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Coccolini F, Shander A, Ceresoli M, Moore E, Tian B, Parini D, Sartelli M, Sakakushev B, Doklestich K, Abu-Zidan F, Horer T, Shelat V, Hardcastle T, Bignami E, Kirkpatrick A, Weber D, Kryvoruchko I, Leppaniemi A, Tan E, Kessel B, Isik A, Cremonini C, Forfori F, Ghiadoni L, Chiarugi M, Ball C, Ottolino P, Hecker A, Mariani D, Melai E, Malbrain M, Agostini V, Podda M, Picetti E, Kluger Y, Rizoli S, Litvin A, Maier R, Beka SG, De Simone B, Bala M, Perez AM, Ordonez C, Bodnaruk Z, Cui Y, Calatayud AP, de Angelis N, Amico F, Pikoulis E, Damaskos D, Coimbra R, Chirica M, Biffl WL, Catena F. Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper. World J Emerg Surg 2024; 19:26. [PMID: 39010099 PMCID: PMC11251377 DOI: 10.1186/s13017-024-00554-7] [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: 04/24/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024] Open
Abstract
Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy.
| | - Aryeh Shander
- Anesthesiology and Critical Care, Rutgers University, Newark, NJ, USA
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Monza University Hospital, Monza, Italy
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | - Brian Tian
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
| | - Dario Parini
- General Surgery Department, Rovigo Hospital, Rovigo, Italy
| | | | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Medical University, Plovdiv, Bulgaria
| | - Krstina Doklestich
- Clinic of Emergency Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Fikri Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Tal Horer
- Vascular and Trauma Surgery, Orebro Hospital, Orebro, Sweden
| | - Vishal Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Timothy Hardcastle
- Department of Trauma and Burns, Inkosi Albert Luthuli Central Hospital and Department of Surgical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Elena Bignami
- Anesthesia Department, Parma University Hospital, Parma, Italy
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, AB, Canada
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Igor Kryvoruchko
- Department of Surgery No. 2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Ari Leppaniemi
- General Surgery Department, Melahiti Hospital, Helsinki, Finland
| | - Edward Tan
- Emergency Surgery Department, Radboud Medical Centre, Nijmegen, The Netherlands
| | - Boris Kessel
- Hillel Yaffe Medical Center, Rappaport Medical School, Haifa, Israel
| | - Arda Isik
- Division of General Surgery, School of Medicine, Istanbul Medeniyet University, Kadikoy, Istanbul, Turkey
| | - Camilla Cremonini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | | | - Lorenzo Ghiadoni
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | - Chad Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Pablo Ottolino
- Unidad de Trauma y Urgencias, Hospital Dr. Sótero del Río, Santiago de Chile, Chile
| | - Andreas Hecker
- Department of General, Thoracic and Transplant Surgery, University Hospital of Giessen, Giessen, Germany
| | - Diego Mariani
- General Surgery Department, Legnano Hospital, Legnano, Italy
| | - Ettore Melai
- ICU Department, Pisa University Hospital, Pisa, Italy
| | - Manu Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Vanessa Agostini
- Medicina Trasfusionale, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Yoram Kluger
- General, Emergency and Trauma Surgery Department, Rambam Medical Centre, Tel Aviv, Israel
| | | | - Andrey Litvin
- Department of Surgical Diseases No. 3, University Clinic, Gomel State Medical University, Gomel, Belarus
| | - Ron Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Belinda De Simone
- Department of Digestive and Emergency Surgery, Infermi Hospital, Rimini, Italy
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Aleix Martinez Perez
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Zenon Bodnaruk
- Hospital Information Services for Jehovah's Witnesses, Tuxedo Park, NY, USA
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | - Nicola de Angelis
- General Surgery Department, Ferrara University Hospital, Ferrara, Italy
| | - Francesco Amico
- Discipline of Surgery, The University of Newcastle, Newcastle, Australia
| | - Emmanouil Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Raul Coimbra
- General Surgery Department, Riverside University Health System Medical Center, Loma Linda, CA, USA
| | - Mircea Chirica
- General Surgery Department, Grenoble University Hospital, Grenoble, France
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
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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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Kang M, Cho JY, Han HS, Yoon YS, Lee HW, Lee B, Park Y, Kim J. A Prospective Analysis of the Effects of a Powder-Type Hemostatic Agent on the Short-Term Outcomes after Liver Resection. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:278. [PMID: 38399565 PMCID: PMC10889996 DOI: 10.3390/medicina60020278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/26/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Postoperative bleeding is a significant cause of morbidity and mortality following liver resection. Therefore, it is crucial to minimize bleeding during liver resection and effectively manage it when it occurs. Arista® AH (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) is a microporous polysaccharide hemosphere (MPH), a new plant-derived polysaccharide powder hemostat that can be applied to the entire surgical field. This study prospectively assessed the effectiveness of Arista for bleeding control when applied intraoperatively to the liver resection surface. Materials and Methods: Data were collected at Seoul National University Bundang Hospital for patients who underwent liver resection owing to malignant hepatocellular carcinoma or benign liver diseases. We compared the outcomes between 45 patients managed with Arista® AH (data were prospectively collected between September 2022 and May 2023) and 156 patients managed without the use of Arista® AH (data were retrospectively collected between January 2021 and December 2021). Results: There were no significant differences in patient characteristics between the two groups. The estimated blood loss (EBL) was significantly lower in the Arista® AH group compared with the control group (495.56 ± 672.7 mL vs. 691.9 ± 777.5 mL, p = 0.049). The mean postoperative hospital stay was significantly shorter in the Arista® AH group (5.93 ± 1.88 days vs. 6.94 ± 4.17 days, p = 0.024). The time to Jackson-Pratt drain removal was also significantly shorter in the Arista® AH group (4.64 ± 1.31 days vs. 5.30 ± 2.87 days, p = 0.030). The patient subgroup was divided into four categories based on the type of resection and the presence or absence of cirrhosis. Within the subgroup of major resections in non-cirrhotic patients, the Arista® AH group demonstrated significantly better outcomes compared to the control group, showed lower EBL, reduced need for blood transfusions, decreased volume of drain fluid collected within 48 h, earlier removal of drains, and shorter hospital stays. In contrast, for the other subgroups such as minor resection (both non-cirrhotic and cirrhotic) and major resection with cirrhosis, the differences between the Arista® AH and control groups in various parameters like EBL, blood transfusion rates, drain fluid volume, time to drain removal, and duration of hospital stay were not statistically significant. Conclusions: Arista® AH significantly improved intraoperative blood management and postoperative recovery in patients undergoing liver resection, particularly in non-cirrhotic patients who underwent major resection.
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Affiliation(s)
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul 13620, Republic of Korea
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Banerjee A, Hariharan D. History of liver surgery. Clin Liver Dis (Hoboken) 2024; 23:e0237. [PMID: 38919867 PMCID: PMC11199012 DOI: 10.1097/cld.0000000000000237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/29/2024] [Indexed: 06/27/2024] Open
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Malik AK, Amer AO, Tingle SJ, Thompson ER, White SA, Manas DM, Wilson C. Fibrin-based haemostatic agents for reducing blood loss in adult liver resection. Cochrane Database Syst Rev 2023; 8:CD010872. [PMID: 37551841 PMCID: PMC10411946 DOI: 10.1002/14651858.cd010872.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Liver resection is the optimal treatment for selected benign and malignant liver tumours, but it can be associated with significant blood loss. Numerous anaesthetic and surgical techniques have been developed to reduce blood loss and improve perioperative outcomes. One such technique is the application of topical fibrin-based haemostatic agents (FBHAs) to the resection surface. There is no standard practice for FBHA use, and a variety of commercial agents and devices are available, as well as non-FBHAs (e.g. collagen-based agents). The literature is inconclusive on the effectiveness of these methods and on the clinical benefits of their routine use. OBJECTIVES To evaluate the benefits and harms of fibrin-based haemostatic agents in reducing intraoperative blood loss in adults undergoing liver resection. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group (CHBG) Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index-Science up to 20 January 2023. We also searched online trial registries, checked the reference lists of all primary studies, and contacted the authors of included trials for additional published or unpublished trials. SELECTION CRITERIA We considered for inclusion all randomised clinical trials evaluating FBHAs versus no topical intervention or non-FBHAs, irrespective of publication type, publication status, language of publication, and outcomes reported. Eligible participants could have any liver pathology and be undergoing major or minor liver resections through open or laparoscopic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened the results of the literature search and used data extraction forms to collate the results. We expressed dichotomous outcome results as risk ratios (RRs) and continuous outcome results as mean differences (MDs), each with their corresponding 95% confidence interval (CI). We used a random-effects model for the main analyses. Our primary outcomes were perioperative mortality, serious adverse events, haemostatic efficacy, and health-related quality of life. Our secondary outcomes were efficacy as sealant, adverse events considered non-serious, operating time, and length of hospital stay. We assessed the certainty of the evidence with GRADE and presented results in two summary of findings tables. MAIN RESULTS We included 22 trials (2945 participants) evaluating FBHAs versus no intervention or non-FBHAs; 19 trials with 2642 participants provided data for the meta-analyses. Twelve trials reported commercial funding, one trial reported no financial support, and nine trials provided no information on funding. Below we present the most clinically relevant outcome results, also displayed in our summary of findings table. Fibrin-based haemostatic agents versus no intervention Six trials (1001 participants) compared FBHAs with no intervention. One trial was at low risk of bias in all five domains, and all other trials were at high or unclear risk of bias in at least one domain. Two trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with no intervention have an effect on perioperative mortality (RR 2.58, 95% CI 0.89 to 7.44; 4 trials, 782 participants), serious adverse events (RR 0.96, 95% CI 0.88 to 1.05; 4 trials, 782 participants), postoperative transfusion (RR 1.04, 95% CI 0.77 to 1.40; 5 trials, 864 participants), reoperation (RR 2.92, 95% CI 0.58 to 14.61; 2 trials, 612 participants), or postoperative bile leak (RR 1.00, 95% CI 0.67 to 1.48; 4 trials, 782 participants), as the certainty of evidence was very low for all these outcomes. Fibrin-based haemostatic agents versus non-fibrin-based haemostatic agents Sixteen trials (1944 participants) compared FBHAs with non-FBHAs. All trials had at least one domain at high or unclear risk of bias. Twelve trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with non-FBHAs have an effect on perioperative mortality (RR 1.03, 95% CI 0.62 to 1.72; 11 trials, 1436 participants), postoperative transfusion (RR 0.92, 95% CI 0.68 to 1.25; 7 trials, 599 participants), reoperation (RR 0.48, 95% CI 0.25 to 0.90; 3 trials, 358 participants), or postoperative bile leak (RR 1.15, 95% CI 0.60 to 2.21; 9 trials, 1115 participants), as the certainty of evidence was very low for all these outcomes. FBHAs compared with non-FBHAs may have little or no effect on the risk of serious adverse events (RR 0.99, 95% CI 0.95 to 1.03; 9 trials, 1176 participants; low-certainty evidence). AUTHORS' CONCLUSIONS The evidence for the outcomes in both comparisons (FBHAs versus no intervention and FBHAs versus non-FBHAs) was of very low certainty (or low certainty in one instance) and cannot justify the routine use of FBHAs to reduce blood loss in adult liver resection. While the meta-analysis showed a reduced risk of reoperation with FBHAs compared with non-FBHAs, the analysis was confounded by the small number of trials reporting the event and the risk of bias in all these trials. Future trials should focus on the use of FBHAs in people undergoing liver resection who are at particularly high risk of bleeding. Investigators should evaluate clinically meaningful and patient-important outcomes and follow the SPIRIT and CONSORT statements.
