Cyanoacrylate glue for closure of proximal enterocutaneous fistula: a case report

Abstract Enterocutaneous fistula (ECF) is a distressing complication. Commonly, it follows abdominal operations that require extensive adhesiolysis. Its management is challenging, burdening health systems. Complete healing can take several weeks. Several modalities have been described, with varying success rates. A 48-year-old male underwent a trauma laparotomy, with resection of a segment of the proximal bowel and anastomosis. He experienced an anastomosis leak, wound infection and ECF and was managed conservatively for 5 weeks with parenteral nutrition and bowel rest. He was then referred to us and treated with approximation sutures and cyanoacrylate adhesive. His wound was closed with a subcutaneous drain. He experienced complete healing of the fistula and wound after undergoing a minimally invasive approach using sutures and a cyanoacrylate sealant. Cyanoacrylate glue is a safe initial non-invasive treatment of low-output ECF. It can be selected over approximation sutures to ensure sealing of the tract before surgery.


INTRODUCTION
Enterocutaneous fistula (ECF) is a connection between the skin and gastrointestinal tract [1] and a complication that requires costly and lengthy hospitalizations. The most common cause is iatrogenic, accounting for 75-85% of cases [2], and primarily occurs post-surgery with extensive adhesions release. Other causes include trauma, malignancy, infection, Crohn disease, bowel leak and radiotherapy. ECF is classified, based on anatomical origin into type 1 (abdominal, oesophageal, gastroduodenal), type 2 (small bowel), type 3 (large bowel) and type 4 (enteroatomospheric) [1]. Its management includes non-operative intervention for at least 5 weeks and operative intervention if the former fails. The aim of this paper is to discuss the effectiveness

CASE REPORT
A 48-year-old male was referred to us from another facility after being treated for injuries due to a motor vehicle accident. Based on the operative report, he suffered from a severe mesenteric vascular injury with a 65-cm ischemic proximal small bowel segment, undergoing resection and anastomosis with primary abdominal closure. After recovery and discharge from the ICU, he developed a wound infection, bowel content discharge and dehiscence in the upper area of the wound, which was managed by frequent wet-to-dry  dressing, TPN and low residual diet, begun as part of the management of the anastomosis leak. However, the wound remained open, and discharge persisted after 5 weeks; thus, he was referred to our facility for further evaluation and management.
On clinical examination, good granulation tissue was seen at the wound site, with greenish discharge, prompting a clinical diagnosis of proximal ECF (Fig. 1). The swap of the wound showed no contamination. The CT scan revealed gapping of the anterior abdominal wall with an underling small bowel but no contrast extravasation. The patient tolerated oral nutrition, with improved nutritional status. He was taken to the operating room, where a suture was used to approximate the external orifice of the fistula, with cyanoacrylate sealant (Glubran ® 2, GEM Italy) applied to maintain the closure; consequently, the wound was closed after creating a flap of skin and subcutaneous tissue. A small drain with no suction was inserted under the skin. The patient was discharged on the second post-operative day. At the follow-up, the drain was removed after 7 days and the wound was clean, and the sutures were removed after 3 weeks. After 4 months, the healing was maintained, with no evidence of fistula or infection (Fig. 2).

DISCUSSION
The use of tissue sealants such as fibrin glue and cyanoacrylate glue for the treatment of ECF began in the 1990s [3]. Reports on cyanoacrylate sealant have shown clear results in promoting healing of fistulae and decreasing the time of closure, with low output (<500 mL) and for proximally originating fistulae. Cyanoacrylate-based glue (Glubran 2) is a synthetic biodegradable material (n-butyl-2-cyanoacrylate and methacryloxysulpholane monomers) with high tensile strength; thus, it has high adhesive and hemostatic properties. It polymerizes once it makes contact with tissues and then creates an efficient antiseptic barrier that prevents the penetration of bacteria and infection. It has no direct adverse effects and minimizes the risk of transmitted infections (prions) that are associated with glue from animal sources (e.g. bovine). Furthermore, it is preferred over other materials, because it can be visualized by fluoroscopy when it is mixed with Lipidol [3][4][5].
ECF is managed conservatively with adequate nutritional support to maintain electrolytes and fluid balance, control the source of sepsis, protect the skin and lessen the output of the fistula using octreotide, with delineation of the tract anatomy. This preliminary treatment can last for 5-6 weeks before further intervention [6], with spontaneous closure in 15-71% of cases [2]. There are several factors in the rate of closure, such as anatomical origin, tract length, defect size and output [6]. Furthermore, the mortality rate can reach 37% [2]. For these reasons, intervention is indicated if the fistula does not close. Various approaches have been tested, such as endoscopic clipping, Gelfoam embolization, suture, plug and acellular dermal patch.
Wu et al. treated 75 patients with platelet-rich fibrin glue (PRFG) and observed a lower median time of closure and more healed fistulae in the treatment versus control group, who was treated conservatively. The ideal time for administration of glue for post-operative fistula has been suggested to be 14 days post-stabilization of the fistula to promote healing and decrease the length of hospital stay [2], in contrast the timing of our application, which was affected by the referral time. Mauri performed percutaneous injection of cyanoacrylic glue to treat non-healing fistulae, noting a cure rate of 89% [4]. Others have described cases of post-surgical ECF that were treated successfully with an injection of cyanoacrylic sealant percutaneously, endoscopically or under radiological guidance, with good outcomes [7][8][9]. Multiple sessions of cyanoacrylate-based glue application might be needed to achieve complete closure in certain cases.
A summary of articles is presented in Table 1.

CONCLUSION
Cyanoacrylate-base sealant is a safe and feasible non-invasive option for initial treatment of low-output ECF. It can be used over approximation sutures to ensure sealing of the fistula tract before advancement to more destructive surgery.