- Email: [email protected]
Upper abdominal exenteration: A life saving procedure following caustic ingestion
386
Correspondence / Digestive and Liver Disease 46 (2014) 384–387
[2] Uetsuji S, Okuda Y, Komada H, et al. Clinical evaluation of a low junction of the cystic duct. Scandinavian Journal of Gastroenterology 1993;28:85–8. [3] Dodda G, Brown RD, O’Neil HK, et al. Cystic duct insertion at ampulla as a cause for acute recurrent pancreatitis. Gastrointestinal Endoscopy 1998;47: 181–3. [4] Roslyn JJ, DenBesten L, Thompson JE, et al. Roles of lithogenic bile and cystic duct occlusion in the pathogenesis of acute cholecystitis. American Journal of Surgery 1980;140:126–30.
Tatsuya Kin ∗ Clinical Islet Transplant Program, University of Alberta, Edmonton, Alberta, Canada Bassam Abu Wasel Multi-Organ Transplant Program, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada Andrew M. James Shapiro Clinical Islet Transplant Program, University of Alberta, Edmonton, Alberta, Canada ∗ Corresponding
author at: Clinical Islet Laboratory, 210 College Plaza, 8215 – 112th Street, Edmonton, Alberta T6G 2C8, Canada. Tel.: +1 780 407 8671; fax: +1 780 407 8760. E-mail address: [email protected] (T. Kin) Available online 7 January 2014
http://dx.doi.org/10.1016/j.dld.2013.11.014
Upper abdominal exenteration: A life saving procedure following caustic ingestion Sir, A 38-year-old previously healthy man presented to the hospital 24 h after deliberate ingestion of 200 ml of drain cleaner contain-
ing 92% sulphuric acid. He was transferred as “trauma call” from a district general hospital to our tertiary centre after 800 ml of hematemesis, and received 2 units of blood during transfer. Immediate initial management included oxygen, intravenous antibiotics, dexamethasone, proton-pump inhibitor (PPI), antiemetic and local anaesthetic diluted with saline as an oral mouthwash to relieve oral pain. An esophagogastroduodenoscopy (EGD) demonstrated mucosal necrosis in the oropharynx, full thickness mucosal burns of the whole oesophagus with haemorrhagic gastritis. An emergency laparotomy was performed with intent to perform an oeosophago-gastrectomy. Intraoperatively the extent of injuries was more advanced than anticipated, with involvement beyond the duodeno-jejunum flexure: full thickness necrosis of the second part of the duodenum was noted and the viability of the pancreas was also doubtful. A trans-hiatal oesophagectomy and gastrectomy with cervical end-oesophagostomy was performed. A “relook” laparotomy at 24 h showed progressive duodenal, proximal jejunal, pancreas, spleen, and gallbladder necrosis. Total pancreasectomy, splenectomy, duodenectomy along with the resection of the proximal jejunum were performed with a Roux-enY biliary reconstruction. One year later the gastrointestinal tract was reconstructed with a colonic transposition, through a laparotomy and cervicotomy. The transverse colon was transposed with its vascular pedicle to the chest through a retrosternal tunnel and anastomosed proximally to the pharynx and distally to the jejunum. The right colon was then anastomosed to the remaining left colon. (Fig. 1B) Two months later and with help of a multi-disciplinary team the patient was able to restart a normal oral diet. Pancreatic insufficiency causing steatorrhoea and type-1 diabetes mellitus was managed with a tailored insulin therapy and nutritional supplements. Ingestion of caustic substances represents a serious condition that can severely damage the upper alimentary tract and can often result in fatalities. 80% of cases are due to accidental ingestion by
Fig. 1. Schematic representation. (A) The organs that were found damaged by the caustic substance are coloured. (B) The reconstruction of the gastrointestinal tract with the transverse colon transposition along with its vascular pedicle.
Correspondence / Digestive and Liver Disease 46 (2014) 384–387
children [1] while the remaining cases are adults with self-harming intent. The extent of the damage depends mainly on the quantity ingested, type of substance and length of time prior to presentation and treatment. The effect of caustic ingestion varies from minimal superficial mucosal erythema and oedema to extensive transmural necrosis and perforation of the digestive tract with involvement of surrounding organs. The ingestion of corrosive substances has higher mortality and morbidity in cases of intentional self-administration, since the amount of corrosive substances swallowed is larger. Following the immediate resuscitation procedures, EGD is the gold standard investigation recommended in the first 12–48 h to assess of the extent of injuries [2]. Computed Tomography (CT) scan is also a valuable adjunct, particularly to evaluate the adjacent organs, and can be more accurate then endoscopy to assess the presence of an impending or established stomach perforation [3]. The standard operation consists in an oesophagectomy and gastrectomy with further debridement of the surrounding tissues as required, with a jejunostomy feeding tube insertion [4]. When necessary a “re-look” laparotomy at 24–48 h might be helpful to re-assess organs not debrided or excised in the initial operation, whose viability was doubtful. In the reported literature several cases of emergency oesophago-gastrectomy after caustic ingestion have been described, but only few cases of successful major resections extending to the adjacent organs were ever reported [5]. The case we presented is the first one in literature describing a true upper abdominal exenteration including the total excision of the pancreas followed by a functioning gastrointestinal reconstruction.
