Patient 3, a 4-year-and-1-month-old child, presented to the emergency department with persistent epigastric pain. A chest X-ray confirmed the presence of a DB in the esophagus. A subsequent angio-CT scan revealed possible vascular involvement. Consequently, an urgent endoscopic examination was initiated, reaching approximately 20 cm from the oral cavity, where extensive necrotic tissue and significant bleeding upon irrigation were observed. Due to the severity of these findings, an emergency left thoracotomy was performed. Intraoperative inspection of the thoracic aorta, from the arch to the diaphragm, excluded aortic fistulas, but a moderate inflammatory reaction around the aortic wall prompted a reinforcement of the aortic wall with a patch. The DB was successfully removed endoscopically, and follow-up esophageal endoscopy revealed significant bilateral ulceration of the mid-esophagus. After surgery, the patient was gradually re-fed and closely monitored in the hospital for 3 weeks. A follow-up endoscopy, conducted 5 months later, showed no duodenal or gastric lesions, and the esophageal mucosa appeared normal, with no evidence of stenosis.

Patient 16, a 1-year-and-4-month-old child, was urgently admitted following two episodes of massive hematemesis and severe anemia. Prior to this, the child had exhibited poor appetite and difficulty swallowing. Upon arrival at the emergency department, a chest X-ray revealed a DB in the middle third of the esophagus, confirmed by an angio-CT scan that also suggested possible contact between the DB and the aortic wall (Fig. 

Angio-CT scan suggested possible contact between the DB and the aortic wall (patient 16)

2). Due to these findings, the patient underwent an emergency sternotomy. The aortic arch and epiaortic vessels were carefully isolated. The DB was removed via a transesophageal endoscopic approach. During the operation, it was confirmed that both the aortic wall and trachea were intact, with no signs of erosion or perforation. The sternum was reconstructed using metal wires, and pleuropericardial drains were placed. Over a 3-week hospitalization, the patient was monitored through clinical, radiological, and endoscopic evaluations. The final endoscopic examination before discharge demonstrated significant healing of the necrotic esophageal lesion, with no evidence of stenosis or perforation.

Patient 20, a 1-year-and-4-month-old girl, presented with a two-weeks history of cough and fever that had not improved following antibiotic treatment for suspected bronchitis. A chest X-ray, revealed a DB in the mid-trachea, which was removed endoscopically at another hospital. A 1 cm tracheoesophageal fistula, caused by battery-induced erosion, was found. The patient was transferred to our center, where she underwent a tracheal resection and anastomosis. The tracheal segment affected by the fistula (from the 5th to the 8th tracheal ring) was resected and the underlining esophageal perforation repaired in multiple layers. In between the esophageal and tracheal repair, a patch of tibial periosteal graft was interposed. The procedure was performed through a cervical approach, and ventilation was maintained through a nasotracheal tube. The patient was extubated on sixth post-operative day. A week after surgery, an esophagogram and a tracheoscopy revealed confirmed success of the operation.

Patient 22, a 1-year-and-4-month-old girl, was initially hospitalized at another facility due to a persistent cough and loss of appetite. Despite antibiotic treatment, no improvement was noted, and a chest X-ray revealed a 2 cm foreign body, likely located in the thoracic esophagus. An urgent angio-CT confirmed the presence of the foreign body in the proximal esophagus. The patient underwent endoscopic removal of the foreign body, which also revealed ulcerative esophagopathy with necrotic areas at the site of the lodged object, along with extensive tissue damage. Post-operatively, the patient experienced a cardiorespiratory arrest, requiring extracorporeal resuscitation, and was transferred to our facility. A follow-up CT scan showed pulmonary parenchymal consolidations, suggesting a possible tracheoesophageal fistula (TEF), later confirmed by flexible bronchoscopy. After multidisciplinary consultations, the patient underwent tracheal resection and closure of the TEF under extracorporeal circulation (ECMO). A cervical incision was made, and a 2 cm segment of the trachea was resected, followed by esophageal repair and an interposition tibial periosteal graft placement (Fig. 

Scanner to see tracheal resection/anastomosis surgery

3). Post-operative recovery was prolonged and complex. Subsequent bronchoscopic evaluations revealed significant tracheal stenosis approximately 0.5 cm from the carina, necessitating multiple balloon dilations and corticosteroid treatments to reduce hyperplastic scar tissue. The pre-discharge endoscopic examination, 4 months post-surgery, showed marked improvement in tracheal diameter. The patient remains under follow-up.