The surgical strategy in massive corrosive injury in digestive tract : is the extensive surgery appropriate ? 林口長庚 外傷科住院醫師 張雍泓 指導醫師: 康世晴 廖健宏

Background Corrosive ingestion results in necrosis of the digestive tract, spillage of intraluminal fluid, and spread of bacteria that threatens the lives of patients. Some authors advise extensive surgery, although others recommend conservative operation , remain inconclusive . Early extensive surgery : difficulty in reconstruction and other issues such as malnutrition 消化道腐蝕性的傷害造成GI tract necrosis 及 消化液外滲

Method A single institute (Linkou CGMH) , retrospective study , from August 2007 to March 2013 Patient who suffer from caustic injury We defined patients with esophagogastrectomy with at least one more organ as extensive surgery

Result The cohort consisted of 112 patients who suffered from corrosive injury with an average age of 51.3 ± 18.8 years. Twenty-three patients required an emergent operation and the other 89 patients did not. The emergent operative rate was 20.5%, and the overall mortality rate was 13.4%.

Discussion Mortality remains high in cases of corrosive injury, especially in patients who need emergent operations . We identified perforation of the digestive tract and unscheduled reoperation as the independent factors that influence the prognosis. Corrosive injury 的病人若需要緊急手術的話 ， 其預後不佳

Discussion Some authors advocate routine early exploration for high-grade injury ,but the benefit does not appear solid, even though the delayed diagnosis and intervention are related to higher mortality . 但欠缺sutdy 證明其好處

Discussion The laparoscopic exploration of patients with caustic injuries has been suggested . However, the limited abdominal exploration and prolonged operative time restrict its role in evaluating the corrosive damage . 有些study 認為laparoscope examination 是可行的 但從我們的經驗上

Discussion The operative procedure and extent are controversial. In our study, extensive surgery does not appear to increase the possibilities of mortality. Though unscheduled reoperation, which was frequently related to inadequate resection, increased mortality (p = 0.024). 手術術式的選擇以其開多大

Discussion All injured organs should be resected during the first operation. Delayed or staged reconstruction might be performed after hemodynamics stable and infection controlled.

Discussion Pancreaticoduodenectomy could be performed in extensive corrosive injury with duodenal invasion . Cattan P et al 2000. Ann Surg There were 7 patients who underwent pancreaticoduodenectomy in this study, and the survival was not influenced by surgical procedure but was influenced by inadequate resection. Whipple operation may be indicated for extensive soft tissue damage to duodenum . Eleven patients underwent an extensive operation, including 16 esophagec- tomy, 14 resections of bowel, 13 gastrectomy, and 7 pan- creaticoduodenectomy (Table 2). There were no non- therapeutic operations in our series. After the primary operation, there were 7 patients (30.4%) who required an unscheduled reoperation because of uncontrolled sepsis, new onset peritonitis, mediastinitis, or bile content present in drainage. After exploration, there were three resections of necrotic bowel, two esophagectomies, one duodenorrhaphy, and one colectomy.

Discussion Recall bias : ingestion amount and time Limitation Restrosepctive study , slecetive bias Small sample size Though CT has become an increasingly used tool in corrosive injury , we did not use CT in all the patients , optional , non contrast Recall bias : ingestion amount and time

Conclusion We advise an early and aggressive surgical intervention in severe corrosive digestive injuries before perforation occurs. Our results suggest inadequate resection might lead to unscheduled reoperations, which lead to a dismal prognosis.

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