Surgical management of catastrophic caustic ingestion in acute phase: A case report and review of the literature

INTRODUCTION

Caustic ingestion almost occurs accidentally in children and mostly intentionally in adults. The ingestion of caustic substances can cause various degrees of damage to the gastrointestinal tract. Depending on the severity of the injury, surgery may be a part of the treatment plan.

PRESENTATION OF CASE

A 32-year-old man was referred to our hospital after swallowing drain cleaner. Due to evidence of peritonitis and endoscopy results, he underwent emergency surgery. During the surgery, necrotic parts, including the esophagus, stomach, duodenum, head of the pancreas, and initial part of the jejunum, were resected. Then, after six months, colon interposition surgery was done to reconstruct the gastrointestinal tract.

DISCUSSION

Like trauma patients, managing patients with caustic injuries begins with an initial survey of the airway, breathing, and circulation status. In the first 48 h, early esophagoscopy is indicated to evaluate the amount of injury. Evidence of transmural necrosis or perforation is the most important indication for surgery, and surgical procedures are specific to each patient. Esophagogastrectomy is the most common surgery in cases of severe gastrointestinal injuries, but removing more abdominal organs may be needed in fewer cases.

CONCLUSION

This case report underscores the urgent need for further research and the development of evidence-based guidelines in managing caustic injury with extensive necrosis in the gastrointestinal tract. Our experience with this rare case highlights the importance of such guidelines in improving patient outcomes.

Esophageal emergencies

The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.

Esophageal emergencies: WSES guidelines

The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.

Caustic ingestion

Corrosive ingestion is a rare but potentially devastating event and, despite the availability of effective preventive public health strategies, injuries continue to occur. Most clinicians have limited personal experience and rely on guidelines; however, uncertainty persists about best clinical practice. Ingestions range from mild cases with no injury to severe cases with full thickness necrosis of the oesophagus and stomach. CT scan is superior to traditional endoscopy for stratification of patients to emergency resection or observation. Oesophageal stricture is a common consequence of ingestion and newer stents show some promise; however, the place of endoscopic stenting for corrosive strictures is yet to be defined. We summarise the evidence to provide a plan for managing these potentially life-threatening injuries and discuss the areas where further research is required to improve outcomes.

The Damage Pattern to the Gastrointestinal Tract Depends on the Nature of the Ingested Caustic Agent

BACKGROUND

The mechanisms of damage to the gastrointestinal tract after caustic ingestion are conditioned by the nature of the ingested agent. Whether the nature of the ingested agent has a direct influence on patient outcomes is unknown.

METHODS

From January 2013 to April 2015, 144 patients underwent emergency management for caustic injuries at the Saint Louis Hospital in Paris. There were 51 men (51 %) and the median age was 44 years [39, 48]. The ingested agents were soda-based strong alkali in 85 patients (59 %), strong acids in 36 patients (25 %), and bleach in 23 patients (16 %). Emergency and long-term outcomes were compared according to the nature of the ingested agent.

RESULTS

Four patients died (3 %) and 40 patients (28 %) experienced complications. After bleach ingestion, emergency morbidity and mortality were nil, no patient required esophageal reconstruction, and functional outcome was successful in all patients. Acids were more likely to induce transmural gastric (31 vs. 13 %, p =0.042) and duodenal (9 vs. 0 %, p = 0.04) necrosis than strong alkalis, but rates of transmural esophageal necrosis were similar (14 vs. 12 %, p = 0.98). No significant differences were recorded between emergency mortality (9 vs. 1 %, p = 0.15), morbidity (33 vs. 33 %, p = 0.92), the need for esophageal reconstruction (25 vs. 20 %, p = 0.88), and functional success rates (76 vs. 84 %, p = 0.31) after acid and alkali ingestion, respectively.

CONCLUSION

Bleach causes mild gastrointestinal injuries, while the ingestion of strong acids and alkalis may result in severe complications and death. Acids cause more severe damage to the stomach but similar damage to the esophagus when compared to alkalis.

Tracheobronchial Necrosis After Caustic Ingestion

OBJECTIVE

The aim of this study was to describe the management and outcome of tracheobronchial necrosis (TBN) after caustic ingestion.

BACKGROUND

Emergency pulmonary patch repair has been reported to be lifesaving in patients with caustic TBN.

METHODS

Patients who underwent management of caustic TBN between 1989 and 2013, were included. TBN was defined as early if present on admission and late if occurring thereafter. Operative outcomes, long-term survival, and functional outcomes were compared with those of 269 patients without TBN who underwent esophagectomy for caustic injuries.

