[Costs and benefits of the use of tissue adhesives in wounds in children]

Costs and benefits of the repair in Emergency Room of skin lacerations by tissue adhesive in children are reported. In 1987-88 2150 children under 16 were referred to our Institute because of lacerations. About one of three of them needed repair by subcutaneous suture; in the others, sutures or sterile stripes or adhesive tissue could be employed. Adhesive tissue use increased significantly during 1988 because of its advantages: no need of local anesthesia, syringes, sterile suture instruments and dressing materials; no further dressing; no suffering of children during the treatment; good aesthetic results. Now it is the first choice treatment of the lacerations in which subcutaneous suture is not necessary. Moreover this technique is cheap, and reduced significantly 1988 costs for laceration repair in our department.

[Prevention of incompetence of duodenal stump sutures after gastrectomy]

The authors present data on methods of prophylactics of incompetence of duodenal stump sutures after resection of the stomach. Decompression of the stomach and duodenum, glue hermetization of the duodenal stump through a drain in the abdominal cavity with the help of a choledochoscope, prevention of postoperative peritonitis, drainage of the stump area with a glove-gauze-tube drain allowed the incompetence of duodenal stump sutures to be avoided in 128 patients with penetrating duodenal ulcers.

[Fibrin glue injection--a hemostatic technic after laparoscopic liver biopsy]

Fibrin glue was injected into or near the site of needle biopsy puncture in 33 patients (38 laparoscopically guided liver biopsies), 21 with histologically confirmed liver cirrhosis, to arrest post-puncture bleeding. A special double-lumen needle was introduced, suitable for multiple injections. Fibrin-glue injection was successful in 37 instances, but in one case it failed because the injection needle could not be optimally placed. The method thus seems to be a reliable and sensible means of obtaining haemostasis if compression and electrocoagulation have failed.

[Frontobasal fractures in children]

In 1987, four children between 5 and 13 years of age with severe frontobasal trauma and dural tears were treated operatively. A CSF rhinorrhea was manifest clinically in only two cases. In addition high-resolution computerised tomography was essential in diagnosis and planning of the operation. In each of the cases an intracranial pneumatocele indicating dural laceration was shown. The fractures were confirmed during surgery in: Case 1. The roof of the ethmoid sinus and the roof of the orbit. Case 2. Both the sphenoid sinuses. Case 3. The roof of the ethmoid sinus and the posterior wall of the frontal sinus. Case 4. The roof of the ethmoidal sinus and the posterior wall of the frontal sinus. The ontogenetically oldest part of the paranasal sinuses in the floor of the anterior cranial fossa forming the anterior part of the roof of the ethmoid bone is the site of predilection for fractures, even in children. The anterior cranial fossa was exposed in each case through a paranasal subfrontal access, in the first case combined with a frontal craniotomy by a neurosurgeon, because of the fracture of the roof of the orbit. In the second case the dural injury had to be closed at a second neurosurgical operation, because of a recurrence of the CSF leak. The third and fourth cases were treated by nasal surgery alone.

[Protection of the pancreatico-digestive anastomosis following resection of the head of the pancreas by pancreatic duct occlusion with fibrin (-glue). Animal experiment and clinical experiences]

The pancreatico-digestive anastomosis is especially then endangered by dehiscence when, following resections due to carcinomas, a healthy lienal pancreatic rest has to be connected to the intestine. In the last years the pancreatic duct occlusion (PDO) with Prolamin proved to be possible for the elimination of the disturbing exocrine secretion. Apart from a strong exocrine fibrosis, a deterioration of the endocrine function results too. In animal experiments as well as clinically a simple and effective method for the protection of the pancreatico-digestive anastomosis could be developed by PDO with fibrin sealant (FS). Contrary to PDO with Prolamin a lower-grade, interstitial fibrosis under intact exocrine function is caused due to the short, 6 days at the most lasting blockade of the exocrine pancreatic secretion. Because of the high tryptic activity of the pancreatic juice 20,000 IU/ml Aprotinin were added to the fibrin sealant. So far this method was employed successfully in 36 patients within the scope of Whipple's operations due to pancreatic head carcinomas.

[Therapy and prognosis of medial ligament injury of the knee joint]

We tried to classify the potential lesions of the medial ligament of the knee joint with regard to the therapeutic and prognostic background elements. We analyzed 354 lesions of the medial ligament and report the therapeutic alternatives. In addition, we made an attempt to correlate some of the lesion forms and their locations with the sport causing the injury.

