Neonatal pharyngoesophageal perforation mimicking esophageal atresia: clues to diagnosis

Clinical Features of iatrogenic Pharyngo-esophageal perforation in very low birth weight infants

BACKGROUND

Iatrogenic pharyngoesophageal perforation (IPEP) is one of the complications of gastric tube insertion and it tends to occur more frequently in premature infants. Although the frequency is significantly low, attention should be paid as it can lead to serious outcomes with high mortality. This study will help raise awareness with respect to early diagnosis, management, and prevention.

METHODS

We performed a retrospective cohort study of all very low birth weight infants diagnosed with IPEP between 1993 and 2022.

RESULTS

A total of 6 patients (0.27% of very low birth weight infants) with the diagnosis of IPEP were included. The median gestational age was 27 + 1 weeks (range 23+5-28 + 6 weeks), and the median birth weight was 823 g (range 630-1232 g). Symptoms included difficulty with gastric tube insertion, bloody secretions in the oral cavity, and increased oral secretions. X-rays revealed aberrant running of the gastric tube in all patients. In three cases, contrast studies demonstrated contrasted mediastinum tapering like a bead. Laryngoscope was used to view the perforation sites but this was not useful in the smallest patient. All patients were treated conservatively with antibiotics and survived.

CONCLUSIONS

When inserting a gastric tube for premature infants, it is critical to remember that these infants are at risk of IPEP. In addition to a frontal X-ray, a lateral X-ray and contrast study may be useful for early diagnosis.

Hypopharyngeal Perforation Mimicking Esophageal Atresia: A Case Report of an Extremely Low Birth Weight Infant Emphasizing the Need for Preoperative Endoscopy

We report a case of an extremely low birth weight premature infant born at 27 weeks of gestation, transferred to our tertiary pediatric referral center for surgical repair of an esophageal atresia. Endoscopic evaluation before the start of surgery revealed a hypopharyngeal perforation, resulting in the false impression of esophageal atresia. If no tracheoesophageal fistula is found during tracheoscopy, esophagoscopy should be done before surgical intervention as the inability to pass a nasogastric tube into the stomach is not sufficiently reliable for a correct diagnosis of esophageal atresia.

Preoperative laryngotracheobronchoscopy in infants with esophageal atresia: why is it not routine?

The value of laryngotracheobronchoscopy (LTB) immediately prior to repair of esophageal atresia with or without tracheo-esophageal fistula is contentious. Currently, there is a wide range of opinion on the utility of this investigation which is reflected by huge variation in clinical practice. This review is a critical analysis of the arguments for and against performing routine LTB prior to esophageal atresia repair. Reserving LTB for selected cases only is potentially disadvantageous since it limits the surgeon's and anesthetist's familiarity with the procedure, equipment, and range of potential findings. There is sufficient evidence to suggest that routine preoperative LTB becomes the standard of care.

Neonatal and pediatric esophageal perforation

Esophageal perforation (EP) is a rare complication that is often iatrogenic in origin. In contrast with adult patients in whom surgical closure of the defect is preferred, nonoperative treatment has become a common therapeutic approach for EP in neonates and children. Principles of management pediatric EP includes rapid diagnosis, appropriate hemodynamic monitoring and support, antibiotic therapy, total parenteral nutrition, control of extraluminal contamination, and restoration of luminal integrity either through time or operative approaches.

Complications in pediatric enteral and vascular access

Obtaining reliable enteral and vascular access constitutes a significant fraction of a pediatric surgeon׳s job. Multiple approaches are available. Given the complicated nature of this patient population multiple complications can also occur. This article discusses the various techniques and potential complications associated with short- and long-term enteral and vascular access.

Nonoperative management of esophageal perforations in the newborn

BACKGROUND

Esophageal perforation in neonates occurs most often in cases of extreme prematurity and is commonly due to iatrogenic causes. Treatment over recent decades has become more conservative. The purpose of this study was to review cases of esophageal perforation in neonates and to describe the presentation, management, and outcomes.