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Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Aimen O Amer
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Steven A White
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Derek M Manas
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
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Dolcetti V, Lori E, Fresilli D, Del Gaudio G, Di Bella C, Pacini P, D'Andrea V, Frattaroli FM, Vallone GG, Liberatore P, Pironi D, Canu GL, Calò PG, Cantisani V, Sorrenti S. US Evaluation of Topical Hemostatic Agents in Post-Thyroidectomy. Cancers (Basel) 2023; 15:cancers15092644. [PMID: 37174110 PMCID: PMC10177612 DOI: 10.3390/cancers15092644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/17/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND the aim of this study was to describe the ultrasound appearance of topical hemostatics after thyroidectomy. METHODS we enrolled 84 patients who were undergoing thyroid surgery and were treated with two types of topical hemostats, 49 with an absorbable hemostat of oxidized regenerated cellulose (Oxitamp®) and 35 with a fibrin glue-based hemostat (Tisseel®). All patients were examined using B-mode ultrasound. RESULTS In 39 patients of the first group (approximately 80%), a hemostatic residue was detected and in some cases confused with a native gland residue, or with cancer recurrence in oncological patients. No residue was detected in patients in the second group. The main ultrasound characteristics of the tampon were analyzed and arranged according to predefined patterns, and suggestions to recognize it and avoid wrong diagnoses were provided. A part of the group of patients with tampon residue was re-evaluated after 6-12 months, ensuring that the swab remained for months after the maximum resorption time declared by the manufacturer. CONCLUSIONS with equal hemostatic effectiveness, the fibrin glue pad is more favorable in the ultrasound follow-up because it creates reduced surgical outcomes. It is also important to know and recognize the ultrasound characteristics of oxidized cellulose-based hemostats in order to reduce the number of diagnostic errors and inappropriate diagnostic investigations.
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Affiliation(s)
- Vincenzo Dolcetti
- Department of Radiological, Anatomo-Pathological Sciences, "Sapienza" University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Eleonora Lori
- Department of Surgery, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Daniele Fresilli
- Department of Radiological, Anatomo-Pathological Sciences, "Sapienza" University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Giovanni Del Gaudio
- Department of Radiological, Anatomo-Pathological Sciences, "Sapienza" University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Chiara Di Bella
- Department of Radiological, Anatomo-Pathological Sciences, "Sapienza" University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Patrizia Pacini
- Department of Radiological, Anatomo-Pathological Sciences, "Sapienza" University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Vito D'Andrea
- Department of Surgery, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Fabrizio Maria Frattaroli
- Department of Surgery "P. Stefanini", Faculty of Medicine, "Sapienza" University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Giulia Giordana Vallone
- Department of Surgery "P. Stefanini", Faculty of Medicine, "Sapienza" University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Piero Liberatore
- Department of Surgery "P. Stefanini", Faculty of Medicine, "Sapienza" University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Daniele Pironi
- Department of Surgery, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Gian Luigi Canu
- Department of Surgical Sciences, University of Cagliari, 09042 Monserrato (Cagliari), Italy
| | - Pietro Giorgio Calò
- Department of Surgical Sciences, University of Cagliari, 09042 Monserrato (Cagliari), Italy
| | - Vito Cantisani
- Department of Radiological, Anatomo-Pathological Sciences, "Sapienza" University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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Kajiwara M, Naito S, Sasaki T, Nakashima R, Hasegawa S. Quick and Easy Application Method of TachoSil®️ During Laparoscopic and Robotic Liver Resections. Cureus 2023; 15:e37252. [PMID: 37182003 PMCID: PMC10167935 DOI: 10.7759/cureus.37252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2023] [Indexed: 05/16/2023] Open
Abstract
TachoSil®️, a fibrin sealant patch, is a sheet-type hemostatic agent. Therefore, it is technically demanding to put it on the target place especially in laparoscopic surgeries due to the motion restriction of straight-fixed instruments. This article describes a quick and easy technique of TachoSil application during laparoscopic liver surgeries, by sewing it to the laparoscopic gauze in advance. This method allows for one-handed operation and stress-free application even in the situation of active bleeding.
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Affiliation(s)
- Masatoshi Kajiwara
- Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Shigetoshi Naito
- Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Takahide Sasaki
- Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Ryo Nakashima
- Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Suguru Hasegawa
- Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
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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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9
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Klune JR, Watson GA, Peitzman AB. Peitzman Paste: A Novel Hemostatic Concoction for Treatment of Intraoperative Medical Bleeding. Am Surg 2023; 89:481-484. [PMID: 33283525 DOI: 10.1177/0003134820954833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John R Klune
- Department of Surgery, 1267Anne Arundel Medical Center, Annapolis, MD, USA
| | - Gregory A Watson
- Division of Trauma and Acute Care Surgery, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew B Peitzman
- Division of Trauma and Acute Care Surgery, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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10
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Roozen EA, Lomme RMLM, Calon NUB, Warlé MC, Van Goor H. Validity of a novel ex vivo porcine liver perfusion model for studying haemostatic products. Lab Anim 2022:236772221138398. [DOI: 10.1177/00236772221138398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction We developed a novel normothermic ex vivo porcine liver perfusion model with whole blood in order to have alternatives for animal experiments in the research and development of new local haemostatic agents. This study aims to assess the construct and content validity of this model. Methods In this study we performed two ex vivo experiments using nine livers and one in vivo experiment using six female Norsvin Topigs pigs: (1) ex vivo liver perfusion for establishing physiological blood parameters of the perfused liver and controlled heparinization, (2) ex vivo liver perfusion with a surgical injury and (3) a surgical liver injury in anaesthetized pigs with and without heparin. Results Ex vivo coagulation parameters were comparable to in vivo with heparin. Blood gas values and metabolic parameters were comparable between ex vivo and in vivo with heparin, but significantly different compared with in vivo baseline, with the exception of (partial pressure of oxygen (PO2). Activated clotting time (ACT) values significantly differed depending on the heparin doses. The coagulation parameters fibrinogen, activated partial thromboplastin time, prothrombin time and ACT were rather constant during the 4 h ex vivo perfusion. Haemostatic efficacy of commercially available products was comparable between in vivo with heparin and the ex vivo liver perfusion experiment. Conclusion This novel ex vivo liver perfusion model demonstrates good construct and content validity for at least 4 h of perfusion. The model is an easily accessible, table-top, tunable and effective alternative for the in vivo testing of (new) haemostatic products on their haemostatic properties. Validité d'un nouveau modèle de perfusion hépatique porcin ex-vivo pour l'étude des produits hémostatiques Résumé
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Affiliation(s)
| | | | | | | | - Harry Van Goor
- Radboud University Medical Centre, Department of Surgery, Nijmegen, The Netherlands
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11
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Jonas E, Bernon M, Robertson B, Kassianides C, Keli E, Asare KO, Alatise IO, Okello M, Blondel NO, Mulehane KO, Abubeker ZA, Nogoud AA, Nashidengo PR, Chihaka O, Tzeuton C, Dusheiko G, Sonderup M, Spearman CW. Treatment of hepatocellular carcinoma in sub-Saharan Africa: challenges and solutions. Lancet Gastroenterol Hepatol 2022; 7:1049-1060. [PMID: 35810767 DOI: 10.1016/s2468-1253(22)00042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/30/2022] [Accepted: 02/02/2022] [Indexed: 06/15/2023]
Abstract
Most patients who develop hepatocellular carcinoma reside in resource-poor countries, a category that includes most countries in sub-Saharan Africa. Age-standardised incidence rates of hepatocellular carcinoma in western, central, eastern, and southern Africa is 6·53 per 100 000 inhabitants to 11·1 per 100 000 inhabitants. In high-income countries, around 40% of patients are diagnosed at an early stage, in which interventions with curative intent or palliative interventions are possible. By contrast, 95% of patients with hepatocellular carcinoma in sub-Saharan Africa present with advanced or terminal disease. In high-income countries, targets of 30-40% that have been set for intervention with curative intent are regularly met, with expected 5-year overall survival rates in the region of 70%. These outcomes are in sharp contrast with the very small proportion of patients in sub-Saharan Africa who are treated with curative intent. Primary prevention through the eradication and reduction of risk factors is still suboptimal because of logistical challenges. The challenges facing primary prevention, in combination with difficult-to-manage historic and emerging risk factors, such as ethanol overconsumption and metabolic dysfunction-associated liver disease, mandates secondary prevention for populations at risk through screening and surveillance. Although the increased treatment needs yielded by screening and surveillance in high-income countries are manageable by the incremental expansion of existing interventional resources, the lack of resources in sub-Saharan Africa will undermine the possible benefits of secondary prevention. An estimate of the projected effect of the introduction and expansion of screening and surveillance, resulting in stage migration and possibilities for active interventions for hepatocellular carcinoma, would facilitate optimal planning and development of resources.
