EARLY AGGRESSIVE RESECTION FORCORROSIVE STRICTURES OF STOMACH : Early Results of Ten Cases
SADANAND V SHETTY, YATINDRA S KASHID,GANESH K BAKSHI, KS KUMAR
Department of General Surgery, Dr. RN Cooper Hospital and Seth GS Medical College, Mumbai.
Background : Gastric stricture following ingestion of corrosive substance like hydrochloric acid is scarcely reported.
Objective : Early aggressive surgical approach for patients with corrosive gastric strictures.
Method : Patients presented with gastric outlet obstruction following ingestion of hydrochloric acid were studied. The diagnosis was established by barium meal and upper GI endoscopy.
Results : Of these ten patients (age range 17-30 years), two were males and eight were females. They presented with complete gastric outlet obstruction 4-6 weeks after acid ingestion. Only two patients had minimal oesophageal involvement. All patients were operated at the time of presentation within six weeks. Two patients were treated by antrectomy, two by distal partial gastrectomy and Billroth-I anastomosis. Roux-en-Y anastomosis without resection was done in four patients. Gastrojejunostomy and gastroplasty was performed in one patient each. Recovery was uneventful in 15 days. All patients tolerated normal meal though with smaller quantity.
Conclusions : In our study, all patients had distal gastric stricture. Only two patients had minimal oesophageal involvement. All patients were operated within six weeks of acid ingestion safely with satisfactory results. Early definitive surgery saves time of hospitalisation. It obviates the need for feeding jejunostomy or prolonged parenteral nutrition. Since, every exploration leads to adhesions, re-explorations become more and more difficult. Hence, we recommend early definitive surgery whenever feasible.
Gastric stricture following ingestion of hydrochloric acid is scarcely reported. It may present acutely as perforation or necrosis of the stomach or it may present as gastric outlet obstruction due to stricture of distal stomach. The timing and type of surgery are still not clear. We present our experience of ten cases presented to us with features of gastric outlet obstruction.
Our experience of ten cases of corrosive stricture of stomach following ingestion of hydrochloric acid treated with early surgery is presented here. Out of these, eight patients had accidental ingestion while two had suicidal intention. Male : Female ratio was 1 : 4. Age group affected was between 17-30 years. The corrosive substance involved was toilet cleaning soap i.e. hydrochloric acid in majority of the patients. All patients presented at about 4-6 weeks after acid ingestion, with repeated episodes of vomiting, weakness and anaemia suggestive of complete gastric outlet obstruction. Details of initial treatment were not available.
At presentation, patients were evaluated by upper GI endoscopy and Barium meal studies. Endoscopy revealed extensive necrosis with fibrosis and contracture with total occlusion of distal end of the stomach in all the patients (Type-3b injury as shown in Table 1). Mild oesophageal changes were seen in two patients. Preoperative barium studies done in six patients showed complete occlusion of distal end of stomach (Fig. 1). All patients were operated during the same admission after improving nutritional status by total parenteral nutrition for 8-10 days.
Fig.1 Berium meal showing complete distal gastric stricture after ingestion of toilet cleaning soap.
Modified endoscopic classification of acid burns 
Grade 0 : Normal examination. Grade 1 : Oedema and hyperaemia of the mucosa. Grade 2a : Friability, haemorrhages, erosions, blisters, exudate whitish membranes, superficial ulcerations. Grade 2b : Deep discrete or circumferential ulceration. Grade 3a : Small scattered areas of necrosis*. Grade 3b : Extensive necrosis*. *areas of brown black or grayish discoloration are taken as evidence of necrosis.`
Treatment involved antrectomy in two patients, distal partial gastrectomy and Billroth I anastomosis in two patients. Roux-en-Y anastomosis without gastric resection was done in four patients as stricture had contracted leading to a small stomach. Gastroplasty for hour glass deformity and gastrojejunostomy was performed in one patient each (Table 2). The patients with mild oesophageal involvement did not require any further treatment. No patient required total gastrectomy as total involvement was not seen.
Surgical treatment of gastric stricture following
toilet cleaning soap
Type of operation
No. of patients - Antrectomy with Billroth I anastomosis 2 - Partial gastrectomy with Billroth I anastomosis 2 - Roux-en-Y anastomosis without resection 4 - Gastrojejunostomy 1 - Gastroplasty 1
The proximal assessment of corrosive injury and selection of type of surgery was done with the help of endoscopic and intraoperative findings. The criteria included - The extent of fibrosis and scarring of the stomach, on endoscopy. At surgery, the amount of contracted, firm, indurated stomach externally was noted along with perigastric adhesions. On opening the stomach careful inspection of interior - mucosa, submucosa and thickness of stomach wall was done. The extent of resection was proximal to the visible involvement of all the layers of the stomach. The resection on lesser curvature was more in cases with extensive involvement of the lesser curve. Clear cut demarcation was seen at pylorus, there was no duodenal or small intestinal involvement. The Roux-en-Y anastomosis without gastric resection was performed when there was extensive involvement of the stomach leading to a small stomach, only fundus was spared with perigastric adhesions. Total gastrectomy was avoided as the patients were young and due to morbidity of the procedure, also because of availability of normal fundic pouch. The anastomosis was performed with a long Roux- en-Y loop. A high anastomosis was performed.
