Tracheoesophageal Fistula Research Articles

Successful Repair of Esophageal Atresia with Tracheoesophageal Fistula and Interrupted Inferior Vena Cava: A Rare Case Report

【Abstract】Esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a congenital anomaly that can present complex surgical challenges, especially when accompanied by rare vascular conditions like an interrupted inferior vena cava (IVC). The division of the azygos vein is a common part of TEF repair, but in the presence of an interrupted IVC, this can lead to life-threatening complications. We report the case of a newborn diagnosed with EA, TEF, and interrupted IVC, successfully treated through thoracotomy. This case underscores the importance of prenatal and postnatal imaging to diagnose vascular anomalies prior to TEF repair, ensuring the preservation of the azygos vein to prevent fatal outcomes. Raising awareness of this rare association is crucial to optimizing surgical planning and outcomes.

Lethal Complication of Postairway Stenting to Trachea and Left Main Bronchus: A Case Series with Discussion of the Diagnosis and Management

Abstract The insertion of a metallic airway stent is a valuable method for the treatment of benign and malignant airway stenosis and tracheoesophageal fistula. Although stenting for airway stenosis has become widely popular with favorable outcomes, several complications can arise after stenting, such as migration, tendency for stent fracture, and ingrowth of tumor or granulation tissue into the stent. Very few of these reports have described the complications of poststenting pneumothorax. We report the cases of three patients diagnosed with squamous cell carcinoma of the esophagus, complicated by tracheoesophageal fistula, and treated with a tracheal stent or bronchial stent, who developed poststenting pneumothorax.

Thoracoscopic Repair for Kluth Type Ⅲb3 Esophageal Atresia and Distal TracheoesophagealFistula

IntroductionThis report aims to present our initial miniseries of successful thoracoscopic repair for esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) of Kluth type Ⅲb3 in accordance with Kluth's classification. MethodsFrom January 2012 to January 2024, ten patients with Kluth type Ⅲb3 EA-TEF were treated by thoracoscopic surgery. The therapeutic methods and surgical outcomes were retrospectively reviewed. ResultsAll procedures were completed thoracoscopically without conversions. A preoperative bronchoscopy assessment was conducted in four of the cases, revealing that the fistula from the distal segment was located high on the trachea at the level of T2 vertebral. The mean age of the patients at the time of operation was 2.0 ± 0.7 d (range, 1-3 d), and the mean weight at operation was 2.6 ± 0.4 kg (range, 1.8-3.0 kg). The mean operative time (skin to skin) for the entire series was 137.0 ± 8.9 min (range, 120-150 min). Oral feeding was initiated on the postoperative day 8.0 ± 1.9 (range, 6-12 d), and the mean duration for patients after surgery was 14.0 ± 2.4 d (range, 12-20 d). The postoperative period has been uneventful with no occurrences of mortality or morbidity to date. Three cases of formatted anastomotic stricture required at least one esophageal dilation after surgery. ConclusionsPediatric surgeons should be aware of the rare variants of EA-TEF to avoid the diagnostic and management pitfalls. Patients with Kluth type Ⅲb3 EA-TEF were amenable to repair by thoracoscopic surgery.

Esophagitis, treatment outcomes, and long-term follow-up in children with esophageal atresia.