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Affiliation(s)
- Eduard Jonas
- Department of Surgery, University of Cape Town, Cape Town, South Africa.
| | - Marc Bernon
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Barbara Robertson
- Division of Radiation Oncology, Department of Radiation Medicine, University of Cape Town, Cape Town, South Africa
| | - Chris Kassianides
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elie Keli
- Department of General and Digestive Surgery, Hôpital Militaire d'Abidjan, Abidjan, Côte d'Ivoire
| | - Kwaku Offei Asare
- Department of Surgery, Korle Bu Teaching Hospital and the University of Ghana Medical School, Accra, Ghana
| | - Isaac Olusegun Alatise
- Department of Surgery, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Nigeria
| | - Michael Okello
- Department of Surgery, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
| | - Nana Oumarou Blondel
- Centre Hospitalier d'Essos and Department of Surgery, University of Yaoundé, Yaoundé, Cameroon
| | | | - Zeki Abdurahman Abubeker
- Department of Surgery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Pueya Rashid Nashidengo
- Department of Surgery, Windhoek Central Hospital, University of Namibia School of Medicine, Windhoek, Namibia
| | - Onesai Chihaka
- Department of Surgery, University of Zimbabwe, Harare, Zimbabwe
| | - Christian Tzeuton
- Faculty of Medicine and Pharmaceutical Sciences of Douala, University of Douala, Douala, Cameroon
| | - Geoffrey Dusheiko
- Institute of Liver Studies, King's College Hospital, London, UK; University College London Medical School, London, UK
| | - Mark Sonderup
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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12
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Jia Y, Zhai G, Wang E, Li P. Efficacy of local hemostatic agents after endoscopic submucosal dissection: a meta-analysis. MINIM INVASIV THER 2022; 31:1017-1025. [PMID: 36000962 DOI: 10.1080/13645706.2022.2111217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Topical hemostatic agents have been used to reduce bleeding rates after endoscopic submucosal dissection (ESD) for gastric cancer. However, to date, no review has summarized evidence on their efficacy. MATERIAL AND METHODS PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar were searched for studies comparing bleeding rates after ESD with and without local hemostatic agents. RESULTS Eleven studies were included. The studies used polyglycolic acid (PGA) sheets and fibrin glue, fibrin glue, oxidized regenerated cellulose, polysaccharide hemostatic powder, or polyethylene oxide adhesive. Meta-analysis revealed a statistically significant reduction in the risk of delayed bleeding with the use of PGA sheets & fibrin glue (six studies; RR: 0.35 95% CI: 0.20, 0.63 p = 0.0005). However, meta-analysis of two studies showed no difference in the risk of bleeding based on the use of fibrin glue (RR: 0.44 95% CI: 0.03, 7.17 p = 0.56). Scarce data were available for the remaining hemostatic agents. CONCLUSION A large number of different hemostatic agents have been used to reduce the risk of bleeding after ESD for gastric cancer. Observational studies indicate that the use of PGA with fibrin glue could reduce the risk of bleeding after ESD. However, evidence for other agents was too scarce to derive conclusions.
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Affiliation(s)
- Yi Jia
- Department of General Surgery, Shanxi Provincial Cancer Hosipital, Shanxi, China
| | - Gang Zhai
- Department of General Surgery, Shanxi Provincial Cancer Hosipital, Shanxi, China
| | - Erli Wang
- Department of General Surgery, Shanxi Provincial Cancer Hosipital, Shanxi, China
| | - Pengcheng Li
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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13
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Bioabsorbable Carboxymethyl Starch-Calcium Ionic Assembly Powder as a Hemostatic Agent. Polymers (Basel) 2022; 14:polym14183909. [PMID: 36146054 PMCID: PMC9505345 DOI: 10.3390/polym14183909] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/22/2022] Open
Abstract
In contrast to hemostatic fabrics, foams, and gels, hemostatic spray powders may be conveniently applied on narrow and complex bleeding sites. However, powdered hemostatic agents are easily desorbed from the bleeding surface because of blood flow, which seriously decreases their hemostatic function. In this study, the hemostatic performance of a bioabsorbable powder with decreased desorption was investigated. The proposed hemostatic powder (OOZFIXTM) is an ionic assembly of carboxymethyl starch and calcium. The microstructure and chemical properties of the hemostatic powder were analyzed. The hemostatic performance (blood absorption, blood absorption rate, and coagulation time), thromboelastography (TEG), rheology, adhesion force, and C3a complement activation of the OOZFIXTM were evaluated and compared with those of the carboxymethyl starch-based commercial hemostatic powder (AristaTM AH). The in vivo rat hepatic hemorrhage model for hemostasis time and bioabsorption of the OOZFIXTM showed quick biodegradation (<3 weeks) and a significantly improved hemostasis rate (78 ± 17 s) compared to that of AristaTM AH (182 ± 11) because of the reduced desorption. The bioabsorbable hemostatic powder OOZFIXTM is expected to be a promising hemostatic agent for precise medical surgical treatments.
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14
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Abstract
Intraoperative bleeding and postoperative bleeding are major surgical complications. Tissue sealants, hemostats, and adhesives provide the armamentarium for establishing hemostatic balance, including the tissue sealant fibrin. Fibrin sealants combine advantages including instantaneous effect, biocompatibility, and biodegradability. However, several challenges remain. This review summarizes current fibrin product generations and highlights new trends and potential strategies for future improvement.
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Affiliation(s)
- Matthias Beudert
- Institute of Pharmacy and Food Chemistry, Julius-Maximilians-University Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Marcus Gutmann
- Institute of Pharmacy and Food Chemistry, Julius-Maximilians-University Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Tessa Lühmann
- Institute of Pharmacy and Food Chemistry, Julius-Maximilians-University Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Lorenz Meinel
- Institute of Pharmacy and Food Chemistry, Julius-Maximilians-University Würzburg, Am Hubland, 97074 Würzburg, Germany.,Helmholtz Institute for RNA-based Infection Research, Josef-Schneider-Straße 2, 97080 Würzburg, Germany
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15
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A review of treatments for non-compressible torso hemorrhage (NCTH) and internal bleeding. Biomaterials 2022; 283:121432. [DOI: 10.1016/j.biomaterials.2022.121432] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/26/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
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16
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Byun Y, Kim EJ, Lee A, Suh YA, Sohn HJ, Lee JM, Kang JS, Choi YJ, Han Y, Kim H, Kwon W, Jang JY. In vivo study for the hemostatic efficacy and foreign body reaction of a new powder-type polysaccharide hemostatic agent. Ann Surg Treat Res 2022; 102:65-72. [PMID: 35198509 PMCID: PMC8831091 DOI: 10.4174/astr.2022.102.2.65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/09/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Various hemostatic agents have been introduced in therapy as postoperative bleeding is a poor prognostic factor for postoperative outcomes. These products can be divided into those that directly promote the hemostatic cascade and those that physically form a barrier by absorbing blood. The latter, powder-type hemostatic agents have the advantages of being inexpensive and more absorbable with less foreign body reactions (FBRs) and are applicable to a relatively wide area. This study was conducted to verify the safety and efficacy of a newly invented polysaccharide product (OOZFIX, Theracion Biomedical), which improves blood absorption and hemostatic effects. Methods Two separate animal experiments were performed. The first evaluated FBRs histologically at 3 days, 2 weeks, and 4 weeks, after implantation of OOZFIX in rats, and the second compared hemostatic performance of OOZFIX and Arista AH (Bard) in the porcine liver punch biopsy model. Results We found minimal FBRs in the 3-day group and no reactions in both the 2-week and 4-week groups after implantation of hemostatic agents. The time to hemostasis of OOZFIX was not significantly different from that of Arista AH (median [interquartile range]: 9 [6–10] minutes vs. 8 [6–10] minutes, respectively; P = 0.522). When comparing the serial bleeding grade tendency, there was no statistical difference between OOZFIX and Arista AH (P = 0.656). Conclusion OOZFIX caused a minimal FBR that disappeared within 2 weeks in vivo, and its hemostatic performance was comparable with that of an existing agent, Arista AH. Further clinical studies are required in the future.
