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Gaspar Reis S, Bernardo P, Mendonça N, Além H, Caetano Z. From an Enteroatmospheric to an Enterocutaneous Fistula Using a Condom. Cureus 2024; 16:e74209. [PMID: 39712812 PMCID: PMC11663260 DOI: 10.7759/cureus.74209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2024] [Indexed: 12/24/2024] Open
Abstract
An enteroatmospheric fistula (EAF) is one of the most feared complications of damage control laparotomy. Its management is highly challenging, often requiring multiple surgeries and prolonged hospitalization. It is a serious condition, and despite significant improvements in mortality rates due to advancements in intensive care, the rate remains substantial. We describe the case of a 75-year-old male who presented to the emergency department with abdominal pain one day after being discharged from another hospital following an elective converted cholecystectomy. He underwent emergency median relaparotomy, revealing fecal peritonitis and jejunum leakage. Following the jejunal segmental resection with mechanical anastomosis, we chose to leave the abdomen open. Eight days later, an EAF was established, and the abdomen was classified as grade 4 according to Bjork (classification of 2016). To manage this complication a four-step technique was employed: latex condom-EAF anastomosis, fistula ring creation, negative pressure wound therapy (NPWT), and adaptation of an ostomy bag. Nine weeks later, the wound was fully healed, and the stoma completely matured. Several recent reports have discussed the treatment of this condition. Techniques employing a baby bottle nipple, silicon plug, and floating stoma have shown promising results. NPWT was considered to increase the risk of fistula formation for many years, but additional studies have demonstrated its safety. No gold standard therapy has been established for EAF treatment; therefore, decisions rely on the surgical staff's experience. This technique for effluent control in patients with a Björk grade 4 abdomen and established EAF is easily reproducible and safe.
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Affiliation(s)
| | | | - Nuno Mendonça
- General Surgery, Centro Hospitalar Barreiro Montijo, Barreiro, PRT
| | - Hélder Além
- General Surgery, Centro Hospitalar Barreiro Montijo, Barreiro, PRT
| | - Zara Caetano
- General Surgery, Centro Hospitalar Barreiro Montijo, Barreiro, PRT
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2
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Menni A, Stavrou G, Tzikos G, Shrewsbury AD, Kotzampassi K. Endoscopic Salvage of Gastrointestinal Anastomosis Leaks—Past, Present, and Future—A Narrated Review. GASTROINTESTINAL DISORDERS 2023; 5:383-407. [DOI: 10.3390/gidisord5030032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2025] Open
Abstract
Background: Anastomotic leakage, which is defined as a defect in the integrity of a surgical join between two hollow viscera leading to communication between the intraluminal and extraluminal compartments, continues to be of high incidence and one of the most feared complications following gastrointestinal surgery, with a significant potential for a fatal outcome. Surgical options for management are limited and carry a high risk of morbidity and mortality; thus, surgeons are urged to look for alternative options which are minimally invasive, repeatable, non-operative, and do not require general anesthesia. Methods: A narrative review of the international literature took place, including PubMed, Scopus, and Google Scholar, utilizing specific search terms such as “Digestive Surgery AND Anastomotic Leakage OR leak OR dehiscence”. Results: In the present review, we try to describe and analyze the pros and cons of the various endoscopic techniques: from the very first (and still available), fibrin gluing, to endoclip and over-the-scope clip positioning, stent insertion, and the latest suturing and endoluminal vacuum devices. Finally, alongside efforts to improve the existing techniques, we consider stem cell application as well as non-endoscopic, and even endoscopic, attempts at intraluminal microbiome modification, which should ultimately intervene pre-emptively, rather than therapeutically, to prevent leaks. Conclusions: In the last three decades, this search for an ideal device for closure, which must be safe, easy to deploy, inexpensive, robust, effect rapid and stable closure of even large defects, and have a low complication rate, has led to the proposal and application of a number of different endoscopic devices and techniques. However, to date, there is no consensus as to the best. The literature contains reports of only small studies and no randomized trials, failing to take into account both the heterogeneity of leaks and their different anatomical sites.
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Affiliation(s)
- Alexandra Menni
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - George Stavrou
- Department of General Surgery, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, UK
| | - Georgios Tzikos
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Anne D. Shrewsbury
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Katerina Kotzampassi
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
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Brito M, Nunes G, Luz C, Oliveira G, Pinto Marques P, Fonseca J. Niti-S Esophageal Mega-Stent: An Emerging Endoscopic Tool with Different Applications in the Management of Surgical Anastomotic Leaks. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:45-51. [PMID: 37818399 PMCID: PMC10561319 DOI: 10.1159/000524420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/08/2022] [Indexed: 10/12/2023]
Abstract
Introduction Anastomotic leak (AL) is a dangerous complication in the early postoperative period after total gastrectomy or esophagectomy being associated with high mortality. Self-expandable metal stents (SEMS) play a significant role in AL management. Only one case report described the use of Mega-Stent in AL setting. The authors report a two-case series with different applications of a Niti-S esophageal Mega-Stent in AL management. Case Report Case 1 is a 67-year-old male who underwent an esophagectomy due to a squamous cell carcinoma of the distal esophagus. The early postoperative period was complicated with AL and gastropleural fistula. Initially, an OTSC was deployed in the dehiscence but failed to resolve AL. The esophageal Mega-Stent was further placed in-between the esophagus and the bulbus. Post-stenting contrast studies confirmed no further AL.Case 2 is an 86-year-old woman who underwent total gastrectomy with roux-en-y esophagojejunostomy due to a gastric adenocarcinoma, complicated with AL. A partially covered metal stent (PCMS) was placed to cover the anastomosis. Computed tomography confirmed leakage persistence and a second PCMS was deployed, resolving the AL. Several weeks later, both PCMSs presented ingrowth from granulation tissue. An esophageal Mega-Stent was placed (stent-in-stent technique) and 2 weeks later, all stents were removed, with no AL recurrence. Discussion/Conclusion SEMS placement for AL is a safe, well-established therapeutic technique. Limitations include stent migration and incomplete cover of large AL. Mega-Stent can be an emerging tool for endoscopic AL management.
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Affiliation(s)
- Mariana Brito
- Department of Gastroenterology, Hospital Garcia de Orta, Almada, Portugal
- PaMNEC – Grupo de Patologia Médica, Nutrição e Exercício Clínico, CiiEM, Centro de investigação interdisciplinar Egas Moniz, Monte da Caparica, Portugal
| | - Gonçalo Nunes
- Department of Gastroenterology, Hospital Garcia de Orta, Almada, Portugal
- PaMNEC – Grupo de Patologia Médica, Nutrição e Exercício Clínico, CiiEM, Centro de investigação interdisciplinar Egas Moniz, Monte da Caparica, Portugal
| | - Carlos Luz
- Department of Surgery, Hospital Garcia de Orta, Almada, Portugal
| | - Gabriel Oliveira
- Department of Surgery, Hospital Garcia de Orta, Almada, Portugal
| | | | - Jorge Fonseca
- Department of Gastroenterology, Hospital Garcia de Orta, Almada, Portugal
- PaMNEC – Grupo de Patologia Médica, Nutrição e Exercício Clínico, CiiEM, Centro de investigação interdisciplinar Egas Moniz, Monte da Caparica, Portugal
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Ahn JY. Endoscopic management of postoperative upper gastrointestinal leakage. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ji Yong Ahn
- Departments of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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5
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Combined endoscopic-percutaneous treatment of upper gastrointestinal enterocutaneous fistula using vacuum therapy and resorbable plug insertion (Vac-Plug). Sci Rep 2022; 12:12221. [PMID: 35851392 PMCID: PMC9293963 DOI: 10.1038/s41598-022-15732-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/28/2022] [Indexed: 11/08/2022] Open
Abstract
After gastrointestinal resections, leakages can occur, persist despite conventional therapy and result in enterocutaneous fistulae. We developed a combination method using flexible endoscopic techniques to seal the enteric orifice with an absorbable plug in addition to a percutaneously and fistuloscopically guided open-pore film drainage (Vac-Plug method). We retrospectively searched our endoscopy database to identify patients treated with the outlined technique. The clinical and pathological data were assessed, the method analyzed and characterized and the technical and clinical success determined. We identified 14 patients that were treated with the Vac-Plug method (4 females, 10 males with a mean age of 56 years, range 50-74). The patients were treated over a time period of 23 days (range 4-119) in between one to thirteen interventions (mean n = 5). One patient had to be excluded due to short follow-up after successful closure. Seventy-seven percent (10/13) were successfully treated with a median follow-up of 453 days (range 35-1246) thereafter. No treatment related complications occurred during the therapy. The data of the analysis showed that the Vac-Plug therapy is safe and successful in a relevant proportion of the patients. It is easy to learn and to apply and is well tolerated. In our opinion, it is a promising addition to the armamentarium of interventional methods of these difficult to treat patients. Of course, its usefulness must be further validated in larger prospective studies.
