Iatrogenic pharyngoesophageal perforation in premature infants

Background: Premature infants are particularly at risk of iatrogenic pharyn goesophageal perforation. It is a rare occurrence but when it does occur it often mimics esophageal atresia. In the light of 10 patients treated in ou r service and those reported in the literature we have highlighted the diag nostic difficulties and discussed the appropriate management. Patients: Between 1980 and 1995, we treated 10 premature neonates for phary ngoesophageal perforation. Six of these neonates weighed less than 1500 g. Esophageal atresia was the primary diagnosis in 4 cases. The pharyngoesopha geal perforation was caused by repeated airway intubation in 3 cases and by overenthusiastic routine postpartum suctioning or nasogastric tube (NGT) i nsertion in 7 others. Severe respiratory distress occurred in 7 neonates. A plain chest x-ray revealed a large right pneumothorax in 3 cases and an a berrant NGT in 3 other cases. Four neonates had a contrast esophagography a nd 4 neonates underwent endoscopy. Five cases were treated surgically. In 3 of these, esophageal atresia was the presumptive diagnosis and the perfora tion was only diagnosed intraoperatively via a right thoracotomy. One neona te required suturing of the perforation and another had a gastrostomy. In a ll 5 cases a mediastinal drain was left in situ. The 5 remaining neonates w ere treated conservatively with broad spectrum antibiotics, total parentera l nutrition, a silastic NGT and pharyngeal aspiration. One of these neonate s had previously had a laparotomy for a colonic perforation. There was a go od outcome in 4 neonates, one of whom required instrumental dilatation for an esophageal stricture. Bronchopulmonary dysplasia developed in 3 cases an d necrotizing enterocolitis in 1 other case. Two neonates died. Conclusion: An iatrogenic perforation is often difficult to diagnose and ca n easily be confused with esophageal atresia. Clinical findings, a plain ch est x-ray, an esophagography and endoscopy are helpful. Surgery can be avoi ded in most instances. The outcome is not always favorable especially as pr emature neonates are at risk of severe concomitant pathology.