Redo Slide Tracheoplasty and Esophagoplasty in a Child Following Button Battery Ingestion

This video presents the case of the third redo slide tracheoplasty and esophagoplasty following a button battery ingestion in a previously healthy fifteen-month-old child.

The patient presented to the emergency department due to vomiting and a possible foreign body ingestion. A sibling had reported that the patient licked a battery and possibly had it in her mouth. Due to confusion in the emergency department, a chest X-ray was not obtained and the patient was discharged. The patient represented six days later with fevers, difficulty eating solids, increased work of breathing (WOB), and hoarseness. Following lateral chest X-ray, the patient was taken to the OR and was found to have significant erosion of the posterior tracheal wall with edema, tracheal narrowing, and significant eschar with likely perforation. A large button battery was noted in the esophagus with significant eschar and anterior perforation. 

The patient then underwent a slide tracheoplasty and tracheoesophageal fistula (TEF) repair 19 days later. She then underwent a repeat slide tracheoplasty, esophagoplasty with a bovine pericardial patch, and anterior pericardial reconstruction five days later following demonstration of tracheal dehiscence on bronchoscopy. The patient was electively placed on percutaneous cervical VA ECMO due to poor ventilation and large volume air leaks synchronous with the ventilator four days later. A repeat bronchoscopy demonstrated dehiscence of trachea in anterolateral aspects and the esophagus was noted to have a small leak. Given the dehiscence, the patient was removed from the ventilator and was fully supported on ECMO.

During the hospitalization, the patient developed Burkholderia cepacia bacteremia with positive cultures from her PICC, which was treated with Bactrim and ceftazidime. She also developed Strep oralis and ampicillin-susceptible E. Faecalis mediastinitis. Subsequently, the patient was transferred on VA ECMO on an international medical flight to Cincinnati Children’s Hospital Medical Center for evaluation.

The patient was taken to the operating room two days after her arrival. The otolaryngology team harvested a 1 cm x 4 cm right tibial periosteum patch. A 20 Fr esophageal bougie was placed and a redo sternotomy was completed. Sternal wires were loose and easily removed. The sternum was devascularized and disintegrated upon reopening, and there was frank pus in the mediastinum. The innominate vein and artery were then mobilized to enhance exposure of the trachea. The right pulmonary artery was also mobilized to expose the carina and mainstem bronchi. The trachea was mobilized anteriorly from above the lower edge of the thyroid gland to the carina with preservation of the lateral stalks. The left pulmonary ligament was divided, providing release of hilar tension.

A large tracheal perforation was immediately noted, and the endotracheal tube was visualized. The trachea was transected in the area of the posterior perforation. The trachea was then separated from the esophagus along the invaginated mucosal ledges. This separation was carried beyond the carina to fully separate the esophagus. A large esophageal perforation, around 3 cm, was noted and the esophageal bougie was easily visualized.

Next, the esophageal edges were debrided. The esophagus was closed using a 4-0 PDS suture in an interrupted horizontal mattress fashion over the esophageal bougie and the nasogastric tube. The esophageal bougie was then removed and the esophagus was oversewn with a continuous suture of 4-0 PDS. The tibial periosteal graft was placed overlying the suture line between the esophagus and trachea. Fibrin glue was applied over the esophageal suture line and tibial graft.

The edges of the trachea were then debrided with scissors. The tracheal anastomosis was run circumferentially starting at the midline and then out laterally on both sides with a continuous suture of 5-0 PDS. The anastomosis was continued cephalad along the lateral edges, meeting on the anterior aspect of the trachea. The anastomosis was then secured. A pedicled autologous pericardial flap was created and used to cover the anterior and lateral aspects of the trachea. This patch was tacked to the trachea with simple interrupted 4-0 PDS sutures. The lungs were then suctioned and ventilated. A leak test was performed after the patient was nasally intubated (4.0 mcETT). There was no air leak to 30 cm of H2O pressure. Fibrin glue was placed along the anastomosis line.

Next, VA-ECMO support was weaned, and the patient was separated without difficulty. The patient was decannulated from cervical VA-ECMO. The right carotid artery was repaired with a series of interrupted 7-0 Prolene sutures. The internal jugular vein was repaired with a continuous 7-0 Prolene suture. Both vessels demonstrated good flow with a doppler probe.

Finally, vancomycin paste was applied to the neck and sternal edges and the neck was closed in layers. The chest was reconstructed with a series of interrupted 4-0 PDS suture, suprasternal tissue, and a sternal wire weave. The incision was closed in layers and a negative pressure dressing was placed.

The patient’s postoperative course was relatively uncomplicated. The patient was extubated on postoperative day 25 to a high-flow nasal cannula and subsequently weaned to room air on postoperative day 29. The patient was discharged home on postoperative day 33.

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