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Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc 2022; 34:43-62. [PMID: 34115407 DOI: 10.1111/den.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.
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Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kitty Kit Ying Auyeung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Siu Fung Lam
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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El-Sourani N, Miftode S, Bockhorn M, Arlt A, Meinhardt C. Endoscopic Management of Anastomotic Leakage after Esophageal Surgery - Ten Year Analysis in a Tertiary University Center. Clin Endosc 2021; 55:58-66. [PMID: 34645084 PMCID: PMC8831416 DOI: 10.5946/ce.2021.099] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/21/2021] [Indexed: 11/22/2022] Open
Abstract
Background/Aims Anastomotic leakage after esophageal surgery remains a feared complication. During the last decade, management of this complication changed from surgical revision to a more conservative and endoscopic approach. However, the treatment remains controversial as the indications for conservative, endoscopic, and surgical approaches remain non-standardized.
Methods Between 2010 and 2020, all patients who underwent Ivor Lewis esophagectomy for underlying malignancy were included in this study. The data of 28 patients diagnosed with anastomotic leak were further analyzed. Results Among 141 patients who underwent resection, 28 (19.9%) developed an anastomotic leak, eight (28.6%) of whom died. Thirteen patients were treated with endoluminal vacuum therapy (EVT), seven patients with self-expanding metal stents (SEMS) four patients with primary surgery, one patient with a hemoclip, and three patients were treated conservatively. EVT achieved closure in 92.3% of the patients with a large defect and no EVT-related complications. SEMS therapy was successful in clinically stable patients with small defect sizes.
Conclusions EVT can be successfully applied in the treatment of anastomotic leakage in critically ill patients, while SEMS should be limited to clinically stable patients with a small defect size. Surgery is only warranted in patients with sepsis with graft necrosis.
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Affiliation(s)
- Nader El-Sourani
- Department for General - and Visceral Surgery, University Hospital, Klinikum Oldenburg AöR, Germany
| | - Sorin Miftode
- Department for General - and Visceral Surgery, University Hospital, Klinikum Oldenburg AöR, Germany
| | - Maximilian Bockhorn
- Department for General - and Visceral Surgery, University Hospital, Klinikum Oldenburg AöR, Germany
| | - Alexander Arlt
- Department for Internal Medicine and Gastroenterology, University Hospital, Klinikum Oldenburg AöR, Germany
| | - Christian Meinhardt
- Department for Internal Medicine and Gastroenterology, University Hospital, Klinikum Oldenburg AöR, Germany
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8
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Choi SI, Park JY. Large anastomotic leak: endoscopic treatment using combined fibrin glue and polyglycolic acid (PGA) sheets. BMJ Case Rep 2021; 14:e240188. [PMID: 34446509 PMCID: PMC8395350 DOI: 10.1136/bcr-2020-240188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/03/2022] Open
Abstract
Anastomotic leak after gastrectomy is a major complication and various endoscopic methods have been suggested. However, the treatment of large-sized leaks remains a challenge. Here, we present a case of a large anastomotic leak successfully treated endoscopically using a combination of fibrin glue and polyglycolic acid (PGA) sheets. A 68-year-old man who underwent laparoscopic total gastrectomy and oesophagojejunal anastomosis presented with abdominal pain and fever. In the endoscopic examination, two fistulas were observed at the anastomosis site. One was small (0.6 cm) while the other measured 2.5 cm. For the large leak, endoscopic treatment using endoclip and detachable snare was attempted, but failed. Subsequently, fibrin glue was injected into the large fistula through an endoscope. After 28 days, the size of the fistula was reduced and PGA sheets were inserted into the remaining fistula. After about 4 weeks, leaks were observed to be completely healed.
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Affiliation(s)
- Soo In Choi
- Internal Medicine, Inje University Sanggye Paik Hospital, Nowon-gu, Seoul, Korea (the Republic of)
| | - Ji Young Park
- Internal Medicine, Inje University Sanggye Paik Hospital, Nowon-gu, Seoul, Korea (the Republic of)
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9
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Nishimura T, Fuse C, Akita M, Takase N, Maeda E, Abe K, Kozuki A, Yokoyama K, Tanaka T, Kishi S, Sakamoto T, Sakai T, Kaneda K. A case report of a gastrobronchial fistula and lung abscess caused by leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer. Surg Case Rep 2021; 7:95. [PMID: 33856574 PMCID: PMC8050132 DOI: 10.1186/s40792-021-01178-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/09/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Gastrobronchial fistulas are rare, but life-threatening, complications of esophagectomy. They are caused by anastomotic leakage and mainly occur around anastomotic sites. In the present paper, we report a rare case of leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer, which was successfully treated using an intercostal muscle flap and lung resection. CASE PRESENTATION A 61-year-old male underwent subtotal esophagectomy with regional lymphadenectomy for esophageal cancer. The sutures along the staple line of the gastric tube failed 11 days after surgery, and a pulmonary abscess was also found on imaging. The abscess did not heal after conservative treatment; therefore, right lower lobectomy, gastrobronchial fistula resection, primary closure, and patching of the leaking portion of the gastric tube with an intercostal muscle flap were performed 9 months after the first operation. The patient's postoperative course was uneventful, and he was discharged on the 354th day. CONCLUSIONS We experienced a case involving a gastrobronchial fistula caused by leakage from the staple line of a gastric tube and successfully treated it by performing right lower lobectomy and patching the leak with an intercostal muscle flap.
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Affiliation(s)
- Tohru Nishimura
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan.
| | - Chisakou Fuse
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Masayuki Akita
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Nobuhisa Takase
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Eri Maeda
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Koichiro Abe
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Akihito Kozuki
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Kunio Yokoyama
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Tomohiro Tanaka
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Shinji Kishi
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
| | - Toshihiko Sakamoto
- Department of Thoracic Surgery, Steel Memorial Hirohata Hospital, Himeji, Japan
| | - Tetsuya Sakai
- Department of Surgery, Steel Memorial Hirohata Hospital, Himeji, Japan
| | - Kunihiko Kaneda
- Department of Surgery, Kakogawa Central City Hospital, Kakogawa, 675-8611, Japan
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Tashiro K, Takeno S, Kawano F, Kitamura E, Hamada R, Ikenoue M, Munakata S, Nanashima A, Nakamura K. Endoscopic filling with polyglycolic acid sheets and fibrin glue of persistent fistula after esophagectomy. Endoscopy 2021; 53:288-292. [PMID: 32544956 DOI: 10.1055/a-1200-8199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treatment of anastomotic leakage in reconstruction after esophagectomy remains challenging. This report presents a new endoscopic filling method for persistent fistula after failure of conservative treatment of leakage caused by anastomotic insufficiency. METHODS 10 of 14 patients, in whom post-esophagectomy leakage had failed to resolve after 2 weeks of conservative treatment, underwent endoscopic filling with polyglycolic acid (PGA) sheet and fibrin glue into the anastomotic leakage site, using a delivery tube and endoscopic catheter, respectively. RESULTS Each patient underwent jejunostomy, to secure nutrition. The leakage was resolved in all 10 patients. The mean number of PGA - fibrin glue procedures was 1.7. The mean period from the first application to the resumption of oral intake was 31.6 days, from the final application it was 14.7 days. CONCLUSIONS The reported filling method offers a new endoscopic approach for persistent fistula after esophagectomy when conservative treatment of leakage has failed.
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Affiliation(s)
- Kousei Tashiro
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Shinsuke Takeno
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Fumiaki Kawano
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Eiji Kitamura
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Rouko Hamada
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Makoto Ikenoue
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Shun Munakata
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Atsushi Nanashima
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Japan
| | - Kunihide Nakamura
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Japan
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Kim HS, Kim Y, Han JH. Endoscopic salvage treatment of histoacryl after stent application on the anastomotic leak after gastrectomy: A case report. World J Clin Cases 2021; 9:262-266. [PMID: 33511194 PMCID: PMC7809665 DOI: 10.12998/wjcc.v9.i1.262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/09/2020] [Accepted: 11/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic approach could effectively manage postoperative anastomotic leakage. Various endoscopic methods have been developed for the treatment of anastomotic leakage.
