Surgical management of esophageal stenosis due to ingestion of corrosive substances.

BACKGROUND: Corrosive ingestion is a significant challenge for healthcare systems. Limited data are available regarding the best treatments, and there remains a lack of consensus about the optimal surgical approach and its outcomes. This study aims to review the current literature and show a single institution's experience regarding the surgical treatment of esophageal stenosis due to corrosive substance ingestion. METHODS: A retrospective review that accounted for demographics, psychiatric profiles, surgical procedures, and outcomes was performed. A systematic review of the literature was performed using PubMed. RESULTS: In total, 27 surgical procedures for esophageal stenosis due to corrosive substance ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. Esophagectomies and esophageal bypasses were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded. CONCLUSION: Surgical intervention either by esophagectomy or esophageal bypass results in durable relief from dysphagia. However, successful clinical outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

Quality of Life After Caustic Ingestion.

OBJECTIVE: The aim of the study was to evaluate long-term QOL after caustic ingestion. BACKGROUND: Caustic ingestion strongly affects patient's QOL but data on the topic is scarce in the literature. METHODS: QOL evaluation was conducted in survivors from a large cohort of patients with caustic injuries. QOL was assessed using the EORTC QLQ-OG25 module, the SF12v2 score, and the hospital anxiety and depression scale questionnaire. One hundred thirty-four patients (59 men, median age 43) completed the survey; 72 (54%) patients underwent emergency digestive resection and in 99 (74%) patients underwent esophageal reconstruction. Results of QOL questionnaires were compared to average values determined in healthy volunteers and in patients with esophageal cancers. RESULTS: The median QLQ-OG25 score was 44 (34, 62) and values were significantly lower when compared to a normal population (P < 0.0001). SF12v2 scores were significantly inferior to those expected in a normal population on both the physical component summary (PCS) (43.3 ±â€Š10.8; P < 0.0001) and the mental component summary (44 ±â€Š9.7; P < 0.0001) scales. Emergency esophageal resection was significantly associated with higher QLQ-OG25 scores (P < 0.0001), but not with mental component summary (P = 0.3), PCS (P = 0.76), HAD anxiety (P = 0.95), and HAD depression scores (P = 0.59); results were similar after extended emergency resection. When compared to esophagocoloplasty alone, pharyngeal reconstruction had a significant negative impact on QLQ-OG25 (P < 0.0001), PCS (P = 0.01), and HAD depression (P = 0.0008) scores. CONCLUSIONS: QOL is significantly impaired after caustic ingestion. QOL issues should not influence the emergency surgical strategy but deserve discussion before esophageal reconstruction for caustic injuries.

Vitriolage (vitriolism) - a medico-socio-legal review.

Vitriolage (acid attack) involves an intentional act of violence in which any corrosive is thrown onto the face and body of a person with the intention of disfiguring them. The most common type of corrosive used in these attacks is sulfuric acid (oil of vitriol) hence the name "vitriolage". Sulfuric acid is a strong acid/corrosive and has a toxic nature that is capable of causing bodily injuries leading to damage to mucous membranes, tissues and skin with blindness, burning, and scars often leading to significant disfigurement with temporary or permanent disability. The main reasons for acid attacks are marriage refusal, rejection of love proposals, dowry issues and male aggression. Acid attacks have horrendous physical, social, psychological and economic effects on victims. This review will delineate the various legal provisions relating to acid attacks with special reference to the recent Indian Criminal Law Amendment Act of 2013 which addressed the issue of these attacks specifically by making it a separate offence in the Indian Penal Code under sections 326 A and B. The Bangladesh Acid Offences Prevention Act 2002 and Acid Crime Control Act, 2002, and legislation and policies combating acid attacks in Cambodia, Nepal and Pakistan will also be mentioned. Additionally, the paper will discuss the role of the judiciary in South Asia by focusing on other landmark judgments and decisions and throw light on the campaign in India namely "Stop Sale Acid" aimed at stopping the unrestricted sale of acid. Finally, further suggestions are proposed to assist in combating this heinous crime.

Acid attacks: Broadening the multidisciplinary team to improve outcomes.

