[Endovascular management of cavernous sinus dural fistulas]

OBJECTIVE

Describe the outcomes of patients diagnosed with indirect carotid-cavernous fistula treated by endovascular methods.

DESIGN

A retrospective case series.

PARTICIPANTS

Twelve patients with dural cavernous sinus fistula with important ophthalmologic involvement admitted and treated at the National Institute of Neurology and Neurosurgery between February 1990 and January 2005.

INTERVENTION

Patients were managed by endovascular embolization for all fistulas.

OUTCOME MEASURES

Angiographic controls to 24 hours and at 6 and 12 months were performed.

RESULTS

67 % were female and 33 % male. The mean age was 44 years. 67 % were spontaneous and 33% of traumatic origin. All patients had eye involvement with proptosis (92%) and involvement of the oculomotor nerve (67%). Headache and pulsatile tinnitus were not frequent ophthalmologic data. All were diagnosed by cerebral angiography, 33 % were type C, type D 67 %, and none of the type B classification Barrow. In 17 % of cases the distal arterial robbery showed severe. Predominance of anterior and superior venous drainage in 83 % and 42 % of cases occurred respectively. The surgical approach was arterial in 84% of cases, while in 17 % venous through the superior ophthalmic vein. Cyanoacrylate embolization material was used in 58 % of the cases, as it was associated with the use of removable ball with polyvinyl alcohol particles in 16 % in of venous approach cases. 17% detachable coils were utilized. There were no complications. After angiographic controls at 24 hours 100% occlusion was seen in patients treated with cyanoacrylate (58%) (p = 0.03). The remaining 42% were prescribed maneuver of manual compression. At 12-months angiography all patients had 100% occlusion of the carotid-cavernous fistula. CONCLSUIONS: This is the world's second largest series with indirect carotid-cavernous fistulas treated after trauma. 100 % of cases were cured with the use of a transarterial-controlled approach and N-butyl-cyanoacrylate after long-term observation.

Use of a fibrin adhesive for conjunctival closure in trabeculectomy

PURPOSE

To assess the safety and efficacy of a fibrin tissue adhesive (Tissucol Duo(®) ) used to close the conjunctiva in trabeculectomy.

METHODS

A nonrandomized prospective study including 57 patients with chronic simple glaucoma who underwent trabeculectomy surgery. All the trabeculectomies were conducted by the same surgeon using the same surgical technique with the exception that conjunctival closure was achieved by either running Nylon 10/0 suture (n = 29) or using the fibrin glue (n = 28). Preoperative and postoperative data were obtained on intraocular pressure (IOP), number of hypotensive medications used, self-reported discomfort and complications arising during and after surgery.

RESULTS

No differences were detected between the two patient groups regarding the intraocular pressure reduction achieved during follow-up. In the first 2 weeks of follow-up, reported discomfort assessed using a visual analogue scale was significantly lower in the Tissucol Duo(®) group. Two patients in the Tissucol Duo(®) group suffered conjunctival dehiscence and suturing was required at 24 hours postsurgery. Remaining complications were similar in the two groups.

CONCLUSION

The use of Tissucol Duo(®) seems to be a safe and efficient option for conjunctival closure in trabeculectomy that simplifies the surgical procedure and reduces patient discomfort in the immediate postoperative period.

Learning curve in the Cut and Paste method for surgery of primary pterygium

PURPOSE

To evaluate the learning curve for the surgery of primary nasal pterygium with conjunctival autograft using fibrin adhesive (the Cut and Paste method).

METHODS

The outcomes of the first consecutive 120 primary pterygium surgery cases for two surgeons (groups A and B) were investigated retrospectively and compared with the first (group C) and second (group D) 120 cases of GK. A and B were previously inexperienced in pterygium surgery. Outcome variables were surgery time, complications, the number and the temporal distribution of the recurrences. The statistics used were moving averages of the recurrences, Scheffé's test of means, learning curve analysis according to Wright and logarithmic curve fitting to operation time data. The impact of age and sex on recurrences was tested using t-tests and chi-square tests.