CASE SUMMARY A 53-year-old woman developed anastomotic leak after laparoscopic proximal gastrectomy. Endoscopic clip closure failed due to strong wall tension; therefore, a fully covered self-expandable esophageal metal stent (fc-SEMS) was placed to cover the leak after it was filled with a mixture of fibrin glue and histoacryl. However, fluoroscopy with gastrograffin showed dye leaking out of the fc-SEMS. Using the previous fluoroscopic image for guidance, a catheter was inserted at the leakage site. The radiocontrast dye was injected and was seen spreading along the sinus tract. Thereafter, histoacryl was injected. Seven days after the last procedure, upper gastrointestinal contrast studies showed no leaks. The patient was subsequently discharged 9 d after histoacryl injection without any complications.
CONCLUSION To seal an anastomosis leak after stent application, salvage technique using histoacryl injection at the leakage site with fluoroscopy guidance could be considered cautiously.
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Affiliation(s)
- Hee-Sung Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju-si 28644, South Korea
| | - Yook Kim
- Department of Radiology, Chungbuk National University Hospital, Cheongju-si 28644, South Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju-si 28644, South Korea
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12
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Chen YS, Loh EW, Shen SC, Su YH, Tam KW. Efficacy of Fibrin Sealant in Reducing Complication Risk After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2020; 31:1158-1167. [PMID: 33145716 DOI: 10.1007/s11695-020-05098-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complications including staple-line leakage and bleeding may occur after sleeve gastrectomy and Roux-en-Y gastric bypass. In this meta-analysis, the efficacy of fibrin sealant in strengthening the staple line and reducing complication risk after bariatric surgery was evaluated. METHODS We searched PubMed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) published up to October 2020. Pooled estimates of the outcomes were computed using a random effects model. The primary outcomes were bleeding and leakage; secondary outcomes were gastric stricture, length of hospital stay, reoperation rate, and total operation time. RESULTS In total, 9 RCTs including 2136 patients were reviewed. Our meta-analysis revealed that compared with controls, fibrin sealants decreased incidence of bleeding significantly (risk ratio [RR] = 0.42; 95% confidence interval [CI], 0.18-0.97), but did not demonstrate significant differences in reducing the incidence of leakage (RR = 0.62; 95% CI, 0.23-1.73), gastric stricture (RR = 1.16; 95% CI, 0.46-2.91), reoperation rate (RR = 0.85; CI, 0.14-5.14), or length of hospital stay (weighted mean difference = 0.62; 95% CI, - 0.31 to 1.55). Compared with oversewing, fibrin sealant use reduced the operation time; however, their efficacies in reducing the incidence of postoperative bleeding and leakage did not differ significantly. CONCLUSIONS Although applying fibrin sealants to the staple line in bariatric surgery may provide favorable results, but it may not reduce postoperative leakage and stricture incidence significantly. Nevertheless, the application of fibrin sealants as a method for reducing risks of complications after bariatric surgery warrant further investigation.
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Affiliation(s)
- Yi-Shyue Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - El-Wui Loh
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Shih-Chiang Shen
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan
| | - Yen-Hao Su
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan
- Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Ka-Wai Tam
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan.
- Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan.
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13
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Abstract
Esophagectomy is a complex operation with many potential complications. Early recognition of postoperative complications allows for the best chance for patient survival. Diagnosis and management of conduit complications, including leak, necrosis, and conduit-airway fistulae, are reviewed. Other common complications, such as chylothorax and recurrent laryngeal nerve injury, also are discussed.
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Affiliation(s)
- Jonathan C Yeung
- Toronto General Hospital, 200 Elizabeth Street 9N-983, Toronto, Ontario M5G 2C4, Canada.
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14
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Tan CY, Kyaw HA, Farhangmehr N, Tang C, Jayanthi NV. Endoscopic management of gastro‐bronchial fistula following two‐stage esophagectomy using over‐the‐scope‐clip (OTSC): Case series. ADVANCES IN DIGESTIVE MEDICINE 2020. [DOI: 10.1002/aid2.13201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Chih Y. Tan
- Department of General Surgery Peterborough City Hospital Peterborough UK
| | - Htet A. Kyaw
- Mid Essex Hospital Services NHS Trust Chelmsford UK
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15
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Sousa P, Noronha Ferreira C, Coutinho J, Carepa F, Rosa R, Barão A, Marques Ferreira C, Girao J, Ruivo A, Bicha Castelo H, Lopes J, Almeida A, Carrilho Ribeiro L, Velosa J. Fistula Recurrence: A Clinical Reality after Successful Endoscopic Closure of Laparoscopic Sleeve Gastrectomy Fistulas. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:242-250. [PMID: 31328138 DOI: 10.1159/000492637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/31/2018] [Indexed: 11/19/2022]
Abstract
Background and Aims Laparoscopic sleeve gastrectomy (LSG)-related fistulas are important and potentially fatal complications. We aimed at determining the incidence, predictive factors, and management of recurrence of post-LSG fistulas. Methods This is a retrospective cohort study of 12 consecutive patients with LSG fistulas managed endoscopically between 2008 and 2013. We analyzed factors associated with recurrence of post-LSG fistulas and the efficacy of a primarily endoscopic approach to manage fistula recurrence. Results The average age at fistula detection after LSG was 43.3 ± 10.9 years, and 10 (83%) patients were female. The median interval between surgery and initial fistula detection was 14 (4-145) days. Fistulas were located at the gastric cardia in 9/12 patients. A median of 4 (1-10) endoscopies were performed per patient until all fistulas were successfully closed. The median follow-up was 30.5 (15-72) months. Fistula recurrence was detected in 3 (25%) female patients with an average age of 31.7 ± 7.9 years after a median of 119 (50-205) days of the initial fistula closure. Fistulas in all 3 patients recurred at the gastric cardia and were successfully managed endoscopically. There was a second recurrence in 1 patient after 6 months, and she was re-operated with anastomosis of a jejunal loop at the site of the fistula orifice at the gastric cardia. We did not find any factors at initial fistula detection that were significantly associated with fistula recurrence. There were no deaths related to initial fistula after LSG and fistula recurrence. Conclusions A primarily endoscopic approach is an effective and safe method for the management of fistulas after LSG. Fistula recurrence occurred in 25% of patients and was managed endoscopically. Key Messages Although we could not define predictive factors of post-LSG fistula recurrence, it is a clinical reality and can be managed endoscopically.
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Affiliation(s)
- Patricia Sousa
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - João Coutinho
- Serviço de Cirurgia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Fátima Carepa
- Serviço de Cirurgia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Rosário Rosa
- Serviço de Cirurgia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Andreia Barão
- Serviço de Cirurgia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Carlos Marques Ferreira
- Serviço de Cirurgia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - José Girao
- Serviço de Cirurgia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - António Ruivo
- Serviço de Cirurgia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Henrique Bicha Castelo
- Serviço de Cirurgia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - João Lopes
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Amélia Almeida
- Serviço de Anestesiologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Luís Carrilho Ribeiro
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - José Velosa
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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16
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Plat VD, Bootsma BT, van der Wielen N, Straatman J, Schoonmade LJ, van der Peet DL, Daams F. The role of tissue adhesives in esophageal surgery, a systematic review of literature. Int J Surg 2017; 40:163-168. [PMID: 28285057 DOI: 10.1016/j.ijsu.2017.02.093] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/25/2017] [Accepted: 02/27/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anastomotic leakage following esophageal surgery is a major contributor to mortality. According to the national database leakage occurs in 20% of esophagectomies carried out in the Netherlands. Therefore anastomotic leakage has been the topic of many studies. However, studies discussing application of tissue adhesives for either prevention or management of anastomotic leakage are limited. This article systematically reviewed all available literature on the potential use of tissue adhesives in esophageal surgery. METHODS Medline, Embase and Cochrane were searched to identify studies that used tissue adhesives as anastomotic sealants to prevent esophageal anastomotic leakage or used tissue adhesives to treat esophageal anastomotic leakage. Two authors independently selected nineteen out of 3107 articles. RESULTS Eight articles, of which five were experimental and three clinical, discussed prevention of anastomotic leakage. Eleven articles, of which one was experimental and ten clinical, discussed treatment of anastomotic leakage. Most articles reported positive results, however overall quality was low due to a high degree of bias and lack of homogeneity. CONCLUSION This study shows mainly positive results for the use of tissue adhesives for the esophageal anastomosis both in prevention of leakage as treating anastomotic leakage. However, the quality of current literature is poor.
