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Zerbib P, Lailheugue A, Labreuche J, Richa Y, Cailliau E, Onimus T, Valibouze C. Can we predict the risk of esophageal stricture after caustic injury? Dis Esophagus 2024; 37:doae001. [PMID: 38282020 DOI: 10.1093/dote/doae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 12/06/2023] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
Nonoperative management of severe caustic injuries has demonstrated its feasibility, avoiding the need for emergency esogastric resection and resulting in low mortality rates. However, leaving superficial necrosis in place could increase the risk of esophageal stricture development. Data on the risk factors of esophageal stricture secondary to caustic ingestion are scarce. The aim of our study was to identify the risk factors for esophageal strictures after caustic ingestion at admission. From February 2015 to March 2021, all consecutive patients with esophageal or gastric caustic injury score ≥ II according to the Zargar classification were retrospectively analyzed. For each patient, we collected over 50 criteria at admission to the emergency room and then selected among them 20 criteria with the best clinical relevance and limited missing data for risk factor analyses. Among the 184 patients included in this study, 37 developed esophageal strictures (cumulative rate 29.4%). All esophageal strictures occurred within 3 months. In multivariate analyses, the risk factors for esophageal strictures were voluntary ingestion (cause-specific hazard ratio 5.92; 95% confidence interval 1.76-19.95, P = 0.004), Zargar's esophageal score ≥ III (cause-specific hazard ratio 14.30; 95% confidence interval 6.07-33.67, P < 0.001), and severe ear, nose, and throat lesions (cause-specific hazard ratio 2.15; 95% confidence interval 1.09-4.22, P = 0.027). Intentional ingestion, severe endoscopic grade, and severe ENT lesions were identified as risk factors for esophageal stricture following caustic ingestion. Preventive measures for this population require further evaluation.
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Affiliation(s)
- Philippe Zerbib
- Department of Digestive Surgery and Transplantation, University Hospital of Lille Nord de France, Lille, France
| | - Aurore Lailheugue
- Department of Digestive Surgery and Transplantation, University Hospital of Lille Nord de France, Lille, France
| | - Julien Labreuche
- Department of Biostatistics, University Hospital of Lille Nord de France, Lille, France
| | - Yasmina Richa
- Department of Digestive Surgery and Transplantation, University Hospital of Lille Nord de France, Lille, France
- School of Medicine, University College Cork, Cork, Ireland
| | - Emeline Cailliau
- Department of Biostatistics, University Hospital of Lille Nord de France, Lille, France
| | - Thierry Onimus
- Department of Intensive Care Medicine, Critical Care Center, University Hospital of Lille Nord de France, Lille, France
| | - Caroline Valibouze
- Department of Digestive Surgery and Transplantation, University Hospital of Lille Nord de France, Lille, France
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Pedersen TØ, Solheim E, Løes S. Accidental ingestion of drain cleaner. BMJ Case Rep 2020; 13:13/9/e237079. [PMID: 32900743 DOI: 10.1136/bcr-2020-237079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Torbjørn Ø Pedersen
- Department of Maxillofacial Surgery, Haukeland University Hospital, Bergen, Norway
| | - Einar Solheim
- Department of Orolaryngology, Førde Central Hospital, Førde, Sogn og Fjordane, Norway
| | - Sigbjørn Løes
- Department of Maxillofacial Surgery, Haukeland University Hospital, Bergen, Norway
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Hall AH, Jacquemin D, Henny D, Mathieu L, Josset P, Meyer B. Corrosive substances ingestion: a review. Crit Rev Toxicol 2020; 49:637-669. [PMID: 32009535 DOI: 10.1080/10408444.2019.1707773] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Corrosive chemical substance ingestions are a major problem, especially in developing countries, but also in developed countries such as the United States, France, and Belgium. Ingestions may be deliberate as suicide attempts (mostly in adolescents and adults) or accidental (mostly in children). The results can be devastating in terms of individual suffering and disability, but also in terms of resource utilization and costs. In developing countries, outcomes may be worse because of limited medical/surgical resources. Common sequelae include gastrointestinal (GI) tract (esophagus, stomach, pylorus, and duodenum) stricture formation, GI tract perforation, and hemorrhage. Systemic effects may also occur, such as disseminated intravascular coagulation (DIC), multi-organ system failure, and sepsis. Various interventions in the acute phase to reduce the severity of injury have been attempted, but there are no large controlled clinical trials to demonstrate efficacy. Dilation therapy in various forms is commonly used for the treatment of strictures and a variety of surgical procedures including esophagectomy and delayed replacement may be required in severe corrosive injury cases.
