The use of fibrin sealant to prevent major complications following laparoscopic gastric bypass: results of a multicenter, randomized trial

The role of tissue adhesives and sealants in colorectal anastomotic healing-a scoping review

PURPOSE

Anastomotic leakage (AL) after colorectal resection is a serious postoperative complication with grave consequences for patients. Despite several efforts to reduce its incidence, AL is still seen among 2-20% of colorectal cancer patients receiving an anastomosis. The use of tissue adhesives and sealants as an extra layer of protection around the anastomosis has shown promising results. We conducted a scoping review to provide an overview of the current knowledge on the effect of tissue adhesives and sealants on colorectal anastomosis healing, as well as their effect on the postoperative outcome.

METHODS

The databases of PubMed, Embase, and Cochrane Library were systematically searched on 14/10/2022. Studies addressing the use of a tissue adhesive or tissue sealant applied around a colorectal anastomosis, with the goal to prevent AL or to decrease AL-related complications, were included. We presented an overview of the available studies and summarized their results narratively.

RESULTS

Seven studies were included out of the 846 screened. All authors reported the rate of AL in their interventions group. Five of the studies found a decreased rate of AL compared to the control group. One study had no incidences of AL, while the last study had a seemingly low rate of AL but no comparison group. Information on secondary outcomes was sparingly reported, but the results hinted at a positive effect.

CONCLUSION

Tissue adhesives and sealants might have a beneficial effect on colorectal anastomosis healing. The literature is sparse, and this review has shown the need for further clinical studies.

New Technologies to Prevent Anastomotic Leak

Leaks from anastomoses can be a serious complication of any gastrointestinal resection. Leaks lead to increased morbidity, delayed postoperative recovery, and potential delays in adjuvant treatment in cancer cases. Prevention of anastomotic leak has been an area of ongoing research for decades. Methods of assessing bowel perfusion have been developed that may provide forewarning of anastomotic compromise. Physical reinforcement of the anastomosis with buttressing material is an available method employed with the goal of preventing leaks. Liquid-based sealants have also been explored. Lastly, interactions between the gut microbiome and anastomotic healing have been investigated as a mean of manipulating the microenvironment to reduce leak rates. Though no single technology has been successful in eliminating leaks, an understanding of these developing fields will be important for all surgeons who operate on the gastrointestinal tract.

Assurance of surgical quality within multicenter randomized controlled trials for bariatric and metabolic surgery: a systematic review

BACKGROUND

Surgical quality assurance methods aim to ensure standardization and high quality of surgical techniques within multicenter randomized controlled trials (RCTs), thereby diminishing the heterogeneity of surgery and reducing biases due to surgical variation. This study aimed to establish the measures undertaken to ensure surgical quality within multicenter RCTs investigating bariatric and metabolic surgery, and their influence upon clinical outcomes.

METHODS

An electronic literature search was performed from the Embase, Medline, and Web of Science databases to identify multicenter RCTs investigating bariatric and metabolic surgery. Each RCT was evaluated against a checklist of surgical quality measures within 3 domain: (1) standardization of surgical techniques; (2) credentialing of surgical experience; and (3) monitoring of performance. Outcome measures were postoperative weight change and complications.

RESULTS

Nineteen multicenter RCTs were included in the analysis. Three studies undertook pretrial education of surgical standard. Fourteen studies described complete standardization of surgical techniques. Four studies credentialed surgeons by case volume prior to enrollment. Two studies used intraoperative or video evaluation of surgical technique prior to enrollment. Only two studies monitored performance during the study. Although there were limited quality assurance methods undertaken, utilization of these techniques was associated with reduced overall complications. Standardization of surgery was associated with reduced re-operation rates but did not influence postoperative weight loss.

CONCLUSION

The utilization of methods for surgical quality assurance are very limited within multicenter RCTs of bariatric and metabolic surgery. Future studies must implement surgical quality assurance methods to reduce variability of surgical performance and potential bias within RCTs.

Efficacy of Fibrin Sealant in Reducing Complication Risk After Bariatric Surgery: a Systematic Review and Meta-analysis

BACKGROUND

Complications including staple-line leakage and bleeding may occur after sleeve gastrectomy and Roux-en-Y gastric bypass. In this meta-analysis, the efficacy of fibrin sealant in strengthening the staple line and reducing complication risk after bariatric surgery was evaluated.

METHODS

We searched PubMed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) published up to October 2020. Pooled estimates of the outcomes were computed using a random effects model. The primary outcomes were bleeding and leakage; secondary outcomes were gastric stricture, length of hospital stay, reoperation rate, and total operation time.

RESULTS

In total, 9 RCTs including 2136 patients were reviewed. Our meta-analysis revealed that compared with controls, fibrin sealants decreased incidence of bleeding significantly (risk ratio [RR] = 0.42; 95% confidence interval [CI], 0.18-0.97), but did not demonstrate significant differences in reducing the incidence of leakage (RR = 0.62; 95% CI, 0.23-1.73), gastric stricture (RR = 1.16; 95% CI, 0.46-2.91), reoperation rate (RR = 0.85; CI, 0.14-5.14), or length of hospital stay (weighted mean difference = 0.62; 95% CI, - 0.31 to 1.55). Compared with oversewing, fibrin sealant use reduced the operation time; however, their efficacies in reducing the incidence of postoperative bleeding and leakage did not differ significantly.

CONCLUSIONS

Although applying fibrin sealants to the staple line in bariatric surgery may provide favorable results, but it may not reduce postoperative leakage and stricture incidence significantly. Nevertheless, the application of fibrin sealants as a method for reducing risks of complications after bariatric surgery warrant further investigation.

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

Current bariatric surgical practice has developed from early procedures, some of which are no longer routinely performed. This review highlights how surgical practice in this area has developed over time.

RECENT FINDINGS

This review outlines early procedures including jejuno-colic and jejuno-ileal bypass, initial experience with gastric bypass, vertical banded gastroplasty and biliopancreatic diversion with or without duodenal switch. The role laparoscopy has played in the widespread utilization of surgery for treatment of obesity will be described, as will the development of procedures which form the mainstay of current bariatric surgical practice including gastric bypass, sleeve gastrectomy and adjustable gastric banding. Endoscopic therapies for the treatment of obesity will be described. By outlining how bariatric surgical practice has developed over time, this review will help practicing surgeons understand how individual procedures have evolved and also provide insight into potential future developments in this field.

Robotic "Double Loop" Roux-en-Y gastric bypass reduces the risk of postoperative internal hernias: a prospective observational study

Background

Internal herniation (IH) is a potentially serious complication after laparoscopic Roux-en-Y gastric bypass (RYGB). The aim of the study is to evaluate the incidence of IH after robot-assisted RYGB (RA-RYGB) performed with the “Double Loop” technique at our Institution.

Methods

Prospective cohort study of patients submitted to RA-RYGB with the “Double Loop” technique, with a minimum follow-up of 2 years. Patients with complaints of abdominal pain at clinical visits or entering the emergency department were evaluated. Primary outcome was the incidence of IH, defined as the presence of herniated bowel through a mesenteric defect, diagnosed at imaging or at surgical exploration.

