Antenatal embolization of a large chorioangioma by percutaneous Glubran 2 injection

We describe a case of a large chorioangioma diagnosed at 18 weeks' gestation. Because of advanced fetal heart failure at 23 weeks' gestation, embolization of the chorioangioma's vessels was performed by percutaneous injection of Glubran 2 surgical glue. There was no immediate secondary effect of treatment. Devascularization was complete and durable. Signs of fetal cardiac failure normalized after 1 month and a healthy infant was delivered at 38 weeks. To our knowledge this is the first reported case of perinatal survival after successful embolization of a chorioangioma using tissue glue.

An experience with the modified total pleural covering technique in a patient with bilateral intractable pneumothorax secondary to lymphangioleiomyomatosis

We present a case of bilateral intractable pneumothorax associated with a modified form of lymphangioleiomyomatosis (LAM), successfully treated with a previously reported surgical procedure, the total pleural covering (TPC) technique, under video-assisted thoracic surgery. The patient was a 28-year-old woman with bilateral pneumothorax secondary to LAM who had undergone thoracoscopic surgery in another hospital. We performed bilateral TPC modified with a preceding coverage of air leak points with polyglycolic acid sheets for reinforcement. Although a minor air leak after the surgery necessitated a mild pleurodesis on the right side, the bilateral pneumothorax was well controlled, and no recurrence has been observed for 9 months. We believe that TPC is a safe and reliable procedure for the management of intractable pneumothorax secondary to LAM. It also has the potential to reduce risk of excessive bleeding in lung transplantation.

Dermabond efficacy in total joint arthroplasty wounds

The goals of wound closure are a low infection rate and timely healing. Total joint arthroplasty (TJA) requires mobile recovery, and, therefore, a high-tension wound care environment. We conducted a study to compare the efficacy of high-viscosity Dermabond (Ethicon, Somerville, New Jersey) and the efficacy of surgical staples in healing high-tension, mobile surgical sites of TJA. Of 236 total knee arthroplasties and 223 total hip arthroplasties (459 surgeries total), 250 were performed with Dermabond and 209 with staples. According to χ2 analysis, case and control infection rates were equivalent. Signs of acute inflammation (redness, drainage, dehiscence) also were statistically equivalent. Absence of staples accounted for a significant decrease in tape blisters and skin abscesses. Dermabond is superior to staples in high-tension wound care.

Bronchoscopic management of bronchopleural fistula

In recent years successful bronchoscopic management of bronchopleural fistulas (BPFs) by locating its site and then blocking the leaking segment with any of the several agents available has gained recognition. It is now considered as an alternate mode of management of BPF. Here we present a case of non-resolving pneumothorax that was managed successfully using bronchoscopic glue (cyanoacrylate glue) instillation.

Long-term efficacy and safety of N-butylcyanoacrylate in endoscopic treatment of gastric varices

INTRODUCTION

Endoscopic glue (N-butyl-2-cyanoacrylate) injection has emerged as promising therapy for bleeding gastric varices (GV). We evaluated safety and long term efficacy of this technique in patients with portal hypertension and large bleeding GV.

PATIENT AND METHODS

170 patients (mean age 40.9 +/- 14y; 132 male; 142 had cirrhosis, 40 Child A, 62 Child B, 40 Child C) underwent glue injection into GV (F3 140, F2 30; fundal 114) as emergency procedure for active bleeding in 62 and electively for prevention of rebleeding in 108. Glue was injected intra-variceally under endoscopic vision, 0.5-4 ml/aliquot, repeated at 3 weeks till varices were eradicated/solidified. The efficacy was assessed by hemostasis at 48 h, primary, secondary, definitive success and treatment failure.

RESULTS

The overall hemostasis rate at 48h was 82.3% (51/62). Follow up was available in 158 patients for mean of 30.7 + 17.2 months. Repeat injections were performed in 76. The mean number of injections were 1.9 +/- 1.0 (1-4); total volume was 2.5 +/- 1.7 ml/patient. The status of GVs at last follow up was: disappeared in 32 (22.6%); F1 solidified in 46 (32.3%); F2 solidified in 64 (45.0%). Bleeding recurred in 14.5% (23/158); 60% within 2 weeks of injection. The primary, secondary and definitive success rates were 85.4% (135/158), 4.4% (7/158) and 89.9% (142/158) respectively and treatment failure rate was 10% (16/158). No significant complications were noticed except for injection site ulceration in 32. Twenty patients died on follow up (9 died of uncontrolled bleeding, 11 died of liver failure).

