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Beneficial effects of fibrin glue on esophageal perforation
Ann Thorac Surg 1996;61:1585-92
ment: endocardial repair with pericardial patch. J Thorac Cardiovasc Surg 1987;93:935-6. 7. Komeda M, David TE, Malik A, Ivanov J, Sun Z. Operative risks and long-term results of surgery for left ventricular aneurysm. Ann Thorac Surg 1992;53:22-9. 8. Komeda M, David TE. Surgical treatment of postinfarction false aneurysm of the left ventricle. J Thorac Cardiovasc Surg 1993;106:1189-91.
Beneficial Effects of Fibrin Glue on Esophageal Perforation To the Editor: We read with great interest the article titled "Reinforced Primary Repair of Thoracic Esophageal Perforation" by Wright and associates [1] in the August 1995 issue of The Annals of Thoracic Surgery. They have suggested primary repair of esophagus in most perforations even when diagnosed late. They have also advised the reinforcement of perforated esophagus with a protective tissue (intercostal muscle, omentum, pleura) to reduce the possibility and severity of postoperative leakage. We agree with them in this surgical strategy. However, we would like to suggest an alternative to suturing of intercostal muscle flap over esophageal suture lines. A 35-year-old woman who underwent esophagoscopic intervention due to foreign body impaction in another hospital a week before was admitted to our hospital with high fever, palpitation, dyspnea, and cough. On examination, she had evidence of sepsis. Telecardiography demonstrated closed right costodiaphragmatic sinus and intensive opacifications in the middle part of the right hemithorax. Diagnosis was defined with the gross leakage of radioopaque barium solution to the right hemithorax through the middle part of the esophagus. A right thoracotomy was performed. All necrotic tissues were debrided, and localized pleural decortication was performed. Injured parts of the esophagus were trimmed until the border of healthy tissue was met. Only the mucosal layer of esophagus, due to intensive induration in the muscle layer, could be repaired with fine 4-0 interrupted sutures (coated Vicryl, polyglactin 910; Ethicon, Edinburgh, UK). Preoperatively, we had planned use of intercostal muscle flap to reduce the risk and severity of postoperative leakage and to give support to the esophageal suture line. Suturing of intercostal muscle flap over the repaired esophagus could not be performed, however, due to cutting of indurated esophageal and adjacent peripheral tissues during the tying of sutures. For this reason, we used fibrin glue (Tisseel-kit; Immuno AG, Vienna, Austria) both to adhere the intercostal muscle flap to the esophagus and to prevent postoperative leakage. No leakage was detected in the control tests during the operation and on the 10th postoperative day. Her clinical condition improved progressively after operation. There are many articles about the beneficial effects of fibrin glue in esophageal surgical procedures [2-4]. In our opinion, fibrin glue has two beneficial effects in this clinical setting. First, fibrin glue may solve the problem of suture insufficiency that results from cutting of intensive induration of healthy esophagus and adjacent peripheral tissues. Therefore, it eliminates the need for any suture by adhering intercostal muscle flap to the esophagus. Second, fibrin glue may prevent minimal postoperative leakage from suture lines during the healing of the sutured esophageal tissue. We therefore would like to suggest the use of © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CORRESPONDENCE
1589
fibrin glue in late esophageal perforations associated with infection.
O~uz Ta~demir, MD Deniz Siiha KiiFiikaksu, MD Haldun Karag6z, MD Kemal Bayazit, MD Cardiovascular Surgery Department Tiirkiye Yiiksek Ihtisas Hospital 06100 Szhhiye, Ankara Turkey References 1. Wright CD, Mathisen DJ, Wain JC, Moncure AC, Hilgenberg AD, Grillo HC. Reinforced primary repair of thoracic esophageal perforation. Ann Thorac Surg 1995;60:245-9. 2. Bardaxoglou E, Campion JP, Landen S, et al. Oesophageal perforation: primary suture repair reinforced with absorbable mesh and fibrin glue. Br J Surg 1994;81:399. 3. McCarthy PM, Trastek VF, Schaff HV, et al. Esophagogastric anastomoses: the value of fibrin glue in preventing leakage. J Thorac Cardiovasc Surg 1987;93:234-9. 4. Vogel S, Volk HW, Wasmer HP, Buchwald J. Treatment of iatrogenic esophageal perforation. Zentralbl Chir 1991;116: 751-6.
Two-Patch Repair of Atrioventricular Canal To the Editor: I have found the article by Dr Backer and associates [1] very interesting, but I cannot agree with one of the thoughts expressed in the Comment section and typical, in my opinion, of many surgeons. Doctor Backer and associates write, "'Preoperative need of assisted ventilation because of respiratory distress, congestive heart failure, or pneumonia can result in major morbidity," and later, " . . . the only two early deaths were in patients who had preoperative assisted ventilation for congestive heart failure complicated by viral bronchiolitis.'" As I understand it, the major morbidity or early deaths were results of respiratory distress, congestive heart failure, pneumonia, and viral bronchiolitis in children with congenital heart disease. Assisted ventilation was one of the procedures that saved the life of these patients and allowed the surgeon to perform repair of complete atrioventricular canal defect with the two-patch technique.
Magdalena Tgdziagolska, MD Department of Anaesthesia Clinic of Paediairic Surgery and Cardiosurgery Medical Academy Dziatdowska 1 Sir 01-184 Warszawa, Poland Reference 1. Backer CL, Mavroudis C, Alboliras ET, Zales VR. Repair of complete atrioventricular canal defects: results with twopatch technique. Ann Thorac Surg 1995;60:530-7.
