Discussion:
Tracheoesophageal fistula is an abnormal communication between trachea and esophagus. A recent common cause of acquired TEF is battery ingestion. Risks involved with TEF surgical ligation are associated with fragile necrotic tissue, including fistula formation, tracheal separation, pneumothorax, pneumomediastinum, esophageal stricture, vocal cord paralysis, thyroid hemorrhage, spine spondylodiscitis, bleeding (if aorto-esophageal fistula formed), chest infections/sepsis, and death.4 Anesthetic management challenges are endotracheal tube (ETT) placement failure if TEF size and position are unknown, post-operative airway obstruction, aspiration, and loss of airway from bleeding or difficulty with ETT replacement. Anesthesia safety precautions for battery swallow-induced TEF rely on understanding size and position of the TEF pre-operatively.
Battery removal is essential as severity of damage and complications correlate to duration of battery lodgment in the esophagus.5 If surgery is not readily available, mitigating efforts to increase pH at the battery site include drinking weakly acidic liquid (lemon/orange juice), honey, sucralfate, and dilute acetic acid.5 Direct laryngoscopy/bronchoscopy should be performed to confirm TEF, followed by surgical repair.3 Conservative management with temporary endoluminal tracheal or esophageal stents has been implemented to prevent pulmonary contamination.1 Surgical management of acquired TEF involves single-stage patch repair of the tracheal and esophageal defects with possible partial esophagectomy, cervical esophagostomy, and gastrostomy. Utilization of vascularized local tissue flaps has been recommended to reinforce repair sites. Post-operatively, intravenous antibiotics are administered if concerned for mediastinitis, tracheal stents inserted to retain airway patency, and gastrostomy feeds implemented for nutritional support.3 Early extubation and avoidance of post-surgical positive-pressure ventilation have been recommended.1
The Button Battery Task Force aims to decrease the incidence of battery ingestion in children. Despite concerted efforts from government, industry, academia, medicine, and public health, battery ingestion continues to occur.5 The National Capital Poison Center (website: http://www.poison.org/battery, accessed April 1, 2020) and National Battery Ingestion Hotline (1-800-498-8666, available 24 hours/7 days a week) guide the public in battery ingestion issues.
In conclusion, we present a life-threatening battery swallow-induced TEF, which required emergent anesthesia for infection drainage and placement of ETT distal to the damage for TEF repair. We emphasize preparation, understanding TEF anatomy, and excellent communication amongst surgeons, radiology, blood bank, and anesthesiologists for the proper care of these pediatric critical airways.
Acknowledgements: None.
Conflict of Interest: None.