CONCLUSION

Endoscopic glue injection into bleeding GVs was effective in achieving hemostasis in 82% with a definitive success rate of 90% and had a good safety profile on long-term follow up.

Prevention of post-coccygectomy infection in a series of 136 coccygectomies

Postoperative infection is a regular complication in coccygectomy. The authors propose the use of a topical skin adhesive on the postoperative wound as a contribution to the prevention of this complication. It was used on the first 56 patients in this study. The rate of infection was 3.6% compared with the 14% rate of infection in a previous study. The 80 following patients had, in addition to the skin adhesive, two prophylactic antibiotics for 48 hours (cefamandole and ornidazole), a preoperative rectal enema, and closure of the incision in two layers. The rate of infection dropped to 0.0%. Topical skin adhesive constitutes a significant contribution in the prevention of infection after coccygectomy.

A single-surgeon randomized trial comparing sutures, N-butyl-2-cyanoacrylate and human fibrin glue for mesh fixation during primary inguinal hernia repair

BACKGROUND

We sought to determine the efficacy of sutures, human fibrin glue and N-butyl-2-cyanoacrylate for mesh fixation in patients undergoing the plug and mesh procedure for groin hernia.

METHODS

A total of 156 patients with 167 inguinal hernias (11 bilateral) underwent a plug and mesh procedure and were randomly assigned to received either sutures (n = 59 hernias), human fibrin glue (n = 52) or N-butyl-2-cyanoacrylate (n = 56) for mesh fixation.

RESULTS

The overall morbidity rate was 38.98% in the suture group, 9.62% in the fibrin glue group and 10.71% in the N-butyl-2-cyanoacrylate group (suture v. fibrin glue, p < 0.001; suture v. N-butyl-2-cyanoacrylate, p < 0.001). There was no significant difference in morbidity between the fibrin glue and N-butyl-2-cyanoacrylate groups. Overall, short-term morbidity was significantly higher in the suture group (27.12%) than in the fibrin glue (9.62%, p = 0.01) or N-butyl-2-cyanoacrylate (8.93%, p = 0.004) groups, but there was no significant difference between the fibrin glue and N-butyl-2-cyanoacrylate groups. There was no significant difference between the groups in terms of mean postoperative stay (32.6 h in the suture group v. 30.8 h in the fibrin glue group v. 32.0 h in the N-butyl-2-cyanoacrylate group) or mean time to return to work (20.4 d in the suture group v. 20.3 d in the fibrin glue group v. 19.8 d in the N-butyl-2-cyanoacrylate group). Overall, long-term morbidity was significantly higher in the suture group (11.86%) than in the fibrin glue (0%, p = 0.001) or N-butyl-2-cyanoacrylate (1.78%, p = 0.03) groups. There was no recurrence in any of the groups. Two cases (3.39%) of chronic groin pain were reported in patients in the suture group. A sensation of extraneous body was reported in 5 (8.47%) patients who received sutures and in 1 (1.78%) patient in the N-butyl-2-cyanoacrylate group; there were no reported cases in the fibrin glue group (suture v. fibrin glue, p = 0.01; suture v. N-butyl-2-cyanoacrylate, p = 0.03; fibrin glue v. N-butyl-2-cyanoacrylate, p = 0.30).

CONCLUSION

The use of human fibrin glue or N-butyl-2-cyanoacrylate is better tolerated than sutures in tension-free inguinal open repair using the plug and mesh technique in terms of overall immediate results, and there is a better trend in the long-term data.

[Use of platelet poor plasma for elimination of Schneider's membrane defects arising during sinus lifting]

Topografical anatomical features of maxillary sinus structure create complexities for carrying out the sinus lifting operation. With Schneider's membrane defect from 3 to 6 mm the technique of its elimination with use of platelet poor plasma is offered. Defects in mucous membrane from 3 to 6 mm arise during operation in 7,9% of cases. In such cases bone window is expanding, mucous membrane is mobilizing and the defect is covered with platelet poor plasma received from patient's blood.

Injectable candidate sealants for fetal membrane repair: bonding and toxicity in vitro

OBJECTIVE

This study was undertaken to test injectable surgical sealants that are biocompatible with fetal membranes and that are to be used eventually for the closure of iatrogenic membrane defects.

STUDY DESIGN

Dermabond (Ethicon Inc, Norderstedt, Germany), Histoacryl (B. Braun GmbH, Tuttlingen, Germany), and Tissucol (Baxter AG, Volketwil, Switzerland) fibrin glue, and 3 types of in situ forming poly(ethylene glycol)-based polymer hydrogels were tested for acute toxicity on direct contact with fetal membranes for 24 hours. For the determination of elution toxicity, extracts of sealants were incubated on amnion cell cultures for 72 hours. Bonding and toxicity was assessed through morphologic and/or biochemical analysis.

