Use of BioGlue in Aortic Surgery: Proper Application Techniques and Results in 92 Patients

BACKGROUND

Surgery for pathology of the proximal aorta requires aortic wall reconstruction, re-approximation of the graft to native vessels, and potentially root replacement and valve resuspension or replacement. The purpose of this study is to describe proper application techniques and the results obtained with the adjunctive use of BioGlue Surgical Adhesive in this challenging patient population.

METHODS

Between August 1998 and June 2002, 92 consecutive patients underwent ascending/arch repairs, ascending/root repairs, Ross procedures, or ascending/arch repairs with a concomitant Ross procedure using BioGlue as an adjunct for anastomotic hemostasis.

RESULTS

Twenty-six patients (28.3%) in this series required no postoperative blood products. The mortality rate for this single-surgeon series was 3.3%. No device-related complications were observed. The incidence rate for postoperative pseudoaneurysm formation was 3.3%.

CONCLUSIONS

This series demonstrates the safety and effectiveness of BioGlue as a hemostatic adjunct in proximal aortic surgery. Use of the product helped to facilitate a minimal reliance on blood products and a low mortality rate.

Use of Surgicel for sealing nephrostomy tract after totally tubeless percutaneous nephrolithotomy

BACKGROUND AND PURPOSE

Fibrin glue and gelatin matrix have been used to seal nephrostomy tracts to reduce bleeding and extravasation after tubeless percutaneous nephrolithotomy (PCNL). In this study, Surgicel (oxidized cellulose) was used to seal the nephrostomy tract after totally tubeless PNL.

PATIENTS AND METHODS

Twenty patients with kidney calculi were treated with totally tubeless PNL. According to randomization, at the conclusion of surgery, the nephrostomy tracts were sealed with Surgicel in ten patients and left unsealed in the other ten. Postoperatively, the two groups were compared with respect to hematocrit changes and extravasation as detected by abdominal ultrasonography and wound-dressing inspection.

RESULTS

There was statistically significant decrease in the hematocrit in both the study (P = 0.017) and the control (P = 0.003) group. When the two groups were compared with respect to the decrease in hematocrit, no statistically significant difference was seen (P = 0.241). Similarly, extravasation from the nephrostomy tract was not significantly different in the two groups.

CONCLUSION

Sealing the nephrostomy tract with Surgicel after totally tubeless PNL did not decrease bleeding or extravasation from the tract.

Transarterial balloon-assisted n-butyl-2-cyanoacrylate embolization of direct carotid cavernous fistulas

BACKGROUND AND PURPOSE

Transarterial detachable balloon embolization of direct carotid cavernous fistulas (DCCFs) has become an optimal treatment. In a few cases, the parent artery has to be sacrificed to achieve morphologic cure. We present our experience with transarterial balloon-assisted n-butyl-2-cyanoacrylate (n-BCA) embolization of DCCFs in which there was failure to achieve angiographic cure and preservation of parent arteries.

METHODS

Of 141 patients with traumatic DCCFs who had been treated by transarterial embolization with occlusion of the fistula and parent artery preservation, 18 received transarterial balloon-assisted n-BCA embolization-6 for residual fistula after the balloons detached, 7 for recurrent fistula because of premature balloon deflation or migration, and 5 for repeated puncture of the detachable balloon by the bony fragment at the cavernous sinus. A total of 27 procedures were performed with an average 1.5 attempts per patient, and the volume of the n-BCA mixture varied from 0.5 to 2.3 mL with a mean of 0.83 mL.

RESULTS

All DCCFs were successfully occluded by the n-BCA mixture with preservation of parent arteries. One patient with a giant cavernous sinus varix had a fatal subarachnoid hemorrhage. One had a recurrence and was treated by internal carotid artery (ICA) occlusion. Five had asymptomatic pseudoaneurysms at the parent artery. There was no adhesion of the n-BCA mixture to the protective balloon or the microcatheter or n-BCA reflux into the parent arteries.

