Conservative Management of Acquired Tracheo-Esophageal Fistula after Lithium Button Battery Ingestion

ABSTRACT

Introduction:Acquired tracheo-esophageal fistula (TEF) is a dreaded complication of lithium button battery (LBB) ingestion in the pediatric population. Traditionally acquired TEFs are managed with surgical interventions. Very few case reports have described successful closure of a TEF secondary to LBB with conservative management. There is no reported literature on the use fibrin glue or laser therapy to enhance closure. Here we describe successful conversative management of TEF secondary to LBB and for the first time, attempted trial of fibrin glue and argon laser therapy. Case presentation 13-month-old female presented to the emergency department with a 3-day history of croupy cough. Neck X ray demonstrated a radio-opaque foreign body suggestive of a button battery. Patient urgently underwent rigid esophagoscopy and found to have a 20 mm lithium battery in the proximal esophagus. The negative pole was facing anteriorly. Battery was retrieved and inspection revealed a Zagar 2 B grade mucosal injury. Site was washed with 0.25% acetic acid. Direct laryngoscopy and bronchoscopy noted significant posterior tracheal wall edema. Patient was kept NPO overnight and an esophagram obtained next day was reassuring. Therefore, diet was advanced as tolerated and patient discharged next day with plan to repeat esophagram in 2 weeks and endoscopy in 4 weeks. Patient presented 3 days later with drooling, coughing, nasal congestion. She tested positive for SARS Covid 19 PCR on admission. Esophagram at admission noted irregularity and distension of the proximal esophagus with persistent focal outpouching. Patient was kept strict NPO and a repeat esophagram 24 hours later showed large volume aspiration associated with excessive coughing. A nasogastric tube was placed, and tube feedings initiated. Esophogastroduodenoscopy (EGD) was delayed by 1 week due to COVID positive status and upper respiratory symptoms. Initial EGD demonstrated purulent exudates in proximal esophagus and a 6 mm fistulous opening surrounded by ulcerated margins. Bronchoscopy confirmed tracheal end of fistula in addition to posterior tracheal wall ulceration. A fiber-optic scope was used to advance the endotracheal tube so that its distal end was positioned beyond the inflamed mucosa. Patient was kept intubated and sedated, on IV antibiotics and PPI, and on NG tube feeds in the ICU. Repeat scope 7 days post TEF diagnosis showed a 4 mm fistula with healing of the ulcerated mucosa. Fibrin glue was injected into the fistula from the tracheal side in an attempt to close the TEF, but this was unsuccessful and lead to dislodgment of fibrin glue into airway creating a foreign body which necessitated endoscopic retrieval. EGD, 14 days after diagnosis of TEF demonstrated a fistula now ~ 3 mm wide. Argon plasma coagulation (APC) probe (Beamer unit flow of 0.5 L/min,15 W) was directed at the mucosa lining the esophageal end of the fistula with an aim to promote healing by secondary intention. At 21 days post TEF diagnosis complete closure of the fistula was demonstrated on EGD and bronchoscopy and the per-operative esophogram was reported as normal. Patient was discharged 5 days later tolerating an age-appropriate diet. A follow-up esophogram 2 weeks later was reassuring. Patient was asymptomatic on clinical follow up visit 4 weeks from discharge. Discussion(s) Acquired TEF secondary to LBB ingestion is traditionally managened through endoscopic or open surgical repair. However, these procedures can be complicated by high rates of recurrent laryngeal nerve injury, tracheal stenosis, recurrent fistula, and mortality. Thus, experts have started to advocate the use of esophageal rest as conservative management of acquired TEF to permit closure by secondary intention. Five pediatric cases to date have reported sustained closure of TEF secondary to LBB with conservative management including strict NPO status and tube feeds/parenteral nutrition. The duration of healing has varied from 4 -11 weeks. We documented successful healing of acquired TEF within 21 days of initial diagnosis making it the shortest recovery period to date. We report the use of argon plasma coagulation at low settings to produce controlled heat coagulation at the fistula site in order to expose the submucosa and enhance healing by secondary intention. Successful closure of congenital TEF have been reported with injection of fibrin glue into the fistulous tract but this technique may not work for acquired TEF because of surrounding inflammation and a patulous tract. We opted to keep our patient sedated and intubated for 2 weeks to minimize movement, and promote healing of the TEF, but risk vs benefit needs to be weighed on a case-to-case basis. In conclusion, conservative management of acquired TEF is a feasible first step and may be considered before opting for surgical repair. Use of APC at low setting may reduce duration of closure of acquired TEF but high-powered, multi-center studies are needed.