RESULTS

Extracts of all adhesives were nontoxic for cultured cells. However, only Tissucol and 1 type of poly(ethylene glycol)-based hydrogel, which is a mussel-mimetic tissue adhesive, showed efficient, nondisruptive, nontoxic bonding to fetal membranes. Mussel-mimetic tissue adhesive that was applied over membrane defects that were created with a 3.5-mm trocar accomplished leak-proof closure that withstood membrane stretch in an in vitro model.

CONCLUSION

A synthetic hydrogel-type tissue adhesive that merits further evaluation in vivo emerged as a potential sealing modality for iatrogenic membrane defects.

Microfabricated devices for enhanced bioadhesive drug delivery: attachment to and small-molecule release through a cell monolayer under flow

The development of a novel microfabricated device for oral drug delivery that overcomes many of the common barriers present in the gastrointestinal tract is reported. Specifically, the attachment of targeting ligands, subsequent device binding, and small molecule release from the microdevices in flow are investigated. A diffusion chamber that permits the simultaneous study of particle binding and small-molecule release under physiologically relevant shear conditions is developed. It is observed that once the particles bind to the cell surface, they remain attached. A small fraction of the devices detach in flow; however, most of these devices readily reattach to the cell layer in a new location. This steady-state density of microdevices is most likely the result of larger order microdevice clusters releasing their loose interactions with nearby microdevices, shifting slightly downstream, and subsequently reattaching to the cell monolayer. The release of a model small molecule from microdevices over time is roughly linear and approximately ten times greater than that observed with the small molecule alone. Overall, the preparation and characterization of an oral drug-delivery microdevice system capable of both targeting and asymmetric release in flow is reported.

Post-embryo transfer interventions for in vitro fertilization and intracytoplasmic sperm injection patients

BACKGROUND

Techniques for embryo transfer (ET) are being developed, optimized, and standardized to provide the best outcomes.This includes methods to reduce the risk of embryo loss following ET.

OBJECTIVES

To systematically locate, analyse, and review the best available evidence regarding the effectiveness of post-ET techniques for women undergoing in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

SEARCH STRATEGY

We searched electronic databases; reference lists of primary studies, review articles, and relevant publications; and conference abstracts. No language restrictions were applied.

SELECTION CRITERIA

Screening and selection of 2436 possible trial citations were performed independently by two review authors. Four prospective, truly randomised trials met the inclusion criteria. The trials compared two competing post ET interventions or an intervention versus no treatment in women undergoing IVF and ICSI.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected data and assessed risk of bias using a standardized data extraction form. Individual outcome data were extracted to support an intention-to-treat analysis.

MAIN RESULTS

The primary outcome, live birth rate, was not reported in any of the included trials. The ongoing pregnancy rate was only available for one trial that compared immediate ambulation with 30 minute bed rest, with no evidence of an effect with bed rest (OR 1.00; 95% CI 0.54 to 1.85).Secondary outcomes were sporadically reported with the exception of clinical pregnancy rate, which was reported in all of the included trials. There was no significant difference between less bed rest and more rest (OR 1.13; 95% CI 0.77 to 1.67). Nor was there any significant difference between the use of a fibrin sealant and control (OR 0.98; 95% CI 0.54 to 1.78). Even so, there was a significantly higher probability of pregnancy following mechanical closure of the cervix compared with no intervention (OR 1.92; 95% CI 1.40 to 2.63).The risk of bias of the included studies was variable. The reporting of a proper method of randomisation and allocation concealment was demonstrated in the majority of trials, while only one trial was reported to be blinded.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support a certain amount of time for women to remain recumbent following ET, or to support the use of fibrin sealants. Finally, there is limited evidence to support the use of mechanical closure of the cervical canal following ET. Further well-designed and powered studies are required to determine the true effect, if any, of these and other post ET techniques for women undergoing IVF and ICSI.

The effect of cyanoacrylate in esophagocutaneous leakages occurring after esophageal anastomosis

OBJECTIVE

Esophageal leakage (EL) continues to be a challenging pediatric surgical problem. The aim of this study was to investigate the effect of cyanoacrylate (Cy) in EL followed esophageal repair (ER).

