The conservative management of severe caustic gastric injuries.

OBJECTIVE: To determine the safety of a conservative approach to treating severe caustic injury in patients lacking clinical and biochemical signs of transmural necrosis.

BACKGROUND: Esophagogastrectomy is thought to limit the progression of severe caustic injury in the upper gastrointestinal tract observed upon initial endoscopic examination. However, endoscopic evaluation of the depth and spread of necrosis is challenging and may lead to unnecessary gastrectomy.

METHODS: From January 2002 to December 2008, 70 patients were classified as having stage III gastric injury in an initial digestive tract endoscopic examination. When patients had no signs of peritonitis, their treatment was determined by 6 clinical and biochemical factors of severity (abdominal rebound tenderness, neuropsychiatric troubles, cardiovascular shock, metabolic acidosis, disseminated intravascular coagulation, and kidney failure) in addition to endoscopic staging. If one of these clinical and biochemical factors was present, the patient underwent emergency laparotomy. Patients with isolated stage III gastric injury were kept under close observation.

RESULTS: Twenty-four of the 70 endoscopic stage III patients required emergency surgery. Conservative treatment was initiated in the remaining 46. There were 4 postoperative deaths (5.7%). Fifteen patients required subsequent surgery: distal gastrectomy with Billroth I anastomosis (n = 7) for distal stricture and esophagoplasty for nondilatable esophageal stricture (n = 8). At the end of the follow-up period, total or partial gastric conservation was achieved in all 46 patients (65.7%) and the esophagus was conserved in 38 patients (54.3%).

CONCLUSION: In the absence of clinical and biological signs of severity, conservative management of stage III gastric injury is clinically feasible, precludes gastrectomy and has a low mortality rate.