CONCLUSION

Transarterial balloon-assisted n-BCA embolization is a feasible, efficient, and safe treatment for DCCFs when angiographic cure and ICA preservation are not achieved by transarterial detachable balloon embolization.

Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli

Bleeding gastric varices are increasingly being obliterated with the aid of endoscopic injection of n-butyl-cyanoacrylate (histoacryl) diluted with lipiodol. This glue acts as a tissue adhesive that polymerizes on contact with blood in a gastric varix. Severe glue pulmonary embolism is a rare complication of injection therapy. This case involves a 52-year-old man with fundal gastric varices, who developed multiple pulmonary emboli following glue injection with profound hypoxia requiring hospital admission for 13 days, but with eventual recovery of normal lung function.

A mucoadhesive in situ gel delivery system for paclitaxel

MUC1 gene encodes a transmembrane mucin glycoprotein that is overexpressed in human breast cancer and colon cancer. The objective of this study was to develop an in situ gel delivery system containing paclitaxel (PTX) and mucoadhesives for sustained and targeted delivery of anticancer drugs. The delivery system consisted of chitosan and glyceryl monooleate (GMO) in 0.33M citric acid containing PTX. The in vitro release of PTX from the gel was performed in presence and absence of Tween 80 at drug loads of 0.18%, 0.30%, and 0.54% (wt/wt), in Sorensen's phosphate buffer (pH 7.4) at 37 degrees C. Different mucin-producing cell lines (Calu-3>Caco-2) were selected for PTX transport studies. Transport of PTX from solution and gel delivery system was performed in side by side diffusion chambers from apical to basal (A-B) and basal to apical (B-A) directions. In vitro release studies revealed that within 4 hours, only 7.61% +/- 0.19%, 12.0% +/- 0.98%, 31.7% +/- 0.40% of PTX were released from 0.18%, 0.30%, and 0.54% drug-loaded gel formulation, respectively, in absence of Tween 80. However, in presence of surfactant (0.05% wt/vol) in the dissolution medium, percentages of PTX released were 28.1% +/- 4.35%, 44.2% +/- 6.35%, and 97.1% +/- 1.22%, respectively. Paclitaxel has shown a polarized transport in all the cell monolayers with B-A transport 2 to 4 times higher than in the A-B direction. The highest mucin-producing cell line (Calu-3) has shown the lowest percentage of PTX transport from gels as compared with Caco-2 cells. Transport of PTX from mucoadhesive gels was shown to be influenced by the mucin-producing capability of cell.

Fibrin sealant for retrograde ureteroscopic closure of urine leak after partial nephrectomy

We present a case of a prolonged urine leak after partial nephrectomy successfully treated by retrograde ureteroscopic injection of fibrin sealant. The technical aspects of retrograde instillation of sealant into the lower renal pole and outcome are discussed.

Mucoadhesive, thermosensitive, prolonged-release vaginal gel for clotrimazole:beta-cyclodextrin complex

The purpose of this study was to achieve a better therapeutic efficacy and patient compliance in the treatment for vaginitis. Clotrimazole (1%) has been formulated in a vaginal gel using the thermosensitive polymer Pluronic F127 (20%) together with mucoadhesive polymers such as Carbopol 934 and hydroxypropylmethylcellulose (0.2% for both). To increase its aqueous solubility, clotrimazole was incorporated as its inclusion complex with 1:1 molar ratio with beta-cyclodextrin. The inclusion complex was thoroughly characterized using various techniques, including 1H NMR spectroscopy, FT IR spectrophotometry, differential scanning calorimetry, scanning electron microscopy, phase solubility studies, and determination of stability constant (k(1:1)). The gelation temperature and rheological behavior of different formulations at varying temperatures were measured. In vitro release profiles of the gels were determined in pH 5.5 citrate buffer. It was observed that complexation with cyclodextrin slowed down the release of clotrimazole considerably. Carbopol 934, on the other hand, was found to interact with beta-cyclodextrin, inducing precipitation. As far as rheological properties are concerned, thermosensitive in situ gelling was obtained with formulations containing drug:cyclodextrin complex rather than with free drug. Thus, the optimum formulation for a controlled-release thermosensitive and mucoadhesive vaginal gel was determined to be clotrimazole:beta-cyclodextrin 1% with 0.2% hydroxypropylmethylcellulose in Pluronic F127 gel (20%) providing continuous and prolonged release of active material above MIC values.