[Marshall-Marchetti-Krantz operation with fibrin gluing. Results after 2 years]

Since broad experience concerning the stability of fibrin sealing is needed, it has become part of the routine program in orthopaedics and in traumatology. Because of these experiences, we decided to modify the standard Marshall-Marchetti-Krantz-Operation replacing all sutures on both sides of the urethra and the bladder neck by fibrin sealing. So far, 76 patients have been operated using to this new method. All patients had a urinary stress incontinence grade II-III, urodynamically verified and a pronounced urethro-cystocele. To judge the results of the operation the following check-ups were instituted: 1. Urodynamic control, 2. lateral cyst-urethrogram, 3. gynecological examination (anatomical control), 4. subjective, individual evaluation of the patient concerning the involuntary loss of urine. Our study shows that we achieved good surgical and functional results as can be demonstrated both clinically and by urodynamic check-up. The advantage of this method of operation using fibrin sealing is to be seen in the broad lifting up of the anterior vaginal wall without unphysiological fixation and at the same time avoiding all risks of sutures.

Pancreatic duct occlusion in the management of acute necrotizing pancreatitis in a canine model

Based on results reported by others in using prolamine (Ethibloc; Ethicon Gmb H) to treat patients with chronic pancreatitis, without any observed pancreatic complications, we decided to use pancreatic duct occlusion experimentally in dogs in which we induced acute pancreatitis by the injection of calcium chloride into the pancreatic duct. This injection proved to be 100% lethal in the 5 animals constituting the control group, none of which were treated after the injection. Acute pancreatitis was then induced in 57 animals, also by injection of calcium chloride. These dogs were then treated with one of three substances that share the same physical properties: prolamine; Tissucol (Immuno AG, Vienna), a biologic tissue adhesive; silicone (Xantopren, Bayer Dental D-5090 Leverkusen). Thirty-seven dogs were treated with prolamine, 10 dogs with Tissucol, and 10 with silicone. The mortality rate in the 57 treated animals was 12.2%, compared to the 100% rate in the untreated control group. The mechanical action achieved by blocking the pancreatic duct shows how the evolution of acute pancreatitis at different stages could be modified. This specific treatment limits the pathophysiologic process of acute pancreatitis in dogs. These findings provide us with a promising outlook for the treatment of this severe illness.

Hemostasis of solid viscus trauma by intraparenchymal injection of fibrin glue

Fibrin glue (FG) is an effective hemostatic agent applied topically to the spleen. In this study, FG was found to be an effective hemostatic agent when applied topically in standardized wounds of the canine liver, spleen, and pancreas. It was markedly more effective, however, when injected intraparenchymally. In a case of severe blunt trauma in a patient with acute alcoholic hepatitis, intraparenchymal FG was lifesaving. Fibrin glue is a useful adjunct in the management of trauma to all the abdominal solid viscera. Intraparenchymal injection is the preferred mode of FG application.

Mediastinal fibrin glue: hemostatic effect and tissue response in calves

There is continued controversy regarding the effectiveness and potential adverse effects of fibrin glue. Thus, we chose to evaluate it in a model of experimental calf aortic valve replacement that has been previously well established. Concentrated fibrinogen and topical thrombin were sprayed to form a thin layer of fibrin glue over the mediastinal tissues of 20 consecutive calves undergoing aortic valve replacement. Chest tube outputs of these animals were compared with those of the preceding 20 consecutive calves undergoing aortic valve replacement without fibrin glue. All procedures were performed by the same surgeon, and no other technical changes were made between the two series. Total postoperative chest tube output (mean +/- standard error) was 553 +/- 50 mL for the calves treated with fibrin glue and 1,155 +/- 103 mL for the control calves (p less than 0.001). On histological examination of mediastinal tissues from 5 treated calves killed 6 weeks after operation, there was no evidence of inflammation, fibrosis, or residual fibrin. To our knowledge, this is the first controlled laboratory study to show that fibrin glue spray is an effective hemostatic agent and that it produces no long-term tissue reaction.

A method of applying fibrin sealant using an atomizing needle

A needle modification is described that enables fibrin sealant to be applied as a fine spray to the operative site. The techniques for modification and use of the needle are presented.

A technique for spot application of fibrin glue during open heart operations

Several techniques have been described for preparing and applying fibrin glue to control surgical bleeding. However, these methods tend to be cumbersome, expensive, or messy. Furthermore, commercial kits have not been approved by the Food and Drug Administration because of the potential risk of hepatitis contamination. Therefore, we have devised a modified, simpler technique that enables the precise, pinpoint application of fibrin glue. The risk of hepatitis transmission is substantially reduced by using cryoprecipitate plasma instead of fibrinogen from pooled donors. This technique is especially well suited for anastomoses of small vessels or for sealing suture holes in nonporous grafts.

