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Hermans BP, Ten Broek RPG, Li WWL, Roozen EA, Vos S, Van Der Heijden EHFM, Van Goor H, Verhagen AFTM. Proof-of-principle of a lung sealant based on functionalized polyoxazolines: experiments in an ovine acute aerostasis model. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae113. [PMID: 38833687 DOI: 10.1093/icvts/ivae113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 06/01/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVES More effective lung sealants are needed to prevent prolonged pulmonary air leakage (AL). Polyoxazoline-impregnated gelatin patch (N-hydroxysuccinimide ester functionalized poly(2-oxazoline)s; NHS-POx) was promising for lung sealing ex vivo. The aim of this study is to confirm sealing effectiveness in an in vivo model of lung injury. METHODS An acute aerostasis model was used in healthy adult female sheep, involving bilateral thoracotomy, amputation lesions (bronchioles Ø > 1.5 mm), sealant application, digital chest tube for monitoring AL, spontaneous ventilation, obduction and bursting pressure measurement. Two experiments were performed: (i) 3 sheep with 2 lesions per lung (N = 4 NHS-POx double-layer, N = 4 NHS-POx single-layer, N = 4 untreated) and (ii) 3 with 1 lesion per lung (N = 3 NHS-POx single-layer, N = 3 untreated). In pooled linear regression, AL was analysed per lung (N = 7 NHS-POx, N = 5 untreated) and bursting pressure per lesion (N = 11 NHS-POx, N = 7 untreated). RESULTS Baseline AL was similar between groups (mean 1.38-1.47 l/min, P = 0.90). NHS-POx achieved sealing in 1 attempt in 8/11 (72.7%) and in 10/11 (90.9%) in >1 attempt. Application failures were only observed on triangular lesions requiring 3 folds around the lung. No influences of methodological variation between experiments was detected in linear regression (P > 0.9). AL over initial 3 h of drainage was significantly reduced for NHS-POx [median: 7 ml/min, length of interquartile range: 333 ml/min] versus untreated lesions (367 ml/min, length of interquartile range: 680 ml/min, P = 0.036). Bursting pressure was higher for NHS-POx (mean: 33, SD: 16 cmH2O) versus untreated lesions (mean: 19, SD: 15 cmH2O, P = 0.081). CONCLUSIONS NHS-POx was effective for reducing early AL, and a trend was seen for improvement of bursting strength of the covered defect. Results were affected by application characteristics and lesion geometry.
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Affiliation(s)
- Bob P Hermans
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Richard P G Ten Broek
- Department of General Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Wilson W L Li
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Edwin A Roozen
- Department of General Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Shoko Vos
- Department of Pathology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Erik H F M Van Der Heijden
- Department of Pulmonology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Harry Van Goor
- Department of General Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Ad F T M Verhagen
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
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de Wilt JHW, Verhoef C, de Boer MT, Stommel MWJ, van der Plas-Kemper L, Garms LM, van der Zijden CJ, Head SJ, Bender JCME, van Goor H, Porte RJ. Clinical Safety and Performance of GATT-Patch for Hemostasis in Minimal to Moderate Bleeding During Open Liver Surgery. J Surg Res 2024; 298:316-324. [PMID: 38640617 DOI: 10.1016/j.jss.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 01/30/2024] [Accepted: 03/21/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Intraoperative blood loss and postoperative hemorrhage affect outcomes after liver resection. GATT-Patch is a new flexible, pliable hemostatic sealant patch comprising fibrous gelatin carrier impregnated with N-hydroxy-succinimide polyoxazoline. We evaluated safety and performance of the GATT-Patch for hemostasis at the liver resection plane. METHODS Adult patients undergoing elective open liver surgery were recruited in three centers. GATT-Patch was used for minimal to moderate bleeding at the liver resection plane. The primary endpoint was hemostasis of the first-treated bleeding site at 3 min versus a prespecified performance goal of 65.4%. RESULTS Two trial stages were performed: I (n = 8) for initial safety and II (n = 39) as the primary outcome cohort. GATT-Patch was applied in 47 patients on 63 bleeding sites. Median age was 60.0 (range 25-80) years and 70% were male. Most (66%) surgeries were for colorectal cancer metastases. The primary endpoint was met in 38 out of 39 patients (97.4%; 95% confidence interval: 84.6%-99.9%) versus 65.4% (P < 0.001). Of all the 63 bleeding sites, hemostasis was 82.7% at 30, 93.7% at 60, and 96.8% at 180 s. No reoperations for rebleeding or device-related issues occurred. CONCLUSIONS When compared to a performance goal derived from state-of-the-art hemostatic agents, GATT-Patch for the treatment of minimal to moderate bleeding during liver surgery successfully and quickly achieved hemostasis with acceptable safety outcomes. (ClinicalTrials.gov Identifier: NCT04819945).
