Repair of pig dura in vivo using temperature controlled CO2 laser soldering

Photosealing of dural defects using a biocompatible patch

PURPOSE

Photosealing of many biological tissues can be achieved using a biocompatible material in combination with a dye that is activated by visible light to chemically bond over the tissue defect via protein cross-linking reactions. The aim of this study was to test the efficacy of photosealing using a commercially available biomembrane (AmnioExcel Plus) to securely close dural defects in comparison to another sutureless method (fibrin glue) in terms of repair strength.

METHODS

Two-millimeter diameter holes were created in dura harvested from New Zealand white rabbits and repaired ex vivo using one of two methods: (1) in n = 10 samples, photosealing was used to bond a 6-mm-diameter AmnioExcel Plus patch over the dural defect, and (2) in n = 10 samples, fibrin glue was used to attach the same patch over the dural defect. Repaired dura samples were then subjected to burst pressure testing. Histological analysis was also performed of photosealed dura.

RESULTS

The mean burst pressures of rabbit dura repaired with photosealing and fibrin glue were 302 ± 149 mmHg and 26 ± 24 mmHg, respectively. The increased repair strength using photosealing was statistically significant and considerably higher than the normal intracranial pressure of ~ 20 mmHg. Histology demonstrated a tight union at the interface between the dura surface and patch with no disruption of the dura structure.

CONCLUSION

The results of this study suggest that photosealing performs better than fibrin glue for the fixation of a patch for ex vivo repair of small dural defects. Photosealing is worthy of testing in pre-clinical models for the repair of dural defects.

Temperature-controlled laser-soldering system and its clinical application for bonding skin incisions

Laser tissue soldering is a method of repairing incisions. It involves the application of a biological solder to the approximated edges of the incision and heating it with a laser beam. A pilot clinical study was carried out on 10 patients who underwent laparoscopic cholecystectomy. Of the four abdominal incisions in each patient, two were sutured and two were laser soldered. Cicatrization, esthetical appearance, degree of pain, and pruritus in the incisions were examined on postoperative days 1, 7, and 30. The soldered wounds were watertight and healed well, with no discharge from these wounds or infection. The total closure time was equal in both methods, but the net soldering time was much shorter than suturing. There was no difference between the two types of wound closure with respect to the pain and pruritus on a follow-up of one month. Esthetically, the soldered incisions were estimated as good as the sutured ones. The present study confirmed that temperature-controlled laser soldering of human skin incisions is clinically feasible, and the results obtained were at least equivalent to those of standard suturing.

Temperature-controlled two-wavelength laser soldering of tissues

BACKGROUND AND OBJECTIVE

Laser tissue soldering is a method for bonding of incisions in tissues. A biological solder is spread over the cut, laser radiation heats the solder and the underlying cut edges and the incision is bonded. This method offers many advantages over conventional techniques (e.g., sutures). Past researches have shown that laser soldering, using a single laser, does not provide sufficient strength for bonding of cuts in thick (>1 mm) tissues. This study introduces a novel method for laser soldering of thick tissues, under temperature control, using two lasers, emitting two different wavelengths.

STUDY DESIGN/MATERIALS AND METHODS

An experimental system was built, using two lasers: (i) a CO(2) laser, whose radiation heated the upper surface of the tissue and (ii) a GaAs laser that heated an albumin layer under the tissue. An infrared fiber-optic radiometer monitored the temperature of the tissue. All three devices were connected to a computer that controlled the process. A computer simulation was written to optimize the system parameters. The system was tested on tissue phantoms, to validate the simulation and ensure that both the upper and lower sides of the cut were heated, and that the temperature could be controlled on both sides. The system was then used ex vivo to bond longitudinal cuts of lengths ∼12 mm in the esophagi of large farm pigs.

RESULTS

The theoretical simulations showed a good stabilization of the temperatures at the upper and lower tissue surfaces at the target values. Experiments on tissue phantom showed a good agreement with these simulations. Incisions in esophagi, removed from large farm pigs, were then successfully bonded. The mean burst pressure was ∼3.6 m of water.

