View metadata, citation and similar papers at core.ac.uk brought to you by CORE

provided by Elsevier - Publisher Connector

International Journal of Surgery 7 (2009) 257–261

Contents lists available at ScienceDirect

International Journal of Surgery

journal homepage: www.theijs.com

Surgical management of gastric cicatrisation resulting from corrosive ingestion

Vikas Gupta a, Jai D. Wig a,*, Rakesh Kochhar b, Saroj K. Sinha b, Birinder Nagi b, Rudra P. Doley a, Rajesh Gupta a, Thakur D. Yadav a

a Department of (Gastrointestinal Surgery Unit), Postgraduate Institute of Medical Education and Research, Chandigarh, India b Department of , Postgraduate Institute of Medical Education and Research, Chandigarh, India

article info abstract

Article history: Background: Caustic injury to the can be complicated by gastric . We review our Received 26 February 2009 experience with surgical management of symptomatic gastric stenosis. Received in revised form 12 April 2009 Methods: This is a retrospective chart review of patients who underwent surgery for gastric stenosis Accepted 18 April 2009 within 6 weeks to 26 months following corrosive ingestion. The data analyzed included the extent of Available online 3 May 2009 cicatrisation, surgical procedure performed and outcome. Preoperative evaluation in these patients included a barium contrast study and upper gastrointestinal . Keywords: Results: Main presenting symptoms were nonbilious vomiting, early satiety, dysphagia and significant Corrosive ingestion weight loss. Antropyloric strictures were present in 28 (64%) patients, total gastric involvement was seen Gastric cicatrisation in 16 (36%) patients, associated esophageal stenosis was present in 18 (40.91%) patients. Surgical procedures performed included distal gastrectomy with Billroth1 reconstruction in 31.82%, distal Partial gastrectomy gastrectomy with Roux-en-Y reconstruction in 20.45%, stricturoplasty in 11.36%, subtotal gastrectomy in Total gastrectomy 18.18% and total gastrectomy with pouch reconstruction in another 18.18% patients. Complications encountered were pneumonitis in 18.18%, wound infection in 11.36%, intra-abdominal infection, anas- tomotic breakdown, reactivation of pulmonary tuberculosis and , each in 2.27% patients. One patient (2.27%) died. Conclusion: Surgical procedure should be tailored according to the extent of gastric involvement. Surgical resection is feasible and safe. Our results suggest that satisfactory outcome could be expected with different therapeutic modalities based on degree of cicatrisation. Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction stomach.8–10 Surgery remains the mainstay of therapy for corrosive strictures of the stomach,8,11 even though good results have been Cicatrisation of the stomach following corrosive ingestion in reported with balloon dilatation.12 We report our experience in adults is rare1 and remains the main long-term complication.2,3 It is managing corrosive induced damage to the stomach over a period of reported equally after both strong acid4 and alkali ingestion.5 The 10 years. overall incidence of gastric outlet obstruction reported varies from 5% to 8%.6,7 The scarring may be segmental or diffuse. Various 2. Materials and methods deformities produced are antropyloric stenosis, hour-glass defor- mity, or contracted small capacity stomach. Patients may develop The present study is a retrospective review of 44 patients with symptoms within 3 months of . Strictures are gastric cicatrisation following corrosive ingestion who underwent known to develop from 1 year to 6 years after the initial ingestion.8 surgical treatment from March 1998 to March 2008, at a tertiary Severe malnutrition is present in a significant proportion of patients care centre in north India. The site and extent of strictures were necessitating a feeding jejunostomy or placement of a nasoduodenal assessed in all patients using upper gastrointestinal (GI) contrast feeding tube (if possible) prior to definitive surgery.8 There are only study as well as esophagogastroduodenoscopy whereever feasible. a few reports highlighting the management of corrosive injury of the The patients were either referred to directly for surgery (n ¼ 36) for symptoms, or after failure of endotherapy (n ¼ 8). An enteral route for nutritional support was maintained wherever feasible. Jeju- nostomy feeds used were either commercially available enriched * Corresponding author at: 8H/5, Sector 12, PGI Campus, Chandigarh 160012, India. Tel.: þ91 172 2745234; þ91 9815016644 (cell); fax: þ91 172 2744401. enteral formulae or, more often, home-made preparations rich in E-mail address: [email protected] (J.D. Wig). proteins, fats and carbohydrates.

