Effect of fibrin sealant on the integrity of colonic anastomoses in rats with faecal peritonitis

OBJECTIVE

To assess the influence of fibrin adhesive on the healing of colonic anastomoses in rats with and without faecal peritonitis.

DESIGN

Controlled study.

SETTING

Laboratory for experimental surgery, Erasmus University Rotterdam, The Netherlands.

MATERIAL

120 male Wag/Rij rats.

INTERVENTIONS

All rats had a single layer end-to-end anastomosis fashioned with 7/0 polypropylene. Faecal peritonitis was then induced in half of the rats by placement of 200 mg powdered autoclaved rat faeces in the peritoneal cavity near the anastomosis. Rats were allocated to one of four groups (n = 30 in each): 1--control; 2--additional sealing with fibrin glue; 3--peritonitis alone; and 4--peritonitis with fibrin glue.

MAIN OUTCOME MEASURES

Body weight, adhesion formation, anastomotic bursting pressure and collagen concentration around the anastomosis on days 2, 4, and 7 in 10 rats from each group.

RESULTS

11 rats died of peritonitis before the experiment was completed. Peritonitis caused increased formation of adhesions and abscesses, with or without fibrin sealant. Bursting pressure at the anastomosis was significantly reduced in peritonitis compared with controls on days 4 and 7, and this was not prevented by fibrin. Sealing of anastomoses resulted in lower bursting pressures on day 4 in control animals. Collagen concentration was significantly reduced in peritonitis with or without fibrin sealant on days 4 and 7, and after fibrin sealing of control anastomoses.

CONCLUSION

Faecal peritonitis reduced mechanical strength and collagen concentration of colonic anastomoses, and this was not prevented by additional sealing of the anastomosis with fibrin sealant.

[Does fibrin glue accelerate wound healing? An autoradiography study of bone defects]

The first 96 hours of wound healing were studied in 80 drillholes in 40 rat skullpans. 40 drillholes were filled with the fibrin tissue glue Tissucol. The other 40 drillholes were only treated by compression until hemostasis was achieved. The marker 3H-Thymidine was injected intraperitoneally one hour before killing the rats. Ten rats at a time were killed after 24, 48, 72 and 96 hours. We saw a significant higher incorporation of 3H-Thymidine in the fibrin sealed holes after 48 and 72 hours. We conclude that wound healing during the first 3 days is stimulated in the presence of fibringlue.

Fibrin sealant adhesive systems: a review of their chemistry, material properties and clinical applications

Fibrin sealants (FS) are the most successful tissue adhesives to date. They have many advantages over adhesive technologies such as cyanoacrylates and marine adhesives in terms of biocompatibility, biodegradation and hemostasis. There are several commercial products in Europe but none in the United States due to the current regulatory stance against pooled plasma blood products. Blood banks and interested investigators have implemented single- and patient autologous-donor production methods with some success. This article will review the history of FS research and development and describe the chemistry of fibrin(ogen) and the production of commercial and research products. Fibrin sealant and purified fibrin characterization is compared and contrasted. The material and adhesive properties are described, and a survey of the clinical applications in which FS has been used is included as well.

Role and innocuity of Tisseel, a tissue glue, in the grafting process and in vivo evolution of human cultured epidermis

Cultured epidermal sheets are currently used for burn wound treatment but reported results on graft take are variable. This study was designed to evaluate the role and influence of Tisseel, a fibrin glue, in the take of cultured human epidermal sheets in an athymic mouse model. On days 4, 10 and 21 post-grafting, histology, electron microscopy and immunofluorescence staining confirmed the presence of a human epithelium and the development of a basement membrane. Tisseel was detectable on day 4 only, but overall treated and untreated grafts were similar. The use of Tisseel enhanced the mechanical stability of these fragile grafts, increased the percentage of graft take, and its innocuity on the in vivo evolution of cultured epidermal sheets was demonstrated. For these reasons, we think that Tisseel may be advantageous in a clinical setting.

Measuring the rupture stress point of biological sealant-collagen bonding: validation of a technique used after hepatectomy

The aim of this experimental study was to measure the rupture stress point of a fibrin clot situated on a liver, in realistic surgical conditions. The experimental method was carried out with a machined wooden cylinder bonded on the liver, connected with a wire to a setup and pulled at a constant speed, and a sensor was placed on the wire measuring the applied strength. This method, realized in the dog, made it possible to validate a precise and reproducible method designed for testing the adhesive characteristics of biological sealant-collagen bonding on the liver.