A rise in the current trend of corrosive substance attacks have been reported in the UK, causing devastating effects on victims. The optimal management of these patients requires the specialist skills of the burn multidisciplinary team (MDT) to address the resulting physical and psychological trauma experienced. However, burn care must commence in the pre-hospital setting. The public and first responders are invaluable resources in helping to limit the adverse effects of burns. Challenges of burn care outside the Burns Unit are not limited to the treatment of the injured patient and the rehabilitation of survivors. These challenges also encompass better education of the public and allied health professionals, as well as planning strategies to reduce the incidence of acid attacks. Prevention is always better than cure. This paper discusses the broadening of the MDT to improve outcomes in acid attacks by exploring the wider roles of the public, media, emergency services, police, legislation and better education.

Corrosive attacks in the UK - Psychosocial perspectives and decontamination strategies.

Acid attacks, or vitriolage, are defined as violent assaults involving the deliberate throwing of an acid or similarly corrosive substance with the intention to "maim, disfigure, torture or kill" [1]. The Acid Survivors Trust International suggest a prevalence of 1500 attacks reported worldwide per annum, although this is likely to be an underestimate by 40% [2]. The UK is thought to have one of the highest of rates of recorded corrosive attacks, with an increase from 228 attacks in 2012 to 601 in 2016. Most were reported by the London Metropolitan police force followed by Northumbria, Cambridgeshire, Hertfordshire, Greater Manchester and Humberside [[2]]. The chemical agents involved include acids, alkalis, oxidising and reducing agents, alkylating and chelating agents and solvents. They cause injury by producing a chemical interaction which can lead to extensive tissue destruction and extreme pain. Herein, we present a review on the changing epidemiology of corrosive attacks in the UK and currently employed management strategies.

Conceptual model of acid attacks based on survivor's experiences: Lessons from a qualitative exploration.

INTRODUCTION: Acid attack, a worldwide phenomenon, has been increasing in recent years. In addition to severe injuries to the face and body, such violence leads to psychological and social problems that affect the survivors' quality of life. The present study provides a more in-depth understanding of this phenomenon and explores the nature and dimensions of acid attacks based on survivors' experiences. METHOD: A grounded theory study using semi-structured, recorded interviews and applying purposeful theoretical sampling was conducted with 12 acid attack survivors in Iran. Data were analysed using constant comparison in open, axial and selective coding stages. RESULTS: A conceptual model was developed to explain the relationships among the main categories extracted through the grounded theory study. Physical and psychological wounds emerged as a core category. Traditional context and extreme beauty value in society acted as the context of the physical and psychological wounds experienced. Living with a drug abuser with behavioural disorders and lack of problem-solving skills in interpersonal conflict were found to be causal conditions. Action strategies to deal with this experience were found to be composed of individual, interpersonal and structural levels. Education, percentage and place of burning acted as intervening conditions that influenced survivors' strategies. Finally, adverse consequences of social deprivation and feeling helpless and hindered were found to have an important impact. CONCLUSIONS: Acid attack lead to physical and psychological wounds in survivors. This is a multi-dimensional phenomenon involving illness, disability, and victimization, and requires a wide range of strategies at different levels. The conceptual model derived through this study can serve as a good basis for intervention programs.

Conservative management of severe caustic injuries during acute phase leads to superior long-term nutritional and quality of life (QoL) outcome.

PURPOSE: Best clinical management of severe caustic injury is still a subject of debate. Most surgical teams consider severe caustic injury as an indication for emergency surgery. But, under certain circumstances, conservative management is feasible, avoids the need for gastrectomy, and has a low mortality rate. Postponed reconstructive surgery is usually performed several months after caustic ingestion to restore intestinal continuity or to treat stricture sequelae. This study aimed to investigate long-term nutritional and quality of life (QoL) outcomes after reconstructive surgery for high-grade esophageal and gastric caustic injury. METHODS: Twenty-one patients were assessed for biological and nutritional parameters, physical findings, and quality of life surveys at least 25 months after reconstructive surgery among patients who have required emergency surgery (n = 10) and patients who did not undergo emergency surgery (n = 11). RESULTS: After median follow-up of 74 months (after caustic ingestion) and 67 months (after reconstructive surgery), patients who avoided emergency surgery experienced faster oral diet resumption (49 vs. 157 days, p = 0.004), less weight loss (0.3 vs. 20 kg, p = 0.002), greater body fat percentage (22 vs. 18 %, p = 0.046), better nutritional and physical status (SF12 PCS 51 vs. 43, p = 0.036), and less trouble eating (EORTC QLQ-OG 25 31 vs. 56, p = 0.01). CONCLUSIONS: Our study is the first to evaluate long-term nutritional and QoL outcomes, following severe caustic injury. It demonstrates better long-term nutritional outcomes and QoL in patients suitable for initial conservative management. These results support full functional recuperation of spared organs, even severely burned. In the absence of clinical or biological signs necessitating immediate surgery, conservative management should be advocated.

