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2] Uetsuji S, Okuda Y, Komada H, et al. Clinical evaluation of a low junction of thecystic duct. Scandinavian Journal of Gastroenterology 1993;28:85–8.

3] Dodda G, Brown RD, O’Neil HK, et al. Cystic duct insertion at ampulla as acause for acute recurrent pancreatitis. Gastrointestinal Endoscopy 1998;47:181–3.

4] Roslyn JJ, DenBesten L, Thompson JE, et al. Roles of lithogenic bile and cystic ductocclusion in the pathogenesis of acute cholecystitis. American Journal of Surgery1980;140:126–30.

Tatsuya Kin ∗

Clinical Islet Transplant Program, University ofAlberta, Edmonton, Alberta, Canada

Bassam Abu WaselMulti-Organ Transplant Program, Queen Elizabeth IIHealth Sciences Centre, Halifax, Nova Scotia, Canada

Andrew M. James ShapiroClinical Islet Transplant Program, University of

Alberta, Edmonton, Alberta, Canada

∗ Corresponding author at: Clinical Islet Laboratory,210 College Plaza, 8215 – 112th Street, Edmonton,

Alberta T6G 2C8, Canada. Tel.: +1 780 407 8671;fax: +1 780 407 8760.

E-mail address: tkin@ualberta.ca (T. Kin)

Available online 7 January 2014

ttp://dx.doi.org/10.1016/j.dld.2013.11.014

pper abdominal exenteration: A life saving pro-edure following caustic ingestion

ir,

A 38-year-old previously healthy man presented to the hospital4 h after deliberate ingestion of 200 ml of drain cleaner contain-

ig. 1. Schematic representation. (A) The organs that were found damaged by the causthe transverse colon transposition along with its vascular pedicle.

r Disease 46 (2014) 384–387

ing 92% sulphuric acid. He was transferred as “trauma call” froma district general hospital to our tertiary centre after 800 ml ofhematemesis, and received 2 units of blood during transfer.

Immediate initial management included oxygen, intra-venous antibiotics, dexamethasone, proton-pump inhibitor(PPI), antiemetic and local anaesthetic diluted with saline as anoral mouthwash to relieve oral pain.

An esophagogastroduodenoscopy (EGD) demonstrated mucosalnecrosis in the oropharynx, full thickness mucosal burns of thewhole oesophagus with haemorrhagic gastritis.

An emergency laparotomy was performed with intent to per-form an oeosophago-gastrectomy. Intraoperatively the extent ofinjuries was more advanced than anticipated, with involvementbeyond the duodeno-jejunum flexure: full thickness necrosis ofthe second part of the duodenum was noted and the viabilityof the pancreas was also doubtful. A trans-hiatal oesophagec-tomy and gastrectomy with cervical end-oesophagostomy wasperformed. A “relook” laparotomy at 24 h showed progressive duo-denal, proximal jejunal, pancreas, spleen, and gallbladder necrosis.Total pancreasectomy, splenectomy, duodenectomy along with theresection of the proximal jejunum were performed with a Roux-en-Y biliary reconstruction.

One year later the gastrointestinal tract was reconstructed witha colonic transposition, through a laparotomy and cervicotomy. Thetransverse colon was transposed with its vascular pedicle to thechest through a retrosternal tunnel and anastomosed proximally tothe pharynx and distally to the jejunum. The right colon was thenanastomosed to the remaining left colon. (Fig. 1B) Two months laterand with help of a multi-disciplinary team the patient was able torestart a normal oral diet. Pancreatic insufficiency causing steator-rhoea and type-1 diabetes mellitus was managed with a tailored

ic substance are coloured. (B) The reconstruction of the gastrointestinal tract with

Ingestion of caustic substances represents a serious conditionthat can severely damage the upper alimentary tract and can oftenresult in fatalities. 80% of cases are due to accidental ingestion by

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hildren [1] while the remaining cases are adults with self-harmingntent. The extent of the damage depends mainly on the quantityngested, type of substance and length of time prior to presentationnd treatment. The effect of caustic ingestion varies from minimaluperficial mucosal erythema and oedema to extensive transmuralecrosis and perforation of the digestive tract with involvement ofurrounding organs.

The ingestion of corrosive substances has higher mortality andorbidity in cases of intentional self-administration, since the

mount of corrosive substances swallowed is larger. Followinghe immediate resuscitation procedures, EGD is the gold standardnvestigation recommended in the first 12–48 h to assess of thextent of injuries [2]. Computed Tomography (CT) scan is also aaluable adjunct, particularly to evaluate the adjacent organs, andan be more accurate then endoscopy to assess the presence of anmpending or established stomach perforation [3].

The standard operation consists in an oesophagectomy and gas-rectomy with further debridement of the surrounding tissues asequired, with a jejunostomy feeding tube insertion [4]. Whenecessary a “re-look” laparotomy at 24–48 h might be helpful toe-assess organs not debrided or excised in the initial operation,hose viability was doubtful. In the reported literature several

ases of emergency oesophago-gastrectomy after caustic inges-ion have been described, but only few cases of successful majoresections extending to the adjacent organs were ever reported5]. The case we presented is the first one in literature describing

true upper abdominal exenteration including the total exci-ion of the pancreas followed by a functioning gastrointestinaleconstruction.

onflict of interest statementone declared.

eferences

1] Gumaste VV, Dave PB. Ingestion of corrosive substances by adults. AmericanJournal of Gastroenterology 1992;87:1–5.

r Disease 46 (2014) 384–387 387

2] Poley JW, Steyerberg EW, Kuipers EJ, et al. Ingestion of acid and alkalineagents: outcome and prognostic value of early upper endoscopy. Gastrointesti-nal Endoscopy 2004;60:372–7.

3] Ananthakrishnan N, Parthasarathy G, Kate V. Acute corrosive injuries of thestomach: a single unit experience of thirty years. ISRN Gastroenterology2011:914013.

4] Andreoni B, Farina ML, Biffi R, et al. Esophageal perforation and causticinjury: emergency management of caustic ingestion. Diseases of the Esophagus1997;10:95–100.

5] Cattan P, Munoz-Bongrand N, Berney T, et al. Extensive abdominal surgery aftercaustic ingestion. Annals of Surgery 2000;231:519–23.

Salvatore Guarino ∗

Department of Surgical Science, Sapienza Universityof Rome, Italy

Fisayomi ShobayoYassar A. Qureshi

Flora DaleyBadriya Alaraimi

Bijendra PatelUpper GI Surgery Unit, The Royal London Hospital,

United Kingdom

∗ Corresponding author at: Dipartimento di ScienzeChirurgiche, “Sapienza” Università di Roma, Viale

Regina Elena 324, 00161 Roma, Italy.Fax: +39 06 490688.

E-mail addresses: salvatore.guarino@gmail.com(S. Guarino), fisayomishobayo@gmail.com(F. Shobayo), yassarqureshi@hotmail.co.uk

(Y.A. Qureshi), Floradaley@doctors.org.uk(F. Daley), Badria77@gmail.com (B. Alaraimi),

Bijendra.Patel@bartshealth.nhs.uk (B. Patel)

14 October 2013

3 December 2013

Available online 7 January 2014

http://dx.doi.org/10.1016/j.dld.2013.12.004