Results

A total of 129 patients were included: 65 (50.4%) were primary procedures, while 64 (49.6%) were revisional operations after primary restrictive bariatric surgery. Mean age was 47.9 ± 10.2 years, mean weight, and body mass index were, respectively, 105.3 ± 22.6 kg and 39.7 ± 9.6 kg/m². Postoperative morbidity rate was 7.0%. Mean follow-up was 53.2 ± 22.6 (range 24–94) months. During the follow-up period, a total of 14 (10.8%) patients entered the emergency department: 1 patient had melena, 4 renal colic, 1 acute cholecystitis, 2 gynecologic pathologies, 2 anastomotic ulcers, 1 perforated gastric ulcer, 1 diverticulitis and 2 gastroenteritis. There were no diagnoses of IH. During the follow-up period, no patient experienced recurrence of symptoms.

Conclusions

In the present study, the robotic approach confirms the low complication rate and absence of IH after “Double Loop” RA-RYGB in a large case-series at a medium-term follow-up.

Costs Analysis of Fibrin Sealant for Prevention of Anastomotic Leakage in Lower Colorectal Surgery

Introduction

Postoperative anastomotic leaks remain a common and serious complication of colorectal surgeries and are a major cause of mortality and morbidity of these procedures. Anastomotic leaks (AL) have been extensively studied; however, there has been no significant reduction in their prevalence over time. In addition, there is a significant economic burden from AL attributed to the need for repeat surgery, radiologic intervention and lengthened hospital stay. We conducted a comparative cost analysis of patients undergoing colorectal surgery with anastomosis, with the application of fibrin sealant (FS) to the sutured anastomosis versus not treating the sutured anastomosis with FS.

Methods

The deterministic decision-tree model was populated with clinical data including operating room time, hospitalization days, occurrence of AL, need for revision surgery, blood products and radiologic interventions to treat the AL in lower colorectal surgery. A systematic literature review was conducted to identify appropriate studies with these variables.

Results

The average cost per case treated lower colorectal surgery with fibrin sealant glue 10 mL Tisseel^® and those not treated with a fibrin sealant after suturing the anastomoses was €3233 and €4130, respectively, for resource expenses paid by the healthcare system. This would suggest potential savings of €897 per surgery, achieved through the application of FS to the sutured anastomosis for preventing AL following colorectal surgery.

Conclusion

Application of FS to the sutured anastomosis in lower colorectal surgery resulted in a decrease in post-operative AL, and cost savings based on a reduction in hospitalization days, a reduction needing: revision surgery, radiologic intervention and blood products to treat AL.

The Safety of Iterative Cytoreductive Surgery and HIPEC for Peritoneal Carcinomatosis: A High Volume Center Prospectively Maintained Database Analysis

INTRODUCTION

Offering iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for recurrence of peritoneal carcinomatosis (PC) poses a surgical dilemma. Safety of this repeated operation in the short and long term has not been largely investigated.

METHODS

Patients with PC who underwent 377 CRS/HIPEC procedures between 2007 and 2018 at our institution were included from a prospectively maintained database. Outcomes for patients who had singular CRS/HIPEC were compared with those for patients who had repeated CRS/HIPEC.

RESULTS

Overall, there were 325 singular and 52 iterative CRS/HIPEC procedures performed during this time period. Age, sex, and ASA class were comparable between cohorts (p = NS). Optimal cytoreduction, mean operative time, mean length of hospital stay, 90-day major morbidity, and 90-day mortality were also similar. At a median follow-up of 24 months, there was no significant difference in recurrence rate (%, 60 vs 63, p = 0.76), disease-free survival (mean months, 19 vs 15, p = 0.30), and overall survival (mean months, 32 vs 27, p = 0.69). The iterative CRS/HIPEC group had significantly higher rates of major late complications than the singular CRS/HIPEC group (%, 18 vs 40, p < 0.01).

CONCLUSION

Repeated CRS/HIPEC for PC has similar perioperative morbidity and mortality, as well as long-term oncological benefits, when compared with singular CRS/HIPEC. However, more than twice as many patients undergoing iterative CRS/HIPEC suffered from major late complications.

The effect of fibrin glue in preventing staple-line leak after sleeve gastrectomy. An experimental study in rats

Purpose

To evaluate the effect of fibrin glue on staple-line leak after sleeve gastrectomy.

Methods

Fourteen adult wistar rats 300 gr were randomized into two groups: Control group (n=7) and study group (n=7). All the rats underwent sleeve gastrectomy using lineer stapler. In the study group, fibrin glue was used to reinforce the staple-line. The rats were sacrificed 7 days after surgery. The stomach was resected, submerged in saline and exposed to excess pressure to obtain a burst pressure value. The gastric staple line was evaluated histopathologically according to the Ehrlich Hunt scale. The results of the two groups were compared.

Results

The mean Ehrlich-Hunt scores for inflammation, fibroblastic activity and neo-angiogenesis were similar between the groups (p>0.05). Collagen deposition was significantly higher in study group (3.42±0.53) when compared with control group (2.57±0.78) (p=0.035). The mean burst pressure was 137.8±8.5 mmHg for control group and 135.0±8.1 mmHg for study group (p=0.536).

Conclusion

Reinforcement of the staple-line with fibrin glue has no effect on the burst pressure after sleeve gastrectomy. More studies are needed to evaluate the precautions against leak after sleeve gastrectomy.

The potential effects of Ankaferd blood stopper and fibrin sealent on sleeve gastrectomy staple-line healing: An experimental study

Staple-line bleeding and leakage is a life-threatening complication in obese patients following laparoscopic sleeve gastrectomy. The aim of this study was to examine the potential effects of Ankaferd blood stopper (ABS) and Fibrin Sealant (FS; Tisseel^®) on sleeve gastrectomy staple-line healing in an experimental animal model. A total of 30 Wistar albino female rats were divided into three groups and were subjected to sleeve gastrectomy with linear stapling. Group A (control group) had nothing administered, Group B was administered FS on the staple-line, and Group C was administered ABS on the staple-line following sleeve gastrectomy. After sacrifice on postoperative day 5, anastomotic burst pressure, tissue hydroxyproline levels and histopathological parameters were measured. The results revealed that group C had the highest mean bursting pressure level. However, the values of this parameter were not found to differ significantly between the groups (P>0.05). Group B and C had a similar hydroxyproline levels but increased compared with group A (P<0.001). Histopathological parameters were similar between the groups, except macrophage scores in group C. In the present experimental study, ABS was demonstrated to improve gastric-sleeved staple-line healing compared with FS. ABS may be used as a novel reinforcement agent in bariatric surgery.

Reinforcement of intrathoracic oesophago-gastric anastomosis with fibrin sealant (Tisseel®) in oesophagectomy for cancer: A prospective comparative study

PURPOSE

Fibrin sealant (Tisseel) is a human protein and thrombin soluble fibrinogen that has been indicated for reinforcement of gastro-intestinal anastomoses to prevent leakage. The objective of this study is to examine the impact of fibrin sealant regarding anastomotic leak, following Ivor-Lewis procedure.

METHODS

This is a prospective comparative study on 2-stage oesophagectomy for cancer of the distal oesophagus or oesophagogastric junction. N = 57 individuals were randomly subjected; n = 22 patients to Tisseel in combination to surgical anastomosis versus n = 35 patients to surgical anastomosis alone. The test of probability was assessed through Chi-Square, independent samples paired T-Test and Log-Rank analysis.

RESULTS

Of the 57 cases included, 56 underwent hybrid and 1 open oesophagectomy. In the Tisseel group, n = 5(22.7%) developed anastomotic leak comparing to n = 3(8.6%) of the control group. No statistically significant difference in leak rate was shown between the two groups; the test of probability was rejected.

CONCLUSIONS

Our results are not supportive of Tisseel tissue sealing property on the intrathoracic oesophago-gastric anastomosis and fibrin sealant's use cannot be justified.