Fibrin glue reduces the dissolution rate of sodium hyaluronate

Sodium hyaluronate (HA) is known to modulate wound healing and interact with inflammatory reactions. High concentrations of extracellular HA are for example correlated to scarless wound healing. Topical treatment with HA has, however, limited effect due to the rapid clearance of HA in the tissue. In an effort to prolong the dissolution rate and enhance the effect of topically administered HA, HA was incorporated in a cross linked fibrin clot and placed in NaCl. The concentration of HA in the NaCl solution was analysed after 30', 60', 4h, 8h, and 24h. It was found that the dissolution rate of HA incorporated in cross linked fibrin was dramatically decreased in vitro, especially when the HA-fibrin mixture was put at rest and not exposed to a mechanical stress. The findings indicate a new possibility for slow release of HA after topical administration.

Bone induction by composites of bioresorbable carriers and demineralized bone in rats: a comparative study of fibrin-collagen paste, fibrin sealant, and polyorthoester with gentamicin

Host tissue response and heterotopic osteoinduction by composites of demineralized bone matrix and three different substances used as bioresorbable carriers implanted in the abdominal muscles were evaluated by strontium 85 uptake and histology 4 weeks postoperatively in 60 male Wistar rats. Both fibrin-collagen paste and fibrin sealant inhibited bone induction and produced a chronic inflammation; part of the fibrin-collagen paste was still present at 4 weeks. Polyorthoester with gentamicin was almost completely absorbed, induced minimal tissue reaction, and did not inhibit osteoinduction.

Fibrin gel limits intra-abdominal adhesion formation

Autologous fibrin gel (FG) has recently been reported efficacious in hepatic injury; the effects of fibrin compounds on intra-abdominal adhesion formation is controversial. This study evaluated intra-abdominal adhesion formation in a rabbit devascularization model. Seventeen New Zealand rabbits were anesthetized and laparotomy was done. The uterine horns were abraded to punctate bleeding followed by bilateral uterine devascularization. Treatment consisted of 10 cc saline control (c) or FG applied to the uterine horns. Peritoneal lavage was done at 15 minutes for red blood cell (RBC) analysis. Autopsy was performed at 1 week. Adhesions were graded from grade 0 (no adhesions) to grade III (dense adhesions). Adhesion grading revealed no difference in average adhesion grade between FG and C with small bowel (1.0 +/- 1.3 vs 0.5 +/- 1.0); bladder (2.1 +/- 1.1 vs 2.4 +/- 1.2); or uterus (1.2 +/- vs 2.0 +/- 1.2). Adhesion grade was significantly less in FG compared to C for the colon and the abdominal incision (0.4 +/- 0.5 vs 1.7 +/- 1.1 and 1.2 +/- 1.1 vs 3.0 +/- 1.2; P less than 0.05 by t-test). There were no differences in lavage RBC count between FG and C (13.1 x 106 +/- 4.1 x 10(6) vs 8.7 x 106 +/- 3.2 x 10(6)). Fibrin gel significantly decreased incisional and colonic adhesions and reduced other abdominal adhesion formation by a nonhemostatic dependent mechanism.

Enhanced endothelialization of expanded polytetrafluoroethylene grafts by fibroblast growth factor type 1 pretreatment

BACKGROUND

Biomaterial pretreatment with endothelial cell mitogens may enhance endothelialization.

METHODS

Modified fibrin glue (FG) containing 1 ng/cm2 recombinant 125I-labeled fibroblast growth factor type 1 (125I-FGF-1), 20 micrograms/cm2 heparin, 2.86 mg/cm2 fibrinogen, and 2.86 x 10(-2) units/cm2 thrombin was pressure perfused into expanded polytetrafluoroethylene (ePTFE) grafts. Grafts were interposed into infrarenal aortas of 24 New Zealand white rabbits and explanted after 0, 5, 30, and 60 minutes and 1, 7, 14, and 30 days. Residual radioactivity was determined by gamma-counting. Remaining 125I-FGF-1 is expressed as percent of value at time 0. To determine the effect of the FG/FGF-1 on graft healing, three groups of 50 x 4 mm 60 microns internodal-distance nonreinforced ePTFE grafts were implanted in the aortoiliac position of 12 dogs. Group I (n = 12) contained the complete modified FG, group II (n = 6) contained FG with heparin but no FGF-1, and group III (n = 6) contained untreated identical ePTFE. Tritiated thymidine (0.5 microCi/kg) was injected intramuscularly 10 hours before explantation after 7 and 28 days for light and electron microscopy and en face autoradiography.

