Caustic injuries from alkaline substances lead to severe esophageal damage, necessitating replacement in some cases due to extensive scarring from persistent injuries. Several conduits for esophageal replacement exist, with the gastric tube noted as the most effective option, particularly using the trans-hiatal route. Postoperative complications and mortality rates highlight significant challenges in esophageal replacement, especially in developing countries.

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??

22. Jejunal Substitution
• More commonly used in adults.
• Advantages vs Disadvantages

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

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

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

29. • 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%).

30. 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.