MATERIALS AND METHODS

A retrospective chart review was performed for patients with International Classification of Diseases, Ninth Revision code for esophageal perforation treated at our institution between the years 2009 and 2015. Data collected included demographic information, etiology of perforation (specifically focusing on cases secondary to orogastric tube placement), treatment course, time to resumption of enteral feeds, length of antibiotic use, time to subsequent radiographic resolution, and mortality.

RESULTS

Twenty-five patients met study criteria. The average post-conceptual age at time of diagnosis was 26.5 ± 2.3 wk. All 25 patients were managed nonoperatively with bowel rest, parenteral nutrition, and broad-spectrum antibiotics. Enteral feeds were resumed after a median of 8 d (interquartile range [IQR]: 7-11), the median antibiotic duration was 7 d (IQR: 7-10), and the median time to follow-up esophagram was 7 d (IQR: 7-10). Overall, 24 of 25 patients (96%) demonstrated radiological resolution of perforation on initial follow-up esophagram. Four patients died during the study period, but no deaths were related to the diagnosis of esophageal perforation.

CONCLUSIONS

In this largest reported sample of neonates treated for esophageal perforation, nonoperative management with bowel rest, parenteral nutrition, and antibiotics was successful.

Management of cervical esophageal and hypopharyngeal perforations

PURPOSE

Evidence is limited for outcomes of surgical versus conservative management for patients with cervical esophageal or hypopharyngeal perforations.

METHODS

Patients with cervical esophageal or hypopharyngeal perforations treated between 1994 and 2014 were identified using an institutional database. Outcomes were compared between patients who underwent operative drainage and those who had conservative management with broad-spectrum antibiotics and withholding oral intake.

RESULTS

Twenty-eight patients were identified with hypopharyngeal or cervical esophageal perforations, mostly due to iatrogenic (nasogastric tube placement, endoscopy, endotracheal intubation) injuries (68%). Fourteen were treated initially with conservative management and 14 with initial surgery. Six patients failed conservative treatment and two patients failed surgical treatment. Patients managed conservatively who had eaten between injury and diagnosis (p=0.003), those who had 24 hours or more between the time of injury and diagnosis (p=0.026), and those who showed signs of systemic toxicity (p=0.001) were significantly more likely to fail conservative treatment and require surgery. No variables were significant for treatment failure in the surgical group. Of the 20 patients who ultimately underwent a surgical procedure, two required a second procedure.

CONCLUSION

Patients who have eaten between the time of perforation and diagnosis, have 24 hours or more between injury and diagnosis, and those that show signs of systemic toxicity are at higher risk of failing conservative management and surgical drainage should be considered. For patients without these risk factors, a trial of conservative management can be attempted.

Neonatal esophageal perforation: nonoperative management

BACKGROUND

Esophageal perforation is a rare complication of enteric instrumentation in neonates. Enteric tube placement in micro-preemies poses a particular hazard to the narrow lumen and thin wall of the developing esophagus. The complication may be difficult to recognize or misdiagnosed as esophageal atresia, and is associated with considerable mortality. Historically, management of this life-threatening iatrogenic disease was operative, but trends have shifted toward nonoperative treatment. Here, we review neonatal esophageal perforation at our own institution for management techniques, risk factors, and outcomes.

MATERIALS AND METHODS

Seven neonatal patients with esophageal perforation were identified and charts reviewed for demographics, comorbidities, etiology of perforation, diagnostic modalities, management decisions, complications, and outcomes.

RESULTS

Mean gestational age was 27.2 ± 4.0 wk, and weight at diagnosis was 892 ± 674 g. All seven patients had esophageal perforation resulting from endotracheal or enterogastric intubation and were managed nonoperatively. Treatment included removal of the offending tube, nil per os, and antibiotics. Five patients required additional interventions: four tube thoracostomies for pneumothoraces and one peritoneal drain for pneumoperitoneum. Three patients died because of sequelae of prematurity (intraventricular hemorrhage, necrotizing enterocolitis, and sepsis). One patient was diagnosed as having esophageal atresia; esophagoscopy before surgical repair established the correct diagnosis.

CONCLUSIONS

Neonates, particularly those under 1500 g, are at substantial risk for iatrogenic esophageal perforation during enterogastric intubation. Nonoperative management may be a safe initial strategy in the neonatal setting, but more aggressive interventions may ultimately be required. Despite recent improvement in early recognition of this injury, misdiagnosis still occurs.

