Brûlures caustiques de l’œsophage – nouvel algorithme thérapeutique et chirurgie en urgence

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 current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Currently, patients with severe endoscopic lesions (grade 3b) are considered for surgery while patients with low grade injuries are offered non-operative treatment. However, inability of endoscopy to predict accurately the depth of intramural necrosis may result in either futile surgery 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. Computed tomography helps palliate shortcomings of endoscopy-based algorithms and can effectively replace endoscopy in the management of caustic injuries. Transhiatal esophagectomy with gastric preservation and total gastrectomy with esophagojejunostomy can be performed if transmural necrosis is limited to the esophagus or the stomach, respectively. Extended surgery beyond esophagogastrectomy should be attempted in case of associated organ injuries as caustic lesions invariably progress. Tracheobronchial necrosis requires transthoracic esophagectomy and pulmonary patch. Factors with a negative impact on outcome include advanced age, tracheobronchial injuries, emergency esophagectomy, and the need for extended resections. 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.Commentateur : Fabienne SAULNIER (Lille)