Caustic Injury and Esophageal Replacement.pptx

A regular morning didactic talk to colleagues - paediatric surgery fellows

1. Caustic Injury and Esophageal Replacement 21/05/’24 DIMINGO

2. Caustic – a substance capable of burning or corroding organ tissues by chemical actions, typically strong acid or alkalis

3. Inadvertent ingestions predominate in children although more than half of ingestions in adolescents are intentional. Severe caustic injury remains the second most cause clinical scenario resulting in an unsalvageable esophagus and is most commonly the result of an alkali substance in household cleaning products.

4. Alkali is tasteless and hence more frequently ingested in large quantities; it causes a liquefactive necrosis beginning on the mucosal surface and potentially progressing through muscle layers resulting in areas of friability, ulceration and eventually full thickness perforation This acute phase occasionally mandates immediate operative intervention to minimize mediastinitis and control ongoing contamination – esophageal diversion and tube thoracostomy typically suffice as initial treatment More commonly, however, extensive scaring gradually replaces esophageal mucosa as the injury progresses from acute to chronic. An intense regimen of dilatation is begun. Should this regimen fail to establish durable continuity of the esophagus replacement of the organ with a conduit requires consideration

5. 3 year old child brough in by parents for concerns of suspected caustic ingestion Proceed …………….

6. History When What Formation How much How concentrated How long (contact duration)

7. General – appearance, WOB Airway – clear Breathing – tarchypnic , depressed Circulation – tarchypnea , bradycardia, cyanosed, hypotension Disability – GCS, pupils Blood sugar Blood gas

8. Alkaline agents are more commonly ingested Acidic agents are better* Alkaline cause esophageal injuries @ >11.5 – 12.5 ph Acids cause injuries @ <2 ph Liquefaction necrosis vs coagulation necrosis

9. Presence or absence of any clinical features does not reliably predict ingestion, or the presence or the severity or esophageal of gastric burns Endoscopy is ideally performed within 24hrs of ingestions CT Scan ***

10. New England Journal in 2020

11. Uptodate recommendation

12. Who gets their esophagus replaced??????

13. Esophageal Replacement Indications: - long-gap esophageal atresia - failed primary repair of esophageal atresia - strictures related to reflux or corrosive injury. First used conduit: colon Others: gastric tube, gastric transposition, and jejunal interposition graft. Best conduit??????

14. Principles: - the esophagus is the optimal conduit - a short straight tract is best - prevent reflux into any conduit - persistence is exceedingly important

15. Criteria for choosing conduits?? Normal esophagus is superior to any substitute Considerations Living viscus Adequacy of its blood supply freedom from intrinsic disease Length of resected esophagus that is it capable of bridging Number of anastomosis Expertise

16. Gastric Tube Esophageal Replacement Popular Vasculature Advantages vs Disadvantages Complications - stricture formation requiring dilation - dumping syndrome - development of Barrett esophagus above the anastamosis .

17. Reverse gastric tube

18. Gastric transposition Mobilize the stomach on a vascular pedicle + /- pyloroplasty Beware of older patients who have had multiple procedures Advantages Complications Death typically secondary to resp failure

19. Gastric pull up

20. Colonic Interpoosition Any segment of colon Retrosternal or posterior mediasternal Left colon most commonly used Advantages vs disadvantages +/- partial fundoplication Accurate measurement of the graft length Timing of colonic interposition??

21. Jejunal Substitution More commonly used in adults. Advantages vs Disadvantages

22. Complications of esophageal substitutions Vascular insufficiency with necrosis of the interposition. Ananstomotic leak Proximal stricture Ulceration

23. Results Total: 93 patients. Conduits: - gastric transposition in 84 cases (90%), - colon interposition in 7 cases (7.5%) - jejunal interposition in 2 cases (2%).

24. Routes of esophageal replacement were - trans- hiatal in 76% - retrosternal in 14% - trans- hiatal with thoracotomy in 10% patients

25. Postoperatively, all of the conduits maintained viability. - Wound infection was seen in 10 (11%), - wound dehiscence in 5 (5%) - anastomotic leak in 9 (10%) - anastomotic stenosis in 12 (13%) - aortic injury 1 (1%) - dumping syndrome 8 (9%) - reflux 18 (19%) - dysphagia 15 (16%) - death occurred in 12 patients (13%).

26. Conclusion There are problems with esophageal replacement in developing countries. In this context, gastric conduit appeared as the best conduit for esophageal replacement, using the trans- hiatal route for replacement, in the authors’ experience.