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Computed tomography evaluation of high-grade esophageal necrosis after corrosive ingestion to avoid unnecessary esophagectomy

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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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Authors and Affiliations

  1. Department of General, Endocrine and Digestive Surgery, Saint-Louis Hospital, APHP, Université Paris 7 Diderot, Paris, France

    Mircea Chirica, Nicolas Munoz-Bongrand, Emile Sarfati & Pierre Cattan

  2. Department of Biostatistics et Medical Informatics, Saint-Louis Hospital, APHP, UMR 717 Inserm, Université Paris 7 Diderot, Paris, France

    Matthieu Resche-Rigon

  3. Department of Gastroenterology, Saint-Louis Hospital, APHP, Université Paris 7 Diderot, Paris, France

    Benjamin Pariente & Jean Marc Gornet

  4. Department of Anesthesiology and Surgical Intensive Care, Saint-Louis Hospital, APHP, Université Paris 7 Diderot, Paris, France

    Fabienne Fieux

  5. Department of Radiology, Saint-Louis Hospital, APHP, Université Paris 7 Diderot, Paris, France

    François Sabatier & Anne Marie Zagdanski

  6. Department of Pathology, Saint-Louis Hospital, APHP, Université Paris 7 Diderot, Paris, France

    Franck Loiseaux

  7. Department of Otorhinolaryngology, Saint-Louis Hospital, APHP, Université Paris 7 Diderot, Paris, France

    Marie-Dominique Brette

  8. Medical ICU, AP-HP, Saint-Louis Hospital, APHP, Université Paris-Diderot, Sorbonne Paris-Cité, Faculté de Médecine, Paris, France

    Elie Azoulay

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  1. Mircea Chirica
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  2. Matthieu Resche-Rigon
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Correspondence to Mircea Chirica.

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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

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