G Chir Vol. 32 - n. 4 - pp. 188-193April 2011

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Introduction

Caustic products are widely available and utilized inevery house, but their danger is often underestimated.The ingestion of these substances is one of the most dif-

SUMMARY: Management of corrosive injuries of the upper ga-strointestinal tract. Our experience in 58 patients.

U. ROBUSTELLI, R. BELLOTTI, F. SCARDI, M. FORTUNATO ARMELLINO,A. DE MASI, A.L. FORNER, E. RICCIO, F. MANGUSO

Background. The ingestion of caustic substances is one of the mo-st difficult conditions to be treated in Emergency Department.

Patients and methods. The medical records of patients with cau-stic ingestion and hospitalized from 2003 to 2008 at the Division ofGeneral Emergency Surgery with Polyspecialistic Observation ofAORN "A. Cardarelli "in Naples, have been revalued.

Results. From 2003 to 2008, 58 patients with caustic ingestionwere admitted to our Division. Ten of these patients (17.24%) un-derwent surgery. Six patients underwent oesophageal and gastric resec-tion with cervical esophagostomy and alimentary digiunostomy inemergency; two underwent exploratory laparotomy, two had gastroen-teroanastomosis for antropyloric stenosis. One patient underwent newoperation for a complication. In total, three reconstructions of oesopha-gus with colon were performed . Of the six patients undergoing esofa-gogastrectomy, two died in the first postoperative day, but four have pas-sed the acute phase.

Conclusions. There is no universally accepted diagnostic and the-rapeutic procedure for the management of these patients, who are oftenleft - as it appears in literature - to the personal experience of the sur-geon who is dealing with this situation.

RIASSUNTO: Management delle lesioni da ingestione di caustici deltratto digestivo superiore. Nostra esperienza in 58 pazienti.

U. ROBUSTELLI, R. BELLOTTI, F. SCARDI, M. FORTUNATO ARMELLINO,A. DE MASI, A.L. FORNER, E. RICCIO, F. MANGUSO

Background. L'ingestione di sostanze caustiche rappresenta unadelle condizioni più diffìcili da gestire che possano presentarsi in un Di-partimento di Emergenza.

Pazienti e metodi. Sono state rivalutate tutte le cartelle di malaticon riferita ingestione di caustici ricoverati dal 2003 al 2008 presso laDivisione di Chirurgia Generale d' Urgenza con Osservazione Polispe-cialistica della AORN "A. Cardarelli" di Napoli.

Risultati. Dal 2003 al 2008 sono stati ricoverati presso la nostraDivisione 58 pazienti ( 28 maschi e 30 femmine) per riferita ingestio-ne da caustici. Dieci di questi pazienti (17,24%) sono stati sottopostiad intervento chirurgico. Sei pazienti sono stati sottoposti ad interven-to di esofagogastrectomia, con esofagostomia cervicale e digiunostomiaalimentare in urgenza/emergenza, 2 a laparotomia esplorativa, 2 a ga-stroenteroanastomosi per stenosi pilorica. Un paziente è stato sottopostoa reintervento per una complicanza (deiscenza della digiunostomia ali-mentare). In totale sono state eseguite tre riconversioni (due pazientiprovenienti dalla serie di sei pazienti già citata ed uno riconvertito inconseguenza di un intervento di demolizione eseguito nel 2002). Deisei pazienti sottoposti ad intervento demolitivo, due sono deceduti nelprimo postoperatorio, ma quattro hanno superato la fase acuta.

Conclusioni. Non esiste una procedura diagnostico-terapeuticauniversalmente accettata per questi malati la cui gestione, come sembraevincersi dalla letteratura, viene spesso lasciata all'esperienza personaledel medico che si trova a gestire tale situazione.

KEY WORDS: Caustic ingestion - Esophageal caustic burns - Esophagogastrectomy - Esophageal reconstruction.Ingestione di caustici - Lesioni esofagee - Esofagogastrectomia - Ricostruzione esofagea.