A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation

Progression of gastric variceal hemorrhage (GVH) is poorer than esophageal variceal bleeding. However, data on its optimal treatment are limited. We designed a prospective study to compare the efficacy of endoscopic band ligation (GVL) and endoscopic N-butyl-2-cyanoacrylate injection (GVO). Liver patients with cirrhosis with or without concomitant hepatocellular carcinoma (HCC) and patients presenting with acute GVH were randomized into two treatment groups. Forty-eight patients received GVL, and another 49 patients received GVO. Both treatments were equally successful in controlling active bleeding (14/15 vs. 14/15, P = 1.000). More of the patients who underwent GVL had GV rebleeding (GVL vs. GVO, 21/48 vs. 11/49; P = .044). The 2-year and 3-year cumulative rate of GV rebleeding were 63.1% and 72.3% for GVL, and 26.8% for both periods with GVO; P = .0143, log-rank test. The rebleeding risk of GVL was sustained throughout the entire follow-up period. Multivariate Cox regression indicated that concomitance with HCC (relative hazard: 2.453, 95% CI: 1.036-5.806, P = .041) and the treatment method (GVL vs. GVO, relative hazard: 2.660, 95% CI: 1.167-6.061, P = .020) were independent factors predictive of GV rebleeding. There was no difference in survival between the two groups. Severe complications attributable to these two treatments were rare. In conclusion, the efficacy of GVL to control active GVH appears not different to GVO, but GVO is associated with a lower GV rebleeding rate.

Effects of fibrin sealant on single-layer uterine incision closure in the New Zealand white rabbit

OBJECTIVE

To determine if the addition of fibrin sealant to incision closure in a rabbit uterine horn myomectomy model affects adhesion formation or strength of incision closure.

DESIGN

Prospective randomized controlled trial.

SETTING

Academic research center.

ANIMAL(S)

New Zealand white female rabbits.

INTERVENTION(S)

A pilot study revealed that the time interval for maximal uterine incision healing was eight weeks. Thirty New Zealand white rabbits underwent a 1-cm standardized myotomy incision on both uterine horns. A single interrupted stitch of 3-0 polygalactin suture was placed to reapproximate each incision. Fibrin sealant was then applied to one of each rabbit's horns (randomized). After eight weeks, the rabbits were killed, and the strength of myotomy closure was determined by measurement of maximal burst pressure for each uterine horn. Adhesion presence was recorded.

MAIN OUTCOME MEASURE(S)

Uterine burst pressure, adhesion presence.

RESULT(S)

The mean burst pressure was 267.8 (+/-75.8) mm Hg in the suture only group and 247.8 (+/-92.3) mm Hg in the suture and fibrin sealant group. There was no statistical difference in the presence of adhesions.

CONCLUSION(S)

Fibrin sealant did not strengthen myotomy repair nor did it reduce postoperative adhesion formation. There is no apparent advantage to fibrin sealant in this myomectomy model.

Bleeding gastric varices: results of endoscopic injection with cyanoacrylate at King Chulalongkorn Memorial Hospital

AIM

To evaluate the efficacy and safety of gastric varices injection with cyanoacrylate in patients with gastric variceal bleeding.

METHODS

Twenty-four patients (15 males, 9 females) with gastric variceal bleeding underwent endoscopic treatment with cyanoacrylate injection. Successful hemostasis, rebleeding rate, and complications were retrospectively reviewed. Followed up endoscopy was performed and repeat cyanoacrylate injection was given until gastric varices were obliterated.

