Button battery removed from the stomach resulting in a missed aortoesophageal fistula - a multidisciplinary approach to rescuing a very young patient: a case report

Esophago-Vascular Fistulae in Children: Five Survivors, Literature Review, and Proposal for Management

INTRODUCTION

Esophago-vascular fistulae in children are almost uniformly fatal with death occurring by exsanguination. We present a single centre series of five surviving patients, a proposal for management and literature review.

MATERIALS AND METHODS

Patients were identified from surgical logbooks, surgeon recollection and discharge coding data. Demographics, symptoms, co-morbidities, radiology, management and follow up details were recorded.

RESULTS

Five patients (1M, 4F) were identified. Four were aorto-esophageal and one caroto-esophageal. Median age at initial presentation was 44 (8-177) months. Four patients had cross sectional imaging prior to surgery. Median time from presentation to combined entero-vascular surgery was 15 (0-419) days. Four patients required repair on cardio-pulmonary bypass with four undergoing staged surgical procedures. All required combined esophageal and cardio-vascular surgery. Length of PICU stay following combined surgery was 4 (2-60) days and overall hospital stay was 53 (15-84) days. Median follow up was 51 (17-61) months. Two patients had esophageal atresia and trachea-esophageal fistula managed as neonates. Three had no co-morbidities. Four had esophageal foreign bodies:1 esophageal stent, 2 button batteries, 1 chicken bone. One patient had a complication following colonic interposition. Four patients required an esophagostomy at the time of definitive surgery. All patients were alive and well at last follow up with one having successful reconnection surgery.

CONCLUSION

In this series, outcomes were favourable. Multidisciplinary discussion and surgery are mandatory. If hemorrhage is controlled at presentation, then survival to discharge is possible but the magnitude of surgical intervention is both significant and very high risk.

LEVEL OF EVIDENCE

Level 3.

Timely Endoscopic Recognition of Aortoesophageal Fistula With Successful Treatment

Aortoesophageal fistula (AEF) is a devastating cause of upper gastrointestinal bleeding that occurs because of pathologic communication of the esophagus with the aorta. Bleeding AEF has high mortality even with appropriate interventions. In this study, we present a case of a 52-year-old man who presented with hematemesis, which was found to be due to an actively bleeding AEF. Prompt identification of the fistula led to multiple endoscopic interventions that stabilized the patient and allowed him to undergo emergent endovascular aortic stent placement with successful bleeding control.

Aortoesophageal Fistula Occurring Due to Aortic Aneurysm

Upper gastrointestinal bleeding is a rare presentation of the aortoesophageal fistula (AEF) and is usually caused by thoracic aortic aneurysms. We present the case of a 61-year-old male who presented with chest pain and hematemesis. A chest X-ray showed a widened mediastinum. The patient underwent computed tomography angiography (CTA), which showed the presence of a large aneurysm in the aorta, which caused compression of the trachea, esophagus, and left pulmonary artery. Additionally, there was evidence of an AEF. It was decided to perform an emergency surgical intervention on the patient. However, the patient had multiple episodes of hematemesis and expired.

Button battery injury causing an aorto-oesophageal fistula in a 1-year-old child - Sengstaken-Blakemore tube, a life-saving bridge during surgery

ABBREVIATION

AEF: aorto-oesophageal fistula;BB: button battery;CTA: computed tomography angiography;ER: emergency room;GI: gastro-intestinal;SBT: Sengstaken-Blakemore tube.

Diagnosis and Management of Button Battery Ingestion Complicated by Tracheo-Esophageal and Aorto-Esophageal Fistulas

Button battery ingestion (BBI) is common in children and its prevalence has increased in the last decades. BBI can be responsible for very severe and potentially fatal complications if not promptly detected. We describe the successful management of two cases of BBI that occurred in two previously healthy infants. Both patients presented with vague symptoms and no witness of foreign body ingestion. The prolonged time of exposure to the corrosive effects of disk batteries was responsible for the development of tracheo-esophageal fistula (TEF) and aorto-esophageal fistula (AEF). We demonstrate how prompt diagnosis and management are crucial for the infants’ survival.

Vascular Complications in Children Following Button Battery Ingestions: A Systematic Review

CONTEXT

Children presenting to health care facilities with button battery (BB) impaction.

