Maria Sylvia Ierardi Ribeiro, MD, Renata A.F.P. de Barros, MD, and Michael B. Wallace, MD, MPH describe this VideoGIE case “Vicryl patch and fibrin glue as treatment of an esophageal leak.”
Achalasia is a motility disorder associated with degeneration of neurons in the wall of the esophagus. It is characterized by failure of relaxation of the lower esophageal sphincter (LES) and is commonly accompanied by a loss of esophageal peristalsis.
Nonsurgical therapy has traditionally involved pneumatic balloon dilation or endoscopic botulinum toxin injection. Although endoscopic therapies have had good short-term clinical response rates, the durability of treatment has been variable. Surgical myotomy, although more invasive, has long been considered to provide more sustained relief of symptoms. More recent data have suggested that serial endoscopic pneumatic dilation and surgical myotomy are comparable in efficacy. Per oral endoscopic myotomy (POEM) is also a new and effective therapy although more data is needed to compare with surgery and pneumatic dilation.
The laparoscopic myotomy’s failure rate, defined as persistent and/or frequent dysphagia, ranges from 2.2% to 23% (mean, 10.9%). Mucosal perforation rates ranges from 2.1% to 23.9% (mean, 7.4%) and are typically more frequent in patients who underwent previous endoscopic therapy with botulinum toxin injection or pneumatic dilation.
The incidence of clinically relevant anastomotic leaks after upper gastrointestinal surgery is approximately 4% to 20%, and the associated mortality is up to 80%. Depending on the clinical presentation, the treatment options include surgery, conservative treatment with or without external drainage or endoscopic treatment.
A 22-year-old man was referred with a history of achalasia. Prior treatments included 4 pneumatic dilations, 2 botox injections, PEG-J feeding tube placement, and 2 previous Heller myotomies with a partial fundoplication complicated by dehiscence requiring laparoscopic and percutaneous drainage of an esophageal leak. Conventional upper GI endoscopy revealed a large fistula at the lower esophageal sphincter with a 2-cm fibrotic orifice and a visible tip of the percutaneous drainage tube. A vicryl (Ethicon, Inc.) patch was inserted endoscopically followed by injection of 4 mL Tisseel/fibrin (Tissucol Duo, Baxter, Germany) glue.
Our case demonstrated a method to treat postoperative upper gastrointestinal fistulas or anastomotic leaks with little morbidity by means of endoscopic insertion of Vicryl patch with fibrin glue, thereby avoiding repetitive major surgery and its associated risks.
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