Endoscopic Management of Gastrointestinal Leaks and Perforation with Polyglycolic Acid Sheets

A Randomized Controlled Trial of Fibrin Glue to Prevent Bleeding After Gastric Endoscopic Submucosal Dissection

INTRODUCTION

This study evaluated the efficacy of fibrin glue for preventing postendoscopic submucosal dissection (ESD) bleeding in high-risk patients for bleeding (expected iatrogenic ulcer size ≥40 mm or receiving antithrombotic therapy).

METHODS

A multicenter, open-label, randomized controlled trial was performed at 4 tertiary medical centers in South Korea between July 1, 2020, and June 22, 2022. Patients with gastric neoplasm and a high risk of post-ESD bleeding were enrolled and allocated at 1:1 to a control group (standard ESD) or a fibrin glue group (fibrin glue applied to iatrogenic ulcers after standard ESD). The primary outcome was overall bleeding events within 4 weeks. The secondary outcomes were acute bleeding (within 48 hours post-ESD) and delayed bleeding (48 hours to 4 weeks post-ESD).

RESULTS

In total, 254 patients were randomized, and 247 patients were included in the modified intention-to-treat population (125 patients in the fibrin glue group and 122 patients in the control group). Overall bleeding events occurred in 12.0% (15/125) of the fibrin glue group and 13.1% (16/122) of the control group ( P = 0.791). Acute bleeding events were significantly less common in the fibrin glue group than in the control group (1/125 vs 7/122, P = 0.034). Delayed bleeding events occurred in 11.2% (14/125) in the fibrin glue group and 7.3% (9/122) in the control group ( P = 0.301).

DISCUSSION

This trial failed to show a preventive effect of fibrin glue on overall post-ESD bleeding in high-risk patients. However, the secondary outcomes suggest a potential sealing effect of fibrin glue during the acute period.

Large anastomotic leak: endoscopic treatment using combined fibrin glue and polyglycolic acid (PGA) sheets

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.

The treatment for refractory rectovaginal fistula after low anterior resection with estriol, polyglycolic acid sheets and primary closure: A case report

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Rectovaginal fistula is a refractory complication following low anterior resection for rectal cancer.

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Rectovaginal fistula is often managed with stoma creation, closure of the fistula and/or re-anastomosis.

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Our case was successfully treated with primary closure of the fistula following administration of estriol.

Introduction

Rectovaginal fistula (RVF) is a refractory complication that occurs after anastomotic leakage following low anterior resection for rectal disease. Due to its refractory nature, RVF is often managed with surgical treatment, such as stoma creation for fecal diversion, closure of the fistula and/or re-anastomosis, rather than conservative therapy.

Presentation of case

A 72-year-old woman who underwent laparoscopic low anterior resection developed RVF on post-operative day (POD) 15. Conservative therapy with the administration of estriol and total parenteral nutrition was started. In addition, a polyglycolic acid (PGA) sheet was inserted into the fistula using colonoscopy, and fibrin glue was applied. However, this treatment with the PGA sheet and fibrin glue seemed to be unsuccessful. Therefore, an operation for simple closure of the RVF was performed on POD47. The PGA sheet was then removed, and primary closure of the RVF from both sides of the rectum and vagina was performed. Following re-operation, solid food with low dietary fiber content was started on original POD55 (POD14 after re-operation), and the dietary fiber content was gradually increased. The patient was discharged from the hospital on original POD 83 (re-operation POD42).

Discussion

The administration of estrogen might result in increased vaginal compliance, decreased vaginal pH, increased vaginal blood flow and improved lubrication. Therefore, vaginal suture was made possible because the vaginal extensibility was restored.

Conclusion

Primary closure of the RVF following administration of estriol may be an effective treatment.

A new technology for reducing anastomotic fistula in the neck after esophageal cancer surgery

Background

To explore the risk factors and prevention methods of cervical mechanical anastomotic fistula and stenosis after the radical resection of esophageal cancer.

Methods

From March 2018 to November 2018, 128 patients undergoing mechanical anastomosis of esophageal cancer were selected from the Department of Thoracic Surgery of The First Affiliated Hospital of Zhengzhou University. All the enrolled patients were operated on using the Mckeown method, and a retrospective study was conducted. Data for preoperative and postoperative test indices, intraoperative embedding materials, postoperative complications, and preoperative and postoperative treatment were collected, and the relationship between various factors and the incidence of cervical anastomotic fistula and stenosis was analysed. Univariate analysis was conducted using t tests or Fisher's exact probability method, and multivariate analysis was conducted using logistic regression models.

