Surg Today Jpn J Surg (1995) 25:119-124

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© Springer-Verlag 1995

Emergency M a n a g e m e n t of Caustic Ingestion in Adults BRUNO ANDREONI, 1 ALDO MARINI, 1 MAURIZIO GAVINELLI,1 ROBERTO BIFFI, 1 GIORGIO TIBERIO, 1 MARIA LUISA FARINA,2 a n d ALFREDO ROSSI2 ~The Department of Emergency Surgery, University School of Medicine, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy 2The Department of Emergency, Niguarda Hospital, Piazza Ospedale Maggiore, 20100 Milan, Italy

Abstract: A study of 57 patients admitted to the Department of Emergency Surgery at the Ospedale Maggiore in Milan between 1980 and 1992 following the recent ingestion of a caustic substance is presented herein. Through this study, an aggressive diagnostic and therapeutic approach has been employed, including early surgery which plays a fundamental role in the prevention of acute hemorrhagic or perforative complications as well as in the development of scar tissue and neoplastic strictures over time. The criteria for early emergency surgery were the presence of endoscopic grade 3 and 4 lesions as well as those on the borderline between grades 2 and 3 with clinical symptoms. In 11 patients with lesions of moderate severity, the treatment of choice was medical therapy, which required subsequent surgical intervention for strictures in 5 patients. In 13 patients with severe lesions, an early surgical approach was performed with a mortality rate of 23 %. Key Words: corrosive burns, endoscopy, esophagectomy,

gastrectomy, lye

Introduction

Episodes involving the accidental or intentional ingestion of caustic substances have become common, the possible consequences being immediate serious injury and the subsequent formation of scar tissue which is hard to remedy. The frequency of these episodes has increased over the last several decades due to: the wide availability of domestic descaling

Reprint requests to: B. Andreoni (Received for publication on Dec. 25, 1992; accepted on July 9, 1993)

and cleansing agents, non-adherence to the safety instructions on containers of toxic products, and the general public being insufficiently informed about the potential hazards. For several years the treatment of choice for acute lesions was conservative. As a result, the patient was operated on only upon the manifestation of acute complications such as peritonitis due to gastric perforation, mediastinitis due to esophageal perforation, aero-digestive fistulae, and enterrorhagia of varying severity; however, the surgical treatment of such acute complications involved a high incidence of perioperative mortality. 1 In patients who did not show acute complications, the development of scar tissue along the upper digestive tract resulted in stricture formation. As a result, the surgeon was faced with having to treat scar tissue formation several months following the original incident, generally after unsuccessful endoscopic dilation. The evolution of neoplastic lesions at a later date was another problem. In fact, patients with esophageal lesions due to the ingestion of caustic substances represent a population at risk of developing epidermoid carcinoma of the esophagus, a-4 The probability of developing squamous cell carcinoma is increased 3,000 times in these patients, and is found after an average latent period of 40 years, but not before 10-15 years have elapsed. At present, a more aggressive diagnostic and therapeutic approach, including early surgery, is proposed for acute lesions caused by the ingestion of caustic substances. 5 This study was conducted to assess the emergency diagnostic and therapeutic procedures performed on such patients, based on our surgical experience of over 10 years of cases filtered through the Poison Control Center of Milan, which maintains epidemiological supervision of a large geographical area of northern Italy, including the region of Lombardy with a population of 9 million in which the city of Milan is situated.