Reply To the Editor: The letter from Dr T~dziagolska highlights an interesting problem with regard to the management of patients with atrioven0003-4975196l$15.00
ment: endocardial repair with pericardial patch. J Thorac Cardiovasc Surg 1987;93:935-6. 7. Komeda M, David TE, Malik A, Ivanov J, Sun Z. Operative risks and long-term results of surgery for left ventricular aneurysm. Ann Thorac Surg 1992;53:22-9. 8. Komeda M, David TE. Surgical treatment of postinfarction false aneurysm of the left ventricle. J Thorac Cardiovasc Surg 1993;106:1189-91.
Beneficial Effects of Fibrin Glue on Esophageal Perforation To the Editor: We read with great interest the article titled "Reinforced Primary Repair of Thoracic Esophageal Perforation" by Wright and associates [1] in the August 1995 issue of The Annals of Thoracic Surgery. They have suggested primary repair of esophagus in most perforations even when diagnosed late. They have also advised the reinforcement of perforated esophagus with a protective tissue (intercostal muscle, omentum, pleura) to reduce the possibility and severity of postoperative leakage. We agree with them in this surgical strategy. However, we would like to suggest an alternative to suturing of intercostal muscle flap over esophageal suture lines. A 35-year-old woman who underwent esophagoscopic intervention due to foreign body impaction in another hospital a week before was admitted to our hospital with high fever, palpitation, dyspnea, and cough. On examination, she had evidence of sepsis. Telecardiography demonstrated closed right costodiaphragmatic sinus and intensive opacifications in the middle part of the right hemithorax. Diagnosis was defined with the gross leakage of radioopaque barium solution to the right hemithorax through the middle part of the esophagus. A right thoracotomy was performed. All necrotic tissues were debrided, and localized pleural decortication was performed. Injured parts of the esophagus were trimmed until the border of healthy tissue was met. Only the mucosal layer of esophagus, due to intensive induration in the muscle layer, could be repaired with fine 4-0 interrupted sutures (coated Vicryl, polyglactin 910; Ethicon, Edinburgh, UK). Preoperatively, we had planned use of intercostal muscle flap to reduce the risk and severity of postoperative leakage and to give support to the esophageal suture line. Suturing of intercostal muscle flap over the repaired esophagus could not be performed, however, due to cutting of indurated esophageal and adjacent peripheral tissues during the tying of sutures. For this reason, we used fibrin glue (Tisseel-kit; Immuno AG, Vienna, Austria) both to adhere the intercostal muscle flap to the esophagus and to prevent postoperative leakage. No leakage was detected in the control tests during the operation and on the 10th postoperative day. Her clinical condition improved progressively after operation. There are many articles about the beneficial effects of fibrin glue in esophageal surgical procedures [2-4]. In our opinion, fibrin glue has two beneficial effects in this clinical setting. First, fibrin glue may solve the problem of suture insufficiency that results from cutting of intensive induration of healthy esophagus and adjacent peripheral tissues. Therefore, it eliminates the need for any suture by adhering intercostal muscle flap to the esophagus. Second, fibrin glue may prevent minimal postoperative leakage from suture lines during the healing of the sutured esophageal tissue. We therefore would like to suggest the use of © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CORRESPONDENCE
1589
fibrin glue in late esophageal perforations associated with infection.
O~uz Ta~demir, MD Deniz Siiha KiiFiikaksu, MD Haldun Karag6z, MD Kemal Bayazit, MD Cardiovascular Surgery Department Tiirkiye Yiiksek Ihtisas Hospital 06100 Szhhiye, Ankara Turkey References 1. Wright CD, Mathisen DJ, Wain JC, Moncure AC, Hilgenberg AD, Grillo HC. Reinforced primary repair of thoracic esophageal perforation. Ann Thorac Surg 1995;60:245-9. 2. Bardaxoglou E, Campion JP, Landen S, et al. Oesophageal perforation: primary suture repair reinforced with absorbable mesh and fibrin glue. Br J Surg 1994;81:399. 3. McCarthy PM, Trastek VF, Schaff HV, et al. Esophagogastric anastomoses: the value of fibrin glue in preventing leakage. J Thorac Cardiovasc Surg 1987;93:234-9. 4. Vogel S, Volk HW, Wasmer HP, Buchwald J. Treatment of iatrogenic esophageal perforation. Zentralbl Chir 1991;116: 751-6.
Two-Patch Repair of Atrioventricular Canal To the Editor: I have found the article by Dr Backer and associates [1] very interesting, but I cannot agree with one of the thoughts expressed in the Comment section and typical, in my opinion, of many surgeons. Doctor Backer and associates write, "'Preoperative need of assisted ventilation because of respiratory distress, congestive heart failure, or pneumonia can result in major morbidity," and later, " . . . the only two early deaths were in patients who had preoperative assisted ventilation for congestive heart failure complicated by viral bronchiolitis.'" As I understand it, the major morbidity or early deaths were results of respiratory distress, congestive heart failure, pneumonia, and viral bronchiolitis in children with congenital heart disease. Assisted ventilation was one of the procedures that saved the life of these patients and allowed the surgeon to perform repair of complete atrioventricular canal defect with the two-patch technique.
Magdalena Tgdziagolska, MD Department of Anaesthesia Clinic of Paediairic Surgery and Cardiosurgery Medical Academy Dziatdowska 1 Sir 01-184 Warszawa, Poland Reference 1. Backer CL, Mavroudis C, Alboliras ET, Zales VR. Repair of complete atrioventricular canal defects: results with twopatch technique. Ann Thorac Surg 1995;60:530-7.
Reply To the Editor: The letter from Dr T~dziagolska highlights an interesting problem with regard to the management of patients with atrioven0003-4975196l$15.00