Foregut caustic injuries: results of the world society of emergency surgery consensus conference
Bonavina et al. World Journal of Emergency Surgery
Foregut caustic injuries: results of the world society of emergency surgery consensus conference
Luigi Bonavina 0
Mircea Chirica 8
Ognjan Skrobic 7
Yoram Kluger 13
Nelson A. Andreollo 12
Sandro Contini 11
Aleksander Simic 7
Luca Ansaloni 10
Fausto Catena 15
Gustavo P. Fraga 12
Carlo Locatelli 14
Osvaldo Chiara 9
Jeffry Kashuk 5
Federico Coccolini 10
Yuri Macchitella 0
Massimiliano Mutignani 6
Cesare Cutrone 3
Marco Dei Poli 4
Tino Valetti 1
Emanuele Asti 0
Michael Kelly 2
Predrag Pesko 7
0 Department of Surgery, IRCCS Policlinico San Donato, University of Milan Medical School , Piazza Malan 1, 20097 San Donato Milanese (Milano) , Italy
1 Department of Anesthesiology, Papa Giovanni XXIII Hospital , Bergamo , Italy
2 Department of Surgery, Wagga Wagga Hospital , Wagga Wagga , Australia
3 Department of Otolaryngology, Azienda Ospedaliera , Padova , Italy
4 Intensive Care Unit, IRCCS Policlinico San Donato , San Donato Milanese , Italy
5 Department of Surgery, University of Jerusalem , Jerusalem, Rehovot , Israel
6 Department of Endoscopy, Niguarda Hospital , Milan , Italy
7 Department of Surgery, University of Belgrade , Belgrade , Serbia
8 Department of Digestive Surgery, Saint-Louis Hospital , Paris , France
9 Emergency Department, Niguarda Hospital , Milan , Italy
10 General Surgery I, Papa Giovanni XXIII Hospital , Bergamo , Italy
11 University of Parma , Parma , Italy
12 Department of Surgery, University of Campinas , Campinas , Brasil
13 Department of General Surgery, Rambam Health Care Campus , Haifa , Israel
14 Institute of Toxicology, University of Pavia , Pavia , Italy
15 Emergency Surgery Department, Maggiore Parma Hospital , Parma , Italy
Introduction: Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available. Purpose of the study: The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition. Methods: An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015). Results: One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council. Conclusions: The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.
A wide variety of chemical agents including mineral and
organic acids and alkalis, oxidizing agents, denaturants,
hydrocarbons and other chemicals may cause corrosive
injuries. Although the mechanism, the severity, and the
timing of the injury may vary, all these substances cause
damage to living tissue on contact. Accidental or
intentional ingestion of corrosive substances cause
lifethreatening injuries of the upper digestive tract. The
degree of injury is related to the concentration, amount,
viscosity, and duration of exposure to the caustic agent.
The large majority of caustic agents are liquids. Strong
acids and alkali are readily available as household
cleaners. Lye is a generic term for the alkali used to
make soap, either potassium hydroxide or sodium
hydroxide. Acids cause coagulation necrosis, whereas alkali
combine with tissue proteins and cause liquefaction necrosis
which penetrates deep into tissues. Concentrated alkali
ingestion may lead to more serious injury and
complications by penetrating tissues and leading to full-thickness
damage of the esophageal/gastric wall. Liquid
household bleach, although often reported, does rarely
cause severe injuries. Children under the age of
5 years account for more than 80 % of accidental
caustic ingestion, whereas adult injuries are more
often intentional and suicidal [1–3].
Foregut caustic ingestion is certainly an under-reported
public health issue. Primary prevention of these dramatic
injuries was initiated in the United States by Chevalier
Jackson who began a campaign that led to the Federal
Caustic Act (1927) which mandated proper labeling of
these harmful compounds. Subsequent acts have enforced
proper labeling, antidote instructions, concentration
restrictions, and child-resistant packaging. The effects of
these changes have decreased but not eliminated the
incidence and severity of caustic ingestions in the United
States . Nowadays, most information on foregut caustic
injuries comes from countries where legislation is less
restrictive or even absent, such as Africa, Turkey, India,
Eastern Europe, Southeast Asia, and France .