Tweens feel the burn: "salt and ice challenge" burns.

PURPOSE: To review our institution's experience with frostbite injury secondary to "salt and ice challenge" (SIC) participation. METHODS: We conducted a retrospective analysis of intentional freezing burns from 2012 to 2014. Demographics, depth and location of burn, total body surface area of burn, treatment, time to wound healing, length of stay, complications, and motives behind participation were analyzed. RESULTS: Five patients were seen in the emergency department for intentional freezing burns that resulted from SIC (all females; mean age: 12.3 years; range age: 10.0-13.2 years). Mean total body surface area was 0.408%. Salt and ice was in contact with skin for >10 min for two patients, >20 min for two patients, and an unknown duration for one patient. Complications included pain and burn scar dyschromia. Four patients cited peer pressure and desire to replicate SIC as seen on the Internet as their motivation in attempting the challenge. CONCLUSION: SIC has become a popular, self-harming behavior among youths. Increased public education, and provider and parent awareness of SIC are essential to address this public health concern.

Cognitive and behavioral characteristics of children with caustic ingestion.

BACKGROUND/AIM: Children with attention-deficit/hyperactivity disorder (AD/HD) have risk taking behavior and are more prone to sustaining injury. It is aimed to evaluate the cognitive and behavioral characteristics of children with caustic ingestion. PATIENTS AND METHODS: Ninety two children with a history of nonsuicidal caustic ingestion (CI, n=46) and healthy subjects (HS, n=46) admitted to pediatric surgery department were enrolled into the study. Patients in groups were evaluated for age, sex, number of siblings and educational status of the parents. Before filling the questionnaires, the children were undergone flexible endoscopy and treated accordingly. Conners Parents Rating Scale-revised long form (CPRS-R:L), validated for Turkish Children, was used to evaluate the cognitive and behavioral characteristics of children. Parents rate their child's behavior with a four-point Likert scale. Subscales of CPRS-R:L including cognitive problems/inattention (CG/I), hyperactivity (H), attention deficit hyperactivity disorder index (AD/HD-I), Conners' Global Index-discomfort-impulsivity (CGI-DI), DSM-IV-symptom subscale-inattention (DSMIV, SS-I), DSM-IV-symptom subscale-hyperactivity-impulsivity (DSM-IV, SS-HI), DSMIV-symptom subscale-total score (DSM-IV SS-T) were used to determine the severity of the AD/HD symptom. Demographic features and cognitive/behavioral characteristics of children with caustic ingestion were compared with healthy subjects. RESULTS: The median age of the patients was 4 (2-14 years) in both CI and HS groups. Female male ratio was 13:33 in CI and 12:34 in HS. Sixty seven percent of patients were preschool children (younger than 5 years of age) in both CI and HS groups. There was no difference between groups for number of siblings (p>0.05). Parents of HS group had higher educational status than parents in CI (p<0.05). When subscale scores of CPRS-R:L compared between CI and HS groups, CI group had higher CGI-DI scores than HS (p<0.05). Children younger than five years of age had higher scores of H, emotional instability and total CG/I in CI than HS group (p<0.05). CONCLUSION: Children with caustic ingestion had impulsiveness behavior when compared to healthy children. In addition to impulsivity, hyperactivity can be also assessed as a risk factor for caustic ingestion in children younger than 5years of age. We suggest that association between AD/HD behavior and risk of sustaining injuries was also confirmed for caustic ingestion in children.

[Deliberate burning with acid. New expressions of violence against women in Medellín, Colombia. Series of cases]. / Quemaduras intencionales con ácido. Nuevas expresiones de violencia contra la mujer en Medellín, Colombia. Serie de casos.

