Ingestion of caustics in adults can result in death or severe digestive sequelae [1]. The reported rates of morbidity and mortality in the emergency, after massive ingestion of strong caustic agents, range between 13% to 16%, and 36% to 80%, respectively [1-3].
After initial conservative management, 14% to 37% of patients develop esophageal stricture [4,5].
Complications, both early and late, associated with caustic ingestion require significant utilization of healthcare resources, and can have a long-term negative impact on patient survival and nutritional outcomes [3,6].
A limitation in the bibliography is that the few studies that focus on this topic are reported by reference centers with high volume of cases, which have significant experience in esophageal surgery.
The paucity of epidemiological data at the national level leads to difficulties related to the applicability of its analysis to less specialized centers that, however, are frequently involved in the emergency treatment of patients after caustic ingestion.
Several large sets of worldwide epidemiological data have been reported [7-9], but their interpretation is hampered by the fact that these reports include all caustic injuries, without a specific focus on caustic ingestion [10].
The objective of this study was to analyze at a national level the epidemiology and early outcomes associated with caustic ingestion in France, over a 10-year period.
| Methods |
In line with legislation in France on retrospective data analyses, written consent or approval by an independent ethics committee was not necessary for the present study. It followed the RECORD ( Reporting of Studies Conducted Using Observational Routinely Collected Data ) guidelines [11].
> Medicalization Program for Database Information Systems
Data were extracted from the French Medical Information System Database Programme De Médicalisation Des Systèmes D’informations (PMSI) [12]. The PMSI is a nationwide prospective database that includes patients from all public and private hospitals in France.
It is based on standardized discharge reports after hospital admissions: each report is a collection of 1 or more summaries from each medical unit to which patients were referred during their hospital stays. Diagnoses are coded using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10).
Therapeutic procedures are coded using the Classification Commune des Actes Médicaux (CCAM), which is a standardized national classification of medical and surgical procedures [13].
Because patients may have multiple hospital stays, each patient is identified in the PMSI using a unique anonymous identification number. That number is generated using the patient’s social security number, date of birth, and sex, and allows for a comprehensive, lifelong record of all hospital admissions in France.
As all discharge reports are mandatory and represent the basis of hospital financing, the PMSI database is comprehensive, and its validity has been confirmed by cross-referencing with other prospective cohort databases [14-16].
> Identification of patients
Data from January 2010 to December 2019 were extracted from the PMSI database. All outpatients admitted on an emergency basis due to esophageal ingestion of caustics were identified and included in the present study.
Esophageal ingestion of caustics was defined as the primary diagnosis, code T281 or T286 according to the ICD-10 classification. Pediatric patients 15 years of age or younger, and patients with invalid identification numbers, were excluded from the analysis.
> Definitions of variables and results
Data related to patient demographic characteristics were extracted from the database. The ICD-10 codes of the associated diagnoses were used to identify any associated psychiatric conditions or comorbidities, which were classified according to the Charlson comorbidity index [17,18]. Psychiatric illness and unintentional ingestion were also recorded.
The nature of ingestion (ie, unintentional or intentional) was based on patient report and was coded as X49, according to ICD-10. The presence of psychiatric disorders was defined by ICD-10 codes F0 to F7. These codes were independent. Intensive care unit (ICU) management was recorded along with mechanical ventilatory support and blood transfusion.
All therapeutic procedures were identified according to the CCAM. Emergency surgical procedures were categorized as esophagectomy, gastrectomy, colectomy, and resections of the small intestine, spleen, and pancreas.
The removal of organs other than the stomach and esophagus was defined as extended resection. The creation of a feeding jejunostomy was also recorded. In the absence of transmural necrosis, patients were offered nonsurgical treatment. It included assistance in the ICU – if necessary – for vital functions (renal, circulatory, respiratory), nursing, psychological support, and gradual resumption of oral feeding.
Mortality and morbidity were defined as in-hospital deaths and complications, respectively. Complications were recorded according to ICD-10 codes. Reconstructive surgery was defined as an esophagocoloplasty or gastroplasty procedure during the study period.
Facility caseload was defined as the number of caustic ingestion incidents per facility during the study period. This variable was categorized using the tertile cutoff to create 3 categories of similar size.
