A pediatric case of endoscopic fistula closure using a polyglycolic acid sheet

Recurrent tracheoesophageal fistula is a common postoperative complication of esophageal atresia [1]. The surgical treatments utilize muscle and pleural flaps [2]. Furthermore, endoscopic fistula closure with fibrin glue, a biomaterial, can be achieved by epithelializing, promoting circulation, and inhibiting leukocyte infiltration [1]. In adults, endoscopic fistula closure using a polyglycolic acid (PGA) sheet is useful for treating postoperative esophageal anastomotic fistulas [3]. However, no such pediatric reports are available.

Herein, we report the first pediatric case of endoscopic fistula closure with PGA sheet ([Video 1]).

Video 1 Use of polyglycolic acid sheets and fibrin glue as an effective alternative to standard procedures during pediatric endoscopic fistula closure.

A 3-year-old girl was admitted with the chief complaint of persistent fever and cough after eating. She underwent postnatal thoracoscopic radical esophagectomy for type C esophageal atresia. Owing to postoperative complication, she underwent multiple endoscopic balloon dilations.

Esophagogastroduodenoscopy revealed an esophageal fistula on the oral posterior wall of the esophageal anastomosis ([Fig. 1]). Tracheal esophagography ([Fig. 2]) revealed tracheoesophageal fistula.

Fig. 1 A fistula on the posterior wall of the oral side of the esophageal anastomosis.

Fig. 2 Esophagography revealed the trachea (yellow arrow).

First, mucosa around the fistula was cauterized using hot biopsy through a single-channel upper gastrointestinal endoscope ([Fig. 3]). Subsequently, small pieces of PGA sheet (Neoveil; Gunze Co., Osaka, Japan) were grasped with biopsy forceps, immersed in fibrinogen solution, and used to fill the fistula through the scope ([Video 1]). Finally, fibrinogen and thrombin solutions of fibrin glue (Beriplast P Combi-Set; CSL Behring Pharma, Tokyo, Japan) were applied to the PGA sheets ([Fig. 4]).

Fig. 3 Image after cauterization of the area around the fistula with hot biopsy forceps, soft mode 80 W of electrosurgical generator (VIO300D; ERBE Elektromedizin GmbH, Tübingen, Germany).

Fig. 4 Fibrinogen and thrombin solutions of fibrin glue were applied to the polyglycolic acid sheets.

Endoscopy 3 weeks later confirmed fistula closure ([Fig. 5]), and oral intake by the patient was possible without symptoms.

Fig. 5 Endoscopy after 3 weeks revealed closure of the fistula.

Fibrin glue is generally used in the treatment of pediatric tracheoesophageal fistula. PGA sheets acting as tissue-regenerative scaffolds may effectively help in the healing process, as granulation tissue can fill and cover the fistula [3].

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Gutiérrez San Román C, Barrios JE, Lluna J. et al. Long-term assessment of the treatment of recurrent tracheoesophageal fistula with fibrin glue associated with diathermy. J Pediatr Surg 2006; 41: 1870-1873
• 2 Smithers CJ, Hamilton TE, Manfredi MA. et al. Categorization and repair of recurrent and acquired tracheoesophageal fistulae occurring after esophageal repair. J Pediatr Surg 2017; 52: 424-430
• 3 Nagami Y, Ominami M, Sakai T. et al. Endoscopic closure of refractory esophageal fistula after esophagectomy using polyglycolic acid sheets: a pilot study. Endosc Int Open 2020; 8: E591-E595

Publikationsverlauf

Artikel online veröffentlicht:
22. Juni 2023