Emergency computed tomography evaluation of caustic ingestion.

Computed tomography (CT) is used increasingly for the emergency assessment of caustic injuries and the need for emergency endoscopy has been challenged. The study evaluates outcomes of caustic ingestion in the modern era and the feasibility of abandoning emergency endoscopy. Between 2013 and 2019, 414 patients (197 men, median age 42 years) were admitted for caustic ingestion. Emergency and long-term outcomes of patients managed by CT and endoscopy (n = 120) and by CT alone (n = 294) were compared. Propensity score-based analysis was performed to limit bias of between-group comparison. A standard mortality ratio (SMR) was used to compare the observed mortality with the expected mortality in the general French population. Complications occurred in 97 (23%) patients and 17 (4.1%) patients died within 90 days of ingestion. Among 359 patients who underwent nonoperative management, 51 (14%) experienced complications and 7 (2%) died. Of 55 patients who underwent emergency surgery, 46 (84%) experienced complications and 10 (18%) died. The SMR was 8.4 for whole cohort, 5.5 after nonoperative management, and 19.3 after emergency surgery. On multivariate analysis, intentional ingestion (P < 0.016), age (P < 0.0001) and the CT grade of esophageal injuries (P < 0.0001) were independent predictors of survival. The CT grade of esophageal injuries was the only independent predictor of success (P < 0.0001). Crude and propensity match analysis showed similar survival in patients managed with and without endoscopy. CT evaluation alone can be safely used for the emergency management of caustic ingestion.

Quality of Life After Caustic Ingestion.

OBJECTIVE: The aim of the study was to evaluate long-term QOL after caustic ingestion. BACKGROUND: Caustic ingestion strongly affects patient's QOL but data on the topic is scarce in the literature. METHODS: QOL evaluation was conducted in survivors from a large cohort of patients with caustic injuries. QOL was assessed using the EORTC QLQ-OG25 module, the SF12v2 score, and the hospital anxiety and depression scale questionnaire. One hundred thirty-four patients (59 men, median age 43) completed the survey; 72 (54%) patients underwent emergency digestive resection and in 99 (74%) patients underwent esophageal reconstruction. Results of QOL questionnaires were compared to average values determined in healthy volunteers and in patients with esophageal cancers. RESULTS: The median QLQ-OG25 score was 44 (34, 62) and values were significantly lower when compared to a normal population (P < 0.0001). SF12v2 scores were significantly inferior to those expected in a normal population on both the physical component summary (PCS) (43.3 ±â€Š10.8; P < 0.0001) and the mental component summary (44 ±â€Š9.7; P < 0.0001) scales. Emergency esophageal resection was significantly associated with higher QLQ-OG25 scores (P < 0.0001), but not with mental component summary (P = 0.3), PCS (P = 0.76), HAD anxiety (P = 0.95), and HAD depression scores (P = 0.59); results were similar after extended emergency resection. When compared to esophagocoloplasty alone, pharyngeal reconstruction had a significant negative impact on QLQ-OG25 (P < 0.0001), PCS (P = 0.01), and HAD depression (P = 0.0008) scores. CONCLUSIONS: QOL is significantly impaired after caustic ingestion. QOL issues should not influence the emergency surgical strategy but deserve discussion before esophageal reconstruction for caustic injuries.

Emergency Computed Tomography Predicts Caustic Esophageal Stricture Formation.