According to the number of patients treated per year, centers were classified as low volume (less than 2 patients/year), medium volume (2 to 9 patients/year), and high volume (more than 9 patients/year). . Using the same method, centers were also categorized by the number of oncologic esophageal resections performed annually, as low (less than 5 per year), medium (5 to 55 per year), and high volume (more than 55 esophageal resections per year). anus).
Data from patients referred to another healthcare center after the initial admission were analyzed. To define center volumes and for subsequent statistical analyses, patients were categorized by presenting center.
> Statistical analysis
Statistical analysis was performed using the R program version 4.1.2 (R Foundation). Descriptive analyzes are presented as medians and interquartile range (IQR), or as means and standard deviation (SD), for quantitative data, and as numbers and percentages for categorical variables.
Univariate analyzes were performed with general linear models for binary outcomes and linear models for continuous outcomes, using the publishing package for R, version 2020.12.23 (R Foundation).
Multivariate analysis was performed according to logistic resection, using a general linear model. All variables with a P value less than 0.20 in the univariate analysis were included in the multivariate model.
The results of the multivariate analyzes are presented as odds ratios (OR) with 95% confidence intervals (CI). All tests were 2-tailed with a significance level set at P < 0.05. A correlation matrix was performed to evaluate collinearity.
| Results |
> Patients
Across the study period, a total of 22,657,226 patients were admitted to hospitals in France as emergency outpatients. 3544 patients (0.016%) who were admitted for caustic ingestion were included in this study.
These patients were treated at a total of 435 hospitals, including 404 low-volume centers (93%), 27 medium-volume centers (6%), and 4 high-volume centers (1%). Overall, 1124 patients (32%) were treated at low-volume centers, 1124 (34%) at medium-volume centers, and 1196 (34%) at high-volume centers.
Of the 2348 patients admitted to the low- and medium-volume centers, 76 (3.2%) were referred to larger centers; of them, 24 (1%) were transferred within 24 hours, and 66 (2.8%) within 48 hours of ingesting the caustic.
The median (IQR) age was 49 (34-63) years, and 1685 patients (48%) were women. Ingestion was recorded as unintentional in 381 patients (11%), and 2546 patients (72%) had a history of psychiatric illness.
The nature of the agent ingested was specified in 1185 patients (33%), and included 221 acids, 604 alkalis, and 360 other agents.
The number of hospital admissions for caustic ingestion per year was stable, while the number of incidents of unintentional ingestion increased steadily throughout the study period. Less than 5% (34 of 744) of ingestion incidents were unintentional at the beginning of the study period, compared to about 20% (119 of 671) at the end of the study.
> Emergency management
Endoscopy was used to evaluate the severity of caustic lesions in 2033 patients (57%), and computed tomography (CT) in 1355 (38%); 969 patients (27%) did not have either endoscopy or CT. The use of endoscopy was stable throughout the study period.
CT use steadily increased from 23% (169 of 744 patients) between January 2010 and December 2011, to 52% (349 of 671 patients) between January 2018 and December 2019 ( P < 0.001).
Surgical resection was performed in 388 patients (11%) during the primary hospital stay, and included 156 esophageal resections (40%), 103 esophagogastrectomies (27%), and 98 gastric resections (25%).
Extended resection was performed in 49 patients (1%), and included 22 pancreatic, 13 colonic, 16 small intestine, and 18 spleen resections. The resection procedure was aborted in 31 patients (8%) due to extensive digestive necrosis.
Non-surgical management was performed in 3156 patients (89%). Of them, 1047 patients (33%) were admitted to the ICU, 346 (11%) received vasopressors for circulatory failure, 236 (7.5%) required ventilatory assistance, and 24 (0.8%) underwent renal filtration. .
Due to the inability to resume oral feeding, a feeding jejunostomy was constructed in 245 patients who did not undergo surgery.
> Early results
A total of 1198 patients (34%) experienced complications, and 294 (8%) died. Pulmonary complications were the most frequent adverse events, occurring in 869 patients (24%).
During emergency management, 1418 patients (40%) required ICU admission. Preoperative respiratory support was necessary in 370 patients (10%), and 122 patients (6%) required blood transfusion. Overall, 202 patients (6%) underwent tracheostomy for the management of respiratory complications.
Among patients who underwent surgery for digestive necrosis, 294 (76%) experienced complications, and 96 (25%) died.
