preparation using standard surgical scrub^f. Cefazolin^e was administered (22 mg/g IV) and redosed once every 90 min perioperatively. The eighth intercostal space was chosen based on the craniocaudal position of the fishhook on the radiographs. After gentle cranial traction of the left caudal lung lobe, the fishhook was palpated within the mediastinum caudal to the heart and ∼1 cm cranial to the diaphragm. The mediastinum was incised over the fishhook, and the hook was visualized to be partially embedded within the left caudal pulmonary artery. The entire fishhook was within the caudal mediastinum, and the fishing line could be seen penetrating the esophagus. The hook was held immobile using two needle drivers while the center was cut using pin cutters. This maneuver allowed the straight portion of the fishhook with the incorporated eyelet to be removed without pulling the eyelet or the barb through the wall of the pulmonary artery. The fishing line was cut and allowed to fall into the esophageal lumen for endoscopic retrieval following surgery. The esophageal wall was inspected, and no defects large enough to warrant closure were noted; therefore, no sutures were placed over the area of perforation. The barbed end was gently released. A purse string suture using 5-0 polypropylene^g was placed in the pulmonary artery around the fishhook. The fishhook was gently extracted from the pulmonary artery and the purse string tightened to close the resultant defect in the arterial wall. Minor hemorrhaging was noted during extraction of the fishhook, but not following tightening of the purse string suture, and no additional sutures were necessary. Following placement of a 14-French chest tube^h, the thoracotomy was closed routinely. Endoscopic retrieval of the fishing line was successful, and the dog recovered uneventfully in the intensive care unit. The chest tube remained in place for 24 hr postoperatively to monitor for hemorrhage and pneumothorax. The dog was discharged from the hospital 48 hr later with a transdermal fentanyl patchⁱ (50 µg), carprofen^j (2.2 mg/kg PO q 12 hr), tramadol^l (3 mg/kg PO q 8–12 hr), and omeprazole^m (1.2 mg/kg PO q 24 hr). At the 2 wk suture removal appointment, physical examination was unremarkable, and the dog was returned to normal activity.