CONCLUSIONS

This study demonstrated the capability of soldering cuts in thick tissues, paving the way for new types of surgical applications.

A multi-wavelength fiber-optic temperature-controlled laser soldering system for upper aerodigestive tract reconstruction: an animal model

OBJECTIVE

Laser soldering of a thick multilayer organ using conventional CO(2) lasers is ineffective. The purpose of this work was to develop a method for bonding the multilayer tissue of the upper aerodigestive tracts (UADT) without the need of sutures or stapling.

STUDY DESIGN

Animal model.

SETTING

Academic research laboratory.

SUBJECTS AND METHODS

The authors developed a multi-wavelength laser system, based on 2 fiber-optic lasers applied simultaneously. A highly absorbable CO(2) laser interacts with the muscular layer, and a nonabsorbable GaAs laser interacts with indocyanine-green solid albumin, placed between the mucosa and the muscular layer. The authors used an ex vivo porcine model to examine the capability of this system to effectively correct esophageal tears.

RESULTS

The soldered esophagi burst pressure was >175 cm H(2)O (98% success rate) in 88 of the 90 experiments. A conventional CO(2) laser soldering resulted in insufficient bonding (mean burst pressure of 40 ± 7 cm H(2)O, n = 5), while the multi-wavelength laser system provided an ~9-fold tighter seal (359 ± 75.4 cm H(2)O, P < .0001, n = 15). Burst pressures after conventional suturing of the defect was significantly lower (106 ± 65.8 cm H(2)O, P < .001) than in the multi-wavelength laser system.

CONCLUSIONS

Bonding of the UADT mucosa using a multi-wavelength, temperature-controlled laser soldering system can support significantly higher pressures then conventional CO(2) laser soldering and suture repair. The mean bonding pressure was 3.5-fold higher than the maximal swallowing pressure. Our findings provide a basis for implementation of new surgical tools for repair of esophageal perforations.

Photochemical tissue bonding with chitosan adhesive films

Background

Photochemical tissue bonding (PTB) is a promising sutureless technique for tissue repair. PTB is often achieved by applying a solution of rose bengal (RB) between two tissue edges, which are irradiated by a green laser to crosslink collagen fibers with minimal heat production. In this study, RB has been incorporated in chitosan films to create a novel tissue adhesive that is laser-activated.

Methods

Adhesive films, based on chitosan and containing ~0.1 wt% RB were manufactured and bonded to calf intestine by a solid state laser (λ = 532 nm, Fluence~110 J/cm², spot size~0.5 cm). A single-column tensiometer, interfaced with a personal computer, tested the bonding strength. K-type thermocouples recorded the temperature (T) at the adhesive-tissue interface during laser irradiation. Human fibroblasts were also seeded on the adhesive and cultured for 48 hours to assess cell growth.

Results

The RB-chitosan adhesive bonded firmly to the intestine with adhesion strength of 15 ± 2 kPa, (n = 31). The adhesion strength dropped to 0.5 ± 0.1 (n = 8) kPa when the laser was not applied to the adhesive. The average temperature of the adhesive increased from 26°C to 32°C during laser exposure. Fibroblasts grew confluent on the adhesive without morphological changes.

Conclusion

A new biocompatible chitosan adhesive has been developed that bonds photochemically to tissue with minimal temperature increase.

Temperature elevation during simulated polymethylmethacrylate (PMMA) cranioplasty in a cadaver model

The aims of this study were to: (i) obtain temperature measurements during in vitro polymerisation of polymethylmethacrylate (PMMA) disks of a range of thicknesses; and (ii) obtain tissue temperature measurements at various locations within a skull defect during a simulated PMMA cranioplasty procedure using a cadaver. In vitro, higher temperatures were recorded with increasing PMMA thickness. During the simulated cranioplasty, the maximum temperature was observed inside the PMMA sample, with nearby tissues being exposed to temperatures of greater than 50 degrees C over prolonged periods. There is conflicting information in the literature concerning the sensitivity of brain tissue and bone to elevated temperatures. Preoperatively fabricated PMMA cranioplasty prostheses are recommended.