BACKGROUND: Endoscopy is the best predictor of stricture formation after caustic ingestion. OBJECTIVE: Our aim was to compare the accuracy of emergency computed tomography (CT) and endoscopy in predicting risks of esophageal stricture. METHODS: We describe a CT classification of esophageal caustic injuries: Grade I show normal esophagus; Grade IIa display internal enhancement of the esophageal mucosa and enhancement of the outer wall conferring a "target" aspect; Grade IIb present as a fine rim of external esophageal wall enhancement. In 152 patients (56 males, median age 45) who underwent esophageal preservation after caustic ingestion we compared the accuracy of the CT and endoscopic (Zargar) classifications in predicting esophageal stricture. RESULTS: On endoscopy esophageal injuries were classified as grade 1 (n = 50; 33%), grade 2a (n = 11; 7%), grade 2b (n = 19; 13%), grade 3a (n = 14; 9%), and grade 3b (n = 58; 38%). On CT, 47 (31%) patients had grade I, 47 (31%) had grade IIa and 58 (38%) had grade IIb esophageal injuries. Fifty-six (37%) patients developed esophageal strictures. The risk of esophageal stricture formation was 0%, 17%, and 83%, for grade I, IIa, and IIb CT injuries and 0, 0, 28, 50, and 76% for endoscopic grade 1, 2a, 2b, and 3a and 3b injuries, respectively. ROC curve analysis at 120 days after ingestion showed that CT outperformed endoscopy in predicting stricture formation (AUC: 85.1 [95% CI, 74.9-95.3] vs 77.8 [95% CI, 66.5-89.0], P = 0.047) and did just as well as a combined CT-endoscopy algorithm (AUC: 85.8 [95% CI, 76.5-95.0] vs 85.1 [95% CI, 74.9-95.3], P = 0.73). CONCLUSION: Emergency CT outperforms endoscopy in predicting esophageal stricture formation after caustic ingestion. Emergency endoscopy evaluation after caustic ingestion is not indispensable.

The Impact of Splenectomy in Myelofibrosis Patients before Allogeneic Hematopoietic Stem Cell Transplantation.

Performing a pretransplantation splenectomy in patients with myelofibrosis (MF) is a matter of debate, as while the procedure improves hematological recovery, it may lead to severe morbidities. We retrospectively analyzed data from 85 consecutive patients who underwent transplantation in our center for MF, including 39 patients who underwent splenectomy before their transplantation. A majority of them had primary MF (78%), were considered high-risk patients (84% dynamic international prognostic scoring system intermediate-2 or higher), and had received transplants from HLA-matched sibling donors (56%) after a reduced-intensity conditioning regimen (82%). One-half of all splenectomized patients presented surgical or postsurgical morbidities, most frequently thrombosis and hemorrhage. After adjustment using Cox models, pretransplantation splenectomy was not associated with nonrelapse mortality or post-transplantation relapse but with an improved overall survival (OS) and event-free survival (EFS). We conclude that some patients with huge splenomegaly may undergo pretransplantation splenectomy without a deleterious impact on post-transplantation outcomes. OS and EFS improvement should in confirmed in controlled study.

Caustic ingestion.

Corrosive ingestion is a rare but potentially devastating event and, despite the availability of effective preventive public health strategies, injuries continue to occur. Most clinicians have limited personal experience and rely on guidelines; however, uncertainty persists about best clinical practice. Ingestions range from mild cases with no injury to severe cases with full thickness necrosis of the oesophagus and stomach. CT scan is superior to traditional endoscopy for stratification of patients to emergency resection or observation. Oesophageal stricture is a common consequence of ingestion and newer stents show some promise; however, the place of endoscopic stenting for corrosive strictures is yet to be defined. We summarise the evidence to provide a plan for managing these potentially life-threatening injuries and discuss the areas where further research is required to improve outcomes.

The cervicosternolaparotomy approach for the treatment of graft dysfunction after retrosternal esophageal reconstruction for caustic injuries.

