Repair of hepatic and splenic injuries by autoplastic peritoneal patches and butyl-2-cyanoacrylate monomer. An experimental study

Effects of caffeic acid phenethyl ester on wound healing in calvarial defects

OBJECTIVE

The aim of this study is to analyze histologically the effect of CAPE on bone healing of Critical Size Defect (CSD) in rat calvaria.

STUDY DESIGN

Thirty-two 3-month-old male rats were used. The animals were randomly divided into four groups. Group A received isotonic saline solution, Group B received CAPE (50 mmol/kg) locally, Group C received CAPE (100 mmol/kg) locally and Group D received CAPE (10 mmol/kg/day i.p. for 28 days) systematically. A 5-mm diameter calvarial defect was created in the right side of the parietal bone without damaging the underlying dura mater. Twenty-eight days after the surgery, all the animals were sacrificed. The original defect area was removed from the animal's calvarium bone en bloc. Beginning at the center of the surgical defect, serial sections of 6 µm thick were cut longitudinally. The sections were stained with hematoxylin and eosin for analysis under a light microscope. The sections were analyzed for the presence of inflammatory infiltrate, connective tissue formation and new bone formation. Computer-assisted histomorphometic measurements were carried out with an automated image analysis system.

RESULTS

The total new bone areas were significantly greater in group D than in all groups and group C was statistically insignificant from the other groups (p < 0.05). Group B had a greater, but not statistically significant (p > 0.05), amount of total regenerated bone area than the control group.

CONCLUSION

The results indicate that 100 mmol/kg topical and 10 mmol/kg/day systemic application of CAPE increases bone healing, especially with systemic application.

Use of 2-Octylcyanoacrylate (Dermabond) Tissue Adhesive for Tip Graft Fixation in Open Rhinoplasty

Objectives. To describe the use of 2-octylcyanoacrylate (2-OCA; Dermabond) for fixation of cartilage grafts in nasal tip surgery via an external approach in Asian patients.

Study Design. Case series with chart review.

Setting. Academic tertiary care medical center.

Subjects and Methods. This retrospective study analyzed data from 33 Korean patients who underwent open rhinoplasty using 2-OCA tissue adhesive for fixation of cartilage grafts in tip surgery. Autologous septal, conchal, costal, or homologous costal cartilage was used as graft materials. Layers of cartilages were bonded using 2-OCA tissue adhesive, and care was taken to prevent the tissue adhesive from spilling and directly contacting surrounding soft tissues. Preoperative and postoperative photographs were reviewed for objective and subjective assessment of aesthetic outcomes.

Results. Postoperative aesthetic outcomes were graded as excellent in 51.5%, fair in 33.3%, and no change/worse in 15.2% of patients. Preoperative and postoperative anthropometric measurements showed that the nasal tip projection increased (0.53 ± 0.03 vs 0.57 ± 0.05; P < .05) and the nasolabial angle improved (92.54 ± 6.95 vs 96.12 ± 5.20; P < .05). The overall complication rate was 24.2%, and complications included erythema (9.1%), infection (12.1%), and aesthetic dissatisfaction (3.0%).

Conclusion. Although using 2-OCA tissue adhesive for tip surgery simplifies the surgical procedures of fixating graft materials, the relatively high complication rate may preclude its use in nasal tip surgery via an external approach for Asian noses.

Hemostatic effect of n-butyl-2-cyanoacrylate (histoacryl) glue in warfarin-treated patients undergoing oral surgery

PURPOSE

Our goal was to evaluate the local hemostatic effect of n-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) glue in warfarin-treated patients who undergo outpatient oral surgery without a change in their level of anticoagulation.

MATERIALS AND METHODS

Thirty consecutive warfarin-treated patients randomly assigned to study and control groups and 10 patients who had never been on anticoagulant therapy serving as the negative control group were included in this trial. Before multiple teeth extractions, all patients had a prothrombin time and the international normalized ratio (INR) determined. To gain hemostasis and primary closure, gelatin sponge and multiple interrupted resorbable sutures were used in the control and negative control groups, and Histoacryl glue and the minimal number of interrupted resorbable sutures were used in the study group. Postoperatively, patients were to contact the oral surgeon if abnormal bleeding occurred. Patients who did not have postoperative bleeding were seen on the 10th postoperative day. Data were collected, and statistical differences in age and gender distributions, number of teeth extracted, INR levels, and bleeding that required treatment were analyzed with the Mantel-Haenzel test. Statistical significance was defined as a value of P <.05.

