Emergency operations for caustic injuries to the upper GI tract

Clinical signs of perforation (eg, mediastinitis, peritonitis) and CT evidence of transmural necrosis of the esophagus or stomach are indications for emergency surgery. Esophagogastrectomy through a combined abdominal cervical approach is most commonly performed for severe caustic upper gastrointestinal injury. After surgery, patients are left with a cervical esophagostomy (spit fistula), a defunctionalized duodenum, and a feeding jejunostomy (A). In 20 percent of patients undergoing esophagogastrectomy for causative ingestion, concomitant necrosis requires excision of additional abdominal organs such as the spleen, colon, small bowel, duodenum, or pancreas (B, in which esophagogastrectomy is performed in conjunction with a pancreaticoduodenectomy). If necrosis is limited to the stomach, a total gastrectomy can be performed with preservation of the native esophagus. Although immediate esophagojejunostomy reconstruction may be safe at high-volume centers (C), esophageal exclusion followed by a delayed anastomosis is generally preferred (not pictured). Neither partial gastrectomy nor esophagectomy with preservation of the stomach based on isolated esophageal necrosis is commonly performed for caustic injury.