Endoscopic Fibrin Glue Injection Research Articles

A Hem-o-Lok–Induced Tracheoesophageal Fistula Cured by Temporary Airway Stenting Modified With Three-Dimensional Printing

We present the case of a fistula between the trachea and the esophagogastric anastomosis in a 58-year-old man after esophagectomy. A Hem-o-Lok clip (Teleflex, Morrisville, NC) used at the time to ligate the azygos vein was discovered by esophagoscopy and bronchoscopy to be eroding into both structures. A covered self-expandable Y-shaped metallic tracheobronchial stent was customized with a three-dimensional printed airway model and inserted in place with endoscopic injection of fibrin glue to the anastomotic site. The stent was withdrawn 64 days after implantation, with complete healing of the fistula.

430 Treatment of Refractory Bleeding Post-Sphincterotomy and Post-Papillectomy With Endoscopic Fibrin Glue Injection. Results in a Large Series

Bleeding is one of the most common complication after therapeutic ERCP. Endoscopic hemostasis can be achieved by epinephrine, hemoclip, thermal coagulation or combining these options. In case of failure, the last options were radiological or surgical treatment. Fibrin glue injection has been proposed for endoscopic hemostasis in this subgroup of patients. Results of endoscopic injection of fibrin glue, for refractory post-sphincterotomy and post-papillectomy bleeding, were analyzed in a large series.

Esophageal Perforation Caused by a Fish Bone Treated with Surgically Indwelling Drainage and Fibrin Glue Injection for Fistula Formation

We herein report a case of thoracic esophageal perforation caused by a fish bone. The patient was a 68-year-old female who presented with a persistent sore throat after eating sea bream four days previously. She was diagnosed with an esophageal perforation and posterior mediastinal abscess formation by chest computed tomography and inflammatory findings in her blood test. Surgically indwelling drainage was able to effectively control the leakage of contaminants and infection. Endoscopic injection of fibrin glue into the long-standing thoracic-esophageal fistula promoted closure of the esophageal wall defect and enabled her to restart oral intake. This case report suggests that effective drainage and the use of fibrin glue sealant may be one of the treatment options for esophageal perforation.

Nonsurgical Treatment of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a "per se" bariatric procedure due to its effectiveness on weight loss and comorbidity resolution. The most feared and life-threatening complication after LSG is the staple line leak and its management is still a debated issue. Aim of this paper is to analyze the incidence of leak and the treatment solutions adopted in a consecutive series of 200 LSG. From October 2002 to November 2008, 200 patients underwent LSG. Nineteen patients (9.5%) had a body mass index (BMI) of >60 kg/m(2). A 48-Fr bougie is used to obtain an 80-120-ml gastric pouch. An oversewing running suture to reinforce the staple line was performed in the last 100 cases. The technique adopted to reinforce the staple line is a running suture taken through and through the complete stomach wall. Staple line leaks occurred in six patients (mean BMI 52.5; mean age 41.6 years). Leak presentation was early in three cases (first, second, and third postoperative (PO) day), late in the remaining three cases (11th, 22nd, and 30th PO day). The most common leak location was at the esophagogastric junction (five cases). Mortality was nihil. Nonoperative management (total parenteral nutrition, proton pump inhibitor, and antibiotics) was adopted in all cases. Percutaneous abdominal drainage was placed in five patients. In one case, a small fistula was successfully treated by endoscopic injection of fibrin glue only. Self-expandable covered stent was used in three cases. Complete healing of leaks was obtained in all patients (mean healing time 71 days). Nonoperative treatment (percutaneous drainage, endoscopy, stent) is feasible, safe, and effective for staple line leaks in patients undergoing LSG; furthermore, it may avoid more mutilating procedures such as total gastrectomy.