RESULTS

The mean surgery time was 17 min for A, 13 min for B and 13 min for GK. There was a certain learning curve slope in operation time in groups A and C. The postoperative complications were few and acceptable. There were ten (8.9%) recurrences in group A, eight (6.8%) in group B, six (5.5%) in group C and five (4.6%) in group D. The temporal distribution of the recurrences did not show any learning curve. Age and sex had no significant correlation with recurrence rate or surgery time (data not shown).

CONCLUSIONS

Our study indicates that the Cut and Paste technique is easy to learn and master. We did not find a significant learning curve regarding surgery time, recurrences or complications. In a clinical setting, it is beneficial to let a few, otherwise experienced eye surgeons learn the technique.

Surgical corner: a prospective randomized evaluation of cyanoacrylate glue devices in the closure of surgical wounds

BACKGROUND

The use of medical adhesives for topical wound closure is gaining in popularity over conventional wound closure materials such as sutures and staples. Adhesives provide advantages in both wound closure and patient management with good cosmetic outcome and surgeon and patient satisfaction reported.

OBJECTIVE

To compare the use of two currently marketed medical adhesives; LiquiBand® Flow Control and High Viscosity Dermabond ™ for the topical closure of surgical incisions.

METHODS

In a prospective blinded manner, subjects were randomly assigned LiquiBand® or DermabondTM for topical closure of a surgical incision. Variables compared included ease of use, time taken to close wound, subject and surgeon satisfaction with device and wound closure, cosmetic outcome at 90 days, and complication rates.

RESULTS

Use of both devices resulted in effective wound closure with similar high levels of cosmesis subject and surgeon satisfaction, with only minor complications reported. There was no statistically significant difference between the devices for all the parameters studied, with the exception that the Liquiband device was found to significantly reduce the amount of time required for closure.

CONCLUSION

As the two devices appear substantially equivalent in terms of key surgeon and patient variables, product cost should be the primary determinant in selection of the tissue glue device.

Effects of medical adhesives in prevention of complications after endoscopic submucosal dissection

AIM: To evaluate the use of medical adhesive spray in endoscopic submucosal dissection (ESD).

METHODS: Patients who underwent ESD between January 2009 and June 2012 (n = 173) were enrolled in the prospective randomized study. Two patients undergoing surgery due to severe intraoperative hemorrhage and failed hemostasis were excluded, and the remaining 171 patients were randomly divided into two groups: group A (medical adhesive group, n = 89) and group B (control group, n = 82). In group A, a medical adhesive spray was evenly applied after routine electrocoagulation and hemostasis using hemostatic clip after ESD. Patients in group B only treated with routine wound management. Intraoperative and postoperative data were collected and compared.

RESULTS: In all 171 patients, ESD was successfully completed. There was no significant difference in the average treatment time between groups A and B (59.4 min vs 55.0 min, respectively). The average length of hospital stay was significantly different between group A and B (8.89 d vs 9.90 d, respectively). The incidence of intraoperative perforation was 10.1% in group A and 9.8% in group B, and was not significantly different between the two groups. In all cases, perforations were successfully managed endoscopically and with conservative treatment. The incidence of postoperative delayed bleeding in group A was significantly lower than that in group B (0.00% vs 4.88%, respectively).

CONCLUSION: ESD is an effective minimally invasive treatment for gastrointestinal precancerous lesions or early-stage gastrointestinal cancer. Medical adhesive spray is effective in preventing delayed bleeding after ESD, and can thus reduce the average length of hospital stay.

