Left colonic graft in esophageal reconstruction for caustic stricture: mortality and morbidity

Short-term and long-term management of caustic-induced gastrointestinal injury: An evidence-based practice guidelines

The Indian Society of Gastroenterology has developed an evidence-based practice guideline for the management of caustic ingestion-related gastrointestinal (GI) injuries. A modified Delphi process was used to arrive at this consensus containing 41 statements. These statements were generated after two rounds of electronic voting, one round of physical meeting, and extensive review of the available literature. The exact prevalence of caustic injury and ingestion in developing countries is not known, though it appears to be of significant magnitude to pose a public health problem. The extent and severity of this preventable injury to the GI tract determine the short and long-term outcomes. Esophagogastroduodenoscopy is the preferred initial approach for the evaluation of injury and contrast-enhanced computed tomography is reserved only for specific situations. Low-grade injuries (Zargar grade ≤ 2a) have shown better outcomes with early oral feeding and discharge from hospital. However, patients with high-grade injury (Zargar grade ≥ 2b) require hospitalization as they are at a higher risk for both short and long-term complications, including luminal narrowing. These strictures can be managed endoscopically or surgically depending on the anatomy and extent of stricture, expertise available and patients' preferences. Nutritional support all along is crucial for all these patients until nutritional autonomy is established.

Surgical management of esophageal stenosis due to ingestion of corrosive substances

BACKGROUND

Corrosive ingestion is a significant challenge for healthcare systems. Limited data are available regarding the best treatments, and there remains a lack of consensus about the optimal surgical approach and its outcomes. This study aims to review the current literature and show a single institution's experience regarding the surgical treatment of esophageal stenosis due to corrosive substance ingestion.

METHODS

A retrospective review that accounted for demographics, psychiatric profiles, surgical procedures, and outcomes was performed. A systematic review of the literature was performed using PubMed.

RESULTS

In total, 27 surgical procedures for esophageal stenosis due to corrosive substance ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. Esophagectomies and esophageal bypasses were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded.

CONCLUSION

Surgical intervention either by esophagectomy or esophageal bypass results in durable relief from dysphagia. However, successful clinical outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

Patient-Reported Long-Term Outcome is Superior After Treatment with Self-Expanding Metallic Stents in Esophageal Perforations

BACKGROUND AND AIMS

Esophageal perforations are life threatening. Since the 1990s, placing of covered esophageal stents has become an alternative to surgery. Theoretically, this minimally invasive approach has several benefits; however, little data are available on long-term outcome in these patients. We aimed to evaluate how patient-reported outcome differed between full surgery and placement of self-expanding metallic stents when treating primary benign esophageal perforations.

MATERIAL AND METHODS

Of 48 patients treated at our hospital in 2000-2015, 23 were alive and asked to answer three questionnaires. We used a short clinical questionnaire, the QLQ-OG25 from the European Organization for Research and Treatment of Cancer and a simplified quality-of-life instrument, the Check Your Health. Non-parametric statistics were used to evaluate differences between the two groups.

RESULTS

In all, 20 (87%) individuals (13 men, 64 years of age) responded. At survey, surgical patients had lost 13 kg of initial weight, compared to no weight loss in the self-expanding metallic stents group (p = 0.01). This involuntary weight loss worried patients according to the QLQ-OG25; otherwise patient-experience measures did not differ between groups. For quality of life, surgical patients scored significantly lower physical health, emotional well-being, social functioning, and overall quality of life after treatment, but after stenting no differences were seen.

CONCLUSIONS

In contrast to stenting, surgical treatment was associated with involuntary, and worrisome, weight loss as well as reduced quality of life. We therefore believe that self-expanding metallic stents should be used when possible in treating benign esophageal perforations.

The Use of Fluorescence Imaging in Colon Interposition for Esophageal Replacement: A Technical Note

Every field of surgery has seen an explosion of new technologies aimed at improving surgical technique and reducing complications. The use of near-infrared (NIR) fluorescence to assess perfusion has been described in several surgical disciplines. NIR provides the surgeon with real-time perfusion assessment of a target organ or anastomosis and can be invaluable in aiding decision-making during the index operation. In the following article we discuss the use of fluorescence-guided perfusion assessment during colonic interposition for esophageal replacement. To our knowledge this is the first description of the use of fluorescence-guided perfusion assessment during colonic interposition.

Quality of life of patients with a colonic interposition postoesophagectomy

OBJECTIVES

After oesophagectomy, stomach grafts are most frequently used to restore intestinal continuity. Less frequently, a colonic graft is used. There is quite a large body of literature addressing the functional outcome after gastric pull-up, but little is known about the functional results of colonic interposition (CI). The aim of this study was to assess the short-term outcomes and the long-term quality of life and function of the CI postoesophagectomy.