A new technical of liver biopsy with plugging of the needle track using a double channel biopsy device. An experimental study

A new liver biopsy technique with plugging of the intrahepatic needle track in one procedure using a double channel biopsy device (Austrian patent No 384,165 invented by K. Zatloukal and H.P. Dinges) is presented in an experimental study. This technique is similar to that described by Menghini, but is combined with a fibrin sealing system (Tissucol, Tisseel). Biopsy and sealing of the biopsy site is performed within less than two seconds. 15 liver biopsies were performed on 6 heparinized dogs after laparotomy. Heparinization was maintained for 6 hours and the efficiency of the sealing in preventing biopsy-related bleeding was checked before the abdominal wound was closed. No bleeding occurred after biopsy with the new needle system and occlusion of the needle track with fibrin sealant. The livers with the sealed needle tracks and all biopsies obtained were examined histologically. It was found that the needle tracks were filled with the fibrin sealant which was almost completely replaced by granulation tissue after 8 days. Biopsies performed with a conventional Menghini needle led to continuous bleeding from the needle track. The results show that this new biopsy device efficiently prevents bleeding from the biopsy site in animals with severely impaired blood coagulation. Therefore, application of this biopsy technique in humans might reduce bleeding complications particularly in patients with severe liver diseases and disturbed blood coagulation.

One lung high frequency ventilation for peroral sealing of bronchial stump fistulae

The use of high frequency ventilation for 28 repairs of bronchial stump fistulae with fibrin sealant is discussed. Intravenous anaesthesia with continuous infusions of methohexitone, alfentanil and suxamethonium was employed. This method of anaesthesia and ventilation proved to be satisfactory.

Reduction of perioperative hemorrhage by anterior mediastinal spray application of fibrin glue during cardiac operations

A variety of published techniques for the production of concentrated fibrinogen from units of screened single-donor human plasma have led to increasing clinical use of fibrin glue in the United States. We have adapted a method of applying this material with a disposable plastic sprayer. In 20 consecutively treated patients, fibrin glue was sprayed on the anterior mediastinum before closure of the median sternotomy incision. A control group of 20 patients undergoing the identical cardiac operations (13 coronary artery bypass grafting procedures [CABG], 4 valve replacements [including 1 reoperative procedure], and 3 combined valve replacements and CABG) by the same surgeon within a one-year period was chosen for comparison of chest tube outputs. Specifically, chest tube outputs were as follows for treated and untreated patients, respectively: at 12 hours, 461 +/- 40 ml (mean +/- 1 standard error of the mean versus 731 +/- 80 ml; at 24 hours, 714 +/- 73 ml versus 1,016 +/- 109 ml; and at 48 hours, 863 +/- 93 ml versus 1,187 +/- 137 ml. The differences between control and spray chest tube output are statistically significant by unpaired t test (p less than 0.05) at both 12 and 24 hours. Thus, this method can reduce perioperative hemorrhage from the anterior mediastinum after cardiac operations.

Autologous fibrin tissue adhesive for peripheral nerve anastomosis

The sciatic nerve in rabbits was exposed, transected, and repaired using either of two methods. The experimental group had an autologous fibrin-based adhesive repair. The control group had conventional perineural suturing. The autologous tissue glue is similar in composition, handling, and performance to the commercially available European product Tisseel. It can be prepared quickly without sophisticated equipment or expense. Autologous glue obviates the risk of transmissible disease that has precluded approval of the commercial product for use in the United States. The glued anastomosis can be performed with accurate apposition and minimal trauma to the nerve. By making a fibrin cocoon, the anastomosis can be insulated. This provides some of the benefits of sheathed anastomosis while minimizing foreign body reaction. Functional evaluation and histologic results comparing the amount of anastomotic fibrosis, axonal regeneration, and alignment of fascicles showed glue to be as good as, if not superior to, conventional suture technique.

Application of fibrin adhesive in the urinary bladder

The investigations on rats and pigs showed that the transuretheral haemostasis of the urinary bladder damaged by radiotherapy is possible by means of fibrin adhesion. The spraying procedure has to be carried out by means of a special balloon-catheter in a bladder filled with CO2. During spraying the bladder must be kept constantly free of pressure.