Hemangioma of the parotid gland: case report

Hemangiomas account for half of the parotid gland tumors occurring in children. After a rapid increase in the first months of life, some of them gradually regress (until complete disappearance) in a period of several years. Hemangiomas that do not regress over time, grow in size (possibly within a short period of time) or develop complications such as intralesional acute bleeding or thrombosis require aggressive therapy: intralesional corticosteroid injection, sclerotherapy. radiation therapy, laser photocoagulation. embolization, or surgical removal. We present the case of a 12-year-old boy with hemangioma of the left parotid gland diagnosed by CT scan, angio-CT with 3D reconstruction and angiography successfully treated by superselective intraarterial embolization with acrylic glue followed after 4 days by left superficial parotidectomy with facial nerve preservation.

Application of hyperdry amniotic membrane patches without fibrin glue over the bony surface of mastoid cavities in canal wall down tympanoplasty

CONCLUSION

Fibrin glue might be an inessential bioadhesive for attachment of hyperdry amniotic membrane (AM) patches in canal wall down (CWD) tympanoplasty.

OBJECTIVE

To clarify the pliability and adherence capability of human hyperdry AM, the feasibility of fixing hyperdry AM without fibrin glue to the bony surface of the mastoid cavity was evaluated in CWD tympanoplasty.

METHODS

This was a retrospective chart review. In seven ears of seven patients, the AM was simply attached over the bony surface of the mastoid cavity without fibrin glue (AMG(-) group). In 22 ears of 20 other patients, hyperdry AM (11 ears of 11 patients, AMG(+) group) or temporal fascia (11 ears of 9 patients, TFG(+) group) was attached over the bony surface of the mastoid cavity with fibrin glue. Times for graft epithelization were compared among the three groups.

RESULTS

Complete epithelization of the mastoid cavity took place in all patients in all three groups. The mean time to complete epithelization of the graft in the AMG(-) and AMG(+) groups was significantly faster than that in the TFG(+) group (p < 0.05) and was not significantly different between the two AM groups (p > 0.05).

A chitosan based, laser activated thin film surgical adhesive, 'SurgiLux': preparation and demonstration

Sutures are a 4,000 year old technology that remain the 'gold-standard' for wound closure by virtue of their repair strength (~100 KPa). However, sutures can act as a nidus for infection and in many procedures are unable to effect wound repair or interfere with functional tissue regeneration.(1) Surgical glues and adhesives, such as those based on fibrin and cyanoacrylates, have been developed as alternatives to sutures for the repair of such wounds. However, current commercial adhesives also have significant disadvantages, ranging from viral and prion transfer and a lack of repair strength as with the fibrin glues, to tissue toxicity and a lack of biocompatibility for the cyanoacrylate based adhesives. Furthermore, currently available surgical adhesives tend to be gel-based and can have extended curing times which limit their application.(2) Similarly, the use of UV lasers to facilitate cross-linking mechanisms in protein-based or albumin 'solders' can lead to DNA damage while laser tissue welding (LTW) predisposes thermal damage to tissues.(3) Despite their disadvantages, adhesives and LTW have captured approximately 30% of the wound closure market reported to be in excess of US $5 billion per annum, a significant testament to the need for sutureless technology.(4) In the pursuit of sutureless technology we have utilized chitosan as a biomaterial for the development of a flexible, thin film, laser-activated surgical adhesive termed 'SurgiLux'. This novel bioadhesive uses a unique combination of biomaterials and photonics that are FDA approved and successfully used in a variety of biomedical applications and products. SurgiLux overcomes all the disadvantages associated with sutures and current surgical adhesives (see Table 1). In this presentation we report the relatively simple protocol for the fabrication of SurgiLux and demonstrate its laser activation and tissue weld strength. SurgiLux films adhere to collagenous tissue without chemical modification such as cross-linking and through irradiation using a comparatively low-powered (120 mW) infrared laser instead of UV light. Chitosan films have a natural but weak adhesive attraction to collagen (~3 KPa), laser activation of the chitosan based SurgiLux films emphasizes the strength of this adhesion through polymer chain interactions as a consequence of transient thermal expansion.(5) Without this 'activation' process, SurgiLux films are readily removed.(6-9) SurgiLux has been tested both in vitro and in vivo on a variety of tissues including nerve, intestine, dura mater and cornea. In all cases it demonstrated good biocompatibility and negligible thermal damage as a consequence of irradiation.(6-10).