The mortality rates associated with esophagectomy, gastrectomy, esophagogastrectomy, extended resection, and aborted surgery were 17%, 17%, 21%, 37%, and 100%, respectively. Among the 3156 patients who underwent nonsurgical treatment, the in-hospital mortality and morbidity rates were 6% (n = 198), and 29% (n = 904), respectively.
In multivariate analysis, independent predictors of mortality included: older age (OR 1.06; 95% CI: 1.05-1.07; P < 0.001), high comorbidity score (OR 1.14; 95% CI : 1.08-1.20; P < 0.001), suicidal ingestion (OR 3.45; 95% CI: 1.85-7.14; P < 0.001), ICU admission (OR 4.42; 95 % CI: 3.17-6.21; P < 0.001), emergency surgery for digestive necrosis (OR 3.44; 95% CI: 2.47-4.78; P < 0.001), and treatment in centers with low volume of cases (OR 1.45; 95% CI: 1.01-2.08; P = 0.04).
In multivariate analysis, independent predictors of morbidity included: older age (OR 1.02; 95% CI: 1.02-1.03; P < 0.001), high comorbidity score (OR 1.07; 95% CI: 1 .03-1.11; P < 0.001), ICU admission (OR 8.07; 95% CI: 6.72-9.10; P < 0.001), and emergency surgery for digestive necrosis (OR 2, 82; 95% CI: 2.16-3.71; P < 0.001).
Mortality and morbidity analyzes were performed using the categorization of centers according to the number of annual oncological esophageal resections, providing similar results.
Management of caustic ingestion in centers that perform fewer than 5 esophageal resections per year was an independent predictor of mortality. Morbidity and mortality rates were not different between patients who ingested acids vs. those who ingested alkalis.
> Therapeutic endoscopy and esophageal reconstruction
Therapeutic endoscopy was used for stricture management in 409 patients (12%); Of these, 323 patients underwent dilation only, 19 only stent placement, and 67 both (dilation and stent). Patients underwent a median (IQR) of 3 (1-5) endoscopic procedures.
Reconstruction surgery was used in 456 patients (13%). The median (IQR) delay in reconstruction was 6 (3-10) months. Esophageal reconstruction was performed using the stomach in 113 patients, including 39 Ivor Lewis operations, 58 McKeown procedures, and 16 retrosternal gastroplasties. Esophageal reconstruction with the colon was performed in 343 patients, and the esophagocolonic anastomoses were located in the neck in all patients.
Esophageal reconstruction was performed at high, medium, and low volume centers in 223 patients (49%), 204 (45%), and 29 patients (6%), respectively. After esophageal reconstruction, 323 patients (71%) experienced in-hospital complications, and 22 (5%) died. In-hospital morbidity and mortality rates were similar after esophageal reconstruction with the stomach and colon.
> Hospital readmissions
During follow-up, 2577 patients (73%) required at least one hospital readmission. The median (IQR) number of readmissions in these patients was 4 (2-9)
| Discussion |
This nationwide study reports the early management and outcomes associated with caustic ingestion, in a cohort of 3,544 patients admitted to hospitals in France, from 2010 to 2019. These patients represented 0.016% of all emergency outpatient admissions in France during the same period.
There is a general consensus in France that ingestion of caustics requires hospital admission [19].
Therefore, it is highly probable that the percentage of lost patients (that is, dead before admission, or not receiving a medical consultation) is minimal, and that these figures faithfully reflect the clinical reality of the country. These data highlight interesting modifications in the patterns of ingestion and emergency management of caustic lesions over time.
First, a steady increase in incidents of unintentional ingestion was found , during a period where the total number of annual cases remained globally stable. There is no clear explanation for this finding; no specific educational programs or effective measures to limit access to strong caustic agents have been implemented in France during the study period.
Second, we found a steady increase in the use of CT in the emergency evaluation of caustic lesions. That finding underscores the clinical impact of recent publications, which showed that CT outperformed endoscopy in the detection of transmural caustic necrosis [1,4,20,21], leading to the approval of CT-based management algorithms by of specialized equipment [22-24]. The lack of examinations (CT and/or endoscopy) in more than a quarter of the patients was surprising.
It may be postulated that the amount ingested was minimal in some patients who may not have required investigation or specific therapy, and whose inclusion in the study may be questioned. However, systematic investigation of caustic ingestion incidents is recommended, given that the quantities ingested are not generally known or reliable, and the symptoms are poorly associated with the severity of the digestive lesions.