Survival rates in children born with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) have improved; however, morbidity associated with the disease remains high. This study aimed to assess the prevalence of gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), fungal esophagitis, esophageal strictures, and long-term outcomes in children with EA/TEF. We conducted a retrospective chart review on patients with EA/TEF who were seen at Children's Wisconsin from January 2003 to January 2023. Patients born with EA/TEF were included if they underwent at least one endoscopy after 1 year of age. GERD was diagnosed based on abnormal findings on endoscopy, pH-metry, and/or history of fundoplication. EoE and fungal esophagitis were diagnosed based on abnormal endoscopy. Esophageal stricture diagnosis was based on findings on endoscopy and/or esophagram, and clinical symptoms necessitating esophageal dilation. Eighty-five patients (64.7% males, mean age 7.5 years) were included, the majority had type C EA/TEF (90.6%). GERD was diagnosed in 61.1% (n = 52), 49.4% (n = 42) by macro and/or microscopic endoscopic findings, 22.3% (n = 19) by abnormal pH-metry, and 21.1% (n = 18) by the need for fundoplication for refractory reflux and/or esophageal stricture. Risk of GERD increased with lower gestational age (p = 0.0030), lower birth weight (p = 0.023), and long-gap EA (p = 0.034). In children diagnosed with GERD, only 13.4% of patients (n = 7/52) were able to be weaned off proton pump inhibitor (PPI) without disease recurrence. However, overall, at the completion of the study, 44.7% (n = 38) of patients were successfully weaned off PPI without evidence of GERD. EoE was diagnosed in 20% of the patients (n = 17). All patients diagnosed with EoE required escalation of therapy from PPI alone to swallowed corticosteroids in 52.9% (n = 9), dupilumab in 23.5% (n = 4), elemental formula in 17.6% (n = 3), and elemental formula and swallowed steroids in 5.8% (n = 1). Fungal esophagitis was diagnosed in 15.3% of patients (n = 13). An esophageal stricture requiring dilation was diagnosed in 77.6% (n = 66) of patients at a mean age of 28.5 months, with over 60% diagnosed by 24 months of age. Children born with EA/TEF continue to be at high risk of developing GERD, EoE, fungal esophagitis, and esophageal stenosis. Diagnostic and therapeutic endoscopy remains a high-yield test to identify and treat these comorbidities.

Surgical management protocol for disk battery ingestion.

Disk battery (DB) ingestion in children can lead to severe complications and mortality. This study details our experience in managing DB ingestion and its complications. We analyzed data from all patients treated for DB ingestion at our hospital from June 2010 to January 2024. A protocol established in 2010 requires angio-CT scans for esophageal DB cases and a multidisciplinary approach involving gastroenterologists, otolaryngologists, pediatric and airway surgeons, and cardiac surgeons. We treated 22 patients. In June 2010, following the tragic death of a patient from an undiagnosed DB ingestion that led to an aortoesophageal fistula, our protocol was established. All DBs were removed endoscopically. Four patients needed additional surgery: two had tracheal resection/anastomosis and esophageal repair for large tracheoesophageal fistulas; one required aortic wall reinforcement with a patch; one underwent endoscopic removal with a sternal split to explore the aortic arch. All 22 patients survived and recovered clinically. One developed bilateral vocal cord palsy as a complication. Effective management of DB ingestion complications necessitates a collaborative, multidisciplinary approach. Our protocol has improved management strategies and patient outcomes.

The Hidden Culprit: A Computed Tomography Diagnosis of H-Type Tracheoesophageal Fistula in an Adult Revealed After Two Decades of Pulmonary Infections

The Hidden Culprit: A Computed Tomography Diagnosis of H-Type Tracheoesophageal Fistula in an Adult Revealed After Two Decades of Pulmonary Infections

Closure of a secondary tracheoesophageal fistula in severe pneumonia using an Amplatzer Duct Occluder II during invasive mechanical ventilation: A case report.

Early and timely closure of secondary tracheoesophageal fistula (TEF) is crucial for critically ill patients. For those requiring invasive mechanical ventilation, the Amplatzer Duct Occluder II (ADO II) can be used as an emergency therapeutic option to rapidly close secondary TEF, providing opportunities for subsequent treatments. Secondary tracheoesophageal fistula (TEF) is a life-threatening condition characterized by high mortality, high recurrence rates, and multiple complications. Reports on the management of secondary TEF in critically ill patients are limited due to the challenges in treatment and the lack of suitable therapeutic options. We report a case of secondary TEF in a 69-year-old male diagnosed with severe pneumonia, whose condition deteriorated rapidly following the onset of TEF. Despite invasive mechanical ventilation, maintaining blood oxygen saturation above 80% was unachievable due to the TEF. Bedside bronchoscopy revealed expansion TEF expansion caused by gastrointestinal fluid reflux and respiratory machine pressure. The TEF was urgently closed using an ADO II device during invasive mechanical ventilation to prevent further deterioration. After the patient's condition stabilized, the ADO II was replaced with a Y-shaped tracheal membrane-covered stent for further TEF management. The patient's condition improved, meeting the criteria for liberation from invasive mechanical ventilation, and bedside chest X-rays revealed a gradual resolution of pulmonary inflammation. Selecting appropriate treatment modalities for early and timely closure of secondary TEF is crucial for critically ill patients. ADO II can serve as a rescue therapy to achieve rapid closure of secondary TEF in critically ill patients requiring invasive mechanical ventilation support, providing opportunities and time for subsequent treatment.