Statistical approach for assessing the influence of calcium silicate and HPMC on the formulation of novel alfuzosin hydrochloride mucoadhesive-floating beads as gastroretentive drug delivery systems

Multiparticulate floating drug delivery systems have proven potential as controlled-release gastroretentive drug delivery systems that avoid the "all or none" gastric emptying nature of single-unit floating dosage forms. An objective of the presence investigation was to develop calcium silicate (CaSi)/calcium alginate (Ca-Alg)/hydroxypropyl methylcellulose (HPMC) mucoadhesive-floating beads that provide time- and site-specific drug release of alfuzosin hydrochloride (Alf). Beads were prepared by simultaneous internal and external gelation method utilizing 3(2) factorial design as an experimental design; with two main factors evaluated for their influence on the prepared beads; the concentration of CaSi as floating aid (X (1)) and the percentage of HPMC as viscosity enhancer and mucoadhesive polymer (X (2)), each of them was tested in three levels. Developed formulations were evaluated for yield, entrapment efficiency, particle size, surface topography, and buoyancy. Differential scanning calorimetry, Fourier transform infrared spectroscopy, in vitro drug release, as well as in vitro mucoadhesion using rat stomach mucosal membrane were also conducted. Percentage yield and entrapment efficiency ranged from 57.03% to 78.51% and from 49.78% to 83.26%, respectively. Statistical analysis using ANOVA proved that increasing the concentration of either CaSi or HPMC significantly increased the beads yield. Both CaSi and HPMC concentrations were found to significantly affect Alf release from the beads. Additionally, higher CaSi concentration significantly increased the beads diameter while HPMC concentration showed significant positive effect on the beads mucoadhesive properties. CaSi/Ca-Alg/HPMC beads represent simple floating-mucoadhesive gastroretentive system that could be useful in chronopharmacotherapy of benign prostatic hyperplasia.

The role of embolization for hemangiomas

We retrospectively studied 31 patients with painful bone (15 patients) and soft-tissue (16 patients) hemangiomas treated with 39 embolizations using N-2-butyl cyanoacrylate from 2003 to 2010. The mean tumor size before embolization was 6 cm for bone and 7 cm for soft-tissue hemangiomas. The technique of embolization was the same for bone and soft-tissue lesions. Preoperative embolization was done in six patients, while the remaining patients had embolization as only treatment. The mean follow-up was 47 months (11-89 months). The clinical and imaging effect of treatment was evaluated at follow-up with a pain score scale, tumor size, and ossification. In four patients, embolization was not feasible because of the inability to catheterize and low blood flow of the feeding vessels. Nine patients with bone and 10 with soft-tissue hemangiomas experienced complete pain relief. Four patients with bone and four with soft-tissue hemangiomas experienced recurrence of pain and were treated with repeat embolization. Re-recurrences were not observed in any of the patients with soft-tissue hemangiomas until the period of this study. Ossification and tumor size reduction were higher for bone hemangiomas. Embolization-related complications were more common for soft-tissue hemangiomas.

[Use of endoscopic tissue adhesive injection for gastric varices]

OBJECTIVE

To evaluate the long-term efficacy and safety of endoscopic tissue adhesive(N-octyl-α-cyanoacrylate) injection for the treatment of gastric varices.

METHODS

A retrospective study was performed to review the clinical and follow up data of 169 patients with gastric variceal who received tissue adhesive injection at the Fudan University Affiliated Zhongshan Hospital between April 2004 and December 2011.