INTRODUCTION: The deliberate burns with acid are recognized as violence against women described in the 17th century. However, in the second half of the 20th Century this practice becomes frequent in South East Asia, Africa and Middle East. In Latin America is a recent phenomena over which little has been published in the scientific literature. OBJECTIVE: To describe the clinical and psychic-pathological characteristics of 8 Colombian women burned with acid in the context of violence based on gender. METHOD: retrospective series of cases, patients admitted at a university hospital in a period of 7 years after being burned with acid within the context of hetero-aggression. The patients were attended by a group of interdisciplinary health professionals, including the psychiatrists. The psychiatric analyses were carried out parting from the non structured psychiatric interview complying with diagnostic criteria of the Statistic and Diagnostic Manual. RESULTS: Eight women with an average age of 29.5 years were attacked with acid in a period of 8 years. The context for the aggression was violence based on gender. All the attackers were males. The body surface burned was 24% in average. The ocular involvement was present in 80% of the cases, two of them with bilateral blindness. The direct aggressor was the partner in three cases. The reason for the attack was jealousy and revenge due to rejection to sexual or love advancements or pretensions. CONCLUSIONS: The burns with acid constitute a new expression of the violence based on gender in Colombia. This type of aggressions generates suffering, rejection and social isolation and although, it does not have the intent to cause death to the victim, it does leave permanent scars of the aggression.

Cost-effectiveness of osteo-odonto keratoprosthesis in Singapore.

PURPOSE: To determine the long-term cost-effectiveness of osteo-odonto keratoprosthesis (OOKP) relative to no treatment among patients with end-stage corneal and ocular surface diseases in Singapore. DESIGN: Cost-effectiveness analysis based on data from a retrospective cohort study. METHODS: From a health system perspective, we calculated the incremental cost-effectiveness ratio of OOKP treatment relative to no treatment over a 30-year horizon, based on data from a cohort of 23 patients who underwent OOKP surgery between 2004 and 2009 at Singapore National Eye Centre. Preoperative and postoperative vision-related quality-of-life values were estimated from patients' visual outcomes and were used to calculate the gain in quality-adjusted life years (QALYs) resulting from OOKP treatment. Unsubsidized costs for surgery, consultations, examinations, medications, follow-up visits, and treatments for complications were retrieved from patients' bills to estimate the total costs associated with OOKP treatment. Sensitivity analyses were conducted to test the robustness of the model. RESULTS: Over a 30-year period, OOKP treatment, compared with no treatment, improved QALYs by 3.991 among patients with end-stage corneal and ocular surface diseases at an additional cost of S$67 840 (US$55 150), resulting in an incremental cost-effectiveness ratio of S$17 000/QALY (US$13 820/QALY). CONCLUSIONS: Based on commonly cited cost-effectiveness benchmarks, the OOKP is a cost-effective treatment for patients with end-stage corneal and ocular surface diseases.

Quemaduras intencionales con ácido. Nuevas expresiones de violencia contra la mujer en Medellín, Colombia. Serie de casos / [Deliberate burning with acid. New expressions of violence against women in Medellín, Colombia. Series of cases].

INTRODUCTION: The deliberate burns with acid are recognized as violence against women described in the 17th century. However, in the second half of the 20th Century this practice becomes frequent in South East Asia, Africa and Middle East. In Latin America is a recent phenomena over which little has been published in the scientific literature. OBJECTIVE: To describe the clinical and psychic-pathological characteristics of 8 Colombian women burned with acid in the context of violence based on gender. METHOD: retrospective series of cases, patients admitted at a university hospital in a period of 7 years after being burned with acid within the context of hetero-aggression. The patients were attended by a group of interdisciplinary health professionals, including the psychiatrists. The psychiatric analyses were carried out parting from the non structured psychiatric interview complying with diagnostic criteria of the Statistic and Diagnostic Manual. RESULTS: Eight women with an average age of 29.5 years were attacked with acid in a period of 8 years. The context for the aggression was violence based on gender. All the attackers were males. The body surface burned was 24

in average. The ocular involvement was present in 80

of the cases, two of them with bilateral blindness. The direct aggressor was the partner in three cases. The reason for the attack was jealousy and revenge due to rejection to sexual or love advancements or pretensions. CONCLUSIONS: The burns with acid constitute a new expression of the violence based on gender in Colombia. This type of aggressions generates suffering, rejection and social isolation and although, it does not have the intent to cause death to the victim, it does leave permanent scars of the aggression.

