Fibrin Glue as a Sealant for High-Risk Anastomosis in Surgery for Morbid Obesity

Background: Fibrin sealants promote hemostasis and wound healing. Complex revisional surgery is performed for morbid obesity, and high-risk patients undergo weight loss surgery routinely. Fibrin sealant, Tisseel™, was used by one surgeon on 120 consecutive patients at the gastrojejunal anastomosis in Roux-en-Y gastric bypass (RYGBP).We hypothesized that the application of fibrin sealant would decrease anastomotic leaks. Methods: One surgeon (Surgeon A) used fibrin sealant for 120 consecutive patients, while two other surgeons (Surgeons B & C) served as controls and did not use fibrin glue for their last 120 patients. Surgeon A did not use fibrin glue in 120 patients to serve as an internal control. All 480 patients underwent a RYGBP. Fibrin glue was applied at the gastrojejunal anastomosis. Results: The fibrin sealant group did not have any documented leaks on the previous 120 patients, while 5 patients with Surgeon B, 2 patients with Surgeon C and 1 patient with Surgeon A without fibrin sealant experienced enteric leaks requiring re-operation, drainage, or long-term total parenteral nutrition (N=480 total patients). Conclusions: Fibrin sealant may be useful in preventing leaks and promoting healing of the "high risk" anastomosis during complex gastrointestinal surgery. While the cost of fibrin glue is to be considered, re-operation and management of subsequent enterocutanous fistulas or anastomotic strictures may be more costly than routine use for high-risk morbidly obese patients.     

Dural substitute with polyglycolic acid mesh and fibrin glue for dural repair: technical note and preliminary results

Background An ideal dural substitute that enables watertight closure, has sufficient strength, and can be absorbed without remnant materials that induce inflammation, adhesion, and infection is not available. The purpose of this study was to evaluate the efficacy of a bioabsorbable polyglycolic acid (PGA) mesh and fibrin glue as a substitute for dural repair. Methods Altogether, 10 patients with noted dural tears during extradural spinal surgery and 20 patients who underwent durotomy for intradural spinal surgery were included in this study. In a series of 20 consecutive cases, dural closure was performed by suture and fibrin glue. In the subsequent 10 consecutive patients, dural closure was performed by suture and fibrin glue with the use of absorbable PGA mesh. The medical records and magnetic resonance imaging (MRI) of the surgical site were retrospectively reviewed to evaluate the presence of a cerebrospinal fluid (CSF) fistula or leakage after the surgery. Results A CSF fistula occurred in five patients who underwent dural repair with fibrin glue alone, and postoperative MRI showed CSF leakage in two patients with incidental dural tears after laminectomy for ossification of ligamentum flavum. No CSF fistula was present in patients who underwent dural repair using PGA mesh and fibrin glue, and no adverse effects or complications were encountered postoperatively. Follow-up MRI revealed no evidence of CSF leakage around the reconstructed dura mater. Conclusions The use of PGA mesh and fibrin glue for the repair of dura mater is a useful method of preventing CSF leakage in spinal surgery.     

Endoscopic management of pancreatic fistulas secondary to intraabdominal operation

Background: Pancreatic fistulas may arise secondary to several disorders of the pancreas. Although ~70% of pancreatic fistulas close with nonoperative management, this course of treatment usually takes several weeks or even months. To reduce this long period, closures with fibrin glue have been attempted in the past. In this study, we describe the course, management, and outcome of eight patients with postoperative external pancreatic fistulas of the pancreatic body and tail that arose after oncologic operations in the upper abdomen. Methods: All eight cases were treated by external drainage, insertion of an endoprosthesis into the pancreatic duct, and closure of the fistula with fibrin glue. Results: Immediately after this intervention, secretion from the fistulas was absent in all cases. None of the patients developed abscesses, recurrent fistulas, or complications associated with the fibrin glue. Conclusion: The early endoscopic management of postoperative pancreatic fistula with an approach combining internal drainage of the pancreatic duct and external occlusion of the fistula with fibrin glue is expeditious and beneficial.     

