2. TOPICS TO BE COVERED Role Of Surgeon In Caustic Poisoning
Role Of Surgeon In Snake Bite

4. INTRODUCTION Poisoning can be by ingestion or by external contact
It can be due to chemical agents and biological agents
It can be accidental, Homicidal or Suicidal
They are managed by medical, surgical and combined modality management

5. CLASSIFICATION
CAUSTIC AGENTS :
ACIDS
ALKALI

6. CAUSTIC POISONING It can be acidic or alkaline
It can be accidental, Homicidal or Suicidal
Accidental – in children, mentally retarded and intoxicated persons
Suicidal – adults
Acids – HCL, HNO3, H2SO4, Acetic acid
Alkalis – Lye, Cleaning agents

7. PATHOPHYSIOLOGY OF CAUSTIC INJURY
Mode of entry – ingestion, inhalation
Factors affecting the extent of injury :
Nature of agent
Amount swallowed
Accidental ingestion – associated with lesser amount
Acid ingestion causes coagulative necrosis which limits further deeper injury
Alkali causes liquefactive necrosis and hence associated with more profound injury

8. PHASES OF INJURY Inflammatory changes in the first 24 hours
Thrombosis of sub mucosal vessels in 48 hours
Inevitable necrosis after 48 hrs
Granulation tissue replaces necrotic slough in 2nd & 3rd week
Risk of perforation by endoscopy or dilatation between 4 and 14 days
Process of stricturing begins from 4th week

9. GRADES OF INJURY
MILD INJURY : involve only mucosa; heals without sequelae , may require only observation
MODERATE INJURY : involve deeper to mucosa; requires ICU care; heals with stricture formation
SEVERE INJURY : full thickness damage leading to perforation or dense undilatable strictures; require major foregut resection

10. CLINICAL FEATURES
Mild erythema to severe edema – in oral cavity and oropharynx Drooling of saliva
Hoarseness of voice
Ulceration or sloughing of oropharynx and lips
Hemetemesis – due to erosion of vessels
Chest pain – due to mediastinitis or aspiration
Abdominal tenderness – due to gastric necrosis
Shock due to perforation
Dysphagia – due to stricture formation

11. DEVELOPMENT OF STRICTURES
Common in recovery phase after an injury deeper to mucosa
It depends on the rapidity of transport of the toxic material down the oesophagus
Damage is maximal at areas of natural narrowing like oropharynx and near the site of left bronchus
Gastric stricture is common in concentrated acid consumption

12. Includes admission and early resuscitation
MANAGEMENT OF CAUSTIC INJURIES
EARLY PHASE :
Includes admission and early resuscitation
Decides whither pt. can be discharged or needs admission in ICU or general ward
INTERMEDIATE PHASE :
Management of acute episode, sepsis, aspiration, maintenance of nutrition, resection of esophagus or stomach or both
CHRONIC PHASE :
Restoration of function after the pt. recovers, repeated endoscopy for strictures, major reconstructive surgery of oropharynx and upper aero-digestive tract

13. EMERGENCY MANAGEMENT ABC
Intravenous access – to combat extra-cellular fluid loss in mediastinum
Oral cavity and oropharynx examination – to assess the extent and magnitude of damage
Examination of neck, chest and abdomen for crepitus and tenderness
Suctioning of oral secretions in excess
Routine blood tests and hematology
CXR & AXR – to rule out pneumothorax, pneumomediastinum and pneumoperitoneum

14. EMERGENCY MANAGEMENT
Decision whither pt. can be discharged or needs admission in ICU or general ward
Criteria for ICU admission :
Fever
Tachycardia
Leucocytosis
Metabolic acidosis
Difficulty in maintaining airway
Endoscopic assessment under General Anesthesia in an operating room

15. EARLY DISCHARGE No symptoms Normal mental status Afebrile
CRITERIA :
No symptoms
Normal mental status
Afebrile
No tachycardia
No abdominal tenderness
No damage in both oral examination and endoscopic assessment
Date is given for the next follow-up visit

16. ENDOSCOPIC ASSESSMENT
It is the single most valuable diagnostic tool in caustic injuries
INDICATION – all symptomatic patients
Point of stoppage of endoscopy – Endoscope should not be advanced beyond the first sign of injury esp. in alkali ingestion
Can be done either under sedation or General Anesthesia with minimal air insufflations.

17. ENDOSCOPIC GRADING GRADE I : Mucosal edema or hyperemia
Heal without stricture
GRADE II :
A : Friability, erosions, exudates
B : Grade IIA + deep or circumferential ulcerations
Heal with strictures
GRADE III :
A : Scattered areas of necrosis with black or grey discoloration
B : Extensive areas of necrosis
May require immediate surgical intervention

18. INPATIENT MANAGEMENT
All pts. with clinical or endoscopic symptoms of severe injury are admitted
Resuscitation
Broad spectrum antibiotics including anaerobic coverage
NPO
Vomiting should NOT be induced
DO NOT attempt to neutralize the material because thermal damage may be induced by the exothermic reaction

19. IMAGING STUDIES
CXR & AXR – to rule out pneumothorax, pneumomediastinum and pneumoperitoneum
Barium and contrast studies – little value – risk of aspiration
Sucralfate labeled with Tc99 detects esophageal ulceration
Sucralfate adheres to the ulcers and can be used if endoscopy is not feasible

20. NON SURGICAL MANAGEMENT
STEROIDS :
Stenosis is reduced at the expense of gastrointestinal hemorrhage
No added advantage
ACID SUPPRESSION :
Avoids exacerbation of esophageal injury and GE reflux
Intravenous H2 blockers in NPO pts.
PPI – once liquids are started