OBJECTIVES

To describe characteristics of children with vascular complications after BB impaction, as well as associated outcomes.

DATA SOURCES

National Capital Poison Center registry and PubMed database from inception to December 2021.

STUDY SELECTION

All reports describing children aged <18 years with vascular, esophageal, or airway complications after BB ingestion.

DATA EXTRACTION

We extracted characteristics including date of publication, age and sex of child, battery type and size, duration and location of impaction, complications, subsequent interventions, and interval between battery removal and death.

RESULTS

A total of 361 cases involved severe complications or death after BB ingestion (321 cases from the National Capital Poison Center registry database, 40 additional cases from PubMed). Nineteen percent (69 of 361) were fatal and 14% (51 of 361) involved vascular injuries. Three-quarters (75%) of vascular complications were aorto-esophageal fistulae and 82% of vascular injuries were not survivable. Fatal vascular cases had significantly longer median impaction time (96 hours versus 144 hours, P <.05) and a wider range of presenting features than survivors.

LIMITATIONS

The total number of cases with vascular complications was small, data reported varied between cases, and no data were available on overall exposure. Long-term morbidity data were not available for the survivors.

CONCLUSIONS

Prolonged BB impaction is a risk factor for vascular complications and death. A high index of suspicion is required for children representing with hematemesis after BB impaction, with prompt transfer to a tertiary center because vascular surgical intervention may offer a chance of survival.

Survival of Toddler with Aortoesophageal Fistula after Button Battery Ingestion

Button batteries (BBs) are found in many households and are a source of esophageal foreign body in the pediatric population. Upon ingestion, significant caustic injury can occur within 2 hours leading to tissue damage and severe, potentially fatal sequelae. Aortoesophageal fistula (AEF) is a rare complication that nearly always results in mortality. We report a rare case of a toddler who developed an AEF after BB ingestion and survived following staged aortic repair. There should be a high index of suspicion for this complication with the history of BB ingestion and presence of hematemesis, hemoptysis, or melena.

A 2-Year-Old Boy Who Developed an Aortoesophageal Fistula After Swallowing a Button Battery, Managed Using a Novel Procedure with Vascular Plug Device as a Bridge to Definitive Surgical Repair

Patient: Male, 2-year-old

Final Diagnosis: Aortoesophageal fistula

Symptoms: Esophageal foreign body • gastrointestinal bleeding

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology • Pediatrics and Neonatology

Successful management of an aorto-esophageal fistula following button battery ingestion: A case report and review of the literature

Foreign body ingestion is a common event among pediatric patients, especially in children less than 6 years of age. Although most cases are relatively benign, with the foreign body passing spontaneously or requiring a brief endoscopic procedure for removal, button battery ingestion is known to cause significant morbidity with the potential for mortality. Although aorto-esophageal fistula (AEF) is a rare complication following button battery ingestion, its clinical manifestations are significant and outcomes are poor. Early diagnosis and aggressive treatment are key in preventing fatal complications. We describe the successful management of an AEF which presented with hematemesis 8 days after removal of a button battery in a 17-month-old female. The literature regarding button battery ingestion and AEF is reviewed and treatment options including intraoperative anesthetic care discussed.

Presentation, management and outcome of aorto-esophageal fistula in young patients: two case-reports and literature review

Aorto-esophageal fistula (AEF) is a rare serious surgical event. The first case developed hematemesis 2 weeks post-sleeve gastrectomy. A covered esophageal stent was placed endoscopically. The esophageal stent implantation was followed by massive bleeding due to an AEF. A thoracic endovascular aortic repair (TEVAR) was performed. Aggravated by infection of the aortic stent, another massive bleed occurred after 1 year. The final procedure was resection of the descending aorta with reconstruction using a bovine pericardial patch. The second case presented with hematemesis post-motor vehicle accident. AEF was confirmed by aortogram and treated by TEVAR followed by fully covered esophageal stent. The patient declined definite surgery. In conclusion, initial endovascular approach is useful as a bridge procedure. Once the patient hemodynamics are stabilized, a definitive surgical repair is required. The post-repair infection and life-long antibiotics could be overcome by using bovine pericardial grafts.

