Corrosive injuries of UGI tract Dr Sumanta Dey

Serious global problem Under-reported Data heavily skewed towards well-resourced centers Do not mirror the full reality of the condition

Epidemiology Children(80%)- accidental ingestion Adult(20%)- suicidal, life threatning Acid ingestion- developing countries Alkali ingestion- western countries

Mechanism of acid injury Coagulation necrosis Eschar formation Limits penetration

Mechanism of alkali injury Alkalis + Tissue proteins Liquefactive necrosis + Saponification Higher viscosity A longer contact time Penetrate deeper into tissues Blood flow to already damaged tissue Thrombosis in blood vessels

Clinical presentation Substance type-amount-physical form-time of presentation (early or delayed) Hoarseness-stridor  Laryngeal/ Epiglottic Dysphagia - odynophagia Esophageal Epigastric pain-bleeding  Stomach Absence of pain does not preclude significant G.I. damage

Clinical presentation Esophageal or gastric perforations - any time during the first 2 wks No single symptom or symptom cluster can predict the degree of esophageal damage Coexistent gastric injury20-62.5% Simple hyperemia/ erosions to diffuse transmural necrosis

Clinical presentation Laryngeal injuries(38% of patients )- flexible fiberoptic or rigid laryngoscopy Only 8% required immediate intubation and mechanical ventilation Protective pharyngeal-glottic mechanism

Evaluation - assessment

Monitoring and guiding Predicting morbidity or mortality Lab studies Predictors of mortality in adults TLC> 20000 High CRP Age Esophageal ulcer Severe esophageal injury - emergency surgery Arterial pH <7.22 Base excess <-12 Monitoring and guiding Predicting morbidity or mortality

Traditional radiology Plain X Ray – Pneumo-mediastinum / peritoneum Contrast X-ray- Gastrograffin / Hypaque Barium swallow – Later-anatomic details

Ultrasounds EUS destruction of muscular layers sign of future stricture formation Predict the response to dilatation

CT scan Better than endoscopy at early stage

Endoscopy Contraindications First 12-48 hrs (up to 96 hrs) Usually avoided in 5-15 days after ingestion Indicated in Case by case basis Contraindications Radiologic suspicion of perforation Supraglottic/ epiglottic burns with edema A third degree burn of the hypopharynx

Suggesting the need for better criteria Endoscopy Each grade  9x increase morbidity/mortality Limitations Gastrectomy was considered unnecessary at laparotomy in 12% staged 3b at endoscopy Unnecessary esophagectomy in 15% of cases Suggesting the need for better criteria

Management

ABCD..... Acute management Debatable role or Contraindicated No “Blind intubation” Fibreoptic laryngoscopy Debatable role or Contraindicated Gastric lavage/ induced emesis Milk/ Water Weak acid/base for neutralization Milk/activated charcoal NG tube placement PPI/H2 blockers Corticosteroids for stricture prevention

Therapy Broad-spectrum antibiotic – If Corticosteroids Lung involvement Grade 1, 2A - oral intake, discharged within days with antacid therapy Grade 2, 3 – ICU, Observation, nutrition

Early surgery FJ Clinical grounds >Radiological findings Clinical/ Radiological Evidence of perforation Immediate laparotomy Esophagectomy ± gastrectomy Cervical esophagostomy FJ Clinical grounds >Radiological findings Doubtful clinical features laparotomy is likely more advantageous

Severe gastric injury on OGD May require laparotomy Gatrotomy-evaluation No role- closure of a perforation Gastric conservative surgery

Surgery for caustic injuries Persistent long-term negative impact both on survival and functional outcome Esophageal resection - an independent negative predictor of survival after emergency surgery

Laparoscopy Limited role in experts hands ≥2˚ injuries Routine Lap examination Dramatic course

Surgical decision making Resect all injured organs – 1st instance “Second-look procedure”- not recommended 2˚ extension – unpredictable Re - exploration - when in doubt

Surgical decision making Extended resection (even the pancreas) Extensive colon resection- ?future reconstruction ?vascular surgery for atypical transplants Massive intestinal necrotic injury- reasonable limit for resection

Surgical decision making Uncontrolled late gastric bleeding(1-2 wk) Total gastrectomy may be necessary Duodenal  duodenotomy-under-running Pediatric population –all resources to try to preserve the child’s native esophagus

Late sequelae Grade 2B / 3 esophageal burn- stricture 71%/100% Strictures develop within 8 wk in 80% 3 wks or as late as after 1 year Long-standing strictures - esophageal motility Intractable pain GOO

Late sequelae Late achlorhydria Protein-losing gastroenteropathy Mucosal metaplasia Carcinoma Diffusely scarred-contracted stomach

Stricture prevention Steroids: ineffective in preventing strictures Antibiotics: in the absence of concomitant infection, is unknown NG tube: ensures patency But... Long strictures Nidus for infection Worsen GER

Stricture prevention NGT feeding ≈ jejunostomy tube feeding Providing a lumen for dilatation should a tight stricture develops The decision should be made with caution and done on a case-by-case basis

Stricture prevention Mitomycin C : injected or applied topically Systemic absorptions- side effects Further studies required

Intraluminal stent Specially designed silicone rubber or polyflex stents Efficacy is <50% High migration rate (25%) Patient selection Development of Hyperplastic tissue Home-made PTFE  72% efficacy at 9-14 mo Home-made silicone stents positioned by endoscopy/ laparotomy for 4-6 mo Biodegradable stents (poly-L-lactide or polydioxanone) are under evaluation