120

B. Andreoni et al.: Management of Caustic Ingestion in Adults

[ INGESTION I

Patients and Methods

l Between 1980 and 1992, 57 patients were admitted to the Department of Emergency Surgery of the Ospedale Maggiore, Milan following the ingestion of caustic materials. Fifty of these patients were admitted within 24 h of ingestion, and the other 7 were admitted following stricture formation from previous ingestion of caustic substances after receiving emergency treatment in other hospitals. All the patients in this study were admitted to our department after an initial evaluation by the Poison Control Center in Milan. The details of our 57 patients are furnished in Table 1. As pediatric cases were dealt with by a separate department, our experience is limited to adults. The algorithm for diagnosis provided by the Poison Control Center in Milan and used for the evaluation of patients suffering from the accidental or intentional ingestion of caustic substances is given in Fig. 1. The algorithm for therapy utilized by us for the treatment of these patients is illustrated in Fig. 2. On admission, all patients are clinically monitored and some subsequently treated in an intensive care unit. The diagnostic procedure is immediately initiated to establish the pretreatment status of acute lesions caused by the caustic substance. The major diagnostic procedures employed include: 1. Clinical and laboratory tests to assess the level of pain, shock, metabolic acidosis, and leukocytosis. 2. X-rays of the thorax and abdomen without contrast followed by subsequent emergency surgery in the presence of signs of esophageal or gastric perforation. 3. Water-soluble medium ingestion. Utilized only where there is doubt about perforation or in selected patients prior to endoscopy. 4. Endoscopic examinations, such as esophagogastroduodenoscopy performed on all patients except those with evident esophagogastric perforation and also as laryngoscopy and bronchoscopy in selected

ACCIDENTAL

SUSPECTED

l

DELIBERATE

CERTAIN

1 ~

CLINICAL OBSERVATION Thorax

Symptoms

/,,,

No I

Yes

J"

Observation 24-36 h

X-rays Abdomen Water-soluble med um swa ow(?) EGDS * 6-12h Laboratory tests: ~ White blood count Blood gases I ' Other ,Symptoms

Recovery

Fig. 1. Diagnostic algorithm for caustic ingestion in adults. EGDS, esophagogastroduodenoscopy; (?) Contrast study should be reserved to selected cases CONTINUOUS CLINICAL OBSERVATION

1

CHEST ~ R A Y ABDOMINAL X-RA Y WITHOUT CONTRAST ±

WATER SOLUBLE MEDIUM SWALLOW

,____.__~_-~~--~-~_~_~

EMERGENCY SURGERY (INTRA OPERATIVE ENDOSCOP~ EARLY SURGERY

ENDOSCOPIC EXAMINATION WITHIN 6 - 1 2 h

T

POSITIVE

NEGATIVE

1

Observation and endoscopic control

Table 1. Details of the patients admitted to the Ospedale

Maggiore, Milan, between 1980 and 1992, following the ingestion of caustic substances Patients: Number Mean age (years) Male/female ratio Deliberate ingestion Employed products: Bleach Acids (hydrochloric/sulfuric) Alkali (sodium hydroxide) Ammonia Others

57 45 (range, 18-79) 4:1 74% 52% 15% 18% 6% 9%

~

l

qbservation

1

Recovery

Fig. 2. Therapy algorithm for caustic ingestion in adults. asterisk, early surgery if endoscopic understaging is suspected (borderline lesions between grades 2 and 3)

patients. The endoscopic examination should be carried out, if possible, within 6h of ingestion of the caustic substance under safe conditions, defined as the availability of cardiopulmonary resuscitation facilities during the procedure and an empty stomach. In the majority of cases, consultation with an anesthesiologist is required.

B. Andreoni et al.: Management of Caustic Ingestion in Adults

121

Emergency treatment (Fig. 2) is indicated by the severity of the clinical picture, the results of laboratory tests, and above all, the results of the endoscopic evaluation. When carried out accurately by an experienced endoscopist, and completely by observation of the entire digestive tract to the duodenum, with a tracheobronchoscopy if necessary, these procedures together permit a precise assessment of the lesion. The endoscopic classification followed by us, as illustrated in Table 2, takes into consideration the degree, depth, location, and extent of the lesion, together with data relevant to peristalsis and the tone of the sphincter. This classification permits the estimation of an endoscopic score of severity with reference to the different sections of the digestive tract observed. The emergency treatment administered by us in the 50 cases in this study can be divided into three groups:

Table 2. The "Milan 1990" classification of adult endoscopic lesions

"1. Emergency surgery, defined as immediate surgical intervention following a certain or highly likely clinical and radiological diagnosis of esophageal or gastric perforation (performed in 4 patients). 2. Early surgery, defined as early surgical intervention, generally within 2 4 - 3 6 h after the ingestion of the caustic substance for endoscopic lesions of grade 3 or 4 (performed in 9 patients). 3. Conselwative medical treatment, carried out for grade 1 and 2 lesions, and borderline lesions between grades 2 and 3 (performed in 37 patients). Rapid scar formation in 5 of these patients defined as grade 2 or borderline lesions between grades 2 and 3 with clinical symptoms, necessitated endoscopic dilation and delayed surgery in 2 patients. All patients discharged by us underwent subsequent clinical and endoscopic follow-up on an outpatient basis. No patients with pharyngolaryngeal or upper airway lesions were included in the present this study.