RESULTS

Retention of 125I-FGF-1 showed rapid initial loss (delta %/delta min = -24.1) followed by slow loss after 1 hour (delta %/delta min = -0.03), with 13.4% +/- 6.9% remaining at 1 week and 3.8% +/- 1.1% at 30 days. Every FG/FGF-1 graft at 28 days showed extensive capillary ingrowth and confluent endothelialized luminal surfaces, not seen in any specimen of the other two groups. Autoradiography revealed a significant increase (p less than 0.05) in 3H-thymidine incorporation in the FG/FGF-1 grafts at 28 days versus all groups as a function of time and graft treatment.

CONCLUSIONS

Pressure perfusion of an FGF-1/FG suspension into 60 microns internodal-distance ePTFE grafts promotes endothelialization through capillary ingrowth and increased endothelial cell proliferation.

[Changes in the vascular wall induced by surgical glues. Experimental study]

The effects on vascular tissues of two different types of surgical glue, gelatin-resorcinol-formaldehyde (GRF) and fibrin (Tissucol) were tested on the rat abdominal aorta. The GRF glue induced destruction of the vascular wall: multiple inclusions of the glue were noted in the media. Conversely, the fibrin glue preserved the normal architecture of the three arterial layers. The use of GRF glue therefore should be avoided on particularly fragile tissues (e.g. coronary arteries), and it seems preferable in such cases to use the fibrin glue.

Effect of antibiotics in fibrin sealant on healing colonic anastomoses in the rat

In 90 rats a colonic anastomosis was constructed with 12 interrupted 7/0 polypropylene sutures. Group 1 (n = 30) served as a control group. In group 2 (n = 30) the anastomosis was sealed with fibrin adhesive and in group 3 (n = 30) a mixture of fibrin, clindamycin and cefotaxime was used. On days 2, 4 and 7, ten animals in each group were killed. Adhesion formation was significantly increased in groups 2 and 3 compared with the control group. On day 2 the anastomosis was significantly stronger after sealing with antibiotic-fibrin mixture. On day 4 the bursting pressure in group 2 was significantly lower than in groups 1 and 3. At the same time the concentration of hydroxyproline was significantly reduced in group 2, but not in group 3. The addition of antibiotics prevents the negative effect of fibrin adhesive on the healing colonic anastomosis and contributes to a stronger anastomosis on day 2 after operation.

Fibrin glue improves the healing of irradiated bowel anastomoses

Many surgeons are reluctant to construct a bowel anastomosis with irradiated intestine. Previous studies have demonstrated diminished tensile strength of rat small bowel anastomoses that have been irradiated intraoperatively. To determine whether fibrin glue, a known tissue adhesive, improves the healing of these anastomoses, 69 male Sprague-Dawley rats were randomized into three anastomotic groups: Group 1, sutured ileal anastomosis without radiation or fibrin glue; Group 2, irradiated sutured ileal anastomosis without fibrin glue; and Group 3, irradiated ileal anastomosis with fibrin glue added to the suture line. Groups 2 and 3 received a single dose of 2,000 R intraoperatively. At seven days, the rats were sacrificed and the anastomotic segment was tested for breaking (tensile) strength. Anastomotic collagen content was evaluated using a hydroxyproline assay. Tensile strength results demonstrated that Group 2 was significantly weaker than Groups 1 and 3 (P = 0.001) and that the hydroxyproline content of Group 3 was significantly greater than that of Group 2 (P = 0.015). These results show that the addition of fibrin glue to an intraoperatively irradiated small bowel anastomosis improves healing, as demonstrated by both tensile strength and hydroxyproline content studies.

Effects of Ringer's lactate and fibrin glue on postsurgical adhesions

The intraabdominal instillation of Ringer's lactate decreased adhesion formation and reformation in the rat. Fibrin glue also reduced adhesion formation but was not superior to Ringer's lactate.

The effect of fibrin glue on intraperitoneal contamination in rats treated with systemic antibiotics

Intraperitoneal fibrin sealant lowers septic mortality in a rat model of peritoneal contamination (2 x 10(6) organism inoculum) at the cost of increased late intraabdominal abscesses. This study utilized parenteral antimicrobials to determine if the protective effect of intraperitoneal fibrin could be achieved without increasing the late abscess formation rate. One hundred and fifty-five rats were divided into four groups. Gelatin capsules containing various dilutions of feces (10(10) CFU/ml) and barium sulfate were placed into the abdomen in all groups. Group I controls had no antibiotics or fibrin. In group II, the capsule was surrounded by a solution of cryoprecipitate, thrombin, and calcium (fibrin "glue"). Groups III (no fibrin, antibiotics) and IV (fibrin, antibiotics) received a broad-spectrum cephalosporin intramuscularly postoperatively and then daily. Surviving rats were sacrificed on the tenth postoperative day. At a moderate volume of fecal inoculum (0.3 ml), fibrin reduced mortality from 100% in the control group to 0% in treated animals (P less than 0.001) that did not receive antibiotics. Abscesses formed in 10% of the surviving fibrin-treated rats which were implanted with 0.1 ml of inoculum. In the 0.2 and 0.3 ml inoculum groups substantially more abscesses occurred (75 and 70%, respectively). The protective effect of fibrin was not manifested in the antibiotic-treated rats since no deaths occurred in either group. At higher and lower inoculum doses, no significant differences between fibrin and control groups were observed in mortality or abscess formation, whether or not antibiotics were given.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of fibrin glue on skin grafts in infected sites

