Not all swallowed foreign bodies require endoscopic extraction. On the contrary, most will be discharged naturally. From pre-endoscopic times, we know that the spontaneous discharge rate is higher than 80% (Longstreth et al. 2001). However, there are emergency situations demanding immediate action for the removal of ingested foreign bodies (◘ Table 8.1). Commonly these are objects where size and/or composition are likely to create injuries to the GI tract or where a spontaneous discharge is highly questionable. Foreign bodies that get stuck in the esophagus may cause ulcerations and subsequent perforation, with eventually deadly mediastinitis. A special situation is seen following the suicidal ingestion of quetiapine (Seroquel, AstraZeneca). But also magnets, with or without metal pieces, may cause pressure sores. Button-shaped batteries may erode their thin covering and provoke chemical burns. Especially in kids, larger batteries of this type can also provoke electrical problems (◘ Fig. 8.3).

Most endoscopic extractions require a standard sedation. Therefore, in addition to the staff member responsible for the surveillance of sedation, one additional auxiliary person is necessary. In cases with complete obstruction of the esophagus and total aphagia, the primary prophylactic endotracheal intubation to prevent aspiration is strongly indicated. Also in children, adequate maintenance by an anesthesiologist is advisable.

The vast variety of possible foreign bodies has demanded the development of multiple helpful instruments for the recovery of all types of items. Whenever feasible, the adequate instrument should be tested for its efficacy before the actual endoscopy by manipulation of a similar foreign body. The choice includes all types of forceps, polyp graspers, slings, and Dormia baskets. The use of a recovery bag may be very helpful (◘ Fig. 8.4). When dealing with objects with sharp edges, sufficient protection of the mucosa is mandatory. For this purpose, overtubes or protective caps are the solution. In particular with small objects that might be lost in the hypopharynx and aspirated, overtubes are a proven safety feature (◘ Fig. 8.5).

First, the urgency of an endoscopic intervention has to be judged. From there, the choice of procedure and the contents of the informed consent have to be determined. The success of the endoscopic recovery is essentially depending upon the correct selection of adequate instruments which — together with alternatives — have to be available and must be mastered. Protection from iatrogenic injury and aspiration is of highest priority and must be taken into account prophylactically as well by having additional tools available and providing preparations for anesthesia. In addition, management of potential complications such as bleeding or bronchoscopy in case of aspiration should be prepared for.

Whenever possible, a pre-interventional practical test of usefulness and handling of the chosen tools should be done on a similar object, since this will facilitate the procedure considerably. Due to the type and consistency of the foreign object, possible complications and counteractions have to be taken into account (securing airways, protecting mucosa in sharp items).