Efficacy and safety of non-suture dural closure using a novel dural substitute consisting of polyglycolic acid felt and fibrin glue to prevent cerebrospinal fluid leakage-A non-controlled, open-label, multicenter clinical trial

Dural Reconstruction Materials for the Repairing of Spinal Neoplastic Cerebrospinal Fluid Leaks

Spinal tumors often lead to more complex complications than other bone tumors. Nerve injuries, dura mater defect, and subsequent cerebrospinal fluid (CSF) leakage generally appear in spinal tumor surgeries and are followed by serious adverse outcomes such as infections and even death. The use of suitable dura mater replacements to achieve multifunctionality in fluid leakage plugging, preventing adhesions, and dural reconstruction is a promising therapeutic approach. Although there have been innovative endeavors to manage dura mater defects, only a handful of materials have realized the targeted multifunctionality. Here, we review recent advances in dura repair materials and techniques and discuss the relative merits in both preclinical and clinical trials as well as future therapeutic options. With these advances, spinal tumor patients with dura mater defects may be able to benefit from novel treatments.

Clinical management of dural defects: A review

Dural defects are common in spinal and cranial neurosurgery. A series of complications, such as cerebrospinal fluid leakage, occur after rupture of the dura. Therefore, treatment strategies are necessary to reduce or avoid complications. This review comprehensively summarizes the common causes, risk factors, clinical complications, and repair methods of dural defects. The latest research progress on dural repair methods and materials is summarized, including direct sutures, grafts, biomaterials, non-biomaterial materials, and composites formed by different materials. The characteristics and efficacy of these dural substitutes are reviewed, and these materials and methods are systematically evaluated. Finally, the best methods for dural repair and the challenges and future prospects of new dural repair materials are discussed.

Efficacy and safety of polyethylene glycol dural sealant system in cranial and spinal neurosurgical procedures: Meta-analysis

Background:

We aimed to assess the efficacy of polyethylene glycol (PEG) dura sealant to achieve watertight closure, prevention of cerebrospinal fluid (CSF) leak and to investigate its possible side effects.

Methods:

We searched Medline (through PubMed), Scopus, and the Cochrane Library through December 2019. We included articles demonstrating cranial or spinal procedures with the use of PEG material as a dural sealant. Data on intraoperative watertight closure, CSF leak, and surgical complications were extracted and pooled in a meta-analysis model using RevMan version 5.3 and OpenMeta (Analyst).

Results:

Pooling the controlled trials showed that PEG resulted in significantly more intraoperative watertight closures than standard care (risk ratio [RR] = 1.44, 95% confidence interval [CI] [1.24, 1.66]). However, the combined effect estimate did not reveal any significant difference between both groups in terms of CSF leaks, the incidence of surgical site infections, and neurological deficits (P = 0.7, 0.45, and 0.92, respectively). On the other hand, pooling both controlled and noncontrolled trials showed significance in terms of leak and neurological complications (RR = 0.0238, 95% CI [0.0102, 0.0373] and RR = 0.035, 95% CI [0.018, 0.052]). Regarding intraoperative watertight closure, the overall effect estimate showed no significant results (RR=0.994, 95% CI [0.986, 1.002]).

Conclusion:

Dura seal material is an acceptable adjuvant for dural closure when the integrity of the dura is questionable. However, marketing it as a factor for the prevention of surgical site infection is not scientifically proved. We suggest that, for neurosurgeons, using the dural sealants are highly recommended for duraplasty, skull base approaches, and in keyhole approaches.

Applications of materials for dural reconstruction in pre-clinical and clinical studies: Advantages and drawbacks, efficacy, and selections

The dura mater provides a barrier to protect the tissue underneath and cerebrospinal fluid. However, dural defects normally cause cerebrospinal fluid leakage and other complications, such as wound infections, meningitis, etc. Therefore, the reconstruction of dura mater has important clinical significance. Current dural reconstruction materials include: homologous, acellular, natural, synthetic, and composite materials. This review comprehensively summarizes the characteristics and efficacy of these dural substitutes, especially in clinical applications, including the advantages and drawbacks of those from different sources, the host tissue response in pre-clinical studies and clinical practice, and the comparison of these materials across different surgical procedures. Furthermore, the selections of materials for different surgical procedures are highlighted. Finally, the challenges and future perspectives in the development of ideal dural repair materials are discussed.

A new technology for reducing anastomotic fistula in the neck after esophageal cancer surgery

Background

To explore the risk factors and prevention methods of cervical mechanical anastomotic fistula and stenosis after the radical resection of esophageal cancer.

Methods

From March 2018 to November 2018, 128 patients undergoing mechanical anastomosis of esophageal cancer were selected from the Department of Thoracic Surgery of The First Affiliated Hospital of Zhengzhou University. All the enrolled patients were operated on using the Mckeown method, and a retrospective study was conducted. Data for preoperative and postoperative test indices, intraoperative embedding materials, postoperative complications, and preoperative and postoperative treatment were collected, and the relationship between various factors and the incidence of cervical anastomotic fistula and stenosis was analysed. Univariate analysis was conducted using t tests or Fisher's exact probability method, and multivariate analysis was conducted using logistic regression models.

