We retrospectively reviewed the clinical data of patients admitted with sharp EFBs to Wuhan Central Hospital between January 2017 and June 2023. A patient flowchart is provided in Figure 1. Inclusion criteria were: (1) Patients aged ≥65 years old. (2) Diagnosis of a sharp EFB (defined as a hard object with sharp edges) confirmed by digestive endoscopy or computed tomography (CT) scan after admission. (3) The foreign body remained impacted in the esophagus during treatment. (4) The patient or their family provided consent for treatment. Exclusion criteria were: (1) No EFB identified on imaging or endoscopy. (2) Patient withdrew from or refused treatment. All patients or their families in this study signed informed consent forms. This study was reviewed and approved by the Ethics Committee of Wuhan Central Hospital (No. WHZXKYL2023-185).

After screening, a total of 58 patients were included in the final analysis. Patients were divided into an endoscopic treatment group (n = 43) and a surgical treatment group (n = 15) based on their presenting clinical severity and the presence of complications.

Upon presentation, a detailed history of foreign body ingestion was recorded. All patients underwent diagnostic imaging to confirm the diagnosis. In our cohort, 5 patients (8.6%) underwent a barium meal examination, all 58 patients (100%) had a CT scan, and 53 patients (91.4%) underwent digestive endoscopy for diagnosis or treatment. Body temperature and white blood cell count were monitored to assess for infection. Based on imaging, endoscopy, and surgical findings, the degree of esophageal injury was classified as mucosal injury, ulcer, perforation, or peri-esophageal abscess.

The decision to proceed with endoscopic or surgical treatment was made by a multidisciplinary team including the attending thoracic surgeon and endoscopist based on a comprehensive clinical evaluation. Generally, endoscopic removal was the first-line approach for all patients. Surgical intervention was indicated for patients who met one or more of the following criteria, indicating severe clinical conditions: (1) Radiological evidence of esophageal perforation with extraluminal contamination (e.g., mediastinitis, para-esophageal abscess, or significant pneumomediastinum); (2) Clinical signs of sepsis or hemodynamic instability; (3) Failure of endoscopic removal, defined as the inability to safely dislodge and extract the foreign body without causing further esophageal injury; or (4) High suspicion of major vascular injury based on preoperative CT imaging. All endoscopic procedures were performed by senior endoscopists with at least 10 years of experience, using standard flexible gastroscopes (Olympus GIF-Q260J). The choice of endoscopic removal tool (e.g., foreign-body forceps, snare, or basket) was at the discretion of the endoscopist based on the EFB’s shape, size, and location. To ensure safe extraction and protect the esophageal mucosa and pharynx from injury during retrieval, a protective overtube was used at the discretion of the endoscopist, particularly for larger or irregularly shaped sharp objects. Endoscopic failure, which necessitated conversion to surgery, was documented in cases where the foreign body could not be visualized, grasped, or safely removed without significant risk of mucosal tearing or perforation, as judged by the attending endoscopist. For patients undergoing successful endoscopic treatment, post-procedural management depended on the extent of esophageal injury. Patients with minor mucosal damage were managed with a liquid diet, while those with suspected or contained perforation without significant infection received nasogastric tube feeding. Surgical treatment involved foreign body removal, esophageal repair, debridement of abscesses, and placement of drainage tubes, with additional interventions as needed for complications.

The analysis indicators included: (1) Basic patient information: age, gender, comorbidities. (2) Admission-related indicators: EFB type, degree of esophageal injury, fever (axillary temperature >37.3 °C), white blood cell count (normal range: 3.5–9.5 × 10⁹/L), time from onset to admission, hospital stay, and pain score (Visual Analogue Scale). Pre-existing esophageal-related diseases included conditions such as esophageal stenosis, a history of esophageal cancer (post-treatment, no active disease), or severe reflux esophagitis. Abnormal swallowing function was primarily identified by the clinical symptom of dysphagia, as reported in the patient’s history. (3) Quality of life comparison: We compared the functional status (Barthel Index total score) between the two groups at admission, at discharge, and 1 month post-procedure. The Barthel Index was used to assess the impact of the event and treatment on patients’ functional independence in activities of daily living (ADL), a critical outcome in geriatric populations. While not a direct measure of disease-specific quality of life, it provides valuable insight into the broader functional recovery (11).