METHODS

Between 2002 and 2016, we retrospectively collected data on 80 patients with CI from personal health records at the Ghent University hospital. We prospectively compared the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, EORTC QLQ-OG25 and Swallowing Quality of Life (SWAL-QOL) questionnaire scores to the healthy reference group and the gastric tube (GT) group.

RESULTS

The 30-day mortality rate was 5%. Anastomotic leakage occurred in 37.5% and stenosis in 20% of the patients. The median overall survival of all patients was 33.9 months (95% confidence interval 8.3-59.4). The mean general health score of the CI patients was less than the healthy reference group but comparable to the GT group (CI = 62.1 vs healthy reference group = 71.2 vs GT = 60). Fifty percent of the patients reported their health as good and 15% as very good. The mean functional results with a CI were better than with a GT. Compared to GT patients, CI patients had less dyspnoea, reflux and dysphagia, but they reported more food selection, diarrhoea and weight loss.

CONCLUSIONS

Despite the high complication rate, the severity of the disease and the demanding operation, patients perceived themselves as being in good health and reported very good long-term functionality after CI.

CLINICAL TRIAL REGISTRATION NUMBER

B670201630635.

Case Report: POST ESOPHAGECTOMY ESOPHAGEAL RECONSTRUCTION IN ESOPHAGEAL INJURY DUE TO CAUSTIC MATERIALS

The esophageal caustic injury is rare, but it requires precise and complex management. A variety of reconstruction techniques have been done, but despite the increasing volume, the incidence of complications is still relatively high. We reported the experience in our center in handling esophageal reconstruction in patients with caustic esophageal injury that caused oesophageal stricture between 2014-2017. This study used case series method with literature review. The results showed that between 2014-2017, there were 3 patients with caustic esophageal injury. All patients undergoing esophageal reconstruction surgery were included under conditions of malnutrition. Two were caused by HCl and the rest by NaOH. All patients underwent a resection of stricture segment of the esophagus, either using partial or total esophagectomy. Anastomosis leakage occurred in all cases, but improved with conservative treatment. The average length of hospitalization was 27 days. The intraoperative blood loss in patients ranged from 450-700 cc. In conclusion, proper preliminary management can provide approppiate preparation of the patients for definitive or reconstructive surgery, especially to avoid malnutrition. The ideal reconstruction still could not be established, and the rate of postoperative complications was still high. The length of patient hospitalization was also relatively long.

Esophagectomy with Esophagocoloplasty for Malignancies: Indications, Technique (with Video), and Results. Systematic Review of the Literature

INTRODUCTION

Esophagocoloplasty represents a useful technique to restore the intestinal continuity after esophagogastrectomy. This technique has been used mainly after esophagogastric caustic injuries. The aim of this review is to assess the role of esophagogastrectomy with esophagocoloplasty for esophageal or gastric neoplasms.

METHODS

A systematic literature search was performed using Embase, Medline, Cochrane, and PubMed databases to identify all studies published in the previous 25 years (1991-2016) reporting cases of esophagocoloplasty after esophagogastrectomy for malignancies. The systematic review was conducted according to the PRISMA guidelines.

RESULTS

The systematic review of the literature shows a morbidity rate of 57% and a mortality rate of 15% in the 93 reported cases of esophagocoloplasty performed for malignant diseases. However, R0 rate ranged from 76.1 to 85%, and 5-year survival was obtained in 11.9-32.8% of patients in the different series.

CONCLUSIONS

In highly selected cases of primary or relapsing gastric or esophageal neoplasms, esophagogastrectomy with esophagocoloplasty is a viable and useful option, which may guarantee complete tumor resection and long-term survival.

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.

European perspective in Thoracic surgery-eso-coloplasty: when and how?

Colon interposition has been used since the beginning of the 20(th) century as a substitute for esophageal replacement. Colon interposition is mainly chosen as a second line treatment when the stomach cannot be used, when the stomach has to be resected for oncological or technical reasons, or when the stomach is deliberately kept intact for benign diseases in young patients with long-life expectancy. During the surgery the vascularization of the colon must be carefully assessed, as well as the type of the graft (right or left colon), the length of the graft, the surgical approach and the route of the reconstruction. Early complications such as graft necrosis or anastomotic leaks, and late complications such as redundancy depend on the quality of the initial surgery. Despite a complex and time-consuming procedure requiring at least three or four digestive anastomoses, reported long term functional outcomes of colon interposition are good, with an acceptable operative risk. Thus, in very selected indications, colon interposition could be seen as a valuable alternative for esophageal replacement when stomach cannot be considered. This review aims at briefly defining "when" and "how" to perform a coloplasty through demonstrative videos.

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.