Esophageal foreign body removal by thoracotomy in a patient with aberrant right subclavian artery

Foreign bodies in the thoracic esophagus can usually be removed by an endoscopist. However, a sharp foreign body placed between large arteries can be difficult and troublesome even for a skilled endoscopist. In such cases, thoracotomy may be required.
A 57-year-old man was referred to our emergency center from a local clinic. After having a fish for his lunch one day before, the patient complained of having sore throat, odynophagia, and substernal chest pain. Emergency gastrofiberscopy revealed a fish bone stuck transversely at the upper thoracic esophagus (Figure 1). There was no retained food material, and neither side of the esophageal wall (piercing site) had signs of inflammation. Chest X-ray did not show any abnormal findings. Chest computed tomography showed a calcified bone located between the aortic arch and an aberrant right subclavian artery which originates from the distal aortic arch distal to the origin of the left subclavian artery. This artery runs under and around the esophagus to the right arm (Figure 2). Laboratory findings were generally normal, except for a slightly elevated white blood cell count (15,000/µl) and C-reactive protein (56 mg/l). Body temperature was normal. As the foreign body removal by an endoscopist was considered difficult and dangerous, the patient was referred to a thoracic surgeon for emergent thoracotomy.
The patient was placed in the lateral decubitus position with a double lumen endo-bronchial tube. Right mini-thoracotomy (10 cm length) was performed through the 4th intercostal space without the 5th rib division. The pleural cavity was entered, and little signs of infection were found. To locate the foreign body, the upper thoracic esophagus was mobilized by making an incision at the mediastinal pleura and dissecting the azygous vein, superior vena cava, and aberrant subclavian artery away from the esophagus. Fortunately, we managed to locate the bone without making an esophagotomy by finger palpation of one end of the fish bone. The bone was successfully pulled out by grabbing the end of the bone with a forceps. The bone was about 3 cm long and 2 mm thick with needle-sharp ends (Figure 3). As there were no signs of infection or inflammation, the perforation site was simply closed with a single polydioxanone 4-0 suture. After bleeding control and thorough irrigation, the thorax was closed layer by layer with a chest tube in place. Oral intake was started 5 days after the operation, and the...


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