Emergency treatment of esophago-gastric lesion in caustic ingestion patients
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KeywordsMetronidazole Enteral Nutrition Esophageal Carcinoma Mediastinitis Stricture Formation
Background and aim
The ingestion of caustic substance can produce severe injury not only to the esophagus, but also to the gastrointestinal tract and can even result in death. The degree and extent of damage depends on several factors like the type of substance, the quantity, and the intent; the quantity is a prognostic value: 20–50 ml = severe, >50 ml = very severe. In the acute phase, perforation and necrosis may occur often with devastating consequences on the esophagus and the stomach; the injuries are associated with high mortality and morbidity rates when mediastinitis, gastrobronchial fistula, chemical peritonitis, or perforation of the gastrointestinal tract occurs. Perforation may occur in the late phase, especially with the ingestion of alkaline solution, because the inflammation invades more deeply with the continuous release of OH- after coming into contact with protein. Long-term complications include stricture formation in the esophagus, antral stenosis and the development of esophageal carcinoma. The aim of this study is to evaluate whether early diagnosis and surgical treatment are essential to improve the prognosis.
From November 2000 to November 2003 six patients were admitted to our department, mean age 38 ± 10 years, with a 1:1 male to female ratio. The average time between the caustic ingestion and admission to the emergency ward was 5 ± 2 hours. The ingested substances were alkali in 80.9% and acid in 19.1% of the cases. The blood gas examination, endoscopy, computed tomography, and chest-abdominal X-ray were performed. They requested an orotracheal intubation and ventilatory support; antibiotic therapy was early initiated with metronidazole and tazobactan-piperacilline and an optimal hemodynamic stabilization was achieved. A combined surgical procedure was performed: in the acute phase, laparoscopic esophageal–total gastrectomy, open cervicotomy, cervicostomy, percutaneous enterostomy for enteral nutrition, while the gastric–esophageal reconstruction was performed subsequently.
Blood gas examination showed the mean pH was 7.22 ± 0.14 and the mean base excess was -10.0 ± 6.5. Endoscopy revealed multiple deep brownish–black ulcers (four patients) and perforation (two patients). Chest X-ray revealed air bubbles close to inferior the IIIrd part of the oesophagus while abdominal X-ray revealed no perforation. The ICU stay was 20 ± 7 days. Complications included: four cases of postoperative complications, including in the first surgical procedure break-up of enterostomy (n = 1) and in the reconstruction phase anastomosis pseudo-diverticula (n = 1), and anastomosis leakage (n = 2 died). The surgical mortality was 33%. All patients tolerated oral intake well after surgery; a high-protein and hypercaloric diet seemed to be beneficial for patients.
Early laparoscopic surgical treatment improved the prognosis in these severe cases.