Fragment First, Remove Second: Laser-Assisted Management of Transversely Impacted Esophageal Foreign Bodies – A Three-Case Series

Transversely impacted esophageal foreign bodies with bilateral wall embedment represent a dangerous and technically challenging subset of endoscopic emergencies. In this configuration, direct extraction risks worsening mural injury or converting a contained perforation into a free perforation. We report three patients with complex transversely impacted foreign bodies managed using Holmium:YAG laser-assisted fragmentation. The procedure was performed using a Holmium:YAG laser (Auriga system) delivered through a 365-µm fiber, with energy settings of up to 2.0 J at 8 Hz (16 W), adjusted according to the composition and response of the foreign body. Fragmentation was carried out in near-contact mode under direct visualization with care to avoid mucosal injury. A denture requiring staged fragmentation (approximately 5,000 laser applications), a V-shaped bone requiring division of one limb (approximately 100 applications), and a long linear bone divided centrally (approximately 50 applications) were successfully removed endoscopically. In one case, a double-channel endoscope was used for simultaneous stabilization and laser application. Two of three patients (66.7%) were found to have esophago-respiratory fistulas following foreign body removal. Both healed completely with conservative management within 60 to 90 days, and no patient required surgical intervention. Laser-assisted fragmentation enables controlled in situ division, reduces extraction forces, and facilitates safe removal in otherwise high-risk cases.