Improving the adhesion, flexibility, and hemostatic efficacy of a sprayable polymer blend surgical sealant by incorporating silica particles

Commercially available surgical sealants for internal use either lack sufficient adhesion or produce cytotoxicity. This work describes a surgical sealant based on a polymer blend of poly(lactic-co-glycolic acid) (PLGA) and poly(ethylene glycol) (PEG) that increases wet tissue adherence by incorporation of nano-to-microscale silica particles, without significantly affecting cell viability, biodegradation rate, or local inflammation. In functional studies, PLGA/PEG/silica composite sealants produce intestinal burst pressures that are comparable to cyanoacrylate glue (160 mmHg), ∼2 times greater than the non-composite sealant (59 mmHg), and ∼3 times greater than fibrin glue (49 mmHg). The addition of silica to PLGA/PEG is compatible with a sprayable in situ deposition method called solution blow spinning and decreases coagulation time in vitro and in vivo. These improvements are biocompatible and cause minimal additional inflammation, demonstrating the potential of a simple composite design to increase adhesion to wet tissue through physical, noncovalent mechanisms and enable use in procedures requiring simultaneous occlusion and hemostasis. STATEMENT OF SIGNIFICANCE: Incorporating silica particles increases the tissue adhesion of a polymer blend surgical sealant. The particles enable interfacial physical bonding with tissue and enhance the flexibility of the bulk of the sealant, without significantly affecting cytotoxicity, inflammation, or biodegradation. These studies also demonstrate how silica particles decrease blood coagulation time. This surgical sealant improves upon conventional devices because it can be easily deposited with accuracy directly onto the surgical site as a solid polymer fiber mat. The deposition method, solution blow spinning, allows for high loading in the composite fibers, which are sprayed from a polymer blend solution containing suspended silica particles. These findings could easily be translated to other implantable or wearable devices due to the versatility of silica particles.

Human fibrin sealant reduces post-operative bile leakage of primary closure after laparoscopic common bile duct exploration in patients with choledocholithiasis

Context:

Primary closure of the common bile duct (CBD) without drainage is considered a suitable approach after laparoscopic CBD exploration (LCBDE); however, the risk of post-operative bile leakage is high. Up to now, it has not been clear whether human fibrin sealant can reduce post-operative bile leakage of the primary suture.

Aims:

In this study, we evaluated the role of human fibrin sealant in primary closure of the CBD after LCBDE.

Subjects and Methods:

Patients with choledocholithiasis who had undergone primary duct closure of the CBD after LCBDE were divided into two groups according to whether fibrin sealant was used.

Statistical Analysis Used:

Fisher's exact test or the Chi-square test was used for categorical variables to calculate frequencies and percentages between the groups. The Student's t-test was used to compare the means of the continuous variables between the groups.

Results:

The human fibrin sealant group had a lower rate of post-operative bile leakage compared to the other group (P < 0.05). There were no significant differences in additional parameters such as operative time, post-operative stay duration, time to drain removal, bile duct stenosis, acute allergic reaction and overall mortality.

Conclusions:

Human fibrin sealant can reduce post-operative bile leakage in primary closure of CBD after LCBDE in patients with choledocholithiasis.

Effectiveness of Fibrin Sealant Application on the Development of Staple Line Complications After Sleeve Gastrectomy: A Prospective Randomized Trial

OBJECTIVES

Evaluate the effectiveness of the use of fibrin sealant (FS) for preventing the development of staple line complications (SLCs) after sleeve gastrectomy (SG).

BACKGROUND

There is no consensus on the best means of preventing SLCs after SG.

METHODS

This was a prospective, intention-to-treat, randomized, 2 center study of a group of 586 patients undergoing primary SG (ClinicalTrials.gov identifier: NCT01613664) between March 2014 and June 2017. The 1:1 randomization was stratified by center, age, sex, gender, and body mass index, giving 293 patients in the FS group and 293 in the control group (without FS). The primary endpoint (composite criteria) was the incidence of SLCs in each of the 2 groups. The secondary criteria were the mortality rate, morbidity rate, reoperation rate, length of hospital stay, readmission rate, and risk factors for SLC.

RESULTS

There were no intergroup differences in demographic variables. In an intention-to-treat analysis, the incidence of SLCs was similar in the FS and control groups (1.3% vs 2%, respectively; P = 0.52). All secondary endpoints were similar: complication rate (5.4% vs 5.1%, respectively; P = 0.85), mortality rate (0.3% vs 0%, respectively; P = 0.99), GL rate (0.3% vs 1.3%, respectively; P = 0.18), postoperative hemorrhage/hematoma rate (1% vs 0.7%, respectively; P = 0.68), reoperation rate (1% vs 0.3%, respectively; P = 0.32). Length of stay was 1 day in both groups (P = 0.89), and the readmission rate was similar (5.1% vs 3.4%, respectively; P = 0.32). No risk factors for SLCs were found.

CONCLUSION

The incidence of postoperative SLCs did not appear to depend on the presence or absence of FS.

Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is considered as a first line treatment for morbid obesity around the globe. Leakage and subsequent gastric fistula is the most dreadful complication, which may lead to serious morbidity and even mortality.

OBJECTIVES

To assess the safety and efficacy of fibrin glue application in the setting of gastric fistula after LSG.

SETTING

University hospital, Israel.

METHODS

Twenty-four morbidly obese patients (mean age = 42.2 yr, mean body mass index = 42 kg/m²) developed gastric fistula after LSG. The fistula was acute in 10 patients, subacute in 9, and chronic in 5. Sixteen patients (67%) have had previous failed endoscopic interventions. Fibrin glue was applied percutaneously with fluoroscopic guidance, under endoscopic visualization. A pigtail drain was left in the distal tract to monitor and manage possible continuous leakage.

RESULTS

There were no complications except abdominal pain in 2 patients associated with fever in 1. Both resolved within 1 to 2 days. Fistula closure was achieved in all patients but 1 (95.8%). Closure was accomplished after a single application in 9 patients (39%), 2 applications in 8, 3 applications in 3, 5 applications in 2, and 6 applications in 1. All patients were followed with a mean time of 42.3 months (range, 20-46).

CONCLUSIONS

Although in most patients there was a need for multiple applications, our experience indicates that percutaneous fluoroscopic application of Fibrin glue under endoscopic visualization proved to be a simple, tolerable, and highly effective method for the treatment of selected patients with gastric fistula after LSG.

The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms

BACKGROUND

Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use.

OBJECTIVES

To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults.

DATA SOURCES

Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms.

REVIEW METHODS

This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis.

RESULTS

We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I² = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I² = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays.

LIMITATIONS

It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available.

CONCLUSIONS

The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020710.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Mesenteric Defect Closure Decreases the Incidence of Internal Hernias Following Laparoscopic Roux-En-Y Gastric Bypass: a Retrospective Cohort Study

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most effective bariatric procedures. Internal hernia (IH) is the commonest long-term complication seen after LRYGB. We analyzed the impact of closure of mesenteric defect at primary surgery on the incidence of IH. We also studied the effectiveness of pre-operative abdominal contrast-enhanced computerized tomography (CECT) in diagnosing IH.

METHODS

This is a retrospective cohort study in which we analyzed prospectively the collected data of all patients who underwent LRYGB from 2005 to 2014. All patients post-LRYGB presenting with unexplained abdominal pain with a suspicion of IH were subjected to a CECT abdomen, in which we looked specifically for "whirlpool" sign and "clustering of bowel loops." All patients underwent diagnostic laparoscopy. We compared the incidence of IH in those who did not undergo mesenteric defect closure (2005-2008, i.e., group A) with those who had the mesenteric defects closed during primary surgery (2009-2014, i.e., group B). We also calculated the sensitivity of abdominal CECT in diagnosing IH pre-operatively.

