Conservative management of an acquired tracheoesophageal fistula caused by a swallowed button battery: A case report

Introduction: The incidence of pediatric button battery (BB) ingestions has increased in recent years with a subsequent rise in secondary esophageal injuries. There is a paucity of published literature on the evaluation and management of acquired trachea-esophageal fistulas (TEF) in this context and therefore, the purpose of this paper was to summarize a case and propose an evidence-based protocol for acquired TEF management. Case presentation: A 15-month-old female presenting with fever, mild tachypnea and lethargy underwent a chest x-ray which demonstrated a BB in the upper thorax. Laryngoscopy, and subsequent rigid esophagoscopy, identified the BB in the proximal esophagus. There was surrounding inflammation and liquefactive necrosis, and the BB was removed via rigid esophagoscopy. A post-procedure chest computerized tomography following BB removal revealed a small collection in the mediastinum consistent with full thickness esophageal perforation as well as mediastinitis. She was treated conservatively and on post-operative day (POD) 7, a swallow study demonstrated no evidence of leak or stricture, thus a trial of oral, clear fluids took place. A next-day repeat swallow study was performed and revealed an acquired TEF. She was treated conservatively with proton pump inhibitor and nasojejunal feeds. Bronchoscopy, upper gastrointestinal endoscopy and repeat esophagram at six-weeks demonstrated resolution of the TEF. Conclusion: Clinicians should have a high index of suspicion for BB ingestion complications, even after removal. This case illustrated that patients with acquired TEF can be managed conservatively. Following literature review and our personal experience in this single case, we propose a suggested algorithm for management of these patients