Chirica M, Resche-Rigon M, Zagdanski AM, Bruzzi M, Bouda D, Roland E, Sabatier F, Bouhidel F, Bonnet F, Munoz-Bongrand N, Marc Gornet J, Sarfati E, Cattan P. Ann. Surg. 2015; 264(1): 107-113.
Affiliation
*Department of General, Endocrine and Digestive Surgery †Department of Biostatistics and Medical Informatics ‡Department of Gastroenterology §Department of Anesthesiology and Surgical Intensive Care ¶Department of Radiology ||Department of Pathology, Saint-Louis Hospital, Paris, France.
BACKGROUND: Endoscopy is the standard of care for emergency patient evaluation after caustic ingestion. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to inappropriate decision-making with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of patients with caustic injuries.
METHODS: In a prospective study, we used a combined endoscopy-CT decision-making algorithm. The primary outcome was pathology-confirmed digestive necrosis. The respective utility of CT and endoscopy in the decision-making process were compared. Transmural endoscopic necrosis was defined as grade 3b injuries; signs of transmural CT necrosis included absence of postcontrast gastric/ esophageal-wall enhancement, esophageal-wall blurring, and periesophageal-fat blurring.
RESULTS: We included 120 patients (59 men, median age 44 years). Emergency surgery was performed in 24 patients (20%) and digestive resection was completed in 16. Three patients (3%) died and 28 patients (23%) experienced complications. Pathology revealed transmural necrosis in 9/11 esophagectomy and 16/16 gastrectomy specimens. Severe oropharyngeal injuries (P = 0.015), increased levels of blood lactate (P = 0.007), alanine aminotransferase (P = 0.027), bilirubin (P = 0.005), and low platelet counts (P > 0.0001) were predictive of digestive necrosis. Decision-making relying on CT alone or on a combined CT-endoscopy algorithm was similar and would have spared 19 unnecessary esophagectomies and 16 explorative laparotomies compared with an endoscopy-alone algorithm. Endoscopy did never rectify a wrong CT decision.
CONCLUSIONS: Emergency decision-making after caustic injuries can rely on CT alone.