Caustic ingestion can result in a number of injuries
ranging in severity from mild oral burns to minimal
mucosal erythema or transmural necrosis of the esophagus
and stomach with visceral perforation. Emergency
surgery is indicated for hemorrhage, free perforation,
mediastinitis or peritonitis. Full thickness esophagogastric
necrosis is a severe form of injury associated with
considerable morbidity and mortality. It may occur due to
ingestion of a large amount or highly concentrated
corrosive substance. The injury may extend and involve
adjacent viscera such as the duodenum, small intestine,
colon, pancreas, and gallbladder. Complications such as
hemorrhage, perforation, aorto-enteric fistula, or
gastrocolic fistula may occur in patients surviving the initial
event during the first 2–3 weeks after ingestion. Patients
who have survived severe caustic injury of the foregut
are at high risk of luminal strictures. After recovery from
the initial injury, collagen deposition and fibrosis
continue for months and scar retraction results in esophageal
shortening and stricture. The incidence of esophageal
stricture following grade IIB and grade III esophageal
burns is in the range of 50–80 % [6, 7]. Concomitant
gastric outlet obstruction occurs in up to 30 % of patients
with esophageal stricture [8, 9]. In the long term,
development of pharyngeal, esophageal, or gastric strictures may
compromise nutritional outcome. Interestingly, the risk of
squamous-cell cancer of the damaged esophagus is
estimated to be 1000 times higher than that of the general
population, and the latent period for the malignant change
is 15–40 years [10, 11].
Currently, in most referral centers therapeutic
algorithms for the management of patients with caustic
injuries rely on the findings of upper digestive endoscopy.
Despite the use of different endoscopic classification
systems, therapeutic approaches are similar and include
conservative management of patients with mild
injuries, while patients with severe injuries undergo
emergency surgical exploration. Although there are studies
describing the short and long-term outcomes of
reconstruction for established caustic strictures of the
esophagus, there is limited literature on the early and
long term outcomes of patients managed in an
emergency setting for corrosive induced acute
esophagogastric and/or adjacent organ necrosis.
Two independent MEDLINE and EMBASE searches
were performed to identify relevant papers published
between 1990 and 2015. The following medical subject
headings terms were used in the searches: caustic
ingestion, caustic lesions, corrosive injuries, esophagus,
stomach, esophageal dilatation, gastric outlet obstruction.
The search terms were identified in the title, abstract, or
medical subject heading. Initially, 2143 abstracts of the
retrieved studies were reviewed and screened for
exclusion criteria. At the end of the search, 1113 abstracts
that fulfilled the inclusion criteria were selected. Finally,
147 full papers which addressed the relevant clinical
questions of the research were admitted to the
consensus conference. The level of evidence for each
recommendation statement was assigned by using the grading
system proposed by the Oxford Centre for
EvidenceBased Medicine . A preliminary manuscript was
prepared by an international panel of 12 experts including
anesthesiologists, endoscopists, surgeons, and
toxicologists. The key recommendations and algorithms were
discussed at a dedicated meeting held in Milan in April
2015, and at the 3rd Congress of the World Society of
Emergency Surgery held in Jerusalem in July 2015.
Finally, evidence based guidelines for the management of
foregut caustic injuries were developed to outline clinical
Initial therapeutic approach [13–57]
Establish the diagnosis of caustic agent ingestion.
Identify the involved agent. Collect the product on
the scene and bring it to the emergency department.
If difficult product identification try to evaluate pH
(<2; > 10), but be aware that some agents cause a
pH-independent corrosive injury. (Level 4–5)
Evaluate the ingestion scenario by: a) ascertain
ingestion; b) determine the accidental or voluntary
character; c) detect co-ingestion of alcohol and/
or drugs; d) try to evaluate ingested quantity
(in adults assess normal sip (30–50 ml) vs. large
gulp (60–90 ml); e) assess delay from ingestion.
