1. Corrosive injuries of UGI tract
Dr Sumanta Dey

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

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

6. Mechanism of acid injury
Coagulation necrosis
Eschar formation
Limits penetration

8. 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

10. 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

11. 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 %
Simple hyperemia/ erosions to diffuse transmural necrosis

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

13. Evaluation - assessment

14. 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

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

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

17. CT scan
Better than endoscopy at early stage

19. 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

22. 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

23. Management

24. 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

25. 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

26. 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

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

28. 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

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

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

31. 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

32. 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

33. 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

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

35. 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

36. 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

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

38. 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

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

40. Stricture management

41. 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%

42. 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

43. 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% %
Caustic stricture 0.4% %
dropping from 17.6% to 4.5% with increased experience

44. 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

45. 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

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

47. Risk of cancer
Both AC and SCC may develop as a late complication
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

48. 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

49. 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

50. 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

51. 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

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

53. 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

54. 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

55. 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.

56. 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)

57. 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

62. Thank you