In vitro conjunctival incision repair by temperature-controlled laser soldering

The common method of closing conjunctival incisions is by suturing, which is associated with several disadvantages. It requires skill to apply and does not always provide a watertight closure, which is required in some operations (e.g., glaucoma filtration). The purpose of the present study was to evaluate laser soldering as an alternative method for closing conjunctival incisions. Conjunctival incisions of 20 ex vivo porcine eyes were laser soldered using a temperature-controlled fiberoptic laser system and an albumin mixed with indocyanine green as a solder. The control group consisted of five repaired incisions by a 10-0 nylon running suture. The leak pressure of the repaired incisions was measured. The mean leak pressure in the laser-soldered group was 132 mm Hg compared to 4 mm Hg in the sutured group. There was no statistically significant difference in both the incision's length and distance from the limbus between the groups, before and after the procedure, indicating that there was no severe thermal damage. These preliminary results clearly demonstrate that laser soldering may be a useful method for achieving an immediate watertight conjunctival wound closure. This procedure is faster and easier to apply than suturing.

A New Porcine Skull Base Model

OBJECTIVES: Fibrin glue is used in addition to grafts and flaps to repair cerebrospinal (CSF) leaks. We designed a porcine model to test the hypothesis that fibrin glue increases biomechanical strength.

STUDY DESIGN: A randomized experimental animal study.

METHODS: Ten pigs underwent craniotomy with creation of a fistula through the cribriform plate into the nasal cavity. CSF leaks were endoscopically confirmed and repaired using pericranial grafts. The animals were randomized into a fibrin glue group (n = 5) and a control group (n = 5). Seven days later, endoscopic examination assessed for CSF leaks. The skull bases were harvested and examined for the degree of graft adherence (graded I-V) and subjected to burst pressure testing and histopathological analysis.

RESULTS: Eight animals survived, four in each group. There were no CSF leaks in the fibrin glue group and one in the control group. The fibrin glue group showed greater graft adherence ( P = 0.029) and higher burst pressures (13.8 ± 5.4 vs 4.6 ± 3.1 psi, P = 0.021). Histopathological analysis revealed no difference in inflammation and bone remodeling.

CONCLUSIONS: The porcine model is a good model for anterior skull base defects. The model confirmed that fibrin glue reduces the rate of CSF leak by improving graft adherence and strength of repair.

Laser-induced hyperthermia for treatment of granulation tissue growth in rats

OBJECTIVE

We aimed to develop a new technique for treatment of granulation tissue (GT) growth using local hyperthermia.

METHODS

A temperature-controlled diode laser system was developed for induction of mild hyperthermia in real time. GT was generated by harvesting the skin over the gluteal fascia in rats. Histopathological analysis was used to estimate the effect of hyperthermia on the tissue.

RESULTS

In untreated rats, GT was detected within 3 days and reached maximal thickness after 12 days. Hyperthermia at 43 degrees C and above significantly decreased GT thickness (n = 8 per group). Hyperthermia at 48 degrees C for 3 minutes was the most efficient parameter for treatment of GT (51% reduction), with minimal (5%) muscle necrosis.

CONCLUSIONS

Hyperthermia can significantly inhibit GT growth, with minimal damage to surrounding structures. Our findings suggest a possible role for hyperthermia as a therapeutic model against GT. Further research and long-term studies are needed to explore the utility of laser-induced hyperthermia for inhibition of GT growth.

Microscopic characterization of collagen modifications induced by low-temperature diode-laser welding of corneal tissue

BACKGROUND AND OBJECTIVE

Laser welding of corneal tissue that employs diode lasers (810 nm) at low power densities (12-20 W/cm(2)) in association with Indocyanine Green staining of the wound is a technique proposed as an alternative to conventional suturing procedures. The aim of this study is to evaluate, by means of light (LM) and transmission electron microscopy (TEM) analyses, the structural modifications induced in laser-welded corneal stroma.