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Affiliation(s)
- Alan H Hall
- Toxicology Consulting and Medical Translating Services, Azle and Springtown, TX, USA.,Colorado School of Public Health, University of Colorado-Denver, Denver, CO, USA
| | | | | | | | - Patrice Josset
- Department of Pathology, Hôpital d'Enfants Armand Trousseau, Director of the Teaching Program of the History of Medicine, Université Pierre et Marie Curie, Paris, France
| | - Bernard Meyer
- Department of Otorhinolaryngology, Université Pierre et Marie Curie, Groupe Hospitalier Pieté-Salpêtrière, Paris, France
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Dinis-Oliveira RJ, Carvalho F, Moreira R, Proença JB, Santos A, Duarte JA, Bastos MDL, Magalhães T. Clinical and forensic signs related to chemical burns: A mechanistic approach. Burns 2015; 41:658-79. [PMID: 25280586 DOI: 10.1016/j.burns.2014.09.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 09/04/2014] [Accepted: 09/08/2014] [Indexed: 12/14/2022]
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Bonnici KS, Wood DM, Dargan PI. Should computerised tomography replace endoscopy in the evaluation of symptomatic ingestion of corrosive substances? Clin Toxicol (Phila) 2014; 52:911-25. [PMID: 25224219 DOI: 10.3109/15563650.2014.957310] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Corrosive ingestions are common, although most ingestions do not result in clinically significant effects. Limited guidance is available on the role of endoscopy and/or computerised tomography (CT) in the investigation of individuals with corrosive ingestion, and the present data regarding predictors of poor outcome are confusing. Furthermore, whilst there are many case series describing the use of endoscopy in corrosive ingestions, no clear ideal time frame has been established as to when it should be undertaken. More recently, CT has been used to grade injuries, but there are few studies on its role in managing corrosive injuries, and those studies that have been reported are conflicting in their results. METHODS A Medline search was performed with the terms 'Caustic ingestion' and 'Corrosive ingestion' and a second search by adding the words 'Endoscopy', 'CT', and 'Computerised tomography' as a subject term or keyword. These searches revealed a total of 277 reviews and papers, of which 33 original papers were relevant for analysis. Three further papers were identified during the analysis of these papers and a PubMed search of the same terms added one further paper, bringing the total to 37. There have been no prospective, randomised controlled trials directly comparing endoscopy and CT. Only two retrospective studies compared the use of CT and that of endoscopy. Thirty-five studies examined whether an endoscopy is always needed, and if so, within what time frame this should be done: CT or endoscopy? A review of these studies suggests that the data regarding the use of CT in these circumstances are not yet of sufficient weight to replace endoscopy as the first-line investigation in corrosive ingestion-related injury. Who needs investigation after corrosive ingestion? We believe that signs and symptoms indicate the likelihood of clinically significant injury in adults. Specifically, any evidence of oropharyngeal burns, drooling, vomiting, pain or dysphagia clearly indicates the need for an endoscopy. In children, it appears that an even greater degree of caution is needed. How soon after ingestion should investigation be performed? For whom an endoscopy is required, it is prudent to enable surgery and other specifics regarding management of corrosives to be decided quickly (< 12 h). There are many incidences where endoscopy has been done safely beyond 48 h although this is not needed frequently. Management recommendations Asymptomatic patients, particularly adults with a normal clinical examination and who can eat and drink normally, can be discharged safely without endoscopy. Endoscopy is preferred over CT in the assessment of risk in symptomatic patients with corrosive ingestion. If patients have any oropharyngeal injury and in particular symptoms of drooling, vomiting, dysphagia or pain (retrosternal or otherwise), the risk of having a high-grade injury is higher, and urgent endoscopy should be performed to grade the injury and determine whether surgical intervention is required. Patients who have non-specific symptoms, such as cough, should also undergo endoscopy, but this is less urgent. CONCLUSIONS Despite the lack of high-quality clinical trial data, the available evidence and clinical experience support the use of early endoscopy (< 12 h) in patients who are symptomatic after ingestion of a corrosive substance. We propose a clinical guideline that can be used to help plan management of corrosives.
