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DOI: 10.1055/s-0042-102452
Polyglycolic acid sheets for closure of refractory esophago-pulmonary fistula after esophagectomy
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Publication History
Publication Date:
07 March 2016 (online)
Anastomotic leakage, which is one of the complications of esophagectomy, sometimes causes a refractory fistula despite conservative therapy [1]. Polyglycolic acid (PGA) sheets (Neoveil; Gunze, Kyoto, Japan), a suture reinforcement material that is absorbed within 4 – 15 weeks, have been used in many fields of open and endoscopic surgery [2] [3] to prevent delayed perforation [4] [5]. Here we report successful closure of a refractory esophago-pulmonary fistula using PGA sheets.
An Ivor–Lewis esophagectomy was performed with gastric tube reconstruction via right thoracotomy on a man in his 70s for advanced esophageal cancer. A mechanical intrathoracic anastomosis was created using a circular stapler (Proximate ILS CDH25; Ethicon Endo-Surgery, LLC., Cincinnati, Ohio, USA).
On Day 27 after surgery, the patient developed a high fever. Contrast computed tomography (CT) with diluted Gastrografin (Bayer Pharma AG, Berlin, Germany) injected into the nasogastric tube showed anastomotic leakage, which was confirmed endoscopically ([Fig. 1 a, b]). Conservative management of the esophago-pulmonary fistula was ineffective ([Fig. 2]).
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102452-i13716cl1.jpg)
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Because the fistula was large, PGA sheeting was used rather than endoscopic closure with endoclips. PGA sheets were cut into 5 × 4-mm pieces, and the fistula was filled with two or three pieces ([Fig. 3]) before being fixed to the fistula by spraying fibrin glue (Beriplast P Combi-Set; CSL Behring Pharma, Tokyo, Japan) using a spray tube. This procedure was repeated three times at 1- or 2-week intervals. The fistula had closed completely by 5 weeks after the initial procedure ([Fig. 4]). No fistula was detected on follow-up CT 1 month later.
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102452-i13716cl3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
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To our knowledge, there are no published reports describing the use of this technique to close refractory post-esophagectomy esophago-pulmonary fistulas. Because PGA sheets promote construction of fibroblasts, they may help to close fistulas. This case suggests that PGA sheeting is a possible treatment option for refractory fistula.
Endoscopy_UCTN_Code_CPL_1AJ_2AG
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Competing interests: None
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References
- 1 Rutegård M, Lagergren P, Rouvelas I et al. Intrathoracic anastomotic leakage and mortality after esophageal cancer resection: a population-based study. Ann Surg Oncol 2012; 19: 90-103
- 2 Ueda K, Tanaka T, Hayashi M et al. Mesh-based pneumostasis contributes to preserving gas exchange capacity and promoting rehabilitation after lung resection. J Surg Res 2011; 167: e71-e75
- 3 Uemura K, Murakami Y, Hayashidani Y et al. Combination of polyglicolic acid felt and fibrin glue for prevention of pancreatic fistula following pancreaticoduodenectomy. Hepatogastroenterology 2009; 56: 1538-1541
- 4 Takimoto K, Toyonaga T, Matsuyama K. Endoscopic tissue shielding to prevent delayed perforation associated with endoscopic submucosal dissection for duodenal neoplasms. Endoscopy 2012; 44 (Suppl. 02) E414-E415
- 5 Tsuji Y, Ohata K, Gunji T et al. Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to cover wounds after colorectal endoscopic submucosal dissection (with video). Gastrointest Endosc 2014; 79: 151-155
Corresponding author
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References
- 1 Rutegård M, Lagergren P, Rouvelas I et al. Intrathoracic anastomotic leakage and mortality after esophageal cancer resection: a population-based study. Ann Surg Oncol 2012; 19: 90-103
- 2 Ueda K, Tanaka T, Hayashi M et al. Mesh-based pneumostasis contributes to preserving gas exchange capacity and promoting rehabilitation after lung resection. J Surg Res 2011; 167: e71-e75
- 3 Uemura K, Murakami Y, Hayashidani Y et al. Combination of polyglicolic acid felt and fibrin glue for prevention of pancreatic fistula following pancreaticoduodenectomy. Hepatogastroenterology 2009; 56: 1538-1541
- 4 Takimoto K, Toyonaga T, Matsuyama K. Endoscopic tissue shielding to prevent delayed perforation associated with endoscopic submucosal dissection for duodenal neoplasms. Endoscopy 2012; 44 (Suppl. 02) E414-E415
- 5 Tsuji Y, Ohata K, Gunji T et al. Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to cover wounds after colorectal endoscopic submucosal dissection (with video). Gastrointest Endosc 2014; 79: 151-155
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102452-i13716cl1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102452-i13716cl2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102452-i13716cl3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102452-i13716cl4.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)