ANNALS OF SURGERY
Vol. 180
AUGUST 1974
No. 2
Surgical Management of Corrosive Gastric In juries
JON F. NICOSIA, M.D., JOSEPH P. THORNTON, M.D.,
FRANK A. FOLK, M.D., JOHN D. SALETTA, M.D.
Four cases of extensive corrosive gastric injury requiring
surgical treatment are presented. Appropriate management
of this life-threatening entity requires an awareness of its
subtle presentation plus a well planned surgical approach.
From the Division of General Surgery,
Cook County Hospital, Chicago, Illinois
bile were noted oozing through the wound. At this time the patient admitted that prior to his first admission he had accidentally
ingested a large quantity of liquid drain cleaner which contained
contain alkalis
which frequently cause esophageal burns and sulfuric acid.
At reexploration the entire gastric mucosa was found to be
strictures, and only occasionally produce gastric injury.
with multiple areas of full thickness necrosis. The
gangrenous,
In contrast, acid ingestions usually spare the esophagus pyloroplasty had
disrupted and was the site of bile leakage. The
but often burn the stomach.
external surface of the esophagus and duodenum appeared norThe following reports represent our personal experi- mal. A total gastrectomy, splenectomy, tube duodenostomy, cloence with four cases of extensive gastric burns resulting sure of the distal esophagus, feeding jejunostomy and doublecervical esophagostomy were performed (Fig. 1).
from the ingestion of corrosive materials and requiring barrelled
The
course was prolonged and complicated by
postoperative
acute and long termiurgical management.
intraperitoneal abscesses requiring surgical drainage. Seven weeks
M
OST INGESTED CORROSIVE SUBSTANCES
Case Reports
Case 1.. J. F., a 30-year-old man, was admitted to Cook County
Hospital on September 9, 1968 with a history of hematemesis and
melena beginning four hours prior to admission. He related a
recent heavy alcohol intake but denied previous gastrointestinal
bleeding. His bleeding stopped spontaneously, and upper gastrointestinal X-rays were interpreted as normal. The patient was discharged one week later with a presumptive, diagnosis of alcoholic
gastritis.
The following day he returned, again vomiting blood. On this
occasion the bleeding persisted, and during the next four days
he received eight units of whole blood. At exploratory laparotomy
an edematous, hyperemic, friable gastric mucosa with absent rugal
folds was noted. A diagnosis of alcoholic gastritis was presumed,
and a vagotomy and pyloroplasty were performed. Postoperatively,
bleeding continued and on the second postoperative day air and
Submitted for publication August 30, 1973.
Reprint requests: John D. Saletta, M.D., Chairman, Division
of General Surgery, Cook County Hospital, 1825 West Harrison
Street, Chicago, Illinois 60612.
139
following the second operation, with the patient's sepsis eradicated
and his nutrition maintained via jejunostomy feedings, he was
discharged. Prior to discharge, esophagoscopy revealed normal
esophageal mucosa without stricture or ulceration.
Three months later, a transabdominal end to side esophagojejunostomy and jejunojejunostomy were performed (Fig. 2). The
following month the cervical esophagostomy was closed. At discharge the patient's weight was 108 pounds, whereas, prior to his
illness, he weighed 180 pounds.
Eighteen months later the patient was readmitted because of
vague postprandial epigastric distress. His weight at that time
was 145 pounds. A complete work-up, including an upper gastrointestinal series and esophagoscopy were within normal limits. At
followup 2% years postoperatively, the patient remained asymptomatic.
Case 2. T. M., a 22-year-old woman, was admitted to Cook
County Hospital on September 20, 1968, after ingestion of an
unknown amount of crystalline lye. Although the patient complained of mild abdominal pain, she had no oropharyngeal burns
or abdominal tenderness. On the fourth hospital day the patient
suddenly developed severe abdominal pain with signs of peritonitis.
At exploratory laparotomy the entire stomach was found to
be necrotic without free perforation. Although the external sur-
NICOSIA AND OTHERS
140
8 6
Fic. 1. Schematic drawing of
/
l
/
m a
patient J. F., following total
gastrectomy and splenectomy.
Note the diverting cervical
esophagostomy,
Ann. Surg. * August 1974
}
/
l-
tube duodenos-
tomy, and feeding
}
jejunostomy.
