Abstract
Background
Esophagectomy is the standard of care for high-grade corrosive esophageal necrosis as assessed endoscopically. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to unnecessary esophageal resection, with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of endoscopic high-grade corrosive esophageal necrosis.
Methods
In a before (2000–2007)/after (2007–2012) study of patients with grade 3b endoscopic esophageal necrosis, we compared outcomes after routine emergency esophagectomy versus selection for emergency esophagectomy based on CT evidence of transmural necrosis, defined as at least two of the following: esophageal-wall blurring, periesophageal-fat blurring, and the absence of esophageal-wall enhancement. Survival estimated using the Kaplan–Meier method was the primary outcome.
Results
Compared to the routine-esophagectomy group (n = 125), the CT group (n = 72) had better overall survival in the crude analysis (hazard ratio [HR], 0.43; 95 % confidence interval [95 %CI], 0.21–0.85; P = 0.015) and in the analysis matched on gender, age, and ingested agent (HR, 0.36; 95 %CI, 0.16–0.79; P = 0.011). No deaths occurred among patients managed without emergency esophagectomy based on CT findings, and one-third of CT-group patients had their functioning native esophagus at last follow-up. Self-sufficiency for eating and breathing was more common (84 % vs. 65 %; relative risk [RR], 1.27; 95 %CI, 1.04–1.55; P = 0.016) and repeat suicide less common (4 % vs. 15 %; RR, 0.27; 95 %CI, 0.09–0.82; P = 0.019) in the CT group.
Conclusion
The decision to perform emergency esophagectomy for endoscopic high-grade corrosive esophageal injury should rely on CT findings.
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Acknowledgments
We thank A Wolfe, MD, for helping with the article preparation.
Disclosures
Mircea CHIRICA, Matthieu RESCHE-RIGON, Benjamin PARIENTE, Fabienne FIEUX, François SABATIER, Franck LOISEAUX, Nicolas MUNOZ-BONGRAND, Jean Marc GORNET, Marie-Dominique BRETTE, Emile SARFATI, Elie AZOULAY, Anne Marie ZAGDANSKI and Pierre CATTAN have no conflicts of interest or financial ties to disclose.
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Chirica, M., Resche-Rigon, M., Pariente, B. et al. Computed tomography evaluation of high-grade esophageal necrosis after corrosive ingestion to avoid unnecessary esophagectomy. Surg Endosc 29, 1452–1461 (2015). https://doi.org/10.1007/s00464-014-3823-0
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DOI: https://doi.org/10.1007/s00464-014-3823-0