Scientific Letter
Conservative Treatment and Use of Fibrin Glue in Oesophageal Perforations
Tratamiento conservador y empleo de pegamento de fibrina en perforaciones esofágicas
Marcos Brunaa,
, Javier Sempereb, Miriam Cantosa, Eva García Del Olmoc, David Dávilaa
Corresponding author
a Servicio de Cirugía General y del Aparato Digestivo, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
b Servicio de Endoscopias y Patología Digestiva, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
c Servicio de Cirugía Torácica, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
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"MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 845 "Ancho" => 895 "Tamanyo" => 83758 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoscopy and extraction of a bony foreign body.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Oesophageal perforations are uncommon and are usually associated with a high morbimortality rate.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The most frequent causes are complications after endoscopic explorations,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> followed by foreign body ingestions, Boerhaave’ syndrome and chemical trauma. Treatment of these patients depends on their general state and the clinical situation, and in some cases requires surgery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present 3 cases of patients with oesophageal perforation treated conservatively in our centre during the past two years.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 58-year-old man presented cardiac arrhythmia, chest pain and a sensation of a tear in the epigastric area after eating meat. He was found to be clinically stable, without dyspnea or tachycardia and a normal abdominal examination. No electrocardiological or blood test anomalies were found. Chest X-ray and CT scan revealed a left pleural effusion and pneumomediastinum. A water-soluble (Gastrografin<span class="elsevierStyleSup">®</span>) contrast study did not reveal any extravasation of contrast, and an upper endoscopy revealed a fragment of meat and bone glued to the oesophageal wall; after mobilization, a 1.5<span class="elsevierStyleHsp" style=""></span>cm perforation was found. Conservative treatment was started with antibiotics (Tigecyclin), NPO, enteral feeding through a nasojejunal tube and drainage of the pleural effusion. In the extracted fluid high levels of amylase and leukocytes were found. A self-expanding covered metallic stent was placed, which migrated to the gastric cavity in two occasions, provoking a limited haemorrhage and needed to be removed. After 4 sessions of endoscopic sealing with fibrin glue (Tissucol<span class="elsevierStyleSup">®</span>) and a new contrast study without evidence of the perforation, the patient began an oral diet and was discharged after 54 days, and remained asymptomatic at one-month follow-up.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 43-year-old man with alcoholic liver disease and oesophageal varices consulted for upper gastrointestinal bleeding. He was treated by sclerosis and banding, but a Sengstaken–Blackemore tube was finally needed to control the bleeding. After it was removed 72<span class="elsevierStyleHsp" style=""></span>h later, the patient presented fever and a CT scan revealed a 6<span class="elsevierStyleHsp" style=""></span>cm collection in the left posterolateral hemithorax. A contrast study revealed a small contained oesophageal leak, and upper endoscopy revealed a 1<span class="elsevierStyleHsp" style=""></span>cm oesophageal perforation on the posterior wall of the mid-oesophagus. The patient remained stable and a chest drain was placed, the patient was kept on NPO and enteral nutrition through a nasojejunal tube and antibiotics (Tigecyclin). Subsequently, a TIPS (transjugular intrahepatic portosystemic shunt) was performed. After 3 sessions of endoscopic sealing with Tissucol<span class="elsevierStyleSup">®</span>, the patient presented a favourable clinical course, and complete closure of the fistula was found after new radiological and endoscopic tests. Subsequently oral intake was started and the patient was discharged 69 days after admission. He has remained asymptomatic at three-month follow-up.