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.