Results

All 128 patients successfully underwent surgery without dying. The enrolled patients were evaluated using the Stooler classification, with 28 patients having grade 0, 41 patients having grade 1, 34 patients having grade 2, 21 patients having grade 3, and 4 patients having grade 4 stenosis. Patients with stenosis of grade 3 or above had obvious choking sensation, which could only be relieved by balloon dilation. Symptoms in all patients with stenosis were relieved by balloon dilation. There were no significant differences between the two groups regarding embedding materials, preoperative choking history, history of alcohol consumption, history of hypertension, history of coronary heart disease, history of diabetes, postoperative calcium concentration, average albumin concentration, average platelet concentration, body mass index, anastomotic fistula, preoperative chemotherapy, postoperative chemotherapy, or postoperative cough (P>0.05). There were significant differences in postoperative reflux (χ²=11.338, P<0.05) and scar constitution (χ²=12.497, P<0.05). The effects of embedding materials in patients with anastomotic fistula were significantly different (χ²=4.372, P<0.05).

Conclusions

Postoperative reflux and scar constitution may be risk factors for postoperative anastomotic stenosis after resection of esophageal cancer. There was almost no difference in the effects on esophageal anastomotic stenosis between embedding materials and the omentum majus, but Neoveil^® may have certain advantages in preventing cervical anastomotic fistula, and thus may have certain clinical application value.

Successful Endoscopic Closure Using Polyglycolic Acid Sheets with Fibrin Glue for Nonhealing Duodenal Ulcer with Perforation after Proton Beam Therapy of Liver Tumor

We describe the first case of a nonhealing duodenal ulcer with perforation after proton beam therapy (PBT) of a liver tumor that was successfully treated endoscopically using polyglycolic acid (PGA) sheets with fibrin glue. A 69-year-old man received PBT for a liver tumor. Esophagogastroduodenoscopy (EGD) 3 months after PBT revealed a duodenal ulcer. A proton pump inhibitor was administered for 7 weeks, and the ulcer healed. Six months after the EGD, recurrence of the duodenal ulcer with perforation occurred. An emergency open surgery with placement of the omental patch was performed. However, 5 days after the surgery, because the EGD revealed a perforation site in the duodenal ulcer that was not closed, the conservative treatment was continued. Twenty-eight days after the surgery, EGD revealed that the perforation size had increased. Therefore, we conducted endoscopic closure therapy using PGA sheets with fibrin glue. Eleven days after the closure procedure, the EGD showed that the perforation site was filled with granulation tissue and was closed. Forty-nine days after the procedure, EGD revealed that the ulcer had healed. This endoscopic closure treatment was effective for a nonhealing duodenal ulcer with perforation after PBT of a liver tumor.

Endoscopic closure of an anastomo-cutaneous fistula: Filling and shielding using polyglycolic acid sheets and fibrin glue with easily deliverable technique

Background and study aims  Recently, endoscopic closure of gastrointestinal fistulas using polyglycolic acid (PGA) sheets with fibrin glue (FG) has been attempted. A 70-year-old woman who had undergone pancreaticoduodenectomy for pancreatic cancer suffered from a refractory anastomo-cutaneous fistula at the site of gastro-jejunostomy. We attempted endoscopic closure with filling and shielding using PGA sheets and FG. After introducing a guidewire into the fistula, a small piece of PGA sheet was skewered onto the guidewire and then pushed using a tapered catheter over the guidewire and delivered into the fistula. A total of 10 sheets were delivered via the same procedure. Next, the mucosa around the fistula was ablated, and the orifice of the fistula along with the surrounding mucosa was shielded with a piece of PGA sheet fixed with hemoclips and FG. After this procedure, the leakage disappeared and the fistula was undetectable on contrast radiograms. Endoscopic closure of anastomo-cutaneous fistula with filling and shielding using PGA sheets and FG is an effective, safe, low-invasive treatment, and the filling technique using a guidewire ensures a safe, smooth procedure.