Endotherapy of Upper GI Anastomotic Leaks Using a Modified Tygon Plastic Stent: Results of a Large Single Center Series

Background: Upper gastrointestinal (GI) anastomotic leaks are associated with significant morbidity and mortality. The risks of repeat surgery are high and further compounded by the possibility of poor anastomotic healing. Endoscopic treatment with self expandable stents (SES) has been reported. SES are costly, and in the absence of associated luminal strictures, there is a high risk of stent migration; in the event of successful placement, SES especially metallic stents may be difficult to remove after fistula resolution. Aim: To examine the feasibility of a modified Tygon plastic stent for the treatment of postoperative upper GI anastomotic leaks. Methods: The clinical data of consecutive patients with upper GI anastomic leaks who were referred for endoscopic treatment with a modified Tygon plastic stent during the period from November 1997 to June 2007 were reviewed. Tygon plastic stents with a diameter ranging from 9-14 mm were individually tailored according to the location of the leaks. After endoscopic placement of a guidewire, the stent was inserted over a bougie without fluoroscopic monitoring. To prevent distal migration, a 7Fr Teflon catheter was attached to the proximal end of the stent and looped around the ear before being fixated with adhesive tape. Results: A total of 40 patients (80% male; mean age 63.5 years) with upper GI anastomotic leaks (post-esophagectomy: 22.5%; post-gastrectomy: 35%; post-esophago-gastrectomy: 37.5%; chronic anastomotic fistula: 5%) were treated with a modified Tygon plastic stent with a mean duration of 32 days (range: 2 - 209) after surgery. Forty percent of these patients had previous unsuccessful treatment with surgery (35%) or endoscopic fibrin glue injection (5%). Stent insertion was technically successful in all patients without any procedure related complications. After stent placement, 30% of patients died from other postoperative complications and severe underlying co-morbidities before resolution of the leaks. Successful resolution of leaks occurred in 96.4% of the remaining cases after stent placement, and the stents were subsequently removed easily without the need for endoscopy after a mean duration of 39 days (range: 17 - 130). Stent dislocation occurred in 15% of cases but successful reinsertion was possible in all instances. No complications occurred after stent placement. Conclusions: Endoscopic temporary placement of a modified Tygon plastic stent is a very effective and safe method for management of upper GI anastomotic leaks.

Endoscopic fibrin glue injection for closure of pancreatocutaneous fistula following transgastric endoscopic necrosectomy

Transgastric endoscopic necrosectomy has been recently introduced as the effective and alternative management of infected pancreatic necrosis and pancreatic abscess. However, up to 40% of patients who undergo endoscopic necrosectomy may need an additional percutaneous approach for subsequent peripancreatic fluid collection or non-resolution of pancreatic necrosis. This percutaneous approach may lead to persistent pancreatocutaneous fistula, which remains a serious problem and usually requires prolonged hospitalization, or even open-abdominal surgery. We describe the first case of pancreatocutaneous fistula and concomitant abdominal wall defect following transgastric endoscopic necrosectomy and percutaneous drainage, which were endoscopically closed with fibrin glue injection via the necrotic cavity.

Endoscopic Injection of Fibrin Glue for the Treatment of Urinary-Tract Pathology

Urinary-tract fistulas present unique clinical challenges that often necessitate open surgical excision with interposition of healthy tissue. Advances in retrograde instrumentation have enabled endourologists to employ more minimally invasive approaches to urologic disease, including fistulas. We reviewed our experience with endoscopic injection of fibrin glue for the treatment of urinary-tract pathology. We performed a retrospective review of the eight patients at our institution who have undergone retrograde endoscopic injection of fibrin glue for the treatment of urinary-tract pathology. The data collected included age, presentation, treatment technique, method/duration of follow-up, complications, and success, which was defined as subjective and objective resolution of the treated pathology. One of these patients was treated for a caliceal diverticulum refractory to percutaneous ablation. The other seven patients were treated for fistulas, including one colovesical fistula, two vesicovaginal fistulas, one ileal conduit-cutaneous fistula, one ureterocutaneous fistula, one urethrocutaneous fistula, and one ureterorectal fistula. All lesions except the urethrocutaneous fistula and the ureterorectal fistula were treated with a single injection of fibrin glue. At a mean follow-up of 11.75 months, this technique was successful in six cases (75%). Two (33%) of the successfully treated patients required two injections. There were no complications. Failures were apparent at initial follow-up. Retrograde endoscopic injection of fibrin glue offers a novel approach to ablation of caliceal diverticula. Additionally, although open surgical excision of urinary-tract fistulae remains the gold standard treatment, endoscopic injection of fibrin glue offers a safe, minimally invasive approach that may avoid the morbidity of open surgery in such challenging patients.