The lack of emergency investigations was probably due to lack of availability, that is, a number of small hospitals not having 24-hour access to CT or endoscopy, combined with a misunderstanding of the degree of emergency by the medical equipment. The high mortality (8.3%) and morbidity (28%) rates in that specific population support this hypothesis.
Although the majority of ingestion incidents in this study (89%) were intentional and more serious outcomes could be expected, the majority of patients (89%) were not treated surgically.
Several factors may explain this finding. In many cases, the cause for the suicide attempt is not a real desire to die; Pain and last-minute changes of mind can limit the amounts ingested. Oxidants induce less severe damage than acids and alkalis, even if ingested intentionally. Of note, these numbers are in line with recent reports, which show a steady decline in surgical approaches in the emergency setting.
The authors reported mortality and morbidity rates of 8% and 34%, respectively.
Mortality and morbidity increased in patients who required surgery for digestive necrosis; Mortality rates were associated with the extent of digestive involvement. Multivariate analysis showed that the results were associated with patient factors (age, comorbidity score, and suicide), and with the severity of the caustic lesions (ie, the need for surgery or ICU management). These results are consistent with published data regarding the outcomes of emergency surgery for caustic injuries [1].
A major finding was the significant improvement in in-hospital survival in patients treated at high-volume centers. Over the past 20 years, a large number of publications have shown greater benefits associated with increasing hospital and surgeon case volume on perioperative outcomes among patients undergoing high-risk elective operations [25,26]. , and emergency [27,28].
Worldwide, there is a current trend toward centralization of high-risk procedures, and minimum thresholds are regularly defined for hospitals and surgeons for esophageal [29], pancreatic [30], liver [31], and rectal resections. [32].
To the authors’ knowledge, the present study is the first to suggest that emergency treatment in high-volume centers may benefit patients with adverse outcomes associated with caustic ingestion. These survival benefits may be associated with better selection of patients for surgery, improvements in intra- and postoperative management strategy, and broad access to multidisciplinary management.
In view of these findings, the very low rate of referral of caustic lesions to larger centers in France is worrying; It may also represent a lever that can be operated to improve patient outcomes.
In contrast, only 6% of esophageal reconstruction procedures were performed in low-volume centers. This may suggest that esophageal reconstructions are perceived as difficult procedures by surgeons, who spontaneously refer them to expert teams; This could also explain why the early results after esophageal reconstruction, in this national study, are comparable with those reported by highly specialized centers [1].
Although the study design did not allow for specific analysis of long-term outcomes, performing esophageal reconstruction in highly specialized units may also benefit nutritional outcomes.
The high readmission rate in this study may indicate the long-term impact of caustic ingestion on patients’ lives, although the study design did not allow for a measurement of the direct correlation between hospital readmission and the episode of caustic ingestion. , the use of health resources was unexpectedly high compared to the age and comorbidities of the population.
> Limitations
This study has limitations. First, an administrative database used for more financial than research purposes was used; this may make the accuracy of the data coding questionable. However, the PMSI database used for hospital budget allocation undergoes regular checks to limit the risk of overcoding, and has been shown to be accurate with internal and external quality control [25].
Second, the study design based on the PMSI database did not allow for patient follow-up, and therefore the authors have not been able to provide a long-term survival and nutritional analysis. This is a major drawback, given that it has previously been shown that survival and functional outcomes in patients with severe caustic injuries tend to deteriorate over time [3]. Furthermore, given that the PMSI only encodes in-hospital mortality , the analysis may have been biased by the exclusion of out-of-hospital deaths.
The PMSI database does not calculate severity scores at the time of ICU admission (e.g., the APACHE [ Acute Physiologic and Chronic Health Evaluation ], or the POSSUM [ Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity ]), which could help identify patients most likely to benefit from early-stage referral to a high-volume center. Furthermore, the registry-based study design did not allow for a personalized patient management algorithm.
In addition to patients at low-volume centers, some patients at medium-volume centers could benefit from transfer to a high-volume center; The presence of extensive damage (eg, pancreatic or duodenal necrosis, or airway compromise), should be considered for referral or, at least, discussed with a team from a high-volume center.
The increase in incidents of unintentional ingestion over time cannot be explained by the present study; Cultural or family factors may be involved, but could not be evaluated since the PMSI database does not include that type of information.
Conclusions
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