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Affiliation(s)
- Johannes H W de Wilt
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marieke T de Boer
- Department of HPB Surgery, University Medical Center Groningen, The Netherlands
| | - Martijn W J Stommel
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Linda M Garms
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Charlène J van der Zijden
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Harry van Goor
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert J Porte
- Department of HPB Surgery, University Medical Center Groningen, The Netherlands
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D'Hondt M, Roozen EA, Nuytens F, Bender J, Mottrie A, Bauwens K, Head SJ. NHS-POx-loaded patch versus fibrin sealant patch in a porcine robotic liver bleeding model. BMC Surg 2023; 23:257. [PMID: 37641071 PMCID: PMC10463878 DOI: 10.1186/s12893-023-02159-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The management of bleeding is paramount to any surgical procedure. With the increased use of less invasive laparoscopic and robotic methods, achieving hemostasis can be challenging since the surgeons cannot manually apply hemostatic agents directly onto bleeding tissue. In this study, we assessed the use of a pliable hemostatic sealant patch comprising fibrous gelatin carrier impregnated with poly(2-oxazoline) (NHS-POx) for hemostasis in robotic liver resection in a porcine bleeding model. METHODS The NHS-POx-loaded patch (GATT-Patch), was first evaluated in a Feasibility Study to treat surgical bleeding in 10 lesions, followed by a Comparative Study in which the NHS-POx patch was compared to a standard-of-care fibrin sealant patch (TachoSil), in 36 lesions (superficial, resection, or deep injuries mimicking metastasectomies). For each lesion type, the NHS-POx and fibrin sealant patches were used in an alternating fashion with 18 lesions treated with NHS-POx and 18 with the fibrin patch. Animal preparation and surgical procedures were consistent across studies. The primary outcome was time to hemostasis (TTH) within 3 min for the Feasibility Study and within 5 min for the Comparative Study. RESULTS In the Feasibility Study, 8 of the 10 NHS-POx-treated lesions achieved hemostasis at 30 s and 3 min. In the Comparative Study, all 18 NHS-POx patch-treated lesions and 9 of the 18 fibrin sealant patch-treated lesions achieved hemostasis at 5 min. Median TTH with NHS-POx vs fibrin sealant patch was 30 vs 300 s (P < 0.001). CONCLUSIONS In this animal study, hemostasis during robotic liver surgery was achieved faster and more often with the NHS-POx loaded vs fibrin sealant patch.
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Affiliation(s)
- Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium.
| | | | - Frederiek Nuytens
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
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Hermans BP, Li WWL, Roozen EA, van Dort DIM, Evers J, van der Heijden EHFM, van der Heide SM, van Goor H, Verhagen AFTM. Sealing effectiveness of a novel NHS-POx based patch: experiments in a dynamic ex vivo porcine lung. J Thorac Dis 2023; 15:3580-3592. [PMID: 37559645 PMCID: PMC10407471 DOI: 10.21037/jtd-22-1821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/12/2023] [Indexed: 08/11/2023]
Abstract
Background Sealants are used to prevent prolonged pulmonary air leakage (PAL) after lung resections (incidence 5.6-30%). However, clinical evidence to support sealant use is insufficient, with an unmet need for a more effective product. We compared a novel gelatin patch impregnated with functionalized polyoxazolines (NHS-POx) (GATT-Patch) to commercially available sealant products. Methods GATT-Patch Single/Double layers were compared to Progel®, Coseal®, Hemopatch® and TachoSil® in an ex vivo porcine lung model (first experiment). Based on these results, a second head-to-head comparison between GATT-Patch Single and Hemopatch® was performed. Air leakage (AL) was assessed in three settings using increasing ventilatory pressures (max =70 cmH2O): (I) baseline, (II) with 25 mm × 25 mm superficial pleural defect, and (III) after sealant application. Lungs floating on saline (37 ℃) were video recorded for visual AL assessment. Pressure and tidal volumes were collected from the ventilator, and bursting pressure (BP), AL and AL-reduction were determined. Results Per sealant 10 measurements were performed (both experiments). In the first experiment, BP was superior for GATT-Patch Double (60±24 cmH2O) compared to TachoSil® (30±11 cmH2O, P<0.001), Hemopatch® (33±6 cmH2O, P=0.006), Coseal® (25±13 cmH2O, P=0.001) and Progel® (33±11 cmH2O, P=0.005). AL-reduction was superior for GATT-Patch Double (100%±1%) compared to Hemopatch® (46%±50%, P=0.010) and TachoSil® (31%±29%, P<0.001), and also for GATT-Patch Single (100%±14%, P=0.004) and Progel (89%±40%, P=0.027) compared to TachoSil®. In the second experiment, GATT-Patch Single was superior regarding BP (45±10 vs. 40±6 cmH2O, P=0.043) and AL-reduction (100%±11% vs. 68%±40%, P=0.043) when compared to Hemopatch®. Conclusions The novel NHS-POx patch shows promise as a lung sealant, demonstrating elevated BP, good adhesive strength and a superior AL-reduction.