RESULTS

Among patients who did not undergo closure of any mesenteric defect (group A 2005-2009), 21/600 (3.5 %) developed IH, while 17/976 (1.7 %) patients who underwent mesenteric defect closure (group B 2009-2014) developed IH (p = 0.027). Pre-operative CECT abdomen confirmed the diagnosis of IH in 47.5 % (19/40 patients).

CONCLUSIONS

Closing of mesenteric defects after laparoscopic gastric bypass seems to be related to a lower incidence of internal hernia in the follow up. As the sensitivity of abdominal CECT is low, laparoscopic exploration is recommended based on clinical suspicion.

Complications of staple line and anastomoses following laparoscopic bariatric surgery

With over 600 million people being obese, and given the scientific demonstration of the advantages of surgical treatment, bariatric surgery is on the rise. The promising long-term results in terms of weight loss, and particularly in relation to comorbidities and the control/cure rate, mean that the number of procedures performed in all countries remains high. However, the risk of potentially complex or fatal complications, though small, is present and is related to the procedures per se. This review is a guide for bariatric and/or general surgeons, offering a complete overview of the pathogenesis of anastomosis and staple line following the most common laparoscopic bariatric procedures: sleeve gastrectomy, gastric bypass, and mini-gastric bypass. The review is divided according to the procedure and the complications (leak, bleeding and stenosis), and evaluates all the factors that can potentially improve or worsen the complication rate, representing a “unicum” in the present literature on bariatric surgery.

The mesenteric defects in laparoscopic Roux-en-Y gastric bypass: 5 years follow-up of non-closure versus closure using the stapler technique

BACKGROUND

Internal hernia (IH) is a common complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Little large-volume data exist on how to handle the mesenteric defects during LRYGB. This study evaluated long-term follow-up (5.5 years) of 2443 patients with primary closure of the mesenteric defects with a stapling device at LRYGB, in comparison with a non-closed group from the same centre.

METHODS

All patients (N = 4013) undergoing LRYGB over a 10-year period (2005-2015) at a single institution were evaluated. The mesenteric defects were routinely closed starting June 2010. In total, 1570 non-closure patients and 2443 patients with stapled closure of the defects were prospectively entered and the results analysed.

RESULTS

Closure of the mesenteric defects increased surgical time by 4 min and did not affect the 30-day complication rate. IH incidence was significantly lower (2.5%) in the closure group compared with 11.7% in the non-closure group, at 60 months. The relative risk reduction by closing the mesenteric defects was 4.09-fold (95% CI = 2.97-5.62) as calculated using a survival model.

CONCLUSIONS

Internal hernia after LRYGB occurs frequently if mesenteric defects are left unclosed. Primary closure with a hernia-stapling device is safe and significantly reduces the risk of internal hernia.

Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage

Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.

Effects and results of fibrin sealant use in 1000 laparoscopic sleeve gastrectomy cases

BACKGROUND

Staple-line leakage and bleeding are worrisome and feared postoperative complications after laparoscopic sleeve gastrectomy (LSG) in morbidly obese patients. The purpose of this study was to review clinical evidence following the use of fibrin sealant in standard LSG.

METHODS

Morbidly obese patients who underwent standard technique of LSG with using fibrin sealant were included in the study. Demographics variables [age, gender, body mass index (kg/m²), and comorbid conditions], the re-admission rate, and postoperative early complications, such as bleeding, staple-line leak, twist and stricture, were evaluated at the follow-up during the postoperative first month.

RESULTS

In total, 1000 patients [586 female (58.6 %)] with a mean age of 42.6 ± 13.6 years underwent LSG. Fibrin sealant was used in all operations. In total, 186 patients (18.6 %) had previous abdominal surgery. The mean operative time was 72 ± 19 min, and the mean hospital stay was 3.2 ± 1.1 days. Only 3 patients (.3 %) experienced bleeding. Staple-line leakage, twist and stricture were not observed. The re-admission rate was .5 %, and no mortalities were noted.

CONCLUSION

This retrospective study indicates that bariatric surgeons should consider implementing standardized surgical operative technique for reduced postoperative complications in LSG. Fibrin sealant is a reliable and useful tool to reinforce the staple line and may prevent potential twists of the sleeved stomach.

Efficacy of Human Fibrinogen-Thrombin Patch (TachoSil) Clinical Application in Upper Gastrointestinal Cancer Surgery

BACKGROUND

Previous studies investigated the efficacy and applicability of tissue adhesives in gastrointestinal surgery while no evidence is available to date about a novel compound, TachoSil (Takeda, Zurich, Switzerland). The primary aim of this observational study was to assess the effect of new fibrin sealant on the incidence of postoperative complications in a homogeneous group of patients submitted to upper gastrointestinal surgery for cancer.

METHODS

Two cohorts of 28 and 34 patients undergoing upper gastrointestinal for surgery were compared. In the first cohort, the anastomotic site was treated with TachoSil fibrinogen-thrombin-collagen patches and in the second no collagen sponge or any other hemostatic sealant was used. Postoperative complications and outcomes as well as postoperative biochemical parameters were analyzed.

RESULTS

Postoperative complications occurred in 12 patients (35.3%) and 2 patients (7.1%) in control and collagen sponge group respectively (χ² = 3.539, p < 0.05), with no anastomotic leakage in the collagen sponge group. A binary logistic regression analysis showed that the nonuse of collagen sponge [odds ratio (OR) = 0.025, 95% confidence interval (CI) = 0.001-0.457, p = 0.01] was independently associated with postoperative complication occurrence.

CONCLUSIONS

The addition of fibrinogen-thrombin-collagen sponge patch may reduce postoperative complication rate after upper gastrointestinal surgery for cancer. Further study to delineate the role of TachoSil in gastrointestinal surgery are also needed to demonstrate improved effectiveness and applicability.

Fibrin glue as a protective tool for microanastomoses in limb reconstructive surgery

Aim: Fibrin glue becomes a more and more routinely used tool for stabilization of microanastomoses and nerve repair. This paper summarizes the technical properties and advantages of its use in a wide variety of microsurgical contexts, and includes an exemplary limb reconstructive case.

Patients and methods: A total of 131 patients who had undergone elective and emergency microsurgery mainly of the limbs were retrospectively analyzed, as was the use of free flaps.

Results: The use of fibrin glue allows for proper positioning of anastomoses and repaired nerves. No torsion of the pedicle could be seen. The flap survival rated >94%. The fibrin glue could stay in place in >99%. In the rare case of revision, the fibrin glue could easily be removed without damaging the region of the microanastomosis.

Conclusion: Fibrin glue should not be used to repair insufficient, i.e., leaking anastomoses, but it does protect the site of anastomosis from tissue and fluid pressure. It prevents the pedickle from torsion and its use facilitates relocation of the microanastomoses in cases of revision surgery.

Surgical Treatment of Pressure Ulcers with a Fibrin Sealant in Patients with Spinal Cord Injury: A Cost-Consequence Analysis

BACKGROUND

A comparative study was performed to evaluate the effectiveness and costs of a fibrin sealant (Tissucol Duo [known as Tisseel in the United States], Baxter International, Deerfield, Illinois) to improve postoperative outcomes in patients with spinal cord injury undergoing surgical treatment for pressure ulcers (PrUs).

