PMC8510820_01
CXR with PA (left) and lateral (right) views of the rounded radiopaque foreign body with double ring appearance peripherally concerning for button battery in the right upper quadrant at the expected region of the duodenum. There is typically approximately 10% magnification on measurement of metallic foreign bodies, consistent with a 20 mm 3V lithium BB.
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fig2
A CXR was obtained which revealed a suspected BB in the right upper quadrant (Figure 2).
EGD revealing grade 2A partially circumferential caustic injury with thickening of mucosa, exudates, and ulcerations in the upper third of the esophagus without active bleeding.
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fig3
She was taken to the operating room (OR) and underwent EGD which revealed a 5 cm long, grade 2A, anterior midesophageal caustic injury with no evidence of bleeding (Figure 3).
Presenting with hematemesis 7 days after initial EGD, CT angiogram axial (left) and coronal (right) views revealing pseudoaneurysm along the posteromedial wall near the distal aortic arch/proximal descending thoracic aorta just caudal to the takeoff of the left subclavian artery with no evidence of active bleeding.
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fig4
A CT angiogram (CTA) was obtained which revealed a pseudoaneurysm at the distal aortic arch beyond the left subclavian artery (Figure 4).
Second surgery in the staged repair of the AEF after the first surgery controlled the active aortic hemorrhage. Rigid bronchoscopy (left) showing no evidence of tracheoesophageal fistula. Rigid esophagoscopy (right) revealing the anterior esophageal injury near start of the midesophagus with friable, healing granulation tissue consistent with a likely negative pole of prior esophageal button battery facing anteriorly.
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fig5
Panendoscopy at that time demonstrated granulation tissue with some active bleeding within the anterior esophagus corresponding with the negative pole of the prior esophageal BB facing anteriorly (Figure 5).
Intraoperative images of intercostal muscle flap (white arrow) second stage surgical repair of aortoesophageal fistula. Acellular collagen bioscaffold (CardioCel , LeMaitre Vascular Inc., Burlington, MA) was also used (orange arrow).
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fig6
Through a left posterior thoracotomy incision, an intercostal muscle flap was created, the esophageal fistula was opened, devitalized esophagus was debrided, and the intercostal muscle flap was interposed (Figure 6) and sutured circumferentially to the esophagostomy, repairing the esophagus.
Esophagram obtained 10 days following repair showing no evidence of leak.
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fig7
She was started on postpyloric tube feeds and underwent an esophagram 10 days postrepair which showed no evidence of leak (Figure 7).
Flexible fiberoptic laryngoscopy 2.5 months after open chest repair reveals improving left vocal cord paresis.
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fig8
Upon repeat flexible laryngoscopy 10 weeks after her repair, vocal cord mobility appeared to be improved with demonstration of left vocal cord paresis rather than complete paralysis (Figure 8).