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Esophageal perforation secondary to gastrostomy tube replacement
Esophageal Perforation Secondary to Gastrostomy Tube Replacement By Kenneth Kenigsberg and Jack Levenbrown Manhasset and N e w York, N e w York 9 A 6-week-old child with esophageal perforation secondary to a misplaced gastromy Foley balloon is described. She was treated successfully with chest tube drainage, antibiotics, and total parental nutrition. This may be an alternative method of treating this rare complication of gastrostomy. 9 1986 by Grune & Stratton, Inc. INDEX WORDS: Esophageal perforation; gastrostomy.
UBE GASTROSTOMY is a frequent concomitant of tracheoesophageal fistula repair. However, the performance of a gastrostomy in newborn infants is not without problems. Haws et al ~reviewing 240 cases found a 5.8% incidence of major complications. One of the unusual complications reported by these authors was a child who had suffered a perforated esophagus. This had been caused by the reinsertion of a Foley catheter that had passed into the esophagus rather than the stomach. The perforation, presumably, was caused by the inflation of the balloon in the lower esophagus. This child underwent cervical esophagostomy and oversewing of the distal esophagus 14 days after the perforation. The patient did not survive. The authors also referred to another patient who had suffered a similar rupture from a misplaced Foley balloon. Abrams and Kiely2 reported a perforation. This child was successfully treated with primary closure shortly after the rupture had occurred. Frech et al 3 reported two children who had suffered perforated esophagus secondary to reinsertion of Foley catheters. However, they ascribed the perforation to obstruction of the pylorus due to the misplaced Foley balloon. Both these patients were successfully operated upon but required sacrifice of the esophagus.
T
CASE REPORT J.P. was born prematurely weighing 1,930 g. She had esophageal atresia with an upper pouch and lower fistula. On the first day of life, she underwent gastrostomy and total tracheoesophageal fistula repair. A leak developed at the anastomosis but closed spontaneously. Before discharge from the hospital, an esophogram was performed and
From the Departments of Surgery and Radiology, North Shore University Hospital, 300 Community Dr, Manhasset, New York 11030, and the Departments of Surgery and Radiology, Cornell University Medical College, New York. Address reprint requests to Jack Levenbrown, MD, North Shore University Hospital, Division of Pediatric Radiology, 300 Community Dr, Manhasset, IVY 11030. 9 1986 by Grune & Stratton, Inc. 0022-3468/86/2111~011503.00/0 946
showed minimal narrowing at the area of the anastomosis and a moderate degree of gastroesophageal reflux. The gastrostomy tube was still in place. One week after discharge, the no. 14 Malecot catheter that had originally been used fell out of the gastrostomy opening and was replaced with a no. 14 Foly catheter. The catheter was introduced without resistance, the balloon inflated easily with 5 mL of saline and appeared to seat well against the underside of the abdominal wall. The catheter irrigated easily. Several hours later, the child was seen again because the mother said the patient was not feeding well. The catheter was withdrawn and replaced with the original no. 14 Malecot catheter. The next day, the child was seen again because she was not feeding well. It was assumed that the patient had some degree of stricture at the anastomotic site. An esophagram with barium offered in a bottle was attempted. The patient would not suck, so a no. 8 infant feeding tube was introduced into the upper esophagus and an esophagram performed. The study showed a large esophageal perforation immediately above the gastroesophageal junction with the barium tracking superiorly in the posterior mediastinum to the level of the aortic arch. There was no evidence of gastric outlet obstruction (Fig 1). Within an hour of the exam, the infant's condition deteriorated markedly. She became ashen grey, was poorly responsive and hypotensive. It was assumed that the baby had gram negative sepsis caused by the barium and secretions entering the mediastinum through the rent in the esophagus. Blood cultures later grew out E coli and Pseudomonas. She responded promptly to treatment with antibiotics, fluids, and steroids. Later on the day of admission, a lateral decubitus film was obtained, which demonstrated layering of the extravasated barium. A chest tube was inserted retropleurally, since the initial operation had been done retropleurally, and the majority of the barium was evacuated. By the time the child was fully resuscitated, the perforation was about 24 hours old. It was thought that primary repair, particularly in the face of known reflux, would be unsuccessful at this time. Repair and exclusive as described by Urschel et aP was considered. However, the patient appeared to be doing so well at this time that it was decided to defer any surgery. The child continued to do well and five days after admission to the hospital, a broviac catheter was inserted. Total parental nutrition was started and continued for 5 weeks. Two weeks after admission, a repeat gastrografin study showed a persistant leak at the lower end of the esophagus. The patient, however, was thriving and gaining weight normally. Antibiotics were continued. After 4 weeks of treatment, the gastrografin esophagram showed no perforation and a normal esophageal lumen (Fig 2). The antibiotics were discontinued, the broviac cather was withdrawn, and the patient was fed by mouth. During the entire hospitalization, growth had continued at a normal rate. One week after discharge, the gastrostomy tube was withdrawn. The patient has continued to feed well by mouth and has remained asymptomatic. DISCUSSION
This newborn infant with a large distal esophagael perforation could have been treated in a number of Journal of Pediatric Surgery, Vol 21, No 11, (November), 1986: pp 946-947
ESOPHAGEAL PERFORATION
947
Fig 1. Marked extravasation of contrast material from perforation of the lower esophagus.