The impact of psychological illness on outcome of corrosive esophageal injury.

PURPOSE OF STUDY: Esophageal stricture is a debilitating condition with significant morbidity and mortality, occurring often as a complication of the ingestion of corrosives. In the adult, majority of cases are intentional whilst being accidental in the pediatric population. We therefore sought to describe the circumstances of intentional corrosive ingestion and determine the presence and impact of psychiatric illness on the outcome of management. MATERIALS AND METHODS: A retrospective analysis of case folders of patients managed with this condition over a ten-year period (2000-2009) was done by comparing sociodemographics and outcome of management in patients with and without psychiatric disorders. RESULTS: Twenty seven cases were reviewed. Mean age was 30.7 (SD =16.01), with a M:F ratio of 1.25:1.86.2% had a diagnosable psychiatric condition, the most common being depression in 55.6% of the patients. Caustic soda (55.6%) was the most common corrosive ingested. There was a significant difference in mean duration before presentation in patients with (1.7 days) and without (6.6 days) previous psychiatric illness (P = 0.01). A significant positive association was also found between surgical outcome and previous history of psychiatric disorder (P = 0.02). CONCLUSION: Early recognition of psychosocial distress is important to prevent deliberate self-harm. Counter-intuitively, a previous history of psychopathology limits esophageal injury by early presentation and therefore improve chances of a good surgical outcome.

Impact of psychological problems in chemical warfare survivors with severe ophthalmologic complication, a cross sectional study.

BACKGROUND: Sulfur mustard (SM) has been used as a chemical warfare agent since the early twentieth century. Despite the large number of studies that have investigated SM induced ocular injuries, few of those studies have also focused on the psychological health status of victims. This study has evaluated the most prominent influences on the psychological health status of patients with severe SM induced ocular injuries. METHODS: This descriptive study was conducted on 149 Iranian war veterans with severe SM induced eye injuries. The psychological health status of all patients was assessed using the Iranian standardized Symptom Check List 90-Revised (SCL90-R) questionnaire. The results of patients' Global Severity Index (GSI) were compared with the optimal cut-off point of 0.4 that has previously been calculated for GSI in Iranian community. The Mann-Whitney U test, T tests and effect sizes (using Cohen's d) were employed as statistical methods. Data were analyzed using SPSS software. RESULTS: The mean age of patients was 44.86 (SD=8.7) and mean duration of disease was 21.58 (SD=1.20) years. Rate of exposure was once in 99 (66.4%) cases. The mean GSI (1.46) of the study group was higher compared to standardized cut off point (0.4) of the Iranian community. The results of this study showed that the mean of total GSI score was higher in participants with lower educational levels (effect size=0.507), unemployment (effect size=0.464) and having more than 3 children (effect size=0.62). Among the participants, 87 (58.4%) cases had a positive psychological history for hospitalization or receiving outpatient cares previously and 62 (41.6%) cases had a negative psychological history. In addition, the mean of GSI in participants with negative psychological history was lower than those with positive psychological history (Mean Change Difference=-0.621 with SD=0.120). There was a significant difference between positive and negative psychological history with respect to GSI (P<0.001). CONCLUSION: The study showed that severe ophthalmologic complications in chemical survivors are accompanied with destructive effects on psychological health status. Appropriate management may improve psychological health status in these patients.

Vision-related quality of life in patients with ocular chemical burns.