Other modalities Intraperitoneal inj 5-FU Anti-oxidants – Vitamin E H1 blocker Mast cell stabilizer Methylprednisolone Phosphatidylcoline Octreotide IF-alfa-2b Cytokines

Stricture management

Endoscopic dilatation Timely evaluation and dilatation Late management - marked esophageal wall fibrosis and collagen deposition dilatation more complex ↑Esophageal wall thickness ↑ number of dilatation Recurrent strictures if delayed dilatation Delayed presentation/treatment  strong predictors of future esophageal replacement Developing countries Late presentations>50%

Endoscopic dilatation Balloon or bougies Failure rate after pneumatic dilatation is higher in caustic strictures Savary bougies > balloon dilators in old caustic stenosis or long, tortuous strictures Dilatation avoided - 7 to 21 d after ingestion

Endoscopic dilatation Although early, prophylactic dilatation with bougienage has been reported to be safe and effective even in this period Perforation rate after dilatation- BES 0.1% - 0.4% Caustic stricture 0.4% - 32.0% dropping from 17.6% to 4.5% with increased experience

Endoscopic dilatation Radiological intramural and well-contained transmural esophageal ruptures were observed in 30% of balloon dilatation procedures Balloon inflation may cause either extrinsic mechanical compression of the trachea or obstruction at the endotracheal tube tip The use of the balloon catheter in children entails careful intraoperative monitoring and likely requires greater endoscopic skill and experience than for Savary bougies

Endoscopic dilatation The interval varies from <1 to 2-3 wk and usually 3-4 sessions are considered sufficient for durable results In challenging strictures, a nylon thread left between the nose and the gastrostomy maintains luminal access

Nutrition Nutritional status Esophageal patency Feeding gastrostomy > NG tube feeding Gastrostomy allows a retrograde approach for dilatation, which is usually easier and safer

Risk of cancer Both AC and SCC may develop as a late complication 1000-3000 times higher than expected in patients of a similar age Have actually been reported only 1 year after ingestion The reported incidence ranges from 2% to 30%, with an interval from 1 to 3 decades after ingestion Areas of anatomic narrowing

Risk of cancer Esophageal bypass surgery does not prevent the development of esophageal cancer following caustic ingestion Some studies said problem may be overestimated Endoscopic screening is still recommended for patients following caustic ingestion Moreover, the role of other confounding factors, such as alcohol abuse or smoking habit, should be considered

Dysmotility Orocecal transit time is prolonged with lower third esophageal involvement Autovagotomy due to vagal entrapment in cicatrization Impaired vagal cholinergic transmission Decreased gallbladder emptying found in patients after lower esophageal damage Gastric emptying time of liquids significantly prolonged Lower esophageal stricture > upper-middle

Surgery for non-responding esophageal strictures Retrosternal stomach or, preferably, right colonic interposition Mortality and morbidity are low in expert hands The native esophagus can be left or removed Resection of the scarred esophagus may be performed without a substantial increase in morbidity and mortality 13% incidence of esophageal cancer after by-pass

Surgery for non-responding esophageal strictures Risk of infected esophageal mucocele in 50% of the patients after 5 years Impossibility of endoscopic follow- up Removal of the native esophagus seems advisable in children because of the risk of cancer in a long life period Conversely, the doubled mortality rate (11.0% vs 5.9%) of resection vs by-pass

Surgery for non-responding esophageal strictures In children, reconstruction with gastroplasty seems easier, and more functional failures can be expected with coloplasty

Surgery for stomach injuries The timing and type of elective surgery for GOO is still controversial Early surgery has been advised to decrease mortality and morbidity Earlier than 3 mo  risky Poor nutritional state Adhesions Edematous gastric wall

Surgery for stomach injuries Assessing limit of gastric resection difficult ongoing fibrosis Balloon dilatation and/or intralesional steroid injection  as alternatives Endoscopic gastric dilatation temporary substitute for surgical resection (gastric wall fibrosis diminishes functional result) Dilatation averts surgery in less than 50% of patients, perforation can occur in strictures longer than 15 mm Pyloroplasty has been recommended for moderate strictures, but progressive fibrosis causing recurrent stricture occurs frequently

Surgery for stomach injuries GJ is a safer alternative to gastric resection If extensive perigastric adhesionan, unhealthy duodenum, and poor general condition Partial gastric resection is preferred by many for the long-term risk of malignant transformation (overstated in the literature) Previous reports of gastric carcinomas after acid ingestion are usually old and limited Regular follow-up and surveillance endoscopy is a more reliable approach.

Late reconstructive surgery after emergency esophagectomy If stomach removed or chronic injuries – No conduit Reconstruction at the end of scarring process, usually after 6 mo (2mo - 1yr) Success rate after colon reconstruction at 5 years is 77% Severity of the initial insult or a delay more than 6 mo- poor outcome Coloplasty dysfunction(half of the failures)

Late reconstructive surgery after emergency esophagectomy 70% success rate after revision surgery in expert hands An emergency tracheostomy may have an adverse impact on the outcome of a colo-pharyngoplasty Secondary esophagocoloplasty should be considered with good results if intraoperative colon necrosis occurs at the time of primary reconstruction

Thank you