Esophageal reconstruction for hypopharyngoesophageal strictures after corrosive injury

Emergency surgical intervention in acute corrosive ingestion: single-center experience from India

BACKGROUND

Surgical intervention for acute corrosive injury is often required. It is associated with considerable morbidity and mortality. Sparce data is available on the types and timing of surgery after acute corrosive ingestion and complications associated with the same.

METHODS

This is a retrospective single-center study from a tertiary care center in India. All patients who underwent surgical exploration after acute corrosive intake between January 2003 and June 2014 were enrolled in the study. Data on patients' presentation, their endoscopic findings, indications of surgery, type of surgery and post-operative follow-up was retrieved.

RESULTS

Out of 170 patients who presented with acute corrosive ingestion, 24 patients (14.11%) required emergency surgery. The mean interval between ingestion and surgery was 9.92 ± 9.03 days. Presence of peritonitis was the most common indication for surgery (n = 10; 41.7%) followed by mediastinitis (n = 7; 29.2%). A total of 17 resectional and 7 non-resectional procedures were performed. Thirteen (54%) patients succumbed to their illness post-operatively due to multi-organ failure (n = 9), refractory shock (n = 3) or pulmonary thromboembolism (n = 1). Patients with early surgery (≤7 days) after corrosive ingestion had similar mortality compared to patients with late surgery (>7 days) (50% versus 67%; P = 0.30). Of the 11 surviving patients, eight patients (72%) underwent successful reconstructive surgery on follow-up.

CONCLUSIONS

Emergency surgery after corrosive ingestion carries high morbidity and mortality. However, after the initial stormy acute phase, majority of patients can undergo successful reconstructive surgery on follow-up.

Innominate Arterial Barrier Blocked a 25-year Substernal Neo-esophagus

A 67 years old woman underwent esophago-gastroduodenectomy, partial jejunectomy, pancreatico-jejunostomy, cervical esophagostomy, and feeding jejunostomy at the age of 42 for corrosive necrosis. She underwent esophageal reconstruction using the ilocolon via the substernal route 4 months later. Twenty-five years after esophageal reconstruction, the proximal part of the neo-esophagus was obstructed by the innominate artery barrier. She could eat regular diets after revision surgery.

Esophageal caustic injuries in pediatrics: a sobering global health issue

Caustic material ingestion by children is considered a global healthcare issue, especially in low-to-middle income countries. The aim of this article was to review the epidemiology, prevention, and management of caustic material ingestion in pediatric patients, comparing low-to-middle income countries with high-income countries. We conducted an English literature review using PubMed with the following keywords: (caustic OR corrosive) AND ingestion AND (pediatric OR pediatric). Our search retrieved 253 citations; all abstracts were screened by the authors, and 52 articles were finally included in our review. Prevention is key in tackling this issue, but legislation is scarce in low-to-middle income countries. Diagnosis of caustic ingestion is mostly achieved using flexible endoscopy, computed tomography, and endoscopic ultrasound, but access is limited in low-to middle income countries and diagnosis is often delayed. After stabilizing patients, the mainstay of treatment is graded endoscopic dilatation, and rarely, esophageal replacement. We concluded that caustic ingestion represents a serious condition where prevention is the key. Once a child suffers an injury, rapid and careful evaluation of the injury with endoscopy, and a course of close observation and dilations if needed, will often avoid esophageal replacement. When necessary, the stomach is the best first option if it is viable, followed by the colon, and finally, the jejunum.

Tight near-total corrosive strictures of the proximal esophagus with concomitant involvement of the hypopharynx: Flexible endoscopic management using a novel technique

AIM

To investigate the role of a novel minimally invasive endoscopic technique in the management of tight near-total corrosive strictures of the proximal esophagus involving the hypopharynx.

METHODS

Two patients with near-total corrosive strictures of the proximal esophagus involving the hypopharynx were managed with the novel endoscopic technique. The technique involved passing a 0.025-inch flexible guide-wire across the stricture, and stricture dilatation, using 10F coaxial diathermy and balloon dilators, followed by electro-incision of the proximal aspect of the residual eccentric stricture by means of a novel approach using a wire-guided sphincterotome.

RESULTS

Both patients were successfully managed on an outpatient department basis with the complete relief of symptoms and resolution of strictures on endoscopy and an esophagogram. No adverse events were seen during or after the procedure. There was no recurrence of symptoms at a follow-up of over a year in both cases. There was a significant improvement in the body mass index of both patients after the procedure.