RESULTS

There were 128 males and 41 females with a mean age of 56.8(37-85) years old. One hundred and thirty-one patients received one injection, 38 received two injections or more with a mean of 1.12 per patient. Volume of injection ranged from 1 to 3 ml(mean, 1.7 ml). Eighty-three patients received adhesive injection alone, 231 received injection combined with ligation, 50 received combined sclerotic agent injection. All the patients had follow up ranging from 1 to 78 months(mean, 3.4 months). The treatment outcome was satisfactory in 130 patients(76.9%), good in 36(21.3%), and ineffective in 3(1.8%). The rate of ectopic embolization was 3.0%, and the rate of early re-bleeding was 1.2%. Postoperatively there were no septic complications or esophageal stricture. There were no deaths within 2 weeks.

CONCLUSION

Injection of tissue adhesive under endoscopic guidance for treatment of gastric varices is convenient, safe and effective.

[Endoscopic sclerotherapy of gastric varices by tissue adhesives]

The diagnosis and treatment of gastric varices is a clinically concerned issue. With the development of endoscopic technology. The success rate of controlling bleeding from gastric and esophageal varices has been improved a lot. It is efficacious and safe to treat gastric and esophageal varices by endoscopic injection of tissue adhesives and to prevent re-bleeding. There is few acute and long-term complications of this modality. It has been the first line treatment for gastric varices.

[Local haemostasis with an adhesive cyanoacrylate-coated membrane following tooth extraction in patients under anticoagulant or anti-platelet therapy]

OBJECTIVE

Assessment of a local hemostasis with a compressive, extemporaneous gutter glued to the alveolar crest after tooth avulsion in patients under anticoagulant and/or platelet aggregation inhibitors, and economical impact of this technique.

MATERIAL AND METHOD

Ninety-seven tooth extractions were performed in patients under AVK and/or anti-platelet drugs. The interventions were consecutive and concerned 251 teeth (138 different alveolar sites). The extraction alveolus was protected by an absorbable oxycellulose membrane coated with sterilized cyanoacrylate adhesive for medical use. This procedure was used with all patients, whatever the hemorrhagic risk (the only inclusion criterion was INR less than 4 for patients under AVK). All procedures were performed under local anesthesia.

RESULTS

There was one hemorrhagic complication (0.72%) due to mechanical gutter destruction by an antagonist tooth. The adhesive did not run, there was no tissue necrosis, and no wound infection requiring gutter removal.

DISCUSSION

This local hemostasis procedure is reliable. It may be an alternative to substitution of heparin, without or with hospitalization. This procedure, requiring modification of treatment, greatly decreases healthcare costs. Contra-indications include the presence of an antagonist tooth harmful for the gutter, and patients with impaired consciousness or tongue dyspraxia.

Endoscopic therapy for severe ulcer bleeding

Upper gastrointestinal (UGI) bleeding secondary to ulcer disease occurs commonly and results in significant patient morbidity and medical expense. After initial resuscitation, carefully performed endoscopy provides an accurate diagnosis of the source of the UGI hemorrhage and can reliably identify those high-risk subgroups that may benefit most from endoscopic hemostasis. Effective endoscopic hemostasis of ulcer bleeding can significantly improve outcomes by reducing rebleeding, transfusion requirement, and need for surgery, as well as reduce the cost of medical care. This article discusses the important aspects of the diagnosis and treatment of bleeding from ulcers, with a focus on endoscopic therapy.

CT portography with gastric variceal volume measurements in the evaluation of endoscopic therapeutic efficacy of tissue adhesive injection into gastric varices: a pilot study

BACKGROUND

N-butyl-2-cyanoacrylate (NBCA) injection is used for treating gastric varices (GV). Determining the degree of obliteration of GV is not readily evident at endoscopy.

AIMS

The aim of this study was to evaluate CT portography with gastric variceal volume calculations to assess endoscopic therapeutic efficacy of NBCA injection.