FIG. 3. Schematic drawing of
patient T. M., showing a substernal colon bypass, utilizing
the descending colon interosed
between the cervical esophagus
and proximal jejunum. The extensively strictured intrathoracic esophagus has not been removed.
face of the esophagus and duodenum appeared normal, the
esophageal mucosa was gangrenous. Because of the patient's precarious condition, extension of the operation to include resection
of the esophagus was deemed inadvisable. Consequently, a total
gastrectomy, closure of the necrotic distal esophagus, cervical
esophagostomy, tube duodenostomy and jejunostomy were performed.
The patient made an uncomplicated recovery and her nutrition was maintained with hyperalimentation and jejunostomy
feedings. Three months later a substernal colon bypass procedure
was performed utilizing the descending colon interposed between
the cervical esophagus and proximal jejunum (Fig. 3).
Postoperatively, a suture line disruption of the proximal esophago-colostomy resulted in a salivary fistula. The patient has subsequently been lost to followup.
Case 3. G. J., a 23-year-old man, ingested an unknown amount
of liquid drain cleaner containing sulfuric acid, approximately four
hours prior to admission on December 31, 1971. He was seen
at another hospital, where gastric lavage was performed prior
to transfer to the Cook County Hospital. On admission, he was
intoxicated and complained of burning abdominal and substernal
pain. He had swollen parched lips and multiple burned areas on
the buccal mucosa. There was no abdominal tenderness. Moist
rales and rhonchi were auscultated throughout both lung fields.
The patient was managed with intravenous fluids, parenteral
antibiotics and nothing by mouth. His chest X-ray revealed bilateral patchy infiltrates, but there was no evidene of free air
on either the upright chest or abdominal X-rays. Parenteral steroids
were administered as adjunctive therapy for presumed chemical
aspiration pneumonitis and a tracheostomy was performed.
Nine days after admission the patient developed abdominal
tenderness and signs of peritonitis. At exploratory laparotomy a
liter of foul-smelling, bile-stained fluid was found in the peritoneal
cavity. The entire stomach and duodenum were necrotic with
multiple free perforations, necessitating a total gastrectomy and
pancreatoduodenectomy. The distal end of the esophagus was
closed and a cervical esophagostomy was constructed. A choledochojejunostomy and feeding jejunostomy were performed and
the remaining pancreas was oversewn with separate ligation of
the pancreatic duct (Fig. 4). The patient developed progressive
pulmonary insufficiency and expired on the second postoperative
day.
Case 4. S.W., a 26-year-old male, was admitted to Cook County
on April 4, 1973, after ingesting liquid drain cleaner
which contained sulfuric acid. Superficial burns were noted on
the patient's tongue and posterior pharynx. Examination of his
abdomen revealed minimal left upper quadrant tenderness without evidence of peritonitis.
Six days after admission the patient had several episodes of
hematemesis during a 24-hour period; however, blood replace-
Hospital
ment was not
required.
On May 21, 1973, he began vomiting after meals. An upper
gastrointestinal X-ray revealed partial stricture of the distal onethird of the esophagus as well as antral stenosis and ulceration
(Figs. 5 and 6).
At operation, the distal antral mucosa was observed to be replaced by granulation tissue and a 1 cm ulceration was present
on the posterior antral wall. The pre-pyloric region was markedly
stenotic, permitting passage of a 3 mm probe (Fig. 7). The
operative procedure consisted of a 40% distal gastrectomy with a
Billroth I gastroduodenostomy, plus a gastrostomy for subsequent
retrograde esophageal dilations.
FIG. 4. Schematic drawing of
\
,9-?
/
/
FIG. 2. Schematic drawing of
patient J. F., following esophagojejunostomy and jejunojejun-
ostomy. The tube duodenostomy
gas been removed but the feedhsing jejunostomy and cervical
esophagostomy remain.
patient G. J., following total
gastrectomy and pancreatoduodenectomy. Note the cervical
esophagostomy, closure of the
proximal jejunum, end to side
choledochojejunostomy,
feeding jejunostomy. The
and
re-
sected end of the remaining
pancreas has been oversewn.
Vol. 180 * No. 2
CORROSIVE GASTRIC INJURIES
141
The patient's postoperative course has been uneventful. He is
currently eating without difficulty.
Discussion
Gastric burns often occur following ingestion of corrosive materials, either accidentally by children and alcoholics, or intentionally by emotionally disturbed individuals.