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Affiliation(s)
- Yoonhyeong Byun
- Department of Surgery, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Eun Jin Kim
- Theracion Biomedical Co., Ltd., Seongnam, Korea
| | - Areum Lee
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Young-Ah Suh
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Hee Ju Sohn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Min Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo Jin Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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17
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Roozen EA, Warlé MC, Lomme RMLM, Félix Lanao RP, van Goor H. New polyoxazoline loaded patches for hemostasis in experimental liver resection. J Biomed Mater Res B Appl Biomater 2021; 110:597-605. [PMID: 34536065 PMCID: PMC9290804 DOI: 10.1002/jbm.b.34938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/14/2021] [Accepted: 08/30/2021] [Indexed: 12/29/2022]
Abstract
A new cost‐effective NHS functionalized polyoxazoline (POx) loaded polymer with strong hemostatic properties has been developed. In this study, we investigate POx loaded hemostatic patches regarding hemostatic efficacy, local inflammatory reaction and wound‐healing, as compared to the non‐POx treated blanks and commercially available hemostatic products. Hundred and ten rats divided into 11 groups of 10 animals underwent partial liver lobe resection. Eight groups received experimental patches, two groups commercially available hemostatic patches (TachoSil® and Veriset™, positive controls), one group with gauzes (negative control). Each animal received twice a patch with a size 1.5 × 2.5 cm, on each partially resected lobe. Primary endpoint was time to hemostasis (TTH). The rats were sacrificed at different time points (1, 3, or 7 days) to measure local inflammatory response and early wound healing. Of the POx loaded patches, GFC NHS‐POx (TTH 20.4 s, p = .019) and GFC‐NHS‐POx1.5 (TTH 0.0 s, p = .003) showed significantly faster TTH compared to TachoSil® (TTH 95.4 s), and were comparable to Veriset™ (TTH 17.0 s). Three patches, GFC‐NHS‐POx 1.5 (TTH 0.0 s, p = .016), ORC NHS‐POx:NU‐POx (TTH 91.4 s, p = .033), and ORC‐PLGA NHS‐POx:NU‐POx (TTH 105.6 s, p = .04) had a lower TTH compared to their own blank carrier (TTH 74.9, 157.8, and 195.7 s, respectively). With regard to biocompatibility, all POx loaded patches showed results comparable to TachoSil® and Veriset™. NHS‐POx‐loaded hemostatic patch demonstrate fast and effective hemostasis, comparable or better than commercially available hemostatic patches, with similar early biocompatibility.
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Affiliation(s)
- Edwin A Roozen
- Department of Surgery, RadboudUMC, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, RadboudUMC, Nijmegen, The Netherlands
| | | | - Rosa P Félix Lanao
- Department of Surgery, RadboudUMC, Nijmegen, The Netherlands.,GATT Technologies BV, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, RadboudUMC, Nijmegen, The Netherlands
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18
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Al Khaldi M, Gryspeerdt F, Carrier FM, Bouchard C, Simoneau È, Rong Z, Plasse M, Létourneau R, Dagenais M, Roy A, Lapointe R, Massicotte L, Vandenbroucke-Menu F, Rioux-Massé B, Turcotte S. Effect of intraoperative hypovolemic phlebotomy on transfusion and clinical outcomes in patients undergoing hepatectomy: a retrospective cohort study. Can J Anaesth 2021; 68:980-990. [PMID: 33945107 PMCID: PMC8175312 DOI: 10.1007/s12630-021-01958-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/03/2020] [Accepted: 12/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is no consensus on how to best achieve a low central venous pressure during hepatectomy for the purpose of reducing blood loss and red blood cell (RBC) transfusions. We analyzed the associations between intraoperative hypovolemic phlebotomy (IOHP), transfusions, and postoperative outcomes in cancer patients undergoing hepatectomy. METHODS Using surgical and transfusion databases of patients who underwent hepatectomy for cancer at one institution (11 January 2011 to 22 June 2017), we retrospectively analyzed associations between IOHP and RBC transfusion on the day of surgery (primary outcome), and with total perioperative transfusions, intraoperative blood loss, and postoperative complications (secondary outcomes). We fitted logistic regression models by inverse probability of treatment weighting to adjust for confounders and reported adjusted odds ratio (aOR). RESULTS There were 522 instances of IOHP performed during 683 hepatectomies, with a mean (standard deviation) volume of 396 (119) mL. The IOHP patients had a 6.9% transfusion risk on the day of surgery compared with 12.4% in non-IOHP patients (aOR, 0.53; 95% confidence interval [CI], 0.29 to 0.98; P = 0.04). Total perioperative RBC transfusion tended to be lower in IOHP patients compared with non-IOHP patients (14.9% vs 22.4%, respectively; aOR, 0.72; 95% CI, 0.44 to 1.16; P = 0.18). In patients with a predicted risk of ≥ 47.5% perioperative RBC transfusion, 24.6% were transfused when IOHP was used compared with 56.5% without IOHP. The incidence of severe postoperative complications (Clavien-Dindo scores ≥ 3) was similar in patients whether or not IOHP was performed (15% vs 16% respectively; aOR, 0.97; 95% CI, 0.53 to 1.54; P = 0.71). CONCLUSIONS The use of IOHP during hepatectomy was associated with less RBCs transfused on the same day of surgery. Trials comparing IOHP with other techniques to reduce blood loss and transfusion are needed in liver surgery.
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Affiliation(s)
- Maher Al Khaldi
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Filip Gryspeerdt
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - François Martin Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
- Critical Care Service, Department of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Claudia Bouchard
- Department of Hematology-Transfusion Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Ève Simoneau
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Zhixia Rong
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Marylène Plasse
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Richard Létourneau
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Michel Dagenais
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - André Roy
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Réal Lapointe
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Luc Massicotte
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Franck Vandenbroucke-Menu
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada
| | - Benjamin Rioux-Massé
- Department of Hematology-Transfusion Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Simon Turcotte
- Hepatopancreatobiliary Surgery and Liver Transplantation Service, Department of Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Pavillon R. 900, rue St-Denis, porte R10.430, Montreal, QC, H2X 0A9, Canada.
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19
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Bodur MS, Tomas K, Topaloğlu S, Oğuz Ş, Küçükaslan H, Dohman D, Karabulut E, Çalık A. Effects of intraoperative blood loss during liver resection on patients’ outcome: a single- center experience. Turk J Med Sci 2021; 51:1388-1395. [PMID: 33576585 PMCID: PMC8283449 DOI: 10.3906/sag-2008-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/11/2021] [Indexed: 12/04/2022] Open
Abstract
Background/aim Operative bleeding is one of the major determinants of outcome in liver surgery. This study aimed to describe the impact of intraoperative blood loss on the postoperative course of liver resection (LR). Materials and methods The data of 257 patients who were treated with LR between January 2007 and October 2018 were retrospectively analyzed. LRs were performed via intermittent portal triad clamping (PTC) under low central venous pressure. Results LRs were performed for 67.7% of patients with a malignant disease and 32.3% of patients with a benign disease. Major LR was performed in 89 patients (34.6%). The mean PTC period was 20.32 min (±13.7). The median intraoperative bleeding amount was 200 mL (5–3500 mL), the 30-day mortality rate was 4.3%, and the morbidity rate was 31.9%. The hospital stay (p = 0.002), morbidity (p = 0.009), and 30-day mortality (p = 0.041) of patients with a bleeding amount of more than 500 mL significantly increased. Conclusion Surgeons should consider the adverse effects of intraoperative bleeding during liver resection on patients’ outcome. Favorable outcomes would be obtained with diligent postoperative care.
