Endoscopic treatment of esophageal fistulas after esophagectomy with injection of an alpha-cyanoacrylate monomer: a phase II study

Successful treatment of an anastomotic leakage after total gastrectomy using a fully covered self-expandable metal stent with an anchoring thread: A case report

INTORODUCTION AND IMPORTANCE

The incidence of anastomotic leakage in the esophagojejunostomy after total gastrectomy is a serious complication of this procedure. Here, we report a case in which a fully covered stent was endoscopically placed into a fistula caused by anastomotic leakage after total gastrectomy.

CASE PRESENTATION

An 88-year-old man diagnosed with advanced gastric cancer had tumor invasion close to the esophagogastric junction. We performed a laparoscopic total gastrectomy and Roux-en-Y reconstruction. On postoperative day (POD) 3, the patient experienced septic shock due to anastomotic leakage and subsequent mediastinitis. Mediastinal irrigation and drainage under laparotomy were performed. Sepsis improved with drainage, but the fistula persisted due to anastomotic leakage.

CLINICAL DISCUSSION

Based on a diagnosis of refractory fistula, a fully covered self-expandable metal stent (HANAROSTENT® Esophagus) was inserted POD 21 using esophagoscopy. To prevent stent migration, a 3-0 silk thread was attached to the ostial side of the stent and fixed at the nose. The stent was endoscopically removed 36 days. Esophagoscopy after stent removal revealed that the fistula had resolved and that the anastomotic leakage had healed. The patient started oral intake and was discharged home.

CONCLUSION

This case demonstrates the potential for use of a fully covered self-expandable metal stent with an anchoring thread for anastomotic leakage after total gastrectomy for gastric cancer.

Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas

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.

Cyanoacrylate injection treatment for postoperative leakage of Boerhaave's syndrome: A case report

RATIONALE

Surgical treatment remains the most effective option for treating Boerhaave's syndrome. However, in cases of postoperative anastomotic leakage of Boerhaave's syndrome, endoscopic interventions such as over-the-scope clip, stenting, or cyanoacrylate injection have emerged over reoperation.

PATIENT CONCERNS

We report the case of a 50-year-old male patient who presented with vomiting and abdominal pain after alcohol consumption. Laparoscopic surgery was performed for primary closure of a laceration at the lower esophagus, and for the closure of a Boerhaave's syndrome, which was detected by abdominal computed tomography. However, postoperative anastomotic leakage was confirmed through esophagography after the operation. In our case, endoscopic treatment with an over-the-scope clip and stenting were not effective for the repair of the anastomotic leakage, but cyanoacrylate injection successfully healed the anastomotic leakage.

DIAGNOSES

Boerhaave's syndrome was initially detected by abdominal computed tomography, but postoperative anastomotic leakage after the operation was confirmed with esophagography.

INTERVENTIONS

A total of 2.0 cc of N-butyl-2-cyanoacrylate and lipiodol mixture (at 1:1) was injected into the leakage tract through the perforation entrance.

OUTCOMES

Complete healing of the anastomotic leakage was confirmed with a follow-up esophagoscopy.

LESSONS

N-butyl-2-cyanocrylate injection treatment can be used as a rescue option for postoperative leakage when over-the-scope clips and stenting fail for this indication.

Application of mediastinal drainage tube in intrathoracic esophageal anastomotic leakage for early diagnosis and effective treatment: a retrospective study

Background

Intrathoracic esophageal anastomotic leakage (AL) is one of the most fatal complications after esophagectomy. In this study, we placed an additional drainage tube in the esophagus bed and evaluated its effect in early diagnosis and treatment of AL.

Methods

From January 2010 to August 2020, 312 patients with esophageal or cardia carcinoma underwent esophageal resection with intrathoracic esophagogastric anastomosis. A total of 138 patients with only one pleural drainage tube were divided into the “Control Group” and 174 patients with a pleural drainage tube and an additional mediastinal drainage tube (MDT) were divided into the “Tube Group”. For all patients, the incidence of postoperative AL, the time to diagnosis, time to recovery, and patient outcome were analyzed.