Identification of additional risk factors such as
extreme ages (young children, elderly), pregnancy,
underlying disease, and the form of the ingested
agent (solid, liquid, gel, vapors-concomitant
aspiration). (Level 5)
Supportive care rather than specific antidotes is the
mainstay of treatment. Secure airway patency and
hemodynamic stabilization. Prevent vomiting, repeat
esophageal passage, and aspiration by: a) use of
antiemetics (metoclopramide); b) seated 45° position
during transport; c) avoid gastric lavage and induced
emesis; d) avoid diluents (milk, water). (Level 5)
Avoid increasing damage by exothermic reaction:
attempts at pH neutralization with either a weak
alkali or acid are prohibited. (Level 5)
Emergency department management
Continue symptomatic treatment including adequate
pain relief while waiting to evaluate the severity of
caustic injuries. If airway support is required favor
fiberoptic laryngoscopy over blind intubation;
perform tracheotomy if necessary. (Level 5)
Laboratory tests should include WBC, hemoglobin,
platelet count, CRP, pH, and serum levels of Na, K,
Cl, Ca, Mg, urea, creatinin, LDH, CPK, AST, ALT,
lactates, alcohol. β-HCG levels should be measured
in young women. (Level 5)
Contact Poison Control Centers to evaluate
systemic toxicity of the ingested agents. (Level 4–5)
Avoid nasogastric tube positioning as their validity
to prevent vomiting and stricture formation has
never been proven; nasogastric tubes have been
reported to increase risks of gastric perforation,
gastroesophageal reflux, and pneumonia. (Level 5)
The efficacy of proton-pump inhibitors and H2
blockers in minimizing esophageal injury by
suppressing acid reflux has not been proven.
The utility of corticosteroid in terms of stricture
prevention is controversial and systematic
administration is not recommended. Steroids
should be reserved for patients with symptoms
involving the airway. (Level 3)
Administration of broad-spectrum antibiotics should
not be done on a systematic basis. Antibiotics are
advised in grade 3 injuries if corticosteroids are
initiated or if lung involvement is identified.
Patients with clinical signs of peritonitis and
hemodynamic instability require immediate surgical
exploration. Although symptoms such as chest pain,
dysphagia, odynophagia, drooling, hemorrhage are
usually associated with severe injuries after
voluntary ingestion, the absence of oropharyngeal
damage does not exclude the possibility of severe
esophagogastric injuries. (Level 4)
Results of laboratory tests such as WBC, platelet
count, CRP, pH, AST, ALT, creatinin, and lactate can
help decision making in difficult situations. (Level 5)
Endoscopy is the cornerstone of management of
caustic injuries. Endoscopy is usually performed 3 to
6 h after ingestion, and injuries are graded according
to the Zargar classification. Patients with severe
(grade 3b) esophagogastric injuries are considered
for surgery while patients with low grade injuries
(≤ grade 3a) are offered non-operative treatment.
Endoscopy grading can also predict the risk to
develop an esophageal stricture during follow-up.
Inability of endoscopy to predict accurately the
depth of intramural necrosis may result in either
futile surgery, with negative effects on survival,
digestive function and management costs, or in
patient death due to inappropriate non operative
treatment. Moreover, emergency endoscopy is futile
in up to 30 % of patients who do not have injuries
of the upper digestive tract following ingestion of
bleach or corrosive agents other than strong acids
or alkali. (Level 4)
Computed tomography helps palliate shortcomings
of endoscopy based algorithms. The use of CT is
helpful in guiding indications for esophagectomy in
patients with grade 3b caustic injury (Fig. 1). In a
recent study CT did better than endoscopy in
selecting patients for surgery or non-operative
Fig. 1 Management algorithm for caustic ingestion based on computed tomography and endoscopic findings
treatment, suggesting that CT can replace endoscopy
in the management of caustic injuries. CT criteria of
transmural esophageal necrosis include
esophagealwall blurring and periesophageal-fat blurring on
unenhanced images, and absence of post-contrast
esophageal-wall enhancement; transmural necrosis
of the stomach was defined as the absence of
postcontrast gastric-wall enhancement. (Level 3)
Emergency surgery for caustic injuries
Emergency surgery is eventually required in a small
number of patients with transmural necrosis to
avoid involvement of adjacent organs and death.
Laparotomy is usually performed but laparoscopic
exploration has been reported as feasible and safe.