METHODS

Between January and June 2011, 27 patients underwent surgical treatment for PrUs with the direct application of Tissucol Duo sprayed before closure. The costs and outcomes obtained in this cohort were compared with those obtained in a previous retrospective study where 71 patients underwent conventional surgery.

RESULTS

Lower rates of hematoma-seroma were observed in the study group (3.7% vs 33.8%; P < .05). Drain removal occurred earlier (10 vs 15 days; P < .05), and the average drain volume was also lower (155 vs 360 mL; P < .05) for this group. The mean length of hospital stay was significantly lower in the study group and was the main contributing factor to the overall costs.

CONCLUSIONS

The application of Tissucol Duo during surgical treatment of PrUs in patients with spinal cord injury has been shown to be effective in reducing postoperative complications and in shortening the duration of the hospital stay with a consequent savings in costs.

Incidence of gastrojejunostomy stricture in laparoscopic Roux-en-Y gastric bypass using an autologous fibrin sealant

BACKGROUND

Anastomotic leak at the gastrojejunostomy is a life-threatening complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Fibrin sealants have been used as topical adjuncts to reduce leaks at the gastrojejunostomy. Our clinical observations suggest that an unintended consequence may be the promotion of anastomotic stricture. We hypothesized that the use of fibrin sealant at the gastrojejunostomy in patients undergoing LRYGB decreases the incidence of anastomotic leak but increases the incidence of clinically significant stricture.

METHODS

Following institutional review board approval, medical records of patients undergoing LRYGB by two surgeons at a single institution over a 5-year period were retrospectively reviewed. Preoperative demographics and postoperative complication rates including incidence of gastrojejunostomy leak and endoscopically diagnosed stricture requiring dilation within 1 year of surgery were recorded.

RESULTS

Four hundred twenty-five patients had fibrin sealant routinely applied to their gastrojejunostomy site and 104 did not. Four leaks occurred in the sealant group and two leaks occurred in the control group (p = 0.2). Of patients who received sealant, 1.6 % needed postoperative blood transfusion compared to 4.8%of those who did not receive sealant (p=0.05) [corrected]. There was a significantly increased rate of strictures requiring dilation in the sealant group (11.3% compared to 4.8% stricture rate in patients who did not receive sealant, p = 0.04).

CONCLUSIONS

In our experience, the use of fibrin sealant at linear stapled gastrojejunostomy site during LRYGB increases the incidence of clinically significant postoperative stricture and does not reduce the incidence of anastomotic leak.

Technical factors associated with anastomotic leak after Roux-en-Y gastric bypass

BACKGROUND

Anastomotic leak is one of the most serious complications after Roux-en-Y gastric bypass (RYGB). Our objective was to examine the relationship between technical factors and incidence of clinically relevant anastomotic leak after RYGB in longitudinal assessment of bariatric surgery (LABS). The setting of the study was 11 bariatric centers in the United States, university, and private practice.

METHODS

Patient characteristics, technical factors of surgery, and postoperative outcomes were assessed by trained researchers using standardized protocols. Correlation of surgical factors of patients undergoing RYGB (n = 4444) with the incidence of postoperative anastomotic leak was assessed by univariate χ(2) analysis.

RESULTS

Forty-four participants (1.0%, 95% CI .7%-1.3%) experienced a clinically relevant anastomotic leak. Of these, 39 (89%) underwent abdominal reoperation and 3 (7%) died. Technical factors associated with anastomotic leak were open surgery (P<.0001), revision surgery (P<.0001), and use of an abdominal drain (P = .02). Provocative leak testing, method of gastrojejunostomy, and use of fibrin sealant were not associated with anastomotic leak.

CONCLUSIONS

Anastomotic leak after RYGB was rare (1.0%). Most cases required reintervention; however, the majority (93%) recovered from this event. Open surgery, revision surgery, and routine drain placement were associated with increased leak rate. Some of these findings may be due to differences in preoperative patient risk.

The effects of reinforcement methods on burst pressure in resected sleeve gastrectomy specimens

BACKGROUND

Staple-line leak is a life-threatening complication of laparoscopic sleeve gastrectomy. Reinforcement materials have been reported to lower the risk of staple-line bleeding, but their effects on leak risk have not been elucidated. The aim of this study was to compare the effects of two supportive techniques on burst pressures in sleeved gastrectomy specimens.

MATERIALS AND METHODS

Thirty patients who underwent laparoscopic sleeve gastrectomy were evaluated. The resected sleeve gastrectomy specimens were categorized into three groups. Group 1 had no extra support in the staple line, Group 2 had oversewing with continuous suture on the staple line, and Group 3 had fibrin sealant (Tisseel(®); Baxter, Deerfield, IL) on the staple line. The end point was the first detectable leakage, at which point leak pressure and the anatomic site of leakage were recorded.

RESULTS

Thirty sleeved gastrectomy specimens were included (each group included 10 specimens). There were no differences among group in terms of age, sex, and body mass index. The leak pressure was significantly higher (106±10.5 mm Hg) in Group 2 (P<.01). Leaks occurred significantly more frequently in the staple line than in the staple junction points (P=.014).

CONCLUSIONS

Oversewing the staple line with 3-0 Vicryl(®) (Ethicon, Somerville, NJ) suture significantly increased the strength of the staple line. Increases in intraluminal pressure are known to be one of the significant risks in leak etiology. Thus, we concluded that oversewing the staple line with 3-0 Vicryl suture can be beneficial in the prevention of leaks. However, further work is necessary in this area of research.

The prevention of colorectal anastomotic leakage with tissue adhesives in a contaminated environment is associated with the presence of anti-inflammatory macrophages

BACKGROUND

Colorectal anastomoses created in a contaminated environment result in a high leakage rate. This study investigated whether using anastomotic sealants (TissuCol(®), Histoacryl(®) Flex, and Duraseal(®)) prevents leakage in a rat peritonitis model.

STUDY DESIGN

Sixty-seven Wistar rats were divided into control and experimental groups (TissuCol, Histoacryl, and Duraseal groups). Peritonitis was induced 1 day before surgery with the cecal ligation puncture model. On day 0, colonic anastomosis was constructed with sutures and then sealed with no adhesive (control group) or one select adhesive (experimental groups). Bursting pressure, abscess formation, and adhesion severity were evaluated on day 3 or day 14. Hematoxylin and eosin staining and immunohistochemical staining for CD4, CD8, CD206, and iNOS were performed.

RESULTS

On day 3, bursting pressures of the TissuCol group (120.1 ± 25.3 mmHg), Histoacryl group (117.3 ± 20.2 mmHg), and Duraseal group (123.6 ± 35.4 mmHg) were significantly higher than the that of the control group (24.4 ± 31.7 mmHg, p < 0.001). Abscesses around the anastomosis were found in the control group (6/7) and Duraseal group (2/9) but not in the TissuCol group or Histoacryl group. A higher number of CD206+ cells (M2 macrophages), a lower number of iNOS+ cells (M1 macrophages), a higher M2/M1 index, and a higher CD4+/CD8+ index were seen at the anastomotic site in all experimental groups compared with the control group on day 3. On day 14, abscesses were only found in the control group. Adhesion severity in the Duraseal group was significantly lower than that in the control group (p = 0.001).

CONCLUSIONS

Anastomotic sealing using TissuCol(®), Histoacryl(®) Flex, or Duraseal(®) seems to be an effective and safe option to prevent leakage in contaminated colorectal surgery. The presence of large numbers of anti-inflammatory macrophages seems to be involved in preventing the leakage.