METHODS

Twelve rabbits were divided into control (C) and leakage (L) groups. A 1cm-length transverse esophageal incision at the level of the cervical region was made. In both groups, feeding was started orally 24h after the surgery for leakage creation. On postoperative day 7, primary repair was carried out in the C group and Cy instillation was performed in the L group. Esophagographic analysis was carried out on postoperative day 9 and the animals were fed orally on the same day on the condition that there was no esophageal leakage. The rabbits were sacrificed to measure diameters of the OR line, bursting pressure (BP), and hydroxyproline (HP) levels in the repaired cervical esophageal segment (RCES) 2 months later.

RESULTS

The values of BP and HP in the C group were significantly higher than those in the L group. The diameters of the OR line in the L group were significantly greater compared to those in the C group.

CONCLUSIONS

Cy glue instillation seems to be the ideal treatment for esophageal anastomosis leakages as shown by increased diameters of the OR line and decreased HP levels.

"How I do it: utilization of high-pressure sealants in aortic reconstruction"

BACKGROUND

Suture-line hemostasis, reinforcement of friable tissue, and adhesion prevention are key concerns for patients undergoing cardiac surgery for aortic reconstruction. Failure to secure hemostasis at anastomotic junctures and reinforce fragile tissue may lead to increased blood loss, additional blood product requirements, increased operative time, and, in extreme cases, reoperation. Patients with aortic pathology may also be at higher risk for reoperation, and adhesion formation from prior surgery is an added risk at resternotomy. The advent of high-pressure sealants has been of benefit in helping to alleviate these perioperative challenges.

METHODS

The author utilizes two high-pressure sealants for aortic reconstructive procedures. The first is made of two polymers of polyethylene glycol (PEG) [Coseal, Baxter Healthcare, Corporation], and is used to secure anastomotic suture-line hemostasis and for adhesion prevention. The second is a bovine serum albumin-glutaraldehyde (BSAG) glue [BioGlue, CryroLife, Inc.], used for the repair of dissected aortic tissue and in reinforcing ("tanning") fragile aortic tissues. The techniques for application in select aortic reconstruction procedures are described.

RESULTS

To substantiate the hemostatic clinical benefit observed by the author, 60 consecutive major thoracic aortic operations in 57 patients in whom PEG sealant was used were retrospectively reviewed. Although comparisons with other agents were not performed for this descriptive report, bleeding results were very favorable for these types of operations. The strong clinical impression is that topical hemostatic application of PEG sealant to anastomotic suture lines is helpful in preventing bleeding.

CONCLUSION

In major aortic reconstructive procedures the need for anastomotic sealing performance, reinforcement of friable tissues, and adhesion prevention should not be underrated. High-pressure surgical sealants represent an important surgical adjunct, and the author has found the use of both PEG sealant and BSAG glue advantageous in aortic reconstruction and repair.

Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial

PURPOSE

The feasibility and safety of stem cell-based therapy with expanded adipose-derived stem cells (ASCs) has been investigated in a phase I clinical trial. The present study was designed as a phase II multicenter, randomized controlled trial to further investigate the effectiveness and safety of ASCs in the treatment of complex perianal fistulas.

METHODS

Patients with complex perianal fistulas (cryptoglandular origin, n = 35; associated with Crohn's disease, n = 14) were randomly assigned to intralesional treatment with fibrin glue or fibrin glue plus 20 million ASCs. Fistula healing and quality of life (SF-12 questionnaire) were evaluated at eight weeks and one year. If healing was not seen at eight weeks, a second dose of fibrin glue or fibrin glue plus 40 million ASCs was administered.

RESULTS

Fistula healing was observed in 17 (71 percent) of 24 patients who received ASCs in addition to fibrin glue compared with 4 (16 percent) of 25 patients who received fibrin glue alone (relative risk for healing, 4.43; confidence interval, 1.74-11.27); P < 0.001). The proportion of patients with healing was similar in Crohn's and non-Crohn's subgroups. ASCs were also more effective than fibrin glue alone in patients with a suprasphincteric fistulous tract (P = 0.001). Quality of life scores were higher in patients who received ASCs than in those who received fibrin glue alone. At one year follow-up, the recurrence rate in patients treated with ASCs was 17.6 percent. Both treatments were well tolerated.

CONCLUSION

Administration of expanded ASCs (20 to 60 million cells) in combination with fibrin glue is an effective and safe treatment for complex perianal fistula and appears to achieve higher rates of healing than fibrin glue alone.

Foreign body reaction after usage of tissue adhesives for skin closure: a case report and review of the literature

INTRODUCTION

The usage of tissue adhesives such as 2-octyl cyanoacrylate is a standard tool for closure of superficial wounds of the body. The benefits using 2-octyl cyanoacrylate are well known and appreciated by surgeons world wide. Especially in superficial or small wounds in children where no surgical procedure is wanted this technique is commonly used. However, so far the risks and possible complications after using 2-octyl cyanoacrylate are not sufficiently published and discussed.