CONCLUSION

We report a novel flexible endoscopic technique for the management of complex hypopharyngo-esophageal strictures. In experienced hands, the procedure is relatively simple, safe and effective with a durable response.

Outcome of dilatation and predictors of failed dilatation in patients with acid-induced corrosive esophageal strictures

Outcome of endoscopic dilatation in acid-induced corrosive esophageal stricture is less known. This study aims to determine the outcome of dilatation and predictors of failed dilatation in patients with acid-induced corrosive esophageal stricture. Patients diagnosed of corrosive esophageal strictures were included. Endoscopic dilatation with graded Savary-Gilliard dilator was performed as the first line treatment. Outcome of dilatation was considered favorable when patients were able to swallow solid without intervention at least six months after successful dilatation. Failure of dilatation was defined as one of the following; complete luminal stenosis, inability to perform safe dilatation, perforation, and inability to maintain adequate luminal patency. Surgery or repeated dilatation was indicated in failed dilatations. There were 55 patients with corrosive esophageal strictures. Of 55 patients, 41 (75%) had failed dilatation (38 having esophageal replacement procedure, two continue repeated dilatation and one unfit for surgery). Of 323 sessions of dilatations, eight out of 55 patients (14.5%) had perforations. There was no dilatation-related mortality. Patients with concomitant pharyngeal stricture (p = 0.0001), long (≥ 10 cm) stricture length (p < 0.0001), number of dilatation >6 sessions per year (p = 0.01) and refractory stricture (inability to pass a larger than 11 mm dilator within three sessions) (p = 0.01) were more likely to have failed dilatation. Thirty-two of 38 patients with surgery had good swallow outcome with one operative mortality (2.6%). At the median follow-up of 61 months, overall favorable outcome was 84% after surgery and 25% for dilatation (p < 0.0001). Majority of patients with acid-induced corrosive esophageal stricture were refractory to dilatation. Esophageal dilatations were ultimately failed in three-fourth of the patients. Concomitant cricopharyngeal stricture, long stricture length, requiring frequent dilatation, and refractory to >11 mm dilatation were factors associated with failed dilatation.

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.

Step-Down Approach for Pharyngoesophageal Corrosive Stricture: Outcome and Analysis

BACKGROUND

Pharyngoesophageal stricture (PES) is an Achilles' heel in the management of corrosive injury. Advances in endoscopic techniques were utilized in its management. We classified the stricture as per its dilatability and then planned their treatment.

METHODS

PES was sub-categorized based on endoscopic dilatation and availability of cervical oesophagus: group-1 stricture with available cervical oesophagus; group-2 stricture with some part of upper oesophagus made available after endoscopic dilatation and anastomosis in cervico-pharyngeal area; group-3 stricture not amenable for dilatation, anastomosis done at the pharynx. Endoscopic dilatation was performed using through-the-scope pyloric balloon. Number and duration of dilatation sessions before surgery, incidence of tracheostomy, time and incidence for re-stricture and present status of swallowing were evaluated.

RESULTS

Of 226 patients managed, 46 underwent oesophageal replacement for PES. Group 1, 2 and 3 had 12, 14 and 20 patients, respectively. An average 3 (2-4) preoperative balloon dilatation sessions were performed over 6-8 weeks. Tracheostomy was required in 1, 0, 8 patients (p = 0.010), and median hospital stay was 10, 9 and 13 days (p = 0.09) in group 1, 2, 3, respectively. Re-stricture developed in 4/12, 4/14, 9/20 patients with average sessions of dilatation required in post-operative period was 4, 3.5 and 8 in group 1, 2, 3, respectively. >90% of patients are taking normal diet in each group.

CONCLUSION

We attempted to avoid the high anastomosis by dilating the PES and step down the level of anastomosis in two-third patients. We thereby avoided tracheostomy, aspiration and swallowing problems related to high strictures.

Comparison of the outcomes of free jejunal flap reconstructions of pharyngoesophageal defects in hypopharyngeal cancer and corrosive injury patients

INTRODUCTION

Free jejunal flap is one of the optimal choices for restoring upper digestive tract. The purpose of this study was to introduce the treatment strategies and to compare the outcomes of free jejunal flap for pharyngoesophageal reconstruction between hypopharyngeal cancer and chemical corrosive injured esophagus.