Fibrin glue does not improve healing of gastrointestinal anastomoses: a systematic review

BACKGROUND/AIM

Anastomotic leakage remains a frequent and serious complication in gastrointestinal surgery. In order to reduce its incidence, several clinical and experimental studies on anastomotic sealing have been performed. In a number of these studies, the sealing material has been fibrin glue (FG), and the results in individual studies have been varying. The positive effect of anastomotic sealing with FG might be due to the mechanical/physical properties, the increased healing of the anastomoses or both. The aim of this systematic review was to evaluate the existing evidence on the healing effects of FG on gastrointestinal anastomoses.

METHODS

PubMed, EMBASE and the Cochrane databases were searched for studies evaluating the healing process of gastrointestinal anastomoses after any kind of FG application. The search period was from 1953 to December 2013.

RESULTS

Twenty-eight studies were included in the qualitative synthesis. These studies were all experimental studies, since no human studies used histological or biochemical evaluation of healing. In 7 of the 28 studies, a positive effect of FG on healing was found, while 8 studies reported a negative effect and 11 studies found no effect. Furthermore, 2 studies reported unclear results. The difference in the study outcome was independent of the study design and the type of FG used.

CONCLUSION

In the available studies, FG did not consistently have a positive influence on the healing of gastrointestinal anastomoses. It is consequently plausible that the positive effect of FG sealing of gastrointestinal anastomoses, if there is any, may be due to a mechanical sealing effect rather than due to improved healing per se.

Laparoscopic sleeve gastrectomy: efficacy of fibrin sealant in reducing postoperative bleeding. A randomized controlled trial

Staple line leakage and bleeding are worrisome complications of laparoscopic sleeve gastrectomy (LSG). Solutions such as buttressing, oversewing or roofing the staple line with gelatin matrix have been proposed with controversial results. Because the use of fibrin sealant has shown a possible benefit in reducing the reoperation rate due to early complication in patients (pts) undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP), this solution has been tested in 100 consecutive pts undergoing LSG. A clinical trial has been performed on 100 consecutive pts. Exclusion criteria from the study were considered ASA IV pts, treated or untreated malignancies at any stage, steroids or FANS assumption, previous sovramesocolic surgery and conversion to open surgery. All pts were randomized to receive (group A, 50 pts) or to not receive (group B, 50 pts) 4 ml of human fibrin sealant (Tisseel™, Baxter(®) Deerfield, IL, USA) sprayed along the suture line. Primary endpoint was the incidence of postoperative complications: leaks, bleeding of the staple line or stenosis of the gastric remnant. Significance was assigned at a p level <0.05. By considering pts in group A vs. pts in group B our results shown no significant difference in fistulas or strictures occurrence (p = 0.2). Bleeding was significantly higher in patients not sprayed with sealant (group A vs. group B, 1/7, p = 0.03). This randomized trial has so far shown the use of fibrin sealant in LSG to significantly reduce postoperative bleeding. Although a trend in reducing leak occurrence emerges, it does not reach statistical significance.

Fibrin glue and stents in the treatment of gastrojejunal leaks after laparoscopic gastric bypass: a case series and review of the literature

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most commonly performed bariatric/metabolic operation in Europe. Different treatment options for the management of gastrojejunal (GJ) leaks following LRYGB have been published. We looked at our own experience with GJ leaks after 645 consecutive LRYGB operations and reviewed the literature with focus on the use of fibrin sealant and self-expandable metal stents as treatment options. Patient data were prospectively collected in the hospital's database for bariatric patients. All patients with confirmed GJ leaks were reviewed. Patients with GJ leaks were actively treated by a combination of laparoscopic drainage and endoscopic fibrin sealant injections and/or stenting. Six patients (0.93%) have been treated for GJ leaks. All leaks were successfully treated and there was no leak-related mortality. The mean (SD) time for closure of the leaks and length of hospital stay was 19.5 days (6.2) and 23.2 days (3.7). The literature concerning endoscopic treatment options in case of GJ leaks following LRYGB operations is scarce and inconclusive. Immediate and active treatment with a combination of operative and endoscopic treatment options, rather than choosing only one treatment over another, may enhance the recovery process.

Protection of colonic anastomosis with platelet-rich plasma gel in the open abdomen

BACKGROUND

Although evidence for colonic anastomosis in the damage control abdomen continues to accumulate, anastomotic leak is common and associated with greater morbidity. The purposes of our study was to evaluate the effect of platelet-rich plasma (PRP) gel on the healing of colon anastomosis and anastomotic strength in the open abdomen.

METHODS

PRP was prepared by enriching whole blood platelet concentration from healthy rat. In the rodent model, standard colonic anastomoses followed by closure of abdomen (Control; n=10) and anastomoses followed by open abdomen (OA; n=10) were compared to PRP-sealed anastomoses in open abdomen (OA+PRP; n=10). One week after surgery, body weight, anastomotic bursting pressure, hydroxyproline concentration, and histology of anastomotic tissue were evaluated.

RESULTS

All rats survived surgery and had no signs of anastomotic leakage. Compared with the control and PRP group, OA group exhibited a significant decrease in body weight, anastomotic bursting pressure, hydroxyproline concentration, and collagen deposition. No significant difference was detected in these variables between the PRP group and the control group.

CONCLUSION

PRP gel application prevented delayed anastomotic wound healing after open abdomen, which suggested that anastomotic sealing with PRP gel might improve outcome of colonic injuries in the setting of open abdomen.

Oncologic impact of anastomotic leakage in rectal cancer surgery according to the use of fibrin glue: case-control study using propensity score matching method

BACKGROUND

The oncologic impact of anastomotic leakage after rectal cancer surgery remains controversial.

METHODS

Between January 1999 and December 2010, 1,148 patients with rectal cancer who underwent curative surgery with sphincter preservation were retrospectively reviewed. Using the propensity score matching method, 328 patients with fibrin glue were matched to 328 patients without fibrin glue, and oncologic outcomes were compared in the matched groups.

RESULTS

Anastomotic leakage was diagnosed in 76 patients (6.6%). On multivariate analysis, fibrin glue was the independent predictor of prevention of anastomotic leakage. In the 656 matched groups, patients with anastomotic leakage had significantly worse 5-year local recurrence-free survival and disease-free survival than those without leakage. Multivariate analysis confirmed that anastomotic leakage was an independent prognostic factor of both local recurrence and disease-free survival, but the use of fibrin glue was not associated with the long-term outcomes when controlling for confounders.

CONCLUSIONS

Anastomotic leakage is a major independent prognostic factor for long-term outcomes. Fibrin glue has a protective effect of anastomosis, without oncologic advantages.

A totally recombinant human fibrin sealant

BACKGROUND

Applications of plasma-derived human fibrin sealants (pdhFS) have been limited because of cost, limited supply of pathogen-screened plasma, the need for bioengineering improvements, and regulatory issues associated with federal approval. We describe a totally recombinant human fibrin sealant (rhFS), which may engender an abundant, safe, and cost-effective supply of efficacious fibrin sealant.

MATERIALS AND METHODS

A first-generation rhFS made from recombinant human fibrinogen (rhFI; produced in the milk of transgenic cows), activated recombinant human factor XIII (rhFXIIIa; produced in yeast), and recombinant human thrombin (rhFIIa; purchased, made in animal cell culture) was formulated using thromboelastography (TEG). The hemostatic efficacy of rhFS versus commercial pdhFS was compared in a nonlethal porcine hepatic wedge excision model.