Closure of proximal colorectal fistulas using fibrin sealant

Fibrin glue has been used in upper gastrointestinal and perianal fistula disease, but its success in proximal colorectal pathology has not been widely documented. This report describes the use of endoscopically injected fibrin glue as a successful adjunct to traditional methods in accelerating the closure of colorectal fistulas. A retrospective review was performed on cases of colon and rectal fistulas treated with fibrin glue using an endoscopic technique of injection. Fistulas were injected via a flexible fiberoptic endoscope with fluoroscopic guidance (three) or directly with a rigid proctoscope (one). Fibrin glue was mixed directly from cryoprecipitate, thrombin, and calcium (one) or using a Tisseel kit (three) (Baxter, Deerfield, IL). Four patients were identified and included: two J-pouch fistulas, a colocutaneous fistula, and a complex rectocutaneous fistula. The median duration of fistula was 33 days (range 4-365 days). Total parenteral nutrition and bowel rest were used in two patients and three required drainage of an abscess. All fistulas were obliterated and patients required a mean of one application of fibrin glue (range one to two). The mean time to resuming a regular diet postinjection was 2 days (range 1-5). No complications were identified. Fistula resolution was documented in all cases with a contrast enema and no patient has had a fistula recurrence at a median follow-up of 12 months (range 6-65). This preliminary series demonstrates that fibrin glue can be used to obliterate proximal rectal, colonic, and pouch fistulas. Endoscopy and fluoroscopy may aid in administering the fibrin glue. This adjunctive technique may shorten the time to fistula closure and may allow some patients to avoid further surgery.     

Initial experience with the endoscopic application of fibrin tissue adhesive in the upper gastrointestinal tract

Summary During a 15-month period, a total of 11 patients underwent endoscopic application of fibrin tissue adhesive in the upper gastrointestinal tract. Our sample consisted of 6 patients with control of bleeding, 4 patients with management of anastomotic leaks, and one very old man undergoing prophylactic sealing of a chronic gastric ulcer with a visible vessel and repeated episodes of bleeding. The method described has proven to be successful in control of bleeding in every case and has resulted in quick cleaning of perianastomotic abscess cavities, growth of granulation tissue, and complete healing in 3 of 4 cases so far. This preliminary report suggests that fibrin adhesive application is effective in the control of oozing gastrointestinal bleeding and may support the healing process in difficult situations, such as chronic peptic ulcers and anastomotic leakages.     

An effective case of a new biological adhesive agent, gelatin-resorcinol formaldehyde-glutaralhyde glue (GRFG-glue) in treating refractory pulmonary fistula following lobectomy for pulmonary aspergilloma]

We report a successful case of thoracoscopic therapy using a new biological adhesive agent, Gelatin-Resorcinol Formaldehyde glue (GRFG glue) for refractory pulmonary fistula. A 69-year-old male underwent right upper lobectomy for lung aspergilloma. Air leakage began 11 days after lobectomy. Closing alveolar fistula was performed 28 days after first operation. Relapsing air leakage began 2 days after second operation. The insertion of fibrin glue through thoracoscope at two times was not effective for refractory pulmonary fistula. But the insertion of GRFG glue was effective to close the fistula completely.     

Endoscopic injection of fibrin glue for the treatment of urinary-tract pathology

BACKGROUND AND PURPOSE: 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. PATIENTS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.     

Diagnosis and management of a mediastinal leak following radical oesophagectomy

BACKGROUND: The aim of this study was to evaluate the diagnosis, management and outcome of mediastinal leaks following radical oesophagectomy with a stapled intrathoracic anastomosis. METHODS: Some 291 consecutive patients underwent two-phase subtotal oesophagectomy with gastric interposition for malignancy. Patients with clinical suspicion of a leak were investigated with contrast radiology and flexible upper gastrointestinal endoscopy. RESULTS: Nineteen patients (6.5 per cent) developed a proven mediastinal leak at a median of 8 (range 3-30) days following surgery. Contrast radiology and flexible upper gastrointestinal endoscopy identified that 13 patients had an isolated leak from the oesophagogastric anastomosis and two had widespread leakage secondary to gastrotomy-line dehiscence. Endoscopy revealed a further four patients with gastric necrosis in whom contrast radiology was normal. In six patients the diagnosis of leakage followed an apparently normal routine contrast examination on day 5-8. All 13 isolated anastomotic leaks were managed non-operatively with targeted mediastinal drainage, intravenous antibiotics and antifungal therapy, nasogastric decompression and enteral nutrition; the mortality rate was 15 per cent (two of 13). Patients with gastrotomy dehiscence or gastric necrosis had a more severe clinical picture; they were managed with repeat thoracotomy and either revision of the conduit or resection and exclusion. Despite early intervention four of the six patients died. CONCLUSION: Routine postoperative contrast radiology cannot be recommended. On clinical suspicion of a leak patients require both contrast radiology and endoscopic evaluation. Isolated anastomotic leaks can be managed successfully with non-operative treatment, whereas more extensive leaks from the gastric conduit require revisional surgery which carries a high mortality rate.     