Transhiatal esophagectomy and total gastrectomy
are the most frequently employed surgical
procedures in the acute setting. Meanwhile,
esophagectomy with gastric preservation and total
gastrectomy with esophagojejunostomy can be
performed if transmural necrosis is limited to the
esophagus or the stomach, respectively. (Level 4)
Feeding jejunostomy should be systematically
constructed at the end of the operation, regardless of
the type of surgical procedure performed. (Level 4)
Extended surgery (beyond esophagogastrectomy)
should be attempted in case of existing injuries on
other abdominal organs. All injured organs should
be resected during the first operation as caustic
lesions invariably progress. Mortality rates are high,
but surgery may be only choice for these patients.
If the patient’s conditions allow, immediate biliary
and pancreatic reconstruction should be attempted
after pancreatoduodenectomy for caustic necrosis.
Transmural esophageal necrosis may lead to
subsequent tracheobronchial extension in a small
number (<10 %) of patients. Preoperative
bronchoscopy should be performed in all patients
considered for surgery. In the presence of
tracheobronchial necrosis, esophagectomy should be
performed by a right thoracic approach.
Tracheobronchial necrosis can be successfully
treated with pulmonary patch technique. (Level 4)
Massive intestinal necrosis should be a reason for
the surgeon to stop due to inability of later
reconstruction and nutrition. (Level 5)
Mortality rates are high, but surgery may be only
choice for these patients. Factors which have a
negative impact on outcome include advanced age,
tracheobronchial injuries, emergency esophagectomy,
need for extended resections and severe modifications
of laboratory tests (pH < 7.2, AST > 2 N, renal failure,
etc.). (Level 4)
The need to perform emergency surgery for
caustic injuries has a persistent long-term negative
impact both on survival and functional outcome.
Moreover, esophageal resection is an independent
negative predictor of survival after emergency
surgery. (Level 4)
Caustic ingestion can induce SIRS or sepsis with a
severe hypermetabolic and catabolic response.
Negative nitrogen balance and weight loss are
related to injury severity. (Level 3–4)
Use as soon as possible the gastrointestinal tract for
nutrition. Patients with low grade injuries should
resume oral alimentation as soon as they are able to
swallow. In patients with severe burns, enteral
feeding through jejunostomy or nasojejunal tube is
recommended rather than a gastrostomy due to the
possibility of a hidden gastric outlet obstruction
Endoscopic treatment of esophageal stricture [58–98]
Esophageal caustic strictures are frequently complex,
i.e. long (>2 cm), angulated, irregular, and multiple.
In addition, the “remodeling time”, i.e. the time to
stricture stabilization ranges between 6 months to
3 years. As a consequence, the reported success rate
of dilatation is lower than for other benign
esophageal strictures. The optimum time for
dilatation is after healing of the acute injury, usually
in the 3rd week. Late management is usually
associated with marked esophageal wall fibrosis and
collagen deposition, which requires more
endoscopic sessions for adequate dilatation. This
is a crucial issue in developing countries, where
late presentations are more than 50 %.
Dilatation can be carried out with balloon dilators
or Savary bougies. A prospective randomized
study has shown no clear advantage of each
method in peptic esophageal strictures. Savary
dilators are considered more reliable and effective
than balloon dilators in consolidated strictures.
Moreover, Savary bougies offer the advantage of
“feeling” the resistance to dilatation under the
operator’s hands. (Level 4)
“Rules of the thumb”: 1)To begin with dilators that
are one or two French sizes smaller than the
estimated diameter of the stricture, 2)Not to dilate
more than two to three sizes larger than the size of
the first dilator meeting resistance. (Level 4)
The perforation rate after dilatation for caustic
strictures ranges from 0.4 to 32 %, higher than for
other benign strictures. Fluoroscopy during
dilatation may help in difficult cases. Although
comparative trials are not available, selective use of
fluoroscopy is supported by extensive clinical
experience. (Level 4)
The interval between dilatations varies from less
than 1 week to 2–3 weeks. Although three or four
sessions may provide durable results, the number
of dilatation required is unpredictable and the
endoscopic treatment may continue for years. A
cut-off value for stopping dilatations is not clear
and is influenced by patient, physician and geographic
factors. In adult studies, the maximal esophageal wall
thickness at CT scan and the involvement of
muscolaris propria at endoscopic ultrasound were
found to be significant predictors of stricture
development, more difficult dilatations, and recurrent
stricture. Gastroesophageal reflux and alterations in
esophageal motility due to esophageal wall fibrosis
can contribute to persistent dysphagia, in spite of
apparently successful dilatations. (Level 4)
A sustained esophageal lumen patency is not the
only therapeutic goal: especially in children, an
associated improvement in nutritional status should
be considered an important end-point. (Level 3–4)
Gastrostomy feeding may be life-saving, especially in
developing countries. Moreover, gastrostomy allows
a retrograde approach for dilatation. In challenging
strictures, a nylon thread left between the nose
and the gastrostomy maintains luminal access and
facilitates further dilatations. (Level 3–4)
Use of intralesional steroids and Mitomycin C
applied endoscopically have been evaluated in
several studies. Apparently, intralesional steroids
favour a longer symptom-free time interval between
dilatations but seem less effective in caustic strictures.