(,~/The followinglocations are considered for grading 0-4: pharynx, proximal esophagus, distal esophagus, proximal stomach, distal stomach, duodenum (B)Presence or absence of peristalsis is referred to the most affected site

Grade (A)

Mucosa

0

Normal

--

1

Hyperemia, edema

--

2

Hyperemia, edema Superficial necrosis (whitish mucosa)

Superficial lesions

Wide necrosis Mucosal sloughing Hemorrhage

Ulcers

Black mucosa - - wide necrosis Full-thickness ulcers, severe hemorrhage "Impending perforation" Peristalsis (B) 0 = Present 1 = Absent

Cardia 0 = Normal 1 = Open

Pylorus 0 = Open 1 = Normal 2 = Spastic

Results

Table 3 enumerates the patients treated by us, subdivided according to the severity of their lesions. In the case of mild lesions, defined as endoscopic grade 1, only simple clinical observation was carried out. These patients were asymptomatic on discharge and subsequent follow-up showed complete healing of the lesions. In the case of moderate lesions defined as endoscopic grade 2, medical therapy in the form of clinical monitoring, parenteral feeding, antisecretives, and antibiotics was carried out without the administration of steroids. Successive controls showed complete

Table 3. Emergency treatment according to the severity of the lesions Lesion type

Lesions

Patients

Emergency therapy

Results

Mild lesions Endoscopic grade 1

26

Observation 48-72 h

Recovery26

Moderate lesions Endoscopic grade 2 Bordeline between grades 2 and 3

11

Medical therapy

Severe lesions Endoscopic grade 3-4 (n = 9) Esophagogastric perforation (n = 4)

13

Surgical therapy: resection 11 conservative 2

Recovery 6 Stricture 5 dilatation 3 surgery 2 Recovery 10 Mortality 3

122

B. Andreoni et al.: Management of Caustic Ingestion in Adults

Table 4. Surgical procedures and results: emergency treatment in 15 patients Timing Patients Surgical Procedure Mortality Emergency surgery

4

2 Blunt esophagogastrectomy 2 Gastrectomies

2a 0

Early surgery

9

5 1 1 2

0 0

Delayed surgery for stricture

2

Blunt esophagogastrectomy Gastrectomy Gastrectomy + duodenopancreatectomy Laparotomy + jejunostomy

1 Partial gastrectomy 1 Gastrectomy 1 Esophagocologastroplasty

1b

0 0 0 0

Sepsis secondaryto jejunal-esophagoanastomoticleakage (1 patient), mediastinitis(1 patient) bSepsis with adult respiratorydistress syndrome a

healing in six patients and stricture formation due to cicatrization in five patients who required endoscopic dilatation. Delayed surgery was also performed in two of these patients. In the case of severe lesions, defined as esophagogastric perforation and endoscopic grades 3 and 4, urgent (emergency and early) surgery was carried out in 13 patients resulting in 3 deaths and 10 cases of "healing", the latter indicated by a lack of symptoms attributable to canalization in the upper digestive tract. The preoperative general condition of the patients in this group was characterized by shock, metabolic acidosis, and evident peritonism. Healing was later confirmed by clinical and endoscopic examination. Table 4 shows the different types of surgery performed on our patients. Emergency resection was performed in four patients, as a gastrectomy in two and as an esophagogastric resection without thoracotomy in two; however, two of these patients died, one from sepsis caused by a jejunal-esophago anastomotic leakage and one from mediastinitis. Early surgery was performed in nine patients. In two of these patients, intraoperative evaluation by laparotomic observation of the visceral lesions and results of intraoperative esophagogastroduodenoscopy permitted the exclusion of serious necrotic lesions for the entire depth of the organs observed. The surgical intervention was thus limited to a precise staging of the lesions and included a feeding jejunostomy without any resection. These two patients recovered after a long period of enteral nutrition. In the other seven patients, early surgery was performed as esophagogastric resection without thoracotomy in five patients; as esophagogastrectomy with duodenopancreatectomy in one patient, who subsequently died of sepsis with acute respiratory distress syndrome (ARDS), and as gastrectomy with immediate reconstruction in one patient. All the others patients recovered. Thus, emergency and early surgery was performed in 13 patients, with resection in 11.

