Abordagem cirúrgica aguda e crônica das lesões cáusticas e suas complicações

Abstract

Introduction The ingestion of caustic agents remains an important public health problem worldwide, especially in developed countries and is a cause of concern in our country due to the seriousness of the cases. In Brazil, due to its easy access, since they are present in several household products, intentional or accidental ingestion occurs frequently. Acid and alkaline substances can cause serious damage to the esophagus and EGD has an important role in the diagnosis and in choosing the appropriate treatment. The endoscopic grading of the lesion is a predictor of the outcome and important for prognosis and management, and although patients with caustic esophageal lesions are at risk of esophageal stenosis, management and treatment choices are still discussed. Given this scenario, the objective of this work is to evaluate the acute and chronic surgical approach to caustic lesions and the role of their endoscopic classification as a predictor of esophageal stenosis.

Methodology An active search was performed of medical records of patients victims of caustic ingestion treated at the Hospital de Pronto Socorro João XXIII (HPSJXXIII). 101 patients were selected, who were adults with acute esophageal lesions classified by EDA. Patients under the age of 15, those who had injuries caused by acidic agents, those who missed outpatient follow-up, those who did not have esophageal injuries or who were not classified by EDA, were excluded from the study. After being discharged, the selected patients were followed up at the General Surgery outpatient clinic of the Hospital and referred to the Júlia Kubitschek Hospital (HJK) in case of chronic complications. Among them, the prevalence and factors associated with the most common, esophageal stenosis, were evaluated. Of the patients followed up at the HJK, 47 had esophageal stricture. Among these, 19 had unresponsive or refractory stenosis to endoscopic dilation, undergoing elective esophagogastroplasty. Subsequently, the outcome of patients undergoing esophagocolplasty and esophagogastroplasty was compared at the same service. Statistical analyzes were performed separately for two groups: chronic patients and acute patients. Descriptive statistics presents the variable age with mean, standard deviation, minimum and maximum. The other variables are qualitative and, therefore, were presented in the form of frequency tables. In cases where it was necessary to assess the interaction between two qualitative variables, the Chi Square test was applied. Results The average age of the participants was 43.43 (SD 17.66), and of the 101 participants, 63 (62.4%) were male. After endoscopic evaluation in the acute phase, using the Zargar Classification, we obtained a sample of 19 (18.9%) patients classified as I, 8 (7.9%) as IIa, 25 (24.8%) as IIb, 31 (30.7%) as IIIa and 18 (17.8%) as IIIb. Of the patients admitted with caustic injury, 12 died in the acute phase of the injury, with 11 (91.7%) operated on due to signs of perforation or refractory hemodynamic instability and 1 (8.3%) maintained instability and severity not tolerating any propaedeutic or procedure. These patients were classified by endoscopy. Regarding the food route, 53 patients underwent jejunostomy and 1 used a nasoenteric tube. The average age of the 34 patients who were operated on in the chronic phase of the injury due to caustic stenosis, was 40.6 (SD 13.91). Among these, 15 were male (44.1%). Esophagectomy with esophagogastroplasty was performed in 19 (55.9%) of them and esophagocolplasty in 15 (44.1%). Conclusion Data related to Zargar's endoscopic classification in patients who ingested exclusively caustic soda, do not exist in the literature. With regard to the type of agent ingested, our data indicate that the type of agent ingested may be related to the degree of injury, as has already been investigated by other authors. Regarding the food route to be offered to patients in the acute phase of caustic injury, data in the literature are lacking. However, at the Trauma Center where this study was carried out, jejunostomy was the food route of choice. The literature that addresses the management of the chronic phase of lesions caused by caustic ingestion reveals that only a small number of patients undergo surgery at this stage and data on the subject are scarce. Our study provides the endoscopic classification of patients undergoing surgery in the chronic phase, differing from all previously published. Our data show that in the groups of patients who received a higher endoscopic classification in the acute phase, the incidence of GI reconstruction surgeries in the chronic phase is higher. We also did not find data that correlated the type of anastomosis with the technique used. With regard to the complications of surgeries performed in the chronic phase, the ones evidenced in this study are similar to those in the literature in terms of types and differ in terms of incidence. However, the heterogeneity of the study samples makes it difficult to perform a statistical analysis of the complications of surgery in the chronic phase. Publications dealing with the approach of patients with injuries secondary to the ingestion of caustic agents in both the acute and chronic phases are scarce. We believe it is imperative to carry out further studies in the area, so that the best treatments are offered to patients.