Anastomotic Leak and its Implications: A Multicenter Analysis of “Type C” Esophageal Atresia / Tracheo-esophageal fistula (EA/TEF)

PurposeRepair of type C esophageal atresia with tracheo-esophageal fistula (EA/TEF) may be complicated by esophageal anastomotic leak. Risk factors associated with leak and the impact of leak on inpatient outcomes remains uncertain. Our objectives are to estimate the associations between clinical factors and esophageal anastomotic leak and quantify the association of leak with length of stay (LOS) in infants who underwent repair of type C EA/TEF. MethodsUsing the Children’s Hospitals Neonatal Database (CHND), we identified infants with type C EA/TEF from 2021-2023. The main outcomes were anastomotic leak and LOS. Multivariable associations between patient and clinical factors and these outcomes were quantified using logistic regression (leak) and Cox proportional hazards modelling (LOS). ResultsAmong 365 infants at 36 centers, anastomotic leak occurred in 55 (15.1%) infants, and thoracoscopic approach, lower birthweight, small for gestational age less than 10th percentile, male sex, staged repair, ventricular septal defect, and center were independently associated with leak (area under receiver operating curve = 0.853). Also, LOS was increased in infants with leak compared to those without [hazard ratio (HR): 0.655, 95% CI = 0.431 – 0.996, p=0.044], independent of birth weight, surgical approach, male sex, or VSD. The adjusted LOS demonstrated a 11-fold inter-center variation (p=0.034). ConclusionsSeveral clinical and operative factors are associated with esophageal anastomotic leak in infants after type C EA/TEF repair. Leak significantly prolongs LOS. The magnitude of inter-center variability in LOS also suggests that identifying best practices could aid in improving patient care in this patient population. Type of StudyRetrospective Comparative Study Level of EvidenceIII

Incidence of associated anomalies in children with anorectal malformation: A 1-year prospective observational study in a low-income setting.

Anorectal malformations (ARMs) consist of a range of anomalies that are often associated with other anomalies The purpose of the study is to assess the incidence of associated congenital anomalies that are seen in patients with ARMs. An observational prospective study was conducted on 162 cases with ARM from February 2019 to January 2020, and data were collected on patient demographics, type of ARM, and associated anomalies using a prestructured questionnaire and analysis done using SPSS (IBM), version 23, software. Relevant statistical analysis was done, and the results are presented in tables and charts. Of 162 cases studied, 70 of them were males and 92 were females with a male-to-female ratio of 0.76:1. The majority of male patients (45%) had rectourethral fistulas, whereas 63% of the females had rectovestibular fistula. While 76 (47%) patients presented with isolated ARM, 86 (53%) had ≥1 associated congenital malformations. Forty-eight (30%) patients presented with a single associated anomaly, whereas 20 (12%) patients had≥3 associated anomalies. The commonest associated anomalies were urologic 26.5% followed by genital (22.8%), cardiac 20.4%, and musculoskeletal 16.6%, and 12.3% of them had vertebral; anorectal; cardiac; tracheoesophageal fistula; renal; limb association. More than half of the children have other associated abnormalities. We found urogenital anomalies to be the most common associated congenital defects. A lower incidence of cardiac and spinal cord anomalies was noted suggesting a need for active workup to be in line with the latest standards of care.

Flexible Endoscopic Management of Tracheo-oesophageal Magnet Foreign Bodies with Acquired Fistula in a Toddler.

