[Intestinal obstruction due to the use of a surgical hemostatic agent].

Dear Editor, We have read with great interest the publication by Ruiz Marı́n et al. about a case of postsurgical intestinal obstruction secondary to the use of the locally-applied hemostatic sealant TachoSil. The fact that we have recently treated a similar case and its exceptional nature, as indicated by the authors, has encouraged us to report our experience. The patient is an 81-year-old woman who had undergone surgery for a rectosigmoid junction neoplasia (moderately differentiated adenocarcinoma T3 N0 M0, stage IIA), who underwent a left hemicolectomy and total hysterectomy with double adnexectomy because the tumor had formed an inflammatory mass with the uterus and adjoining structures (the biopsy reported the gynecological resection piece to be chronic xanthogranulomatous inflammation with no evidence of malignancy). Given the diffuse, moderate bleeding in the area of the hysterectomy caused by the existing inflammatory component, we opted to use a TachoSil synthetic hemostatic patch in the pelvic surgical bed. On the 5th day post-op, the patient presented symptoms that were compatible with small bowel obstruction; abdominal CT ruled out anastomotic dehiscence and confirmed the obstructive process (Fig. 1). During surgery, we observed intestinal obstruction involving several intestinal loops that were firmly and cohesively adhered to the hemostatic patch. Releasing these adhesions was quite labor-intensive, but it was performed without further incident. As the authors of the manuscript have stated, in our search of the literature we have found no other reports of similar cases, although there are descriptions of analogous situations secondary to the use of different hemostatic sealants. The information provided by the manufacturer describing the characteristics of the product makes no mention of possible intestinal obstruction, even though (as correctly noted by the authors) the fact that its composition includes fibrinogen may condition the formation of adherences or an excessive production of granulation tissue. There have been case reports of immunological reactions and transmission of infectious diseases related with the use of these products. We cannot determine whether the fact that the obstructions arose after gynecological resection may have influenced the development of this complication. The authors indicate that there may have been poor positioning of the patch. This possibility could be ruled out in our case as it was positioned correctly, with the yellow part facing the surgical bed and with no buckles or folds, as indicated in the instructions for use. Moreover, no other intra-abdominal adhesions were detected, and therefore the process of intestinal obstruction is attributable to the patch alone, which appeared to be in proper condition.