RESULTS

The maximal clot strength of rhFS measured in vitro by TEG was not statistically different than that of pdhFS. TEG analysis also showed that the rhFS gained strength more quickly as reflected by a steeper α angle; however, the rhFS achieved this clot strength with a 5-fold lower factor I content than the pdhFS. When these fibrin sealants were studied in a porcine hepatic wedge excision model, the hemostatic scores of the rhFS were equivalent or better than that of the pdhFS.

CONCLUSIONS

The bioengineered rhFS had equivalent or better hemostatic efficacy than the pdhFS in a nonlethal hemorrhage model, despite the factor I concentration in the rhFS being about one-fifth that in the pdhFS. Because the rhFS is amenable to large-scale production, the rhFS has the potential to be more economical and abundant than the pdhFS, while having a decreased risk of blood-borne pathogen transmission.

Tensile strength after closure of mesenteric gaps in laparoscopic gastric bypass: three techniques tested in a porcine model

BACKGROUND

Internal hernias occur frequently after laparoscopic gastric bypass. We have found no data on the relative strength of the various techniques available for closing these defects. The present study was performed to obtain such data to form a theoretical basis for clinical studies.

METHODS

Six piglets were operated laparoscopically and four loops of small bowel created in each. These mesenteric gaps were closed over a distance of 40 mm using (1) running 2-0 Ethibond® suture, (2) Endo Hernia stapler, (3) fibrin glue (Tisseel®) and (4) controls, where the mesenteric surfaces were rubbed with a sponge and approximated without further intervention. After 6 weeks, the different segments of the mesentery were excised. The tensile strength was measured using continuously increased traction until the closure ruptured. The ordinary mesentery served as the control. The breaking tension and total amount of energy transferred to the tissue were registered.

RESULTS

Control areas with rubbed areas developed no adhesions. Suture and staple lines contracted by 30 % in length, whereas the fibrin glued lines were even shorter. Median tensile strength was greatest for the sutured lines (14,293 mN) and stapled lines (10,798 mN). Fibrin glued lines were significantly weaker (6,780 mN, p = 0.013 and p = 0.026), but as strong as ordinary mesentery (4,165 mN).

CONCLUSIONS

If ongoing controlled randomized trials show closure to be beneficial, further studies should include staples as one of the options for the closure of mesenteric defects. The role of fibrin glue needs to be further investigated.

Prevention of leakage by sealing colon anastomosis: experimental study in a mouse model

BACKGROUND

In colorectal surgery, anastomotic leakage (AL) is the most significant complication. Sealants applied around the colon anastomosis may help prevent AL by giving the anastomosis time to heal by mechanically supporting the anastomosis and preventing bacteria leaking into the peritoneal cavity. The aim of this study is to compare commercially available sealants on their efficacy of preventing leakage in a validated mouse model for AL.

METHODS

Six sealants (Evicel, Omnex, VascuSeal, PleuraSeal, BioGlue, and Colle Chirurgicale Cardial) were applied around an anastomosis constructed with five interrupted sutures in mice, and compared with a control group without sealant. Outcome measures were AL, anastomotic bursting pressure, and death.

RESULTS

In the control group there was a 40% death rate with a 50% rate of AL. None of the sealants were able to diminish the rate of AL. Furthermore, use of the majority of sealants resulted in failure to thrive, increased rates of ileus, and higher mortality rates.

CONCLUSIONS

If sealing of a colorectal anastomosis could achieve a reduction of incidence of clinical AL, this would be a promising tool for prevention of leakage in colorectal surgery. In this study, we found no evidence that sealants reduce leakage rates in a mouse model for AL. However, the negative results of this study make us emphasize the need of systemic research, investigating histologic tissue reaction of the bowel to different sealants, the capacity of sealants to form a watertight barrier, their time of degradation, and finally their results in large animal models for AL.

Tissue adhesives in gastrointestinal anastomosis: a systematic review

BACKGROUND

Anastomotic leakage in gastrointestinal (GI) surgery remains a major problem. Although numerous studies have been undertaken on the role of tissue adhesives as GI anastomotic sealants, no clear overview has been presented. This systematic review aims to provide a clear overview of recent experimental and clinical research on the sealing of different levels of GI anastomosis with tissue adhesives.

METHODS

We searched MEDLINE and Embase databases for clinical and experimental articles published after 2000. We included articles only if these addressed a tissue adhesive applied around a GI anastomosis to prevent anastomotic leakage or decrease leakage-related complications. We categorized results according to level of anastomosis, category of tissue adhesive, and level of evidence.

RESULTS

We included 48 studies: three on esophageal anastomosis, 13 on gastric anastomosis, four on pancreatic anastomosis, eight on small intestinal anastomosis, and 20 on colorectal anastomosis; 15 of the studies were on humans.

CONCLUSIONS

Research on ileal and gastric/bariatric anastomosis reveals promising results for fibrin glue sealing for specific clinical indications. Sealing of pancreatico-enteric anastomosis does not seem to be useful for high-risk patients; however, research in this field is limited. Ileal anastomotic sealing was promising in every included study, and calls for clinical evaluation. For colorectal anastomoses, sealing with fibrin glue sealing seems to have more positive results than with cyanoacrylate. Further research should concentrate on the clinical evaluation of promising experimental results as well as on new types of tissue adhesives. This research field would benefit from a systematic experimental approach with comparable methodology.

Cholestasis as the leading sign of a transmesenteric hernia in a split-liver transplanted child - a case report and review of literature

Internal hernias are an extremely rare complication after pediatric liver transplantation, and its presentation with cholestasis has not been described to date. We report the case of a 12-yr-old boy who presented with moderate abdominal pain 11 yr after split liver transplantation and biliary-enteric anastomosis. He developed severe jaundice within 24 h of initial presentation. Imaging studies revealed ascites, dilation of the intrahepatic bile ducts, a dilated Roux-en-Y-loop, with the loop truncated at the level of the mesenteric artery, which performed a narrow right-to-left loop. At laparotomy, a transmesenteric internal hernia at the root of the jejunal mesentery was identified, originating from the creation of the Y-loop; the Roux-en-Y-loop and its adjacent intestinal loops had slipped through the opening. The Roux-en-Y loop was ischemic from strangulation, and the rest of the intestine well perfused. No surgical resection was necessary following reduction. The patient recovered completely. We discuss diagnosis and management of internal hernias, and review radiological signs. Internal transmesenteric hernias can occur at any time after liver transplantation and prompt diagnosis and surgical treatment are vital.

[Use of fibrin based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract: preliminary results of the multicentre, prospective, randomised, controlled, and simple blind phase IV clinical trial: Protissucol001]

INTRODUCTION

A multicentre, prospective, randomised, controlled, and simple blind clinical trial was started in January 2007, with the aim of demonstrating the efficacy of fibrin-based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract.

MATERIAL AND METHODS

A study on the prevention of anastomotic healing defects by applying biological adhesives along the suture line began in January 2007, and included the hospitals, Gregorio Marañón, Universitario de San Carlos, and Hospital del Sureste, in Madrid. The enrolled patients were randomised to one of 2 groups: the study group in which the adhesive was applied to the suture line, and a control group in which it was not applied. The primary outcome of the study was the presence or absence of leaks. The trial was approved by the corresponding Clinical Research Ethics Committees and the Spanish Medicines Agency (AEMPS) and registered www.clinicaltrials.gov (NCT01306851). The authors declared not to have any conflict of interests with the company, Baxter, which markets the product in Spain.