OBJECTIVE: The study purpose was to report the indications, technical aspects, and outcomes of cervicosternolaparotomy during revision surgery after esophageal reconstruction for caustic injuries. METHODS: Patients who underwent cervicosternolaparotomy during revision surgery for graft dysfunction between 1999 and 2015 were included. Cervicosternolaparotomy was performed to mobilize and pull up the primary conduit during surgery for strictures (rescue cervicosternolaparotomy) or to allow retrosternal access for management of other graft-related complications (exposure cervicosternolaparotomy). Statistical tests were performed to identify factors associated with primary conduit preservation during rescue cervicosternolaparotomy. RESULTS: Fifty-five patients were included (28 men; median age, 43 years). Median delay between primary reconstruction and cervicosternolaparotomy was 15 months. Exposure cervicosternolaparotomy was performed in 12 patients (22%) for redundancy (n = 8), spontaneous perforation (n = 2), and caustic reingestion (n = 2). Rescue cervicosternolaparotomy was performed in 43 patients (78%) to treat supra-anastomotic (n = 11), anastomotic (n = 23), and diffuse (n = 9) stenosis. During rescue cervicosternolaparotomy, the primary conduit was preserved in 32 patients; median length gain obtained by transplant release was 8 cm. Failure to preserve the primary conduit was associated with previous surgical repair attempts (P = .003) and lack of initial concomitant pharyngeal reconstruction (P = .039). Two patients died (4%), and 35 patients (64%) experienced operative complications. Operative outcomes were similar after rescue and exposure cervicosternolaparotomy. With a median follow-up of 4.4 years, the functional success rate was 85%. CONCLUSIONS: Cervicosternolaparotomy during revision surgery for graft dysfunction is reliable, is associated with low morbidity and mortality, and has good results.

Computed Tomography Evaluation of Esophagogastric Necrosis After Caustic Ingestion.

BACKGROUND: Endoscopy is the standard of care for emergency patient evaluation after caustic ingestion. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to inappropriate decision-making with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of patients with caustic injuries. METHODS: In a prospective study, we used a combined endoscopy-CT decision-making algorithm. The primary outcome was pathology-confirmed digestive necrosis. The respective utility of CT and endoscopy in the decision-making process were compared. Transmural endoscopic necrosis was defined as grade 3b injuries; signs of transmural CT necrosis included absence of postcontrast gastric/ esophageal-wall enhancement, esophageal-wall blurring, and periesophageal-fat blurring. RESULTS: We included 120 patients (59 men, median age 44 years). Emergency surgery was performed in 24 patients (20%) and digestive resection was completed in 16. Three patients (3%) died and 28 patients (23%) experienced complications. Pathology revealed transmural necrosis in 9/11 esophagectomy and 16/16 gastrectomy specimens. Severe oropharyngeal injuries (P = 0.015), increased levels of blood lactate (P = 0.007), alanine aminotransferase (P = 0.027), bilirubin (P = 0.005), and low platelet counts (P > 0.0001) were predictive of digestive necrosis. Decision-making relying on CT alone or on a combined CT-endoscopy algorithm was similar and would have spared 19 unnecessary esophagectomies and 16 explorative laparotomies compared with an endoscopy-alone algorithm. Endoscopy did never rectify a wrong CT decision. CONCLUSIONS: Emergency decision-making after caustic injuries can rely on CT alone.

The Damage Pattern to the Gastrointestinal Tract Depends on the Nature of the Ingested Caustic Agent.

BACKGROUND: The mechanisms of damage to the gastrointestinal tract after caustic ingestion are conditioned by the nature of the ingested agent. Whether the nature of the ingested agent has a direct influence on patient outcomes is unknown. METHODS: From January 2013 to April 2015, 144 patients underwent emergency management for caustic injuries at the Saint Louis Hospital in Paris. There were 51 men (51 %) and the median age was 44 years [39, 48]. The ingested agents were soda-based strong alkali in 85 patients (59 %), strong acids in 36 patients (25 %), and bleach in 23 patients (16 %). Emergency and long-term outcomes were compared according to the nature of the ingested agent. RESULTS: Four patients died (3 %) and 40 patients (28 %) experienced complications. After bleach ingestion, emergency morbidity and mortality were nil, no patient required esophageal reconstruction, and functional outcome was successful in all patients. Acids were more likely to induce transmural gastric (31 vs. 13 %, p =0.042) and duodenal (9 vs. 0 %, p = 0.04) necrosis than strong alkalis, but rates of transmural esophageal necrosis were similar (14 vs. 12 %, p = 0.98). No significant differences were recorded between emergency mortality (9 vs. 1 %, p = 0.15), morbidity (33 vs. 33 %, p = 0.92), the need for esophageal reconstruction (25 vs. 20 %, p = 0.88), and functional success rates (76 vs. 84 %, p = 0.31) after acid and alkali ingestion, respectively. CONCLUSION: Bleach causes mild gastrointestinal injuries, while the ingestion of strong acids and alkalis may result in severe complications and death. Acids cause more severe damage to the stomach but similar damage to the esophagus when compared to alkalis.