Overall, there is no convincing evidence of the efficacy
of these procedures. (Level 5)
There is no convincing evidence that intraluminal
stenting as an alternative to repeat dilatations is
beneficial. Early stenting has been proposed to
prevent stricture in uncontrolled studies. The
number of dilatations and the duration of treatment
were reduced. Notably, 50 % of children in whom a
home-made stent was placed after the first dilatation,
did not require further treatment. (Level 5)
Long-term outcomes of stent placement for
refractory benign esophageal strictures are poor.
Partially covered SEMS are almost abandoned,
in spite of their superior anchoring capacity,
because of the associated hyperplastic ingrowth
or overgrowth, with consequent difficult removal
and recurrent dysphagia. Fully covered Self
Expanding Polyflex Stents (SEPS) and Self
Expanding Metallic Stents (SEMS) show a
reduced reactive hyperplasia at a price of a
higher migration rate. Biodegradable (BD) stents
begin to degrade after 4–5 weeks and to dissolve
within 2–3 months. Although the migration rate
is reduced owing to the uncovered design, BD
stents are only temporarily effective and
sequential stenting has been suggested to avoid
serial dilations. Moreover, hyperplastic tissue
reactions have emerged as a significant problem.
A recent systematic review of patients with a
benign esophageal stricture (25 % caustic)
treated by SEPS showed that only 52 % of the
patients were dysphagia-free after a median
follow-up of 13 months. A recent publication
evaluated the results of stenting in benign strictures
from twelve prospective studies. The stent was
successfully placed in 98.7 %, but the overall clinical
success rate was 24.2 %. (Level 4)
Management of gastric outlet obstruction [99–118]
Grade three injury to the stomach is an
independent risk factor for gastric outlet
obstruction that can occur from a few days up to
6 years after caustic ingestion. Distal obstructions
account for 60–100 % of the lesions and are
located in the prepyloric area. Endoscopic balloon
dilatation is safe and successful in the management of
a subgroup of patients with gastric outlet obstruction.
Progressive endoscopic dilatation can safely be
initiated even at 2 weeks from ingestion,
especially in short strictures (<25 mm).
There is no clear evidence supporting the use
of stents in the management of gastric outlet
obstruction. (Level 5)
Early surgery seems to decrease morbidity and
mortality, but elective surgery earlier than 3 months
is considered risky because of the poor nutritional
status, adhesions, edematous gastric wall, difficult
assessment of the extent of gastric resection due to
ongoing fibrosis. (Level 5)
Pyloroplasty may be performed in patients with
moderate/localized strictures, but the risk of
recurrent stricture is high. (Level 5)
Gastrojejunostomy is indicated in the presence of
extensive perigastric adhesions, unhealthy
duodenum, and poor general condition; marginal
ulcerations are reported. In selected patients the
operation can safely be performed through a
laparoscopic approach. (Level 5)
The indication for gastric resection as prophylaxis
against malignancy has been probably overstated
in the literature. Partial gastric resection seems
preferred by most surgeons. The type of surgery
should be chosen according to local and general
conditions. (Level 5)
Esophageal reconstruction [119-156]
When esophageal dilatation is not possible or fails
to provide an adequate esophageal caliber in the
long-term, esophageal replacement by retrosternal
stomach or, preferably, colonic interposition should
be considered. (Level 3–4)
A laryngoscopic examination is mandatory prior to
all esophageal reconstructions for caustic injuries.
