Closure of a Tracheoesophageal Fistula by Bronchoscopic Application of Tissue Glue

Abstract

To the Editor: We read with interest in the August 1991 issue of Chest the article by Antonelli et al1Antonelli M Cicconetti F Vivino G Gasparetto A Closure of a tracheoesophageal fistula by bronchoscopie application of fibrin glue and decontamination of the oral cavity.Chest. 1991; 100: 578-579Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar regarding the closure of a tracheoesophageal fistula by bronchoscopic application of fibrin glue. We would like to report briefly another case of tracheoesophageal fistula closed by means of a bronchoscopie procedure. A 17-year-old boy was admitted to the ICU in October 1990 after a car accident. Flail chest, multiple bone fractures, and a brain concussion were noted. He was intubated, and mechanical ventilation was started. Twelve days later the patient underwent a tracheostomy for long-term respiratory assistance. Thirty-two days after the tracheostomy, the patient had recovered completely, and successful weaning from the ventilator permitted oral feeding instead of enteral feeding by nasogastric tube. Immediately after the first fluid ingestion the patient experienced a severe cough, which recurred after each fluid intake. A Gastrografin swallow study showed a communication between the superior third of the esophagus and the trachea. A bronchofiberscopic attempt was made to close the fistula with tissue glue (N-butyl-2-cyanoacrylate [Histoacryl, Braun Melsungen, Germany]). The technique described by Roksvagg et al2Roksvagg H Skalleberg L Nordberg C Solheim K Hoivik B Endoscopic closure of bronchial fistula.Thorax. 1983; 38: 696-697Crossref PubMed Scopus (46) Google Scholar for closing a bronchial fistula was used. Twenty-four hours before the procedure the patient gargled with distilled water with 5 percent Betadine every 15 min. Atropine was given by intravenous instillation until the mouth was completely dry, beginning 1 h before the procedure and continuing 2 h afterward. Cardiac monitoring was performed throughout the same period. The bronchofiberscopic procedure was performed under local anesthesia. The tissue glue was applied to the fistula under direct vision; 2 ml of Histoacryl was used. After the procedure the patient received nothing by mouth for 2 days. On the third day a second bronchofiberscopic procedure was done, which demonstrated complete visual obliteration of the fistula by the glue. A Gastrografin swallow showed no more communication between the esophagus and the trachea. On the same day fluid intake was permitted, and the patient did not cough. Six months of follow-up showed no recurrence of the fistula. Histoacryl was chosen because of its fast solidification (10 to 30 s) and its associated inflammatory reaction, which enhances fibrosis with formation of a foreign-body resorptive granuloma. Fistula closure is rapid with Histoacryl, and as a safety measure, 3 days was allowed for complete fistula closure before the patient resumed oral feeding To obtain good results, the tracheal and the esophageal mucosa must be clean, noninfected, and dry; for this reason, we used Betadine for decontamination and atropine for mucosal dryness. This is believed to be the first report of use of Histoacryl for closing a tracheoesophageal fistula, sparing the patient a major surgical procedure and providing a very good result in a few days' time. In our opinion, bronchofiberscopic closure of tracheoesophageal fistula using tissue glue has to be tried before any surgical repair since it is less aggressive and less costly.