Indian J Thorac Cardiovasc Surg (2010) 26:198–203 DOI 10.1007/s12055-010-0040-x
ORIGINAL ARTICLE
Aluminium phosphide poisoning with esophageal stricture and tracheoesophageal fistula Damyanti Agrawal & Anand Kumar & Mumtaz Ahmed Ansari & Vivek Srivastava & Tapan Kumar Lahiri
Received: 26 March 2010 / Revised: 21 May 2010 / Accepted: 8 July 2010 / Published online: 13 August 2010 # Indian Association of Cardiovascular-Thoracic Surgeons 2010
Abstract Background Aluminium phosphide tablets popularly known, as ‘celphos’ is a highly toxic fumigant used as insecticide for preservation of food grains. India is an agricultural country and celphos tablets are easily available to psychologically vulnerable young people. It is swallowed with suicidal intent and death comes in minutes. Patients and methods In this series there were seven patients with tracheo esophageal complications out of 342 patients reviewed. Four patients had esophageal stricture and three had stricture plus tracheo esophageal fistulas. Types of symptoms including progressive dyshagia and extent of respiratory symptoms were evaluated. Nutrition status and success or failure of dilatation at the time of endoscopy was taken into account. The criteria for oesophageal replacement was failed dilatation and compli-
cations. They were treated with supportive treatment, antegrade esophageal dilatation, gastric bypass and colon bypass. This was a descriptive interventional study. Results One of the two patients died before any definitive procedure could be done. Survivors were followed up for 7 months to 4 years. They were evaluated by Quantitative and Qualitative measure instrument (QQMI). QQMI showed the final out come as ‘good’ in one patient and ‘very good’, in four patients. Conclusions Due to their psychological state, inability to swallow oral medicines, critical nature of illness these patients needed intensive individualized therapy to obtain a good outcome. Keyword Fistula . Computed tomography . Endoscopy
Introduction D. Agrawal (*) : T. K. Lahiri Department of Cardiothoracic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005 UP, India e-mail:
[email protected] T. K. Lahiri e-mail:
[email protected] A. Kumar : M. A. Ansari : V. Srivastava Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP, India A. Kumar e-mail:
[email protected] M. A. Ansari e-mail:
[email protected] V. Srivastava e-mail:
[email protected]
Aluminium phosphide tablet is a fumigant and widely used as an insect repellent, for preservation of food grains. Swallowing Aluminium Phosphide tablets can produce esophageal edema, hyperemia, mucosal bleeding, ulceration, perioesophageal penetration, perioesophagitis, stricture and fistula. The changes follow prolonged contact, impaction and chemical reaction in the low motility areas of esophagus. The effect is due to release of phosphine gas, which is a mitochondrial toxin that inhibits cytochrome oxidase, and subsequent generation of reactive oxygen species. This results in cytoplasmic toxic effects, dehydration, oxidation-reduction, bleb formation and corrosion. The chemical effects are responsible for various corrosive changes in the lumen of the aero-digestive tract. Aluminium phosphide (celphos, alphos, quickphos) is available as tablets (3 gm) or as pellets (0.6 gm). The various forms of
Indian J Thorac Cardiovasc Surg (2010) 26:198–203
aluminium phosphide available are broken or granular powder of the exposed tablets and fresh active tablets. Ingestion of the fresh active tablet form has the highest mortality. An unexposed half tablet (1.5 gm) is usually fatal [1]. The fatal dose for a 70 Kg adult is 0.5 gm [2]. The tablet is composed of an active ingredient, aluminium phosphide, and an inert ingredient, ammonium carbamate/ carbonate in the ratio of 56:44, respectively. On contact with moisture each 3 gm tablet liberates about 1 gm of phosphine gas along with carbon dioxide and ammonia, which prevents self-ignition of phosphine. This is why it is known as protective gas. Phosphine gas may spontaneously ignite in presence of oxygen above a threshold limit of 0.48 to 1.9% (v/v) [3]. The study reports seven patients with esophageal strictures and/or associated tracheo esophageal fistulae that occurred after attempted suicidal poisoning with exposed tablets of aluminium phosphide.
Materials and methods A retrospective study was conducted in the university hospital from 2004 to 2007 that included patients with celphos poisoning secondary to ingestion of exposed tablets. These patients developed esophageal stricture with or without tracheo esophageal fistula. Institutional review board approved the retrospective review of this material. The demographic profile, intent of poisoning and socio economic conditions were analyzed. Clinical including progressive dysphagia and extent of respiratory symptoms along with nutritional status and routine hematological examinations were performed. Preoperative assessments were performed by X-Ray of the neck, barium swallow examination and Computed Tomography (CT )scan. The most important diagnostic technique was ‘Panendoscopy’ i.e. complete visualization of nasal passages, naso-orolaryngopharynx, larynx, subglottic area, trachea, bronchial tree, cricopharynx, entire esophagus and stomach with help of flexible fiberoptic bronchoscope, and esophagoscope. When the acute stage was over, patients under went dilatation protocol, if they had short segment and isolated stricture. In patients with multiple strictures, long segment stricture, and following failed or complications of dilatation, surgery was preferred. Repeated dilatation was performed using olive pointed gum elastic or Neoplex dilators, wire guided Savary Gilliard dilators, or guide wire mounted balloon dilator (Eliminator) as per need of the patient (daily to three weekly). The methods of dilatation were graduated bougie, forced pneumatic dilatation with balloon, and through the scope balloon. The patients were frequently evaluated by dysphagia scoring system, into five categories: Swallowing normal diet (score 0), swallowing solids (Score 1), swallowing
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semisolids (Score 2), swallowing liquids only (score 3), and not swallowing even liquids (score 4). Scores were summated on follow up [4]. The salient anesthetic principles were followed with the goal of obtaining an extubated patient with adequate airway at the end of the procedure. These included premedication with acid suppression, intravenous or inhalational induction, spontaneous ventilation, controlled ventilation, rapid isolation of tracheo esophageal fistula, single lung ventilation, and distal ventilation during resection of lesion, railroading technique to provide distal ventilation during reconstruction. Operative strategies depended on the nature of the lesion. For stricture of the esophagus with difficult distal assessment and extensive involvement, gastric tubes were used. An isoperistaltic coloplasty was reserved for long strictures. The approach for tracheo esophageal fistula was cervical and abdominal exploration for gastric or colonic conduits to bypass the fistulae. Thoracotomy was reserved for lower tracheal, carinal and bronchial lesion. The colonic conduit was based on middle colic artery and right colic artery. In all cases feeding jejunostomy or gastrostomy was done to maintain nutrition. The outcome of dilatation and surgical process was measured by using QQMI. This was possible because this was a consecutive non-randomized controlled study with a prospective longitudinal phase. There were seven items designed to measure the health related quality of life (physical, social and psychological). Item 1 measures the psychological domain and also introduces the patient and the interviewer. Item 2 measures the social domain of the patient along with preoperative symptoms. Item 3 measures the physical domain and evaluates the late complications of the procedure. Item 4 addresses early postoperative complications and most of the surgical outcomes traditionally reported. Item 5 measures the physical and social domains together. Item 6 and 7 measure the psychological, physical and social domains all together. QQMI evaluated the satisfaction of the patient with the surgery. The final score obtained allows for stratification of the results in five levels of final outcome [5]. Categorical variables were reported as a percentage and comparative analysis was performed by student’s t-test. Statistical significance level was defined at p