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case 3</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 44 year-old man with a history of schizophrenia was admitted for vomiting and foreign body ingestion. The patient was clinically stable, with no dyspnea, sepsis or signs of peritoneal irritation. Endoscopy revealed a fistulous opening of approximately 1<span class="elsevierStyleHsp" style=""></span>cm at the oesophageal-gastric junction and a plastic foreign body in the stomach, which was fragmented and extracted (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). An upper gastrointestinal contrast study revealed a lineal leak in the distal oesophagus, and CT scan revealed a small right pleural condensation that did not require drainage. Antibiotic treatment was started (piperacillin–tazobactam), parenteral nutrition, bowel rest and 4 endoscopic sealing sessions with Tissucol<span class="elsevierStyleSup">®</span>. He presented a favourable progression, and was discharged 45 days after admission, after a normal radiological study. Since then (6 months later) he has remained asymptomatic and endoscopy found an incomplete stenosis with no fistulous opening.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Surgical treatment of oesophageal perforations by laparotomy and/or thoracotomy, debridement, drainage, stomas and enteral or parenteral nutrition is associated with high morbidity and mortality rates,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although it is the only alternative in patients with important clinical repercussion or in septic shock. However, in clinically stable patients, that usually present all the clinical criteria described by Cameron<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and Altorjay<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> with contained leaks without sepsis, obstruction or tumours, an “aggressive” conservative treatment based on NPO, drainage of the pleura and mediastinum, enteral or parenteral nutrition and the use of broad-spectrum antibiotics is a valid and less aggressive<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> alternative, with a cure rate of around 90% and a mortality rate lower than 5%.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In these cases, it is essential to maintain a strict control of the patient, and if any sign of deterioration is seen, or signs of severe sepsis appear, surgical treatment would be necessary.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis if usually confirmed by contrast radiology or CT scan, and the use of endoscopy are controversial, because it could, hypothetically, increase the size of the perforation and contamination of the mediastinum. However, with the advance in safety and experience of endoscopists, this technique is a safe option that has a high sensitivity and specificity for the diagnosis, location and determination of the size of the perforation, and also allows detection non-suspected lesions,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> removal of foreign objects and placement of enteral feeding tubes, sealing substances or stents.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The use of covered stents seems promising, although complications have been described (bleeding, increase in the size of the perforation, fistulisation to adjacent structures, etc.),<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and in some cases new tests, re-placement of the stent, or removal are needed, as in one of our cases. Other options, such as the application of clips, have been published as case reports, with cure rates over 90% and a decrease in hospital stay compared to surgical treatment.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The use of fibrin glue is a safe technique with acceptable results and less morbidity; the fistulous opening must be identified, cleaned and debridement for an adequate application (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Several sessions are usually necessary to obtain closure of the fistula, and some series have presented good results in smaller fistulous orifices than our cases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In tracheoesophageal fistulas, it has been shown that approximately 50% remain sealed after endoscopic treatment, and recurrences are common in the first year of follow-up.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Therefore, “aggressive” conservative treatment of patients with oesophageal perforations and clinical stability is a therapeutic option that obtains high survival rates and healing in many cases.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 3" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bruna M, Sempere J, Cantos M, García Del Olmo E, Dávila D. Tratamiento conservador y empleo de pegamento de fibrina en perforaciones esofágicas. Cir Esp. 2013;91:336–338.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 845 "Ancho" => 895 "Tamanyo" => 83758 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoscopy and extraction of a bony foreign body.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 543 "Ancho" => 1369 "Tamanyo" => 82255 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Location of the opening and instillation of fibrin glue.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Personal management of 57 consecutive patients with esophageal perforation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 0 | 4 |
