title: Computed tomography evaluation of high-grade esophageal necrosis after corrosive ingestion to avoid unnecessary esophagectomy.
abstract: 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.
  
  
  CONCLUSIONS
  The decision to perform emergency esophagectomy for endoscopic high-grade corrosive esophageal injury should rely on CT findings.
authors.affiliation: Department of General, Endocrine and Digestive Surgery, Saint-Louis Hospital, APHP, Université Paris 7 Diderot, Paris, France, mirceaxx@yahoo.com.
authors.forename: Mircea
authors.initials: M
authors.lastname: Chirica
authors.forename: Matthieu
authors.initials: M
authors.lastname: Resche-Rigon
authors.forename: Benjamin
authors.initials: B
authors.lastname: Pariente
authors.forename: Fabienne
authors.initials: F
authors.lastname: Fieux
authors.forename: François
authors.initials: F
authors.lastname: Sabatier
authors.forename: Franck
authors.initials: F
authors.lastname: Loiseaux
authors.forename: Nicolas
authors.initials: N
authors.lastname: Munoz-Bongrand
authors.forename: Jean Marc
authors.initials: JM
authors.lastname: Gornet
authors.forename: Marie-Dominique
authors.initials: MD
authors.lastname: Brette
authors.forename: Emile
authors.initials: E
authors.lastname: Sarfati
authors.forename: Elie
authors.initials: E
authors.lastname: Azoulay
authors.forename: Anne Marie
authors.initials: AM
authors.lastname: Zagdanski
authors.forename: Pierre
authors.initials: P
authors.lastname: Cattan
mesh_terms: D000328:Adult; D002057:Burns, Chemical / Q000000981:diagnostic imaging* / Q000401:mortality / Q000473:pathology / Q000601:surgery; D002424:Caustics / Q000633:toxicity*; D016629:Esophagectomy; D004945:Esophagoscopy; D004947:Esophagus / Q000000981:diagnostic imaging / Q000293:injuries* / Q000473:pathology / Q000601:surgery; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D009336:Necrosis / Q000000981:diagnostic imaging / Q000601:surgery; D012189:Retrospective Studies; D013406:Suicide, Attempted; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D019564:Unnecessary Procedures
chemical_list: D002424:Caustics