Alkaline battery-induced tracheo-oesophageal fistula

Abstract

The rapid propagation of small electronic gadgets and toys controlled by alkaline batteries has brought these potentially lethal objects within the reach of small children whose natural instinct is to put everything into the mouth. Tracheooesophageal fistula caused by alkaline battery ingestion is a rare complication but highlights the hazards of ignoring these foreign bodies. Case reportA 16-month-old girl was admitted with dysphagia of 4 weeks' duration. Chest radiography showed a coin-shaped foreign body in the upper oesophagus ( Figure I ) , which was removed endoscopically. The object was a 1-cm diameter watch battery which the child had swallowed several weeks earlier.Postoperatively, the child continued to have feeding problems which failed to resolve with nasogastric feeds. A barium swallow showed a large tracheo-oesophageal fistula at the level of the thoracic inlet ( Figure 2). Nasogastric feeding was continued, and chest physiotherapy and antibiotics were commenced to improve her nutritional and respiratory status.Three weeks later, via a right-sided cervical approach, a I-cm diameter fistula was found between the trachea and the oesophagus. The fistula was divided and the defects repaired with 4-0 silk sutures. A postoperative oesophageal leak closed spontaneously, and a repeat contrast study was satisfactory. Oral feeding was re-established, but 6 weeks later the child was readmitted with a radiologically confirmed recurrent fistula.Re-exploration revealed a 3-mm diameter tracheo-oesophageal fistula which was divided. The trachea and oesophagus were completely separated over a 5-cm length and the defects were repaired with 4-0 polydiaxonone sutures. A 5-cm square patch of GORE-TEX" (W. L. Gore and Associates Incorporated) was laid in between the trachea and oesophagus and was sutured to the trachea.A temporary oesophageal leak occurred after operation but a contrast study 6 weeks later failed to detect recurrence of the fistula. The symptoms of coughing with feeds persisted and a repeat study confirmed a second recurrence of the tracheo-oesophageal fistula. The child was then referred to the Hospital for Sick Children, Great Ormond Street, for further management.The recurrence of the tracheo-oesophageal fistula was confirmed endoscopically. A ureteric catheter was passed into the oesophagus through the fistula at bronchoscopy, via a transverse cervical incision; the trachea and oesophagus were exposed with considerable difficulty because of dense fibrosis and the fistula was identified. The tracheal defect was repaired with interrupted 4-0 Prolene(* (Ethicon Ltd., Edinburgh, UK) sutures. A 3-cm length of oesophagus including the fistula was resected and an end-to-end anastomosis was performed in two layers with 4-0 polyglycolic acid sutures. Omohyoid muscle was mobilized and placed between the trachea and oesophagus.Repeat endoscopy at 3 weeks confirmed successful repair. The child remains symptom-free 9 months after operation.

Acquired tracheoesophageal fistula following disc-battery ingestion: Can we watch and wait?

“…Several cases of spontaneous TEF closure after disc-battery ingestion have been reported leading some authors to advocate conservative management with esophageal rest as an alternative to surgical repair [5,[10][11][12][13][14][15]. The current study describes a situation in which spontaneous closure of an acquired TEF was confirmed by endoscopy and esophageal contrast studies after 70 days of esophageal rest.…”

“…However, immediate surgical intervention can be complicated by high mortality rates, recurrence and the need for multiple procedures [2,8,9]. Thus, several authors have advocated the use of conservative management for acquired TEF following reports of spontaneous closure by secondary intention [5,[10][11][12][13][14][15]. Esophageal rest with reflux precautions, no oral intake, and a diet supplied by gastrostromy, nasogastric, or gastro-jejunal tube feeds, comprise the conservative management in such patients.…”

Tracheoesophageal fistula secondary to disk battery ingestion: a case report of gastric interposition and tracheal patch

“…The other approach aims to preserve esophageal continuity with primary repair. Although delayed repair may allow some fistulae to heal spontaneously, the procedure may be more technically difficult, with a higher probability of recurrent fistula [11] or stenosis [5,[7][8][9]. Because of the extensive destruction of esophagus in this case, primary esophageal repair or resection and anastomosis were not achievable, and esophagectomy with gastric interposition was performed in the acute phase.…”

Swallowed Foreign Bodies in Children: Aspects of Management

“…17 They can pass through the gastrointestinal tract without adverse effects but may become lodged in the gut, leading to ulceration, necrosis and perforation. There have been reports of tracheoesophageal fistula 18 and Meckel diverticulum perforation 19 secondary to disc battery ingestion. These are attributed to pressure necrosis, corrosive toxic contents and short circuit burns.…”