Iatrogenic Neonatal Esophageal Perforation: A European Multicentre Review on Management and Outcomes

Abstract

Background: The aim of this multicenter retrospective study and literature review was to review management and outcomes of neonatal esophageal perforation (NEP). Methods: Protocol data were collected from four European Centers on gestational age, factors surrounding feeding tube insertion, management and outcomes. Results: The 5-year study period (2014–2018) identified eight neonates with median gestational age of 26 + 4 weeks (23 + 4–39) and median birth weight 636 g (511–3500). All patients had NEP from enterogastric tube insertions, with the perforation occurring at median 1st day of life (range 0–25). Seven/eight patients were ventilated (two/seven-high frequency oscillation). NEP became apparent on first tube placement (n = 1), first change (n = 5), and after multiple changes (n = 2). Site of perforation was known in six (distal n = 3, proximal n = 2 and middle n = 1). Diagnosis was established by respiratory distress (n = 4), respiratory distress and sepsis (n = 2) and post-insertion chest X-ray (n = 2). Management in all patients included antibiotics and parenteral nutrition with two/eight receiving steroids and ranitidine, one/eight steroids only and one/eight ranitidine only. One neonate had a gastrostomy inserted, while in another an enterogastric tube was orally successfully re-inserted. Two neonates developed pleural effusion and/or mediastinal abscess requiring chest tube. Three neonates had significant morbidities (related to prematurity) and there was one death 10 days post-perforation (related to prematurity complications). Conclusions: NEP during NGT insertion is rare even in premature infants after evaluating data from four tertiary centers and reviewing the literature. In this small cohort, conservative management seems to be safe. A larger sample size will be necessary to answer questions on efficacy of antibiotics, antacids and NGT re-insertion time frame in NEP.

Iatrogenic Esophageal Perforation in Premature Infants: A Multicenter Retrospective Study from Poland

“…This would be advisable for a more precise diagnosis. Another complication described by Sorens was mediastinal abscess requiring chest drain insertion [ 16 ]. Occasionally, patients with intra-abdominal EP might present symptoms of peritonitis or dysphagia and drooling [ 1 ].…”

“…In particular, there seems to be a recent tendency to avoid surgery. The treatment of EP includes fasting, total parenteral nutrition and intravenous antibiotics [ 16 ]. Broad-spectrum antibiotics providing coverage for aerobes and anaerobes might be necessary to prevent mediastinal and peritoneal infections [ 14 ].…”

“…Broad-spectrum antibiotics providing coverage for aerobes and anaerobes might be necessary to prevent mediastinal and peritoneal infections [ 14 ]. In contrast to Sorens’ study, we did not administer steroids or ranitidine [ 16 ]. Antifungal coverage is warranted in some cases, such as for patients who have received broad-spectrum antimicrobial drugs prior to perforation, patients who have received steroids and patients who have not improved after several days of appropriate antibacterial therapy.…”

“…Polyvinyl feeding tubes are stiffer, less flexible and easier to insert but more traumatic. Silicone and PUR tubes are tissue-compatible, unlike PCV tubes [ 16 ].…”

Iatrogenic Esophageal Perforation in Preterm Neonate Managed Conservatively

“…Iatrogenic esophageal injury in the neonates usually occurs at the pharyngoesophageal junction where the lumen is narrowed by the cricopharyngeus muscle. [3,4] Over the past decade, a shift from an urgent surgical intervention to more wise, nonsurgical management of esophageal perforation in selected adult patients has been reported. [5,6] In children although the most important prognostic factor is the time span between the injury and the initiation of treatment, The experience in managing esophageal perforation, especially in extremely low-birthweight infants, is relatively lacking [3,7].…”