CASE REPORT

We report a case of foreign body reaction after 3 weeks in a 39-year-old female patient after usage of 2-octyl cyanoacrylate treating a superficial wound of the right wrist.

CONCLUSION

The use of 2-octyl cyanoacrylate for the closure of superficial and small wounds or lacerations is a simple, quick and comfortable method. However, there is clinical evidence that in some cases the use of this type of tissue adhesive may lead to foreign body reaction. We suggest that each patient who is treated by this type of wound closure technique should be mandatory informed on the potential risk of a foreign body reaction.

Effect of sustained-release lidocaine on reduction of pain after subpectoral breast augmentation

BACKGROUND

Subpectoral breast augmentation is a popular procedure that increases the attractiveness of the female breast. However, this surgical procedure often causes postoperative breast pain.

OBJECTIVE

The author reports a new method of controlling postoperative breast pain following subpectoral augmentation.

METHODS

Thirty patients were randomly divided into 3 groups of 10 patients each. In all patients, silicone gel prostheses were placed in the subpectoral pocket. Patients in group A received 7.5 mL of 3.5% lidocaine dissolved in fibrin glue. Group B received 7.5 mL of lidocaine alone, and those in group C received 7.5 mL of fibrin glue alone. Breast pain was observed for 1 week postoperatively for all 3 groups. Patients completed questionnaires on each postoperative day in which pain assessment was scored according to a 0 to 3 scale: 0 equaled "no pain" and 3 equaled "worst pain."

RESULTS

Postoperative breast pain reported by patients in group A was significantly less than that reported by patients in groups B and C (P < .05).

CONCLUSIONS

Sustained-release lidocaine applied in the subpectoral pocket significantly reduced postoperative pain and discomfort without complications for patients who received cosmetic subpectoral breast augmentation. The relatively small size of the patient group limits the impact of these results; a much larger randomized, double-blind study is planned.

Formulation and Evaluation of Limonene-Based Membrane-Moderated Transdermal Therapeutic System of Nimodipine

The aim of the present study was to design a membrane-moderated transdermal therapeutic system (TTS) of nimodipine using 2% w/w hydroxypropyl methylcellulose (HPMC) gel as a reservoir system containing 4% w/w of limonene as a penetration enhancer. The permeability flux of nimodipine through ethylene vinyl acetate (EVA) copolymer membrane was found to increase with an increase in vinyl acetate content in the copolymer (9 to 28%). The effect of pressure-sensitive adhesives such as TACKITE A 4MED on the permeability of nimodipine through EVA membrane 2825 (28% w/w vinyl acetate) or membrane/rat skin composite also was studied. The permeability flux of nimodipine from the chosen EVA 2825 (with 28% vinyl acetate content) was 159.72 +/- 1.96 microg/cm2/hr, and this flux further decreased to 141.85 +/- 1.54 microg/cm2/hr on application of pressure-sensitive adhesive (TACKWHITE A 4MED). However, the transdermal permeability flux of nimodipine across EVA 2825 membrane coated with TACKWHITE A 4MED/rat skin composite was found to be 126.59 +/- 2.72 microg/cm2/hr, which is 1.3-fold greater than the required flux. Thus, a new transdermal therapeutic system for nimodipine was formulated using EVA 2825 membrane coated with a pressure-sensitive adhesive TACKWHITE 4A MED and 2% w/w HPMC gel as reservoir containing 4% w/w of limonene as a penetration enhancer. The bioavailability studies in healthy human volunteers indicated that the TTS of nimodipine, designed in the present study, provided steady-state plasma concentration of the drug with minimal fluctuations for 20 hr with improved bioavailability in comparison with the immediate release tablet dosage form.

Fibrin glue to reduce seroma after axillary lymphadenectomy for breast cancer

Axillary lymphadenectomy remains an integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among the methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial

RESULTS

Sixty patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray was applied to the axillary fossa in 30 patients; the other 30 patients were treated conventionally. Suction drainage was removed between postoperative days III and IV. Seroma magnitude and duration were significantly reduced (P=0.004 and 0.02, respectively), and there were fewer evacuative punctures, in patients receiving fibrin glue compared with the conventional treatment group. The authors conclude that the use of fibrin glue does not always prevent seroma formation, but does reduce seroma magnitude, duration and necessary evacuative punctures.