Esophageal reconstruction by colon interposition after esophagectomy for cancer analysis of current indications, operative outcomes, and long-term survival.

INTRODUCTION: Colon interposition is an alternative solution for esophageal reconstruction if the stomach cannot be used. The study reviews current indications and results of coloplasty for cancer. METHODS: Patients who underwent colon interposition for gastro-esophageal malignancy were included. Primary coloplasty was defined as upfront colon interposition. Salvage coloplasty was defined as colon interposition after primary reconstruction failure. Mortality, morbidity, function, and survival were evaluated. RESULTS: We included 28 patients (24 men, median age 61 years). Ten (36%) patients underwent primary coloplasty due to previous gastrectomy (n = 5), conduit gastric cancer (n = 2), extensive gastroesophageal involvement (n = 2), and gastric cancer recurrence (n = 1). Salvage coloplasty was performed in 18 (64%) patients for postoperative graft necrosis (n = 5) and intractable strictures (n = 3). Operative mortality, morbidity, and graft necrosis rates were 14% (4/28), 86% (24/28), and 14% (4/28), respectively; there were no significant differences between primary and salvage coloplasty. Survival rates at 1-, 3-, and 5 years were 81%, 51%, and 38%, respectively. Survival was decreased after primary coloplasty when compared to salvage coloplasty (P = 0.03). Nine patients experienced tumor recurrence (primary: n = 6, salvage: n = 3) after coloplasty and eight of them died. CONCLUSION: Colon interposition after esophagectomy is a useful but morbid endeavor. Colon interposition as salvage therapy is associated with improved survival compared to its use as primary esophageal replacement, and colon interposition in the latter cohort should be used with caution due to poor cancer-specific survival in this patient population.

Tracheobronchial Necrosis After Caustic Ingestion.

OBJECTIVE: The aim of this study was to describe the management and outcome of tracheobronchial necrosis (TBN) after caustic ingestion. BACKGROUND: Emergency pulmonary patch repair has been reported to be lifesaving in patients with caustic TBN. METHODS: Patients who underwent management of caustic TBN between 1989 and 2013, were included. TBN was defined as early if present on admission and late if occurring thereafter. Operative outcomes, long-term survival, and functional outcomes were compared with those of 269 patients without TBN who underwent esophagectomy for caustic injuries. RESULTS: Twenty patients were included (10 men; median age = 39 years). Early TBN was detected in 14 patients, and late TBN occurred in 7 patients, 8 days (range:: 6-10 days) after admission. TBN involved the left bronchus (n = 17; 85%), the carina (n = 10; 50%), the supracarinal trachea (n = 9; 45%), the right bronchus (n = 4; 20%), and the cervical trachea (n = 3; 15%). Seventeen patients underwent esophagogastrectomy, 2 underwent esophagectomy, and in 1 patient, resection was eventually abandoned. Pulmonary patch repair was performed in 16 patients (80%). Nine patients (45%) died and morbidity was 100%. In univariate analysis, late TBN (P = 0.017) and acid ingestion (P = 0.002) were predictors of mortality. All survivors underwent restoring colopharyngoplasty. Five-year survival (28%) and functional success (25%) rates were significantly impaired when compared with esophagectomy patients without TBN. CONCLUSIONS: TBN is one of the most devastating complications of caustic ingestion. Pulmonary patch repair is technically simple and can be lifesaving in this difficult situation.

