Laparoscopy can be very effective in reducing mortality rate for caustic ingestion in suicide attempt

Successful treatment of gastric necrosis after ingestion of hydrochloric acid: a two-stage minimally invasive surgical procedure

Caustic ingestion may cause devastating injuries of the upper gastrointestinal tract and the respiratory system. We report here the successful treatment of a 37-year-old patient who ingested hydrochloric acid (100 mL; 24%) in suicidal intention. An oesophagogastroduodenoscopy revealed extensive necrosis of the gastric mucosa. A diagnostic laparoscopy was performed and confirmed the suspected transmural necrosis which resulted in a discontinuous laparoscopic gastrectomy. During the next days, the oesophageal stump was monitored through frequent oesophagoscopies and showed a good recovery. Thus, it was possible to restore continuity as early as by the sixth postoperative day performing a roux-en-y oesophagojejunostomy using the da Vinci Xi surgical robot. The patient underwent all procedures without any surgical complications and was discharged almost 1 month after initial presentation in good general condition.

Caustic ingestion management: world society of emergency surgery preliminary survey of expert opinion

Caustic material ingestion injuries (CMI) are uncommon. Only 5,000 cases are reported in the United States each year and most acute care healthcare facilities admit only a few cases annually. Accordingly, no single institution can claim extensive experience, and management protocols are most probably based on either expert opinion or literature reports.

In this study, we will attempt to review opinions and practices of representatives of the board members of the World Society of Emergency Surgery and compare them to the current literature.

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.

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.

Caustic injury of the upper gastrointestinal tract: A comprehensive review

Prevention has a paramount role in reducing the incidence of corrosive ingestion especially in children, yet this goal is far from being reached in developing countries, where such injuries are largely unreported and their true prevalence simply cannot be extrapolated from random articles or personal experience. The specific pathophysiologic mechanisms are becoming better understood and may have a role in the future management and prevention of long-term consequences, such as esophageal strictures. Whereas the mainstay of diagnosis is considered upper gastrointestinal endoscopy, computed tomography and ultrasound are gaining a more significant role, especially in addressing the need for emergency surgery, whose morbidity and mortality remains high even in the best hands. The need to perform emergency surgery has a persistent long-term negative impact both on survival and functional outcome. Medical or endoscopic prevention of stricture is debatable, yet esophageal stents, absorbable or not, show promising data. Dilatation is the first therapeutic option for strictures and bougies should be considered especially for long, multiple and tortuous narrowing. It is crucial to avoid malnutrition, especially in developing countries where management strategies are influenced by malnutrition and poor clinical conditions. Late reconstructive surgery, mainly using colon transposition, offers the best results in referral centers, either in children or adults, but such a difficult surgical procedure is often unavailable in developing countries. Possible late development of esophageal cancer, though probably overemphasized, entails careful and long-term endoscopic screening.