RESULTS

Twenty patients were included (10 men; median age = 39 years). Early TBN was detected in 14 patients, and late TBN occurred in 7 patients, 8 days (range:: 6-10 days) after admission. TBN involved the left bronchus (n = 17; 85%), the carina (n = 10; 50%), the supracarinal trachea (n = 9; 45%), the right bronchus (n = 4; 20%), and the cervical trachea (n = 3; 15%). Seventeen patients underwent esophagogastrectomy, 2 underwent esophagectomy, and in 1 patient, resection was eventually abandoned. Pulmonary patch repair was performed in 16 patients (80%). Nine patients (45%) died and morbidity was 100%. In univariate analysis, late TBN (P = 0.017) and acid ingestion (P = 0.002) were predictors of mortality. All survivors underwent restoring colopharyngoplasty. Five-year survival (28%) and functional success (25%) rates were significantly impaired when compared with esophagectomy patients without TBN.

CONCLUSIONS

TBN is one of the most devastating complications of caustic ingestion. Pulmonary patch repair is technically simple and can be lifesaving in this difficult situation.

Foregut caustic injuries: results of the world society of emergency surgery consensus conference

INTRODUCTION

Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available.

PURPOSE OF THE STUDY

The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition.

METHODS

An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015).

RESULTS

One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council.

CONCLUSIONS

The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.

Emergency pancreatic surgery--demanding and dangerous

BACKGROUND

Elective pancreatic surgery can be carried out with mortality rates below 5% in specialized centers today. Only few data exist on pancreatic resections in emergency situations. The aim of the study was to characterize indications, procedures, and outcome of emergency pancreatic surgery in a tertiary center.

METHODS

Prospectively collected data of all patients undergoing pancreatic operations at the authors' institution between October 2001 and December 2012 were analyzed regarding primary emergency operations in terms of indications, procedures, perioperative complications, and outcome. Emergency operations after preceding resections were excluded from the analysis.

RESULTS

Twenty-three emergency operations were performed during the observation period. Indications were duodenal perforation (n = 8), upper GI bleeding (n = 6), complicated pseudocysts (n = 3), bile duct perforation (n = 2), pancreatic bleeding after blunt abdominal trauma (n = 1), pancreatic stent perforation (n = 1), necrotizing cholecystitis (n = 1), and ileus (n = 1). Procedures included partial and total duodeno-pancreatectomy (n = 15), cystojejunostomy (n = 2), distal pancreatectomy (n = 4), reconstruction of the ampulla Vateri (n = 1), and duodenectomy (n = 1). Median intraoperative blood loss was 750 (200-2500) ml and OP time 4.25 (1.75-9.25) h. Mean ICU stay was 21.3 (1-80) days with an overall surgical morbidity of 52.2%. Overall in-hospital mortality was 34.8% (8/23 pat.).

CONCLUSIONS

Emergency pancreatic operations are infrequent and mainly performed due to duodenal perforation or bleeding; blunt abdominal trauma is rarely leading to emergency pancreas resections. They are associated with an increased morbidity and mortality and require a high level of surgical as well as interdisciplinary experience. Perioperative anesthesiological care and interventional radiological complication management are essential to improve outcome in this selective patient collective.

Different possible surgical managements of caustic ingestion: diagnostic laparoscopy for Zargar's grade 3a lesions and a new technique of "Duodenal Damage Control" with "4-tubes ostomy" and duodenal wash-out as an option for extensive 3b lesions in unstable patients

In the present study, we have described two possible approaches in the management of caustic injuries. Diagnostic emergency laparoscopy can be used for exploration in case of stable patients with Zargar's 3a gastric lesions and equivocal peritoneal signs. On the other hand, in case of patients with Zargar's 3b gastric lesions with perforation, diffuse peritonitis and hemodynamic instability, a new possible technique is described as an option to be used in such extensive caustic injuries: duodenal damage control with "4-tubes ostomy" for duodenal and jejunal wash-out of the caustic agent. The aim of this simple technique is to wash-out the caustic agent from the duodenum when the duodenum and Treitz are not yet gangrenous/perforated, as well as to avoid duodenal primary closure and jejuno-jejunal anastomosis over damaged tissues.

Emergency pancreaticoduodenectomy: When is it needed? A dual non-trauma centre experience and literature review

INTRODUCTION

Emergency pancreaticoduodenectomy (EPD) has been very rarely reported in literature as a lifesaving procedure for complex pancreatic injury, uncontrollable hemorrhage from ulcers and tumors, descending duodenal perforations, and severe infection. The aim of this study was to analyze the experience of two non-trauma centers and to review the literature concerning emergency pancreaticoduodenectomy.

METHODS

From January 2005 to December 2014, from a population of 169 PD (92 females and 77 males; mean age: 61.3, range 23-81) 5 patients (3%; 2 females and 3 males; mean age: 57.8, range: 42-74) underwent EPD for non-traumatic disease performed at two Academic Units of the University of Bari.