Iatrogenic perforation of upper pouch in pure esophageal atresia: a rare complication and review of literature

Iatrogenic perforation of the neonate's pharynx and esophagus with normal anatomy was first described by Eklöf et al in 1968. It typically occurs in severely premature neonates who have undergone repeated traumatic attempts at endotracheal intubation or passage of orogastric tubes. It may also mimic esophageal atresia (EA). Perforation of upper pouch in tracheoesophageal fistula with EA was rarely reported. We report a 1,400 g (32 weeks) neonate with pure EA and iatrogenic perforation of upper pouch due to use of catheter for diagnostic radiography.

Iatrogenic perinatal pharyngoesophageal injury: a disease of prematurity

OBJECTIVE

Perinatal pharyngoesophageal instrumentation, including endotracheal intubation, oral suctioning, and feeding tube placement, is often necessary but risks tissue damage. Our objective was to estimate the incidence of iatrogenic perinatal pharyngoesophageal injury (IPPI) in preterm versus term infants in a children's hospital neonatal intensive care unit (NICU). A secondary goal was to explore the clinical characteristics and outcomes associated with these complications.

METHODS

All NICU discharge summaries from 2004 to 2008 were searched for IPPI-related keywords. Highlighted records were reviewed and the incidence of complications calculated by gestational age and weight.

RESULTS

Of 5910 total NICU discharges, 6 cases of IPPI were identified, for an overall incidence of 0.10%. All injuries occurred in infants less than 33 weeks gestational age and 1500g, with a trend towards higher incidence with increasing prematurity. The incidence of IPPI rose to 4/1321 (0.30%) at 27-32 weeks and 2/521 (0.38%) at less than 27 weeks gestation. Similarly, IPPI occurred in 3/675 (0.44%) babies born at 1000-1500g and 3/642 (0.47%) babies below 1000g. All affected infants survived with conservative management.

CONCLUSIONS

IPPI is a rare but serious complication of perinatal airway instrumentation and is primarily a disease of prematurity. In this sizeable cohort, no complications occurred in term infants, and the incidence of injury increased with decreasing gestational age and weight. This increased propensity towards injury should prompt special care when performing even routine airway procedures on premature neonates.

Pharyngeal perforation masquerading as esophageal atresia

We present a case of pharyngeal perforation from a nasogastric tube mistakenly diagnosed as esophageal atresia with tracheoesophageal fistula in a full term infant female. The correct diagnosis was identified with rigid bronchoscopy and esophagoscopy immediately prior to the planned thoracotomy which was aborted. After one week of oral restriction and antibiotics, the healed perforation did not demonstrate leakage on a contrasted pharyngoesophagogram and bottle feeds were initiated. The infant was discharged to home on day of life 13 without any further complications.

Iatrogenic esophageal perforation in children

Esophageal perforation is most commonly iatrogenic in origin with nasogastric tube insertion, stricture dilation, and endotracheal intubation, being the most frequent sources of the injury in infants and children. Clinical presentation depends on whether the cervical, thoracic, or abdominal esophagus is injured. Any patient complaining of chest pain after an upper endoscopy has esophageal perforation until proven otherwise. In infants and children, plain chest films and esophagography may assist in making the diagnosis. Hemodynamically stable patients with a contained perforation may be managed medically. Free perforation and hemodynamic lability mandates a more aggressive surgical approach for wide drainage of the mediastinum and pleural spaces. Exploration of the chest for attempted direct repair of the injury is now only rarely indicated. Mortality rates have been reported between 20 and 28% with delays in diagnosis and treatment appearing to be most strongly correlated with poor outcomes.

Enteral feeding for high-risk neonates: a digest for nurses into putative risk and benefits to ensure safe and comfortable care

Enteral feeding is considered a relatively safe method of providing nutritional support to high-risk neonates. Nonetheless, there are associated risks, which can be classified as follows: factors to consider before initiating enteral feeding; feeding tube placement; delivery of milk feedings; and gastrointestinal, environmental, and technical factors. For each classification, this article highlights adverse consequences and synthesizes the literature for evidence-based nursing practice recommendations, which are summarized in the "Conclusion" section. Many gaps are identified in the research literature, and directions for future research are described to ensure safe and comfortable care for high-risk neonates receiving enteral feedings.