Aerodigestive foreign bodies (FBs) aspiration is a common problem in children; however, simultaneous aerodigestive localisation is rare. Ingestion of multiple magnetic FBs can lead to serious complications, especially tracheo-oesophageal fistula and recurrent chest infections. These depend on the duration of foreign-body ingestion/aspiration, prompt intervention and adequate technique for foreign-body retrieval. A 1.8-year-old female child was found to have two magnetic FBs lodged simultaneously in the oesophagus and trachea. The magnetic FBs in the aerodigestive tract in children were removed in the same session using flexible endoscopes.

Acquired tracheoesophageal fistula following rubber toy ingestion.

We depict an uncommon presentation of rubber toy ingestion which remained impacted in the esophagus for months, gradually eroding the mucosa, and ultimately causing a traumatic acquired tracheoesophageal fistula.

Critical Role of Pleural Wrap and Post-operative Neonatal Protocol in Long-gap Oesophageal Atresia: A Team Effort.

The objectives of this study were to bring out the results of application of pleural wrap in primary repair of tracheo - esophageal fistula (TEF) with long-gap oesophageal atresia (LGEA) and also define the role of neonatologists and paediatric intensivists in post-operative management in these patients by laying down standard neonatal management protocol. This was a retrospective descriptive observational study conducted between March 2011 and April 2019 on 23 cases of LGEA with TEF. The study was conducted at two tertiary care paediatric surgery centres in Northern part of India wherein these newborn babies were operated by two paediatric surgeons with variable experience of 8-12 years. It also describes the neonatal management protocol used in post-operative period. Out of 23 patients, 15 were boys and 8 were girls, with a mean age of 32.25 weeks and a mean birth weight of 2.02 kg. The mean hospital stay was 23.5 ± 8 days. Eleven cases had gap between 3 and 3.5 cm, 8 cases between 3.5 and 4 cm and 4 cases had gap more than 4 cm. The incidence of associated anomalies was 52%. Anastomotic leak rate was 8.69%, and 3 (13.04%) patients died in the post-operative period. All the operated patients were managed postoperatively as per strict neonatal management protocol exclusively by the team of neonatologists and neonatal intensivists. Application of pleural wrap over anastomosis following primary repair of LGEA with TEF significantly reduced the incidence of anastomotic leak in our study. Apart from the pleural wrap, the key to successful outcome also is contributed by the little prolonged, controlled ventilation and patience and perseverance in post-operative feeds. This post-operative management protocol that has been followed by us in our study is easily reproducible and can be adopted by paediatric surgeons working alongside neonatologists as a team.

Development and validation of a realistic type III esophageal atresia simulator for the training of pediatric surgeons

BackgroundThe technical complexity and limited casuistry of neonatal surgical pathology limit the possibilities of developing the necessary technical competencies by specialists in training. Esophageal atresia constitutes the paradigm of this problem. The use of synthetic 3D models for training is a promising line of research, although the literature is limited.MethodsWe conceptualized, designed, and produced an anatomically realistic model for the open correction of type III oesophageal atresia. We validated it with two groups of participants (experts and non-experts) through face, construct, and content-validity questionnaires.ResultsThe model was validated by nine experts and nine non-experts. The mean procedure time for the experts and non-experts groups was 34.0 and 38.4 min, respectively. Two non-experts did not complete the procedure at the designed time (45 min). Regarding the face validity questionnaire, the mean rating of the model was 3.2 out of 4. Regarding the construct validity, we found statistically significant differences between groups for the equidistance between sutures, 100% correct in the expert group vs. 42.9% correct in the non-expert group (p = 0.02), and for the item “Confirms that tracheoesophageal fistula closure is watertight before continuing the procedure”, correctly assessed by 66.7% of the experts vs. by 11.1% of non-experts (p = 0.05). Concerning content validity, the mean score was 3.3 out of 4 for the experts and 3.4 out of 4 for the non-experts.ConclusionsThe present model is a cost-effective, simple-to-produce, and validated option for training open correction of type III esophageal atresia. However, future studies with larger sample sizes and blinded validators are needed before drawing definitive conclusions.