Fibrin bonding of skin grafts to wounds is an essential part of the graft-adherence process. Bacteria, in concentrations greater than 10(5)/gm of tissue, are associated with graft failure. Sixty-five rats were randomly divided into three groups, dorsal split-thickness skin grafts were harvested, and the sites were inoculated with Staphylococcus aureus. After incubation, each wound was quantitatively biopsied and treated with saline, fibrin glue with aprotinin, or fibrin glue alone. We found that the addition of commercially available fibrin glue with or without the antifibrinolytic agent aprotinin is capable of restoring graft adherence to normal levels in graft sites infected with greater than 10(5) bacteria/gm of tissue. Fibrin glue may have potential for increasing skin-graft take in the clinical situation where the graft bed is infected.

Haemostyptic preparations on the basis of collagen alone and as fixed combination with fibrin glue

Preparations containing collagen play a prominent role among local haemostyptic agents in surgery. Sheets of collagen are used as degradable haemostyptic tampons. Various investigations have shown better haemostasis with collagen compared to other degradable materials, although the haemostyptic effect of these collagen preparations is limited. Concerning the mechanism of haemostasis, not all the reactions stimulated, e.g. by the collagen of an injured vessel wall, may be activated by a haemostyptic tampon from collagen. This depends very much on the kind of preparation. The combined application of a sheet of collagen with fibrin glue improved local haemostasis to a great extent. Large areas of capillary bleeding can be treated successfully with this method. Despite the very good results, this method has not been applied on a broad scale. This is due to the necessary skill and experience and the relatively cumbersome preparation required at the operation site. These drawbacks have been overcome with the latest development in this field--a sheet of collagen covered with a fixed layer of the solid components of a fibrin glue (fibrinogen, thrombin and aprotinin). The performance of this new local haemostyptic agent is described with special emphasis on the results of clinical trials. Haemostasis of large areas of capillary bleeding was very efficient and safe with the new material. Moreover, bile leakage and liquor, pancreatic and aerial fistulae could be sealed without problems.

Autologous fibrin gel: bactericidal properties in contaminated hepatic injury

Fibrin glue is an effective hemostatic agent in a variety of clinical situations; its utility is limited by potential transmission of viral infection. We studied the bactericidal properties of fibrin gel (FG) in a murine contaminated hepatic injury model and in vitro by agar plate culture method. Intra-abdominal abscess formation and adhesion rate were assessed following controlled liver injury in association with abdominal contamination with 10(7) Bacteroides fragilis and hepatorrhaphy (H, n = 15) or FG (n = 12). Animals treated by hepatorrhaphy had a significantly greater intra-abdominal abscess rate (15/15 vs. 4/12, p less than 0.05) and adhesion rate (14/15 vs. 6/12, p less than 0.05) than animals treated with FG. Fibrin gel is bactericidal to Bacteroides fragilis, Enterobacter faecium, Escherichia coli, and Staphylococcus aureus but has no effect against Klebsiella pneumoniae or Pseudomonas aeruginosa; the plasma component appears active. Fibrin gel demonstrates significant improvement in adhesion formation and intra-abdominal abscess rate when compared with suture hepatorrhaphy. Fibrin gel appears protective in contaminated hepatic injury.

[Radical prostatectomy and biologic glue]

Fibrin glue (reconstituted fibrin glue-Tissu-col-Immuno-France) was used in 24 patients following radical prostatectomy with ilio-obturator lymphadenectomy (Group II) to improve haemostasis of the operative field, to decrease or eliminate lymphatic oozing and to promote healing of the urethrovesical anastomosis. The results in terms of duration of drainage, quantity of fluid evacuated by these drains, operative complications and length of hospital stay were compared to those obtained in 24 clinically identical patients operated previously without the use of fibrin glue (Group I). Although fibrin glue is easy to use, ensures a particularly dry operative field at the end of the operation and does not induce any infectious complications (abscess, hepatitis), it increases the cost of the operation (5 ml vial = 2,500 FF) and the use of this product does not reduce the drainage time (Group I: 7 +/- 4.6 days; Group II: 8.5 +/- 5.4 days) the volume of blood or lymphatic discharge (Group I: 500 +/- 570 ml; Group II: 660 +/- 825 ml) or the length of hospital stay (Group I: 16.5 +/- 4.8 days; Group II: 17.4 +/- 5.5 days). These results argue against the routine use of fibrin glue in radical prostatectomy.

