Discussion

Button battery ingestion poses a significant risk to the pediatric population, with cases increasing worldwide owing to the widespread use of button batteries in household electronic devices [1-3]. Recent evidence suggests that this rising incidence has been accompanied by a sevenfold increase in the relative risk of severe morbidity over the past two decades [12]. When lodged in the esophagus, button batteries can cause rapid tissue necrosis, often beginning within one to two hours, potentially progressing to severe complications [4,13]. Clinical outcomes are strongly influenced by the timing of intervention [1,3,4,13]. Once esophageal button battery impaction is identified, prompt endoscopic removal is imperative. Current World Society of Emergency Surgery (WSES) and European Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines recommend emergent endoscopy within two hours and no later than six hours to minimize the risk of severe injury [6,12]. During removal, careful inspection of the esophageal mucosa is essential for assessing the extent of injury and identifying early complications [1].

Esophageal perforation is among the most serious complications of button battery ingestion. Although relatively uncommon in children [9], it represents a life-threatening emergency and most frequently involves the intrathoracic esophagus [10,11]. In this setting, management strategies vary widely, ranging from conservative treatment to extensive surgical intervention, and no universally accepted gold standard has been established. Treatment should therefore be individualized, guided by the patient’s clinical status, the extent of tissue injury, and the presence of associated complications [5,7,10,14].

Although operative closure is typically favored in adults, pediatric esophageal perforation is more commonly managed nonoperatively [5,8]. Conservative management typically includes cessation of oral intake, gastric decompression, antibiotic and acid-suppression therapy, adequate drainage, and total parenteral nutrition when required [3,8,9]. This approach may be appropriate for clinically stable patients with contained perforations and limited contamination, provided close monitoring is ensured [6]. Martinez et al. [8] demonstrated successful nonoperative management even in extensive pediatric perforations, while both their findings and those of Kimball et al. [3] emphasized that surgical intervention should be reserved for patients in whom conservative measures fail or when the defect persists or worsens. Nevertheless, nonoperative treatment is not universally successful, and clinical deterioration may require delayed surgery. In the present case, persistent mediastinal leakage, progressive pleural contamination, and subsequent clinical sepsis despite initial conservative management necessitated surgical intervention.

Surgery remains central to the management of esophageal perforation [11]. In pediatric patients, reported operative approaches include primary repair, diversion or exclusion procedures, esophageal resection, and endoscopic techniques [5,11].

Primary repair consists of debridement, layered closure, and reinforcement with vascularized flaps when feasible. In adults, it has been associated with the lowest mortality, even in delayed presentations [5,10]. Pediatric outcomes are also favorable in selected cases. In a series of 24 pediatric patients with esophageal perforation, most were successfully managed with primary closure [9]. Similarly, Peters et al. [7] reported successful foreign body removal and primary repair of the defect during the same procedure after failed rigid esophagoscopy.

According to the WSES guidelines, esophageal diversion or exclusion may be considered when direct repair is not feasible, in a manner analogous to a colostomy for distal colonic injury, to prevent ongoing contamination [6]. Diversion is particularly indicated in hemodynamically unstable patients, in cases of friable esophageal tissue, or when extensive mediastinitis precludes safe closure [5,11]. In these circumstances, complete diversion serves as a salvage strategy to control intrathoracic contamination and sepsis, and is commonly achieved through a cervical esophagostomy combined with a gastrostomy or a jejunostomy [6,15].

Complete diversion can be achieved with end-esophagostomy; however, subsequent restoration of esophageal continuity is often challenging and may require gastric or colonic interposition. Conversely, loop esophagostomies preserve the native esophagus and are more readily reversible, yet incomplete diversion may allow persistent mediastinal contamination by oral secretions [15].

To overcome this limitation, temporary esophageal exclusion using absorbable ligatures has been described to achieve complete diversion while preserving the native esophagus. In a series of five patients, Koniaris et al. [15] demonstrated that placement of a distal absorbable ligature beyond a loop esophagostomy was associated with no leaks or strictures during four years of follow-up. Double esophageal exclusion was first described in 1956 and later refined to reduce the need for reconstructive surgery. The technique involves placement of absorbable ligatures distal to the cervical esophagostomy, to divert oral secretions, and at the esophagogastric junction, to prevent reflux, thereby allowing effective control of leakage and sepsis. As the ligatures dissolve spontaneously after approximately four weeks, esophageal continuity may be restored without reoperation [9,15,16]. Chang et al. [16] described seven adult patients treated with a one-stage approach that combined primary closure, cervical T-tube esophagostomy, and total esophageal exclusion with absorbable ligatures, all of whom achieved luminal recanalization without reoperation.

In our patient, we applied the same principle of temporary total esophageal exclusion using absorbable ligatures. Unlike the one-stage procedure described by Chang et al., esophageal exclusion was performed as a staged salvage intervention after persistent bilious output from both the esophagostomy and chest drains. This strategy achieved effective control of sepsis while preserving the native esophagus, underscoring the adaptability of this rarely used adult technique to complex pediatric injuries.

A similar principle is applied in duodenal injuries, where temporary diversion protects a fragile repair. Alsaadi et al. [17] reported primary duodenal closure with pyloric exclusion using absorbable ligatures, thereby diverting gastric contents and allowing healing without resection. Spontaneous pyloric reopening occurred as the ligatures dissolved, restoring gastrointestinal continuity without reoperation. This approach parallels temporary esophageal exclusion, as both employ controlled, reversible diversion to limit contamination, preserve native tissue, and permit recovery before spontaneous restoration of luminal continuity.

Other surgical options include esophageal resection, which is generally reserved as a last-resort strategy, typically in the setting of delayed presentation, extensive tissue necrosis, advanced mediastinitis, or hemodynamic instability [6,11,14]. In pediatric patients, resection is rarely required, as most perforations can be managed with esophagus-preserving strategies [9].

Finally, endoscopic therapy has gained an increasingly important role in the management of esophageal perforation. In line with contemporary series evaluating multimodal treatment strategies [14], endoscopy is recommended as the first-line modality for diagnosis and initial management; however, its therapeutic role is limited to early diagnosed, hemodynamically stable, nonseptic patients, particularly those with small iatrogenic perforations or high surgical risk. In cases of extensive mediastinal contamination, surgical intervention should not be delayed. Endoscopic treatment options include clips, stents, suturing, and endoscopic vacuum-assisted closure [10,11].

Close follow-up is essential even after clinical recovery. Contrast study or endoscopy within the first four weeks is strongly recommended to rule out esophageal stenosis, the most common complication following button battery ingestion [1].