Ussat S, Lodes U, Wex C, Rapp L, Schulz H-U, Meyer F
Chirurgischen Intensivstation, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland.
Dtsch Med Wochenschr. 2013 Jul;138(27):1406-9. doi: 10.1055/s-0033-1343238. Epub 2013 Jun 25.
HISTORY AND INTERVENTION: A 52-year-old female patient underwent open abdominothoracic cardia and esophageal resection with gastric transposition because of histologically diagnosed Barrett metaplasia with "high-grade" intraepithelial neoplasia (HGIEN) and parts of an invasive adenocarcinoma. The anastomotic insufficiency on the 10th postoperative day including an esophagobronchial fistula prompted to a subsequent surgical re-intervention with suture of the fistula, lavage and additional drainage, an endoscopic stenting of the fistula from esophageal site, as well as repeated (n = 22) bronchoscopic applications of fibrin glue (1-3 ml each) into the lumen of the fistula after each bronchoscopic lavage of the fistula until the complete closure was achieved. The changeful clinical course of 77 days on the surgical ICU was characterized by secondary complications such as pneumonia, mediastinitis and respiratory insufficiency with long-term artificial respiration and creation of a percutaneous dilatation tracheotomy.
The application of fibrin glue can be considered a promising, minimally invasive therapeutic option in the management of postoperative fistula after esophageal resection, which requires expertise in decision-making and the finding-specific approach, in particular, if indicated inital steps of the sequential complication management such as surgical re-intervention and conventional endoscopic measures (stenting, Endo-VAC[-sponge]) do not provide great therapeutic potential any more due to the prolonged postoperative time course and the unfavorable local findings. In the presented case, modes of an assisted artificial respiration with low pressure and short phases of apnoe after fibrin glue application were the crucial predictions for an initial and favorable adhesion of this glue and finally for a successful sealing resulting in a sufficient closure of the fistula.
病史与干预措施：一名52岁女性患者因组织学诊断为伴有“高级别”上皮内瘤变（HGIEN）的巴雷特化生及部分浸润性腺癌，接受了开腹胸腹联合贲门及食管切除术并胃转位术。术后第10天出现吻合口漏，包括食管支气管瘘，促使进行后续手术再次干预，包括瘘管缝合、冲洗及额外引流，经食管部位对瘘管进行内镜支架置入，以及在每次支气管镜冲洗瘘管后，向瘘管腔内重复（共22次）应用纤维蛋白胶（每次1 - 3毫升），直至瘘管完全闭合。患者在外科重症监护病房（SICU）经历了77天多变的临床病程，其特征为继发并发症，如肺炎、纵隔炎和呼吸功能不全，需要长期人工呼吸并进行经皮扩张气管切开术。
在食管切除术后吻合口瘘的管理中，纤维蛋白胶的应用可被视为一种有前景的微创治疗选择，但这需要决策方面的专业知识和针对性的方法，特别是当术后病程延长且局部情况不利，导致诸如再次手术干预和传统内镜措施（支架置入、Endo - VAC[海绵]）等序贯并发症管理的初始步骤不再具有很大治疗潜力时。在本病例中，应用纤维蛋白胶后采用低压辅助人工呼吸及短时间呼吸暂停模式，是该胶水初始良好黏附以及最终成功封闭瘘管实现充分闭合的关键预测因素。
