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Corrosive injury of esophagus
Philip WY Chiu Associate Professor Department of Surgery Department of Surgery Prince of Wales Hospital Chinese University of Hong Kong
Background • Relatively rare Relatively rare • Dire emergency for UGI • Corrosive: – Substance that causes destruction of or damage to living tissue on contact to living tissue on contact
• Prevalence – Varies geographically Varies geographically – Local domestic and industrial customs – Availability of substance y
Type of caustic related to injury Type of caustic related to injury • Acid – Generally less severe injury – Coagulative necrosis – Coagulum lessen tissue penetration Coagulum lessen tissue penetration
• Alkaline – – – –
Liquefactive necrosis Sodium hydroxide (哥士的) Very hazardous Very hazardous 30% causes full thickness necrosis in animal model for a second exposure
Early management Resuscitation • Upper airway U i – Assessment of severity of damage – Secure the airway Secure the airway • Fiberoptic intubation • Tracheostomy
• ? Dilution – May induce vomiting – i d ii more extensive injury i i j – Rapid action of caustics – probably useless
Early management Pathogenesis h • Animal studies Animal studies – Corrosive enter to stomach ‐> reflex pyloric spasm – Limit passage of corrosive to duodenum Limit passage of corrosive to duodenum – Regurgitation of corrosive against a closed cricopharyngeus ‐> damage to esophagus and ‐> damage to esophagus and stomach –3 3‐5 5 mins mins ‐>> gastric atonia gastric atonia ‐>> opening of pylorus opening of pylorus
Goldman et al Am J Gastro 1984
Early management Assessment of extent of injury f f • CXR CXR – any pneumomediastinum any pneumomediastinum • Endoscopy – < 12 hrs & not later than 24 hrs < 12 h & t l t th 24 h Zargar’s grading of mucosal injury caused by corrosive ingestion G d 0 Grade
N Normal examination l i i
Grade 1
Edema & hypermia of the mucosa
Grade 2a
Superficial ulceration, erosions, friablility
Grade 2b
Grade 2a + deep discrete or circumferential ulcerations
Grade 3a
Small scattered areas of multiple ulceration & areas of necrosis with brown black / greyish discoloration
Grade 3b
Extensive necrosis Zargar et al GIE 1991; Orringer 1993
Endoscopic assessment Endoscopic assessment
Endoscopic classification Implications l • Grade 1 Grade 1 – 2 – Conservative management – Insertion of feeding tube g
• Problems – Difficult to differentiate between 2b and 3 Difficult to differentiate between 2b and 3
Conservative management Use of Steroid? f d • AIM – Reduction of stricture formation – 80% of grade 3 injuries developed stricture 80% of grade 3 injuries developed stricture – 67% of grade 2 injuries developed pyloric sternosis
• RCT – 18 yr prospective study in 60 children – 10 / 31 steroid group developed stricture vs 10 / 31 steroid group developed stricture vs 11 / 29 11 / 29 non‐steroid group – No use in preventing stricture p g Anderson et al. NEJM 1990
Conservative management Conservative management • ICU care • IV antibiotics • IV PPI • Nutritional support • Close monitoring
Operative treatment Operative treatment • Indications – Full thickness injury of esophagus, stomach or duodenum – Clinical deterioration with ↑sepsis ↑
• Early Radical Surgery – 10 / 22 patients underwent esophagogastrectomy – 4 of 10 patients died (40%) – 7 of 12 conservative had stricture – Authors advocate early surgery Olah et al Orv Hetil 1992
Approach to emergency resection Approach to emergency resection • Laparotomy p y + Transhiatal + Cervical – Laparotomy first to assess the extent of disease in abdomen – Transhiatal • Avoid opening the thorax • Risk of bleeding Risk of bleeding
• Laparotomy + Transthoracic Transthoracic + Cervical Cervical – Transthoracic • Need to open thorax • Extent of injury within thorax can be assessed
Next Step… Reconstruction Next Step… Reconstruction • Colonic interposition p – Left colon basing on left colic artery – Right colon Right colon • Blood supply • Distal ileum can be used to connect to esophagus connect to esophagus