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Affiliation(s)
- K S Bonnici
- Department of Acute Medicine, Chelsea & Westminster Hospital NHS Trust , London , UK
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Chibishev AA, Simonovska N, Bozinovska C, Pereska Z, Smokovski I, Glasnovic M. Respiratory complications from acute corrosive poisonings in adults. Mater Sociomed 2014; 26:80-3. [PMID: 24944527 PMCID: PMC4035138 DOI: 10.5455/msm.2014.26.80-83] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 03/15/2014] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Acute corrosive poisonings are caused by ingestion of corrosive chemicals which are most commonly used as household agents. Intoxications with these kind of agents produce numerous and severe post-corrosive complications of the upper gastrointestinal tract. On the other hand, our experience showed that corrosive agents may also cause injuries of the respiratory system, which makes the treatment very hard and additionally complicates the severe clinical condition of the patient. OBJECTIVE The aim of the study is to show the incidence of respiratory complications in acute corrosive poisonings, the need of various clinical investigations and also the treatment and final outcome of these kind of poisoning. METHODS We retrospectively analyzed clinical records of 415 patients hospitalized and treated at the University clinic for toxicology and urgent internal medicine, in Skopje, Republic of Macedonia, in the period between 2007 and 2011. The protocol consisted of methods for analyzing the systemic complications, with an accent on the post-corrosive respiratory complications. RESULTS From the total number of patients even 98 (23.61%) exhibited systemic complications, from which 51 (52.04%) are respiratory complications. The majority of patients are female (n=40, 78.43%) and the most common complication is pneumonia (n=47). The youngest patient in this study was 14 and the oldest was 87 years old. CONCLUSION Besides the gastrointestinal complications in the acute corrosive poisonings respiratory complications are also very often. They complicate the clinical state of patient and very often lead to fatal endings.
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Affiliation(s)
- Andon A. Chibishev
- University Clinic of Toxicology and urgent internal medicine, University “Ss Cyril and Metodius”, Medical faculty, Skopje, Republic of Macedonia
- Corresponding author: Andon Chibishev, MD, PhD. Address: Vodnjanska, 17, Skopje, Republic of Macedonia. Tel: 0038975303630.
| | - Natasa Simonovska
- University Clinic of Toxicology and urgent internal medicine, University “Ss Cyril and Metodius”, Medical faculty, Skopje, Republic of Macedonia
| | - Cvetanka Bozinovska
- University Clinic of Toxicology and urgent internal medicine, University “Ss Cyril and Metodius”, Medical faculty, Skopje, Republic of Macedonia
| | - Zanina Pereska
- University Clinic of Toxicology and urgent internal medicine, University “Ss Cyril and Metodius”, Medical faculty, Skopje, Republic of Macedonia
| | - Ivica Smokovski
- University Clinic of Toxicology and urgent internal medicine, University “Ss Cyril and Metodius”, Medical faculty, Skopje, Republic of Macedonia
| | - Marija Glasnovic
- University Clinic of Toxicology and urgent internal medicine, University “Ss Cyril and Metodius”, Medical faculty, Skopje, Republic of Macedonia
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Dray X, Cattan P. Foreign bodies and caustic lesions. Best Pract Res Clin Gastroenterol 2013; 27:679-89. [PMID: 24160927 DOI: 10.1016/j.bpg.2013.08.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 07/31/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Xavier Dray
- Sorbonne Paris Cité Paris 7, University, Paris, France; APHP, Lariboisière Hospital, Department of Gastroenterology, Paris, France.