METHODS

From 2001 to 2012, patients who had been received esophageal reconstruction by free jejunal flap for pharyngoesophageal defect were divided into squamous cell carcinoma (SCC) group and corrosive chemical injury (CCI) group. All data on outcomes and complications including relevant radiographic investigations were collected retrospectively.

RESULTS

Sixteen patients were in SCC group and 9 patients in CCI group underwent free jejunal flap reconstruction. Two cases of flap failure were noted in SCC group, and no flap failure in CCI group-the total failure rate was 8% (2/25 patients). In SCC group, 5 of 16 patients (31.3%) developed fistula; however, no fistula in CCI group. One patient in SCC group and 3 patients in CCI group developed esophageal strictures. Other than early stricture (stricture <1 year) which reached significant difference, all of other complications were not statistically significant between two groups. The average follow-up time was 42 months.

CONCLUSIONS

Postoperative early stricture but lower fistula occurrence is expected in patients with corrosively injured esophagi. This helpful preliminary findings could not only early-check complication, but also better explanation and prepare were taken placed before operation.

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.

A case of corrosive injury-induced pharyngeal stricture treated by endoscopic adhesiolysis using an electrosurgical knife

Here, we report a case of corrosive injury-induced pharyngeal stricture in a 69-year-old female, which was successfully treated with endoscopic adhesiolysis using an electrosurgical knife. The patient had ingested sodium hydroxide in an attempted suicide, and immediate endoscopy revealed corrosive injuries of the pharynx, esophagus, and stomach. When a liquid diet was permitted, she complained of nasal regurgitation of food. Follow-up endoscopy revealed several adhesive bands and a web-like scar that did not allow passage of the endoscope into the hypopharyngeal area. For treatment of the hypopharyngeal stricture, the otolaryngologist attempted to perform an excision of the fibrous bands around the esophageal inlet using microscissors passed through an esophagoscope, but this procedure was not effective. We then dissected the mucosal adhesion and incised the adhesive bands using an electrosurgical knife. After this procedure, nasal regurgitation of food no longer occurred. To our knowledge, this case is the first report of endoscopic adhesiolysis with an electrosurgical knife in a patient with a corrosive injury-induced pharyngeal stricture.

Caustic injuries of the upper digestive tract: a population observational study

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.

Therapeutic options for management of pharyngoesophageal corrosive strictures

INTRODUCTION

Pharyngoesophageal strictures due to corrosive injury raise difficult therapeutic problems due to the site of stricture, the possible association with laryngeal injury and the presence of downstream esophageal strictures. We present here our approach to management of 51 consecutive patients with pharyngoesophageal strictures seen over a 30-year period.

METHODS

Patients (51) with PES were managed by one of several options depending on the individual case, viz. dilatation alone, dilatation followed by esophagocoloplasty, dilatation after cervical esophagostomy with or without an esophagocoloplasty, pectoralis major or sternocleidomastoid myocutaneous flap inlays with or without esophagocoloplasty, pharyngocoloplasty with tracheostomy, and neck exploration followed by esophagocoloplasty if a lumen was found in the cervical esophagus.

RESULTS

The overall results were excellent with satisfactory swallowing restored in 45 out 51 patients (88.2%). There was one death and three incidences of complications, two patients with temporary cervical salivary fistula, and one patient in whom swallowing could not be restored because of lack of suitable conduit. The mean dysphagia score was improved from a pre-operative value of 3.6 to 1.5 post-operatively.

CONCLUSION

In conclusion, pharyngoesophageal strictures require considerable expertise in management, and one should be aware of various options for this purpose. The choice of procedure depends on site of stricture, time of presentation after the corrosive injury, relationship of the stricture to the laryngeal inlet, status of the larynx and the airway, length of the stricture, presence or absence of a lumen distal to the stricture in the cervical esophagus, and presence or absence of strictures further downstream. With proper treatment, mortality is negligible and morbidity minimal and is usually restricted to temporary salivary fistula.

Anatomically based comparison of the different transthoracic routes for colon ascension after total esogastrectomy

Colon interposition is the method of choice to restore the digestive tract after esogastrectomy. The aim of this study was to compare the length of the four available routes for colon transposition (posterior mediastinum route, transpleural route, substernal route and subcutaneous route) and to achieve a specific evaluation of the transpleural route. Our study was conducted with anatomical (dissection) and radiological (2D CT scan reconstructions) protocols. For both, the posterior mediastinum route was always the shortest way and the subcutaneous route was always the longest. For the anatomical results, the transpleural route and the substernal route were similar in terms of length and for the radiological study, the transpleural route was shorter than the substernal route (P < 0.001) and shorter than the subcutaneous route (P < 0.001). We demonstrated that the transpleural route was acceptable for colon transposition in term of length, and could be an alternative when the substernal route is unavailable.

