Iatrogenic esophageal perforation in infants: how to avoid thoracotomy? Two case reports

Abstract

Background: Esophageal perforation is uncommon and often iatrogenic in the neonatal period, and premature and low birth weight infants (<1500 g) are particularly susceptible. Esophageal injury in neonates usually occurs at the pharyngoesophageal junction and can be confused with esophageal atresia due to respiratory signs and excessive salivation. Diagnostic evaluation and treatment are still debated. 
 Case Presentation: This case report aims to describe two neonatal cases of iatrogenic esophageal perforation. The suspected diagnosis was confirmed only with thoracotomy. Diagnostic difficulties and therapeutic modalities are discussed. 
 Conclusion: These two cases show the importance of the clinical clues (anamnesis and clinical findings) to suspect the diagnosis of esophageal perforation.

Iatrogenic Esophageal Perforation in Preterm Neonate Managed Conservatively

“…Esophageal perforation injury divided to three patterns pseudodiverticulum, mucosal perforation where limited extravasation extends posteriorly in a blind-ending submucous tract, and full-thickness esophageal injury with free intrapleural leak of air/esophageal contents [2,10]. Proximal esophageal perforation normally gives signs and radiological abnormalities on the left side of chest radiograph while distal perforation gives signs and radiological abnormalities on the right [3,7]. Most common causes of injury to the esophagus are iatrogenic injuries and account for up to 73% of the cases in reported series [6,11,12].…”

“…Moreover, there is considerable narrowing of the esophagus in this region [6,9]. Chest radiography is the most reliable modality for confirmation of nasogastric tube position seeing the tip of the tube is positioned below the level of the gastroesophageal junction [3,7]. The abnormal position of the nasogastric tube on the chest radiograph easily suggested perforation of the esophagus.…”

“…[3,4] Over the past decade, a shift from an urgent surgical intervention to more wise, nonsurgical management of esophageal perforation in selected adult patients has been reported. [5,6] In children although the most important prognostic factor is the time span between the injury and the initiation of treatment, The experience in managing esophageal perforation, especially in extremely low-birthweight infants, is relatively lacking [3,7]. We described one case of probable iatrogenic esophageal perforation was adequately managed by watchful waiting for 2 weeks of broad-spectrum antimicrobial therapy.…”