1743-9191/$ – see front matter Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2009.04.009 258 V. Gupta et al. / International Journal of Surgery 7 (2009) 257–261

3. Surgical management

The choice of definitive surgical procedure was governed by the extent of cicatrisation of the stomach and the patient’s general condition. Resection and reconstruction were tailored according to the pattern of gastric involvement. In patients with segmental involvement of the stomach (Figs. 1 and 2), a limited gastrectomy was performed. Following antrec- tomy, a gastroduodenostomy in Billroth I fashion or a Roux-en-Y reconstruction was performed. The choice of reconstruction was based on the adequacy of the mobilized stomach. In patients with short segment stricture (Fig. 3), a stricturoplasty could be performed. In patients with diffuse gastric involvement (Fig. 4), a total gastrectomy with jejunal pouch reconstruction was performed. A 15 cm jejunal pouch (J shaped using GIA 75 2) was made and anastomosed with distal end of abdominal oesophagus in a Roux- en-Y fashion. In patients with diffuse involvement and relative sparing of the fundus, a subtotal gastrectomy with gastro- jejunostomy was done. Intraoperative parameters and postoperative complications were noted. The patients were followed up for a period of 3 months to 9 years. Fig. 2. Dilated stomach with residue. Long antral stricture with pseudodiverticuli. Duodenal bulb is normal. He underwent Billroth I reconstruction.

4. Results An enteral feeding line could be established in 43 (97.73%) patients – nasoenteric tube in 24 (54.55%) and feeding jejunostomy The study included 28 females and 16 males, age range was16– in 19 (43.18%). One patient (2.27%) in whom nasoenteral tube could 72 years (median age 37 years). The presenting symptoms were not be placed, refused for surgical placement of feeding tube and recurrent vomiting and pain in the abdomen suggestive of gastric was maintained on parentral nutrition till definitive reconstruction outlet obstruction in 33 (75%) patients and early satiety with failure could be undertaken. to thrive in 11 (25%) patients. The interval between the corrosive A contrast study was done in all the patients to define the site intake and presentation was 6 weeks to 26 months (median 5 and extent of cicatrisation. In 28 (64%) patients, there were months). The corrosive agent responsible for the injury was toilet segmental involvement of the stomach, while 16 (36%) had diffuse cleaning acid in 34 (77.27%) cases, adulterated country liquor in 6 involvement with a small capacity cicatricial stomach (Table 1). (13.64%), phenolic acid in 2 (4.55%), and undetermined in 2 (4.55%). Small fibrosed and tubular stomach were the commonest pattern of The ingestion was with suicidal intent in 27 (61.36%), accidental in involvement in the diffuse variety while the antropyloric involve- 12 (27.27%) and homicidal in 5 (11.36%) patients. ment was the commonest pattern in the segmental variety.

Fig. 1. Long segmental narrowing in distal body and antrum with pseudodiverticuli. Stomach proximal to the stricture is dilated and shows polypoidal filling defects Fig. 3. Short segmental stricture in the distal body. The proximal and distal parts of the suggestive of regenerative hyperplasia. stomach are normal. He underwent stricturoplasty. V. Gupta et al. / International Journal of Surgery 7 (2009) 257–261 259

Table 2 Operative procedures.

Procedure n Segmental involvement 28 Stricturoplasty (antrum) 5 Antrectomy with Bilroth I reconstruction 14 Antrectomy with Roux-en-Y reconstruction 9

Diffuse involvement 16 Subtotal gastrectomy 8 Total gastrectomy with pouch reconstruction 8

Total 44

gastrectomy and jejunal pouch esophagojejunostomy. In 3 patients with hourglass stomach and in five with distal narrowing, the gastric fundus was healthy and these patients underwent a subtotal gastrectomy.

