Endoscopic treatment of esophageal fistulas after esophagectomy with injection of an alpha-cyanoacrylate monomer: a phase II study

Abstract

Background and study aims Interventional endoscopic treatments including the application of glue are becoming more frequently used for the treatment of esophageal fistulas. However, there are no prospective studies of endoscopic treatment for esophageal fistulas. This prospective study aims to investigate the efficacy and safety of endoscopic injection of alpha-cyanoacrylate monomer for intractable esophageal fistulas. Patients and methods This single-center prospective phase II trial included patients with more than 1 wk of conservative medical treatment for intractable esophageal fistulas after esophagectomy. In the image-guided therapy suite, a mixture of alpha-cyanoacrylate monomer and oily contrast agent in a ratio of 0.3 to 1.7 mL was endoscopically injected through the fistula. Results Twenty-five patients who underwent esophagectomy at Wakayama Medical University Hospital were enrolled in this study. The primary disease was esophageal cancer in 16 patients (64 %) and gastric cancer in the remaining 9 patients (36 %). Complete closure of the esophageal fistula was performed in 22 patients after endoscopic injection of alpha-cyanoacrylate monomer. The overall success rate was 88 %. There was no fistula recurrence in any successful closure cases. Three patients with failed esophageal fistula closure had esophageal cancer with cervical esophageal fistulas and required reoperation of the fistulectomy under general anesthesia. No complications associated with this endoscopic treatment were detected. Conclusions Endoscopic treatment with injection of alpha-cyanoacrylate monomer facilitated healing of post-esophagectomy fistula in 88 % of patients without complications. This suggests that the treatment is effective and safe for patients with esophageal fistulas.

Endoscopic closure of refractory esophageal fistula after esophagectomy using polyglycolic acid sheets: a pilot study

“…Therefore, PGA sheets with fibrin glue may be the first treatment for esophageal fistulas after esophagectomy without adverse events. Recently, injection of an alpha-cyanoacrylate monomer successfully closed esophageal fistulas in 88 % of cases without AEs [7]. However, they attempted this therapy in the earlier phase, 1 to 8 days after diagnosing the fistula, which may have affected the results because most fistulas would close just by conservative treatment.…”

“…Several endoscopic therapies for closure of esophageal fistulas have been reported [1,[3][4][5][6][7]. Although endoscopic stenting can close esophageal fistulas in some cases, high recurrence and many adverse events were reported, such as migration, and severe pain; especially in cases of aorto-esophageal fistulas, the stenting can result in death [1,3,4].…”

The best endoscopic method to close refractory esophageal fistula: vacuum? clips? stenting? sheet? glue? ablation?

“…We must emphasize that use of this material is indicated in the absence of infection and protein lysis, upstream stenosis or high-grade esophageal axis deviation as elevated intraluminal pressure acts as fistula maintenance factor. Other approaches are also described, such as use of endoscopic insertion of Vicryl plug along with fibrin glue [12], solo injection of cyanoacrylate [13], overstitch closure of esophagus leaks combined with vacuum therapy [14], bronchoscopic closure of tracheoesophageal fistulas [15] and placement of cardiac septal occluder (CSDO) in esophagotracheal fistula closure [16].…”

Esophageal leaks: I thought that glue was not effective

“…In this issue of Endoscopy International Open, Ojima et al 2 publish an original article evaluating the efficacy and safety of endoscopic injections of alpha-cyanoacrylate monomer in 25 patients with intractable esophageal “fistulas” secondary to esophageal surgery. This study, although interesting and necessary, incorrectly uses the term fistula instead of leak and, indeed, patients with esophagotracheal fistulas were excluded from the study.…”

“…Management of leaks and fistulas is quite similar but not equal in terms of timing, techniques, follow-up and outcomes. Therefore, the results of Ojima et al 2 should be taken into account only in patients with esophageal leaks and not those with fistulas.…”