Experience with thoracoscopic surgery for primary bronchial stump fistula after pneumonectomy

After a left pneumonectomy, thoracoscopic closure with fibrin glue was performed for a fistula on the bronchial stump and the postoperative state progressed favorably thereafter. In this paper, we report on this successful case.Case: A 61 year-old male, who underwent a left pneumonectomy on January 17, 1996 for pulmonary carcinoma (T 3 N 1M 0 stage III A). The bronchial stump was covered with anterior serratus muscle flap. On April 1 (the 76th postoperative day), after two courses of Carboplatin and Vindesine treatment, the patient suddenly developed a fistula on the bronchial stump. Bronchofiberscopic closure with fibrin glue was attempted, but failed to close the fistula. Thoracoscopic surgery was then performed on May 15 (the 45th day after the onset of the fistula). After the intrathoracic opening of the fistula was found with a contrast medium, fibrin glue was injected to fill up to the bronchial stump, and communication with the thoracic cavity was blocked. Owing to coverage with a myocutaneous flap, the patient’s general postoperative state remained relatively stable. Thoracoscopic surgery is useful as a treatment for some cases of bronchial stump fistula after pneumonectomy.     

Postoperative magnetic resonance imaging after acoustic neuroma surgery: influence of packing materials in the drilled internal auditory canal on assessment of residual tumor

Serial magnetic resonance (MR) images taken after acoustic neuroma surgery were analyzed to evaluate the pattern and timing of postoperative contrast enhancement in 22 patients who underwent acoustic neuroma removal via the suboccipital transmeatal approach. The opened internal auditory canal (IAC) was covered with a muscle piece in nine patients and with fibrin glue in 13. A total of 56 MR imaging examinations were obtained between days 1 and 930 after surgery. MR imaging showed linear enhancement at the IAC within the first 2 days after surgery, and revealed nodular enhancement on day 3 or later in patients with a muscle piece. MR imaging tended to show linear enhancement at the IAC, irrespective of the timing of the examination in the patients with fibrin glue. Postoperative MR imaging on day 3 or later showed the incidence of nodular enhancement in patients with muscle was significantly higher than in patients with fibrin glue. The results illustrate the difficulty in differentiating nodular enhancement on a muscle piece from tumor by a single postoperative MR imaging study. Therefore, fibrin glue is generally advocated as a packing material of the IAC because it rarely shows masslike enhancement on postoperative MR imaging. When a muscle piece is used in patients at high risk for postoperative cerebrospinal fluid leaks, MR imaging should be obtained within the first 2 days after surgery, since benign enhancement of muscle will not occur and obscure the precise extent of tumor resection.     

Management of Anastomotic Leaks After Laparoscopic Roux-en-Y Gastric Bypass

Background Anastomotic leaks after bariatric surgery carry high morbidity and mortality. We aimed to describe our experience of the diagnosis and management of gastrointestinal anastomotic leaks in patients undergoing laparoscopic gastric bypass in a single institution. Methods Of 1,200 patients who underwent laparoscopic Roux-en-Y gastric bypass with manual gastrojejunal anastomosis for morbid obesity from January 2002 to January 2007, we retrospectively analyzed 59 patients with anastomotic leak. The location of the leak, day of diagnosis, diagnostic methods, clinical manifestations, treatment modalities, associated complications, and length of hospital stay were analyzed. Results Leaks were located as follows: 67.8% in the gastrojejunostomy, 10.2% in the gastric pouch, 3.4% in the excluded stomach, 5.1% in the jejunojejunal anastomosis, 3.4% in the gastrojejunostomy plus pouch, 3.4% in the pouch plus excluded stomach, and 6.8% in undetermined sites. Routine upper gastrointestinal series revealed contrast extravasation in nine patients (15.3%). Leaks were asymptomatic at diagnosis in 29 patients (49.2%). Surgical reintervention was carried out in 23 patients, and conservative treatment was provided in the remaining 36. Transfer to the intensive care unit was required in 11 patients, with five deaths (0.4%). Conclusion In our experience, most anastomotic leaks can be managed with conservative measures alone. In many patients, abdominal drains are effective in the management of leaks, obviating the need for reintervention. Nasoenteral nutrition was effective in the non-operative management of gastrojejunal leaks in patients without signs of systemic toxicity.     