Establishment and characterization of a human parathyroid carcinoma derived cell line.

Parathyroid carcinoma is a rare neoplasia associated with PTH-dependent hypercalcaemia. It is infrequent in primary hyperparathyroidism (HPT) and very rarely associated with uremic HPT. A continuous cell line named Pt.Kich-1 from a parathyroid carcinoma diagnosed in a patient with secondary hyperparathyroidism (II° HPTH) was established and maintained in vitro for more than 60 passages. The cells were characterized for their immunophenotypic and endocrine characteristics as well as for their functional status after treatment by the extracellular [Ca(2+)]e, and the calcium homeostasis regulator 1α,25 (OH)2D3. The cytogenetic features were established by the R-banding. The Pt.Kich-1 cultures show an aspect of admixed epithelial/mesenchymal like cells with a doubling time between 96 and 112h. The cells are immunoreactive for cytokeratin (60%), EMA (26%), vimentin (46%), E-cadherin (32%), and synaptophysin (16%), while chromogranin A was not detected. Hypotetraploid karyotype containing large chromosomal markers and double minute chromosomes was identified in 30% of the metaphases. Treatment of Pt.Kich-1 cells with 1.0mM, 1.5mM, and 1.7mM of extracellular [Ca(2+)]e increased the DNA synthesis, while the calcium homeostasis regulator, the 1α,25 (OH)2D3, at 10(-9)-10(-7)M inhibited the cell growth. The levels of PTH measured in the medium of early cultures ranging between 547 and 610pg/µg of DNA declined during the passages to a level between 6 and 12pg/µg of DNA. No effect on the PTH release by the Pt.Kich-1 cells was observed after treatment with the all-trans (ATRA) and 9-cis retinoic acid differentiation inducers. The described in vitro cellular model can serve as a useful tool to study the pathogenesis of parathyroid carcinoma and to improve the knowledge of the molecular mechanisms involved in the control of gland sensitivity to [Ca(2+)]e leading to PTH synthesis and secretion.

Upper digestive tract reconstruction for caustic injuries.

OBJECTIVE: The aim of the study was to compare the short- and long-term outcomes of colopharyngoplasty and esophagocoloplasty for caustic injuries of the upper digestive tract. BACKGROUND: Simultaneous esophageal and pharyngeal reconstruction by colopharyngoplasty allows regaining nutritional autonomy in patients with severe pharyngoesophageal caustic injuries. METHODS: Patients who underwent upper digestive tract reconstruction for caustic injuries by colopharyngoplasty (n = 116) and esophagocoloplasty (n = 122) between 1993 and 2012 were included. Survival and functional outcomes were analyzed. Success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. Quality of life was assessed using the QLQ-OG25 and SF12v2 questionnaires. RESULTS: Overall Kaplan-Meyer survival at 1, 5, and 10 years after colopharyngoplasty and esophagocoloplasty were 92%, 74%, 67% and 92%, 83%, 73%, respectively (P = 0.56). Quality of life and functional results (success: 57% vs 95%, P < 0.0001) were impaired after colopharyngoplasty. On multivariate analysis, older age (odds ratio [OR]: 0.94; confidence interval [CI]: 0.91-0.97 P < 0.0001) and pharyngeal reconstruction (OR: 0.05; CI: 0.02-0.13, P < 0.0001) were associated with failure. The decline in success with age was more pronounced after colopharyngoplasty with only 1 (7%) of 15 patients operated after the age of 55 being self-sufficient for eating and breathing. Laryngeal resection during colopharyngoplasty had no influence on success (54% vs 58%, P = 0.67) CONCLUSIONS:: The need to associate pharyngeal reconstruction during esophageal reconstruction for caustic injuries has a long-term negative impact on functional outcome.

Laparoscopic partial splenectomy: a technical tip.