Neurosurgical application of fibrin adhesive

We have tried fibrin adhesive, which mimics the end stage of plasmatic coagulation, in 26 patients with various neurosurgical problems such as: repair of cerebrospinal fluid (CSF) leaks, sealing of the vascular anastomosis sites, reinforcements of aneurysmal clippings, and hemostasis after resection of brain tumors. Presented in this report are 11 intracranial aneurysms, 11 brain tumors, 2 lipomyelo-meningoceles, and one each of cerebral arteriovenous malformation and torn dura resulting from a mastoidectomy. Procedures which seemed to be impossible or very difficult by conventional neurosurgical techniques could be accomplished in all cases without any complication. Our experience with fibrin adhesive suggests that it is a valuable adjuvant to various microneurosurgical procedures, and it may be potentially useful for protection of major cerebral veins and venous sinuses during cerebral retraction.

[Improvement of muscular re-innervation by using an enriched biological glue in the rat]

The use of biological glue for the repair of nerve lesions offers the possibility of acting on axonal regeneration by means of trophic substances included in the glue. A comparative study conducted in the sciatic nerve of the rat shows that incorporation of the liquid exuded by sectioned nerve extremities into the glue to repair a section of the sciatic nerve trunk of other animals significantly increases the muscular tension of the force jerk and the of tetanic contraction of the reinnervated extensor digitorum longus 21 and 28 days after repair. It therefore appears possible to influence the regeneration or the maturation of the regenerating axons by local application of exogenous substances.

[Use of fibrin glue in gynecology-obstetrics]

The aim of the various fibrinogen-based biological glues is to reproduce and magnify the physiological coagulation processes. They can be defined as long-life reinforced clots. These glues have the following properties: adhesive property, haemostatic property, cicatrizing property, antiseptic property. Two proprietary medicinal products are actually available on the French market: Tissucol, Biocol. These glues require a preparation time of about 20 minutes; they can be used either drop by drop or continuously by spraying, with the use of a special device.

Fibrin seal in wound healing: effect of thrombin and [Ca2+] on human skin fibroblast growth and collagen production

To assess the interaction of a fibrin sealant with wound healing, an in vitro study using human skin fibroblasts was carried out. The effect of thrombin and calcium concentrations in the sealant on the growth parameters and collagen synthesis by normal human skin fibroblasts was examined. The fibroblast proliferation was increased 3 times for 50 and 25 IU of thrombin/ml. However for 20 mM [Ca2+], this stimulating effect of thrombin was observed after an 8 day incubation period, whereas it was observed as soon as the 2nd day in the presence of 2 mM [Ca2+]. The high rate of [Ca2+] (20 mM) partly inhibited DNA synthesis: for 2 mM [Ca2+], the incorporation of [3H]-Thymidine was 4 times greater than for 20 mM [Ca2+]. Further experiments demonstrated that human skin fibroblasts in the presence of 50 IU of thrombin/ml and 2 mM [Ca2+] in fibrin seal could increase the type I and III collagen synthesis while increasing the ratio of type III to type I. Thus, our results suggest that in vivo wound healing which required fibroblast growth and collagen synthesis can be stimulated in the presence of fibrin glue which is in good accordance with previous clinical observations.

Single-donor fibrin glue for hand burns

Early tangential excision sometimes results in considerable blood loss, prolonged operative time, and partial loss of the graft secondary to hematoma formation. Previous reports document positive hemostatic effects and improved skin fixation with fibrin "glue." The commercial preparation used in Europe, however, has not been approved by the United States Food and Drug Administration because of the high risk of hepatitis and human immunodeficiency virus transmission. Using a method developed at the University of Virginia, we applied single-donor fibrin glue as an adjunct in early excision and grafting in 16 patients (26 hands). The overall graft take was 99%. In all patients, better adherence of the split-thickness graft to the recipient bed, during and immediately after application, was noted. We have observed no negative effects with regard to infection or healing. We recommend the use of single-donor fibrin glue to reduce operative blood loss, improve survival and ease of graft application, and possibly to accelerate healing.