The management of esophago-gastric necrosis due to caustics ingestion: Anastomotic reinforcement with Cyanoacrylate glue and damage control with Vacuum Assisted Closure Therapy—A case report

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ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

j o u r n al ho m e p a g e :w w w . c a s e r e p o r t s . c o m

The

management

of

esophago-gastric

necrosis

due

to

caustics

ingestion:

Anastomotic

reinforcement

with

Cyanoacrylate

glue

and

damage

control

with

Vacuum

Assisted

Closure

Therapy—A

case

report

A.

Picciariello

,

V.

Papagni,

G.

Martines,

N.

Palasciano,

D.F.

Altomare

DepartmentofEmergencyandOrganTransplantation,UniversityAldoMoroofBari,Bari,Italy

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received14February2019

Receivedinrevisedform16June2019 Accepted19June2019

Availableonline28June2019

Keywords: Gastricnecrosis Cyanoacrylateglue

Esophago-jejunumanastomosis Damagecontrol

Vacuumassistedclosure

a

b

s

t

r

a

c

t

INTRODUCTION:Thesurgicaltreatmentofacompletegastricnecrosisduetocausticingestionisextremely challengingandlifethreatening.Inthisemergencyscenario,afirst-timereconstructionofthe gastroin-testinaltractisoftendangerousforthepatientbecauseofthehighriskofinfectionsandanastomosis leakage.Literaturelacksofclearindicationsforthemanagementofthiscondition.

PRESENTATIONOFCASE:Malepatientwithhistoryofmajordepressiondisorderwasadmittedtoour EmergencyUnitaftertheingestionofmuriaticacid.CTscanshowedmassivepneumo-peritoneumwith esophago-gastricthickening.Freefluidsintheabdominalcavityweredetected.Intraoperativefinding wasacompletenecrosisofthestomachandcorrosionoftheloweresophagus.

DISCUSSION:Inthiscasereportweproposedafirstapproachwiththedrainageandlavageoftheabdomen cavity.Then,anesophago-jejunumanastomosisreinforcedbyCyanoacrylategluewasperformedanda damagecontrolwithVACtherapy(VacuumAssistedClosure)wascarriedout.

CONCLUSION:Cyanoacrylategluecouldbeconsideredusefulandefficientinthereinforcementof anas-tomosiseveninemergencysurgicalprocedures.DamagecontrolusingVACallowstokeepagoodcontrol ofthesurgeryperformed.

©2019TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

1. Introduction

Upper gastrointestinal injuries due to caustic ingestion are rare surgical emergencies often associated to intentional sui-cideattemptsinadults[1,2].Theseemergenciesusuallyconcern patientswithanagestartingfrom21yearsold[3].

Thescenarioafteracausticingestionisextremelyvarious, rang-ing froma single perforation of thestomachor an esophageal stricturetoacompletegastricnecrosis[4].

Patientssurvival afterseverecausticgastrointestinalinjuries dependsonthetimeframebetweeningestionandsurgical treat-ment[5].

Esophagogastroduodenoscopyrepresentsthegoldstandardto evaluatetheseverityandtheextensionoftheinjuryanditalso allowstochoosethebesttreatmentforpatients[6].

Itisquitedebatedinliteraturewhatisthebestsurgical proce-duretotreatthiscondition;infactbothonestageandtwostages procedureshavebeenproposed[6,7].

Weaimedtoreportourexperienceinthemanagementof a patientwithseverefull-thicknessgastricwallnecrosisassociated

∗ Correspondingauthor.

E-mailaddress:arcangelopicciariello@gmail.com(A.Picciariello).

withpartiallowesophagealinjuryaftertheingestionof hydrochlo-ricacid.

Atwo-timesurgerywasperformedusingcyanoacrylategluefor thereinforcementoftheesophaho-jejunalanastomosis. Further-more,wecarriedoutadamagecontrolusingVAC(VacuumAssisted Closure)therapyinordertokeepagoodcontrolofsurgery.

ThiscasereportiswrittenaccordingtoSCAREcriteria[8].

2. Presentationofcase

A 64 years old male was admitted to our Emergency Unit showinganxiety,confusionandagitation,pharyngealburnsand epigastricpain.GCS15.