Results

No significant differences were observed in the AL rate (P = 0.837) and postoperative pain between two groups. However, in the Tube Group, almost all the patients were diagnosed prior to the appearance of hyperpyrexia, which was considered as the earliest and most common symptom after AL. In the Tube Group, a significant decrease was observed in the incidence of incurable fistula, which required re-operation or variable treatments under gastroscopy when compared to the Control Group (P = 0.032). Finally, patients in the Tube Group showed reduced post AL hospital day (P = 0.015) and a lower mortality, however, when compared to the Control Group, no significant differences were observed (P = 0.188).

Conclusions

Placement of an MDT does not prevent AL, but it is an effective approach for earlier diagnosis of AL and facilitates fistula healing and patient recovery.

Successful Management of a Tracheo-gastric Conduit Fistula after a Three-field Esophagectomy with Combined Sternocleidomastoid Muscle Rotation Flap and Histoacryl Injection Treatment

Tracheo-gastric conduit fistula is an extremely rare but severe complication that is difficult to manage. Conservative care, esophageal or tracheal stent placement, or cutaneomuscular flaps have been suggested; however, no definite treatment has been proven. We report a case of tracheo-gastric conduit fistula that occurred after a minimally invasive radical three-field esophagectomy. Following the primary surgery, the diagnosis was made while evaluating the patient's frequent aspiration and coughing. Conservative management failed, and a surgical correction was undertaken to identify the multifocal mucosal defect and exposed tracheal ring. A sternocleidomastoid muscle rotation flap and subsequent Histoacryl injection into the remaining fistula were performed, and the fistula was successfully managed.

Successful treatment of enterocutaneous fistula after esophagectomy with scopolamine ointment and negative pressure wound therapy: a case report

Background

Despite improved surgical techniques and perioperative management, anastomotic leakage (AL) after esophageal cancer surgery remains a potential complication. In most cases, spontaneous healing upon proper drainage is observed, but sometimes, AL results in intractable enterocutaneous fistulas. We here report a case of intractable enterocutaneous fistula caused by post-esophagectomy AL and successfully treated by scopolamine ointment and negative pressure wound therapy (NPWT).

Case presentation

A 77-year-old man underwent thoracoscopic subtotal esophagectomy with 3-field lymph node dissection, followed by gastric tube reconstruction through the posterior mediastinal route. On the 6th postoperative day, AL was identified, forming an enterocutaneous fistula. Initially, conservative treatment was performed, but the fistula failed to close. We hypothesized that the substantial amount of exudate might be hampering fistula closure. Scopolamine ointment was used to reduce the amount of fluid. NPWT was also initiated to promote wound healing. Approximately 3 weeks after the beginning of the treatment, the fistula closed; oral intake became possible, and the patient was discharged from the hospital without any symptoms.

Conclusions

The combination of scopolamine ointment and NPWT may be regarded as one effective treatment option for intractable enterocutaneous fistula due to AL after esophagectomy.

Endoscopic closure of refractory esophageal fistula after esophagectomy using polyglycolic acid sheets: a pilot study

Background and study aims  Esophageal fistulas after esophagectomy are associated with high mortality and poor quality of life. They are sometimes intractable to conservative management and surgery that increases mortality. Few studies have assessed use of polyglycolic acid (PGA) sheets with fibrin glue for esophageal fistulas. We investigated the safety of using PGA sheets with fibrin glue for esophageal fistulas after esophagectomy. Patients and methods  This was a single-center prospective pilot study. Patients who had refractory esophageal fistulas after esophagectomy were included. PGA sheets were filled in the fistula using biopsy forceps. Fibrin glue was applied to the PGA sheets. We repeated the procedure 1 week later. The outcome measures were the incidence of adverse events (AEs) and closure of the fistula. Results  Five patients were assessed. No adverse events were observed. The esophageal fistula was closed with the application of PGA sheets four times in 40 % (2/5) of the cases. Conclusions  PGA sheets with fibrin glue were safe for esophageal fistula closure after esophagectomy and do not involve the risk of AEs.

Endoscopic closure systems for perforations, fistulas, and leaks. In expert hands or in all endoscopy units?

Improvement and innovation have been ongoing in gastrointestinal (GI) endoscopy for the last few years, including highly maneuverable endoscopes, high-definition visualization, digital chromoendoscopy, and wide working channels, which allow a correct identification, catheterization, and delimitation of early neoplastic lesions. Technological innovation has also provided novel devices, both to perform treatments and prevent complications.