Pancreaticoduodenal Necrosis Due to Caustic Burns

Corrosive Ingestion

Corrosive ingestion remains a common problem in developing countries, such as India due to the lack of strict laws that regulate the sale of caustics. While appropriate treatment of the acute phase can mitigate tissue damage improper management of the acute corrosive injury is widely prevalent due to the limited experience of the individual physicians in managing this condition. The aim of this review is to summarize the epidemiology and pathophysiology of corrosive ingestion, principles in the management of acute phase injury, long-term effects of caustic ingestion, and prevention of corrosive ingestion.

HOW TO CITE THIS ARTICLE

Kalayarasan R, Ananthakrishnan N, Kate V. Corrosive Ingestion. Indian J Crit Care Med 2019;23(Suppl 4):S282-S286.

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.

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.

Computed tomography evaluation of high-grade esophageal necrosis after corrosive ingestion to avoid unnecessary esophagectomy

BACKGROUND

Esophagectomy is the standard of care for high-grade corrosive esophageal necrosis as assessed endoscopically. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to unnecessary esophageal resection, with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of endoscopic high-grade corrosive esophageal necrosis.

METHODS

In a before (2000-2007)/after (2007-2012) study of patients with grade 3b endoscopic esophageal necrosis, we compared outcomes after routine emergency esophagectomy versus selection for emergency esophagectomy based on CT evidence of transmural necrosis, defined as at least two of the following: esophageal-wall blurring, periesophageal-fat blurring, and the absence of esophageal-wall enhancement. Survival estimated using the Kaplan-Meier method was the primary outcome.

RESULTS

Compared to the routine-esophagectomy group (n = 125), the CT group (n = 72) had better overall survival in the crude analysis (hazard ratio [HR], 0.43; 95 % confidence interval [95 %CI], 0.21-0.85; P = 0.015) and in the analysis matched on gender, age, and ingested agent (HR, 0.36; 95 %CI, 0.16-0.79; P = 0.011). No deaths occurred among patients managed without emergency esophagectomy based on CT findings, and one-third of CT-group patients had their functioning native esophagus at last follow-up. Self-sufficiency for eating and breathing was more common (84 % vs. 65 %; relative risk [RR], 1.27; 95 %CI, 1.04-1.55; P = 0.016) and repeat suicide less common (4 % vs. 15 %; RR, 0.27; 95 %CI, 0.09-0.82; P = 0.019) in the CT group.

CONCLUSION

The decision to perform emergency esophagectomy for endoscopic high-grade corrosive esophageal injury should rely on CT findings.

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.

Duodenal necrosis secondary to a closed-loop bowel obstruction with novel reconstruction

Duodenal necrosis is rare in children and presents a significant surgical challenge. We describe a 12-year-old girl who presented with duodenal necrosis secondary to a closed-loop bowel obstruction. We describe the diagnostic images, operative findings, and a novel reconstruction technique. This case highlights an alternative strategy for reestablishing gastrointestinal and biliopancreatic continuity while avoiding more complex procedures.

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.

Oesophagogastrectomy and pancreatoduodenectomy for caustic injury

Background

The justification for pancreatoduodenectomy (PD) for extended duodenal and pancreatic caustic necrosis is still a matter of debate.

Methods

This was a retrospective evaluation of patients who underwent PD in association with oesophagogastrectomy from a large single-centre cohort of patients with caustic injuries. Morbidity, mortality and long-term outcome were assessed.

Results

PD was performed in 18 (6·6 per cent) of 273 patients who underwent emergency surgery for caustic injuries. Biliary and pancreatic duct reconstruction during PD was performed in ten and six patients respectively. Seven patients died and 17 experienced operative complications after PD for caustic injuries. Twelve patients required at least one reoperation. Specific PD-related complications occurred in 13 patients. Initial (P = 0·038) or secondary (P &lt; 0·001) extension of necrosis to adjacent organs were independent predictors of operative death. After a median follow-up of 24 months following reconstruction, three patients had recovered nutritional autonomy. In an intention-to-treat analysis, functional success was recorded in three patients and the 5-year survival rate was 39 per cent after PD for caustic injury.

Conclusion

PD can save the lives of patients with caustic injuries extending beyond the pylorus, but has poor functional outcome. Immediate pancreatic duct reconstruction should be preferred to duct occlusion to decrease the rate of pancreatic complications.