387
[2] Poley JW, Steyerberg EW, Kuipers EJ, et al. Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy. Gastrointestinal Endoscopy 2004;60:372–7. [3] Ananthakrishnan N, Parthasarathy G, Kate V. Acute corrosive injuries of the stomach: a single unit experience of thirty years. ISRN Gastroenterology 2011:914013. [4] Andreoni B, Farina ML, Biffi R, et al. Esophageal perforation and caustic injury: emergency management of caustic ingestion. Diseases of the Esophagus 1997;10:95–100. [5] Cattan P, Munoz-Bongrand N, Berney T, et al. Extensive abdominal surgery after caustic ingestion. Annals of Surgery 2000;231:519–23.
Salvatore Guarino ∗ Department of Surgical Science, Sapienza University of Rome, Italy Fisayomi Shobayo Yassar A. Qureshi Flora Daley Badriya Alaraimi Bijendra Patel Upper GI Surgery Unit, The Royal London Hospital, United Kingdom ∗ Corresponding
author at: Dipartimento di Scienze Chirurgiche, “Sapienza” Università di Roma, Viale Regina Elena 324, 00161 Roma, Italy. Fax: +39 06 490688. E-mail addresses: [email protected] (S. Guarino), fi[email protected] (F. Shobayo), [email protected] (Y.A. Qureshi), [email protected] (F. Daley), [email protected] (B. Alaraimi), [email protected] (B. Patel)
Conflict of interest statement None declared.
14 October 2013 3 December 2013
References
Available online 7 January 2014 [1] Gumaste VV, Dave PB. Ingestion of corrosive substances by adults. American Journal of Gastroenterology 1992;87:1–5.
http://dx.doi.org/10.1016/j.dld.2013.12.004
Correspondence / Digestive and Liver Disease 46 (2014) 384–387
[2] Uetsuji S, Okuda Y, Komada H, et al. Clinical evaluation of a low junction of the cystic duct. Scandinavian Journal of Gastroenterology 1993;28:85–8. [3] Dodda G, Brown RD, O’Neil HK, et al. Cystic duct insertion at ampulla as a cause for acute recurrent pancreatitis. Gastrointestinal Endoscopy 1998;47: 181–3. [4] Roslyn JJ, DenBesten L, Thompson JE, et al. Roles of lithogenic bile and cystic duct occlusion in the pathogenesis of acute cholecystitis. American Journal of Surgery 1980;140:126–30.
Tatsuya Kin ∗ Clinical Islet Transplant Program, University of Alberta, Edmonton, Alberta, Canada Bassam Abu Wasel Multi-Organ Transplant Program, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada Andrew M. James Shapiro Clinical Islet Transplant Program, University of Alberta, Edmonton, Alberta, Canada ∗ Corresponding
author at: Clinical Islet Laboratory, 210 College Plaza, 8215 – 112th Street, Edmonton, Alberta T6G 2C8, Canada. Tel.: +1 780 407 8671; fax: +1 780 407 8760. E-mail address: [email protected] (T. Kin) Available online 7 January 2014
http://dx.doi.org/10.1016/j.dld.2013.11.014
Upper abdominal exenteration: A life saving procedure following caustic ingestion Sir, A 38-year-old previously healthy man presented to the hospital 24 h after deliberate ingestion of 200 ml of drain cleaner contain-
ing 92% sulphuric acid. He was transferred as “trauma call” from a district general hospital to our tertiary centre after 800 ml of hematemesis, and received 2 units of blood during transfer. Immediate initial management included oxygen, intravenous antibiotics, dexamethasone, proton-pump inhibitor (PPI), antiemetic and local anaesthetic diluted with saline as an oral mouthwash to relieve oral pain. An esophagogastroduodenoscopy (EGD) demonstrated mucosal necrosis in the oropharynx, full thickness mucosal burns of the whole oesophagus with haemorrhagic gastritis. An emergency laparotomy was performed with intent to perform an oeosophago-gastrectomy. Intraoperatively the extent of injuries was more advanced than anticipated, with involvement beyond the duodeno-jejunum flexure: full thickness necrosis of the second part of the duodenum was noted and the viability of the pancreas was also doubtful. A trans-hiatal oesophagectomy and gastrectomy with cervical end-oesophagostomy was performed. A “relook” laparotomy at 24 h showed progressive duodenal, proximal jejunal, pancreas, spleen, and gallbladder necrosis. Total pancreasectomy, splenectomy, duodenectomy along with the resection of the proximal jejunum were performed with a Roux-enY biliary reconstruction. One year later the gastrointestinal tract was reconstructed with a colonic transposition, through a laparotomy and