Data analysis was conducted using SPSS 23.0 software. Normally distributed data are expressed as mean ± standard deviation (Mean ± SD) and compared using an independent sample t-test. Non-normally distributed data are represented by the median (interquartile range, IQR) and compared using the Mann–Whitney U test. Count data are expressed as n (%) and compared using the chi-square test or Fisher’s exact test. Effect sizes were calculated: odds ratios (OR) with 95% confidence intervals (CI) for categorical data, Cohen’s d for t-tests, and Rosenthal’s r for non-parametric comparisons. To identify independent predictors of requiring surgical treatment, a binary logistic regression analysis was performed. Variables that were statistically significant in the univariate analysis (p < 0.05) were included in the multivariable model. A p-value <0.05 was considered statistically significant.

The types of sharp objects included jujube pits, fish bones, bullfrog bones, poultry bones, and pig bones. Fish bones (n = 35, 60.3%) and jujube pits (n = 15, 25.9%) were the most common. The incidence rates of bullfrog bones, poultry bones, and pig bones were 2 (3.4%), 4 (6.9%), and 2 (3.4%), respectively (examples are shown in Figure 2).

The baseline characteristics of the 58 patients are compared in Table 1. There were no significant demographic differences between groups (p > 0.05). However, patients in the surgical group had a significantly longer median pre-hospital delay compared to the endoscopic group [3.00 (IQR 1.00, 4.00) days vs. 0.50 (IQR 0.19, 1.00) days; p < 0.001]. A significantly higher proportion of patients in the surgical group presented with fever (60.0% vs. 4.7%; p < 0.001) and an abnormal white blood cell count (46.7% vs. 16.3%; p = 0.031) at admission.

Sharp object impaction occurred most frequently in the upper esophagus in both groups, with no significant difference in location (p > 0.05) (Table 2). The median pain score was significantly higher in the surgical group [3.00 (IQR 3.00, 3.00)] compared to the endoscopic group [2.00 (IQR 1.00, 3.00); p = 0.003]. The effect size (Rosenthal’s r = −0.39) indicates a medium-sized effect, where the negative correlation signifies that the surgical group (coded as the higher value group) was associated with higher pain scores. There was a significant difference in esophageal injury severity: all 15 patients (100%) in the surgical group had esophageal perforation or a peri-esophageal abscess, compared to only 11 of 43 patients (25.6%) in the endoscopic group (p < 0.001) (Table 2). Among the 15 surgical cases, 5 underwent right thoracotomy, 7 required a cervical incision after failed endoscopic attempts, and 3 had other surgical approaches.

There were no significant differences in dental status between the groups (p > 0.05) (Table 3). However, comorbidities were strongly associated with treatment selection. Patients requiring surgery were significantly more likely to have pre-existing esophageal-related diseases (53.3% vs. 14.0%; p = 0.004) or present with dysphagia (20.0% vs. 2.3%; p = 0.041) compared to those managed endoscopically (Table 4).

To identify independent predictors for requiring surgical intervention, a binary logistic regression analysis was performed. The variables included were pre-hospital delay, fever at admission, abnormal WBC count, dysphagia, and pre-existing esophageal disease. The analysis, summarized in Table 5, revealed that a longer pre-hospital delay (OR 2.55, 95% CI [1.29–5.04]; p = 0.007) and the presence of fever at admission (OR 15.8, 95% CI [3.01–82.9]; p = 0.001) were significant independent predictors for the necessity of surgical treatment. Other factors did not retain statistical significance in the multivariable model.

All patients were discharged without major complications. As shown in Table 6, endoscopic treatment was associated with a significantly shorter hospital stay (mean 4.30 vs. 13.73 days; mean difference −9.43, 95% CI for difference [−12.50, −6.36]; p < 0.001, Cohen’s d = −2.18). While functional status at admission was similar between groups (p = 0.429), the endoscopic group had significantly higher Barthel Index scores at discharge (mean 89.53 vs. 76.00; mean difference 13.53, 95% CI [3.78, 23.28]; p = 0.008) and at 1 month post-procedure (mean 100.00 vs. 97.00; mean difference 3.00, 95% CI [1.88, 4.12]; p < 0.001). At the 6-month follow-up, four patients in the surgical group reported minor residual symptoms (e.g., occasional dysphagia or retrosternal discomfort), compared to two in the endoscopic group. All symptomatic patients underwent a follow-up gastroscopy, which revealed mild esophageal mucosal inflammation without evidence of stenosis or residual foreign bodies; they were managed conservatively with proton pump inhibitors.