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Cabral C, Chirica M, de Chaisemartin C, Gornet JM, Munoz-Bongrand N, Halimi B, Cattan P, Sarfati E. Caustic injuries of the upper digestive tract: a population observational study. Surg Endosc 2011; 26:214-21. [PMID: 21858575 DOI: 10.1007/s00464-011-1857-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 07/04/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Both observational and aggressive surgical strategies have been advocated for the treatment of corrosive injuries of the upper gastrointestinal tract (UGT) but the optimal management is still a dilemma. The aim of this study was to report our experience with caustic UGT injuries in adult patients treated with a surgically aggressive, endoscopy-based therapeutic protocol over a 6-year period. PATIENTS AND METHODS Between January 2002 and December 2007, 315 patients (138 men, mean age = 40 ± 15.5 years) were referred for corrosive UGT injuries. Emergency endoscopy was performed in all patients at admission. Patients with mild injuries (grades I-IIIa) were offered nonoperative management, whereas emergency surgery was performed for severe injuries (grades IIIb and IV). Esophageal reconstruction was offered to psychologically stable patients after emergency esophageal resection and for esophageal strictures that failed endoscopic dilation. Functional failure was defined as the impossibility to remove the jejunostomy or/and the tracheotomy tube. RESULTS At endoscopy 73 (23%) patients did not have UGT injuries, 158 (50%) patients had mild injuries eligible for nonoperative management and 84 (27%) patients had severe injuries. Nonoperative management was successful in 93% of patients with mild injuries. Surgical exploration was eventually performed in 88 (28%) patients and resection was undertaken in 76 of them. Emergency mortality was 7% and all fatalities were patients with initial severe injuries. After a median follow-up of 6 days (range = 1 day-8.5 years), functional failure was recorded in 9 (3%) patients, all of whom had initial severe injuries. CONCLUSION Emergency endoscopic grading of caustic injuries is the main factor that conditions outcome after caustic ingestion.
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Affiliation(s)
- Carmen Cabral
- Service de Chirurgie Générale, Digestive et Endocrinienne, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
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Chou SH, Chang YT, Li HP, Huang MF, Lee CH, Lee KW. Factors predicting the hospital mortality of patients with corrosive gastrointestinal injuries receiving esophagogastrectomy in the acute stage. World J Surg 2011; 34:2383-8. [PMID: 20512491 DOI: 10.1007/s00268-010-0646-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The aim of this study was to identify the preoperative factors that affect the survival of patients who undergo esophagogastrectomy after corrosive ingestion, using analysis of their physiological condition, associated diseases, physical examination, and laboratory data. METHODS Between January 1995 and December 2005, 71 consecutive patients who underwent esophagogastrectomy for corrosive ingestion injuries were retrospectively reviewed. Of them, 41 survived and 30 (42.3%) died during the perioperative period. Logistic regression analyses were used to model markers for postoperative mortality, including descriptive data, clinical symptoms/signs, and laboratory data. RESULTS There were 35 males and 36 females included in the study, with an average age of 54.7 +/- 14.9 years. After adjustments in the logistic regression model, age of over 65 years (p = 0.021), presence of gross hematuria (p = 0.016), twofold level of serum AST (p = 0.012), blood pH level below 7.2 (p = 0.017), and deficit of blood base over 16 (p = 0.007) were found to be independent risk factors for patient mortality. CONCLUSIONS We consider age over 65 years, preoperative pH < 7.2, base deficit >16, twofold level of serum AST, and presence of gross hematuria to be the important factors predicting postoperative hospital mortality in patients presenting with corrosive ingestion injuries who require emergency surgery.
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Affiliation(s)
- Shah-Hwa Chou
- Department of Surgery, Kaohsiung Medical University Hospital, No. 100, Tzyou 1st Road, Kaohsiung, 80756, Taiwan.
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Ryan F, Witherow H, Mirza J, Ayliffe P. The oral implications of caustic soda ingestion in children. ACTA ACUST UNITED AC 2006; 101:29-34. [PMID: 16360605 DOI: 10.1016/j.tripleo.2005.04.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2005] [Revised: 04/25/2005] [Accepted: 04/25/2005] [Indexed: 10/25/2022]
Abstract
The morbidity related to caustic soda (sodium hydroxide) ingestion is well described in the literature. The majority of publications have concentrated on the effects to the trachea and gastrointestinal tract, with little reference to the oral and peri-oral areas. Accidental ingestion of sodium hydroxide-containing substances is fortunately rare; however the consequences can be devastating. Three cases of children who drank caustic substances are described. Treatment included fitting splints, injecting steroids, local surgical procedures, and the use of dynamic appliances to maintain mouth opening. Despite these interventions, all patients developed severe scarring, resulting in stenosis of the oral musculature and extra-articular ankylosis. There is perhaps a role for further investigation of early use of antiproliferative agents to prevent scarring, more aggressive surgery, and long-term physiotherapy appliance use. These patients require lifelong follow-up.
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Affiliation(s)
- Fiona Ryan
- Oral and Maxillofacial Surgery, Dental and Maxillofacial Department, Great Ormond Street Hospital, London, UK.