The anamnesis was collectedby his relatives who reported muriaticacidingestionabout5hbeforeFirstAidadmission. Fur-thermore,thepatienthasbeeninastateofmajordepressionfor10 years.Noothercomorbiditiesorprevioussurgerieswerereported. Patient vital signs were BP 100/55mmHg, HR 125/min, RR 22/min,temperature37◦C,weight95Kg,height180cm.

Atphysicalexamination:tendernessoftheabdomen,positive Blumbergsign,absenceofbowelsounds.

Thehemogasanalysis showeda metabolicacidosis (pH7.14) withaslighthypercalcaemia(1,29mmol/L)andahyperchloremia (118mmol/L).

https://doi.org/10.1016/j.ijscr.2019.06.032

2210-2612/©2019TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons. org/licenses/by/4.0/).

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Fig.1. SpecimenTotalgastrectomywithomentectomy.

Bloodtestsshowedneutrophilicleukocytosisandanincreaseof C-reactiveprotein(112mg/L),Hb16.7g/dlandHct51%,lacticacid 1.8mmol/L.

AtFirstAidanECGwasperformed(sinustachycardia,117bpm) and thepatient underwent a chest x-ray and an Esophagogas-troduodenoscopy(EGDS)showinganextensivemucosalnecrosis (Zargar3B).

The abdomen CT scan demonstrated a massive pneumo-peritoneumwithesophago-gastricthickening.Free fluidsinthe abdominalcavityaroundthestomachweredetected.

Thepatientunderwentemergencysurgery(ASAIVE)andduring thefirstoperationtheabdomenwasexploredwithevidenceofa largeapertureoftheposterior-lateralgastricwallandtotalgastric necrosiswiththepresenceofingestedmaterial.Consideringthe patients’poorperformancestatus,asfirstapproachthreetubular drainswereputintheabdomenafteralavage;theapertureonthe posteriorwallofthestomachwasclosedandthenecrotictissues wasremoved.Inthesecondoperation(18hafter)atotal gastrec-tomywithomentectomy(Fig.1)andastapledfunctionalside-to sideesophago-jejunal(E-J)anastomosisontheanterioresophageal wallwereperformed.Anendtosidejejuno-jejunalanastomosis wascarriedouttorestorethegastrointestinaltransit.

CyanoacrilategluewasusedtoreinforcetheE-Janastomosisand damagecontrolwithVAC(VacuumAssistedClosure)(Fig.2)was carriedoutinordertokeepagoodcontrolandtoallowasecond looksurgery.

After48hVACSystemwasremovedandtheanastomosiswas checkedwithanesophagojejunoscopywithanairleaktest (neg-ative).TheabdomenwasclosedwithinterruptedVicryl1forthe fascia.

Onpostoperativeday(POD)5thepatientunderwentparenteral nutritionin theIntensiveCareUnitandonPOD8 atemporary tracheostomywasperformedandthepatientstartedtodrink.

OnPOD14hehadapneumoniatreatedbyantibiotictherapyand on22PODhewasmovedtothePsychiatryUnitwherehestarted atherapyforthemajordepressionandasemisoliddiet.

OnPOD26afurtheresophagojejunoscopydemonstratedthe absenceofleakage anda good transitthroughtheanastomosis

Fig.2.VacuumAssistedClosureTherapy.

Fig.3.EndoscopiccontrolonPOD26.

(Fig.3).Thewoundhealingwascompletelynormalandthepatient wasdischargedonPOD33.

3. Discussion

MassiveIngestionofcorrosivesubstancesforsuicidalintentin adultsrepresentsasurgicalemergencywithahighrateofmortality (about20%)andlong-termconsequences[9].Therealprevalence oftheseinjuriesisunderratedbecauseliteraturelacksofreviews andincludesonlyrandompapersandcasereports/caseseries.

InjuriesfromcausticsubstancesaremorecommoninWestern countriesthanindevelopingcountrieswherepeoplecaneasilyfind acidswhichareusedforsuicidalintent[10].

Lesionsaftercausticingestionaremoreseverinadults,maybe duetothemassiveamountofcausticingested[1].Among devastat-ingconsequencesduetocausticingestion,severeinjuries,suchas necrosisoftheoesophagusand/orthestomach,canoccurleading toshortandlongtermlife-threateningcomplications[11].

Mostoftimes,thefirstapproachisalife-savingmedical ther-apyperformedtokeepthepatientstable(e.vfluids,antibioticsand electrolytescorrection)and,ifnecessary,anorotrachealintubation toassessairwaysafety[9].