RESULTS

A total of 104 patients were recruited between January 2007 and November 2010, of whom 52 were randomised to the study group, and 52 to the control group. A total of 22 anastomotic leaks were recorded, of which 7 (13.4%) were in the study group, and 15 (28.8%) in the control group (P=.046). The leak risk index was 0.384, which means that there was a 61% reduction in leaks in the patients who had the fibrin-based biological adhesive applied. There were 3 (5.7%) further surgeries in the study group, compared to 12 (23%) in the control group (P=.12). On analysing the mortality, it was observed that 3 patients in the study group and 4 patients in the control group died (5.7% vs. 7.7%, P=.5). No other significant differences were found as regards the type of suture, surgical time, or pre-surgical history, except that the use of drainages appeared to be a protective factor of anastomotic leak (P=.041), although the use or not of a drainage was not a controlled factor, but at the discretion of each surgeon.

CONCLUSIONS

Our study demonstrates, significantly, that in the 104 patients in the study that fibrin based biological adhesives are capable of preventing anastomotic leaks in the high risk digestive tract, reducing the risk of leaks by 61% and a further surgeries. This is the first clinical trial that shows these significant results. If our results are maintained at the end of the study, it will show that anastomotic leaks can be prevented with the application of these adhesives, thus their application may be recommended in all the anastomosis of the high risk digestive tract.

Training programs influence in the learning curve of laparoscopic gastric bypass for morbid obesity: a systematic review

The makeup of a new surgical bariatric team may be associated with a higher number of postoperative complications due to the learning curve. The aim of this study was to evaluate the outcomes during the learning curve of laparoscopic gastric bypass (LGBP) depending on surgeons' training. A systematic approach was used to review studies from the Pubmed, Embase (Ovid), Cancer Lit, Biomes Central via Scirus, Current Contens (ISI), and Web of Science (SCI) databases. Two reviewers independently screened all titles/abstracts and included/excluded studies based on full copies of manuscripts. The outcomes included were: specific training of the surgeon, postoperative complications (leaks, occlusion, hemorrhage, pneumonia, etc.), mortality, and surgical technique. One reviewer put data onto an Excel spreadsheet. Statistical analysis was performed with weighted linear regression. We identified 448 citations, of which 120 abstract and 50 full-text publications were reviewed. Fourteen papers were selected. Data from 1,848 patients were included. Eighteen different surgeons were analyzed during their learning curve (including the first author of this study). Surgeons were divided into two groups: (1) without formal laparoscopic bariatric training (13 surgeons) and (2) with formal laparoscopic bariatric training (five surgeons). Postoperative complications were more frequent in group 1: 18.1% (± 7.6) vs. 7.7% (± 1.96, p = 0.046); also, mortality was more frequent in group 1: 0.57% (± 0.87) vs. 0% (p = 0.05). An appropriated training in laparoscopic bariatric surgery contributes to a significant reduction in postoperative complications and mortality during the learning curve of LGBP.

Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial

BACKGROUND

The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. The purpose of this study was to compare prospectively and randomly three different techniques of SLR during LSG.

METHODS

From April 2010 to April 2011, patients submitted to LSG were randomly selected for the following three different techniques of SLR: oversewing (group A); buttressed transection with a polyglycolide acid and trimethylene carbonate (group B); and staple-line roofing with a gelatin fibrin matrix (group C). Primary endpoints were reinforcement operative time, incidence of postoperative staple-line bleeding, and leaks. Operative time was calculated as follows: oversewing time in group A; positioning of polyglycolide acid and trimethylene carbonate over the stapler in group B; and roofing of the entire staple line in group C.

RESULTS

A total of 120 patients were enrolled in the study (82 women and 38 men). Mean age was 44.6 ± 9.2 (range, 28-64) years. Mean preoperative body mass index was 47.2 ± 6.6 (range, 40-66) kg/m². Mean time for SLR was longer in group A (14.2 ± 4.2 (range, 8-18) minutes) compared with group B (2.4 ± 1.8 (range, 1-4) minutes) and group C (4.4 ± 1.6 (range, 3-6) minutes; P < 0.01). Four major complications were observed (3.3 %): one leak and one bleeding in group A; one bleeding in group B; and one leak in group C, with no significant differences between the groups. No mortality was observed.

CONCLUSIONS

SLR with either polyglycolide acid with trimethylene carbonate or gelatin fibrin matrix is faster compared with oversewing. No significant differences were observed regarding postoperative staple-line complications.

Is bariatric surgery safe in patients who refuse blood transfusion?

BACKGROUND

A small, but significant, number of patients undergoing bariatric surgery refuse blood transfusion for religious or other personal reasons. Jehovah's Witnesses number more than 1 million members in the United States alone. The reported rates of hemorrhage vary from .5% to 4% after bariatric surgery, with transfusion required in one half of these cases. Pharmacologic prophylaxis against venous thromboembolism could further increase the perioperative bleeding risk. Our objective was to report the perioperative outcomes of bariatric surgery who refuse blood transfusion at a bariatric center of excellence, private practice in the United States.

METHODS

A retrospective review of all patients who refused blood transfusion when undergoing bariatric surgery during a 10-year period was conducted. Patients were identified from a prospectively maintained database by the bloodless surgery program at Legacy Good Samaritan Hospital. Data were collected on demographics, co-morbidities, laboratory values, medication use, blood loss, and 30-day complications.

RESULTS

Thirty-five bloodless surgery patients underwent bariatric surgery from 2000 to 2009. Of these 35 patients, 21 underwent laparoscopic adjustable gastric banding and 14 Roux-en-Y gastric bypass. Before 2006, only pneumatic compression devices were applied for venous thromboembolism prophylaxis (n = 6). Subsequently, combination venous thromboembolism prophylaxis was performed with fondaparinux sodium 2.5 mg for RYGB or enoxaparin 40 mg for LAGB (n = 29). One RYGB patient developed postoperative hemorrhage requiring reoperation. No venous thromboembolisms or deaths occurred.

CONCLUSION

Bariatric surgery can be performed in patients who refuse blood transfusion with acceptable postoperative morbidity. Larger studies are necessary to confirm the safety of this approach and to examine the effect of pharmacologic thromboprophylaxis in this patient group.

The effect of fibrin glue on the early healing phase of intestinal anastomoses in the rat

PURPOSE

Protecting the anastomotic integrity using suture or staple line reinforcement remains an important goal for ongoing research. The present comprehensive study aims to establish the effects of fibrin glue on the early phase of anastomotic healing in the rat intestine.

METHODS

One hundred and eight young adult male Wistar rats underwent resection and anastomosis of both the ileum and colon. In half, fibrin glue was applied around the anastomoses. Parameters for repair included wound strength, both bursting pressure and breaking strength at days 1, 3, and 5 after operation; hydroxyproline content; and histology, the latter also after 7 days.

RESULTS

A transient colonic ileus was observed in the experimental group. Anastomotic breaking strength was always similar in both the control and fibrin glue groups. Anastomotic bursting pressures remained low at days 1 and 3, without any differences between the groups. In both groups, the bursting pressure increased sharply (p < 0.001) between days 3 and 5. At day 5, the bursting pressure in the fibrin glue group remained below than that in the controls, although only significantly (p = 0.0138) so in the ileum. At day 5, but not at day 7, the wounds in the fibrin glue group contained less collagen. Other aspects of microscopic wound architecture appeared to be the same.

CONCLUSIONS

There is no justification for using fibrin glue on patent anastomoses constructed under low-risk conditions. Its potential benefit under conditions where chances for anastomotic leakage are enhanced needs further investigation.