RESULTS

Seventeen patients achieved definite hemostasis. Of these, 14 patients had primary success after initial endoscopic therapy. Ten patients developed recurrent bleeding. Repeated cyanoacrylate injection stopped rebleeding in three patients. Transjugular intrahepatic portosystemic shunt (TIPS) was performed to control rebleeding in one patient which occurred after repeat endoscopic therapy. Six patients died (three from uncontrolled bleeding, two from sepsis, and one from mesenteric vein thrombosis). Minor complications occurred in 11 patients (six epigastric discomfort and five post injection ulcers). Cyanoacrylate embolism developed in two patients. One of these patients died from mesenteric vein thrombosis. The other had pulmonary embolism which resolved spontaneously. Advanced cirrhosis and hepatocellular carcinoma (HCC) were major risk factors for uncontrolled bleeding.

CONCLUSION

Endoscopic treatment for bleeding gastric varices with cyanoacrylate injection is effective for immediate hemostasis. Repeat cyanoacrylate injection has a lower success rate than the initial injection. Cyanoacrylate embolism is not a common serious complication.

Characterization and in vivo evaluation of ocular minitablets prepared with different bioadhesive Carbopol–starch components

The purpose of this study was to evaluate different bioadhesive ocular formulations based on drum dried waxy maize starch (DDWM), Amioca starch and Carbopol 974P. The concentrations of Carbopol 974P in the mixtures varied between 5 and 25% (w/w). The rheological properties of the non-sterilized and gamma-irradiated physical blends of Carbopol 974P with either DDWM or Amioca were compared to those of the corresponding co-spray dried Amioca starch/Carbopol powders. Higher viscosity or consistency values were measured for sterilized co-spray dried powder mixtures containing an amount of Carbopol 974P equal or above 15% (w/w) compared to the physical blends. Sustained release minitablets (2 mm, 6 mg), consisting of sodium fluorescein as model drug and the bioadhesive powders, were manufactured at a compression force of 1.25 kN. Afterwards, the tablets were sterilized with gamma-irradiation. The amount of Carbopol in the co-spray dried powder mixtures on the one hand and gamma-irradiation on the other hand had no significant influence on the crushing strength and friability of the minitablets evaluated. However, these two factors affected the in vitro release properties of the minitablets. The slowest release was obtained with tablets containing 25% Carbopol 974P, which unfortunately possess mucosal irritating properties. By using co-spray dried Amioca with 15% (w/w) Carbopol 974P, a slower release can be achieved compared to the physical mixtures of DDWM or Amioca starch with Carbopol 974P. Moreover, this ocular formulation is very promising and is preferred, as it did not cause any mucosal irritation and released the model drug for at least 12 h, after application in the fornix.

[Treatment of dural arteriovenous fistula by transarterial embolization with low dose of N-butyl-2-cyanoacrylate]

OBJECTIVE

To evaluate the efficacy of treatment of dural arteriovenous fistula (DAVF) by transarterial embolization with low dose of N-butyl-2-cyanoacrylate (NBCA).

METHODS

Eighteen patients, 6 males and 12 females, aged 47.5 (23-72), with DAVF, 12 with carotid cavernous fistula and 6 with fistula in parietal lobe, underwent transarterial embolization with low dose of NBCA (10%-20%). The key point of transarterial embolization with low dose of NBCA was that low dose NBCA was injected and embolized the veins and then was reversed into the other supplying arteries.

RESULTS

Seventeen patients with DAVF in cavernous region and 6 patients with DAVF in parietal lobe were cured anatomically, with the clinical syndromes disappearing. In 1 patient with DAVF in cavernous region the clinical syndrome were moderately improved after transarterial embolization, however, worsened 2 days later. Cerebrovascular angiography demonstrated that the vein was not completely embolized and the draining vein was broadened, and the clinical syndromes were moderately improved again after carotid artery compression therapy for 10 days.

CONCLUSION

Convenient and fast, and with low cost and satisfying efficacy, transarterial embolization with low dose of NBCA is a better choice for treatment of DAVF in some cases. The key point of this approach is that the tip of microcatheter is close as much as possible to the fistulae, and NBCA is injected into the fistulae and make the vein diffused well. Attention should be paid to avoid dangerous anastomosis.