748. CAUSES, TREATMENT AND OUTCOMES OF CONDUIT NECROSIS FOLLOWING OESOPHAGECTOMY: A SINGLE CENTRE RETROSPECTIVE STUDY

Abstract Background Conduit necrosis (CN) following esophagectomy is a poorly described entity associated with high morbidity and mortality. Identifying factors associated with CN would help stratify patients at risk of this devastating complication. Furthermore, describing the outcomes of various treatment options may aid in personalising treatment to maximise the chance of recovery. The aim of this study was to describe the causes, treatment and outcomes of CN following esophagectomy. Methodology Between 01/2006 and 12/2023, a single centre retrospective review of a prospectively maintained comprehensive oesophageal cancer surgical database was performed. Complications data from the online Canadian Thoracic Surgery Quality Improvement Program was also utilized. All patients with oesophageal and junctional cancer who underwent transthoracic en bloc surgical resection were included. Defined as circumferential ischaemia of the neo-esophageal conduit identified on postoperative endoscopy, patients with CN were identified. Clinical and demographic data of these patients was compared to those with no documented history of conduit complications. The treatment and outcomes of CN were also recorded. Results Anastomotic leak occurred in 146/1043 patients (14.0%), CN in 39 (3.7%) and tracheo-oesophageal fistula in 7 (0.7%). Compared to the 853 patients without conduit complications, CN was associated with BMI >34.5kg/m2 (3/39 vs 15/853,p = 0.03), proximal lesions (5/39,12.9% vs 23/853,2.7%, p = 0.002) and McKeown oesophagogastrectomy (13/39,33.3% vs 125/853,14.7%, p=<0.001). Initially, endoscopic treatment, anastomotic refashioning, taking down the conduit and oesophagostomy was used in 14, 13, 8 and 4 patients (35.9%,33.3%,20.5% and 10.3%) with success rates of 7/14(50.0%), 6/13(46.2%), 4/8(50.0%), and 3/4(75.0%) respectively. The 90-day mortality of CN was 10.9% and associated with a prolonged hospital admission (median 46 vs 12 days, p=<0.001) Conclusion CN is an uncommon entity but associated with high morbidity, mortality and prolonged postoperative length of stay. Treatment decisions remain complex and whilst endoscopic management seems feasible, re-intervention is often required. Further understanding of how to improve salvage treatment in this unique cohort of patients is required.

777. COMBINED OESOPHAGEAL AND AIRWAY STENTING FOR MALIGNANT OESOPHAGEAL STRICTURES: THE UK’S LARGEST TERTIARY CENTRE EXPERIENCE AND DEVELOPMENT OF A NOVEL ALGORITHM

Abstract Background Malignant oesophageal strictures can cause airway compromise and fistula formation. Combined oesophageal and airway stenting is a potential treatment yet no guidelines exist. This study aims to describe the outcomes of same-session oesophageal and airway endoscopic stenting for malignant strictures and propose an algorithm for intervention. Methods A retrospective study on patients undergoing same-session gastroenterology (GI) and respiratory endoscopy at University College London Hospital, 2019-2023. All procedures were with anaesthetic-led propofol sedation. Endoscopic decision making was based on pre-procedure multidisciplinary team meeting (MDM) and intra-procedure clinical assessment. Data collected included malignancy type, luminal narrowing, complications, and mortality. Results 26 patients were identified. Mean age was 63 years. Cancer type was oesophageal (81%) or lung (19%). The most common referral indication was dysphagia (42%); airway compromise was often seen on imaging (65%). Stent insertion was oesophageal only (35%), airway only (19%) and dual (27%). Airway stenting was common (80%) if airway stenosis was >50%. No airway stenting occurred if stenosis was <50%. After oesophageal stenting, repeat bronchoscopy showed increased airway stenosis in 4 patients (25%). The only intraoperative complication was one oesophageal perforation. New tracheooesophageal fistula was the most common post-intervention complication (15%). Median time from malignancy diagnosis to death was 7.9 weeks. Conclusion We present the first algorithm (Figure 1) for endoscopic stenting in patients with malignant oesophageal stricture and airway involvement. We suggest upper GI and respiratory MDM to plan same-session endoscopy with decision-making framed by patient-centred goals given their poor prognosis.