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Affiliation(s)
- Muhammed Selim Bodur
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Kadir Tomas
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Serdar Topaloğlu
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Şükrü Oğuz
- Department of Radiology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Hakan Küçükaslan
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Davut Dohman
- Department of Anesthesiology, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Erdem Karabulut
- Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Adnan Çalık
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
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20
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Przywózka-Suwał A, Ziółkowski B, Szczepkowski M. The use of state-of-the-art haemostatic materials in gastrointestinal surgery. POLISH JOURNAL OF SURGERY 2021; 93:49-54. [PMID: 33729174 DOI: 10.5604/01.3001.0014.7914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Haemostatic materials such as: gelatine sponges, oxygenated cellulose meshes, tissue sealants, collagen matrices with human thrombin and fibrinogen are gaining on popularity in gastrointestinal surgery, especially in colorectal surgery. We searched for available scientific publications in the Pubmed and Cochrane database on the use of individual hemostatic materials in the field of gastrointestinal surgery. The analysis focused on the assessment of the safety of the use of individual materials in terms of the rate of bleeding complications and the rate of anastomotic leakage cases. The use of haemostatic materials has for years been a recognized method of reducing the rate of intra- and postoperative complications, both in gastrointestinal surgery and in other surgical specialties. Based on the available studies, it can be concluded that the use of hemostatic materials such as matrices, sponges and adhesives in gastrointestinal surgery, even in patients at high risk of anastomotic leakage and bleeding complications, reduces the incidence of complications. The growing popularity of haemostatics and sealants in surgery means that they are currently used in a wide range of indications, and surgeons are more and more willing to use them even in case of standard surgical procedures, which is reflected in the available studies. Choosing a haemostat should be a conscious decision, taking into account the site and type of bleeding, mechanism of action, ease of use, efficacy, safety, and price, among others.
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Affiliation(s)
- Alicja Przywózka-Suwał
- Klinika Chirurgii Kolorektalnej, Ogólnej i Onkologicznej Centrum Medycznego Kształcenia Podyplomowego, Szpital Bielański, Warszawa
| | - Bartosz Ziółkowski
- Klinika Chirurgii Kolorektalnej, Ogólnej i Onkologicznej Centrum Medycznego Kształcenia Podyplomowego, Szpital Bielański, Warszawa
| | - Marek Szczepkowski
- Klinika Chirurgii Kolorektalnej, Ogólnej i Onkologicznej Centrum Medycznego Kształcenia Podyplomowego, Szpital Bielański, Warszawa
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21
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Abstract
Polymeric tissue adhesives provide versatile materials for wound management and are widely used in a variety of medical settings ranging from minor to life-threatening tissue injuries. Compared to the traditional methods of wound closure (i.e., suturing and stapling), they are relatively easy to use, enable rapid application, and introduce minimal tissue damage. Furthermore, they can act as hemostats to control bleeding and provide a tissue-healing environment at the wound site. Despite their numerous current applications, tissue adhesives still face several limitations and unresolved challenges (e.g., weak adhesion strength and poor mechanical properties) that limit their use, leaving ample room for future improvements. Successful development of next-generation adhesives will likely require a holistic understanding of the chemical and physical properties of the tissue-adhesive interface, fundamental mechanisms of tissue adhesion, and requirements for specific clinical applications. In this review, we discuss a set of rational guidelines for design of adhesives, recent progress in the field along with examples of commercially available adhesives and those under development, tissue-specific considerations, and finally potential functions for future adhesives. Advances in tissue adhesives will open new avenues for wound care and potentially provide potent therapeutics for various medical applications.
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Affiliation(s)
- Sungmin Nam
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
| | - David Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
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22
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Danker Iii W, DeAnglis A, Ferko N, Garcia D, Hogan A. Comparison of fibrin sealants in peripheral vascular surgery: A systematic review and network meta-analysis. Ann Med Surg (Lond) 2020; 61:161-168. [PMID: 33425351 PMCID: PMC7782199 DOI: 10.1016/j.amsu.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/02/2020] [Indexed: 01/26/2023] Open
Abstract
Background Evidence comparing fibrin sealants (FSs) in surgery are limited. This study evaluated the efficacy and safety of FSs, and manual compression in peripheral vascular surgery. Methods A systematic review of randomized trials was conducted in Medline, Embase, and Cochrane databases within the last 15 years. Data were available to conduct a network meta-analysis (NMA) in peripheral vascular surgery. Fibrin sealant treatment arms were further broken-down and assessed by clotting time (i.e., 2-min [2C] or 1-min [1C]). The primary efficacy outcome was the proportion of patients achieving hemostasis by 4 min (T4). Treatment-related serious and non-serious adverse events (AEs) were qualitatively assessed. Results Five studies (n = 693), were included in the NMA. Results predicted VISTASEAL 2C, followed by EVICEL 1C, had the highest probability of achieving T4. Compared with manual compression, significant improvements in T4 were found with VISTASEAL 2C (relative risk [RR] = 2.67, 95% CrI: 2.13–3.34), EVICEL 1C (RR = 2.58, 95% CrI: 2.04–3.23), VISTASEAL 1C (RR = 2.00, 95% CrI: 1.45–2.65), and TISSEEL 2C (RR = 1.99, 95% CrI: 1.48–2.60). TISSEEL 1C was not significantly different than manual compression (RR = 1.40, 95% CrI: 0.70–2.33). Among FSs, VISTASEAL 2C was associated with a significant improvements in T4 compared with VISTASEAL 1C (RR = 1.33, 95% CrI: 1.02–1.82), TISSEEL 2C (RR = 1.34, 95% CrI: 1.05–1.77), and TISSEEL 1C (RR = 1.90, 95% CrI: 1.18–3.74). Treatment-related serious and non-serious AE rates were typically lower than 2%. Conclusions In peripheral vascular surgeries, VISTASEAL 2C and EVICEL 1C were shown to have the highest probabilities for achieving rapid hemostasis among the treatments compared. Future studies should expand networks across surgery types as data become available. Fibrin sealants can control perioperative bleeding, yet comparative evidence is limited. This network meta-analysis compared fibrin sealants and compression in peripheral vascular surgery. VISTASEAL and EVICEL had the highest probability of achieving hemostasis by 4 min. These results show differences exist between fibrin sealants in peripheral vascular surgery.
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Affiliation(s)
| | | | - Nicole Ferko
- CRG-EVERSANA Canada Inc., 204-3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | - David Garcia
- CRG-EVERSANA Canada Inc., 204-3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | - Andrew Hogan
- CRG-EVERSANA Canada Inc., 204-3228 South Service Road, Burlington, ON, L7N 3H8, Canada
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23
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Rahimli M, Perrakis A, Schellerer V, Andric M, Stockheim J, Lorenz E, Franz M, Arend J, Croner RS. A falciform ligament flap surface sealing technique for laparoscopic and robotic-assisted liver surgery. Sci Rep 2020; 10:12143. [PMID: 32699283 PMCID: PMC7376099 DOI: 10.1038/s41598-020-69211-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 07/08/2020] [Indexed: 11/09/2022] Open
Abstract
Whether sealing the hepatic resection surface after liver surgery decreases morbidity is still unclear. Nevertheless, various methods and materials are currently in use for this procedure. Here, we describe our experience with a simple technique using a mobilized falciform ligament flap in minimally invasive liver surgery (MILS). We retrospectively analyzed the charts from 46 patients who received minor MILS between 2011 and 2019 from the same surgical team in a university hospital setting in Germany. Twenty-four patients underwent laparoscopic liver resection, and 22 patients received robotic-assisted liver resection. Sixteen patients in the laparoscopic group and fourteen in the robotic group received a falciform ligament flap (FLF) to cover the resection surface after liver surgery. Our cohort was thus divided into two groups: laparoscopic and robotic patients with (MILS + FLF) and without an FLF (MILS-FLF). Twenty-eight patients (60.9%) in our cohort were male. The overall mean age was 56.8 years (SD 16.8). The mean operating time was 249 min in the MILS + FLF group vs. 235 min in the MILS-FLF group (p = 0.682). The mean blood loss was 301 ml in the MILS + FLF group vs. 318 ml in the MILS-FLF group (p = 0.859). Overall morbidity was 3.3% in the MILS + FLF group vs. 18.8% in the MILS-FLF group (p = 0.114). One patient in the MILS-FLF group (overall 2.2%), who underwent robotic liver surgery, developed bile leakage, but this did not occur in the MILS + FLF group. Covering the resection surface of the liver after minor minimally invasive liver resection with an FLF is a simple and cost-effective technique that does not prolong surgical time or negatively affect other perioperative parameters. In fact, it is a safe add-on step during MILS that may reduce postoperative morbidity. Further studies with larger cohorts will be needed to substantiate our proof of concept and results.
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Affiliation(s)
- M Rahimli
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - A Perrakis
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - V Schellerer
- Department of Pediatric Surgery, University Hospital Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - M Andric
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - J Stockheim
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - E Lorenz
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - M Franz
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - J Arend
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - R S Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
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Rahbari NN, Birgin E, Sturm D, Schwanebeck U, Weitz J, Reissfelder C. Randomized clinical trial of BioFoam® Surgical Matrix to achieve hemostasis after liver resection. HPB (Oxford) 2020; 22:987-995. [PMID: 31680010 DOI: 10.1016/j.hpb.2019.10.1529] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/04/2019] [Accepted: 10/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Topical agents were designed to facilitate hemostasis during hepatic resection. The aim of this prospective randomized controlled clinical trial was to evaluate the effectiveness and safety of BioFoam® Surgical Matrix for achieving hemostasis after open hepatic resection. METHODS This was a prospective, randomized controlled monocentric trial of patients undergoing elective open liver resection between December 2015 and September 2017. The primary endpoint was time-to-complete hemostasis. RESULTS A total of 101 patients were enrolled in this trial, giving 51 patients in the BioFoam® group and 50 patients in the control group (without use of BioFoam®). Time-to-complete hemostasis was significantly reduced in the BioFoam® group (156 ± 129 versus 307 ± 264 s; P = 0.001). There were no significant differences in postoperative bile leaks (n = 6 (12%) vs. n = 5 (10%); P = 0.776), postoperative morbidity (n = 37 (73%) vs. n = 40 (80%); P = 0.482) or mortality (n = 3 (6%) vs. n = 1 (2%); P = 0.618) between groups. CONCLUSION BioFoam® is a safe topical agent for achieving faster hemostasis during hepatic resection, however, the true clinical relevance of this finding needs to be further evaluated. ClinicalTrials.gov ID NCT02612220.