Current management of button battery injuries

Button batteries (BB) are found in common household items and can lead to significant morbidity and mortality in the pediatric population when ingested. BBs are made of various chemistries and have a unique size and shape that yield significant injury when lodged in the pediatric esophagus. BBs create a local tissue pH environment of 10 to 13 and can induce liquefactive necrosis at the negative pole. This initial injury can progress with further tissue breakdown even after removal. Unfortunately, patients may present with vague symptoms similar to viral illnesses and there is not always a known history of ingestion. Plain film X-ray can be diagnostic. Exposure can lead to caustic injury within 2 hours. Thus, timely endoscopic removal is the mainstay of treatment. Novel mitigation and neutralization strategies have been implemented into treatment guidelines. These include the preremoval ingestion of honey or sucralfate and intraoperative irrigation with acetic acid. Depending on the severity of injury following removal, careful consideration should be given for potential delayed complications including fistulization into major vessels which often leads to death. The National Button Battery Taskforce and several industry members have implemented prevention strategies such as educational safety outreach campaigns, child-resistant packaging changes, and warning labels. Governmental regulation and industry changes are key to limit not only the amount of BB ingestions, but also the devastating consequences that can result. Anonymous reporting of BB injuries through the Global Injury Research Collaborative has been made convenient and centralized through the advent of a user-friendly smartphone iOS/App Store and Android/GooglePlay application called the "GIRC App"; all specialists who manage foreign body cases should contribute their cases to help prevent future injuries. BB ingestion must be recognized and treated promptly using a multidisciplinary approach to optimize outcomes for these patients. Ultimately, a safer BB technology is critically needed to reduce or eliminate the severe and life-threatening injuries in children.

LEVEL OF EVIDENCE

5.

Development and repair of aorto-esophageal fistula following esophageal button battery impaction: A case report

Background:

Complications from esophageal button battery impactions remain a real fear for practicing pediatric gastroenterologists and surgeons. This case describes a child who developed an aorto-esophageal fistula 25 days after initial battery ingestion and survived due to prompt placement of an aortic stent via minimally invasive surgery, avoiding an open procedure.

Case presentation:

A 6-year-old female presented acutely with a mid-esophageal button battery impaction witnessed by her parents. Presenting symptoms included chest pain and emesis. Button battery location and size were confirmed on X-ray. She underwent removal with flexible esophagogastroduodenoscopy (EGD) and rigid esophagoscopy. She was admitted to the hospital and received conservative medical management, with serial cross-sectional imaging via chest MRIs to assess the evolution of her injury according to available national guidelines, and was discharged after 12 days of close inpatient monitoring. Despite these measures the patient represented 25 days post-ingestion with hematemesis from a new aorto-esophageal fistula, requiring emergent cardiac catheterization with successful, life-saving aortic stent placement. She remained admitted for an additional 12 days of monitoring as her diet was advanced slowly post-catheterization. Since this second hospitalization she continues to do well, with outpatient follow-up by multiple subspecialists.

Conclusions:

This case highlights the continued uncertainty regarding the risk of developing this complication, as well as gaps in the current literature and guidelines for managing these patients following ingestion and esophageal injury. It also details the unique course following development of this complication and its surgical repair.

Massive hemorrhage from an aortoesophageal fistula caused by esophageal stent implantation: A case report and literature review

RATIONALE

Aortoesophageal fistula (AEF) is the direct communication between the aorta and esophagus, which can cause fatal hemorrhage, and its incidence increased with the use of an esophageal stent (ES).

PATIENT CONCERNS

A 79-year-old man was admitted due to hemodynamic shock with massive hematemesis caused by AEF 1 month after the implantation of an ES.

DIAGNOSES

Computed tomography angiography visualized an AEF with an ulcer-like projection on the aortic arch where the ES was placed. Angiography of the aorta revealed extravasation of contrast media from the aortic arch into the stented esophagus, which confirmed the diagnosis.

INTERVENTIONS

Thoracic endovascular aortic repair (TEVAR) was performed for massive hematemesis caused by ES-related, AEF but did not solve the underlying problem, leading to the second fatal hemorrhage.

LESSONS

TEVAR for the unique treatment of ES-related AEF is feasible in certain cases but may lead to collapse after a specific period.