Author(s)
Russell De Jong, MD
Clayton Farhani, DO
Affiliation(s)
San Antonio Uniformed Services Health Education Consortium; Christus Children's Hospital
Abstract:
Introduction: We present a case of esophagostomal foreign body complicated by significant birth defects that were initially treated in a third world country.
Case description: A six-year-old male with history of Down syndrome presented to the emergency department with foreign body ingestion. His past medical history included unrepaired atrioventricular canal defect status post pulmonary artery banding, esophageal stricture status post G-tube and cervical esophagostomy to the left cervical skin, and renal problems which the mother could not provide details on. All of his care to this point had been provided in Nicaragua. On the day of presentation, his mother noted increased salivary discharge from the esophagostomy and increased fussiness. During workup, a plain film showed a 2.2 x 1.4 x 1.4 cm trapezoidal foreign body in the ostomy. Attempts at bedside dislodgement with a right angle pick and hemostat were unsuccessful. He was taken to the OR with a cardiovascular anesthesiologist where the foreign body was removed after making small releasing incisions anterior and posterior to the object. It was found to be a rock. Air escape from the ostomy was noted after removal, so microdirect laryngoscopy and esophagoscopy were performed revealing an intact airway and esophagus. Laryngeal mask airway ventilation was found to be the cause of the air escape after tracheoesophageal fistula was ruled out. Upon further interview, the patient's mother was unsure of how the rock may have gotten there. He is ambulatory, and was outside by himself earlier in the day. Before discharge, the family and patient were evaluated by pediatric surgery and pediatric cardiothoracic surgery to establish care.
Discussion: Cervical esophagostomy is very rare, with a 20-year case series out of a tertiary care center collating only 18 patients. It is usually an emergent maneuver performed for cases such as esophageal rupture due to malignancy or gunshot wounds. A recent practice guideline by the European Reference
Network for rare Inherited and Congenital Anomalies recommends against the procedure in cases of esophageal stricture or atresia, as was the case with our patient. We believe this is the first reported foreign body extraction from a cervical esophagostomy.