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Affiliation(s)
- Victor Dirk Plat
- Department of Gastrointestinal Surgery, VU University Medical Center Amsterdam, The Netherlands.
| | - Boukje Titia Bootsma
- Department of Gastrointestinal Surgery, VU University Medical Center Amsterdam, The Netherlands
| | - Nicole van der Wielen
- Department of Gastrointestinal Surgery, VU University Medical Center Amsterdam, The Netherlands
| | - Jennifer Straatman
- Department of Gastrointestinal Surgery, VU University Medical Center Amsterdam, The Netherlands
| | | | | | - Freek Daams
- Department of Gastrointestinal Surgery, VU University Medical Center Amsterdam, The Netherlands
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17
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Ashkenazi I, Turégano-Fuentes F, Olsha O, Alfici R. Treatment Options in Gastrointestinal Cutaneous Fistulas. Surg J (N Y) 2017; 3:e25-e31. [PMID: 28825016 PMCID: PMC5553539 DOI: 10.1055/s-0037-1599273] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 01/25/2017] [Indexed: 12/15/2022] Open
Abstract
Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context.
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Affiliation(s)
- Itamar Ashkenazi
- Department of Surgery, Hillel Yaffe Medical Center, Hadera, Israel
| | | | - Oded Olsha
- Department of Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ricardo Alfici
- Department of Surgery, Hillel Yaffe Medical Center, Hadera, Israel
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18
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Hwang JJ, Jeong YS, Park YS, Yoon H, Shin CM, Kim N, Lee DH. Comparison of Endoscopic Vacuum Therapy and Endoscopic Stent Implantation With Self-Expandable Metal Stent in Treating Postsurgical Gastroesophageal Leakage. Medicine (Baltimore) 2016; 95:e3416. [PMID: 27100431 PMCID: PMC4845835 DOI: 10.1097/md.0000000000003416] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The aim of the present study was to evaluate the more effective therapy for the postsurgical gastroesophageal leakage by a head-to-head comparison of endoscopic vacuum therapy (EVT) and endoscopic stent implantation with self-expandable metal stent (E-SEMS). In this hospital-based, retrospective, observative study, the patients were classified into 2 groups. Those treated with EVT were assigned to the EVT group (n = 7), and those treated with E-SMS were assigned to the E-SEMS group (n = 11). We evaluated the clinical characteristics and treatment outcomes between the 2 groups. All 7 patients (100%) were treated with EVT, but only 7 of 11 patients (63.6%) in the stenting group were treated successfully. The median time to clinical success was 19.5 (5-21) days in the EVT group and 27.0 (3-84) days in the E-SEMS group. The median hospital stay was 37.1 (13-128) days in the EVT group and 87.3 (17-366) days in the E-SEMS group. The complicaion rate was lower in the EVT group (0/7, 0.0%) than that in the E-SEMS group (6/11, 54.5%) with statistically significant difference (P = 0.042). EVT is more effective and has fewer adverse effects than E-SMS therapy as a treatment for postsurgical gastroesophageal leakage.
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Affiliation(s)
- Jae J Hwang
- From the Department of Internal medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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19
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Shehab H. Endoscopic management of postsurgical leaks. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Hany Shehab
- Gastrointestinal Endoscopy Unit, Kasr Alainy University Hospital, Cairo University, Cairo, Egypt
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20
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Nasa M, Sharma ZD, Choudhary NS, Puri R, Sud R. Removable self-expanding metal stents insertion for the treatment of perforations and postoperative leaks of the esophagus. Indian J Gastroenterol 2016; 35:101-5. [PMID: 27041378 DOI: 10.1007/s12664-016-0639-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 03/07/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Esophageal rupture, spontaneous or iatrogenic, is associated with significant morbidity and mortality. The current study aims at highlighting the various clinical scenarios, where esophageal fully covered self-expanding removable metal stents (FCSEMS) can be used in esophageal rupture. METHODS In patients who underwent insertion of FCSEMS between January 2013 and June 2014, all data regarding demographics, indications, insertion, removal, and outcomes were studied retrospectively. RESULTS Seven patients underwent the placement of esophageal covered SEMS. Two patients had Boerhaave syndrome, two had leak following the repair of aortic aneurysm, one had extensive esophageal injury following transesophageal echocardiography, one had carcinoma esophagus with tracheaesophageal fistula, and one had dehiscence of esophagogastric anastomosis. Stent insertion was successful in all the patients; one had stent migration which was managed endoscopically. Two patients died due to underlying illness; the rest had successful removal of stents after 8-10 weeks and good outcomes. CONCLUSION Esophageal FCSEMS placement is safe and effective modality in management of patients with esophageal rupture.
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Affiliation(s)
- Mukesh Nasa
- Department of Gastroenterology, Institute of Digestive and Hepatobiliary Sciences, Medanta-The Medicity, Sector 38, Gurgaon, Delhi NCR, 122 001, India.
| | - Zubin Dev Sharma
- Department of Gastroenterology, Institute of Digestive and Hepatobiliary Sciences, Medanta-The Medicity, Sector 38, Gurgaon, Delhi NCR, 122 001, India
| | - Narendra S Choudhary
- Department of Gastroenterology, Institute of Digestive and Hepatobiliary Sciences, Medanta-The Medicity, Sector 38, Gurgaon, Delhi NCR, 122 001, India
| | - Rajesh Puri
- Department of Gastroenterology, Institute of Digestive and Hepatobiliary Sciences, Medanta-The Medicity, Sector 38, Gurgaon, Delhi NCR, 122 001, India
| | - Randhir Sud
- Department of Gastroenterology, Institute of Digestive and Hepatobiliary Sciences, Medanta-The Medicity, Sector 38, Gurgaon, Delhi NCR, 122 001, India
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21
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Clinical Outcomes of Postoperative Upper Gastrointestinal Leakage According to Treatment Modality. Dig Dis Sci 2016; 61:523-32. [PMID: 26537488 DOI: 10.1007/s10620-015-3880-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 09/10/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIM We evaluated the clinical outcomes according to treatment modality for gastrointestinal anastomotic leakage. METHODS Of the 19,207 patients who underwent gastrectomy for gastric cancer from March 2000 to April 2013, we retrospectively analyzed the 133 cases who developed anastomotic leakage. These patients were treated using endoscopic management, surgery, or conservative management (endoscopic treatment was introduced in 2009). To evaluate the efficacy of endoscopic treatment, we compared the clinical outcomes between the conservative management-only group before 2009 and the conservative or endoscopic management group from 2009; and between the surgical management-only group before 2009 and the surgical or endoscopic management group from 2009. RESULTS Seventy-three were initially managed conservatively, 35 were treated surgically, and 25 were treated using endoscopic procedures. Chronologically comparing each treatment group as 'before 2009' (n = 54) and 'from 2009' (n = 79), there were differences in the length of hospital stay (median 32 versus 27, p = 0.048) and duration of antibiotic use (median 28 versus 20, p = 0.013). Patients who underwent conservative or endoscopic management from 2009 showed a shorter hospital stay, period of fasting, and duration of antibiotic use than patients who underwent only conservative management before 2009. Patients who received surgery or endoscopic management from 2009 showed a shorter hospital stay and duration of antibiotic use than patients who underwent only surgery before 2009. CONCLUSION Endoscopic management for selected cases can reduce duration of hospital stay and antibiotic administration in the treatment of anastomotic leakage after gastrectomy.
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Dabizzi E, De Ceglie A, Kyanam Kabir Baig KR, Baron TH, Conio M, Wallace MB. Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula. Clin Res Hepatol Gastroenterol 2016. [PMID: 26209869 DOI: 10.1016/j.clinre.2015.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.
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Affiliation(s)
- Emanuele Dabizzi
- Gastroenterology and Digestive Endoscopy Division, Vita-Salute San Raffaele Univeristy, San Raffaele Scientific Institute, Milan, Italy.