Management of corrosive injuries of the upper gastrointestinal tract. Our experience in 58 patients

U. ROBUSTELLI, R. BELLOTTI, F. SCARDI, M. FORTUNATO ARMELLINO, A. DE MASI, A.L. FORNER, E. RICCIO1, F. MANGUSO1

AORN "A. Cardarelli" Hospital, Naples, ItalyUOC General and Émergency Surgery with Surgical and Polyspecialistic Observation1 UOSC of Gastronterology and Digestive Endoscopy

© Copyright 2011, CIC Edizioni Internazionali, Roma

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Management of corrosive injuries of the upper gastrointestinal tract. Our experience in 58 patients

ficult condition to be treated in an Emergency Depart-ment because its effects can be immediately deadly or candetermine serious and disabling sequelae involvinghigh social, health, and human costs. Mortality due toinjuries from ingestion of caustic substances (1.5%) (1-2) is only ascribed to adulthood, although the majorityof poisonings occurs in children, where the event is of-ten accidental and therefore less serious. In adulthood,instead the ingestion of toxic substances and thereforealso caustic, is voluntary in at least half of the cases, andthis inevitably involves higher doses, with more severelesions and higher risk for life. The lesions resulting fromingestion of caustic substances pose considerable dia-gnostic and therapeutic problems in acute phase and inpost-acute phase. In literature there is no standard of re-ference and diagnostic-therapeutic decisions often dependon the personal experience of the operators.

There are no recent data on the number of hospita-lizations of patients reporting ingestion of caustics in Italy.If you browse the website of the Ministry of Health thelatest data date back to 2005; this year 225 patients havebeen hospitalized in Italy for toxic effects from causticor corrosive substances and 34 were in Campania (3).In the same year 11 patients were hospitalized for thiscondition in our division which is approximately 5% ofall the hospitalized patients in Italy and 34% of the to-tal of all patients hospitalized in Campania.

Patients and methods

The medical records of patients who reported ingestion of cau-stic and hospitalized at the Division (UOC) of General and Emer-gency Surgery of AORN “A. Cardarelli “ in Naples, from 2003 to2008, have been valued. The data of all patients undergoing sur-gery were extrapolated and all surgery indications have been as-sessed, as well as those who had surgery more often performed inemergency and those who had surgery performed under deferredemergency and the follow up of patients undergoing surgery wasrated.

Results

From 2003 to 2008, 58 patients (28 male and 30female) were admitted to our Division (Table 1). Theaverage stay in hospital was 7.67 days (range 20 to 178).Ten of these patients (17.24%) underwent surgery fora total of thirteen surgical procedures (Table 2). Six pa-tients underwent esofagogastrectomy with cervicalesophagostomy and alimentary digiunostomy in emer-gency; two underwent exploratory laparotomy, two hadgastroenteroanastomosis for pyloric stenosis; one pa-tient had a new operation for a complication (dehi-scence of alimentary digiunostomy). In total, three ali-mentary reconstructors were performed (two from theabove six patients) and one resulting from esofagoga-strectomy carried out in 2002).

The two patients undergoing gastroenteroanasto-mosis for duodenal stenosis came to our observationnot in the acute phase. Both reported ingestion of cau-stic substances about twenty days to two months priorto admission and onset of dysphagia. At endoscopy andcontrast examination of gastrointestinal transit the an-tropliroyc stenosis (Fig. 1) was confirmed in both pa-tients. In both cases a gastroenteroanastomosis wasperformed to bypass the stenosis without resection ofthe stomach. We use this procedure, in contrast withother authors (4), because it is faster and less invasi-ve for patients. In both cases, postoperative course wasregular and the patients were discharged after abouttwelve days of hospitalization.

Two patients underwent exploratory laparotomy.

TABLE 1 - NUMBER, SEX AND TERAPY IN OUR EXPE-RIENCE.

Year Admitted Submitted to surgeryMales Females Males Females

2003 5 4 1 12004 6 6 0 02005 3 8 0 32006 8 7 2 12007 5 3 1 02008 1 2 1 0

28 30 5 5

Total 58 10 (17,24%)

TABLE 2 - TYPE OF SURGERY.

Year Oesophageal and Reconstrution Surgical Gastroentero- Reoperationgastric resection exploration anastomosis

2003 1 0 1 0 02004 0 0 0 0 02005 3 1 0 0 02006 1 0 1 1 02007 1 1 0 0 12008 0 0 0 1 0

6 2 2 2 1

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In both cases endoscopy showed third degree lesionsof the gastric mucosa, but instrumental examinationsshowed no sign of perforation. At laparotomy, the wal-ls of the stomach and the intra-abdominal tract of theesophagus showed neither areas of necrosis nor lesionsin other organs; therefore a conservative attitude wasadopted, with alimentary digiunostomy.

Six patients underwent radical surgery in emergency.