Successful endoscopic management of postoperative GI fistula with fibrin glue injection: report of two cases

Postoperative fistula is an important complication of GI surgery that is associated with significant morbidity and mortality. Endoscopic fibrin glue injection is increasingly being used as an alternative to re-operation when conservative therapy fails to close a fistula. Reported here are two cases of postoperative fistula occurring after surgical repair of perforated peptic ulcer that were successfully sealed by endoscopic injection of fibrin glue.

Ulcers and nonvariceal bleeding.

Although peptic ulcer continues to be the commonest cause of acute upper gastrointestinal bleeding, obscure haemorrhage from the Dieulafoy malformation and haemobilia must be considered, and may be amenable to endoscopic therapy. The patients who are at the highest risk of rebleeding and death are elderly, in shock at presentation, and have major stigmata of recent haemorrhage (SRH). The endoscopist must identify SRH, and identification may be made easier by washing the area with hydrogen peroxide. The natural history of SRH has been defined. There is wide interobserver variation in the interpretation of SRH, and there is probably therefore little value in the endoscopist describing subtle appearances. Although the value of endoscopic haemostatic therapy is established, it has still not been taken up by all institutions. Endoscopic injection of fibrin glue into the bleeding ulcer is a logical and relatively easy approach, and a systematic histological study of resected ulcers has shown that this does not adversely affect the ulcer healing process. Thermal therapies such as argon plasma coagulation and the heater probe have comparable efficacy. Although a combination of injection and thermal treatments may be logical, there are only trends suggesting that this is better than monotherapy. Nevertheless, the gold probe continues to be used in clinical practice. Experiments in an animal model of gastric bleeding suggest that the gold probe is effective, and that the version with a wide-gauge needle is best. Haemoclips may stop acute upper gastrointestinal bleeding from a range of sources. Patients who rebleed after initial endoscopic haemostasis have a tenfold increase in the risk of death. An important study from Hong Kong suggests that repeat endoscopic treatment after rebleeding has comparable morbidity and mortality to a policy of urgent surgery without endoscopic repeat intervention.

Endoscopic Fibrin Glue Injection with Coaxial Double Lumen Needle for Severe Upper Gastrointestinal Bleeding.

Although endoscopic hemostasis is an effective treatment for acute upper gastrointestinal bleeding, permanent hemostasis may be difficult to achieve by conventional endoscopic treatment alone in some patients. In addition, conventional hemostatic endoscopic therapy is limited in patients with a risk of gastrointestinal ulcer perforation. We tried endoscopic fibrin glue injection in 21 patients as a new approach to control severe upper gastrointestinal bleeding. A new type of coaxial double lumen needle was used in the last 15 patients. Hemostasis was obtained immediately by fibrin glue injection in all 7 patients after unsuccessful attempts using conventional methods, including absolute alcohol or epinephrine injection, clipping, or electrocoagulation. There were no episodes of rebleeding in this group. In 10 of the 14 patients who underwent endoscopic fibrin glue injection as the primary therapy, complete hemostasis was achieved with the initial treatment. The remaining 4 required a second injection within 48 hours. There were no treatment-related complications. None of the patients required an additional surgical operation for bleeding, and the period of hospitalization was reduced after the introduction of fibrin glue injection. Considering the effect on acceleration of ulcer healing, endoscopic fibrin glue injection is an effective treatment with no risk of tissue injury. This technique can be used as the first choice or after failure of conventional endoscopic hemostatic methods.

Fibrin sealing in peptic ulcer bleeding: the fate of the clot.

