What is the recommended approach for endoscopically removing an esophageal lithium battery ingestion in a patient?

Endoscopic Removal of Esophageal Lithium Battery

Perform immediate emergent flexible endoscopy within 2 hours of presentation under general anesthesia with endotracheal intubation to remove the esophageal lithium battery, as this is a true endoscopic emergency requiring the fastest possible intervention to prevent catastrophic tissue damage from high-voltage current release. 1, 2

Immediate Pre-Endoscopy Management

Timing Considerations

• Esophageal button batteries require removal within 2 hours of presentation, as they represent the highest urgency category among all esophageal foreign bodies 1, 2
• Lithium batteries generate hydroxide through electrolysis and release high-voltage current that causes tissue necrosis, with damage beginning immediately upon contact 3, 2
• While esophageal perforation is unlikely within the first 12 hours (only 2% of perforations occur before 24 hours), severe mucosal and muscular damage can occur much earlier 4

Pre-Procedure Interventions (If Delay Expected)

• Administer honey or sucralfate suspension while awaiting endoscopy if the ingestion occurred ≤12 hours ago, as these agents coat the battery and reduce hydroxide generation 2
• These coating agents carry low risk of extravasation during the first 12 hours and should not delay endoscopic removal 4, 2
• Do NOT perform contrast swallow studies, as they increase aspiration risk and impair endoscopic visualization 5

Imaging Before Removal (Delayed Diagnosis Only)

• If diagnosis is delayed >12 hours after ingestion, obtain CT scan with contrast before battery removal to assess for vascular injury, transmural necrosis, or perforation 6, 2
• CT is also indicated if clinical signs suggest complications: fever, sepsis, subcutaneous emphysema, severe chest pain, or respiratory distress 6
• Absence of post-contrast wall enhancement indicates transmural necrosis and requires emergency surgical consultation 6

Endoscopic Removal Technique

Procedural Setup

• Perform under general anesthesia with endotracheal intubation to protect the airway, especially given the risk of aspiration and need for secure airway control 1, 5
• Use flexible endoscopy as the first-line approach, with 90% success rates when performed by an experienced gastroenterologist 1

Retrieval Method

• Use appropriate retrieval devices: grasping forceps, baskets, or snares to extract the battery 1
• Avoid excessive manipulation that could cause additional mucosal trauma 3
• The battery may be fused to the esophageal wall in cases with prolonged contact, making removal technically challenging 3

Intraoperative Assessment

• Document the extent of esophageal injury using established classification systems during the procedure 6
• Assess for depth of tissue damage, ulceration, and necrosis 6
• Obtain biopsies if there is uncertainty about depth of injury or infection 6

Post-Removal Management

Immediate Post-Procedure Care

• Keep patient NPO initially and assess for signs of perforation or mediastinitis 6
• Monitor for fever, chest pain, respiratory distress, or subcutaneous emphysema 6

Follow-Up Imaging and Endoscopy

• Perform repeat endoscopy to grade esophageal injury, assess for stricture formation, ongoing ulceration, or healing 6
• Consider CT with contrast if clinical signs suggest perforation or vascular injury develop post-removal 6
• In delayed diagnosis cases (>12 hours), even if the battery has passed beyond the esophagus, endoscopy to screen for esophageal damage and CT to rule out vascular injury should be performed even in asymptomatic children 2

When Endoscopic Removal Fails

Surgical Intervention

• Consult thoracic or pediatric surgery immediately if flexible endoscopy fails to remove the battery 1, 3
• Surgical approach involves left cervical esophagotomy with battery extraction, minimal debridement of necrotic tissue, and primary repair over a feeding tube 3
• Surgery is also indicated for confirmed perforation, irretrievable foreign body, or evidence of transmural necrosis 6, 1

Multidisciplinary Coordination

• Engage pediatric surgical expertise simultaneously with endoscopy planning, even in asymptomatic patients, as reducing esophageal exposure time to high-voltage current is the main factor determining prognosis 3
• Have ENT surgery available for rigid endoscopy if flexible approach fails, particularly for upper esophageal locations 1

Critical Pitfalls to Avoid

• Never delay endoscopy for observation or pharmacologic trials – the 24-hour observation approach used for other foreign bodies is absolutely contraindicated for esophageal batteries 1, 2
• Do not underestimate injury severity based on symptom absence – severe muscular damage and even perforation can occur in asymptomatic patients 3, 7
• Recognize that children ≤4 years with lithium batteries ≥20mm diameter are highest risk for severe complications including tracheoesophageal fistula, which occurred in 91-92% of severe cases 4, 7
• Anticipate late complications including esophageal stenosis (developing weeks after removal) and tracheoesophageal fistula, which may require prolonged follow-up and multiple interventions 3, 7