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Tracheo‐oesophageal fistula caused by electrolysis of a button battery impacted in the oesophagus

An 11-month-old child cried and screamed after being observed swallowing an unidentified foreign body. A general medical practitioner was consulted. An anterior–posterior chest X-ray revealed the circular silhouette of an object, suggesting a button battery, in the lower oesophagus at T4 level. The infant was referred to hospital where another chest X-ray 4 h later located the object in the same position. Its orientation, that is, whether the cathode was facing the trachea, was not discernible. Atraumatic endoscopic removal using forceps under general anaesthesia was performed 9 h after ingestion. Subsequently, the infant fed satisfactorily from a bottle and was discharged from hospital. Over the ensuing 2 days, liquid food was taken, but solids were refused. After another 3 days, the volume of liquid feeds taken declined and the infant became unsettled, agitated and unable to sleep. This was followed by stridor and by episodes of choking and inability to swallow anything, including saliva. Seven days after the original ingestion, he was again brought to hospital where another oesophagoscopy and tracheoscopy identified a tracheo-oesophageal fistula. On induction of anaesthesia, spontaneous ventilation via mask was followed by an uneventful laryngoscopy and passage of an endotracheal tube. A muscle relaxant was given, and controlled ventilation was initially unremarkable. However, when the oesophagoscope was passed to the level of the lesion, ventilation became impossible and anaesthetic gases vented from the oesophagoscope. On removal of the oesophagoscope, ventilation returned to normal. A gastrostomy was performed and unsuccessful attempts were made to pass a nasogastric tube up the oesophagus from the gastrostomy. A nasogastric tube was then passed into the stomach via the oesophagoscope. Thereafter, ventilation again became impossible, even after removal of the oesophagoscope and then the nasogastric tube. In desperation, the endotracheal tube was also removed and some mechanical ventilation by mask was then possible. Fortunately, spontaneous respiration resumed and assisted mask ventilation was also possible. Preparations were made to commence emergency cardiopulmonary bypass, which at this hospital was not routinely provided for children. Reintubation was undertaken and the tip of the tube positioned just above the carina after initial advancement into the right main bronchus. However, the airway again occluded intermittently and satisfactory ventilation was only possible in the assisted spontaneous mode. Transport of the infant to the Royal Children’s Hospital was met with similar difficulties, but was achieved safely. On arrival, repeated intermittent tracheal obstruction continued to compromise ventilation with numerous but transient pulse oximetry measurements down to 40–50% over a period of several hours. The endotracheal tube was re-advanced into the right main bronchus and urgent repair of the fistula undertaken on full cardiopulmonary bypass. There was a very large fistula between the anterior wall of the lower cervical oesophagus and the trachea, surrounded by inflammatory oedema but little pus. The oesophageal perforation lay at a slightly higher level than that in the trachea, which suggested that perforation had occurred in an oblique fashion and that instrumentation may have been contributory. The defect in the oesophagus was 2 cm in length and spiral, with deficiencies in the left lateral and anterior aspects. The oesophagus was mobilized inferiorly until a short distance above the diaphragm. Direct repair was achieved using interrupted 4/0 vicryl sutures without undue tension. The defect in the trachea was 1.5 cm in length and 1 cm in width. The endotracheal tube was withdrawn, and the trachea was mobilized and repaired with interrupted 5/0 vicryl sutures and then tested by ventilation. The endotracheal tube was then advanced across the repair. Postoperatively, the endotracheal tube tip was maintained distal to the site of repair in the trachea and the infant was extubated after 8 days. A mild stridor lasting several hours was treated with nebulized adrenaline and dexamethasone. A combination of gastrostomy feeds and parenteral nutrition was J. Paediatr. Child Health (2002) 38, 201–203