Sonographic detection of a malpositioned feeding tube causing esophageal perforation in a neonate

We report a case of esophageal perforation caused by a malpositioned feeding tube in a neonate of extremely low birth weight, 632 g. The infant had respiratory distress, which increased rapidly when he was 6 days old. Radiography revealed right-sided hydrothorax that had not been evident a day earlier but no sign of a perforated esophagus. We performed sonography, which revealed fluid in the right pleural cavity and extra-esophageal placement of the feeding tube. Analysis of a fluid specimen obtained on thoracocentesis indicated that the fluid was feeding formula. The feeding tube's misplacement was confirmed sonographically by injecting a small amount of sterile distilled water into the tube and visualizing its entry into the pleural cavity. The feeding tube was removed, and antimicrobial agents were administered. When the infant was 15 days old, feeding resumed through another tube, the placement of which was verified radiographically. The infant was discharged when he was 118 days old with no severe complications, although he had mild chronic lung disease. Because radiography did not reveal the tube's misplacement in this case, we believe that the use of sonography can contribute to an early diagnosis of esophageal perforation in such cases.

Pitfalls of gastric intubation in premature infants

Gastric intubation, by oral or nasal route is an essential procedure in the management of premature infants, for gastric aspiration and for feeding. Oesophageal perforation is a rare but important complication of this commonly performed procedure. An illustrative case is presented. Difficulty passing a tube into the stomach is the first clue to the diagnosis. Understanding the evolution of clinical signs and recognizing the radiological changes facilitates an early diagnosis, thereby enabling successful non-operative management.

Oesophageal perforation presenting as oesophageal atresia in a premature neonate following difficult intubation

Iatrogenic oesophageal perforation in neonates is well recognized in the medical and surgical literature with intubation injury listed as a possible contributing mechanism besides nasogastric tube placement and suctioning. Diagnosis can be difficult and sometimes confused with other entities. With early diagnosis, nonsurgical management often leads to complete resolution in neonates. We report the case of a 1-day-old premature neonate who was brought to the operating room with the preliminary diagnosis of proximal oesophageal atresia with stump perforation and distal tracheo-esophageal fistula. His intubation for respiratory distress at birth had been difficult due to Pierre-Robin sequence with micrognathia. Oesophagoscopy in the operating room revealed a patent oesophagus but perforations in the pharynx and in the proximal oesophagus with the nasogastric tube entering the pharyngeal perforation. Oesophageal perforation and the limitations of the difficult airway algorithm in small neonates are discussed.

Traumatic pharyngo-oesophageal perforation in the newborn: a condition mimicking oesophageal atresia

Two newborn infants with traumatic perforation of the pharyngo-oesophageal region are presented. This injury was induced by pharyngeal suction catheters and/or vigorous attempts at nasogastric or tracheal intubation during resuscitation of the newborn. The true nature of this condition remained unrecognized and the babies were thus referred with a tentative diagnosis of oesophageal atresia. The perforation itself could be treated successfully without surgery, despite a severe complication in one infant resulting from inadvertent use of barium sulphate contrast medium. Raising awareness of the possibility of this injury should help in avoiding this complication by gentle and skilful action during newborn resuscitation, particularly in the premature infant.

[Traumatic pharyngoesophageal perforation in newborn infants]

BACKGROUND

Neonatal perforation of the esophagus appears to occur rarely and often can mimic esophageal atresia. This report presents 12 cases of pharyngoesophageal perforation with a review of the literature.