ways. P r i m a r y repair as a d v o c a t e d by A b r a m s and Kiely, 2 g a s t r o s t o m y with double g a s t r o s t o m y as advocated by S h o r - P i n s k e r et al, 5 and exclusion with diversion as a d v o c a t e d by Urschel et al 4 were considered. However, in this case, the clinical i m p r o v e m e n t following d r a i n a g e and antibiotics a p p e a r e d to j u s t i f y non-
Fig 2. Esophagram obtained 1 month after admission showing contrast passing into the stomach and no evidence of extravasation.
operative m a n a g e m e n t . W i t h the addition of total p a r e n t a l nutrition, the patient continued to gain t h r o u g h o u t the hospitalization and healed the perforation without difficulty.
REFERENCES
1. Haws EB, Sleber WK, Klesewetter WB: Complications of tube gastrostomy in infants and children. Ann Surg 164:284-290, 1966 2. Abrams LD, Kiely EM: Oesophageal rupture due to gastrostomy catheter. Z Kinderchir 33:274 275, 1981 3. Frech RS, Roper C, McAlister WH: Esophageal rupture
secondary to pyloric obstruction by a gastrostomy Foley catheter balloon. J Can Assoc Radiol 21:263-265, 1970 4. Urschel HC, Razzuk MA, Wood RE, et al: Improved management of esophageal perforation. Ann Surg 587-591, 1974 5. Shor-Pinsker E, Silva-Cuevas A, Franco-Vazquez, et al: Gastrotomy with double gastrostomy in the perforation of the esophagus. Arch Surg 101:433-435, 1970
UBE GASTROSTOMY is a frequent concomitant of tracheoesophageal fistula repair. However, the performance of a gastrostomy in newborn infants is not without problems. Haws et al ~reviewing 240 cases found a 5.8% incidence of major complications. One of the unusual complications reported by these authors was a child who had suffered a perforated esophagus. This had been caused by the reinsertion of a Foley catheter that had passed into the esophagus rather than the stomach. The perforation, presumably, was caused by the inflation of the balloon in the lower esophagus. This child underwent cervical esophagostomy and oversewing of the distal esophagus 14 days after the perforation. The patient did not survive. The authors also referred to another patient who had suffered a similar rupture from a misplaced Foley balloon. Abrams and Kiely2 reported a perforation. This child was successfully treated with primary closure shortly after the rupture had occurred. Frech et al 3 reported two children who had suffered perforated esophagus secondary to reinsertion of Foley catheters. However, they ascribed the perforation to obstruction of the pylorus due to the misplaced Foley balloon. Both these patients were successfully operated upon but required sacrifice of the esophagus.
