Spontaneous resolution of a large caustic tracheo-esophageal fistula following multimodal esophageal rest: A case report

Background: Esophageal ulceration is the most common complication of button battery (BB) ingestion. This can progress to development of tracheo-esophageal fistula (TEF). Operative intervention is the standard, as spontaneous healing is not expected. We describe a patient who had complete spontaneous resolution of caustic TEF by multimodal "complete" esophageal rest without operative repair. Case: A 20-month-old girl ingested a BB which resulted in TEFwith mediastinitis. After 8 days, endoscopy demonstrated a large (1.5cm) TEF. "Complete" esophageal rest was imposed with a multimodal approach: nothing by mouth; pharmacologic suppression of oral secretions and gastric acid; and placement of a gastrojejunostomy tube for gastric venting and jejunal feeding. She was discharged home 14 days later, continuing esophageal rest. One month later, endoscopy revealed complete resolution of the TEF. Oral feeding was resumed 3 months following the initial ingestion when vocal fold dysfunction (and aspiration) resolved. There was no suggestion of recurrent fistula or diverticulum on the last endoscopy and exam at 15, 19, and 49 months post injury.Conclusion: A few prior reports of non-operative management of TEF following disc battery ingestion have been published, with length of stays between 28 and 82 days. We report a case suggesting that even with a large caustic TEF, multimodal "complete" esophageal rest can allow complete spontaneous resolution, and with shorter duration of hospitalization. This experience prompts consideration of a novel non-operative approach. Even if complete resolution is not achieved, eventual operation would benefit from partial contracture, resolution of mediastinitis, and time for planning and preparation.