[The use of tissue glue and its effect on hospital cost in patients undergoing pulmonary surgery]

Prolonged air leak following pulmonary resections is an important cause of morbidity and increased hospital costs. We compared 19 homologous/autologous tissue glue (fibrin glue) applied patients (FG group), 12 beriplast-P applied patients (beriplast group) and 27 control patients with respect to prolonged air leak, chest tube removal time and hospital costs. The mean ages for FG group (19 patients), beriplast group (12 patients) and control group (27 patients) were 48.5 +/- 14, 50.5 +/- 6.8 and 55 +/- 12.9 respectively. The groups were comparable with respect to age (p= 0.210), sex (p= 0.287) and the surgical procedure performed (p= 0.289). The incidence of prolonged air leak in FG group, beriplast group and the control group was 48%, 50% and 63%, respectively (p= 0.533). The mean chest tube removal time in FG group, beriplast group and the control group was 10.7 +/- 8.7, 9 +/- 4.1 and 8 +/- 3.1 days, respectively (p= 0.282). Mean hospital costs in FG group, beriplast group and the control group were 4633 +/- 3272 YTL, 4611 +/- 1583 YTL and 4015 +/- 911 YTL, respectively (p= 0.547). Fibrin glue had no effect on the incidence of prolonged air leak, chest tube removal time and hospital costs.

Thoracoscopic Application of a Topical Sealant for the Management of Persistent Posttraumatic Pneumothorax

BACKGROUND

Persistent posttraumatic pneumothorax (PPP) is an uncommon complication of blunt or penetrating chest trauma. Currently, most patients are managed with pleural chest tube(s) and suction drainage. Prolonged hospital stay and added cost of care are not uncommon.

METHODS

Over a 2-year period, 13 patients with PPP, nonresponsive to conventional management, underwent video-assisted thoracoscopic surgery (VATS). As part of our protocol for PPP, routine preoperative computed tomography of the chest and bronchoscopy to determine the presence of associated injuries were performed in all of the patients. During the VATS procedure, all of the patients underwent drainage of any retained hemothorax, and a topical surgical sealant was applied to the source of the air leak as definitive treatment.

RESULTS

A persistent pneumothorax with an air leak was identified in all 13 of the patients. There were 10 patients with blunt and 3 patients with penetrating injuries, respectively. The mean age for the patients was 34 years (range, 13 to 64 years). Parenchymal lacerations were identified in all of the patients ranging in size from 0.5 to 3 cm. After the VATS procedure and application of the surgical sealant, 11 patients had the chest tubes removed within 24 hours of the procedure. In the other two patients, the chest tubes were removed within 48 hours. There was no recurrence of the pneumothorax in any of these patients. The mean length of hospital stay before VATS and the application of the surgical sealant was 6 days (range, 2-14 days).

CONCLUSION

Early VATS and the use of a topical sealant in patients with PPP is a safe and effective alternative to the conventional management with prolonged thoracostomy chest tubes or an open thoracostomy. This alternative management, when used early in the appropriate patient, will decrease the length of hospital stay, cost of care, and unnecessary procedures.

[The use of cyanoacrylate tissue adhesive in the pterygium excisions with amniotic membrane transplantation]

PURPOSE

To find the proper way to use the cyanoacrylate tissue adhesive (CTA) in the pterygium excisions with amniotic membrane transplantation and To evaluate the therapeutic effects of it.

METHOD

A prospective randomized clinical trial was carried out in 27 patients (32 eyes) who would have pterygium excision. They were divided into 2 groups randomly: 15 eyes in the CTA group, 17 eyes in the suture group. We evaluate the benefits of them with the respect to surgery time and postoperative sighs and symptoms.

RESULTS

Average surgery time was 15.8 minutes for CTA group and 23.7 minutes for sutures, P < 0.05. The postoperative sighs were much more light in CTA group. The average pain was significantly lower when CTA had been used, P < 0.05. And the amniotic membrane was attached much better. The two groups have no significant difference in the other aspects.