534. EVALUATION OF SURGICAL OUTCOMES IN ROBOTIC-ASSISTED ESOPHAGECTOMY

Abstract Background The adoption of robotic surgery for the treatment of esophageal cancer is on the rise, with reports indicating favorable short-term outcomes. This study aims to evaluate the performance of robotic-assisted esophagectomies at our hospital. Methods We conducted a retrospective analysis of perioperative outcomes in patients who underwent robotic-assisted esophagectomies. Cases requiring a two-stage operation were excluded. Results A total of 64 cases were evaluated, with a median age of 72.0 years (range 46-83). Histological types included SCC/AC/ASC/Other: 49/10/1/4 cases. Clinical stages were 0/I/II/III/IVA/IVB: 1/20/11/27/4/1 cases, respectively. Postoperative complications, classified as Clavien-Dindo (CD) Grade II or higher, occurred in 24 cases (37.5%), which included respiratory complications (pneumonia, atelectasis, pneumothorax) in 7 cases (10.9%), anastomotic leakage in 7 cases (10.9%), recurrent laryngeal nerve palsy in 3 cases (4.7%), anastomotic stricture in 2 cases (3.1%), wound infection in 2 cases, gastric conduit necrosis in 1 case (1.5%), cervical lymphorrhea in 1 case, tracheoesophageal fistula in 1 case, and other complications in 3 cases. Conclusion Robotic-assisted esophagectomies have demonstrated favorable short-term outcomes when compared with prior reports. Further studies are warranted to elucidate the reduction of complications and to determine long-term outcomes.

409. TWO-STAGE OPERATIVE PROCEDURE FOR A BENIGN, COMPLICATED TRACHEOESOPHAGEAL FISTULA CAUSED BY FOREIGN BODY IMPACTION

Abstract Background Benign Tracheoesophageal fistula (TOF) caused by foreign body impaction is a rare condition requiring technical expertise. There are choices available based on the individual patient's situation, including endoscopic management, local resection and defect closure, and, in rare cases, esophagectomy. Methods A 58-year-old male had a history of artificial tooth dislodgement that got impacted in the esophagus, resulting in dysphagia. Endoscopy showed an impacted denture with an underlying transmural esophageal perforation, closed with clips and an endoloop. Two weeks later, partially covered SEMS was placed. Failure to retrieve the SEMS after repeated attempts due to tissue ingrowths, he was referred for management. CECT showed a stent in situ with a small air-filled cavity left lateral to the tracheal bifurcation. Bronchoscopy revealed the compression of the posterior tracheal wall and the presence of an endoclip in the posterior wall of the left main bronchus (LMB). Results The patient was planned for a two-stage operation. In the first stage, esophagus was mobilized along with the stent and the fistulous tract was excised. The esophagus was divided at both ends in the thorax. Up to this part, the procedure was done with single-port VATS without CO2 and in the left semi-prone position with a bronchial blocker in the right main bronchus. The fistula with the LMB was closed with an intercostal muscle flap and a bovine pericardial patch with transient apnoea. During this part, we extended the incision in the fourth space to raise the flap. Cervical esophagostomy was matured, and a feeding jejunostomy was created. The postoperative phase was uneventful, and he was discharged on the 5th postoperative day. After 4 weeks, we did the second phase of surgery, where we made a 4 cm retrosternal gastric conduit and performed the hand-sewn anastomosis with the cervical esophagus, which was taken down from the skin. The patient had an uneventful postoperative course and was allowed to be taken orally on day five and discharged subsequently two days later. Conclusions TOF demands a multidisciplinary treatment strategy. Successful outcomes are determined by patient triage, delineation of the location and size of the defect, mediastinal contamination, and the availability of expertise.

