PEDIATRICS Vol. 107 No. 6 June 2001, pp. 1497

Esophageal Coins

To the Editor.

Soprano and Mandl's decision analytic comparison of 4 esophageal coin management strategies¹ is an important contribution toward integrating cost-effectiveness into the management of this common problem. This article suggests that, in low-risk patients, less commonly used alternatives to endoscopic coin removal may be cheaper and have fewer complications, confirming earlier findings.² However, important limitations in the present study's decision analytic model weaken the authors' conclusions.

As the authors state, the Foley catheter method is a leading alternative to endoscopic coin removal; for selected patients, it may be cheaper and safer.² The omission of consideration of the Foley catheter method from the model, however, leaves those interested in its use without guidance. Also omitted from the model is the sensible strategy of observation to allow spontaneous coin passage, followed by bougienage if the coin remains in the esophagus; in the unlikely event of unsuccessful bougienage, the child would then undergo endoscopy. This strategy combines the safety and cost savings of both observation and bougienage, especially if bougienage is performed in the first 24 hours after coin ingestion.³

The study model assumes that patients who are to undergo endoscopy do so instantly. A model more consistent with usual hospital practice would assume a few hours' delay between identifying esophageal coins in low-risk patients and their endoscopic removal. This is important because many esophageal coins will pass spontaneously into the stomach during this interim period,^4,5 making endoscopy unnecessary and dramatically reducing the high cost attributed to endoscopy under the study model.

Not all complications of removal methods are of equal importance. Although the authors calculate the probability of complications of the removal methods, there is no attempt to categorize them by magnitude. Clinicians would be better informed if minor or transient complications were weighted differently in the study model from more severe ones. A justification for the universal assignment of a cost-to-charge ratio of .72 would also enhance the discussion.

Finally, the study model uses a success rate for bougienage of 100%, based on 2 published case series.^6,7 A recent report of bougienage for esophageal coin removal in low-risk patients reported a success rate of 83% (10/12); as in previous studies, no complications were reported.⁸

In summary, the model presented by Soprano and Mandl seems overly simplistic, despite their appropriate sensitivity analysis. Results from a more comprehensive model would be more useful when making practice decisions.

Gregory P. Conners, MD, MPH, FAAP
Departments of Emergency Medicine and Pediatrics
University of Rochester School of Medicine and Dentistry
Rochester, NY 14642

REFERENCES

1. Soprano JV, Mandl KD. Four strategies for the management of esophageal coins in children. Pediatrics. 2000;105(1). URL: http://www.pediatrics.org/cgi/content/full/105/1/e5
2. Conners GP A literature-based comparison of three methods of pediatric esophageal coin removal. Pediatr Emerg Care. 1997; 13:154-157 [Medline]
3. Bonadio WE, Emslander H, Milner D, Johnson L Esophageal mucosal changes in children with an acutely ingested coin lodged in the esophagus. Pediatr Emerg Care. 1994; 10:333-334 [Medline]
4. Conners GP, Chamberlain JM, Ochsenschlager DW Symptoms and spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med. 1995; 149:36-39 [Abstract/Free Full Text]
5. Soprano JV, Fleisher GR, Mandl KD The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med. 1999; 153:1073-1076 [Abstract/Free Full Text]
6. Bonadio WA, Jona JZ, Licklich M, Cohen R Esophageal bougienage technique for coin ingestion in children. J Pediatr Surg. 1988; 23:917-918 [Medline]
7. Emslander HC, Bonadio W, Klatzo M Efficacy of esophageal bougienage by emergency physicians in pediatric coin ingestion. Ann Emerg Med. 1996; 27:726-729 [CrossRef][Medline]
8. Calkins CM, Christians KK, Sell LL Cost analysis in the management of esophageal coins: endoscopy versus bougienage. J Pediatr Surg. 1999; 34:412-414 [CrossRef][Medline]