CONCLUSION

Using CTA instead of sutures when attaching the amniotic membrane in pterygium surgery shortens surgery time significantly and improve the postoperative sighs and symptoms. It's easy, safe and effective.

Effect of a Fibrin-Fibronectin Sealing System as a Carrier for Recombinant Human Bone Morphogenetic Protein-4 on Bone Formation in Rat Calvarial Defects

BACKGROUND

Bone morphogenetic proteins (BMPs) have been shown to play an important role in bone formation during development and wound healing. Despite there being good prospects for BMP applications, an ideal carrier system for BMPs has yet to be determined. The purpose of this study was to evaluate the possibility of a fibrin-fibronectin sealing system (FFSS) as a carrier for recombinant human BMP-4 (rhBMP-4) and to evaluate the genuine osteoconductive potential of the FFSS in a rat calvarial defect model.

METHODS

An 8-mm, calvarial, critical-size osteotomy defect was created in each of 30 male Sprague-Dawley rats. Three groups of 10 animals each received rhBMP-4 (0.025 mg/ml) in the FFSS, FFSS control, or sham-surgery control. The groups were evaluated using histologic and histometric parameters following 2- and 8-week healing intervals (five animals per group per healing interval).

RESULTS

Surgical implantation of rhBMP-4/FFSS resulted in enhanced local bone formation at 2 and 8 weeks. New bone formation was also evident in the FFSS control; however, the amount of defect closure, new bone area, and bone density was significantly greater in the rhBMP-4/FFSS group (P < 0.05). At 8 weeks, the quantity of the new bone was greater than that observed at 2 weeks, and the specimens showed a more advanced stage of remodeling and consolidation in both groups (P < 0.05). Only very limited bone formation was observed in the sham-surgery control.

CONCLUSION

The results of the present study indicated that the FFSS has osteoconductive potential and may be employed as a carrier for BMPs.

Prospective, multicenter evaluation of highly concentrated fibrin glue in the treatment of complex cryptogenic perianal fistulas

PURPOSE

The surgical management of complex perianal fistulas is challenging and may be associated with the risk of sphincter injury. Instillation of fibrin glue to the fistula tract is a simple procedure that does not involve any muscle division, and potentially results in healing of the fistula. This study was designed to assess the use of highly concentrated fibrin glue with intra-adhesive antibiotics in the treatment of complex cryptogenic perianal fistulas.

METHODS

Patients with complex perianal fistulas of cryptogenic origin were prospectively included in this multicenter study. Injection of the fibrin glue mixed with antibiotics was performed in a uniform fashion. After the procedure, patients were actively examined at fixed time intervals; in cases of recurrent fistula, reinjection of fibrin glue was offered.

RESULTS

Sixty patients were enrolled; complete healing of the fistula was achieved in 32 patients (53 percent). Eight of 28 patients (29 percent) who were not completely healed had significant symptomatic improvement. All patients resumed normal daily activity the day after surgery and none had any deterioration in continence related to the procedure. The majority of the 26 (43 percent) adverse events were considered mild and spontaneously resolved; 2 patients (3 percent) with perianal septic complications were successfully treated by drainage.

CONCLUSIONS

Injection of fibrin glue for the treatment of perianal fistulas is safe, simple, and associated with early return to normal activity. Although moderately successful, it may preclude extensive surgery in more than one-half of these patients.

Bioadhesive tablets for controlled transdermal delivery of drugs

Transdermal bioadhesive tablets were formulated by the direct compression method and evaluated. Carboxyfluorescein (CF) was used as a model permeant. The compression parameters were kept consistent and the composition of the formulation was varied to alter the release rate of the drug from the formulations. The dosage form was evaluated for physicochemical, adherence, and in vitro diffusion parameters. The transdermal flux of the drug decreased with the increasing ratio of Ethyl cellulose (EC)/hydroxypropyl cellulose (HPC). The test formulations were subjected to pharmacokinetic studies in mice. The formulations were able to maintain a steady state plasma concentration up to 12 hours. They were found to be safe for transdermal use as interpreted from skin irritation studies carried out on rabbits.