At endoscopy they all had third degree lesions and si-gns of esophago or gastric parietal perforation and /or necrosis at TC examination. Five patients showedinvolvement of the esophagus and stomach, the sixthpatient showed also involvement of the I and II duo-denal portion. Therefore the first five patients un-derwent esophagogastrectomy and the sixth also hada resection of the I and II duodenal portion with ex-ternal duodenal biliary drainage.

Two of these patients died in immediate postope-rative, within twenty-four hours from surgery. Four pas-sed the acute phase: two of these underwent retrosternalesophagocoloplasty, one asked to another hospital, the-refore we lack information about the follow-up, foranother black patient, male, hospitalized in a long-termpatient division, developed cervical esophagostomy ste-nosis. This situation has resulted in a clinical aspira-tion pneumonia that led to the patient’s death abouttwo months after the operation (Table 3).

In total, however, over the years ranging from 2003to 2008 three patients underwent alimentary recon-structions (Table 4). Two from the above six patientsand one digestive reconstruction resulting from radi-cal surgery was carried out in 2002.Two were male pa-tients and one was female. One of the male patientsdied with multiorgan failure after twenty-four hours

Fig. 1 - Thè radiogram shown antropyloric stenosis.

TABLE 4 - OUTCOME OF OESOPHAGUS RECONSTRUTION.

Patient, sex Type of graft Outcome Postoperative complications Follow up

M Left colon Exitus within 24 hours — —

M Right colon MOF syndrome within 7 days — —

F Left colon — Stenosis of cervical anstomosis Alive

TABLE 3 - OUTCOME OF OESOPHAGEAL AND GASTRIC RESECTION.

Patient, sex Organs involved Type of surgery Outcome Postoperative complications Follow up

M Oesophagus, "Esophagectomy; Exitus within — —Stomach, Gastrectomy; 24 hours

Duodenum Partial resection of duodenum"

M Oesophagus, Esofagogastrectomy Exitus within — —Stomach 24 hours

M Oesophagus, Esofagogastrectomy Alive None Reconstruction Stomach in other hospital

F Oesophagus, Esofagogastrectomy Alive None ReconstructionStomach

M Oesophagus, Esofagogastrectomy Alive Dehiscent jejunostomy ReconstructionStomach

M Oesophagus, Esofagogastrectomy Alive Exitus by ab ingestis —Stomach pneumonia

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from the conversion. The other had two postoperati-ve complications that delayed plastic surgery and in-fluenced surgery techniques at the time of conversion.At first, despite a silicone tube placed in cervical esopha-gostomy, there was a stenosis of the esophagostomy as-sociated with hypersalivation. This was treated with ad-ministration of atropine, which had only a partial ef-fect. In addition, approximately 40 days after the fir-st surgery, there was a dehiscence of alimentary di-giunostomy that resulted in a biliary peritonitis. Thisrequired an additional surgery which consisted of re-section of the ‘perforated loop, peritoneal toilet, andmechanical termino-terminal anastomosis between thetwo ileal stumps with repackaging of alimentary di-giunostomy on another loop further downstream. Itwas therefore necessary to extend the period of con-valescence by delaying the time of reconstruction and,at the time of conversion, as a result of previous biliaryperitonitis, the transverse colon was now completelyinseparable from the pancreas and the wall of the ab-domen, which has influenced the choice of the part ofthe intestine for transplantation, in this case the ascen-ding colon and the last ileal loop (about 20 cm fromthe valve). The cervical anastomosis was performedbetween esophageal stump and ileal loop. This patientdied of a multi organ syndrome seven days after theoperation.

The female patient has undergone conversion byinterposition of the left colon, using the technique de-scribed later. About four months from the operationand after an initial period of apparent prosperity, shedeveloped a partial stenosis of cervical anastomosis. Thiscondition was treated with endoscopic dilatations andthe patient is currently able to feed herself in a sati-sfactory manner and in good health.