| | - Antonella De Ceglie
- Gastroenterology and Digestive Endoscopy Unit, "G. Borea" Hospital, San Remo, Italy
| | | | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Massimo Conio
- Gastroenterology and Digestive Endoscopy Unit, "G. Borea" Hospital, San Remo, Italy
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, Florida, USA
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23
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Baruah A, Kee Song LMW, Buttar NS. Endoscopic management of fistulas, perforations, and leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2016.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Blot C, Sabbagh C, Rebibo L, Brazier F, Chivot C, Fumery M, Regimbeau JM. Use of transanastomotic double-pigtail stents in the management of grade B colorectal leakage: a pilot feasibility study. Surg Endosc 2015; 30:1869-75. [PMID: 26183957 DOI: 10.1007/s00464-015-4404-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 07/02/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) is a major complication of colorectal surgery. The leakage is classified as grade B when the patient's clinical condition requires an active therapeutic intervention but does not require further surgery. The management of grade B AL commonly includes administration of antibiotics and/or the placement of a pelvic drainage performed under radiological guidance or transanal drain. The objective of this study was to evaluate the feasibility and the efficacy of endoscopic transanastomotic drainage using double-pigtail stents (DPSs) in the management of grade B AL in colorectal surgery. PATIENTS AND METHODS Between September 2011 and December 2014, 650 patients underwent a colorectal procedure in our university hospital; 8.7 % presented with AL, including 42.8 % with grade B. Fourteen patients required endoscopic management and constituted the study population. The study's primary objective was to assess the feasibility and efficacy of DPS placement for the treatment of grade B AL after colorectal surgery. The secondary endpoints were the requirement for radiological drainage, the DPS placement failure rate, the rate of stoma closure and, lastly, feasibility of chemotherapy (if indicated). RESULTS DPS placement was feasible in 92.8 % of the 14 patients (n = 13). The overall success rate for endoscopic management was 78.5 % (n = 11). The median length of hospitalization after DPS placement was 5 days (3-17). The average duration of drainage through a DPS was 62 days (28-181). Five patients (35.7 %) also underwent drainage with radiological guidance. Of the 10 patients with stoma, closure occurred in 80 %. All patients that required adjuvant chemotherapy were able to receive it. CONCLUSION The treatment of AL requires multidisciplinary collaboration to save the anastomosis. DPS placement under endoscopic control is associated with AL healing, good clinical tolerance and the ability to undergo chemotherapy and is an alternative to repeat laparotomy when radiological drainage is unfeasible or inefficient.
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Affiliation(s)
- Christelle Blot
- Department of Digestive and Oncological Surgery, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France.,Jules Verne University of Picardie, Amiens Cedex 01, France
| | - Charles Sabbagh
- Department of Digestive and Oncological Surgery, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France.,Jules Verne University of Picardie, Amiens Cedex 01, France.,INSERM Unit 1088, Amiens Cedex 01, France
| | - Lionel Rebibo
- Department of Digestive and Oncological Surgery, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France.,Jules Verne University of Picardie, Amiens Cedex 01, France
| | - Franck Brazier
- Department of Hepatogastroenterology, Amiens University Hospital, Amiens Cedex 01, France
| | - Cyril Chivot
- Department of Radiology, Amiens University Hospital, Amiens Cedex 01, France
| | - Mathurin Fumery
- Jules Verne University of Picardie, Amiens Cedex 01, France.,Department of Hepatogastroenterology, Amiens University Hospital, Amiens Cedex 01, France
| | - Jean-Marc Regimbeau
- Department of Digestive and Oncological Surgery, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France. .,Jules Verne University of Picardie, Amiens Cedex 01, France. .,EA4294, Jules Verne University of Picardie, Amiens Cedex 01, France. .,Clinical Research Centre, Amiens University Hospital, Amiens Cedex 01, France.
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Percutaneous BioOrganic Sealing of Duodenal Fistulas: Case Report and Review of Biological Sealants with Potential Use in Interventional Radiology. Cardiovasc Intervent Radiol 2015; 38:1036-42. [PMID: 25613669 DOI: 10.1007/s00270-015-1051-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/26/2014] [Indexed: 10/24/2022]
Abstract
Biological sealants are being increasingly used in a variety of surgical specialties for their hemostatic and sealing capabilities. However, their use in interventional radiology has not been widely reported. The authors describe a case of duodenal perforation occurring after 15 years of gastric bypass surgery, in whom surgical diversion was unsuccessfully attempted and the leakage was successfully controlled using percutaneous administration of a combination of biological and organic sealants.
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26
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Kotzampassi K, Eleftheriadis E. Tissue sealants in endoscopic applications for anastomotic leakage during a 25-year period. Surgery 2015; 157:79-86. [PMID: 25444220 DOI: 10.1016/j.surg.2014.06.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/03/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leakage after gastrointestinal operation is a complication difficult to manage because conservative therapy and/or reoperation may be unsuccessful and carry the risk of increased morbidity and mortality. The endoscopic use of tissue sealants appears to be a promising alternative to avoid operation. METHOD We present conclusively our 25-year experience with tissue sealing in a series of 63 patients referred after gastrointestinal anastomosis leakage; 48 of the upper and 15 of the lower gastrointestinal tract, experiencing a drainage volume ranging 50-2,400 mL. RESULTS Tissue glue was applied orally in 37, anally in 10, through the fistula tract in 8, and through a combination of approximation routes in another 8 cases. Biological glue (fibrin) was used in 47, cyanoacrylate in 8, and both glue types in another 8 patients. The total volume of fibrin applied was 2-36 mL, in a median of four sessions, 0.5-4 mL for cyanoacrylate, in a median of two sessions, and, whenever a combination of glues was used, a volume of 12-40 mL of fibrin plus 1-4 mL of cyanoacrylate, in a median of nine sessions. The median hospital stay after initiation of gluing was 14 days (range 8-32). The clinical and technical success rate was 96.8% (61 of 63 patients). CONCLUSION Tissue glue appears to be a valuable clinical tool that would prevent further operative interventions and the associated morbidity and mortality after a gastrointestinal anastomosis dehiscence. However, it must be borne in mind that repeated sessions and large volumes of sealants are necessary in many cases.
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Affiliation(s)
- Katerina Kotzampassi
- Department of Surgery, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymios Eleftheriadis
- Department of Surgery, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Filgate R, Thomas A, Ballal M. Treatment of foregut fistula with biologic plugs. Surg Endosc 2014; 29:2006-12. [PMID: 25427409 DOI: 10.1007/s00464-014-3903-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 09/02/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Enteric fistulas are a recognised complication of various diseases and surgical interventions. Non-operative medical management will result in closure of 60-70% of all fistulas over a six- to eight-week period, those that fail non-operative management will require operative intervention if they are to close. We present a series of upper gastrointestinal fistula managed with endoscopic intervention and insertion of biological fistula plug over a 3-year period across three Hospitals, both public and private, in Western Australia. METHODS Over a three-year period, 14 patients were referred for treatment of acute or persistent foregut fistulas. All fistulas were managed with endoscopic intervention and insertion of a porcine small intestine sub-mucosa plug (Biodesign (®) Cook medical Inc., Bloomington, IN, USA). No patients with fistula were excluded. Data were collected on patient demographics and underlying diagnosis. The biological plugs were deployed using three different endoscopic techniques (direct deployment via the endoscope, catheter-assisted endoscopic deployment, or a pull through via a guide wire using a rendezvous technique). RESULTS Fourteen patients with foregut fistula were treated using biological plugs. The age of the fistulas treated ranged from 14 days to 3 years. The fistulas were predominantly gastric in origin (eight cases). Three oesophageal, one gastro-pleural-bronchial, and two jejunal fistulas were also managed using this technique. Of the 14 fistulas treated using this method, 13 resolved following the treatment. Median time to closure of the fistula was 2 days (range 1-120 days). Three patients required more than one intervention to complete closure. CONCLUSION Biological plugs offer a further option for management of the traditionally difficult foregut fistula, without major morbidity associated with other treatment modalities. It is limited to the ability to deploy the plug endoscopically.
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Rahman FN, Stavas JM. Interventional radiologic management and treatment of enterocutaneous fistulae. J Vasc Interv Radiol 2014; 26:7-19; quiz 20. [PMID: 25443456 DOI: 10.1016/j.jvir.2014.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 09/10/2014] [Accepted: 09/13/2014] [Indexed: 12/15/2022] Open
Abstract
Enterocutaneous fistulae (ECFs) are abnormal sinus tract communications between the alimentary system and skin surface that can cause significant management problems and cost to the health care system. Interventional radiology can play an important role in diagnosis and treatment when conventional measures fail and additional surgery is difficult or poses a high risk. The management of patients with fistulae requires operator ingenuity and dedication, a multidisciplinary team approach, and an understanding of the pathophysiology. This article reviews the major issues in ECF management and the role of interventional radiology.
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Affiliation(s)
- Feraz N Rahman
- Division of Vascular and Interventional Radiology, University of North Carolina, 101 Manning Dr., CB 7510, Chapel Hill, NC 27599-7510
| | - Joseph M Stavas
- Division of Vascular and Interventional Radiology, University of North Carolina, 101 Manning Dr., CB 7510, Chapel Hill, NC 27599-7510.