| 2024 October | 15 | 4 | 19 |
| 2024 September | 14 | 3 | 17 |
| 2024 August | 12 | 1 | 13 |
| 2024 July | 14 | 1 | 15 |
| 2024 June | 15 | 2 | 17 |
| 2024 May | 19 | 4 | 23 |
| 2024 April | 23 | 4 | 27 |
| 2024 March | 25 | 6 | 31 |
| 2024 February | 47 | 2 | 49 |
| 2024 January | 70 | 2 | 72 |
| 2023 December | 19 | 4 | 23 |
| 2023 November | 14 | 3 | 17 |
| 2023 October | 25 | 3 | 28 |
| 2023 September | 8 | 3 | 11 |
| 2023 August | 23 | 2 | 25 |
| 2023 July | 22 | 2 | 24 |
| 2023 June | 23 | 0 | 23 |
| 2023 May | 26 | 3 | 29 |
| 2023 April | 30 | 1 | 31 |
| 2023 March | 26 | 2 | 28 |
| 2023 February | 15 | 2 | 17 |
| 2023 January | 16 | 3 | 19 |
| 2022 December | 23 | 4 | 27 |
| 2022 November | 21 | 10 | 31 |
| 2022 October | 11 | 4 | 15 |
| 2022 September | 20 | 8 | 28 |
| 2022 August | 27 | 5 | 32 |
| 2022 July | 12 | 6 | 18 |
| 2022 June | 12 | 6 | 18 |
| 2022 May | 11 | 6 | 17 |
| 2022 April | 10 | 6 | 16 |
| 2022 March | 8 | 12 | 20 |
| 2022 February | 13 | 3 | 16 |
| 2022 January | 20 | 5 | 25 |
| 2021 December | 11 | 10 | 21 |
| 2021 November | 15 | 12 | 27 |
| 2021 October | 20 | 9 | 29 |
| 2021 September | 11 | 14 | 25 |
| 2021 August | 9 | 4 | 13 |
| 2021 July | 10 | 6 | 16 |
| 2021 June | 11 | 11 | 22 |
| 2021 May | 15 | 9 | 24 |
| 2021 April | 23 | 14 | 37 |
| 2021 March | 11 | 9 | 20 |
| 2021 February | 13 | 5 | 18 |
| 2021 January | 10 | 10 | 20 |
| 2020 December | 14 | 5 | 19 |
| 2020 November | 7 | 4 | 11 |
| 2020 October | 6 | 1 | 7 |
| 2020 September | 12 | 15 | 27 |
| 2020 August | 8 | 19 | 27 |
| 2020 July | 13 | 14 | 27 |
| 2020 June | 18 | 6 | 24 |
| 2020 May | 4 | 11 | 15 |
| 2020 April | 9 | 2 | 11 |
| 2020 March | 6 | 0 | 6 |
| 2020 February | 10 | 7 | 17 |
| 2020 January | 8 | 10 | 18 |
| 2019 December | 12 | 6 | 18 |
| 2019 November | 10 | 2 | 12 |
| 2019 October | 4 | 1 | 5 |
| 2019 September | 9 | 4 | 13 |
| 2019 August | 13 | 1 | 14 |
| 2019 July | 8 | 23 | 31 |
| 2019 June | 27 | 16 | 43 |
| 2019 May | 111 | 8 | 119 |
| 2019 April | 9 | 17 | 26 |
| 2019 March | 3 | 2 | 5 |
| 2019 February | 7 | 10 | 17 |
| 2019 January | 3 | 1 | 4 |
| 2018 December | 6 | 8 | 14 |
| 2018 November | 12 | 1 | 13 |
| 2018 October | 18 | 7 | 25 |
| 2018 September | 5 | 3 | 8 |
| 2018 August | 10 | 1 | 11 |
| 2018 July | 10 | 1 | 11 |
| 2018 June | 12 | 1 | 13 |
| 2018 May | 14 | 1 | 15 |
| 2018 April | 9 | 1 | 10 |
| 2018 March | 27 | 0 | 27 |
| 2018 February | 71 | 1 | 72 |
| 2018 January | 26 | 1 | 27 |
| 2017 December | 65 | 1 | 66 |
| 2017 November | 6 | 0 | 6 |
| 2017 October | 10 | 2 | 12 |
| 2017 September | 11 | 0 | 11 |
| 2017 August | 18 | 1 | 19 |
| 2017 July | 8 | 0 | 8 |
| 2017 June | 12 | 2 | 14 |
| 2017 May | 5 | 2 | 7 |
| 2017 April | 8 | 0 | 8 |
| 2017 March | 8 | 2 | 10 |
| 2017 February | 8 | 0 | 8 |
| 2017 January | 6 | 1 | 7 |
| 2016 December | 15 | 4 | 19 |
| 2016 November | 8 | 4 | 12 |
| 2016 October | 18 | 0 | 18 |
| 2016 September | 15 | 4 | 19 |
| 2016 August | 9 | 4 | 13 |
| 2016 July | 10 | 1 | 11 |
| 2016 June | 14 | 3 | 17 |
| 2016 May | 15 | 22 | 37 |
| 2016 April | 6 | 5 | 11 |
| 2016 March | 14 | 14 | 28 |
| 2016 February | 11 | 5 | 16 |
| 2016 January | 8 | 7 | 15 |
| 2015 December | 13 | 5 | 18 |
| 2015 November | 19 | 3 | 22 |
| 2015 October | 11 | 6 | 17 |
| 2015 September | 12 | 5 | 17 |
| 2015 August | 15 | 8 | 23 |
| 2015 July | 11 | 2 | 13 |
| 2015 June | 3 | 1 | 4 |
| 2015 May | 11 | 4 | 15 |
| 2015 April | 11 | 11 | 22 |
| 2015 March | 14 | 5 | 19 |
| 2015 February | 8 | 5 | 13 |
| 2015 January | 26 | 0 | 26 |
| 2014 December | 42 | 11 | 53 |
| 2014 November | 24 | 4 | 28 |
| 2014 October | 23 | 6 | 29 |
| 2014 September | 29 | 2 | 31 |
| 2014 August | 16 | 7 | 23 |
| 2014 July | 22 | 4 | 26 |
| 2014 June | 13 | 3 | 16 |
| 2014 May | 14 | 3 | 17 |
| 2014 April | 8 | 3 | 11 |
| 2014 March | 10 | 4 | 14 |
| 2014 February | 12 | 3 | 15 |
| 2014 January | 17 | 4 | 21 |
| 2013 December | 11 | 3 | 14 |
| 2013 November | 4 | 2 | 6 |
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