QUAD #4: Surgical Management of Button Battery & Caustic Ingestion with Dr. Aaron Garrison

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi, I'm M. Goti from Cincinnati Children's Hospital. And last year, in October 2022, Cincinnati Children's hosted the Quad Conference, which was a combination of four conferences. The International Organization for Esophageal Atresia, the Aero Digestive Society Conference, the Cincinnati Children's Airway course, and the Cincinnati Children's Pediatric Dysphagia series. And today we're going to review surgical management of ingestions with Dr. Aaron Garrison from Cincinnati Children's Hospital Medical Center. A study from 1992 reviewed more than 2,000 cases where children had ingested button batteries. Their findings found no deaths following ingestion. Unfortunately, more recent studies have found a sevenfold increase in the number of fatalities following ingestions. And this is because of the change in the battery to a 20-volt lithium cell, which causes coagulative necrosis. There are three locations in the esophagus where things tend to get stuck. So the upper esophageal sphincter, behind the aortic arch, and then at the lower esophageal sphincter. And then if the button battery sits in one of these positions, it causes transmural injury, and it will make a fistula between whatever it finds. Trachea, blood vessels, vocal cords. And this brings up the question, which patients do surgeons need to worry about? There's high-risk criteria and that basically the younger the patient, smaller the esophagus. If you have a larger battery over 20 mm or greater, it is riskier. Timing of ingestion, so the longer that the duration that the battery's been in there, obviously the worst. And the battery behind aortic arch is a little more concerning. And then I think the one take home point if you can remember anything is that if you have a patient who has had a battery removed and they present later with a bleed, that's an emergency that needs to be taken seriously and have a plan for. This was a study out of Colorado, looking at 13 patients with these high severity injuries, and 30% had esophageal perforation. 23% had a stricture. Some of them required G2 placement, and they stayed in the hospital for nearly two weeks. And almost a quarter of the patients in this series died. But what I thought was particularly sad is that two of the fatalities presented with the buttons already in the stomach. The reason that these sentinel bleeds are something to take seriously is because they can often be the first sign of these order enteric fistulas. And you could see from the autopsy picture below that any small communication between the esophagus and the aorta can be potentially life-threatening. Interestingly, some of these fistulas showed up over two weeks after the button batteries were removed. So it is not something that always happens in the hospital. So I think having a high index of suspicion and a plan for what to do once the battery is removed is helpful. Here, we reviewed the decision map that Dr. Garrison brought for us. The top brackets are for a sick patient and the bottom ones are for a well appearing child. If you just think about stratifying sick from not sick, that's where you start. If there's active bleeding, then triaging which areas you're going to intervene on that patient are helpful. We're talking about esophageal foreign bodies with active bleeding or clinically unstable. They recommend getting GI, surgery, CT surgery um available and and around for the procedure. Sometimes imaging beforehand with a CTA to just get some idea about how much inflammation and proximity to the aorta is helpful. So if you have that imaging and it shows that there is an injury close to the aorta, continuing NPO and antibiotics and then repeating an MRI in five to seven days just to see what is the trajectory of the inflammation. If there's any bleeding in that time or if there's any concern for a sentinel bleed, then you have a plan with interventional radiology or cardiology or anyone who can help in that situation in your hospital. This is one of the case reports. I did follow-up with imaging and they notice that there is a pseudoaneurysm from off the arch of the aorta. And so they fixed this with a staged approach. In this case, the patient had a sternotomy, then went on bypass where they fixed the aorta with a graft, and later they went back and did a flap repair and fixed the esophagus. If you have a high risk patient less than five, larger battery size, then they recommend endoscopic evaluation of the esophagus because you don't know how long that button battery was there higher up than in the stomach. So if you get out of the acute setting and you're trying to plan these complex repairs, how do you know if you're going to need ECMO or cardiopulmonary bypass? Obviously some of that is the location of the fistula. But can you intubate past the injury enough to ventilate during the case? If the fistula is near the carina, then you know you're going to need some complex airway reconstruction and you're not going to be able to adequately ventilate during the case. Here, we're looking at a button battery in the esophagus. And now, on the left lower quadrant, with the button battery removed, airway is anterior and the esophagus is posterior. So there's a very large fistula. They ended up putting the patient on ECMO because they're unable to adequately ventilate. And by the time she got here two days later, that fistula, as you can see, is even larger. Trying to figure out how to repair this is a challenge. During the procedure, Cincinnati Children's team tried upsizing the patient's esophageal stent to a larger one, and then they were unable to ventilate or repair with the larger stent. So what Dr. Ruder did in his with his team, did a interposition graft by removing a little segment of the trachea and actually using that trachea as the front wall of the esophagus. Easier to see here. The airway is on the left and we're looking through the trachea after repair. And the esophagus is on the right, and you'll see where it changes. And you can make out the posterior wall of the trachea that had become the anterior wall of the esophagus. While button batteries are ingested more than 3,500 times per year in the United States, unfortunately they're not the only cause for caustic injuries for children. Caustic ingestion is most common in young children between one and three years of age. Most ingestions by children are accidental, and the amounts ingested tend to be small. Sometimes I think it's easy to get caught up in what the child drank and to forget that the kind of airway may take priority and sometimes these patients can show up in extremis or almost like an allergic reaction, especially if it's an acidic substance that they don't swallow because they can spit it back up. And you can get a really severe injury to epiglottis here. So it's important to remember your ABCs and keep that in your differential. So anytime there's an esophageal perforation, we try to stay with the same exposure, debreed to viable tissue, get a layered closure and some coverage. And then if you can flap or cover with something like muscle, then that's preferable. If the hole's too big, then we try to drain it with something to get a delayed repair. In summary, being prepared for the unexpected, knowing which patients are at high risk is important. Smaller children, bigger batteries, and longer ingestion time pose a greater risk. Don't be reassured by a battery in the stomach, and know that injuries can progress even after they're removed. So having an imaging plan to be proactive about finding transmural and worsening inflammation that's going to tour towards vessels is important. And then for caustic ingestions, be patient. Know that small perforations can heal and be managed, and if they develop strictures, either dilation or surgery may be necessary. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.