In four patients, reconstruction was carried out immediately, with 50% mortality, and in seven patients reconstruction was deferred, with 14% mortality. Reconstructive surgery was carried out within an average of 3.2 months, from 2 to 5 months after the original urgent demolitive surgery. Delayed surgery was performed in two patients after initial conservative treatment and a long period of inpatient care. During this time, progressive cicatrization and stricture formation of the acute lesions, which had been diagnosed at the initial endoscopy as being borderline between grades 2 and 3, had taken place, and unsatisfactory attempts at endoscopic dilation had been made. In the first patient, a retrosternal esophagocologastroplastic bypass with conservation of the esophagus was carried out 3 months later due to widespread esophageal stenosis. Two surgical operations were necessary in the second patient: first, B1 gastric resection due to antropyloric stenosis, and later, a degastroresection due to anastomotic stenosis.

Discussion

Lesions caused by the intentional or accidental ingestion of caustic substances are more frequent than commonly believed, and are associated with high morbidity and mortality rates. The statistical data available in Italy lists lesions resulting from the ingestion of caustic substances to be the cause of 146 out of a total of 534,676 deaths per year; almost certainly an underestimation (ISTAT, 1984). In the Lombardy region in 1988, from a total of 12,516 requests for information received by the Poison Control Center regarding domestic cases of poisoning, 1995 (16%) concerned the ingestion of caustic substances: 336 cases of deliberate ingestion and 1659 cases of accidental ingestion. Even though this problem is relatively common on a national or regional scale, it is a fairly rare occurrence

B. Andreoni et al.: Management of Caustic Ingestion in Adults for the individual hospital which makes the collection of adequate data and a reliable comparison of the various treatment methods difficult. The geographical dispersion of cases often leads to unsatisfactory management, especially where hospitals do not have an emergency department which permits the necessary multidisciplinary aggressive approach indicated in Figs. 1 and 2. For this reason, a multicentric coordinated study was launched in 1991 by the Poison Control Center in the Lombardy region with the aim of collecting information on every possible patient to enter in a register containing all cases of lesions caused by the ingestion of caustics. The objective was to verify the validity of the diagnostic and therapeutic protocols illustrated by the algorithms in Figs. 1 and 2. Several years ago the traditional treatment for acute lesions resulting from the ingestion of caustic substances was generally of the conservative "wait and see" type. Surgery was therefore limited to immediate treatment of such acute complications as hemorrhage, peritonitis, or mediastinitis with perforation and aerodigestive fistulas, or later to that of scarring and neoplastic stricture development. However, the present more aggressive therapeutic and diagnostic approach has since been proposed with widely applied surgical intervention at an early stage, based on precise clinical and endoscopic indications, as early surgery not only reduces acute complications, but also minimizes the formation of scar tissue and neoplastic lesions. 6'7 The evaluation of emergency treatment must take into consideration: where it should be performed, who it should be performed by, and how it should be performed. The diagnostic and therapeutic approach must be aggressive (Figs. 1, 2), and should be carried out in an emergency department equipped with 24-h facilities for diagnostic X-ray and endoscopy, an intensive care unit, an emergency surgery department, and an emergency digestive and respiratory endoscopy department, in close collaboration with the admitting physician, the emergency surgeon, the anesthesiologist, the intensive care specialist, and the radiologist. Endoscopy plays a determining role in diagnosis and the choice of therapy, although endoscopic examination may be difficult with these patients who are often critical and uncooperative. Even for a skilled endoscopist, there is some chance of over- or underestimation of the severity of the lesion. Thus, it is important to have the support of a clinical evaluation. In our study, five patients with an endoscopic evaluation of grade 2 - 3 borderline lesions presented with clinical and laboratory evidence of more severe damage. The later development of stenotic scar tissue necessitated endoscopic dilation, and surgery was required in two of these patients. We may, therefore, assume that there was initial endoscopic underestimation in these five patients.