On the basis of experimental animal studies and
clinical observation, it is well known that acids tend to
destroy the stomach and spare the esophagus.23 On the
other hand, alkalis usually injure the esophagus and
spare the stomach.2 Large amounts of either substance
cause severe damage to both organs in approximately
20% of ingestions.'0
The esophageal sparing noted in acid ingestions appears related to the resistance of the esophageal squamous epithelium to acid erosion and rapid esophageal
transit time.5 Alkalis are usually prevented from damaging the stomach by the neutralizing effect of the acid
normally present in the stomach.24
In most instances, the gastric burn injury is greatest
along the lesser curvature and in the pre-pyloric area.21
The explanation for this distribution was provided by
Testa in 1938. He introduced caustic soda mixed with
barium into the esophagus of dogs and demonstrated
by X-ray that the alkali-barium bolus flowed along the
lesser curvature, produced severe pylorospasm, and was
retained in the pre-pyloric area.23
The extent of gastric injury appears related to the
nature, volume, and concentration of corrosives ingested;
the length of time they remain in contact with the
stomach; the content of the stomach at the time of ingestion; and the relative tonicity of the pyloric sphincter.4
At times only superficial mucosal injuries occur which
heal uneventfully. More extensive gastric burns which
involve the submucosa and muscularis produce various
degrees of deformity including antral stenosis,8"10"12"14,16,19
hourglass strictures,7 22 and rigidity simulating infiltrating
gastric carcinoma."1'l3 Elective surgical correction of
these deformities may be necessary when signs of gastric
outlet obstruction develop. This usually develops between the first and second month post-injury.'4 Partial
gastric resection is the procedure of choice.7 Gastroenterostomy without resection has been used for definitive therapy, but the uncertain fate of the burned
stomach would appear to be a good indication for its
resection.'158,20 In this regard, O'Donnel in 1949 reported a case of gastric carcinoma developing six years
following gastroenterostomy for a nitric acid burn which
had produced pyloric obstruction.17
In the extensively burned stomach, visceral perforation may occur immediately. More frequently, massive
gastrointestinal bleeding or peritonitis are delayed for
FIG. 5. Barium esophagogram of patient S.W., taken seven weeks
following acid ingestion. Note the incomplete stricture of the
distal one-third of the esophagus.
FIG. 6. Barium filled distal stomach of patient S.W., seen on an
upper gastrointestinal X-ray performed seven weeks following
acid ingestion. The complete antral obstruction and posterior
ulcer crater are seen.
NICOSIA AND OTHERS
142
Ann. Surg.
-
August 1974
FIG. 7. Intraoperative
photograph of the antrum
in patient S.W., as seen
through a gastrotomy incision. The thickened antral wall as well as the
antral stricture, which
pennits the passage of a
3 mm probe, can be seen.
three to fourteen days, making it imperative that repeated daily abdominal examinations be performed during the first two weeks following corrosive ingestions.3
The frequent absence of oral and esophageal burns may
further mask the suspicion of severe injuries to the stomach and duodenum.
Initial management should consist of nothing by
mouth, antacids per nasogastric tube, antibiotics, intravenous fluids, and blood transfusions when indicated.24
Fiberoptic endoscopy should be performed initially to
determine the most proximal level of injury.5 The fiberoptic scope should not be passed beyond the most
proximal area of mucosal burn because of the danger of
perforation. Developing signs of peritonitis may be
masked if steroids are used (Case 3). Gastric lavage
or the inducing of emesis is contraindicated, since perforation of the injured organ or tracheobronchial aspiration
may occur.
Emergent surgery is indicated for hemorrhage, free
perforation or peritonitis. Removal of necrotic tissue is
essential and may necessitate total gastrectomy, pancreatoduodenectomy and small bowel resection. Attempts
at definitive restoration of intestinal continuity should
be deferred at the time of emergency surgery as anastomoses of edematous friable segments of esophagus, stomach or small bowel are prone to disrupt.3 Following total
gastrectomy and closure of the distal esophagus, cervical
esophagostomy is recommended for diversion of saliva.6'9
Tube drainage of the distal esophagus without cervical
esophagostomy has been inadequate because esophageal
stricture, mediastinitis or tracheoesophageal fistulae have
developed.' Since the postoperative course may be prolonged, a feeding jejunostomy is nutritionally beneficial
and provides either an adjunct or an alternative to intravenous hyperalimentation. Staged reconstruction of intestinal continuity should be performed when the patient's condition warrants.
Full recovery can be expected in most patients and
nutrition can be maintained with minor adjustments in
eating habits plus supplemental vitamins, especially B12,
for patients
who
have undergone total gastrectomy.
References
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