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11
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Abstract
Some toxicologic emergencies require immediate or urgent surgical intervention in addition to routine medical care. The EP must be familiar with the indications for operative care, even though many of these poisonings and exposures are relatively rare. The EP must also be knowledgeable regarding the various means of surgical decontamination that are available, including temporary cardiopulmonary bypass. Finally, a high level of vigilance must be maintained for patients who have delayed presentation and fulminant organ failure necessitating early involvement of the transplantation team.
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Affiliation(s)
- Ashok L Jain
- Department of Emergency Medicine, LAC + USC Medical Center, Keck School of Medicine, 1200 N. State Street, Los Angeles, CA 90033, USA.
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Pruvot FR, Brami F, Saulnier F, Gambiez L, Roumilhac D, Chambon JP, Paris JC, Quandalle P. [Gastric conservation in severe caustic lesions of the digestive tract: is it legitimate?]. ANNALES DE CHIRURGIE 2003; 128:11-7. [PMID: 12600323 DOI: 10.1016/s0003-3944(02)00002-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate advantages and drawbacks of a controlled conservative management of patients with severe gastric caustic injuries. METHODS Among 40 patients with severe caustic gastric burns (> IIb), 28 with stade III lesions (mosaic necrosis: n = 10, extensive or circumferential necrosis: n = 18) were managed prospectively from 1990 to 1998. Twenty-two patients had associated stage III oesophageal lesions and 6 had stage III duodenal lesions. All patients were followed up by daily surgical examination. Total gastrectomy with esophageal exclusion or stripping was performed in case of perforation. RESULTS Five immediate and 7 secondary total gastrectomies, two associated esophagectomies and two jejunal resections were performed. Mortality rate was 18% (5/28). Sixteen gastric preservations (60%) were achieved, including 7 complete and 9 partial because of gastric stricture. Eighteen esophagoplasties for oesophageal strictures or after gastrectomy were performed without mortality. CONCLUSION Stage III caustic injuries of the stomach, when they are not immediately life-threatening, do not systematically require total gastrectomy. A strict conservative attitude can be done with significant morbidity and acceptable mortality and significantly raises the numbers of preserved stomach.
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Affiliation(s)
- F R Pruvot
- Service de chirurgie digestive et transplantations, CHU--hôpital Claude-Huriez, avenue Michel-Polonovski 59037 Lille cedex, France.
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Abstract
CONTEXT Caustic substances cause tissue destruction through liquefaction or coagulation reactions and the intensity of destruction depends on the type, concentration, time of contact and amount of the substance ingested. OBJECTIVES To analyze the complications in patients who ingested caustic substances and correlate them with the amount of caustic soda ingested. DESIGN Retrospective study. SETTING University hospital, a referral center. PARTICIPANTS A total of 239 patients who ingested caustic soda. MAIN MEASUREMENTS The amount of granulated caustic substance ingested was measured as tablespoonfuls and the following complications were analyzed: esophagitis, esophageal stenosis and progression to cancer, fistulas, perforations, stomach lesions, brain abscesses, and death. Stenosis was classified as mild, moderate or severe according to the radiological findings. RESULTS We observed an 89.3 % incidence of esophagitis; 72.6 % of the cases involved progression to stenosis and 1 per cent died during the acute phase. Stenosis was mild in 17.6 % of cases, moderate in 59.3 % and severe in 23 %. The incidence of stenosis was 80.8 per cent in women and 62.5 % in men. The incidence of stenosis was 46.9 % in the group that ingested "fragments" and 93.6 % in the group that ingested one or more tablespoonfuls of caustic substances. Among subjects who ingested one or more tablespoonfuls, 32.2 % developed lesions of the stomach-duodenum, whereas the ingestion of "fragments" was not sufficient to induce these lesions. There was no correlation between the intensity of lesions of the esophagus and of the stomach. Progression to cancer of the esophagus occurred in 1.8 % of cases, death during the chronic phase in 1.4 %, perforations in 4.6 %, fistulas in 0.9 %, and brain abscesses in 1.4 %. CONCLUSIONS The complications were related to the amount of caustic soda ingested. Small amounts caused esophagitis or stenosis and large amounts increased the risk of fistulas, perforations and death.
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Affiliation(s)
- R C Mamede
- Head and Neck Surgery Service, Department of Surgery, Orthopedics and Traumatology, Faculdade de Medicine de Ribeirão Preto, Ribeirão Preto, Brazil.
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Abdominalchirurgisch relevante Aspekte des Suizidversuchs. Langenbecks Arch Surg 1997. [DOI: 10.1007/bf02539305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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