The injection of fibrin tissue glue is a promising endoscopic method for hemostasis of peptic ulcer bleeding. So far, no clinical study has focused on the ulcer healing process after endoscopic fibrin injection. A morphological study was performed on all resection specimens from patients operated on between 1 January 1994 and 31 December 1996 for gastroduodenal ulcer bleeding with prior endoscopic injection of fibrin glue. The fibrin clot was characterized histologically for its size, location and aspect. Of 227 patients endoscopically treated with a double-lumen needle, 20 underwent resection. The interval between fibrin injection and resection ranged from 6 hours to 9 days. In 15 patients the ulcer was identified in the resection specimen. No fibrin remnants were detectable in three, sparse fibrin deposits were seen in eight and large amounts of fibrin were noted in the submucosa or subserosa in four specimens. With increasing time, the clot was gradually organized by phagocytes and angio-fibroblasts and was finally replaced by endogenous granulation tissue. An exuberant or tissue-destructive reaction did not appear. In this study, endoscopic fibrin sealing of bleeding ulcers resulted in appearance of a bland fibroblast-rich granulation tissue. The depth of fibrin glue injection is difficult to standardize with the aid of double-lumen needles.

Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer

Although injection treatments for ulcer haemostasis seem to be effective, recurrent bleeding remains a serious problem. Large randomised clinical trials are required to show differences between treatment modalities for gastrointestinal bleeding. The aim of this study was to compare the safety and efficacy of repeated endoscopic injection of fibrin glue (FG) with that of single endoscopic injection of polidocanol in the prevention of recurrent bleeding. 854 patients with active gastroduodenal bleeding (spurting, oozing), or ulcers with a visible non-bleeding vessel, were randomly assigned one of three endoscopic treatments: single application of polidocanol 1%, single application of FG, or daily repeated application of FG until the visible vessel had disappeared. All patients were pretreated with local injection of epinephrine (1/10,000), and had daily repeat endoscopies until the vessel observed at initial endoscopy was no longer visible. Recurrent bleeding rates among the 790 patients in whom the rates could be assessed were 58 (22.8%) of 254 in the polidocranol group, 51 (19.2%) of 266 in the FG-single group, and 41 (15.2%) of 270 in the FG-repeated group. The difference between FG-repeated treatment and polidocanol was significant (p = 0.036). Treatment failed, making other treatments (including surgery) necessary, in 34 (13.0%) of 261 in the polidocanol group, 34 (12.4%) of 274 in the FG-single group, and 21 (7.7%) of 274 in the FG-repeated group. The difference between FG-repeated treatment and polidocanol was significant (p = 0.046). The 30-day-mortality rates were low in all three treatment groups (polidocanol 4.7%; FG-single treatment 5.3%, FG-repeated treatment 4.3%). The safety profiles of the three treatment strategies were similar. Repeated injection with FG glue is significantly more effective than injection with polidocanol 1% in the treatment of bleeding from gastroduodenal ulcers.

Fibrin sealing in peptic ulcer bleeding: The fate of the clot

Background and study aims The injection of fibrin tissue glue is a promising endoscopic method for hemostasis of peptic ulcer bleeding. So far, no clinical study has focused on the ulcer healing process after endoscopic fibrin injection. Patients and methods A morphological study was performed on all resection specimens from patients operated on between 1 January 1994 and 31 December 1996 for gastroduodenal ulcer bleeding with prior endoscopic injection of fibrin glue. The fibrin clot was characterized histologically for its size, location and aspect. Results Of 227 patients endoscopically treated with a double-lumen needle, 20 underwent resection. The interval between fibrin injection and resection ranged from 6 hours to 9 days. In 15 patients the ulcer was identified in the resection specimen. No fibrin remnants were detectable in three, sparse fibrin deposits were seen in eight and large amounts of fibrin were noted in the submucosa or subserosa in four specimens. With increasing time, the clot was gradually organized by phagocytes and angio-fibroblasts and was finally replaced by endogenous granulation tissue. An exuberant or tissue-destructive reaction did not appear. Conclusions In this study, endoscopic fibrin sealing of bleeding ulcers resulted in appearance of a bland fibroblast-rich granulation tissue. The depth of fibrin glue injection is difficult to standardize with the aid of double-lumen needles.