RESULTS

The emergency pancreaticoduodenectomy subgroup of patients showed an overall morbidity of 80%, and mortality of 40%. In 80% (4/5) of patients treated by emergency pancreaticoduodenectomy, the pancreatic remnant was not reconstructed, and in 20% (1/5) a pancreaticojejunostomy was performed.

CONCLUSION

Emergency pancreaticoduodenectomy is an effective life-saving operation reservable to pancreatoduodenal trauma, perforations, and bleeding, unmanageable by a less invasive approach. It should be preferentially approached by surgeons with a high level of experience in hepatobiliary and pancreatic surgery and in trauma centers too, but it should also be in the armamentarium of general surgeons performing hepato-pancreato-biliary surgery.

Foreign bodies and caustic lesions

Foreign body ingestions, food bolus impactions, and caustic agent injuries are frequent but specific situations. Although most foreign bodies will naturally pass through the digestive tract, practitioners should recognize specific situations were endoscopic management is required. In such cases, timing and adequate equipment are critical. Endoscopic treatment is successful in about 95% of patients. Severe complications (including oesophageal perforations) are rare. Underlying diseases (including eosinophilic oesophagitis) must be investigated after food bolus impaction. Accidental or suicidal ingestion of corrosive agents may result in severe upper gastrointestinal tract injuries requiring a multidisciplinary approach including gastroenterologists, surgeons, otorhynolaryngologists, anaesthesiologists and psychiatrists. Treatment includes conservative management of patients with mild injuries, while patients with severe injuries undergo emergency surgical exploration. At distance of the ingestion episode, oesophageal reconstruction is required in patients who underwent oesophageal resection and in patients who developed oesophageal strictures that failed dilatation.

Surgery for caustic injuries of the upper gastrointestinal tract

BACKGROUND

Surgery is the criterion standard for the treatment of severe burns and of late sequels after ingestion of corrosive agents, but long-term outcome is unknown.

METHODS

Patients who underwent surgery between 1987 and 2006, for the treatment of severe caustic burns (group I, n = 268) or of late sequels (group II, n = 79) were included in the study. Survival and functional outcomes were analyzed. Functional success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. To compare the observed mortality with the expected mortality in the general population, a standardized mortality ratio (SMR) was used.

RESULTS

Overall Kaplan-Meyer survival at 1, 5, 10, and 20 years of patients in group I was 76.4%, 63.6%, 53.9%, and 44.1%, respectively. On multivariate analysis, advanced age (P = 0.0021), extended resection (P = 0.0009), emergency esophagectomy (P = 0.013), and tracheobronchial injuries (P = 0.0011) were independent negative predictors of survival. The SMR of patients in group I was increased to 21.5 when compared to the general French population. Functional success was recorded in 147 (56%) patients in group I. Advanced age (P = 0.012), extended resection (P = 0.012), and emergency tracheotomy (P = 0.02) were independent predictors for failure. After esophageal reconstruction, patients in group II fared better than patients in group I in terms of survival (P = 0.0006) and functional success (P < 0.0001). Still, the SMR of patients in group II increased to 3.67.

CONCLUSIONS

The need to perform surgery for caustic injuries has a persistent long-term negative impact on survival and functional outcome.

Similar outcomes after primary and secondary esophagocoloplasty for caustic injuries

BACKGROUND

The main purpose of the study was to report a comparative experience with primary and secondary esophagocoloplasty for caustic injuries. Secondary esophagocoloplasty is the main rescue option after graft loss, but data in the literature are scarce.

METHODS

The operative characteristics, postoperative course, and functional outcomes of 21 secondary and of 246 primary esophagocoloplasty operations performed for caustic injuries between 1987 and 2006 were compared. Intraoperative events requiring significant changes in the planned operative strategy, such as graft ischemia or necrosis, were recorded. Statistical tests were performed in both cohorts to identify factors predictive of postoperative graft necrosis. Univariate analysis was performed to identify factors predictive of functional failure after secondary esophagocoloplasty.

RESULTS

Operative mortality (5% vs 4%, p=0.56), morbidity (62% vs 59%, p=0.96), postoperative graft necrosis (14% vs 7%, p=0.16), and functional success (68% vs 70%, p=0.79) rates of the secondary and primary esophagocoloplasty operations were similar. Intraoperative graft ischemia at the time of secondary esophagocoloplasty was significantly associated with the risk of postoperative graft necrosis (p=0.015) and functional failure (p=0.046). At the time of primary esophagocoloplasty, intraoperative necrosis of the colon was the only independent predictive factor of postoperative graft necrosis (p<0.0001).

CONCLUSIONS

Secondary esophagocoloplasty is a safe and reliable salvage option after primary graft loss in patients with caustic injuries. Delayed esophagocoloplasty should be considered if intraoperative colon necrosis occurs at the time of primary reconstruction.