cervicotomy. The transverse colon was transposed with its vascular pedicle to the chest through a retrosternal tunnel and anastomosed proximally to the pharynx and distally to the jejunum. The right colon was then anastomosed to the remaining left colon. (Fig. 1B) Two months later and with help of a multi-disciplinary team the patient was able to restart a normal oral diet. Pancreatic insufficiency causing steatorrhoea and type-1 diabetes mellitus was managed with a tailored insulin therapy and nutritional supplements. Ingestion of caustic substances represents a serious condition that can severely damage the upper alimentary tract and can often result in fatalities. 80% of cases are due to accidental ingestion by
Fig. 1. Schematic representation. (A) The organs that were found damaged by the caustic substance are coloured. (B) The reconstruction of the gastrointestinal tract with the transverse colon transposition along with its vascular pedicle.
Correspondence / Digestive and Liver Disease 46 (2014) 384–387
children [1] while the remaining cases are adults with self-harming intent. The extent of the damage depends mainly on the quantity ingested, type of substance and length of time prior to presentation and treatment. The effect of caustic ingestion varies from minimal superficial mucosal erythema and oedema to extensive transmural necrosis and perforation of the digestive tract with involvement of surrounding organs. The ingestion of corrosive substances has higher mortality and morbidity in cases of intentional self-administration, since the amount of corrosive substances swallowed is larger. Following the immediate resuscitation procedures, EGD is the gold standard investigation recommended in the first 12–48 h to assess of the extent of injuries [2]. Computed Tomography (CT) scan is also a valuable adjunct, particularly to evaluate the adjacent organs, and can be more accurate then endoscopy to assess the presence of an impending or established stomach perforation [3]. The standard operation consists in an oesophagectomy and gastrectomy with further debridement of the surrounding tissues as required, with a jejunostomy feeding tube insertion [4]. When necessary a “re-look” laparotomy at 24–48 h might be helpful to re-assess organs not debrided or excised in the initial operation, whose viability was doubtful. In the reported literature several cases of emergency oesophago-gastrectomy after caustic ingestion have been described, but only few cases of successful major resections extending to the adjacent organs were ever reported [5]. The case we presented is the first one in literature describing a true upper abdominal exenteration including the total excision of the pancreas followed by a functioning gastrointestinal reconstruction.
387
[2] Poley JW, Steyerberg EW, Kuipers EJ, et al. Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy. Gastrointestinal Endoscopy 2004;60:372–7. [3] Ananthakrishnan N, Parthasarathy G, Kate V. Acute corrosive injuries of the stomach: a single unit experience of thirty years. ISRN Gastroenterology 2011:914013. [4] Andreoni B, Farina ML, Biffi R, et al. Esophageal perforation and caustic injury: emergency management of caustic ingestion. Diseases of the Esophagus 1997;10:95–100. [5] Cattan P, Munoz-Bongrand N, Berney T, et al. Extensive abdominal surgery after caustic ingestion. Annals of Surgery 2000;231:519–23.
Salvatore Guarino ∗ Department of Surgical Science, Sapienza University of Rome, Italy Fisayomi Shobayo Yassar A. Qureshi Flora Daley Badriya Alaraimi Bijendra Patel Upper GI Surgery Unit, The Royal London Hospital, United Kingdom ∗ Corresponding
author at: Dipartimento di Scienze Chirurgiche, “Sapienza” Università di Roma, Viale Regina Elena 324, 00161 Roma, Italy. Fax: +39 06 490688. E-mail addresses: [email protected] (S. Guarino), fi[email protected] (F. Shobayo), [email protected] (Y.A. Qureshi), [email protected] (F. Daley), [email protected] (B. Alaraimi), [email protected] (B. Patel)
Conflict of interest statement None declared.
14 October 2013 3 December 2013
References
Available online 7 January 2014 [1] Gumaste VV, Dave PB. Ingestion of corrosive substances by adults. American Journal of Gastroenterology 1992;87:1–5.
http://dx.doi.org/10.1016/j.dld.2013.12.004