Eveniftherearenostrictguidelinesregardingtheindication ofendoscopyaftertheingestionofalargeamountofcorrosives,

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A.Picciarielloetal./InternationalJournalofSurgeryCaseReports60(2019)327–330 329

Fig.4.Algorithmforemergencymanagementofcausticinjuries.

Table1

Zargar’sgradingclassificationofmucosalinjurycausedbyingestionofcaustic substances.

GRADE DESCRIPTION

0 Normalexamination

1 Edemaandhyperemiaofthemucosa

2a Superficialulceration,erosions,friability,blisters, exudates,hemorrhages,whitishmembranes 2b Grade2◦_{+deepdiscreteofcircumferentialulceration} 3a Smallscatteredareasofmultipleulcerationandareasof

necrosiswithbrown/blackorgreyishdiscoloration

3b Extensivenecrosis

4 Perforation

anEGDS,inabsenceofathirddegreeburnofthehypopharynx,is usefultostagetheinjuryandtomakethebestchoicetotreatit [6].Grade3Binjury,accordingtoZargarendoscopicclassification

(Table1),isalife-threateningconditionandanimmediate

laparo-tomyismandatory[11](Fig.4).

AccordingtoCattanetal.thesurgicaltreatmentofseverecaustic injuriesshouldperformedassoonaspossibleinordertoimprove theprognosisofpatients[12].

Data from literature showthe lack of a standardized surgi-calprocedurefornecrosisofstomachand/oroesophagusdueto causticsingestion.Someauthorsreportgoodshortandlongterm outcomesof one-timesurgical treatmentwith esophagojejunal reconstructionaftertotalgastrectomy[11,13].

Ontheotherhand,damagecontrolsurgery(DCS)[14]withthe useofVACsystemcouldbeavalidapproachforlife-threatening conditions. In fact, DCS involves more steps for the treatment and,usually,themainsurgicalprocedureisperformedonlywhen patientsarestable.Inthisway,therateofadversecomplications aftersurgerycouldbelower.

In this case we report our experience using a three steps approach for complete stomach necrosisdue to acidingestion. Firstly,adrainageoftheabdomencavitywasperformed clean-ingtheabdomenbythenecrotictissueandclosingtheaperture ontheposteriorwallofthestomachwitharunningsuture.During thesecondoperationatotalgastrectomyandesophago-jejunum anastomosis reinforced by Cyanoacrylate glue was carried out. Cyanoacrylateglueisasyntheticgluewithsealing,adhesiveand hemostaticpropertieswidelyusedinelectivesurgery[15].Afterthe operation,thepatientunderwentdamagecontrolwithVAC ther-apythatallowedustochecktheconditionoftheanastomosisafter 48h.

VACcouldbeconsideredveryhelpfulforcriticalpatientssince itallowsafasterabdominalclosureandanearlierdischargefrom theIntensivecareUnit[16,17].

4. Conclusion

Ingestionofcausticsubstanceshasdevastatingconsequences ontheesophagusandthestomachandoftenemergencysurgery is required. Cyanoacrylate glue couldbe considereduseful and efficientinthereinforcementofanastomosiseveninemergency surgicalprocedures.DamagecontrolusingVACallowstohavea goodcontrolofthesurgeryperformedandtomakearevisionofthe abdomentwodaysafterthecriticalsurgicalprocedureandbefore theclosureoftheabdomen.

Conflictsofinterest

Noconflictofinteresttodeclaire.

Funding

Nofoundingreceived.

Ethicalapproval

EthicalapprovalwasobtainedbyInternationalReviewBoard ofAziendaOspedalieraUniveristaria–PoliclinicodiBari,P.zzaG. Cesare,Bari,Italy

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

Arcangelo Picciariello: conception of studydesign, data col-lection, analysis, manuscript writing, revision and manuscript submission.

PapagniVincenzo:conceptionofstudydesign,datacollection, analysis,revisionofthemanuscript.

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GennaroMartines:criticalrevisionofthemanuscript,approved thefinalversionofthemanuscriptforsubmission.

NicolaPalasciano:datacollection,analysis,manuscriptwriting andrevision.

DonatoF.Altomare:manuscriptwriting,drafting,revisingofthe manuscriptandparticipationinthecareofthepatient.

Registrationofresearchstudies

Thisstudydoesnotrequiretheregistration.

Guarantor

ArcangeloPicciariello,MD.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

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