LAUSR

We read the article titled “Cylindrical and button battery ingestion in children: a single-centre experience” by Akilov et al. [1] with keen interest. We applaud the authors for successfully managing and reporting such a substantial number of pediatric patients of battery ingestion. These data sheds some light on the abovesaid topic and strengthens the available literature on battery ingestion among children. However, some points need justification. First, the authors have demonstrated that 75 patients (60.5%) had undergone endoscopic removal of the ingested batteries [1]. However, the study had not mentioned whether the endoscopy was done via a rigid esophagoscopy (RE) or a flexible esophagoscopy (FE). We would appreciate it if the authors could shed some light on this aspect as the patient may sometimes present late, leading to a fair degree of oedema at the site of the impaction. FE can be challenging in these cases as it cannot generate enough traction to dislodge the battery [2]. Moreover, the authors have also failed to mention the grading system adopted by them for categorizing the degree of tissue injury. The majority of the previously published studies have used the Zargar classification [3] for grading the injuries in esophagal button batteries. Objective grading of the injury can predict the outcomes and can help standardize the patient follow-up. The authors have further reiterated that 41/45 patients (91%) with gastric button batteries had undergone endoscopic removal, and only four patients underwent conservative management [1]. Further data have shown that only 8 (19.5%) of these patients had mucosal injuries (in the form of hyperaemia and erosion). The authors have discussed that the absence of severe gastric injury in their cohort may be attributed to the authors’ institutional protocol of endoscopic retrieval of the gastric button battery even if the presentation is within 24–48 h. In support of this, the authors have referred to a study by Khalaf et al. [4]. However, the cohort size of this study is limited, with only 65 patients. A much more relevant study in this regard would be by Litovitz et al. [5], which evaluated patients from two data sources viz. National Poison Data System (56,535 cases) and National Battery Ingestion Hotline (8648 cases). They have shown that clinically significant outcome was documented in only 1.3% of the cases. The data also showed that the spontaneous passage of battery through the gastrointestinal tract was observed in 56.5% of the patients, with 63.6% of these patients passing the battery within 72 h and up to 3/4th of the patients passing the battery within 96 h. Moreover, another study by Litovitz et al. [6], comprising 2320 button battery ingestion cases, has also highlighted that the incidence of tissue injury decreases significantly once the battery goes beyond the esophagus. This is because the mucosal contact cannot be easily established with both the surfaces of the battery in any of the organs except the esophagus. The present study also shows that gastric injury in their cohort was limited to superficial mucosa only. Hence, we feel that routine removal of gastric foreign bodies is an unwarranted and unnecessary practice as it exposes the majority of children to the risk of anaesthesia and endoscopy. However, we agree that a small fraction of these patients does require endoscopy, that too for a diagnostic purpose to ascertain the grade of esophageal injury and not for removal [5]. The symptoms and the degree of injury in patients of button battery ingestion depend on many factors, the crucial factors being—battery size, location of impaction, make of the battery and voltage [5]. The authors have shown that the most important factor determining the outcomes is the location of the battery, and a correlation coefficient analysis has supported the same. However, the location of the battery is a * Sachit Anand [email protected]