Results

All 128 patients successfully underwent surgery without dying. The enrolled patients were evaluated using the Stooler classification, with 28 patients having grade 0, 41 patients having grade 1, 34 patients having grade 2, 21 patients having grade 3, and 4 patients having grade 4 stenosis. Patients with stenosis of grade 3 or above had obvious choking sensation, which could only be relieved by balloon dilation. Symptoms in all patients with stenosis were relieved by balloon dilation. There were no significant differences between the two groups regarding embedding materials, preoperative choking history, history of alcohol consumption, history of hypertension, history of coronary heart disease, history of diabetes, postoperative calcium concentration, average albumin concentration, average platelet concentration, body mass index, anastomotic fistula, preoperative chemotherapy, postoperative chemotherapy, or postoperative cough (P>0.05). There were significant differences in postoperative reflux (χ²=11.338, P<0.05) and scar constitution (χ²=12.497, P<0.05). The effects of embedding materials in patients with anastomotic fistula were significantly different (χ²=4.372, P<0.05).

Conclusions

Postoperative reflux and scar constitution may be risk factors for postoperative anastomotic stenosis after resection of esophageal cancer. There was almost no difference in the effects on esophageal anastomotic stenosis between embedding materials and the omentum majus, but Neoveil^® may have certain advantages in preventing cervical anastomotic fistula, and thus may have certain clinical application value.

[Application of adhesive compositions in surgery (in Russian only)]

New adhesive compositions will almost completely prevent leakage of surgical sutures and undue tissue damage, improve healing and postoperative rehabilitation. At present time there is no universal type of bioadhesives that is suitable for all tissues and types of sutures because of various surgeries and their specificity. The article describes the advantages and disadvantages of all common types of bioadhesives, as well as the ways to overcome their disadvantages.

Postoperative subdural hematoma with blood flow from an epidural hematoma through a tear at the suture point of an artificial dura substitute

OBJECTIVE

We have recently seen cases of postoperative epidural and subdural hematomas after duraplasty with an artificial dura substitute. In these cases, the epidural hematoma flowed into the subdural space through a tear at the suture point of the artificial dura substitute. In this study, whether such hematomas are specific to a certain artificial dura substitute was investigated, and the cause and risk factors were examined.

METHODS

In our institute, 46 patients underwent brain tumor extirpation with duraplasty with an artificial dura substitute; Gore-Tex and SEAMDURA were used as the artificial dura substitutes. Patients with postoperative hemorrhage after brain tumor extirpation with duraplasty with an artificial dura substitute were retrospectively analyzed. Moreover, suture strength was compared experimentally between Gore-Tex and SEAMDURA.

RESULTS

In patients who underwent brain tumor extirpation with duraplasty with an artificial dura substitute, the rate of postoperative hemorrhage was 8.6%. Epidural and subdural hematomas were seen in four patients after tumor extirpation with duraplasty with SEAMDURA, but there were none with Gore-Tex. Exposure of the superior sagittal sinus at craniotomy, older age, and longer operative time were seen more frequently in patients with hematoma than in patients without hematoma. The strength of the suture point was significantly weaker with SEAMDURA than with Gore-Tex (P = 0.00016).

CONCLUSIONS

Postoperative epidural and subdural hematomas seem to be specific for SEAMDURA and may be caused by the weak suture strength of SEAMDURA. In cases of duraplasty, a nonabsorbable artificial dura substitute may be suitable.

Application of osteoinductive calcium phosphate ceramics in children's endoscopic neurosurgery: report of five cases

This work aimed at investigating the possibility and effectiveness of osteoinductive calcium phosphate (CaP) ceramics to close the drilled skull holes and prevent the postoperative cerebrospinal fluid (CSF) leaking in children’s endoscopic neurosurgery. Five children patients (four boys and one girl, 3- to 8-years old) underwent the surgery, in which the endoscopic third ventriculostomy (ETV) was operated in four cases of hydrocephalus, and biopsy and ETV were both performed in one case of pineal tumor. The drilled skull holes were filled with the commercial osteoinductive CaP ceramics. The patients were followed up by CT scan at 1, 7 days, 3 and 6 months postoperatively. All the five cases were successful, and the holes were closed well after filled with the ceramics. The follow-up survey showed that no CSF leaking or rejection reaction was found. The CT scan indicated that the drilled holes began healing at 7 days postoperatively, and a relatively complete healing happened at 6 months postoperatively. The excellent ability of the CaP ceramics to induce bone regeneration was also confirmed by repairing the skull defects in a monkey model. The results of μ-CT and histological analysis showed that a bony structure with irregular array occurred at the defect area, and the newly formed bone volume density reached 65.7%. In conclusion, the osteoinductive CaP ceramics could be an ideal material to treat the drilled skull holes in children’s endoscopic neurosurgery and prevent CSF leaking afterwards. However, further investigation with more cases and longer follow-up was required to evaluate the clinical effect.