Endoscopic treatment of mediastinal anastomotic leaks

BACKGROUND: Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic anastomotic leaks are often associated with poor results and carry a high morbidity and mortality. This report describes our results with the endoscopic treatment of intrathoracic anastomotic leakages. PATIENTS: 27 consecutive patients presenting with clinically apparent intrathoracic anastomotic leak, caused by resection of an epiphrenic diverticulum (n=1), esophagectomy for esophageal cancer (n=19), limited resection for carcinoma of the gastroesophageal junction (n=1) or gastrectomy for gastric cancer (n=6) were endoscopically treated. The extent of the dehiscences ranged from about 10-70%. After endoscopic lavage and debridement of the leakage (mean duration: 16,8 days) the leaks were closed with fibrin clue (n=9) or endoclips (n=2) in cases of smaller leaks or by stent placement (n=11), stent placement after unsuccessful fibrin clue injections (n=3) or stent placement and endoclipping (n=1) in patients with a large leakage. Simultaneously the periesophageal mediastinum was drained by chest drains. RESULTS: 25 of 27 patients were successfully treated endoscopically. Under endoscopic treatment one patient died due to septic multiorgan failure. Another patient developed a refractory, persistent leak. Procedure related complications (stent migration, anastomotic stenosis) were obtained in 6 patients. CONCLUSION: An endoscopic approach is successful and safe to treat symptomatic intrathoracic anastomotic leaks smaller than 70% of the circumference. An endoscopic lavage and debridement of the leak, prior to leak closure, seems to be helpful to reduce mediastinal and pleural inflammation. In patients with smaller leaks (<30%) fibrin clue injections and endoclipping is recommended. Patients with a dehiscence from 30-70% of the circumference profit from stent placement.     

Anastomotic Leak Prophylaxis Using a Vapor-Heated Fibrin Sealant: Report on 738 Gastric Bypass Patients

Background: Excluding pulmonary embolism, anastomotic leak is the leading cause of death and major morbidity in patients undergoing open or laparoscopic gastric bypass operations. We observed a number of these leaks (11 out of 1,120 Micropouch^SM gastric bypass [MGB] patients; 0.9%). The majority (80%) required emergency laparotomy and drainage, massive fluid resuscitation, and aggressive nutritional support. Therefore, we designed a 2-year, prospective study to determine the therapeutic efficacy of vapor-heated fibrin sealant to prevent anastomotic leaks at the gastro-jejunostomy (GJS) site. Methods: Between April, 2000 and March, 2002, 738 patients underwent a primary (n=671) or revisionary (n=67) MGB procedure.The gastric reservoir was limited to the cardia of the stomach. Vapor-heated fibrin glue 1 cc was applied circumferentially to a 12-mm, non-banded GJS anastomosis. Once activated, fibrin sealant polymerized into a soft, closely adherent gel. No omental patch was used to cover the fibrin-sealed anastomosis. Results: Of 738 patients, 2 required emergency laparotomy for leaks and 2 for adhesive bands that contributed to a distal small bowel obstruction.There were no anastomotic leaks at the fibrin-sealed GJS sites. No gastro-gastric or gastro-enteric fistulas were recorded. Conclusion. Fibrin sealant applied to the GJS site appears to have eliminated anastomotic leaks in our Micropouch^SM gastric bypass patients. These results suggest that fibrin glue application may contribute to "leak prophylaxis" in patients undergoing open Rouxen-Y gastric bypass. Glue placements may also benefit patients undergoing a laparoscopic Roux-en-Y procedure, wherein anastomotic leaks have been reported early in the learning curve.     