123 Numerous types of endoscopic evaluation have been reported in the literature; 8'9 however, we believe that the system adopted by us (Table 2) has certain advantages. It permits to define a score of severity; it specifies the degree of lesions in the various segments of the upper digestive tract, and it takes into consideration not only morphological factors but also several functional elements such as peristalsis and the tone of the sphincters which, in our experience, are related to the depth of parietal necrosis. Contrast medium ingestion has limited applicability in our diagnostic algorithm. The decision to use this test is made by the radiologist in consultation with the surgeon and endoscopist, and is only carried out in patients with suspected perforation and in those observed 36-48h after ingestion of the caustic substance. The more severe type of lesions can lead to reduced elasticity and lowered resistance of the visceral walls after some time. Under these conditions, endoscopy can be dangerous and radiological examinations may furnish precious clues. Surgery for the treatment of severe lesions caused by the ingestion of caustics can be immediate, in cases of perforation or massive hemorrhage, or early. Figure 2 lists the factors which, in our experience, are indicative of the type of surgery required. The most complex problem in the treatment of patients with severe lesions lies in the choice between early surgery and the wait and see approach. The former carries the risk of unnecessary surgery, and the latter that of delayed surgery. In our opinion, the risk of an unnecessary operation is irrelevant as early surgery does not necessarily mean resection. According to our experience of early surgery revealing less severe lesions than previously estimated on preoperative endoscopy in two patients, exploratory surgery guided by intraoperative endoscopy and feeding jejunostomy proved useful in the successive medical management of these patients, both of whom recovered without cicatrization after several weeks of enteral nutrition. Exploratory laparotomy with intraoperative endoscopy allows for the precise surgical estimation of lesions which appear to be between grades 2 and 3 in severity at the time of preoperative endoscopy. It is thus possible to avoid the risks connected with endoscopic under- or overestimation. We believe that patients with extensive grade 2 endoscopic lesions, especially those with borderline characteristics leaning towards grade 3 lesions should be operated on early, particularly if there are clinical symptoms indicating the possibility of severe lesions; thereby the risks of endoscopic underestimation can be avoided. Early surgery offers the following two alternatives: 1. exploratory laparotomy + intraoperative endoscopy + feeding jejunostomy; or

124 2. demolitive surgery guided by pre- and intraoperative estimation aimed at the prevention of severe acute complications and later stricture formation. 1°-13 W h e r e there are duodenal lesions, the surgical options are difficult and every possible solution carries risks and potential complications. W e p e r f o r m e d drainage of the duodenal region with esophagogastrect o m y in three patients and a d u o d e n o p a n c r e a t e c t o m y in one patient who died in the postoperative period. In the presence of severe lesions in the second part of the d u o d e n u m , conservative surgery must provide for closure of the duodenal stump and multiple drainage from the duodenal region. 14'a5 This is generally comprising of intraduodenal Petzer drainage, one or two p a r a d u o d e n a l drainages, T-tube c o m m o n bile duct drainage, possibly a Wirsung duct drainage, and, in all cases, retrograde duodenal drainage. Possible leakage from the duodenal stump would thus result in a biliopancreaticoduodenal fistula which m a y be treated medically by total parenteral nutrition, enteral nutrition, somatostatin or its synthetic analogues, or surgically. In three patients treated conservatively for severe duodenal lesions, we observed the late appearance of severe enterorrhagia seen on the 5th to 6th days caused by falling eschar f r o m deep parietal lesions. In such patients, it is possible to m a k e an angiographic diagnosis to localize the blood loss and use an efficient embolizing treatment selecting a branch of the gastroduodenal artery. In conclusion, although the diagnostic and therapeutic approach for caustic lesions must follow standard algorithms, the variability of clinical cases often requires different solutions. Thus, collaboration between the endoscopist, surgeon, intensive care physician, and psychiatrist is necessary to suggest new therapeutic approaches.

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