BACKGROUND: Increased awareness of asplenia-related life-threatening complications has led to development of parenchyma sparing splenic resections. The aim of the study was to report a new technique of laparoscopic partial splenectomy, which helps minimize perioperative bleeding risks. METHODS: From November 2004 to October 2012, 12 patients underwent partial laparoscopic resection of the spleen. There were six men (50 %), and median age was 30 years (19-62). Transection of the splenic parenchyma was performed along a line situated 1 cm within the ischemic demarcation, which appeared after ligation of the sectorial vascular pedicles feeding the tumor. Antibiotic prophylaxis and preventive antibacterial immunization were prescribed systematically according to generally accepted guidelines. RESULTS: Mortality was nil, and operative complications occurred in 2 (17 %) patients. Conversion to open partial splenectomy and to laparoscopic total splenectomy was performed in one patient (8.3 %) each. Median operative time was 120 min (range 80-180 min). Median blood loss was 90 ml (range 10-450 ml), and transfusion was not required. Median tumor size was 7 cm (4-12 cm). The median in hospital stay was 5 days (4-7 days). Patients did not comply with long-term (>2 years) immunization and antibioprophylaxis rules. After a median follow-up of 5 years (18 months-9 years), no case of overwhelming post-splenectomy infections occurred. CONCLUSION: Laparoscopic partial splenectomy can be safely performed in patients with splenic tumors. Parenchyma transection 1 cm inside the ischemic demarcation line is a key technical point to minimize blood loss.

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

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.

Bone mineral density evolution after successful parathyroidectomy in patients with normocalcemic primary hyperparathyroidism.

CONTEXT: It is unclear whether bone mineral density (BMD) improves in patients with normocalcemic primary hyperparathyroidism (PHPT) after parathyroidectomy (PTX). OBJECTIVE: The objective of the study was to evaluate and compare the impact of PTX on BMD change at 1 year in normocalcemic vs hypercalcemic PHPT. DESIGN: This was a longitudinal cohort study. SETTING: The study took place at a referral center. PATIENTS: We included 60 PHPT patients (mean age 64.0 ± 10.1 years), successfully treated by PTX by the same surgeon. Two groups were individualized according to baseline serum total (albumin corrected) calcium: 39 patients with normal baseline serum total calcium (normocalcemic group) and 21 patients with hypercalcemia at baseline (hypercalcemic group). MAIN OUTCOME MEASURE: BMD changes 1 year after PTX were measured. RESULTS: In the normocalcemic group, BMD increased significantly by +2.3 ± 5.0% at the spine (P = .016) and +1.9 ± 5.7% at the hip (P = .048). In the hypercalcemic group, BMD increased significantly by +4.0 ± 3.8% at the spine (P = .0003) and +3.2 ± 4.2% at the hip (P = .003). There was no difference in these BMD gains between both groups (P > .1). The presence of multiple adenomas or hyperplasia was more frequent in the normocalcemic group than in the hypercalcemic group (P = .04). CONCLUSION: Our results indicate for the first time that successful PTX in normocalcemic PHPT patients with osteoporosis is followed with mild but significant BMD improvement at the spine and hip at 1 year, comparable with that observed in hypercalcemic PHPT, suggesting that PTX may be beneficial in normocalcemic PHPT.

Early detection of hypocalcemia after total/completion thyroidectomy: routinely usable algorithm based on serum calcium level.