Discussion

When emergency radical surgery is necessary, ourgoal is to remove the necrotic lesions and to save as muchas possible of the organs to facilitate subsequent re-construction. In general, the first phase of the opera-tion is an exploratory laparotomy, which allows an ac-curate account of endo-abdominal injuries and can sug-gest the most appropriate surgical approach. In our ex-perience, all patients had involvement of the stomachand esophagus, therefore the first step has always beenthe stomach preparation which was prepared in a clas-sical way, sinking the duodenal stump with a stapler andthen strengthened with a long absorption material. Thefollowing step is to prepare the esophagus. The esopha-go-gastric junction is completely dissected on tourni-quet without sectioning it from the stomach. Then cer-vical incision can be performed: oblique incision me-

dially to the border of the left sternocleidomastoid mu-scle. Beyond the lateral margin of the thyroid lobe, theesophagus is identified and removed with the help ofa nose gastric device or preferably of gastroscopy. Theesophagus is then manually mobilized from the neckand from the abdomen. When the esophagus is com-pletely mobile, it is cut in the cervical region, trying toleave the cranial stump free from necrotic areas. Thena small incision is performed at the lower esophaguswhere it enters the stomach. We introduce a vein strip-per from the stomach into the pharynx, which gets outfrom the cervical esophageal stump and, contrary towhat other authors do (5), we strip the esophagus inoral gastric direction: following bleeding is usually small.At the end the procedure, the sample consists of thecomplete esophagogastric stump (Fig. 2). The opera-tion is always completed with alimentary digiunostomy.

Before reconstructive surgery all patients undergoto Computed Tomography (CT) angiography and con-ventional catheter angiogram of mesenteric vessels toexclude vascular malformations. Moreover, colonoscopyis also performed to exclude concomitant diseases. Eventhough there is no agreement in international literatureabout the surgical procedure for reconstruction (4, 6-8), the use of left colon for esophageal replacement hasbeen considered by many to be a preferable behaviour.In our series only one patient required the use of theascending colon for replacement. During assessment ofthe colon and its evaluation, care is taken not to damagethe vessels. After vessels identification, for left colongrafts, the left colic artery is isolated and all collateralsare clamped to assess the adequacy of the circulationof the Riolan’s arcade. To minimize the possibility ofintimal damage, the pressure applied by vascularclamps should not be higher than that just occludingthe circulation. The vessels are not stretched with clam-

Fig. 2 - Postoperative sample after esofagogastrectomy.

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ps in place. The length to which the colon could beunfolded is limited by the vascular arcade and not bythe colon itself. After this procedure, the resection ofan appropriate length of healthy colon for anastomo-sis is performed. After cervical esophagus and retrosternalpreparation, the colic segment is transferred via retro-sternal space and a manual cervical termino-lateralesophagocolic anastomosis is performed. Finally, the di-stal anastomosis stays in the abdomen. The colon graftis joined to the jejunum. The completation of the ab-dominal phase includes a Roux-en-Y jejunal loop to pre-vent bile reflux into the colon. Colonic continuity isre-established by bringing the remaining previously mo-bilized right colon to the distal stump of the colon andperforming an end-to-end single-layer anastomosis.

In literature there is no universally recognizedprocedure for the treatment of these patients. Mostauthors consider the ‘endoscopic examination’ the fir-st examination to be executed as soon as possible, be-cause it is the most appropriate procedure to plan moresuitable diagnostic therapeutic processes and to excludepatients who do not show lesions of the gastrointesti-nal tract (2-5 -8- 9). Although in literature it is possi-ble to find interesting endoscopic classifications (2) ofcaustic injuries, the most widely accepted (5-9) iden-tifies three levels of lesions. Grade I: hyperaemia, erythe-ma and / or edema of the mucosa, Grade II: superfi-cial necrosis, Grade III: extensive necrosis and / or si-gns of perforation. At present there are different opi-nions whether to stop the examination at the first le-sion identified to avoid the risk of iatrogenic perfora-tion (9) or to continue into upper digestive tract in or-der to obtain a more complete staging of possible le-sions (2).

When endoscopic lesions are present in the upperdigestive tract, of whatever degree, we always performX-ray examination of the abdomen and chest, and - inthe presence of third degree lesions or suspectedperforation - in contrast with other authors who con-sider useful to perform a barium contrast examination(5-9) - a chest and abdomen CT is performed. We be-lieve this is the only procedure to study chest, media-stinum and abdomen appropriately and extensively; italso provides adequate information on the tracheo bron-chial tree, without using diagnostic procedures such asbronchoscopy, which may lengthen the operation (2-8), and it helps planning an adequate surgical access tochest in case of injury to the bronchial tree (10). In ad-dition, last generation equipment have shortened exa-mination length.