6. Morbidity and mortality

Eight (18.18%) patients had pneumonitis, five (11.36%) had wound infection, one (2.27%) had intra-abdominal infection, one (2.27%) had anastomotic leak and another (2.27%) had reactivation of pulmonary tuberculosis. However, all these complications could Fig. 4. Small contracted and tubular stomach with a nasojejunal tube in situ. be managed expectantly and none required surgical intervention. There was one (2.27%) mortality and was as a result of reactivation Concomitant esophageal involvement was observed in 18 of pulmonary tuberculosis. (40.91%) patients. The esophageal stricture was short segment and was considered dilatable. 7. Follow-up Initial endoscopic management was carried out in all the patients and endoscopic failure was the reason for surgical referral. Periodic dilatation of the esophageal strictures was continued in The esophageal stricture could be dilated successfully in all the the post-operative period. Five (11.36%) patients developed patients at the initial attempt. dysphagia in the late post-operative period. One patient had food A Billroth I gastroduodenostomy was done in 14 (31.82%) bolus impaction while another defaulted the dilatation programme patients and Roux-en-Y reconstruction was performed in 9 but both could be managed successfully by endoscopic interven- (20.45%) patients. In 5 patients (11.36%) with a short segment tion. Three (6.82%) patients underwent esophageal resection and stricture, a stricturoplasty could be performed. In patients with colon interposition at a later date. All the patients made an diffuse gastric involvement, a total gastrectomy with jejunal pouch uneventful recovery. reconstruction was performed in 8 (18.18%) patients. In another 8 All the patients gained weight after surgery. The eating pattern (18.18%) patients, a subtotal gastrectomy with gastrojejunostomy was near normal in all the patients. Patients with total gastrectomy was done (Table 2). were given appropriate nutritional supplementation in the post- operative period. One of the patients with total gastrectomy developed early dumping syndrome which required dietary 5. Correlation of barium findings with operative procedures modifications. Five patients with short segment antral stricture underwent stricturoplasty. Fourteen patients with short segment involvement 8. Discussion and a normal underwent antrectomy with Billroth I reconstruction. Nine patients with long antral stricture or a scarred Ingestion of strong acids and alkalis leads to esophageal and/or gastric cicatrisation. The latter produces symptoms if there is nar- duodenum underwent antrectomy with Roux-en-Y reconstruction. 1 Eight patients with small fibrosed stomach underwent total rowing in the antropyloric area or if there is diffuse cicatrisation. The presenting symptoms range from frequent nonbilious vomiting to marked weight loss.7 In a recent study the mean period between Table 1 ingestion and development of initial signs and symptoms were 26 Barium meal findings. (range 15–45) days.7 Most of the patients develop obstruction Finding n (%) within 3 months of corrosive ingestion, though it has been reported 6–11 Diffuse involvement 16 (36) to occur from 19 days to 20 years. Our patients presented with Small fibrosed tubular stomach 8 gastric outlet obstruction between 6 weeks to 26 months following Hour glass stomach 3 caustic ingestion. Distal narrowing with decreased capacity 5 Gastric damage commonly occurs in the antrum or in gastric 1 Segmental involvement 28 (64) body. Antrum is the commonest site involved owing to spasm and Antral stenosis with irregular contour 4 the resultant pooling of the corrosive agent in this area.1,13 The Prepyloric narrowing 13 ensuing fibrosis results in a stricture causing gastric outlet Pyloroduodenal scarring 1 obstruction.13 Gastric cicatrisation becomes a clinical problem Total 44 (100) when either the pyloric channel is involved or when gastric Values in the parenthesis represent percentages, n number. capacity is markedly reduced as a result of total gastric distoration. 260 V. Gupta et al. / International Journal of Surgery 7 (2009) 257–261