21. NON SURGICAL MANAGEMENT
STENTING :
Early dilatation and stenting – may reduce the extent of future strictures
Complications – migration, bleeding, tissue in-growth
May require esophagectomy to remove the stent

22. ESOPHAGEAL DILATATION
Strictures usually start from 2nd to 3rd weeks and progress rapidly
Dilatation- Associated with a high risk of perforation
Chevalier Jackson’s quoting of Trousseau’s aphorism : “Those who live by the bougie die by the bougie”

23. TUCKER’S RETROGRADE BOUGIE TECHNIQUE :
String is swallowed which is retrieved during gastrostomy
Gastrostomy is used for both feeding and retrograde passing of fusiform bougies guided by the string swallowed
Reduces the risk of perforation
Skin problems due to maintenance of a large gastrostomy
OTHER METHODS :
Savary-type bougie over an endoscopically placed wire
Flexible endoscopy and through-the-scope balloon dilatation

24. NUTRITION GASTROSTOMY : FEEDING JEJUNOSTOMY :
Can be performed endoscopically – PEG – Percutaneous Endoscopic Gastrostomy
Contraindication :
When stomach is severely inflamed
Stomach is anticipated to be used for esophageal replacement
FEEDING JEJUNOSTOMY :
When gastrostomy is contraindicated
Energy requirement – 30 kcal/kg/day
TPN can also be used but associated with risk of sepsis

25. SURGICAL MANAGEMENT IN SEVERE FULL THICKNESS INJURY :
Trans hiatus Esophago-Gastrectomy
Duodenal sump is closed
Proximal end of cervical esophagus is brought out as a spit fistula
Approach is via left cervical incision for cervical esophagus mobilization and laparotomy for Esophago-Gastrectomy.
Feeding jejunostomy is done
No reconstructive procedure is done immediately
Prior laparoscopy can be done to assess the damage before formal laparotomy

26. SURGICAL MANAGEMENT
IN INTRACTABLE STRICTURES :
It occurs when the damaged esophagus is not resected in the initial period
Resection or bypass of the strictured segment in-situ are the choices
Resection is done via a thoracotomy due to dense peri-esophageal adhesions
Bypass can be done via a substernal route
Advantage – avoids the morbid procedure of esophageal resection
Disadvantage – increased risk of malignancy in the strictured segment which is left in-situ

27. ESOPHAGEAL SUBSTITUTES
GASTRIC CONDUIT :
Requires only one anastomosis
Can be done laparoscopically and is quicker
Cannot be used if stomach is grossly damaged
Prior gastrostomy has to be avoided
COMPLICATIONS :
Symptomatic reflux
Stricture
Columnar metaplasia
Functional results deteriorate over time

28. ESOPHAGEAL SUBSTITUTES
COLONIC CONDUIT :
Transverse colon is used
More extensive procedure
Requires 3 anastomosis
Functional results improve over time
Lesser incidence of stricture

29. ESOPHAGEAL SUBSTITUTES
OTHER CONDUIT :
In unusual cases when both stomach or transverse colon are resected for some other reason or damaged due to the same caustic injury
Options are:
Terminal ileum
Ascending colon
Jejunum – free flap
Skin and myocutaneous flaps – not done nowadays.

30. ROLE OF SURGEON :
Snake bite
Mammalian bites

31. SNAKE BITES Local effects - Edema, erythema, tissue necrosis
Common poisonous snakes are cobra, viper and krait
CLINICAL FEATURES :
Local effects -
Edema, erythema, tissue necrosis
Ulceration and gangrene
Systemic effects –
neurotoxicity, pulmonary edema, renal failure and shock
SURGICAL COMPLICATIONS
Cellulitis, Gangrene, DVT

32. SNAKE BITES – SURGICAL MANAGEMENT
Bite site is incised and cleaned
Tourniquet to occlude lymphatics alone and not veins and arteries
Polyvalent anti-snake venom
Wound is thoroughly cleaned and debrided
In advanced cellulitis , acute compartmental syndrome is ruled out and fasciotomy is done.

33. Surgical Treatment
Fasciotomy
ICP monitoring 33

34. Fasciotomy - Principles
Make early diagnosis
Long extensile incisions
Release all fascial compartments
Preserve neurovascular structures
Debride necrotic tissues
Coverage within 7-10 days 34

35. FASCIAL COMPARTMENTS OF THIGH

36. FASCIAL COMPARTMENTS OF LEG
Lateral: Peroneal
Anterior
Superficial posterior
Deep posterior
Four compartments of the leg contain these named muscles and corresponding arteries and nerves. Complete release of all four compartments is mandatory. Physical exam based on sensory loss may be useful in exercise induced CS. The nerves are the most sensitive to ischemic changes. 36

37. FASCIOTOMY

38. Forearm Fasciotomy Volar-Henry approach
Include a carpal tunnel release
Volar approach use Henry Approach to release superficial and deep flexors flexors followed by the pronators and supinator. The dorsal approach is centered over the proximal forearm and can be used to release the Mobile Wad (BR, ECRL,ECRB). It is important to remember when treating and electrical injury with a compartment syndrome, the most damage is deep along the bone (i.e. the Pro and Sup muscles) and may require debridement at the initial surgery…Do not miss this! 38

39. HUMAN BITE – SURGICAL MANAGEMENT
Proper wound toileting
Within 12 hrs incised wound is closed primarily
All lacerated wounds and wounds more than 12 hrs old are left open and closed secondarily
Antibiotics
No immediate primary closure for any bite wound

40. THANK YOU !!! 40