Case presentation

A previously healthy six-year-old boy, weighing 24 kg, presented to our emergency department with retrosternal burning pain following button battery ingestion. Plain radiographs demonstrated impaction of the battery in the distal esophagus (Figures 1a, 1b). Urgent endoscopy, performed within four hours, revealed extensive mucosal necrosis and two submucosal tunnels (Figure 2). The battery was advanced into the stomach; however, initial retrieval was unsuccessful. Contrast esophagogram confirmed distal esophageal perforation, while computed tomography revealed mediastinal leakage and pleural effusion (Figure 3). A chest tube was inserted, immediately draining 170 mL of serous fluid, and a repeat endoscopy successfully removed the battery. The patient was managed in the pediatric intensive care unit, with intravenous antibiotics, proton pump inhibitors, and corticosteroids.

Figure 1: Plain radiographs demonstrating a button battery impacted in the distal esophagus. (a) Anteroposterior view showing the button battery lodged in the distal esophagus. (b) Lateral view confirming the esophageal location of the foreign body. White arrows indicate the impacted button battery.

Figure 2: Endoscopy view demonstrating extensive necrosis of the esophageal mucosa with two submucosal tunnels, findings consistent with a full-thickness esophageal rupture.

Figure 3: Axial thoracic CT scan showing a left pleural effusion and mediastinal inflammatory changes. The white arrow indicates the area of mediastinal inflammation adjacent to the distal esophageal rupture.CT: computed tomography

He remained intubated for 48 hours, and within 24 hours of extubation, he developed severe respiratory deterioration associated with bilateral pleural effusions. Thoracic ultrasonography showed air bubbles within the pleural fluid, raising suspicion of ongoing esophageal leakage. Reintubation was required, after which the chest tube drained thick purulent material. Although the patient initially stabilized, persistent respiratory compromise, bilateral pleural collections, and purulent drainage prompted surgical intervention. Thoracotomy was performed, with loop cervical esophagostomy and Stamm gastrostomy, alongside mediastinal drains (Figures 4, 5).

Figure 4: Intraoperative photograph during thoracotomy, with DeBakey forceps pointing to the site of esophageal perforation.

Figure 5: Postoperative chest radiograph showing one left thoracic drain (orange arrow) and two mediastinal drains (blue arrows).

Despite cervical esophageal diversion, bilious output persisted from both the esophagostomy and chest drains, indicating ongoing contamination of the injured esophageal segment. As a salvage procedure, No. 2 absorbable multifilament braided ligatures were placed at the esophagogastric junction and just below the cervical esophagostomy. This maneuver created complete proximal and distal isolation of the perforated esophagus (Figure 6).

Figure 6: Schematic of temporary esophageal exclusion using absorbable ligatures. Proximal and distal absorbable ligatures (black arrows) were placed just below the cervical esophagostomy and at the esophagogastric junction, respectively. This created complete isolation of the injured thoracic esophageal segment, while the gastrostomy tube provided gastric decompression and enteral access until spontaneous recanalization occurred.Image credit: The figure was created by the author Despina Panayiotou using Notes on iPad (Apple Inc., Cupertino, CA)

This resulted in a rapid reduction of drainage output, resolution of sepsis, and progressive clinical improvement. After several weeks of parenteral nutrition and gradual recovery, the drains were removed, and the patient was discharged.

A follow-up contrast study two months later demonstrated brisk passage of contrast into the stomach, confirming spontaneous recanalization of the previously excluded esophagus and restoring luminal continuity without formal reanastomosis. A focal narrowing at the T9 level was also identified, for which serial postoperative balloon dilatations were performed through the distal limb of the loop esophagostomy.

The patient was later readmitted for elective esophagostomy closure. Repeat contrast study showed no stricture or leak, with only mild mid-esophageal dilatation below the tracheal bifurcation (Figure 7a). Following esophagostomy closure, a contrast study demonstrated uninterrupted passage of contrast into the stomach, without evidence of a leak or significant stricture (Figure 7b). He subsequently resumed oral intake and was discharged in good condition. At 12 months, he remained clinically well, with no additional complications documented. No further hospital presentations related to the esophageal injury occurred over the following eight years.

Figure 7: Postoperative esophagograms following temporary esophageal exclusion. (a) Contrast study performed before esophagostomy closure demonstrating passage of contrast into the stomach. The double asterisk indicates mild mid-esophageal dilatation distal to the tracheal bifurcation. (b,c) Sequential images obtained during the contrast study after esophagostomy closure demonstrating uninterrupted passage of contrast into the stomach without evidence of leak or significant stricture.

The timeline of the patient’s clinical course is summarized in Figure 8.

Figure 8: Timeline of the patient’s clinical course. Major clinical and radiological findings, interventions, and recovery milestones are summarized in chronological order.PICU: pediatric intensive care unit; TPN: total parenteral nutrition; CT: computed tomography; U/S: ultrasonographyImage credit: The figure was created by the authors using Microsoft PowerPoint (Microsoft Corporation, Redmond, WA)