Various pathological lesions include antral stenosis, hourglass stomach is evident. Others also recommend surgical intervention deformity, linits plastica type picture, or total gastric distoration. 3–24 months after corrosive ingestion.8,10 Diffuse injury results following ingestion in an empty stomach.3 Concomitant damage to both the oesophagus and stomach Grossly, the stomach appears to be firm, contracted and nodular. occurs in approximately 6–50%.16,19,20,25 The surgical management The lumen may be completely obliterated.3 Pattulo et al.14 have is complicated when following correction of gastric injury, endo- endoscopically documented evolution of severe gastric antral scopic therapy fails to correct dysphagia. In these situations the injury to refractory high grade stenosis. choice is either to resect the oesophagus or bypass it. We resorted In a study of 34 cases with corrosive induced gastric injury 53% to a transhiatal oesophagectomy with colon interposition in 17% of had associated oesophageal stricture, 44% had features of gastric the patients who had concomitant esophageal involvement. Some outlet obstruction, 82% had segmental lesions and 18% had diffuse suggest that esophageal resection is not always necessary and gastric injury.10 In another study of 28 patients 46% had associated caution that oesophageal resection is difficult and dangerous. stricture of the oesophagus (responded to oesophageal dilatation), Concluding, surgical procedures are tailored according to the 78% had segmental lesions, and 21.4% had diffuse involvement.8 In extent and pattern of involvement of stomach. Gastric resection in an earlier report we have reported that out of 155 patients of our study gave good long-term results. Following correction of corrosive injury, the oesophagus was involved in 131 (84%) and gastric injury, the patients gained weight and are free of stomach in 74 (48%), with 50 (32%) patients having simultaneous complaints. involvement of both. Pyloroantral area was involved in 45/74 (61%). Diffuse involvement causing linitis plastica like deformity was seen Conflict of interest in 22/74 (39%) patients.15 In our study 64% had segmental lesions, No conflict of interest. 36% had diffuse involvement, and 41% had oesophageal stricture. Ethical approval The useful diagnostic tools are upper gastrointestinal contrast Approved. studies and upper gastrointestinal endoscopy which show the extent and severity of injury.12,16 Endoscopic ultrasonography (EUS) Funding is reported to provide accurate evaluation of depth of lesions and None required. may be useful in predicting gastric stenosis. In a recent study EUS disclosed diffuse thickening of entire gastric wall and lack of References demarcation of muscular layer in the antrum.16 Radiological find- ings in our study included segmental gastric lesions and diffuse 1. Tohda G, Sugawa C, Gayer C, Chino A, MC Guire TW, Lucas CE. Clinical evaluation and management of caustic injury in the upper gastrointestinal gastric involvement with markedly shrunken stomach. tract in 95 adult patients in an urban medical centre. Surg Endosc 2008;22: Surgery remains the mainstay of therapy for corrosive strictures 1119–25. of the stomach. Gastric resection reported in 59–93%, is safe, free of 2. Keh SM, Onyekwelu N, McManus K, McGuigan J. Corrosive injury to upper : still a major surgical dilemma. World J Gastroenterol complications, and eliminates the long-term risk of malig- 2006;12:5223–8. 1,8,9,10,17 nancy. Mucosal metaplasia with carcinoma has been 3. Sharma S, Debnath PR, Agarwal LD, Gupta V. Gastric outlet obstruction without reported in adults.17 Gastric resection remains the procedure of esophageal involvement: a late sequelae of acid ingestion in children. J Indian 18–20 16,21 Assoc Pediatr Surg 2007;12:47–9. choice, and can be performed laparoscopically also. Some 4. Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Ingestion of corrosive acid. patients require total gastrectomy and gastric reconstruction. Gastroenterology 1989;97:702–7. Construction of a jejunal pouch is a feasible solution to this 5. Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Ingestion of corrosive alkalies. 22 Am J Gastroenterol 1992;87:337–41. problem. Gastrojejunostomy in patients without extensive gastric 6. Ciftci AO, Senocak ME, Buyukpamukcu N, Hicsonmez A. Gastric outlet damage is reported as an option and provides good long-term obstruction due to corrosive ingestion – incidence and outcome. Pediatr Surg Int results.6,7,11,23–25 In our study, gastric resection was undertaken in 1999;15:88–91. 88%. In a recent study,10 gastric resection was performed in 59%, 7. Ozcan C, Erqun O, Sen T, Mutaf O. Gastric outlet obstruction secondary to acid ingestion in children. J Pediatr Surg 2004;39:1651–3. and a bypass procedure in 32%. Some authors do not recommend 8. Agarwal S, Sikora SS, Kumar A, Sexena R, Kapoor VK. Surgical management of gastroenterostomy due to risk of development of carcinoma, corrosive strictures of stomach. Indian J Gastroenterol 2004;23:178–80. metaplasia and late marginal ulceration.6 Pyloroplasty, though 9. Chung PH, Chih YC, Nan YH, Jiun YH. Surgical treatment and its long-term results for caustic induced prepyloric obstruction. Eur J Surg 1997;163: advocated is not recommended for cicatrized pyloric obstruction 275–9. because the scarring is not limited to the pylorus but affects the 10. Chaudhary A, Puri AS, Dhar P, Reddy P, Sachdev A, Lahoti D, et al. Elective adjacent tissues as well,26 and is not an adequate long-term solu- surgery for corrosive-induced gastric injury. World J Surg 1996;20:703–6. 17 11. Tseng YL, Wu MH, Lin MY, Lai WW. Early surgical correction for isolated gastric tion. Other procedures reported include Y–V advancement strictures following acid corrosion injury. Dig Surg 2002;19:276–80. 13 antropylroplasty or augmentation gastroplasty using a segment 12. Kochhar R, Sethy PK, Nagi B, Wig JD. Endoscopic balloon dilatation of benign of transverse colon.19,27 Endoscopic balloon dilatation may be tried gastric outlet obstruction. J Gastroenterol Hepatol 2004;19:418–22. 13. Brown RA, Miller AJ, Numanoglu A, Rode H. Y–V advancement antropylor- for pyloric stenosis. Some series have reported successful endo- oplasty for corrosive antral strictures. Pediatr Surg Int 2002;18:252–4. scopic balloon dilatation of the pyloric canal based on experience 14. Pattulo V, Bourke MJ, Alexander S. Endoscopic evaluation of severe injury to with managing gastric outlet obstruction with different aetiologies. gastric antrum. Gastrointest Endosc 2009;69:581–4. 15. Nagi B, Kochhar R, Thapa BR, Singh K. Radiological spectrum of late sequelae of However, the short term failure and long-term recurrence rates for corrosive injury to upper gastrointestinal tract. A pictorial review. Acta Radiol 28,29 balloon dilatation were as high as 30–84%. This may not be 2004;45:7–12. possible especially in cases of complete pyloric obstruction after 16. Kamijo Y, Kondo I, Watanebe M, KanoT Ide A, Soma K. Gastric stenosis in severe circumferential injury. In an experience of 8 patients, corrosive corrosive : prognostic evaluation by endoscopic ultrasonography. Clin Toxicol (Phila) 2007;45:284–6. induced gastric outlet obstruction required a larger number of 17. Mc Auley CE, Steed DL, Webster MW. Late sequelae of gastric acid injury. Am J dilatation sessions (2–9, mean 5–63 þ 2.88), and the response was Surg 1985;149:412–5. good with follow-up of 12–30 months.12 Intralesional steroid 18. Subbarao KS, Kakkar AK, Chandrasekhar V, Ananthakrishnan N, Benerjee A. Cicatricial gastric stenosis caused by corrosive ingestion. ANZ J Surg injections for corrosive induced pyloric stenosis has also been 1988;58:143–6. reported.30 Early surgical correction is safe and has decreased 19. Feng J, Gu W, Li M, Yuan J, Weng Y, Wei M, et al. Rare causes of gastric outlet morbidity and mortality.6 Tseng et al.11 performed surgery obstruction in children. Pediatr Surg Int 2005;21:635–40. 20. Tekant G, Eroglu E, Erdogon E, Yesildag E, Emir H, Bujukunal C, et al. Corrosive 35.7 þ 3.2 days after ingestion. We prefer to postpone surgical injury – induced gastric outlet obstruction: a changing spectrum of agents and intervention until the full extent of scarring and deformity of the treatment. J Pediatr Surg 2001;36:1004–7. V. Gupta et al. / International Journal of Surgery 7 (2009) 257–261 261