METHODS

The study design is a retrospective series pilot study. The setting is a single, tertiary care academic medical center. Ten patients underwent esophagogastroduodenoscopy (EGD) with NBCA injection of GV and had biphasic CT scans performed before and after injection therapy. Based on portal venous images, 3D reconstruction and semi-automated volume calculations of GV were performed. Pre and post injection GV volume calculations were compared.

RESULTS

The mean pre-procedure GV volume was 89.84 cm3. Eight patients had significant improvement in GV volume from pre-treatment versus post-treatment (95.65 cm3 vs. 49.65 cm3, P-value 0.04). Pre-procedure GV volume was not significantly different in patients treated for active hemorrhage versus no hemorrhage (101.66 cm3 vs. 72.11 cm3, P-value 0.33). Two patients had a subsequent GV hemorrhage after NBCA injection. The mean residual GV volume in these patients versus those that did not re-bleed was significantly more (127.77 cm3 vs. 38.00 cm3, P-value 0.005).

CONCLUSIONS

CT portography with measurement of GV volume is a potentially useful tool in determining the therapeutic efficacy NBCA injection of GV. Patients with higher residual GV volumes are at increased risk of hemorrhage and may benefit from repeat injection to reach ideal GV volumes.

Nitrogenous subcutaneous emphysema caused by spray application of fibrin glue during retroperitoneal laparoscopic surgery

We report a case of a patient treated by retroperitoneoscopic partial nephrectomy who developed nitrogenous subcutaneous emphysema (SCE) as a complication. The use of a nitrogen gas-pressured fibrin tissue adhesive applied as a spray caused excessively increased pressure in the closed retroperitoneal space and resulted in widespread SCE with protracted clinical course. To the best of our knowledge, this is the first report of nitrogenous SCE associated with pneumoperitoneum. The clinical significance of nitrogenous SCE is emphasized, and the risks associated with the use of fibrin glue as a spray during laparoscopic surgery are discussed.

Administration of intrapericardial tissue adhesive after cardiac rupture and cardiac tamponade

OBJECTIVE

To describe a series of patients treated with intrapericardial glue.

DESIGN

Case reports. Descriptive study.

PATIENTS

We describe the results obtained using the injection of a surgical intrapericardial adhesive in 19 patients who presented cardiac tamponade and shock after cardiac rupture. The technique was done using puncture and echocardiographic subxiphoid control. At the one-year follow-up, 5 patients had survived, with neither pseudoaneurysms nor constriction. One patient was injected with said adhesive in the right ventricular cavity.

CONCLUSIONS

Pericardial drainage, followed by the administration of intrapericardial glue may be an attractive technique. This technique should be studied for its possible utility when faced with surgical impossibility.

Mucoadhesive curcumin nanospheres: biological activity, adhesion to stomach mucosa and release of curcumin into the circulation

Although mucoadhesive drug carriers for the gastro-intestinal tract (GIT) have been reported, the mucoadhesive property and drug release characteristics have never been evaluated separately, whilst the adherence of the carriers to the surface of GIT has not been directly visualized. Here, a monopolymeric carrier made from ethylcellulose (EC) and a dipolymeric carrier made from a blend of methylcellulose (MC) and EC (ECMC) were easily fabricated through a self-assembling process and yielded the highest reported curcumin loading of ~48-49%. Both curcumin loaded ECMC (C-ECMC) and curcumin loaded EC (C-EC) particles showed an in vitro free radical scavenging activity and a dose-dependent in vitro cytotoxic effect towards MCF-7 human breast adenocarcinoma and HepG2 hepatoblastoma cells in tissue culture. The in vivo evaluation of their adherence to stomach mucosa and their ability to release curcumin into the circulation were carried out through quantification of curcumin levels in the stomach tissue and in blood of mice orally administered with the two spheres. Direct evidence of the adherence of the C-EC and C-ECMC particles along the mucosal epithelia of the stomach is also presented for the first time through SEM images. The mucoadhesive property of self-assembled C-EC nanoparticles is discussed.