Use of endoscopic stents to treat anastomotic complications after bariatric surgery

BACKGROUND: Complications after bariatric surgery often require longterm parenteral nutrition to achieve healing. Recently, endoscopic treatments have become available that provide healing while allowing for oral nutrition. The purpose of this study was to present outcomes of the largest series to date treating staple line complications after bariatric surgery with endoscopic covered stents. STUDY DESIGN: A retrospective evaluation was performed of all patients treated for staple line complications after bariatric surgery at a single tertiary care bariatric center. Acute postoperative leaks, chronic gastrocutaneous fistulas, and anastomotic strictures refractory to endoscopic dilation after both gastric bypass and sleeve gastrectomy were included. RESULTS: From January 2006 to June 2007, 19 patients (11 with acute leaks, 2 with chronic fistulas, and 6 with strictures) were treated with a total of 34 endoscopic silicone covered stents (23 polyester, 11 metal). Mean followup was 3.6 months. Immediate symptomatic improvement occurred in 90% (91% of acute leaks, 100% of fistulas, and 84% of strictures). Oral feeding was started in 79% of patients immediately after stenting. Resolution of leak or stricture after stent treatment occurred in 16 of 19 patients (84%). Healing of leak, fistula, and stricture occurred at means of 33 days, 46 days, and 7 days, respectively. Three patients (1 with leak, 1 with fistula, and 1 with stricture) had unsuccessful stent treatment. Migration of the stent occurred in 58% of 34 stents placed. Most migration was minimal, but three stents were removed surgically after distal small bowel migration. There was no mortality. CONCLUSIONS: Treatment of anastomotic complications after bariatric surgery with endoscopic covered stents allows rapid healing while simultaneously allowing for oral nutrition. The primary morbidity is stent migration.     

经T管窦道生物蛋白胶植入协助治疗拔T管后胆漏

目的 研究经腹腔镜胆总管切开取石T管引流术（LCTD）后,拔除T管出现胆漏的处理办法;在临床常规方法的基础上,探讨生物蛋白胶封堵T管窦道漏口的可行性。方法 研究对象为LCTD术后,拔除T管出现胆漏的患者36例,按照随机分组原则分为2组。对照组18例,拔除T管出现胆漏后,行禁食水、胃肠减压、抑酸、抑酶、抗感染治疗,同时经胆道镜T管窦道尿管置入或经十二指肠镜鼻胆管引流;研究组18例,拔除T管出现胆漏后,除禁食水、胃肠减压、抑酸、抑酶、抗感染治疗、经胆道镜T管窦道尿管置入或经十二指肠镜鼻胆管引流外,经胆道镜从T管窦道置入生物蛋白胶堵漏,封闭窦道撕裂或未完全愈合处。统计、对比两组患者的病情恢复情况。结果 对照组单纯使用T管窦道尿管置入或鼻胆管引流,腹膜炎体征恢复慢,治疗时间长,费用高,其中2例患者行二次手术;研究组在使用T管窦道尿管置入或鼻胆管引流的基础上,加用生物蛋白胶封堵窦道漏口,腹膜炎体征恢复快,治疗时间短,费用低,无二次手术患者。两组比较,各指标差异有统计学意义（P＜0.05）。结论 对于拔除T管后出现胆漏的患者,除禁食水、胃肠减压、抑酸、抑酶、抗感染、再次T管窦道置入尿管引流或鼻胆管引流外,联合胆道镜植入生物蛋白胶堵漏治疗拔T管后胆漏,较单纯使用尿管引流或鼻胆管引流效果更好,恢复快,费用低,值得推广。     

Management of low-output pancreatic fistulas with fibrin glue

BACKGROUND: Despite advances in surgical, endoscopic, and percutaneous therapeutic techniques, pancreatic fistulas remain a source of significant morbidity and long-term patient discomfort. The intraoperative use of fibrin sealant has been used prophylactically to prevent formation of fistula. We recognized the potential use of fibrin glue as a therapeutic modality for successful resolution of low-output pancreatic fistulas. METHODS: Three patients with low (<20 ml per day) output pancreatic fistulas underwent fluoroscopically directed injection of fibrin glue along their fistula tract. RESULTS: All 3 patients underwent successful fibrin glue injection without procedural complication. All fistula output stopped, and the 3 patients remained asymptomatic at 1 year. CONCLUSIONS: Fibrin glue inserted with image-guided catheter delivery systems may be a useful option in selected patients with low-output pancreatic fistulas.     

