E. A. Onwuka1, P. Saadai1, L. A. Boomer2, B. C. Nwomeh1 1Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA 2LeBonheur Children’s Hospital,Pediatric Surgery,Memphis, TENNESSEE, USA
Introduction:
Esophageal perforation in neonates occurs most often in cases of extreme prematurity. Common etiologies include orogastric (OG) tube placement, endotracheal intubation, and endoscopy. Mortality as high as 29% has been reported. Treatment over the last decade has leaned towards non-operative management with nil per os (NPO), total parenteral nutrition (TPN), antibiotics, and radiographic examination prior to the re-institution of oral feeds. To date, treatment duration for non-operative management has not been well studied, therefore neonates may experience unnecessarily prolonged periods of enteral feed disruption and antibiotic exposure. The purpose of this study was to review cases of esophageal perforation in neonates to assess the outcomes of non-operative management.
Methods:
A retrospective chart review was performed of patients under one year of age with ICD-9 code 530.4 for esophageal perforation treated at our institution between the years of 2009 and 2015. Data collected included demographic information, etiology of perforation, treatment course, time to resumption of enteral feeds, length of antibiotic use, time to subsequent radiographic resolution, and mortality.
Results:
Twenty-nine patients met study criteria. The etiologies of perforation were orogastric tube placement (n=26) and esophageal dilation for stricture (n=1). Three patients with a primary surgical diagnosis (diaphragmatic hernia, esophageal atresia, non-accidental trauma) were analyzed separately. Of the 26 patients with a non-surgical etiology for esophageal perforation, the average post-conceptual age at time of diagnosis was 27 ± 3.3 weeks. All 26 patients were managed non-operatively for the esophageal perforation. All were kept NPO with TPN and were placed on broad-spectrum antibiotics. Enteral feeds were resumed after a median of 8 days [Interquartile Range (IQR): 7-11]. Median antibiotic duration was 7 days (IQR: 7-9.8), and the median time to follow-up esophagram was 7 days (IQR: 7-9.8). Twenty-five of 26 patients (96%) demonstrated radiological resolution of perforation on initial follow-up esophagram, with only one requiring a second study. Five patients expired during the study period, but no deaths were related to the diagnosis of esophageal perforation.
Conclusion:
In this largest reported sample of neonates treated for esophageal perforation, non-operative treatment with NPO, TPN, antibiotics, and follow-up esophagram was successful. In addition, all but one neonate demonstrated radiographic resolution of perforation by the time of initial esophagram. This data suggests that further investigation of a shorter duration for non-operative management and time to contrast study may be warranted, thus reducing the morbidities associated with enteral feed interruption and antibiotic administration.