PURPOSE: To assess vision-related quality of life in patients with ocular chemical burns by the application of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25). METHODS: Eighty-seven patients with ocular chemical burns were enrolled in the study from January 1 through May 31, 2010. Apart from the collection of sociodemographic and clinical data, NEI VFQ-25 with an additional appendix question, being translated to Chinese, was administered to all subjects. Main outcome measures were comparison of the NEI VFQ-25 subscale item scores among subgroups and multivariate analysis of the NEI VFQ-25 subscale scores. RESULTS: Fifty-five subjects were bilaterally burned and the rest were unilaterally injured. The mean age of enrolled subjects was 39.4 ± 11.6 years, with the majority being male (98.9%) and worker (77.0%); the mean composite score of all subjects was 40.4 ± 23.8. The composite score and majority subscale scores of binocularly injured patients were significantly lower than those of monocularly injured patients. Further comparisons among groups divided by either clinical severity classification or best-corrected visual acuity (BCVA) produced similar results. The BCVA of both the better-seeing eye and the worse-seeing eye strongly correlated with the NEI VFQ-25 composite score (ρ = 0.664 and 0.498, both P = 0.000). Multivariate regression analysis revealed that the VFQ-25 composite score correlated significantly with the following independent variables: BCVA of the better-seeing eye and the worse-seeing eye, the injury classification of the less severely injured eye, and correct and immediate irrigation after injury as well. CONCLUSIONS: Ocular chemical burns have a significant and extensive impact on patients' visual function outcomes and vision-related quality of life.

Epidemiology of burn injuries: highlighting cultural and socio-demographic aspects.

Burns are devastating injuries that disproportionately affect people in developing countries, including children. In addition to a high mortality rate, survivors are burdened with life-long physical and emotional scars. The etiology and nature of burn injuries varies significantly by country, and this chapter explores the predominant causes and patterns of burn injury in both the developing and industrialized worlds. Gender differences play a significant role in the risk of burn injuries, across a spectrum with a predominance of women injured in fires from cooking and heating fuels in the developing world and industrial accidents primarily affecting men in developed nations. Children are particularly vulnerable to burn injuries, accounting for almost 50% of all burn patients in some studies. A majority of pediatric burns are scald injuries usually affecting very young children below the age of 5 years, and we discuss the behavioral patterns underlying this finding. Finally, the elderly form a rapidly increasing proportion of the population in many countries, and are often burdened with comorbidities that are likely to pose significant challenges in burn care.

Quality of life impact as outcome in burns patients.

PURPOSE: Severe burns have not only physical but also psychological consequences both during and after hospitalisation. By identifying the mainly impaired areas of a patient's quality of life (QoL), specific psychological support programmes can be provided. The assessment of subjectively perceived QoL impairment can also provide an indicator of the outcome of the medical and psychological treatment. METHOD: This study used the Sickness Impact Profile (SIP) to investigate QoL in 30 burned patients after discharge and again three months' later. RESULTS: At the first assessment, both the physical and psychological dimensions were significantly impaired, although there was an improvement at the 3-month follow-up, particularly in the physical dimension. Data suggest that there are QoL areas that appear to be compromised in burn patients. Even after hospital discharge, the burn injury causes major limitations that extend well beyond the physical area and involve emotional, social and relational aspects. Nevertheless, most of the categories in the physical dimension tend to improve during follow-up and, three months after the first administration, the predominant limitations are in emotional behaviour and sleep and rest in the psychosocial dimension. The SIP score matched for depth and extent of burns show that females were in poorer health than males. At the first administration, gender-related differences were particularly marked in Ambulation (p = .005), Body Care and Movement (p = .004), Home Management (p = .013), Mobility (p = .011), Physical Dimension (p = .004) and the QoL general score (p = .031). Although all of these areas had improved by the time of the retest, the gender-related differences remained. The categories assessed with the Psychosocial Dimension of SIP did not correlate with the clinical parameters of the burn, whereas those pertaining to the Physical Dimension did. CONCLUSION: Multidisciplinary support for burn patients appears to be necessary even many months after hospital discharge.

Early intervention reduces morbidity in extravasation injuries from 'lighter fuel' injection.

Injection of 'lighter fuel' with suicidal intent is rare. Extravasation of the chemical may rarely cause systemic toxicity, but usually it results in extensive soft tissue damage. Such injuries when managed by the traditional expectant policy are associated with considerable morbidity. Early aggressive surgical management using 'saline flush out' limits the tissue damage by stopping the natural progression of the chemical mediated injury and the subsequent inflammatory response, thereby allowing better skin preservation and functional outcome in these cases. We report a case of 'lighter fuel' subcutaneous extravasation injury managed by 'saline flush out' technique soon after presentation.