Introduction: We present a multistage Kimura extra-thoracic oesophageal lengthening (ETOL) technique in the context of acquired trachea-oesophageal fistula (aTOF) secondary to button battery injury.
Case: A 14-month-old female presented with a one week history of swallowing difficulties. Following multiple GP attendances, a chest x-ray was performed revealing a double rimmed circular opacification overlying T2 vertebra indicating button battery ingestion.
Method: The patient underwent rigid oesophagoscopy and removal of the button battery. Post-operatively she was unable to swallow secretions and a computed tomographic scan suggested aTOF. A laryngotracheobronchoscopy confirmed a 1cm midline defect in the posterior trachea. Following failure to control secretions with replogle suction she underwent neck exploration where the anterior oesophageal wall from the pharynx to T2 vertebral level was absent. The remaining proximal oesophagus was tubularised over a 10Fr NG tube and cervical oesophagostomy fashioned. The tracheal fistula was closed and laparoscopic gastrostomy performed. One month post-operatively she was discharged on gastrostomy feeds and oral fluids. Prior to planned ETOL, she was admitted for balloon dilatation of the proximal oesophagus and three times for management of symptomatic skin-level stenosis of the oesophagostomy. Stage 1, 2 and 3 ETOL and oesophageal anastomosis followed 4, 7, 9 and 10 months after oesophagostomy formation respectively. Between the 2nd and 3rd stage, a retrograde insertion of distal oesophageal stent was performed to prepare the oesophagus and aid assessment of positioning and timing of the final anastomosis. She is now 5 months following oesophageal reconnection surgery and has required 3 dilatations for an anastomotic stricture which appears to be improving.
Conclusion: Retrograde distal oesophageal stenting and factors aiding dilatation of the proximal oesophagus contributed to successful ETOL and oesophageal reconnection in the context of aTOF.