MATERIALS AND METHODS

Experiments were carried out in 20 freshly enucleated pig eyes. A 3.5 mm in length full-thickness cut was produced in the cornea, and was then closed by laser welding. Birefringence modifications in samples stained with picrosirius red dye were analyzed by polarized LM to assess heat damage. TEM analysis was performed on ultra-thin slices, contrasted with uranyl acetate and lead citrate, in order to assess organization and size of type I collagen fibrils after laser welding.

RESULTS

LM evidenced bridges of collagen bundles between the wound edges, with a loss of regular lamellar organization at the welded site. Polarized LM indicated that birefringence properties were mostly preserved after laser treatment. TEM examinations revealed the presence of quasi-ordered groups of fibrils across the wound edges preserving their interfibrillar spacing. These fibrils appeared morphologically comparable to those in the control tissue, indicating that type I collagen was not denatured during the diode laser corneal welding.

CONCLUSIONS

The preservation of substantially intact, undenatured collagen fibrils in laser-welded corneal wounds supported the thermodynamic studies that we carried out recently, which indicated temperatures below 66 degrees C at the weld site under laser irradiation. This observation enabled us to hypothesize that the mechanism, proposed in the literature, of unwinding of collagen triple helixes followed by fibrils "interdigitation" is not likely to occur in the welding process that we set up for the corneal suturing.

Immediate tight sealing of skin incisions using an innovative temperature-controlled laser soldering device: in vivo study in porcine skin

BACKGROUND

A feedback temperature-controlled laser soldering system (TCLS) was used for bonding skin incisions on the backs of pigs. The study was aimed: 1) to characterize the optimal soldering parameters, and 2) to compare the immediate and long-term wound healing outcomes with other wound closure modalities.

MATERIALS AND METHODS

A TCLS was used to bond the approximated wound margins of skin incisions on porcine backs. The reparative outcomes were evaluated macroscopically, microscopically, and immunohistochemically.

RESULTS

The optimal soldering temperature was found to be 65 degrees C and the operating time was significantly shorter than with suturing. The immediate tight sealing of the wound by the TCLS contributed to rapid, high quality wound healing in comparison to Dermabond or Histoacryl cyanoacrylate glues or standard suturing.

CONCLUSIONS

TCLS of incisions in porcine skin has numerous advantages, including rapid procedure and high quality reparative outcomes, over the common standard wound closure procedures. Further studies with a variety of skin lesions are needed before advocating this technique for clinical use.

Closure of skin incisions by 980-nm diode laser welding

A 980-nm diode laser is proposed to be an alternative welding laser in dermatology due to its optimal penetration in tissue. An in vivo predosimetry study was done to estimate the optimal laser energy delivery conditions (6 W, 400 ms). Next, in vivo experiments were comparatively performed to examine healing of wounds closed either with suture or laser welding. One-centimeter-long, full-thickness incisions were done on the dorsal side of Wistar rats. Wounds were surgically removed at 1, 4, 7, 14, and 21 days postoperatively. Macroscopic examinations showed that welding had minimal scarring and a fine quality healing. According to histological (hematoxylin and eosin staining) results, change of epidermal thickness and granulation tissue formation through 21 days of healing period showed similarities in both methods. Epidermal thickness of welded wounds decreased from 62.46+/-6.87 microm (first day) to 36.49+/-0.92 microm (21st day) and that of sutured wounds decreased from 62.94+/-13.53 microm (first day) to 37.88+/-7.41 microm (21st day). At day 14, epidermal thickness of sutured wounds (61.20+/-6.60 microm) were higher than welded wounds (49.69+/-6.31 microm) (p<0.05). Besides, granulation values were greater for the sutured wounds but the difference was statistically significant (p<0.05) only for the seventh day (197,190.29+/-.89,554.96 microm(2) for sutured wounds, 138,433.1+/-51,077.17 microm(2) for welded wounds). Those differences indicate a faster recovery with laser welding. It is concluded that tissue welding with a 980-nm diode laser can be a good candidate for tissue welding applications with accelerated and improved healing, but further investigations are in progress for clinical use.