Anesthetic Considerations in Neonates with Tracheoesophageal Fistula: Navigating Challenges for Successful Outcomes

Tracheoesophageal fistula (TEF) is an anomalous connection between the trachea and esophagus with an incidence of 1 in every 2500 live births making it one of the most common congenital anomalies seen in major neonatal surgical centers. If left undiagnosed and untreated, it may lead to neonatal morbidity and early mortality. This case report focuses on the challenges faced in the anesthetic management of neonates with TEF, their airway management, and ventilation strategies in a health center with low neonatal surgical load.

Prenatal diagnosis of tracheo-oesophageal fistula/oesophageal atresia: is MRI helpful?

Oesophageal atresia (OA) with or without tracheo-oesophageal fistula (TOF) affects 2.75 per 10,000 births within the UK. It is most frequently suspected on antenatal imaging when the stomach is absent or appears small. Studies have shown fetal magnetic resonance imaging (MRI) has greater diagnostic accuracy than ultrasound; however, there remains uncertainty over what size constitutes a small stomach and how frequently this correlates with a diagnosis of TOF/OA. A retrospective study of patients referred for fetal MRI due to suspicions of TOF/OA on antenatal ultrasound from 2011 to 2022. We also included patients with a fetal MRI suspecting TOF/OA who had been referred for other reasons. The indication, MRI findings and postnatal outcome were compared to assess diagnostic accuracy. For each case, the size of the stomach bubble was measured on MRI, and stomach volumes in a control group were measured for comparison. The positive predictive value for USS was 45.5% and 51.7% for fetal MRI. Fetal MRI had a negative predictive value and sensitivity of 100% (p = 0.027). The control group showed a strong positive correlation between stomach size and increasing gestational age (R2 = 0.69, p < 0.001), but this correlation was less positive in the TOF/OA group (R2 = 0.26, p = 0.03), and the stomach volumes in TOF/OA were consistently lower than the control group. The receiver operating characteristic curve illustrates that an absent stomach or unmeasurably small stomach is more diagnostic of TOF/OA as volumes ≤0.06 ml had 90% sensitivity. Fetal MRI can accurately exclude TOF/OA but only has marginally improved positive predictive value over ultrasound. Research with larger numbers is required to further aid the development of a cut-off value for what can be considered a pathologically small stomach. There are several features on imaging that raise the suspicion of TOF/OA. Fetal MRI has some improved diagnostic accuracy compared with antenatal ultrasound alone; however, it is only marginally better. Absence of stomach bubble and presence of oesophageal dilatation combined on fetal MRI are more diagnostic of TOF/OA.

Complications of button battery ingestion or insertion in children: a systematic review and pooled analysis of individual patient-level data.

Button battery (BB) exposures are common in children and can have devastating consequences. We reviewed current evidence on the complications associated with BB exposure and identified predictors of outcomes using individual patient-level data. We carried out a systematic review and pooled analysis by searching MEDLINE, Embase, and Scopus up to May 19, 2023. Included studies describe complications following BB exposures in children (aged < 18years). Odds ratios (ORs) were calculated using binary logistic regression to measure associations between predictive factors and different outcomes. Two-hundred seventeen studies (439 children) were included. The median age at presentation was 1.75 [interquartile range (IQR) 1.00-3.00] years and 399 (90.9%) exposures were ingestions. Of the 380 cases reporting sex, 162 (42.6%) were female. Feeding (192, 48.1%) and respiratory difficulties (138, 34.6%) were common presenting features for ingestions, while symptomatology was site-specific for insertions. Common complications included oesophageal mucosal damage alone (105, 26.3%) and tracheooesophageal fistula (93, 23.3%) for ingestions, and nasal septal perforation (22, 55.0%) and mucosal damage alone (13, 32.5%) for insertions. Intestinal perforation occurred in 2.5% of ingestion cases, including perforation of Meckel's diverticulum, peritonitis, and jejunocolic fistula. Vascular complications were common among children who died. Age (≤ 2years), battery exposure duration (> 6hours), and battery diameter (≥ 20mm) were associated with common and severe complications of ingestions. BB injuries are time-critical, with severe sequelae predominantly affecting young children. Diagnosis is challenging. Preventative work through regulation and safer battery design are required to eliminate this problem.