To the Editor,

I send this letter in relation to the article published by Malick (2013) titled "Endoscopic Management of Ingested Foreign Bodies and Food Impactions." While I congratulate the author on her article, I disagree completely with the information about "when not to do endoscopy."

In my limited experience, I believe that endoscopic treatment of internal concealment of illegal drugs is safe and effective in selected cases as some authors describe in the literature. This is certainly controversial, because some authors consider endoscopic treatment contraindicated on the basis of the risk of puncturing the package and causing acute poisoning because of the externalization of the drug contained, whereas others consider endoscopy safe based on their own experience (De Bakker et al., 2012).

In 1990, Sherman and Zingler (1990) published the first case of a body-packer treated by endoscopy. Since then, only isolated cases of this therapeutic alternative have been described but with satisfactory results and without complications (Choudhary, Taubin, Gupta, & Roberts, 1998; Mandava et al., 2011; Sherman & Zingler, 1990).

I believe that the shortage of cases treated using endoscopic removal is motivated by three main reasons. First is the risk of perforation associated with endoscopic treatment with subsequent acute poisoning. It is important to know what type of drug the patient is concealing. For instance, hashish (Cannabis sativa) has a lower risk of perforation and its toxicity is less severe than that of other substances such as cocaine or heroin. Second, it is relatively rare that foreign bodies are located in the gastric chamber at the moment of diagnosis, which limits the possibilities of successful endoscopic treatment. Finally, body-packers usually eat plenty of packages so it is very rare that all are located in the same location. Even in the unlikely event that one was located in the stomach, if the patient has others that have made it through the pylorus and require surgical removal by enterotomy, this would be a relative contraindication for endoscopic removal.

Luis Tallon-Aguilar, PhD, MD

General Surgery Department

Hospital Infanta Elena

Huelva, Spain

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