Subtotal gastrectomy was not performed because it was technically difficult due to high involvement of lesser curve almost upto the cardia. Also anastomosis at diseased and devitalised area of stomach would have produced anastomotic leak with subsequent morbidity and mortality.
All patients recovered well after surgery. There was no mortality. All patients were started on orals on 4th to 5th day and discharged 8 to 10 days after surgery. They tolerated normal meal though the quantity was small. They had gradual weight gain. No patient had vomiting or reflux symptoms after surgery. One out of two patients with oesophageal involvement required oesophageal dilatation once postoperatively, however he had no symptoms. Other patient did not require any intervention postoperatively.
Five out of ten patients followed upto three months. One patient with Roux-en-Y anastomosis followed for 3 years. He had no symptoms but required multiple small meals. Barium studies postoperatively showed good results in five patients (Fig. 2). No patient followed for endoscopic evaluation at a later date.
Though the early results of our aggressive surgical approach are encouraging, we do not have a long term follow-up in these patients. The long term follow-up is mandatory as the stricture is thought to be a pre-malignant condition.
Fig.2 Barium study after antrectomy and Billroth I anastomosis, showing passage of barioum in the duodenum.
Ingestion of corrosive acids is well known to cause injury to upper gastrointestinal tract. Depending upon the extent and degree of burns, it may lead to fibrotic changes culminating in complete gastric outlet obstruction. It has been the belief that acids cause maximum damage to stomach and minor damage to the oesophagus owing to their rapid transit and tough squamous mucosa of oesophagus. Four factors determining the extent of damage after acid ingestion are the amount and concentration of acid, contact time with gastric mucosa, the amount of food in stomach.
With the availability of small sized fibreoptic endoscopes, immediate endoscopy is practicable, simple and safe. The site, extent and severity of mucosal damage can be accurately assessed by endoscopy. Modified endoscopic classification is suggested  (Table 1). Contrast studies are not of great help in assessing the degree of injury in the acute phase. It is however of great value in the evaluation of sequelae.
Timing of surgery is controversial. Immediate fibreoptic endoscopy within 12 hours, followed by exploratory laparotomy and oesophagogastric resection is recommended. A "second look" procedure within 36 hours is also suggested, where viability of the stomach or oesophagus is in doubt.4 But fibrosis induced by corrosive ingestion continues in most cases for about three months. Therefore, elective surgery performed earlier than this period is fraught with risk due to poor nutritional state of patient and difficult dissection due to adhesions and oedematous gastric wall. Moreover assessment of the limits of gastric resection may be erroneous as fibrosis may be ongoing. A feeding jejunostomy is recommended preoperatively in patients in whom oral intake is inadequate or impossible. This also allows definitive surgery to be safely postponed until the oesophageal and perioesophageal reaction is settled. A stepwise algorithm is suggested. Favoured surgical procedure is resection of cicatrated segment as the condition is thought to be premalignant. However, in presence of extensive perigastric adhesions, unhealthy duodenum and poor general condition gastrojejunostomy is a safer alternative. Diffuse gastric involvement may require total gastrectomy with Roux-en-Y anastomosis.
In our study, all patients had distal gastric stricture. Only two had minimal oesophageal involvement. All patients were treated surgically when they presented with complete gastric outlet obstruction within six weeks of acid ingestion, safely. These patients were treated wherever possible by surgical resection of the stricture segment of stomach. The early results were satisfactory as patients tolerated normal meals though with smaller quantity. There was no mortality in our study.
Early definitive surgery saves time of hospitalisation. It obviates the need for feeding jejunostomy. If the surgery is delayed, the patient requires prolonged parenteral or tube enteral feeding to maintain nutrition. Also, every exploration leads to adhesions, re-explorations become more and more difficult. Hence we recommend early definitive surgery whenever feasible. However, we do not have long term follow-up of these patients, which is mandatory.
Ingestion of hydrochloric acid affected distal stomach causing stricture with minimal oesophageal involvement. Treatment of choice is resection of the strictured part of the stomach whenever possible. Early definitive surgery can be performed within six weeks, safely with no complications or mortality.
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