PATIENTS

From 1980 to 1995, we treated 12 infants for pharyngo-esophageal perforation. Ten infants were pre-term, seven of them weighing less than 1,500 g. Five infants had severe respiratory distress. Four infants had repeated attempt on intubation of the airway and eight infants had a routine postpartum suctioning and gastric aspiration. On plain X-ray, a large right pneumothorax was observed in three cases and the nasogastric tube deviated widely from its expected course in three cases. Four infants underwent contrast esophagography and three infants esophagoscopy. In five cases esophageal atresia was the initial diagnosis. Five infants underwent a thoracotomy. A gastrostomy was performed in one case. The six remaining neonates were treated non-operatively: broad spectrum antibiotics, total parenteral nutrition, and silastic nasogastric tube. Follow-up was uneventful in five cases. One infant with an esophageal stricture underwent instrumental dilatation. Bronchopulmonary dysplasia occurred in two cases and necrotizing enterocolitis in one. Two infants died.

CONCLUSION

Iatrogenic perforation remains a difficult diagnosis. Clinical findings, plain chest x-ray and oesophagography are helpful. Surgery can be completely avoided in most instances. Infants with low birthweight and prematurity are most at risk.

Iatrogenic esophageal perforation in children: patterns of injury, presentation, management, and outcome

Iatrogenic esophageal perforations in children are rare. To evaluate patterns of injury, clinical presentation, and treatment options for such patients, the authors reviewed the case records of 11 children who had sustained transmural injury to the esophagus during a dilatation procedure at their institution between 1967 and 1994. Strictures requiring dilatation were attributable to caustic ingestion in eight, esophageal atresia repair in two, and congenital stenosis in one. Eight were penetrating injuries, and three were disruptions. Two involved the cervical esophagus; and nine involved the thoracic esophagus. Pain, pyrexia, and tachycardia were early signs. Proximal thoracic perforations led to signs in the left chest region (effusion/pneumothorax); with distal perforation the signs were on the right side. Treatment along conventional lines (local drainage, gastrostomy, primary repair after early recognition, and antibiotic therapy) was successful, with two major complications, both empyemas. The most recent case, a disruption of a tracheoesophageal fistula stricture, was successfully treated with oral water irrigation and antibiotics only. Six had colonic interposition (all caustic ingestion), one required endoesophageal resection of a distal stricture, and four had resolution of the stricture, three without additional dilatation. The majority of children with iatrogenic injuries of the esophagus can be managed successfully by conservative measures and pleural drainage, with surgical procedures reserved for large disruptions of the esophagus, intraabdominal perforations, and cases that do not respond to appropriate conservative measures. Patients with caustic injury to the esophagus have a greater risk for the development of penetrating injury, and this may be one indicator of the severity of scarring. There are distinct clinical patterns of presentation, which depend on the level at which the esophagus is perforated. Dilatation disruption of a localized stricture has a good long-term prognosis for the esophagus and may even cure the stricture. The role of oral irrigation still must be fully evaluated where disruption has occurred as distinct from a penetrating injury.

Esophageal perforation: a continuing challenge

Perforation of the esophagus remains a diagnostic and therapeutic challenge. Currently, the most common cause of perforation is instrumentation of the esophagus, and the incidence of esophageal perforations has increased as the use of endoscopic procedures has become more frequent. Diagnosis depends on a high degree of suspicion and recognition of clinical features, and is confirmed by contrast esophagography or endoscopy. Outcome after esophageal perforation is dependent on the cause and location of the injury, the presence of underlying esophageal disease, and the interval between injury and initiation of treatment. Reinforced primary repair of the perforation is the most frequently employed and preferable approach to the surgical management of esophageal perforations. Nonoperative management consisting of antibiotics and parenteral nutrition is particularly successful for limited esophageal injuries meeting proper selection criteria.

Unusual problems in oesophageal surgery in childhood

Unusual problems in oesophageal surgery in childhood include problems seen both frequently and infrequently. The former includes oesophageal atresia, peptic oesophagitis and corrosive oesophagitis; the latter includes such conditions as neonatal rupture of the oesophagus, explosive rupture of the oesophagus, achalasia of the cardia, pharyngo-oesophageal fibromatosis, nasogastric intubation stricture and stricture in the immunologically compromised patient. Examples of all of these conditions have been presented and reference has also been made to a wide variety of other conditions which have been reported in the literature. Because diagnostic delay is relatively common it is important for the paediatric surgeon carefully to evaluate the symptom of dysphagia when it is present and appreciate the fact that although organic disease in childhood is relatively uncommon there are many conditions which demand diagnosis and appropriate treatment.