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Sharata A, Bhayani NH, Dunst CM, Kurian AA, Reavis KM, Swanström LL. Gastro-bronchial fistula closed by endoscopic fistula plug (with video). Surg Endosc 2014; 28:3500-4. [PMID: 24993168 DOI: 10.1007/s00464-014-3631-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/21/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fistulae between the tracheobronchial tree and the gastric conduit post-esophagectomy are a rare but sometimes fatal complication. Clinical presentation can range from asymptomatic to acute pulmonary decompensation. Traditional management options, such as esophageal exclusion alone or combined with transthoracic fistula division, and closure (with tissue interposition), are highly invasive, technically difficult, and associated with variable success rates. This video presents closure of highly complex, chronic esophagobronchial fistula (EBF) using simultaneous bronchoscopic and upper endoscopic techniques. METHODS Diagnostic bronchoscopy and upper endoscopy are performed to assess the size and location of fistulae. Fistulae with sufficient luminal size to accommodate a biologic plug were selected for treatment. Steps of EBF plug insertion. (1) Wire across fistula with ends exposed through the mouth. (2) Delivery sheath passed across wire from bronchial side to esophageal side (3) Plug loaded on the esophageal side of the sheath. (4) Plug pulled into position across the fistula from esophageal to bronchial side. (5) Delivery sheath released from bronchial side. RESULTS Two of four fistulae were suitable for plug therapy. A temporary covered-stent was placed to help maintain the plugs in place. Endoscopy at 1 month showed healing of the plugged fistula following stent removal. Respiratory symptoms were improved with no further episodes of pneumonia. Over course of 2 years, the patient has required three additional endoscopic procedures to control new fistulae from this broad area of exposed lung paranchyma, but the initial fistula plug repair is durable. CONCLUSION Post-esophagectomy fistula is a morbid complication and the surgical treatments available are highly morbid and have variable success rates. Due to the development of new endoscopic technologies, the endotherapy has assumed new prominence for treatment of enteric fistula. This complex case illustrates feasibility of endoscopic fistula treatment using dual scope, biologic plug application which effectively controlled this patient's EBF symptoms.
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Affiliation(s)
- Ahmed Sharata
- Providence Portland Cancer Center, 4805 NE Glisan Street, #6N60, Portland, OR, 97213, USA,
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Meyerson SL, Mehta CK. Managing complications II: conduit failure and conduit airway fistulas. J Thorac Dis 2014; 6 Suppl 3:S364-71. [PMID: 24876943 DOI: 10.3978/j.issn.2072-1439.2014.03.32] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/25/2014] [Indexed: 12/19/2022]
Abstract
Conduit failure and conduit airway fistula are rare complications after esophagectomy, however they can be catastrophic resulting in high mortality. Survivors can expect a prolonged hospital course with multiple interventions and an extended period of time prior to being able to resume oral nutrition. High index of suspicion can aid in early diagnosis. Conduit failure usually requires a period of proximal esophageal diversion and staged reconstruction. Conduit airway fistulas may be amenable to endoscopic repair but this has a high failure rate and many patients will require surgical repair with closure of the fistula and interposition of vascularized tissue to minimize recurrence.
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Affiliation(s)
- Shari L Meyerson
- Division of Thoracic Surgery, Northwestern University, Feinberg School of Medicine, Chicago IL, 60611, USA
| | - Christopher K Mehta
- Division of Thoracic Surgery, Northwestern University, Feinberg School of Medicine, Chicago IL, 60611, USA
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Fibrin glue and stents in the treatment of gastrojejunal leaks after laparoscopic gastric bypass: a case series and review of the literature. Obes Surg 2014; 23:1692-7. [PMID: 23912265 DOI: 10.1007/s11695-013-1048-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most commonly performed bariatric/metabolic operation in Europe. Different treatment options for the management of gastrojejunal (GJ) leaks following LRYGB have been published. We looked at our own experience with GJ leaks after 645 consecutive LRYGB operations and reviewed the literature with focus on the use of fibrin sealant and self-expandable metal stents as treatment options. Patient data were prospectively collected in the hospital's database for bariatric patients. All patients with confirmed GJ leaks were reviewed. Patients with GJ leaks were actively treated by a combination of laparoscopic drainage and endoscopic fibrin sealant injections and/or stenting. Six patients (0.93%) have been treated for GJ leaks. All leaks were successfully treated and there was no leak-related mortality. The mean (SD) time for closure of the leaks and length of hospital stay was 19.5 days (6.2) and 23.2 days (3.7). The literature concerning endoscopic treatment options in case of GJ leaks following LRYGB operations is scarce and inconclusive. Immediate and active treatment with a combination of operative and endoscopic treatment options, rather than choosing only one treatment over another, may enhance the recovery process.
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Lyon JW, Hodde JP, Hucks D, Changkuon DI. First experience with the use of a collagen fistula plug to treat enterocutaneous fistulas. J Vasc Interv Radiol 2014; 24:1559-65. [PMID: 24070512 DOI: 10.1016/j.jvir.2013.05.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 05/16/2013] [Accepted: 05/17/2013] [Indexed: 11/28/2022] Open
Abstract
This report describes the authors' first experiences with the use of the Biodesign Enterocutaneous Fistula Plug (EFP). Six patients presented with intraperitoneal abscess and associated chronic bowel fistulas. The fistulas were treated by delivering an EFP by using radiologic guidance. The EFP placement procedure was successfully performed in all patients. All fistulas were closed within 2 weeks. Fistula recurrence occurred in two patients (33%) at 9 and 12 months after the procedure. One recurrence was associated with an adverse reaction to chemotherapy. The other was associated with the silicone flange migrating out of the bowel lumen. The Biodesign EFP offers a promising new approach for the treatment of enterocutaneous fistulas.
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Endoscopic closure of postoperative anastomotic leakage with endoclips and detachable snares. Surg Laparosc Endosc Percutan Tech 2013; 23:e74-7. [PMID: 23579534 DOI: 10.1097/sle.0b013e31827479ba] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Anastomotic leakage, although uncommon, is a life-threatening complication and requires prompt recognition and treatment. Surgical closure has been recommended for defects that are large and symptomatic. However, recent reports on successful endoscopic closure of anastomotic leakage suggest that endoscopic techniques may be a feasible alternative to surgical approaches in patients with comorbid conditions that are not suitable for undergoing second operation or for those who refuse to be reoperated. Herein, we describe a case of postoperative gastrojejunal anastomotic leakage that was successfully treated with endoscopic closure using endoclips and detachable snares.
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35
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Manta R, Magno L, Conigliaro R, Caruso A, Bertani H, Manno M, Zullo A, Frazzoni M, Bassotti G, Galloro G. Endoscopic repair of post-surgical gastrointestinal complications. Dig Liver Dis 2013; 45:879-885. [PMID: 23623147 DOI: 10.1016/j.dld.2013.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 01/28/2013] [Accepted: 03/09/2013] [Indexed: 12/11/2022]
Abstract
Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.
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Affiliation(s)
- Raffaele Manta
- Gastroenterology and Endoscopy Unit, New S. Agostino Hospital, Modena, Italy.
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Shim CN, Kim HI, Hyung WJ, Noh SH, Song MK, Kang DR, Park JC, Lee H, Shin SK, Lee YC, Lee SK. Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy? Surg Endosc 2013; 28:833-40. [PMID: 24114516 DOI: 10.1007/s00464-013-3228-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 09/12/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Anastomotic leaks are a life-threatening complication of gastrectomies with high mortality after surgical reintervention. Endoscopic therapy using fibrin glue injection, endoclip, and other devices is an alternative to surgical intervention for anastomotic leaks. Recently, self-expanding metal stents (SEMS) were introduced to treat anastomotic leaks. The purpose of this study was to assess the clinical characteristics and therapeutic outcomes of SEMS and nonstent endoscopic therapy (NSET) for treatment of anastomotic leaks after total gastrectomy with the aim of assisting endoscopists in choosing a treatment method. METHODS Between July 2002 and March 2013, 13 patients treated with SEMS and 14 patients treated with NSET for anastomotic leaks after total gastrectomy were enrolled onto the study. Enrolled patients received 16 SEMS placement sessions and 21 NSET sessions. RESULTS No significant differences in baseline characteristics or clinical characteristics related to leakage were detected in patients with SEMS compared to NSET. The successful sealing rate at the first attempt by SEMS was significantly better than that of NSET (80.0 vs. 28.6 %, P = 0.036), whereas the successful sealing rate after multiple endoscopic treatments was not statistically different (80.0 vs. 64.3 %, P = 0.653). The main reason for reintervention with SEMS was complications and with NSET was nonseal (P = 0.004). Clinical outcomes including length of hospital stay, endoscopic treatment-related mortality, and all-cause mortality were not significantly different between the 2 groups. CONCLUSIONS In terms of efficacy by single effort, SEMS was superior to other methods for treating anastomotic leaks after total gastrectomy. However, complications with SEMS should be considered when choosing an endoscopic treatment method.