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Affiliation(s)
- Nuh N Rahbari
- Department of Gastrointestinal, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany.
| | - Emrullah Birgin
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Dorothée Sturm
- Department of Gastrointestinal, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Uta Schwanebeck
- Coordination Center for Clinical Trials Dresden, Biostatistics, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Gastrointestinal, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Christoph Reissfelder
- Department of Gastrointestinal, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
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25
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Haemostatic Efficacy of Topical Agents During Liver Resection: A Network Meta-Analysis of Randomised Trials. World J Surg 2020; 44:3461-3469. [PMID: 32488664 DOI: 10.1007/s00268-020-05621-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hepatic resection carries a high risk of parenchymal bleeding both intra- and post-operatively. Topical haemostatic agents are frequently used to control bleeding during hepatectomy, with multiple products currently available. However, it remains unknown which of these is most effective for achieving haemostasis and improving peri-operative outcomes. METHODS A systematic review and random-effects Bayesian network meta-analysis of randomised trials investigating topical haemostatic agents in hepatic resection was performed. Interventions were analysed by grouping into similar products; fibrin patch, fibrin glue, collagen products, and control. Primary outcomes were the rate of haemostasis at 4 and 10 min. RESULTS Twenty randomized controlled trials were included in the network meta-analysis, including a total of 3267 patients and 7 different interventions. Fibrin glue and fibrin patch were the most effective interventions for achieving haemostasis at both 4 and 10 min. There were no significant differences between haemostatic agents with respect to blood loss, transfusion requirements, bile leak, post-operative complications, reoperation, or mortality. CONCLUSIONS Amongst the haemostatic agents currently available, fibrin patch and fibrin glue are the most effective methods for reducing time to haemostasis during liver resection, but have no effect on other peri-operative outcomes. Topical haemostatic agents should not be used routinely, but may be a useful adjunct to achieve haemostasis when needed.
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26
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Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
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Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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27
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Severinov D, Lazarenko S, Sotnikov K, Pohozhay V, Ansimova P, Lipatov V. In vitro Evaluation of Performance Properties of Sponge Hemostatic Dressings (Review). Sovrem Tekhnologii Med 2020; 12:139-146. [PMID: 34513047 PMCID: PMC8353698 DOI: 10.17691/stm2020.12.1.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Indexed: 11/19/2022] Open
Abstract
Dressings for restoring organ defects and/or hemostasis in the injury site are being actively applied in operational units. These dressings are used in various surgeries and are widely represented in the foreign and domestic markets of medical products. Many local implants have different levels of hemostatic activity, which requires standardization of the algorithm of choice and the methods of their study. Here the methods of studying the performance properties of hemostatic implants in vitro have been considered and evaluation criteria of their physical, chemical and organoleptic properties in vitro have been proposed. This will allow a researcher to choose optimal variants of samples for further experiments on biological models more effectively as well as to save funds, time and reduce the number of experiments in vivo.
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Affiliation(s)
- D.A. Severinov
- Assistant, Department of Human Anatomy, Kursk State Medical University, 3 K. Marx St., Kursk, 305041, Russia
| | - S.V. Lazarenko
- Assistant, Department of Oncology, Kursk State Medical University, 3 K. Marx St., Kursk, 305041, Russia
| | - K.A. Sotnikov
- Radiologist, Computer Tomography Unit, Department of Radiodiagnostics, S.P. Botkin City Clinical Hospital, Moscow Department of Public Health, 5, 2-y Botkinskiy Proezd, Moscow, 125284, Russia
| | - V.V. Pohozhay
- Associate Professor, Department of Oncology, Gomel State Medical University, 5 Lange St., Gomel, 246000, Republic of Belarus
| | - P.V. Ansimova
- Student, Kursk State Medical University, 3 K. Marx St., Kursk, 305041, Russia
| | - V.A. Lipatov
- Associate Professor, Professor, Department of Operative Surgery and Topographic Anatomy, Kursk State Medical University, 3 K. Marx St., Kursk, 305041, Russia
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28
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Fonouni H, Khajeh E, Ghamarnejad O, Kashfi A, Aydogdu E, Majlesara A, Mohammadi S, Gharabaghi N, Konstantinidis L, Longerich T, Mehrabi A, Kulu Y. Histopathological effects of modern topical sealants on the liver surface after hepatectomy: an experimental swine study. Sci Rep 2019; 9:7088. [PMID: 31068637 PMCID: PMC6506469 DOI: 10.1038/s41598-019-43694-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 04/27/2019] [Indexed: 12/11/2022] Open
Abstract
The present study aimed to determine the impact of different sealant materials on histopathological changes to the liver surface after liver resection. Thirty-six landrace pigs underwent left anatomical hemihepatectomy and were assigned to a histopathological control group (HPC, n = 9) with no bleeding control, a clinically simulated control group (CSC, n = 9) with no sealant but bipolar cauterization and oversewing of the liver surface, and two treatment groups (n = 9 each) with a collagen-based sealant (CBS) or a fibrinogen-based sealant (FBS) on resection surface. After postoperative day 6, tissue samples were histologically examined. There were no significant differences in preoperative parameters between the groups. Fibrin production was higher in sealant groups compared with the HPC and CSC groups (both p < 0.001). Hepatocellular regeneration in sealant groups was higher than in both control groups. A significantly higher regeneration was seen in the FBS group. Use of sealants increased the degree of fibrin exudation at the resection plane. Increased hepatocellular necrosis was seen in the CBS group compared with the FBS group. The posthepatectomy hepatocellular regeneration rate was higher in the FBS group compared with the CBS group. Randomized studies are needed to assess the impact of sealants on posthepatectomy liver regeneration in the clinical setting.
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Affiliation(s)
- Hamidreza Fonouni
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arash Kashfi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Emre Aydogdu
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ali Majlesara
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sara Mohammadi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Negin Gharabaghi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Lukas Konstantinidis
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas Longerich
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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29
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Patient blood management for liver resection: consensus statements using Delphi methodology. HPB (Oxford) 2019; 21:393-404. [PMID: 30446290 DOI: 10.1016/j.hpb.2018.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/21/2018] [Accepted: 09/27/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. METHODS An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. RESULTS The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. CONCLUSIONS PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.
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30
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Campos-Cuerva R, Fernández-Muñoz B, Farfán López F, Pereira Arenas S, Santos-González M, Lopez-Navas L, Alaminos M, Campos A, Muntané J, Cepeda-Franco C, Gómez-Bravo MÁ. Nanostructured fibrin agarose hydrogel as a novel haemostatic agent. J Tissue Eng Regen Med 2019; 13:664-673. [PMID: 30793853 PMCID: PMC6594136 DOI: 10.1002/term.2831] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/12/2019] [Accepted: 02/21/2019] [Indexed: 12/18/2022]
Abstract
Blood loss remains a major concern during surgery and can increase the morbidity of the intervention. The use of topical haemostatic agents to overcome this issue therefore becomes necessary. Fibrin sealants are promising haemostatic agents due to their capacity to promote coagulation, but their effectiveness and applicability need to be improved. We have compared the haemostatic efficacy of a novel nanostructured fibrin‐agarose hydrogel patch, with (c‐NFAH) or without cells (a‐NFAH), against two commercially available haemostatic agents in a rat model of hepatic resection. Hepatic resections were performed by making short or long incisions (mild or severe model, respectively), and haemostatic agents were applied to evaluate time to haemostasis, presence of haematoma, post‐operative adhesions to adjacent tissues, and inflammation factors. We found a significantly higher haemostatic success rate (time to haemostasis) with a‐NFAH than with other commercial haemostatic agents. Furthermore, other relevant outcomes investigated were also improved in the a‐NFAH group, including no presence of haematoma, lower adhesions, and lower grades of haemorrhage, inflammation, and necrosis in histological analysis. Overall, these findings identify a‐NFAH as a promising haemostatic agent in liver resection and likely in a range of surgical procedures.
