Fully-covered metallic stenting in an infant with tracheoesophageal fistula due to button battery ingestion

Abstract

Previously, the main treatment options for tracheoesophageal fistula included surgery and conservative treatment. Herein, we report a child suffering from severe tracheoesophageal fistula due to button battery ingestion. The child relapsed soon after a repair surgery. Then, he was endotracheally implanted with a fully-covered metallic stent combined with a jejunal tube feeding. He recovered soon and the stent was removed five months later. The fistula was healed with no relapse during a 25-month follow-up. Therefore, endotracheal implantation of fully-covered metallic stent is an alternative treatment for tracheoesophageal fistula due to button battery ingestion, especially in cases with severe respiratory disorders.

Introduction

According to pathogenetic features, tracheoesophageal fistula in children can be divided into congenital and acquired types. Congenital tracheoesophageal fistula is mostly accompanied by esophageal atresia, while the acquired type is found in cases with foreign body ingestion, endo-esophageal prosthesis, corrosive ingestion with extensive burn, chest trauma, malignant tumors, burns, and tracheotomy tubes [1], [2]. Tracheoesophageal fistula due to button battery ingestion has been most frequently reported. In children with tracheoesophageal fistula, oral feeding as well as reflux of gastric contents may enter the trachea through the fistula, thereby causing choking, suffocation, recurrent pneumonia and mediastinitis. In cases with a large fistula, large amounts of inhaled air leak into the esophagus, resulting in abdominal distension and dyspnea; long-term eating difficulties can lead to malnutrition. Surgical repair was previously considered the main treatment option for tracheoesophageal fistula; however, it may induce complications such as anastomotic stenosis, leak and recurrent tracheoesophageal fistula [3]. In addition, some children are unable to tolerate surgery in a short term due to severe infection or malnutrition. Thus, conservative treatment and endoscopic interventional therapy are attracting increasing attention. Some scholars [1], [4], [5] suggested performing conservative therapy (anti-reflux, proton pump inhibitor, gastrostomy or nasogastric tube, or nasojejunal feeding tube) prior to surgery for cases with tracheoesophageal fistula due to button battery ingestion. However, taking into consideration the safety of the airway, an initial repair can be carried out. Meier JD et al. [6] reported a total effective rate of 60% for endoscopic interventional therapy in the treatment of tracheoesophageal fistula, tissue and fibrin adhesive, laser treatment and local injection of tissue hardening agents being mostly used. Tracheal and/or esophageal stenting is widely used in adults for tracheoesophageal fistula, with good effectiveness [7], [8], but seldom used in pediatric patients, especially for tracheal stenting. In this study, we report a child with severe tracheoesophageal fistula due to button battery ingestion. He relapsed soon after repair surgery, and presented with dyspnea and difficult weaning from mechanical ventilation. Subsequently, he was endotracheally implanted with a fully-covered metallic stent combined with a jejunal tube feeding, and obtained good recovery.