Role of Fibrin Glue as a Sealant to Esophageal Anastomosis in Cases of Congenital Esophageal Atresia with Tracheoesophageal Fistula

Objective The aim of this study was to characterize a successful approach for the management of infants with long-gap esophageal atresia (EA) with tracheoesophageal fistula (TEF). The goal was to preserve the native esophagus and minimize the incidence of esophageal anastomotic leaks using fibrin glue as a sealant over the esophageal anastomosis. Method A total of 52 patients were evaluated in this study. Only patients in whom, gap between the two ends of the esophagus was ≥ 2 cm were selected during January 2005 to January 2007. Patients were divided in two groups on the basis of block randomization. Group A comprised the patients in whom fibrin sealant was used as reinforcement on a primary end-to-end esophageal anastomosis; in group B, fibrin glue was not used. The two groups were compared in terms of esophageal anastomotic leak (EL), postoperative esophageal stricture (ES), and mortality. The statistical analysis was done using Fisher’s exact test and the chi-squared test. Result The number of anastomotic leaks in group A (glue group) was about one-fifth that in group B (no glue group). The incidence of ES was almost twice as high in group B as in group A. The mortality rate was almost threefold higher in group B (no-glue group). The higher incidence of EL and ES in group B compared to group A was statistically significant. Conclusion Thus, fibrin glue when used as an adjunct to esophageal anastomosis for primary repair of long-gap EA with TEF appears safe in the clinical setting and may lower the chances of esophageal leak and anastomosis-site strictures. Hence, it can diminish the mortality and morbidity of these patients.     

Verification of Early Removal of the Chest Tube after Absorbable Mesh-based Pneumostasis Subsequent to Video-assisted Major Lung Resection for Cancer

Background

We previously reported that the combined use of absorbable mesh and fibrin glue is superior to the use of fibrin glue alone to stop intraoperative air leaks. However, concern remains about whether mesh-based pneumostasis can induce the recurrence of air leaks after chest tube removal.

Methods

We reviewed our prospective database of selected patients (n?=?206) who underwent video-assisted major lung resection for cancer. Exclusion criteria included simultaneous combined resection, induction radiotherapy, entire intrathoracic adhesion, or a history of prior ipsilateral thoracotomy. We sealed any intraoperative air leaks with absorbable mesh and fibrin glue and then carried out prophylactic chest-tube drainage for 1?day.

Results

Intraoperative air leaks were detected in 133 (65%) patients. Overall, air leaks were not detected postoperatively in 186 (91%) patients, allowing chest tube removal on the day after the operation. The mean length of time for chest tube drainage was 1.2?days. A prolonged air leak (>7?days) was observed in one (0.5%) patient, and this leak resolved by itself. After chest tube removal, an air leak recurred in six (2.9%) patients during the 30?day follow-up period, necessitating chest tube reinsertion. Although the recurrence was observed more frequently after segmentectomy than after lobectomy (p?=?0.04), the recurrence was not observed more frequently in patients who had an intraoperative air leak than in patients who did not (p?=?0.3).

Conclusion

Early removal of the chest tube after pneumostasis with absorbable mesh is verified in selected patients who underwent video-assisted major lung resection for cancer. However, further attempts should be made to prevent air leaks after anatomical segmentectomy.     

Management of low colorectal anastomotic leak: Preserving the anastomosis

Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy (Hartmann’s procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.     

Esophagogastric anastomoses: the value of fibrin glue in preventing leakage

Disruption of an esophagogastric anastomosis can result in a high mortality despite aggressive treatment. The efficacy of fibrin "glue" to seal esophagogastric anastomoses was evaluated as a means of preventing this complication. A left thoracotomy was performed in 25 adult mongrel dogs. After esophagogastric resection, a standardized esophagogastrostomy was performed and eight interrupted sutures were used to completely close the posterior wall. The anterior wall was approximated with only three sutures, leaving four large holes between sutures. The dogs were then randomized into the control group (n = 14; no attempt to seal the leaks) or into the fibrin glue-treated group (n = 11). An average of 3.3 ml of glue was applied to the anterior wall of the anastomosis in the treated group. In the control group, 13 of 14 dogs (92.9%) died of anastomotic leak a median of 3 days after operation. In the fibrin glue-treated group, only four of 11 dogs (36.4%) died of anastomotic leaks (p less than 0.01). Dogs that survived were put to death at 14 days. Postmortem examination in all dogs revealed no deleterious effects or complications related to the glue. Postmortem examination of the one surviving control dog and the seven fibrin glue-treated dogs that did not die of sepsis revealed a healed anastomosis without abscess formation. We conclude that fibrin glue is effective in lessening the incidence of esophagogastric anastomotic leaks as employed in this experimental model.