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Affiliation(s)
- Rafael Campos-Cuerva
- Centro de Transfusiones, Tejidos y Células de Sevilla (CTTS), Seville, Spain.,Cell Therapy and Cell Reprogramming Unit, GMP Network of the Andalusian Initiative for Advanced Therapies, Junta de Andalucia, Seville, Spain.,PhD Program in Molecular Biology, Biomedicine and Clinical Research, Universidad de Sevilla, 41013, Seville, Spain
| | - Beatriz Fernández-Muñoz
- Cell Therapy and Cell Reprogramming Unit, GMP Network of the Andalusian Initiative for Advanced Therapies, Junta de Andalucia, Seville, Spain.,Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain
| | - Francisco Farfán López
- Servicio de Anatomía Patológica, Hospital Universitario Virgen del Rocío (HUVR), Seville, Spain
| | - Sheila Pereira Arenas
- Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain
| | - Mónica Santos-González
- Centro de Transfusiones, Tejidos y Células de Sevilla (CTTS), Seville, Spain.,Cell Therapy and Cell Reprogramming Unit, GMP Network of the Andalusian Initiative for Advanced Therapies, Junta de Andalucia, Seville, Spain
| | - Luis Lopez-Navas
- Andalusian Initiative for Advanced Therapies, Junta de Andalucia, Seville, Spain
| | - Miguel Alaminos
- Department of Histology, University of Granada, Granada, Spain.,Instituto de Investigación Biosanitaria, ibs.GRANADA, 18016 Granada, Spain
| | - Antonio Campos
- Department of Histology, University of Granada, Granada, Spain.,Instituto de Investigación Biosanitaria, ibs.GRANADA, 18016 Granada, Spain
| | - Jordi Muntané
- Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain.,Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Carmen Cepeda-Franco
- Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain.,Unidad de Cirugia Hepato-Bilio-Pancreática y Trasplantes, HUVR, Spain
| | - Miguel Ángel Gómez-Bravo
- Instituto de Biomedicina de Sevilla, IBIS (HUVR/CSIC/Universidad de Sevilla, Junta de Andalucía), Spain.,Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Unidad de Cirugia Hepato-Bilio-Pancreática y Trasplantes, HUVR, Spain
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31
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Bjelović M, Ayguasanosa J, Kim RD, Stojanović M, Vereczkei A, Nikolić S, Winslow E, Emre S, Xiao G, Navarro-Puerto J, Courtney K, Barrera G. A Prospective, Randomized, Phase III Study to Evaluate the Efficacy and Safety of Fibrin Sealant Grifols as an Adjunct to Hemostasis as Compared to Cellulose Sheets in Hepatic Surgery Resections. J Gastrointest Surg 2018; 22:1939-1949. [PMID: 29967969 DOI: 10.1007/s11605-018-3852-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Local hemostatic agents have a role in limiting bleeding complications associated with liver resection. METHODS In this randomized, phase III study, we compared the efficacy and safety of Fibrin Sealant Grifols (FS Grifols) with oxidized cellulose sheets (Surgicel®) as adjuncts to hemostasis during hepatic resections. The primary efficacy endpoint was the proportion of patients achieving hemostasis at target bleeding sites (TBS) within 4 min (T4) of treatment application. Secondary efficacy variables were time to hemostasis (TTH) at a later time point if re-bleeding occurs and cumulative proportion of patients achieving hemostasis by time points T2, T3, T5, T7, and T10. RESULTS The rate of hemostasis by T4 was 92.8% in the FS Grifols group (n = 163) and 80.5% in the Surgicel® group (n = 162) (p = 0.01). The mean TTH was significantly shorter (p < 0.001) in the FS Grifols group (2.8 ± 0.14 vs. 3.8 ± 0.24 min). The rate of hemostasis by T2, T5, and T7 was higher and statistically superior in the FS Grifols group compared to Surgicel®. No substantial differences in adverse events (AE) were noted between treatment groups. The most common AEs were procedural pain (36.2 vs. 37.7%), nausea (20.9 vs. 23.5%), and hypotension (14.1 vs 6.2%). CONCLUSIONS FS Grifols was safe and well tolerated as a local hemostatic agent during liver resection surgeries. Overall, data demonstrate that the hemostatic efficacy of FS Grifols is superior to Surgicel® and support the use of FS Grifols as an effective local hemostatic agent in these surgical procedures.
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Affiliation(s)
- Miloš Bjelović
- Department for Minimally Invasive Upper Digestive Surgery, Clinical Center of Serbia, Hospital for Digestive Surgery - First Surgical Hospital, Dr Koste Todorovica Street No 66, Belgrade, 11000, Serbia.
| | | | - Robin D Kim
- Division of Transplantation and Advanced Hepatobiliary Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - András Vereczkei
- Department of Surgery, Medical School, University of Pécs, Pécs, Hungary
| | - Srdjan Nikolić
- Clinic of Surgical Oncology, Institute of Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Emily Winslow
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Sukru Emre
- Department of Surgery: Transplant & Immunology, Yale-New Haven Hospital, New Haven, CT, USA
| | - Gary Xiao
- Division of Multi-Organ Transplantation and Hepato-Pancreato-Biliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
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32
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Schindl M, Függer R, Götzinger P, Längle F, Zitt M, Stättner S, Kornprat P, Sahora K, Hlauschek D, Gnant M. Randomized clinical trial of the effect of a fibrin sealant patch on pancreatic fistula formation after pancreatoduodenectomy. Br J Surg 2018; 105:811-819. [PMID: 29664999 PMCID: PMC5989938 DOI: 10.1002/bjs.10840] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/15/2017] [Accepted: 01/23/2018] [Indexed: 12/19/2022]
Abstract
Background The potential for a fibrin sealant patch to reduce the risk of postoperative pancreatic fistula (POPF) remains uncertain. The aim of this study was to evaluate whether a fibrin sealant patch is able to reduce POPF in patients undergoing pancreatoduodenectomy with pancreatojejunostomy. Methods In this multicentre trial, patients undergoing pancreatoduodenectomy were randomized to receive either a fibrin patch (patch group) or no patch (control group), and stratified by gland texture, pancreatic duct size and neoadjuvant treatment. The primary endpoint was POPF. Secondary endpoints included complications, drain‐related factors and duration of hospital stay. Risk factors for POPF were identified by logistic regression analysis. Results A total of 142 patients were enrolled. Forty‐five of 71 patients (63 per cent) in the patch group and 40 of 71 (56 per cent) in the control group developed biochemical leakage or POPF (P = 0·392). Fistulas were classified as grade B or C in 16 (23 per cent) and ten (14 per cent) patients respectively (P = 0·277). There were no differences in postoperative complications (54 patients in patch group and 50 in control group; P = 0·839), drain amylase concentration (P = 0·494), time until drain removal (mean(s.d.) 11·6(1·0) versus 13·3(1·3) days; P = 0·613), fistula closure (17·6(2·2) versus 16·5(2·1) days; P = 0·740) and duration of hospital stay (22·1(2·2) versus 18·2(0·9) days; P = 0·810) between the two groups. Multivariable logistic regression analysis confirmed that obesity (odds ratio (OR) 5·28, 95 per cent c.i. 1·20 to 23·18; P = 0·027), soft gland texture (OR 9·86, 3·41 to 28·54; P < 0·001) and a small duct (OR 5·50, 1·84 to 16·44; P = 0·002) were significant risk factors for POPF. A patch did not reduce the incidence of POPF in patients at higher risk. Conclusion The use of a fibrin sealant patch did not reduce the occurrence of POPF and complications after pancreatoduodenectomy with pancreatojejunostomy. Registration number: 2013‐000639‐29 (EudraCT register). Not effective in reducing complications
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Affiliation(s)
- M Schindl
- Department of Surgery, Medical University of Vienna - General Hospital, Vienna, Austria
| | - R Függer
- Department of Surgery, Hospital Elisabethinen, Linz, Austria
| | - P Götzinger
- Department of Surgery, University Hospital St Pölten, St Pölten, Austria
| | - F Längle
- Department of Surgery, State Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - M Zitt
- Department of Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Department of Surgery, District Hospital Dornbirn, Dornbirn, Austria
| | - S Stättner
- Department of Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Department of Surgery, Medical University of Salzburg, Salzburg, Austria
| | - P Kornprat
- Department of Surgery, Medical University of Graz, Graz, Austria
| | - K Sahora
- Department of Surgery, Medical University of Vienna - General Hospital, Vienna, Austria
| | - D Hlauschek
- Department of Statistics, Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - M Gnant
- Department of Surgery, Medical University of Vienna - General Hospital, Vienna, Austria
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Olthof PB, Rassam F, van Gulik TM. The use of a NHS-PEG coated, collagen-based sealant in a patient undergoing Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS). Int J Surg Case Rep 2018; 47:7-10. [PMID: 29698885 PMCID: PMC5994687 DOI: 10.1016/j.ijscr.2018.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/13/2018] [Accepted: 03/26/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION ALPPS (Associating Liver Partition and Portal vein Ligation for Staged hepatectomy) is a new two-stage hepatectomy for patients in whom conventional treatment is not feasible due to insufficient future liver remnant (FLR). During stage one of ALPPS, accelerated growth of the FLR is induced by ligation of the portal vein and in situ split of the liver, which prevents interlobar collateral portal circulation and attributes to the accelerated hypertrophy response. This can present a risk for postoperative haemorrhage. Furthermore, adhesion of the adjacent resection surfaces might complicate the second stage of the procedure. Hemopatch® is a flexible, NHS-PEG coated, absorbable collagen-based sealant that provides haemostasis. This paper illustrates the use of Hemopatch during ALPPS for hemostasis and prevention of adhesions between the cut-surfaces of the liver. PRESENTATION OF CASE An 81-year-old patient requiring right hemihepatectomy for synchronous liver metastases underwent ALPPS. During stage one, Hemopatch was applied according to the manufacturer's instructions to the hepatic resection surfaces. Stage-2 was performed uneventfully, with no adhesions observed in the resection plane 18days after the first stage. The patient was discharged without any major complications. DISCUSSION Hemopatch is a useful tool in prevention of postoperative haemorrhage in patients undergoing ALPPS procedure as well as in the prevention of adhesions between the cut-surfaces after transection. This facilitates stage-2 of the procedure which potentially improves postoperative outcomes. CONCLUSION Topic haemostatic agents to cover the transection surface during stage one of ALPPS could help to prevent adverse interstage events.