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Affiliation(s)
- Choong Nam Shim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul, 120-752, South Korea,
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Endoscopic treatment of internal gastrointestinal fistulas with fibrin glue. Surg Laparosc Endosc Percutan Tech 2013; 23:37-40. [PMID: 23386148 DOI: 10.1097/sle.0b013e318277d3cb] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Gastrointestinal fistulae are a heterogenous entity originating from various etiologies. When occurring, these fistulae are associated with considerable morbidity and even mortality. One third of the fistulae heal spontaneously and the rest have traditionally required major revisional surgery at a later stage. Even after surgery, the healing rate remains at a level of 75% to 90%. During the last years, gastrointestinal fistulae have been successfully treated endoscopically with fibrin glue. METHODS All (n = 8) consecutive patients with diagnosed internal upper or lower gastrointestinal fistula treated endoscopically with fibrin glue. RESULTS During the minimum follow-up of 11 months, 7 of 8 patients (87.5%) were successfully treated endoscopically, and in only 1 case (12.5%) with a major diagnostic delay, a reoperation was required. CONCLUSIONS Our results support the view that endoscopic treatment with fibrin glue may be considered as a first-line therapy to treat small caliber gastrointestinal fistulas.
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Lee S, Ahn JY, Jung HY, Lee JH, Choi KS, Kim DH, Choi KD, Song HJ, Lee GH, Kim JH, Kim BS, Yook JH, Oh ST, Kim BS, Han S. Clinical outcomes of endoscopic and surgical management for postoperative upper gastrointestinal leakage. Surg Endosc 2013; 27:4232-40. [PMID: 23783553 DOI: 10.1007/s00464-013-3028-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 05/10/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the safety and efficacy of endoscopic therapy, an alternative and less invasive modality for the management of leakage after gastrectomy. METHODS An electronic database of 35 patients with anastomotic leaks after surgery for stomach cancer that were treated with either an endoscopic procedure or surgery between January 2004 and March 2012 was reviewed. The success rates and safety of both modalities were evaluated. RESULTS Endoscopic treatment was performed in 20 patients and surgical treatment in 15 patients. The median time interval between the primary surgery and diagnosis of leakage was 8.0 days (interquartile range, 5.0-14.0 days). Of the 20 patients with endoscopic treatment, technical success was achieved in 19 patients (95 %) with resulting clinical success achieved in all of these 19 patients (100 %). One patient with failed endoscopic management went on to receive surgery. There were no cases of leakage-related deaths after endoscopic treatment. Of the 15 patients with surgical treatment, 5 died due to sepsis, bleeding, or hospital-acquired pneumonia. For diagnosis of leakage, 17 patients from the endoscopy group underwent computed tomography (CT) scanning, which revealed leakages in 3 patients (17.6 %) and occult leakages were subsequently defined at fluoroscopy in all 20 patients. Seven of twelve patients (58.3 %) from the surgical group had leakages diagnosed by CT scan. CONCLUSIONS Endoscopic treatment can be considered a valuable option for the management of postoperative anastomotic leakage with a high degree of technical feasibility and safety, particularly for leakages that are not excessively large.
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Affiliation(s)
- Seohyun Lee
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, No. 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea,
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Kang GH, Yoon BY, Kim BH, Moon HS, Jeong HY, Sung JK, Lee ES. A case of spontaneous esophagopleural fistula successfully treated by endoscopic stent insertion. Clin Endosc 2013; 46:91-4. [PMID: 23423837 PMCID: PMC3572360 DOI: 10.5946/ce.2013.46.1.91] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 04/22/2012] [Accepted: 04/26/2012] [Indexed: 12/29/2022] Open
Abstract
The most common cause of esophagorespiratory fistulas (ERFs) is associated with malignancy. The use of self-expandable metal stents is effective for the treatment of malignant ERFs, but benign ERF is rare, which is why its optimal treatment is not defined yet. There have been few reports describing benign esophagopleural fistula and its treatments in South Korea. Here, we report a rare case of spontaneous esophagopleural fistula, which was successfully treated by endoscopic placement of a membrane covered metal stent.
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Affiliation(s)
- Gu Hyum Kang
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
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40
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Cardoso E, Silva RA, Moreira-Dias L. Use of cardiac septal occluder device on upper GI anastomotic dehiscences: a new endoscopic approach (with video). Gastrointest Endosc 2012; 76:1255-8. [PMID: 23022049 DOI: 10.1016/j.gie.2012.07.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 07/30/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Elisabete Cardoso
- Gastroenterology Department, Portuguese Oncology Institute, Porto, Portugal
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41
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Brolin RE, Lin JM. Treatment of gastric leaks after Roux-en-Y gastric bypass: a paradigm shift. Surg Obes Relat Dis 2012; 9:229-33. [PMID: 22336493 DOI: 10.1016/j.soard.2012.01.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 12/30/2011] [Accepted: 01/06/2012] [Indexed: 01/19/2023]
Abstract
BACKGROUND During the past decade, nonoperative treatment of leaks after bariatric surgery has been deemed acceptable in selected patients. The setting of our study was 2 university affiliated hospitals. METHODS We reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by 1 surgeon during the past 8 years, including 836 primary laparoscopic Roux-en-Y gastric bypass (RYGB), 114 primary open RYGBs, and 119 revisional procedures. Drains were used routinely in the laparoscopic and revision groups and selectively in the open group. Perforations and jejunojejunostomy leaks were excluded. RESULTS There were no leaks after open RYGB, 8 leaks (.95%) after laparoscopic RYGB, and 5 leaks (4.2%) after the revisional procedures. Of the 13 leaks, 7 occurred at the gastrojejunostomy, 6 at the staple line of the upper pouch, and none in the excluded stomach. Of the 8 postlaparoscopic RYGB leaks, 3 required reoperation versus 2 of 5 postrevision leaks. There were no perioperative deaths. All but 2 patients in the nonoperative group were treated with endoscopic injection of fibrin sealant (EIFS). Of the 4 leaks in the laparoscopic RYGB group, 2 treated by EIFS closed after 1 treatment; however, all leaks in the revision group required >1 EIFS treatment. The mean length of stay was 36 ± 34 days in the operative group and 33 ± 7 days in the EIFS patients. Operation for failure of EIFS was not required in any patient. CONCLUSION EIFS provides safe and successful treatment of patients who develop gastric leaks after bariatric operations. We recommend EIFS for all patients with endoscopically accessible leaks who can safely be treated nonoperatively.
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Affiliation(s)
- Robert E Brolin
- Department of Surgery, University Medical Center at Princeton, Princeton, New Jersey 08844, USA.
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Abstract
<b><i>Hintergrund: </i></b>Nahtinsuffizienzen stellen eine gefürchtete Komplikation nach Operationen an der Speiseröhre dar, die mit hoher Morbidität und Mortalität vergesellschaftet sind. <b><i>Methoden: </i></b>Die Einlage komplett beschichteter Stents stellt die am häufigsten eingesetzte Methode zur Behandlung ösophagealer Leckagen dar. Eine neue endoskopische Therapiemodalität besteht mit der endoskopischen Vakuumschwammtherapie. Hierbei macht man sich die positiven Effekte des vakuumassistierten Verschlusses (Vacuum-Assisted Closure, V.A.C.), der eine etablierte Therapiemodalität zur Behandlung ausgedehnter infizierter Hautdefekte darstellt, zunutze. Durch neue Entwicklungen haben auch Clips (insbesondere der «Over-the-Scope-Clip», OTSC) wieder eine Bedeutung beim Verschluss von ösophagealen Nahtinsuffizienzen erhalten. <b><i>Ergebnisse: </i></b>Mit diesen endoskopischen Techniken lassen sich Nahtinsuffizienzen des Ösophagus in über 80% der Fälle erfolgreich verschließen. <b><i>Schlussfolgerung</i></b>: Endoskopische Techniken stellen eine geeignete Methode zum Verschluss ösophagealer Leckagen dar und konnten daher in den letzten 10 Jahren die chirurgische Revision weitestgehend verdrängen
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Lundy JB, Fischer JE. Historical perspectives in the care of patients with enterocutaneous fistula. Clin Colon Rectal Surg 2011; 23:133-41. [PMID: 21886462 DOI: 10.1055/s-0030-1262980] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Evidence can be found throughout surgical history of how devastating an enterocutaneous fistula (ECF) can be for both patient and surgeon. From antiquity, this complication of abdominal surgery, malignancy, radiation, trauma, or inflammatory processes has been a significant challenge to surgeons due to high associated mortality and significant morbidity. An ECF causes dehydration, malnutrition, skin excoriation, and sepsis, and has profound psychological effects on the patient. Recent mortality rates of patients suffering an ECF approach 20%. The authors illustrate the history of management of patients with ECF and discuss advances in perioperative care including parasurgical care, nutrition, wound care, and the history of surgical techniques.
