A. J. Hesketh1,2, C. A. Behr1,3, S. Z. Soffer1,3, A. R. Hong1,3, R. D. Glick1,3 1Cohen Children’s Medical Center,Division Of Pediatric Surgery,New Hyde Park, NY, USA 2Elmezzi Graduate School Of Molecular Medicine,Manhasset, NY, USA 3Hofstra North Shore-LIJ School Of Medicine,Hempstead, NY, USA
Introduction: Esophageal perforation is a rare complication of enteric instrumentation in children, most commonly following endoscopy for stricture dilation or foreign body extraction. In preterm and low birth weight infants, enteric tube placement for suction or feeding poses a particular hazard to the delicate esophagus. Esophageal perforation in neonates due to oro/nasogastric tube insertion may be misdiagnosed as esophageal atresia or may go undiagnosed altogether. Historically, management of this life-threatening iatrogenic disease was operative, until case reports published over the last several decades described successful non-operative management. In the present study, we review neonatal esophageal perforations at our own institution in an effort to evaluate management techniques, risk factors and outcomes.
Methods: Our institution’s clinical database was queried for the ICD-9 code for esophageal perforation. Seventeen patients were identified, and 9 were excluded because they were older than one year. The charts of the remaining 8 patients were retrospectively reviewed for the following information: age and sex, demographics, comorbidities, cause and type of perforation, diagnostic modalities, management decisions, complications and outcomes. All study components were conducted in accordance with institutional review board policies.
Results: All 8 patients had esophageal perforations resulting from traumatic esophageal intubations. Six of the 8 patients were preterm, with a mean gestational age of 27.2 ± 4 weeks and birth weight of 862 ± 690 grams. The average age at diagnosis was 7 ± 6.6 days with 5 patients diagnosed within the first week of life. In all 8 patients, chest x-ray was the initial radiologic modality utilized and a non-operative approach was instituted as the initial management plan. Six patients ultimately required surgical intervention, 5 for pneumothoraces (tube thoracostomy) and one for a large thoraco-abdominal air leak (peritoneal drain insertion). Three patients died due to sequelae of prematurity (grade IV IVH and subsequent withdrawal of care, fungemia from NEC, and sepsis from chorioamnionitis). Treatment strategies included removal of the offending tube, non per os and antibiotics. One patient was diagnosed as having esophageal atresia prior to transfer to our institution; esophagoscopy in the operating room prior to operative repair of the presumed esophageal atresia established the correct diagnosis of an esophageal perforation.
Conclusion: Preterm, extremely low birth weight neonates are at significant risk for traumatic esophageal perforation during nasogastric or orogastric intubation. Non-operative management may be a safe initial management of esophageal perforation in the neonatal setting, but surgical interventions are often eventually indicated. Although recent early recognition and awareness of this iatrogenic disease has improved, missed and incorrect diagnoses still occur.