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Affiliation(s)
- Pim B Olthof
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands.
| | - Fadi Rassam
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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34
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Fath JJ. Recombinant Film and Opportunity. J INVEST SURG 2017; 32:262-263. [PMID: 29286834 DOI: 10.1080/08941939.2017.1412544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Boerman MA, Roozen E, Sánchez-Fernández MJ, Keereweer AR, Félix Lanao RP, Bender JCME, Hoogenboom R, Leeuwenburgh SC, Jansen JA, Van Goor H, Van Hest JCM. Next Generation Hemostatic Materials Based on NHS-Ester Functionalized Poly(2-oxazoline)s. Biomacromolecules 2017; 18:2529-2538. [PMID: 28699748 PMCID: PMC5558194 DOI: 10.1021/acs.biomac.7b00683] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
![]()
In order to prevent hemorrhage during
surgical procedures, a wide
range of hemostatic agents have been developed. However, their efficacy
is variable; hemostatic devices that use bioactive components to accelerate
coagulation are dependent on natural sources, which limits reproducibility.
Hybrid devices in which chain-end reactive poly(ethylene glycol) is
employed as active component sometimes suffer from irregular cross-linking
and dissolution of the polar PEG when blood flow is substantial. Herein,
we describe a synthetic, nonbioactive hemostatic product by coating N-hydroxysuccinimide ester (NHS)-functional poly(2-oxazoline)s
(POx-NHS) onto gelatin patches, which acts by formation of covalent
cross-links between polymer, host blood proteins, gelatin and tissue
to seal the wound site and prevent hemorrhage during surgery. We studied
different process parameters (including polymer, carrier, and coating
technique) in direct comparison with clinical products (Hemopatch
and Tachosil) to obtain deeper understanding of this class of hemostatic
products. In this work, we successfully prove the hemostatic efficacy
of POx-NHS as polymer powders and coated patches both in vitro and
in vivo against Hemopatch and Tachosil, demonstrating that POx-NHS
are excellent candidate polymers for the development of next generation
hemostatic patches.
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Affiliation(s)
- Marcel A Boerman
- Institute for Molecules and Materials (IMM), Radboud University Nijmegen , Heyendaalseweg 135, 6525 AJ Nijmegen, The Netherlands.,Department of Biomaterials, Radboudumc , Philip v. Leydenlaan 25, 6525 EX Nijmegen, The Netherlands.,GATT-Technologies BV, Toernooiveld 1, 6525 ED Nijmegen, The Netherlands
| | - Edwin Roozen
- Department of Surgery, Radboudumc , Geert Grooteplein 10, 6525 GA Nijmegen, The Netherlands
| | - María José Sánchez-Fernández
- Department of Biomaterials, Radboudumc , Philip v. Leydenlaan 25, 6525 EX Nijmegen, The Netherlands.,GATT-Technologies BV, Toernooiveld 1, 6525 ED Nijmegen, The Netherlands
| | | | - Rosa P Félix Lanao
- Institute for Molecules and Materials (IMM), Radboud University Nijmegen , Heyendaalseweg 135, 6525 AJ Nijmegen, The Netherlands.,GATT-Technologies BV, Toernooiveld 1, 6525 ED Nijmegen, The Netherlands
| | | | - Richard Hoogenboom
- Supramolecular Chemistry Group, Department of Organic and Macromolecular Chemistry, Ghent University , Krijgslaan 281 S4, 9000 Ghent, Belgium
| | - Sander C Leeuwenburgh
- Department of Biomaterials, Radboudumc , Philip v. Leydenlaan 25, 6525 EX Nijmegen, The Netherlands
| | - John A Jansen
- Department of Biomaterials, Radboudumc , Philip v. Leydenlaan 25, 6525 EX Nijmegen, The Netherlands
| | - Harry Van Goor
- Department of Surgery, Radboudumc , Geert Grooteplein 10, 6525 GA Nijmegen, The Netherlands
| | - Jan C M Van Hest
- Institute for Molecules and Materials (IMM), Radboud University Nijmegen , Heyendaalseweg 135, 6525 AJ Nijmegen, The Netherlands
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Fonouni H, Kashfi A, Stahlheber O, Konstantinidis L, Kraus TW, Mehrabi A, Oweira H. Analysis of the biliostatic potential of two sealants in a standardized porcine model of liver resection. Am J Surg 2017; 214:945-955. [PMID: 28683896 DOI: 10.1016/j.amjsurg.2017.06.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/28/2017] [Accepted: 06/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Improved resection techniques has decreased mortality rate following liver resections(LRx). Sealants are known as effective adjuncts for haemostasis after LRx. We compared biliostatic effectiveness of two sealants in a standardized porcine model of LRx. MATERIAL AND METHODS We accomplished left hemihepatectomy on 27 pigs. The animals were randomized in control group(n = 9) with no sealant and treatment groups (each n = 9), in which resection surfaces were covered with TachoSil® and TissuFleece®/Tissucol Duo®. After 5 days the volume of ascites(ml), bilioma and/or bile leakages and degree of intra-abdominal adhesions were analysed. RESULTS Proportion of ascites was lower in TissuFleece/Tissucol Duo® group. The ascites volume was lower in TachoSil® group. In sealant groups, increased adhesion specially in the TachoSil® group was seen. A reduction of the "bilioma rate" was seen in sealant groups, which was significantly lower in TissuFleece®/Tissucol Duo® group. CONCLUSION In a standardized condition sealants have a good biliostatic effect but with heterogeneous potentials. This property in combination with the cost-benefit analysis should be the focus of future prospective studies.
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Affiliation(s)
- H Fonouni
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - A Kashfi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - O Stahlheber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - L Konstantinidis
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - T W Kraus
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - A Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - H Oweira
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
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Reflections on multiple strategies to reduce transfusion in cancer patients: A joint narrative. Transfus Apher Sci 2017; 56:322-329. [DOI: 10.1016/j.transci.2017.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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38
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Ferreira RS, de Barros LC, Abbade LPF, Barraviera SRCS, Silvares MRC, de Pontes LG, Dos Santos LD, Barraviera B. Heterologous fibrin sealant derived from snake venom: from bench to bedside - an overview. J Venom Anim Toxins Incl Trop Dis 2017; 23:21. [PMID: 28396682 PMCID: PMC5379742 DOI: 10.1186/s40409-017-0109-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 03/16/2017] [Indexed: 12/25/2022] Open
Abstract
Hemostatic and adhesive agents date back to World War II, when homologous fibrin sealant came onto scene. Considering that infectious diseases can be transmitted via human blood, a new heterologous fibrin sealant was standardized in the 1990s. Its components were a serine protease (a thrombin-like enzyme) extracted from the venom of Crotalus durissus terrificus snakes and a fibrinogen-rich cryoprecipitate extracted from the blood of Bubalus bubalis buffaloes. This new bioproduct has been used as a coagulant, sealant, adhesive and recently as a candidate scaffold for mesenchymal stem cells and bone and cartilage repair. This review discusses the composition of a new heterologous fibrin sealant, and cites published articles related to its preclinical applications aiming at repairing nervous system traumas and regenerating bone marrow. Finally, we present an innovative safety trial I/II that found the product to be a safe and clinically promising candidate for treating chronic venous ulcers. A multicenter clinical trial, phase II/III, with a larger number of participants will be performed to prove the efficacy of an innovative biopharmaceutical product derived from animal venom.
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Affiliation(s)
- Rui Seabra Ferreira
- Graduate Program in Tropical Diseases, Botucatu Medical School, São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil.,CEVAP/UNESP, Avenida José Barbosa de Barros, 1780, Botucatu, SP CEP 18610-307 Brazil
| | - Luciana Curtolo de Barros
- Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil
| | - Luciana Patrícia Fernandes Abbade
- Department of Dermatology and Radiology, Botucatu Medical School, São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil
| | | | - Maria Regina Cavariani Silvares
- Department of Dermatology and Radiology, Botucatu Medical School, São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil
| | - Leticia Gomes de Pontes
- Graduate Program in Tropical Diseases, Botucatu Medical School, São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil
| | - Lucilene Delazari Dos Santos
- Graduate Program in Tropical Diseases, Botucatu Medical School, São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil
| | - Benedito Barraviera
- Graduate Program in Tropical Diseases, Botucatu Medical School, São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil.,Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP - Univ Estadual Paulista), Botucatu, SP Brazil
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