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Affiliation(s)
- Bob P. Hermans
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Wilson W. L. Li
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Edwin A. Roozen
- Department of General Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Daniël I. M. van Dort
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jort Evers
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Erik H. F. M. van der Heijden
- Department of Pulmonology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Stefan M. van der Heide
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of General Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Ad F. T. M. Verhagen
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Roozen EA, Lomme RMLM, Calon NUB, Ten Broek RPG, van Goor H. Efficacy of a novel polyoxazoline-based hemostatic patch in liver and spleen surgery. World J Emerg Surg 2023; 18:19. [PMID: 36918896 PMCID: PMC10012589 DOI: 10.1186/s13017-023-00483-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/19/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND A new hemostatic sealant based on a N-hydroxy-succinimide polyoxazoline (NHS-POx) polymer was evaluated to determine hemostatic efficacy and long-term wound healing and adverse effects in a large animal model of parenchymal organ surgical bleeds. METHODS Experiment 1 included 20 pigs that were treated with two NHS-POx patch prototypes [a gelatin fibrous carrier (GFC) with NHS-POx and an oxidized regenerated cellulose (ORC) with poly(lactic-co-glycolic acid)-NHS-POx:NU-POx (nucleophilically activated polyoxazoline)], a blank gelatin patch (GFC Blank), TachoSil® and Veriset™ to stop moderate liver and spleen punch bleedings. After various survival periods (1-6 weeks), pigs were re-operated to evaluate patch degradation and parenchymal healing. During the re-operation, experiment 2 was performed: partial liver and spleen resections with severe bleeding, and hemostatic efficacy was evaluated under normal and heparinized conditions of the two previous prototypes and one additional NHS-POx patch. In the third experiment an improved NHS-POx patch (GATT-Patch; GFC-NHS-POx and added 20% as nucleophilically activated polyoxazoline; NU-POx) was compared with TachoSil®, Veriset™ and GFC Blank on punch bleedings and partial liver and spleen resections for rapid (10s) hemostatic efficacy. RESULTS NHS-POx-based patches showed better (GFC-NHS-POx 83.1%, ORC-PLGA-NHS-POx: NU-POx 98.3%) hemostatic efficacy compared to TachoSil® (25.0%) and GFC Blank (43.3%), and comparable efficacy with Veriset™ (96.7%) on moderate standardized punch bleedings on liver and spleen. All patches demonstrated gradual degradation over 6 weeks with a reduced local inflammation rate and an improved wound healing. For severe bleedings under non-heparinized conditions, hemostasis was achieved in 100% for Veriset™, 40% for TachoSil and 80-100% for the three NHS-POx prototypes; similar differences between patches remained for heparinized conditions. In experiment 3, GATT-Patch, Veriset™, TachoSil and GFC Blank reached hemostasis after 10s in 100%, 42.8%, 7.1% and 14.3%, respectively, and at 3 min in 100%, 100%, 14.3% and 35.7%, respectively, on all liver and spleen punctures and resections. CONCLUSIONS NHS-POx-based patches, and particularly the GATT-Patch, are fast in achieving effective hemostatic sealing on standardized moderate and severe bleedings without apparent long-term adverse events.
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Affiliation(s)
- Edwin A Roozen
- Department of Surgery, RadboudUMC, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands.,GATT Technologies BV, Nijmegen, the Netherlands
| | - Roger M L M Lomme
- Department of Surgery, RadboudUMC, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands.
| | - Nicole U B Calon
- Department of Surgery, RadboudUMC, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands
| | - Richard P G Ten Broek
- Department of Surgery, RadboudUMC, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands
| | - Harry van Goor
- Department of Surgery, RadboudUMC, Geert Grooteplein 10, 6525 GA, Nijmegen, the Netherlands
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