The surgical bypass should be performed at least
6 months after caustic ingestion or emergency
surgery since the “remodeling time”, i.e. time to
stricture stabilization, is rather long. (Level 3–4)
Removal of the native esophagus in adult patients
is largely debated. It seems advisable in children
because of the higher risk of cancer in the long-term.
No randomized studies address the issue of which
type of esophagoplasty is preferable. There are
pros and cons for either right or left colon. An
expert surgeon should do what he/she is used to
do. (Level 5)
One-stage esophageal resection and replacement
with a gastric conduit, instead of a bypass, is feasible
and safe in patients with isolated distal esophageal
strictures. (Level 5)
Minimally invasive/hybrid surgical techniques have
been used with favourable results in selected
patients. (Level 5)
Angiographic study of the vascular pedicle is not
routinely recommended before colon interposition
or bypass, with the exception of patients with
previously failed surgical attempts. (Level 5)
Surgical revision is effective in patients who present
with redundancy of the interposed colon years after
retrosternal or mediastinal reconstruction. (Level 4)
Pharyngeal strictures are difficult to manage and
require special expertise. Endoscopic laser therapy of
pharyngo-laryngeal adhesions may prove useful in
selected patients before definitive surgical treatment.
Colopharyngoplasty for strictures involving the
pharynx is a safe and effective procedure. In such
circumstances, the restoration of upper digestive
tract continuity requires concomitant esophageal
and pharyngeal reconstruction with resection of
all scar tissue. Treatment of pharyngeal and
laryngeal injuries should be done at the same
surgical session. Supraglottic laryngectomy and
suprahyoid pharyngectomy are required if the
epiglottis and/or the base of the tongue are
involved (Level 4–5)
Temporary tracheostomy is mandatory during
the rehabilitation training period after
colopharyngoplasty. The postoperative re-education
process is long and difficult and requires full
cooperation from a psychiatric stable patient. (Level 5)
Advanced age has a negative impact on esophageal
reconstruction. Patients older than 55 years are
likely to experience severe complications, worse
functional outcomes, and decreased long-term
survival. For these reasons colopharyngoplasty
should not be offered after this age limit. (Level 4)
Use of myocutaneous flaps and free jejunal grafts
should be considered for salvage cervical esophageal
reconstruction and restoration of alimentary transit
after previously failed surgical attempts. (Level 4)
The recommendations of these clinical practice guidelines
are based on an extensive review of the literature and
expert advice. Published data lack homogeneous classification
systems and prospective methodology, the majority of
papers being retrospective case reports, case series, or
literature reviews. Moreover, the non-standardized definition of
technical and clinical success precludes any accurate
comparison of therapeutic modalities. There has been only one
negative controlled trial assessing the effect of steroids to
prevent esophageal stricture after caustic ingestion in
children . For all the above reasons, the
extrapolated recommendations are mainly based on expert
opinions, retrospective studies, and literature reviews
with a low level of evidence.
Despite all these limitations, the value of this
consensus conferences was to gather a panel of recognized
experts and over 200 physicians attending the two meetings.
Among the debated issues, an unanimous consensus has
emerged on the fact that use of CT scan in the initial
patient staging may indeed represent a true change of
paradigm. The new diagnostic algorithm may allow to
avoid endoscopy in selected patients, to increase the rate
of esophageal preservation, and it could translate into a
better long-term patients outcome and quality of life.
Interestingly, a previous WSES survey has found that
80 % of the responders to a questionnaire treat fewer than
ten cases of caustic ingestion per year , indicating the
utility to apply and share clinical practice guidelines to
improve patients’ care.
Caustic ingestion continues to be a complex clinical
problem and a burden for the healthcare systems
worldwide. Emergency surgery and subsequent alimentary
tract reconstruction are a formidable challenge in these
patients. On the light of the consensus that has emerged
among experts in Milan and Jerusalem, the World Society
of Emergency Surgery will be running a World Registry of
foregut caustic injuries (www.clinicalregisters.org). This
could be the first step toward a more standardized
data collection and the implementation of prospective
LB MC and OS designed the guidelines. LB and MC wrote the manuscript.
All authors reviewed and approved the final manuscript
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