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Affiliation(s)
- Jonathan B Lundy
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
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Palmes D, Brüwer M, Bader FG, Betzler M, Becker H, Bruch HP, Büchler M, Buhr H, Ghadimi BM, Hopt UT, Konopke R, Ott K, Post S, Ritz JP, Ronellenfitsch U, Saeger HD, Senninger N. Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group. Langenbecks Arch Surg 2011; 396:857-66. [PMID: 21713594 DOI: 10.1007/s00423-011-0818-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/07/2011] [Indexed: 12/16/2022]
Abstract
PURPOSE Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. MATERIALS AND METHODS The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement). RESULTS Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy. CONCLUSION The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.
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Affiliation(s)
- Daniel Palmes
- Department of General and Visceral Surgery, University of Münster, Waldeyerstrasse 1, 48149 Münster, Germany.
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Schneider G. Tissue adhesives in otorhinolaryngology. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2011; 8:Doc01. [PMID: 22073094 PMCID: PMC3199812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The development of medical tissue adhesives has a long history without finding an all-purpose tissue adhesive for clinical daily routine. This is caused by the specific demands which are made on a tissue adhesive, and the different areas of application. In otorhinolaryngology, on the one hand, this is the mucosal environment as well as the application on bones, cartilage and periphery nerves. On the other hand, there are stressed regions (skin, oral cavity, pharynx, oesophagus, trachea) and unstressed regions (middle ear, nose and paranasal sinuses, cranial bones). But due to the facts that adhesives can have considerable advantages in assuring surgery results, prevention of complications and so reduction of medical costs/treatment expenses, the search for new adhesives for use in otorhinolaryngology will be continued intensively. In parallel, appropriate application systems have to be developed for microscopic and endoscopic use.
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Affiliation(s)
- Gerlind Schneider
- Department of Otorhinolaryngology, Friedrich Schiller University Jena, Germany,*To whom correspondence should be addressed: Gerlind Schneider, Department of Otorhinolaryngology, Friedrich Schiller University Jena, Lessingstrasse 2, 07743 Jena, Germany, Telephone 03641/935015, Fax 03641/935129, E-mail:
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Fibrin glue in the endoscopic treatment of fistulae and anastomotic leakages of the gastrointestinal tract. Int J Colorectal Dis 2011; 26:303-11. [PMID: 21190028 DOI: 10.1007/s00384-010-1104-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fistulae or leakages of anastomotic junctions of the gastrointestinal tract used to be an indication for surgery. However, patients often are severely ill and endoscopic therapeutic options have been suggested to avoid surgical intervention. PURPOSE This is a retrospective analysis of fibrin glue application in the treatment of gastrointestinal fistulae or anastomotic leakages. AIM The aim of this study was to investigate the value of fibrin glue in the treatment of gastrointestinal fistulae and leakages. METHODS From September 1996 to November 2002, 52 patients with gastrointestinal fistulae or insufficiencies have been treated endoscopically including the use of fibrin glue (Tissucol Duo S®, Baxter, Unterschleissheim, Germany). Clinical data comprising concomitant therapies and results were analysed by chart review. RESULTS Twenty-six lesions were located in the oesophagus or gastroesophageal junction, 4 in the stomach, 7 in the small intestine, 13 colorectal and 2 in the pancreas. The duration of treatment ranged from 12 to 1,765 days. Two to 81 ml fibrin glue (median 8.5) was used in 1-40 sessions (median 4). All patients received antibiotics; additional endoscopic options were frequently applied. Endoscopic therapy cured 55.7% patients (n = 29); 36.5% (n = 19) were cured with fibrin glue as sole endoscopic option. In 23.1% (n = 12), surgical intervention became necessary. Patients without major infectious complications tended to have a higher cure rate without surgery (87.5% vs. 50%). Eleven patients died (21.1%). CONCLUSION Endoscopic therapy is a valuable option in the treatment of fistulae and anastomotic insufficiencies of the gastrointestinal tract. It usually is applied repeatedly. Fibrin glue is a mainstay of this procedure. Major infectious complications seem to define a subgroup of patients with poorer outcome.
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Percutaneous endoscopic gastrojejunostomy for a patient with an intractable small bowel injury after repeat surgeries: a case report. J Med Case Rep 2011; 5:55. [PMID: 21310033 PMCID: PMC3047429 DOI: 10.1186/1752-1947-5-55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Accepted: 02/10/2011] [Indexed: 11/10/2022] Open
Abstract
Introduction The management of intestinal injury can be challenging, because of the intractable nature of the condition. Surgical treatment for patients with severe adhesions sometimes results in further intestinal injury. We report a conservative management strategy using percutaneous endoscopic gastrojejunostomy for an intractable small bowel surgical injury after repeated surgeries. Case presentation A 78-year-old Japanese woman had undergone several abdominal surgeries including urinary cystectomy for bladder cancer. After this operation, she developed peritonitis as a result of a small bowel perforation thought to be due to an injury sustained during the operation, with signs consistent with systemic inflammatory response syndrome: body temperature 38.5°C, heart rate 92 beats/minute, respiratory rate 23 breaths/minute, white blood cell count 11.7 × 109/L (normal range 4-11 × 109/μL). Two further surgical interventions failed to control the leak, and our patient's clinical condition and nutritional status continued to deteriorate. We then performed percutaneous endoscopic gastrojejunostomy, and continuous suction was applied as an alternative to a third surgical intervention. With this endoscopic intervention, the intestinal leak gradually closed and oral feeding became possible. Conclusion We suggest that the technique of percutaneous endoscopic gastrojejunostomy combined with a somatostatin analog is a feasible alternative to surgical treatment for small bowel leakage, and is less invasive than a nasojejunal tube.
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Fritscher-Ravens A, Hampe J, Grange P, Holland C, Olagbeye F, Milla P, von Herbay A, Jacobsen B, Seehusen F, Hadeler KG, Mannur K. Clip closure versus endoscopic suturing versus thoracoscopic repair of an iatrogenic esophageal perforation: a randomized, comparative, long-term survival study in a porcine model (with videos). Gastrointest Endosc 2010; 72:1020-6. [PMID: 21034902 DOI: 10.1016/j.gie.2010.07.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 07/21/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Esophageal full-thickness wall repair is an important but unsolved issue in endoscopy. It is unknown how well endoscopic clip closure (ECC) and endoscopic closure with suturing (ECS) perform compared with the criterion standard of thoracoscopic closure (TC). OBJECTIVE Comparison of technical success, feasibility, long-term patency, complications, and histological quality of the different closure techniques (ECC, ECS, TC) for esophageal perforations. DESIGN Comparative animal study. SETTING Approved animal facility. SUBJECTS Eighteen pigs. INTERVENTIONS Eighteen pigs were randomized, 6 each into 3 groups (ECC, ECS, TC). After endoscopic wall incision and mediastinoscopy, closure was performed by using 1 of the 3 techniques. After 8 to 12 weeks, pre-euthanasia endoscopic, necropsy, histological, and morphometric analyses were performed. MAIN OUTCOME MEASUREMENT Long-term survival and histological quality of the repair. RESULTS The closure of the esophageal incisions was successful in all pigs. On days 2 and 6, 1 animal died of mediastinitis, 1 in the ECS group because of reflux of gastric contents into the mediastinum before the repair and 1 in the TC group because of leakage of the sutured closure (P = 1.0). No strictures were seen on prenecropsy endoscopy. At necropsy, 1 mediastinal abscess was found in an ECS animal (P = 1.0). Minor complications included periesophageal adhesions and reactive lymph nodes in 3 of 6 (ECC group) and 5 of 6 (TC and ECS groups). Histology showed muscle layer defects up to 12 mm in width and 21 mm in length, with a trend toward smaller defect size of width and length in the ECS group of animals. LIMITATIONS Animal study of limited size. CONCLUSIONS Overall, ECS and ECC performed similarly to TC. ECS showed the smallest histological defects in the long-term repair.
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Affiliation(s)
- Annette Fritscher-Ravens
- Interdisciplinary Endoscopy, Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany.
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Stent for nonmalignant leaks, perforations, and ruptures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010. [DOI: 10.1016/j.tgie.2011.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Repici A, Presbitero P, Carlino A, Strangio G, Rando G, Pagano N, Romeo F, Rosati R. First human case of esophagus-tracheal fistula closure by using a cardiac septal occluder (with video). Gastrointest Endosc 2010; 71:867-9. [PMID: 20185124 DOI: 10.1016/j.gie.2009.08.036] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 08/30/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
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