Total gastric transposition is better than partial gastric tube esophagoplasty for esophageal replacement in children

Whenever the surgeon uses the stomach as an esophageal substitute, either one of two techniques is generally performed: total gastric transposition or gastric tube esophagoplasty. No existing reports compare the complications associated with these two surgical procedures. The purpose of this study is to review the authors' experience with total gastric transposition and verify whether this technique is superior to gastric tube esophagoplasty in children by comparing the main complications with those reported in the publications of gastric tubes esophagoplasties in the English language literature published in the last 38 years. A total of 35 children underwent total gastric transposition according to the classical technique. Most of these patients (27, or 77.1%) had long gap esophageal atresia. The most frequently observed complications were compared to those reported in nine studies of gastric tube esophagoplasty comprising 184 patients. Mortality and graft failure rates were also compared. Seven patients (20.0%) presented with leaks, all of which closed spontaneously. Six children were reoperated, three experienced gastric outlet obstruction secondary to axial torsion of the stomach placed in the retrosternal space and the other three experienced delayed gastric emptying that required revision of the piloroplasty. There were two deaths (5.7%) and no graft failure. Strictures were observed in five patients (14.2%) and all of these were resolved with endoscopic dilatations. Six patients had diarrhea that spontaneously resolved. In the late follow-up period, all patients were on full feed and thriving well. The comparisons with gastric tube patients demonstrated that the total gastric transposition group presented with significantly less leaks and strictures (P = 0.0001 and 0.001, respectively). The incidence of death and graft failure was not statistically different. In conclusion, gastric transposition is as a simple technical procedure for esophageal replacement in children with satisfactory results, and is superior to gastric tube esophagoplasty.

Which is better for esophageal substitution in children, esophagocoloplasty or gastric transposition? A 27-year experience of a single center

BACKGROUND/PURPOSE

Esophagocoloplasty and gastric transposition are 2 major methods of esophageal substitution in children. The purpose of this study is to review the authors' experience with these 2 techniques and compare the complications of these operations to determine whether 1 method emerges superior to the other.

METHODS

A total of 149 children underwent surgery: 115 children underwent esophagocoloplasty, and 34 children underwent gastric transposition. Most patients (113-75.8%) had long-gap esophageal atresia. The operative technique of esophagocoloplasty consisted of the interposition of the transverse colon maintained by a double vascular pedicle based on the left colic vessels and the marginal paracolic arcade. Gastric transposition was performed according to classical technique. The transposition of colon and stomach was performed using blunt mediastinal dissection in all patients without thoracotomy. Complications and mortality of the 2 groups of patients were compared. These complications were classified as minor (cervical anastomosis leak, abdominal evisceration, diarrhea, strictures, and reflux to the interposed viscera) and major (necrosis of transposed viscera, dehiscence of an intra-abdominal or intrapleural suture, torsion of transposed viscera, delayed gastric emptying requiring reoperation, and cologastric anastomosis stricture).

RESULTS

There were 2 graft necrosis, 1 (0.8%) in the esophagocoloplasty group and another (2.9%) in the gastric transposition group. Patients who underwent esophagocoloplasty experienced a greater incidence of minor complications (P = .001) and less major complications in comparison with the gastric transposition group (P = .001). All minor complications were treatable and had no consequences. No difference was noted between the 2 groups with regard to the mortality rate (0.9% and 5.9%, respectively, P > .05).

CONCLUSIONS

Esophagocoloplasty and gastric transposition are satisfactory means of esophageal substitution in children. Considering the incidence of major postoperative complications, esophagocoloplasty must be the first choice for esophageal replacement in children.

