Assessment the Risk Factors for the Complications of Gastric Pull-Up Method in Esophageal Stenosis due to Ingestion of Caustic Agents

The ingestion of caustic agents is one of the most consequential and dangerous poisonings associated with a high mortality rate. Esophageal stricture is the most common complication associated with caustic ingestion. Up to one-third of patients with caustic injury of the esophagus develop strictures, especially in patients with severe injuries (1). Although endoscopic dilation is the primary treatment for this complication, patients who have had several unsuccessful attempts at endoscopic dilation should be evaluated for reconstructive surgery, which may include selective esophagectomy with esophagogastric anastomosis or colonic interposition (2,3). These can play an effective role in improving the prognosis of patients given the potential for stenosis and malignancy in the burned esophagus. Multiple factors affect the success rate of this surgery. However, there is no consensus on the optimal surgical approach given the morbidity rates. The decision is often based on the extent of injury, patient age, overall health, and the surgical team's expertise (4).
This study aimed to determine the role of other background factors including age, sex, BMI and type of caustic agent, in determining the success rate of the Gastric Pull-up surgical procedure to identify candidate patients for this surgical method.

In this retrospective cross-sectional study, after obtaining the ethics code IR.IUMS.REC.1398.1358 from the Ethics Committee of Iran University of Medical Sciences, the clinical records of 70 patients with chemical burns of the esophagus who were hospitalized …. hospitals in Tehran between 2011-2019 and underwent treatment with esophagectomy and Gastric Pull-up, and met the inclusion criteria were reviewed, using chi-square and independent t-tests. It was done using SPSS 16 statistical software. P<0.05 was considered significant.
The inclusion criteria were as follows: definitive diagnosis of esophageal burns due to caustic chemicals based on endoscopic findings performed within the first 48 hours after ingestion of caustic substances, treatment with esophagectomy and Gastric Pull-up, complete patient records in terms of follow-up, and presence of informed consent from the patient or parents (for children) regarding the use of file contents for research purposes. Exclusion criteria were lack of access to patient records and outcomes, treatment of patients with other therapeutic methods, and lack of informed consent for the use of file content for research purposes.
After reviewing the medical records, 70 patients were included in the study. Data were collected using a checklist that included demographic and clinical information forms and short-term (infection, length of ICU stay, anastomotic leakage, and bleeding) and long-term (dysphagia, stricture, and mortality rate) outcome forms.
The appropriate sample size was calculated based on a complication prevalence of 80% in the study by Hamza et al. (5) and using the following formula, considering an alpha of 0.05 and d of 0.1, the sample size was calculated as 64.
n = (z^2 * p * (1 - p)) / d^2
Statistical analysis was performed using SPSS 16, based on variable types and sample sizes, using the appropriate tests.

Of the 70 patients studied, 64.3% were male and 35.7% were female with a mean age of 15.6 ± 5.4 years (range 1-33 years).
The mean follow-up duration was 42 ± 15.6 months. The prevalence of short-term complications including vomiting, anastomosis leakage, infection and bleeding was 52.8% and the most common short-term complication was nausea (24.3%). Long-term complications including mortality, anastomotic stenosis, dysphagia and reflux were reported in 81% of the cases. Dysphagia was the most common long-term complication (25.7%). A total of 3.4% of caustic ingestion cases resulted in patient death.
There was no significant association between short-term complications, long-term complications, length of hospital stay (in ICU and hospital), mortality rate, and patients' demographic characteristics, including age, sex, body mass index, and type of substance used (p>0.05).

In the present study, which was conducted on 70 patients undergoing Gastric Pull-up surgery to correct esophageal strictures following caustic ingestion, no significant association was found between long-term and short-term complications, length of hospital stay, and mortality rate with variables of age, sex, BMI, and type of substance used.
Harlak et al. in their study reported few complications associated with this surgical method. They attributed this to the common anatomical location of the esophageal burns and the presence of suitable esophageal tissue after removing the involved section (6). The results of the present study also emphasize that other background factors do not affect short- and long-term complications of this surgery.
Contini et al. attributed the better outcomes of esophagectomy in children to their better tissue repair capability (7). In the present study, no significant differences were observed in short- and long-term complications or mortality rates between children and adults. This finding could be due to the fact that both age groups usually undergo similar surgical procedures to repair or reduce damage caused by ingestion of leaches, using advanced medical techniques and postoperative care strategies, which could contribute to similar outcomes (8). Furthermore, regardless of age, the human esophagus has basic physiologic characteristics that respond to injury and subsequent surgical interventionin a comparable manner (9). It is also important to consider that comprehensive preoperative assessment and postoperative care, including nutritional support and infection management, were performed equally in both groups and may have influenced the observed outcomes. provides (10).
According to a 1992 study by Zargar et al., both acidic and alkaline substances cause serious damage to the esophageal tissue; however, they noted greater tissue damage by alkaline substances (11). Based on this, Harlak et al. also reported a greater need for reconstructive surgery after the acute phase following ingestion of alkaline substances. Based on the results of the present study, no significant differences were observed in the short- and long-term complications and mortality between acidic and alkaline substances.
In a study by Chirica et al. on long-term complications of reconstructive esophageal surgery after caustic ingestion by Colon Interposition, the only factor affecting these complications was delay in reconstructive surgery, and age, sex, and type of ingested substance did not affect the long-term complications of this corrective surgery (12), which is consistent with the results of the present study regarding complications of gastric pull-up surgery.
Based on the results of this study, factors including age, sex, body mass index, and type of ingested substance in patients with esophageal burns did not affect the short- and long-term complications and mortality rate after gastric pull-up surgery and cannot be used as criteria for selecting candidates for this surgical procedure.