21. Kanayama Y, Fujiwara M, Kodera Y, Miura S, Kasai Y, Hibi K, et al. Laparoscopic 26. Ragheb MI, Ramadan AA, Khali MA. Corrosive gastritis. Am J Surg distal gastrectomy for severe corrosive gastritis: report of a case. Surg Today 1977;134:343–5. 2003;33:937–9. 27. Kumar A, Ansari M, Shukla D, Tripathi AK, Shyam R. Augmentation gastroplasty 22. Aktub T, Olguner M, Akgur FM. A case of gastric cicatrization caused by using a segment of transverse colon for corrosive gastric stricture. Int J Colo- ingestion of sulphuric acid treated with Hunt-Lawrence jejunal pouch substi- rectal Dis 2006;21:470–2. tution for the stomach. J Pediatr Surg 1995;30:1376–7. 28. Khullar SK, Disano JA. Gastric outlet obstruction. Gastrointest Endosc Clin N Am 23. Hsu C, Chen C, Hsu N, Hsia J. Surgical treatment and long-term results for 1996;6:585–603. caustic induced prepyloric obstruction. Eur J Surg 1997;163:275–9. 29. Kuwada SK, Alexander GL. Long term outcome of endoscopic dilatation of 24. Cotton MH. Corrosive acid gastric stricture: a plea for conservative surgery. Trop nonmalignant pyloric stenosis. Gastrointest Endosc 1995;41:15–7. Doct 1989;19:186–7. 30. Kochhar R, Sriram PV, Ray JD, Kumar S, Nagi B, Singh K. Intralesional 25. Erdogen E, Eroglu E, Tekant G, Yeker Y, Emir H, Sarimurat N, et al. Management of steroid injections for corrosive induced pyloric stenosis. Endoscopy esophagogastric corrosive injury in children. Eur J Pediatr Surg 2003;13:289–93. 1998;30:734–6.