Combined retrograde and anterograde hypopharyngeal puncture and dilatation in a child with complete hypopharyngeal stenosis

The management of complete hypopharyngeal stenosis is a complex task, and various methods of re-creating a lumen and maintaining its patency have been described in both the adult and pediatric literature. We present our experience using a modification of the combined anterograde-retrograde endoscopic technique for managing a 15-year-old child who developed complete hypopharyngeal and upper esophageal obliteration following successful treatment of a parapharyngeal rhabdomyosarcoma. During an 18-month period following initial cannulation of the aerodigestive tract, we performed 17 dilatations using a double-balloon technique that combined anterograde and retrograde approaches to the stenosis. Initially, Kenalog injections and topical Mitomycin-C were used as adjunctive treatments. We observed no major complications following dilatations. At 33 months follow-up the patient was asymptomatic, tolerating a near normal diet, had not required dilation for more than 18 months, and no longer required a gastrostomy tube.

Esophageal reconstruction with intraoperative dilatation of the hypopharynx for the management of chronic corrosive esophageal strictures. A technical tip

Chronic corrosive strictures of the upper cervical esophagus and hypopharynx resulting from ingestion of caustic substances are a challenging surgical entity when repeated endoscopic dilatations fail to yield satisfactory results. Restoring the continuity of the upper digestive tract by esophageal substitution at healthy tissue margins not only compromises the integrity of the swallowing mechanism, but also often requires the performance of a tracheostomy in order to ensure avoidance of recurrent aspirations. We describe three cases of corrosive upper cervical esophageal strictures treated with intraoperative dilatation of the proximal hypopharyngeal stump and concurrent 'stenting' of the pharyngeal anastomosis with the conduit replacing the esophagus. All patients tolerated the procedure well. Avoidance of both impairment of deglutition and respiratory complications, as well as restoration of normal esophageal function, was successfully accomplished.

Pharyngocolonic anastomosis for esophageal reconstruction in corrosive esophageal stricture

BACKGROUND

The aim of our study is to observe the outcome of pharyngocolonic anastomosis in esophageal reconstruction for diffuse corrosive esophageal stricture involving hypopharynx.

METHODS

This is a retrospective report of the experience and results of 14 patients undergoing esophageal reconstruction with pharyngocolonic anastomosis without resection of the strictured intrathoracic esophagus. The left colonic segment was pulled up to the neck through the substernal space in all patients.

RESULTS

There was no operative or hospital death. Postoperative complications included cervical anastomotic leakage in 4 patients, rupture of abdominal incision in 1 patient, and aspiration pneumonia in 2 patients. The length of follow-up ranged from half a year to 10 years, with an average of 4 years. Anastomotic stenosis occurred in 2 patients. One patient was improved after dilatation and the other was relieved by plastic operation. One patient began to have vomiting after meals 7 months after surgery and was found to have redundant abdominal colon graft, which was corrected with a side-to-side anastomosis between the colon and the stomach.

CONCLUSIONS

A successful reconstruction for hypopharyngoesophageal stricture requires a sufficiently large hypopharyngocolonic anastomosis and a technique of good anastomosis. From our experience, this procedure is shown to be safe and effective.

Massive upper gastrointestinal bleeding after acid-corrosive injury

Our purpose was to delineate the characteristics and outcome of massive upper gastrointestinal bleeding (UGI) caused by acid-corrosive injury and to determine its management protocol. From June 1988 to June 2000, all patients with the history of acid-corrosive injury at our institution were reviewed. Patients with massive UGI bleeding (hematocrit level <25% or transfusion of three or more units of whole blood required to restore normal vital sign) were enrolled into this study. Altogether, 12 (3.2%) of 378 patients with acid-corrosive injury developed massive bleeding: 8 gastric bleeding, 2 duodenal bleeding, and 2 first gastric and then duodenal bleeding. Gastric bleedings started an average of 12.1 days after the initial injury (range 9-21 days). Duodenal bleeding usually occurred later, at 10.1 days (range 6-18 days) after a gastric or esophagogastric operation. Nine of the ten patients with gastric bleeding underwent surgery during the subacute stage: three esophagogastrectomy, three gastric mucosectomy with gastrostomy and jejunostomy, and three total or subtotal gastrectomy. Operative findings were hemorrhagic gastritis with diffuse mucosal bleeding. Two of four patients with duodenal bleeding underwent duodenotomy with suture-ligation of bleeding vessels, and the other two had conservative treatment. Nine patients (75%) had postoperative complications. One patient (8%) died from complications of surgery performed to stop duodenal bleeding. Massive UGI bleeding rarely occurs after acid-corrosive injury; but when it does, it occurs during the subacute stage. Aggressive surgical treatment is mandatory for gastric bleeding. How duodenal bleeding can be better managed requires further study.