Foregut caustic injuries: results of the world society of emergency surgery consensus conference

A wide variety of chemical agents including mineral and organic acids and alkalis, oxidizing agents, denaturants, hydrocarbons and other chemicals may cause corrosive injuries. Although the mechanism, the severity, and the timing of the injury may vary, all these substances cause damage to living tissue on contact. Accidental or intentional ingestion of corrosive substances cause life-threatening injuries of the upper digestive tract. The degree of injury is related to the concentration, amount, viscosity, and duration of exposure to the caustic agent. The large majority of caustic agents are liquids. Strong acids and alkali are readily available as household cleaners. Lye is a generic term for the alkali used to make soap, either potassium hydroxide or sodium hydroxide. Acids cause coagulation necrosis, whereas alkali combine with tissue proteins and cause liquefaction necrosis which penetrates deep into tissues. Concentrated alkali ingestion may lead to more serious injury and complications by penetrating tissues and leading to full-thickness damage of the esophageal/gastric wall. Liquid household bleach, although often reported, does rarely cause severe injuries. Children under the age of 5 years account for more than 80 % of accidental caustic ingestion, whereas adult injuries are more often intentional and suicidal [1‐3].

Foregut caustic ingestion is certainly an under-reported public health issue. Primary prevention of these dramatic injuries was initiated in the United States by Chevalier Jackson who began a campaign that led to the Federal Caustic Act (1927) which mandated proper labeling of these harmful compounds. Subsequent acts have enforced proper labeling, antidote instructions, concentration restrictions, and child-resistant packaging. The effects of these changes have decreased but not eliminated the incidence and severity of caustic ingestions in the United States [4]. Nowadays, most information on foregut caustic injuries comes from countries where legislation is less restrictive or even absent, such as Africa, Turkey, India, Eastern Europe, Southeast Asia, and France [5].

Caustic ingestion can result in a number of injuries ranging in severity from mild oral burns to minimal mucosal erythema or transmural necrosis of the esophagus and stomach with visceral perforation. Emergency surgery is indicated for hemorrhage, free perforation, mediastinitis or peritonitis. Full thickness esophagogastric necrosis is a severe form of injury associated with considerable morbidity and mortality. It may occur due to ingestion of a large amount or highly concentrated corrosive substance. The injury may extend and involve adjacent viscera such as the duodenum, small intestine, colon, pancreas, and gallbladder. Complications such as hemorrhage, perforation, aorto-enteric fistula, or gastro-colic fistula may occur in patients surviving the initial event during the first 2–3 weeks after ingestion. Patients who have survived severe caustic injury of the foregut are at high risk of luminal strictures. After recovery from the initial injury, collagen deposition and fibrosis continue for months and scar retraction results in esophageal shortening and stricture. The incidence of esophageal stricture following grade IIB and grade III esophageal burns is in the range of 50–80 % [6, 7]. Concomitant gastric outlet obstruction occurs in up to 30 % of patients with esophageal stricture [8, 9]. In the long term, development of pharyngeal, esophageal, or gastric strictures may compromise nutritional outcome. Interestingly, the risk of squamous-cell cancer of the damaged esophagus is estimated to be 1000 times higher than that of the general population, and the latent period for the malignant change is 15–40 years [10, 11].

Currently, in most referral centers therapeutic algorithms for the management of patients with caustic injuries rely on the findings of upper digestive endoscopy. Despite the use of different endoscopic classification systems, therapeutic approaches are similar and include conservative management of patients with mild injuries, while patients with severe injuries undergo emergency surgical exploration. Although there are studies describing the short and long-term outcomes of reconstruction for established caustic strictures of the esophagus, there is limited literature on the early and long term outcomes of patients managed in an emergency setting for corrosive induced acute esophagogastric and/or adjacent organ necrosis.

Two independent MEDLINE and EMBASE searches were performed to identify relevant papers published between 1990 and 2015. The following medical subject headings terms were used in the searches: caustic ingestion, caustic lesions, corrosive injuries, esophagus, stomach, esophageal dilatation, gastric outlet obstruction. The search terms were identified in the title, abstract, or medical subject heading. Initially, 2143 abstracts of the retrieved studies were reviewed and screened for exclusion criteria. At the end of the search, 1113 abstracts that fulfilled the inclusion criteria were selected. Finally, 147 full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. The level of evidence for each recommendation statement was assigned by using the grading system proposed by the Oxford Centre for Evidence-Based Medicine [12]. A preliminary manuscript was prepared by an international panel of 12 experts including anesthesiologists, endoscopists, surgeons, and toxicologists. The key recommendations and algorithms were discussed at a dedicated meeting held in Milan in April 2015, and at the 3rd Congress of the World Society of Emergency Surgery held in Jerusalem in July 2015. Finally, evidence based guidelines for the management of foregut caustic injuries were developed to outline clinical recommendations.

The recommendations of these clinical practice guidelines are based on an extensive review of the literature and expert advice. Published data lack homogeneous classification systems and prospective methodology, the majority of papers being retrospective case reports, case series, or literature reviews. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. There has been only one negative controlled trial assessing the effect of steroids to prevent esophageal stricture after caustic ingestion in children [157]. For all the above reasons, the extrapolated recommendations are mainly based on expert opinions, retrospective studies, and literature reviews with a low level of evidence.

Despite all these limitations, the value of this consensus conferences was to gather a panel of recognized experts and over 200 physicians attending the two meetings. Among the debated issues, an unanimous consensus has emerged on the fact that use of CT scan in the initial patient staging may indeed represent a true change of paradigm. The new diagnostic algorithm may allow to avoid endoscopy in selected patients, to increase the rate of esophageal preservation, and it could translate into a better long-term patients outcome and quality of life. Interestingly, a previous WSES survey has found that 80 % of the responders to a questionnaire treat fewer than ten cases of caustic ingestion per year [158], indicating the utility to apply and share clinical practice guidelines to improve patients’ care.

Caustic ingestion continues to be a complex clinical problem and a burden for the healthcare systems worldwide. Emergency surgery and subsequent alimentary tract reconstruction are a formidable challenge in these patients. On the light of the consensus that has emerged among experts in Milan and Jerusalem, the World Society of Emergency Surgery will be running a World Registry of foregut caustic injuries (www.​clinicalregister​s.​org). This could be the first step toward a more standardized data collection and the implementation of prospective clinical studies.