T
CASE REPORT J.P. was born prematurely weighing 1,930 g. She had esophageal atresia with an upper pouch and lower fistula. On the first day of life, she underwent gastrostomy and total tracheoesophageal fistula repair. A leak developed at the anastomosis but closed spontaneously. Before discharge from the hospital, an esophogram was performed and
From the Departments of Surgery and Radiology, North Shore University Hospital, 300 Community Dr, Manhasset, New York 11030, and the Departments of Surgery and Radiology, Cornell University Medical College, New York. Address reprint requests to Jack Levenbrown, MD, North Shore University Hospital, Division of Pediatric Radiology, 300 Community Dr, Manhasset, IVY 11030. 9 1986 by Grune & Stratton, Inc. 0022-3468/86/2111~011503.00/0 946
showed minimal narrowing at the area of the anastomosis and a moderate degree of gastroesophageal reflux. The gastrostomy tube was still in place. One week after discharge, the no. 14 Malecot catheter that had originally been used fell out of the gastrostomy opening and was replaced with a no. 14 Foly catheter. The catheter was introduced without resistance, the balloon inflated easily with 5 mL of saline and appeared to seat well against the underside of the abdominal wall. The catheter irrigated easily. Several hours later, the child was seen again because the mother said the patient was not feeding well. The catheter was withdrawn and replaced with the original no. 14 Malecot catheter. The next day, the child was seen again because she was not feeding well. It was assumed that the patient had some degree of stricture at the anastomotic site. An esophagram with barium offered in a bottle was attempted. The patient would not suck, so a no. 8 infant feeding tube was introduced into the upper esophagus and an esophagram performed. The study showed a large esophageal perforation immediately above the gastroesophageal junction with the barium tracking superiorly in the posterior mediastinum to the level of the aortic arch. There was no evidence of gastric outlet obstruction (Fig 1). Within an hour of the exam, the infant's condition deteriorated markedly. She became ashen grey, was poorly responsive and hypotensive. It was assumed that the baby had gram negative sepsis caused by the barium and secretions entering the mediastinum through the rent in the esophagus. Blood cultures later grew out E coli and Pseudomonas. She responded promptly to treatment with antibiotics, fluids, and steroids. Later on the day of admission, a lateral decubitus film was obtained, which demonstrated layering of the extravasated barium. A chest tube was inserted retropleurally, since the initial operation had been done retropleurally, and the majority of the barium was evacuated. By the time the child was fully resuscitated, the perforation was about 24 hours old. It was thought that primary repair, particularly in the face of known reflux, would be unsuccessful at this time. Repair and exclusive as described by Urschel et aP was considered. However, the patient appeared to be doing so well at this time that it was decided to defer any surgery. The child continued to do well and five days after admission to the hospital, a broviac catheter was inserted. Total parental nutrition was started and continued for 5 weeks. Two weeks after admission, a repeat gastrografin study showed a persistant leak at the lower end of the esophagus. The patient, however, was thriving and gaining weight normally. Antibiotics were continued. After 4 weeks of treatment, the gastrografin esophagram showed no perforation and a normal esophageal lumen (Fig 2). The antibiotics were discontinued, the broviac cather was withdrawn, and the patient was fed by mouth. During the entire hospitalization, growth had continued at a normal rate. One week after discharge, the gastrostomy tube was withdrawn. The patient has continued to feed well by mouth and has remained asymptomatic. DISCUSSION
This newborn infant with a large distal esophagael perforation could have been treated in a number of Journal of Pediatric Surgery, Vol 21, No 11, (November), 1986: pp 946-947
ESOPHAGEAL PERFORATION
947
Fig 1. Marked extravasation of contrast material from perforation of the lower esophagus.
ways. P r i m a r y repair as a d v o c a t e d by A b r a m s and Kiely, 2 g a s t r o s t o m y with double g a s t r o s t o m y as advocated by S h o r - P i n s k e r et al, 5 and exclusion with diversion as a d v o c a t e d by Urschel et al 4 were considered. However, in this case, the clinical i m p r o v e m e n t following d r a i n a g e and antibiotics a p p e a r e d to j u s t i f y non-
Fig 2. Esophagram obtained 1 month after admission showing contrast passing into the stomach and no evidence of extravasation.
operative m a n a g e m e n t . W i t h the addition of total p a r e n t a l nutrition, the patient continued to gain t h r o u g h o u t the hospitalization and healed the perforation without difficulty.
REFERENCES
1. Haws EB, Sleber WK, Klesewetter WB: Complications of tube gastrostomy in infants and children. Ann Surg 164:284-290, 1966 2. Abrams LD, Kiely EM: Oesophageal rupture due to gastrostomy catheter. Z Kinderchir 33:274 275, 1981 3. Frech RS, Roper C, McAlister WH: Esophageal rupture
secondary to pyloric obstruction by a gastrostomy Foley catheter balloon. J Can Assoc Radiol 21:263-265, 1970 4. Urschel HC, Razzuk MA, Wood RE, et al: Improved management of esophageal perforation. Ann Surg 587-591, 1974 5. Shor-Pinsker E, Silva-Cuevas A, Franco-Vazquez, et al: Gastrotomy with double gastrostomy in the perforation of the esophagus. Arch Surg 101:433-435, 1970