In the presence of sure signs of instrumental perfo-ration or endoscopic III grade injury - in agreement with

international literature (4-9) - we all claim surgery, sin-ce a delayed operation may interfere with patient’s life.In case of perforation, our goal is to remove the necrosisand to save as much as possible of the organs to faci-litate subsequent reconstruction. In our experience re-section in urgency is still fraught with significant mor-tality: out of six patients undergoing esophagoga-strectomy in urgency/emergency, two died within thepostoperative 24 hours. However this corresponds toa percentage of 33% and it is in line with other authors’rates, ranging from 22% (5-8) 40% (4) to 66% (11).

Also the lapse of time before plastic surgery is un-der debate. In literature there is no agreement. Someauthors recommend immediate reconstruction at thesame time of radical surgery (5). Others suggest variablewaiting periods: thirty days according to Tognini (2),three months according to Berthet (4), from four to ei-ght months according to Cattan (8), more than sixmonths according to Hang (6). We have not a well-de-fined time limit, but we simply wait for patient’s re-covering after the first surgery and reaching a good nu-tritional status.

As for mortality after conversion operation, thereare different rates in literature, ranging from 5% ac-cording to Zhou (7) to 37.5% according to Cattan (8).However, since these are personal experiences and notcontrolled studies, it is not possible to value the diffe-rent treatments of these patients and what affected theirsurvival. In our experience three patients have been con-verted and only one is currently living.

Conclusions

There is no universally accepted diagnostic and the-rapeutic procedure for the treatment of these patients,who are often left, as it appears in literature, to the per-sonal experience of the surgeon. We believe that oncewe have supported the patient’s vital functions, an en-doscopic examination and a CT are essential for a cor-rect classification of these patients and for proper the-rapeutic planning. Integrated assessment of the infor-mation provided by these two procedures may help todetermine which patients should undergo conservati-ve treatment and which surgery has to be done. In thepresence of grade III endoscopic lesions or instrumentalsigns of perforation, in our opinion there is evidencefor surgery to be performed as soon as possible, becauseit is the only way to improve the survival of these pa-tients and make then possible for them to undergo areconstructive operation that can give these patients agood quality of life.

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1. M.L. Farina. Ingestione di sostanze Caustiche. Dossier InFad,anno 3, n° 45, maggio 2008, Editore Zadig, Milano.

2. Tognini L., Gavinelli M., Scacchi G.L., Martino E., Padalino P.,Belloli F., Tiberio G.A.M , Massari M., Tiberio G. Indicazionialla Chirurgia d’ Urgenza nelle lesioni da ingestione da causti-ci. Ruolo di una classificazione endoscopica originale. Chir Ital1998;50,5-6:41-46

3. http://www.ministerosalute.it/programmazione/sdo/ric_infor-mazioni/interrogad.jsp.

4. Berthet B.; Castellani P.; Brioche M.I.; Assadourian R. andGauthier A. Early operation for severe corrosive injury of the up-per gastrointestinal tract. Eur J Surg 1996; 162:951-955.

5. Makela J.T., Laitinen S. and Salo J.A. Corrosion injury of theupeer gastrointestinal tract after swallowing strong alkali. Eur JSurg 1998;164: 575-580.

6. Yong Han, Qing-Shu Cheng, Xiao-Fei Li, Xiao-Ping Wang Sur-gical management of esophageal strictures after caustic burns: A30 years of experience . World J Gastroenterol 2004;10(19):2846-

2849.7. Zhou J., Jiang Y., Wang R., Lin y., gong T., Zhao Y., Zheng M.

and Tan Q. management of corrosive esophageal burns in 149cases. J Thorac Cardiovasc Surg 2005; 130:449-445.

8. Cattan P., Munoz-Bongrand N., Berney T., Halimi B†., SarfatiE., Celerier M., Extensive abdominal surgery after caustic in-gestion. Ann Sur 2000;231(4): 519-523.

9. Keh S.M, Onyekwelu N. , McManus K., McGuigan J., Corro-sive injury to upper gastrointestinal tract: still a major surgicaldilemma World J Gastroenterol 2006; 12(32): 5223-5228.

10. S. Jaillard, S. Nseir, D. Métois, C. H. Marquette, J. Darras, H.Porte and A. Wurtz. Extensive corrosive injuries of the upperairways and gastrointestinal tract. J Thorac Cardiovasc Surg2002;123:186-188.

11. Munoz E.M., Garcia – Domingo M.,I., Santiago J.R., Veloso E.V.,Molina C.M. Massive necrosis of the gastrointestinal tract afteringestion of hydrochloric acid. Eur J Surg 2001;167(3):195-198(4).

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