BACKGROUND: The purpose of this prospective bicentric study was to investigate the course of serum calcium (Ca) and phosphorus (Phph) after total/completion thyroidectomy to establish a reliable and cost-effective strategic algorithm to detect patients at risk for postoperative hypocalcemia. METHODS: This observational study included 136 patients. Serum Ca and Phph levels were preoperatively and postoperatively recorded 6, 12, 20, and 48 h (H) after skin closure. Criteria for hypocalcemia were postoperative Ca levels ≤1.9 mmol/L at any time point and/or patients experiencing symptoms of hypocalcemia. Postoperative Ca supplementation was never given before H20 assay. Ca levels and their differences between time points were compared. RESULTS: Twenty-four percent of patients experienced hypocalcemia. At H12 and H20, the rates of patients with Ca levels ≤1.9 mmol/L were similar and larger than at H6 (p < 0.001). The H20-preoperative difference had the best area under the ROC curves (value = 0.87), and a difference ≤-0.3 was significantly more frequent in case of hypocalcemia (p = 0.001). The H20 assay and the difference H20-preop were consequently selected to design a new algorithm for hypocalcemia detection. Adding H48 assay in some specific cases (12.5 % of all included patients) enabled 100 % detection. Phosphorus assays were not informative in detecting hypocalcemia. CONCLUSIONS: This new algorithm enables, with 100 % sensitivity and 88.4 % specificity, early detection of severe hypocalcemia after total/completion thyroidectomy. It may become a useful and cost-effective tool for safe and early patient discharge, especially if PTH assays cannot be routinely used because of their availability or cost.

Surgery for caustic injuries of the upper gastrointestinal tract.

BACKGROUND: Surgery is the criterion standard for the treatment of severe burns and of late sequels after ingestion of corrosive agents, but long-term outcome is unknown. METHODS: Patients who underwent surgery between 1987 and 2006, for the treatment of severe caustic burns (group I, n = 268) or of late sequels (group II, n = 79) were included in the study. Survival and functional outcomes were analyzed. Functional success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. To compare the observed mortality with the expected mortality in the general population, a standardized mortality ratio (SMR) was used. RESULTS: Overall Kaplan-Meyer survival at 1, 5, 10, and 20 years of patients in group I was 76.4%, 63.6%, 53.9%, and 44.1%, respectively. On multivariate analysis, advanced age (P = 0.0021), extended resection (P = 0.0009), emergency esophagectomy (P = 0.013), and tracheobronchial injuries (P = 0.0011) were independent negative predictors of survival. The SMR of patients in group I was increased to 21.5 when compared to the general French population. Functional success was recorded in 147 (56%) patients in group I. Advanced age (P = 0.012), extended resection (P = 0.012), and emergency tracheotomy (P = 0.02) were independent predictors for failure. After esophageal reconstruction, patients in group II fared better than patients in group I in terms of survival (P = 0.0006) and functional success (P < 0.0001). Still, the SMR of patients in group II increased to 3.67. CONCLUSIONS: The need to perform surgery for caustic injuries has a persistent long-term negative impact on survival and functional outcome.

Similar outcomes after primary and secondary esophagocoloplasty for caustic injuries.

BACKGROUND: The main purpose of the study was to report a comparative experience with primary and secondary esophagocoloplasty for caustic injuries. Secondary esophagocoloplasty is the main rescue option after graft loss, but data in the literature are scarce. METHODS: The operative characteristics, postoperative course, and functional outcomes of 21 secondary and of 246 primary esophagocoloplasty operations performed for caustic injuries between 1987 and 2006 were compared. Intraoperative events requiring significant changes in the planned operative strategy, such as graft ischemia or necrosis, were recorded. Statistical tests were performed in both cohorts to identify factors predictive of postoperative graft necrosis. Univariate analysis was performed to identify factors predictive of functional failure after secondary esophagocoloplasty. RESULTS: Operative mortality (5% vs 4%, p=0.56), morbidity (62% vs 59%, p=0.96), postoperative graft necrosis (14% vs 7%, p=0.16), and functional success (68% vs 70%, p=0.79) rates of the secondary and primary esophagocoloplasty operations were similar. Intraoperative graft ischemia at the time of secondary esophagocoloplasty was significantly associated with the risk of postoperative graft necrosis (p=0.015) and functional failure (p=0.046). At the time of primary esophagocoloplasty, intraoperative necrosis of the colon was the only independent predictive factor of postoperative graft necrosis (p<0.0001). CONCLUSIONS: Secondary esophagocoloplasty is a safe and reliable salvage option after primary graft loss in patients with caustic injuries. Delayed esophagocoloplasty should be considered if intraoperative colon necrosis occurs at the time of primary reconstruction.