RESULTS

Local hemostasis was obtained immediately in study patients and only after 10 to 20 minutes in the control and negative control patients. In relation to bleeding complications, there were no cases of postoperative bleeding requiring treatment in both the negative control patients and study patients. In the control patients, 5 cases had postoperative spontaneous bleeding that required treatment. This difference was statistically significant. No patient had wound infection and the healing process appeared to be normal.

CONCLUSION

Multiple extractions can be performed in patients taking oral anticoagulant therapy without a change in their level of anticoagulation provided an efficient local hemostatic measure is instituted. And, in this regard, Histoacryl glue, used as a topical adhesive over approximated wound edges, is an effective and easily applicable local hemostatic for oral surgery in such patients.

Enhanced bone regeneration and formation around implants using guided bone regeneration

This study investigated the use of a prototype expanded polytetrafluoroethylene membrane attached to bone with butyl-cyanoacrylate, in facilitating guided bone regeneration into bone defects and around titanium screws in rabbit femora. Two experimental models were used to assess bone growth. The first model investigated two unicortical defects in each femora. The second was bone growth in a 500-micron engineered space around one transcortical titanium screw. In the first model there was a significant increase in bone formation at 1 and 2 months in the membrane groups (p < 0.01) as compared to the controls. In the second model the percentage of bone in contact with the implant was significant at 1 and 2 months in the defects covered with membrane compared to the uncovered defects. The uncovered defects had fibrous tissue adherent to the implant continuous with the overlying soft tissue. Our study demonstrated three points: this membrane can be used to increase bone regeneration into defects, this technique allows bone to grow directly around an implant, and butyl-cyanoacrylate can be used in deep soft tissue and bone applications without any apparent deleterious effects.

Enteroplication in cats, using suture of N-butyl cyanoacrylate adhesive

Enteroplication has been recommended to prevent recurrence of intussusception in dogs and cats. This study investigated the impact of enteroplication on subsequent function of the plicated small intestine as measured by transit time of barium impregnated polyethylene spheres (BIPS) and compared two methods of achieving enteroplication--sutures using polydioxanone and cyanoacrylate tissue adhesive. Twenty-two healthy young cats were used--four controls, nine sutured and nine glued. The mean +/-SD transit times before, one week after and four weeks after enteroplication were respectively 2.0+/-0.80 hours, 1.6+/-0.80 hours, 2.2+/-1.18 hours. There was no significant difference in transit time or in the time to create enteroplication in the two plicated groups. Maintenance of intestinal adhesion was greater for the sutured plications. There was no significant change in internal diameter with either technique. Adverse clinical signs after enteroplication were not severe, however, they were more prevalent in cats which had glued plication. The inflammation associated with the suture was of a greater depth initially but that associated with the adhesive was more widespread and persisted for the four weeks of the experiments. Enteroplication in cats was a relatively benign procedure which did not cause significant alterations in small intestinal function. However, cyanoacrylate tissue adhesive cannot be recommended for this clinical procedure.

Variable histotoxicity of histoacryl when used in a subcutaneous site: an experimental study

Histoacryl (butyl-2-cyanoacrylate) is one of the least histotoxic cyanoacrylate derivatives and is used as a tissue adhesive. Clinical applications primarily include skin closure (blepharoplasty incisions, etc.). In a recent study, we demonstrated that Histoacryl elicits minimal histotoxicity when used to glue bone grafts to rabbit-ear cartilage. Acute inflammation was limited to areas where Histoacryl escaped from between the bone graft and ear cartilage to contact well-vascularized soft tissue. In this study, Histoacryl was applied between bone graft and cartilage in one rabbit ear and adjacent to well-vascularized soft tissue with no graft in the opposite ear. Histologic analysis revealed minimal if any inflammation when small amounts of glue was used in the nonvascular region between bone graft and cartilage. However, subcutaneous implantation contacting well-vascularized soft tissue resulted in increased acute inflammation and prolonged foreign-body giant-cell response. Further studies are required to rule out any long-term problems associated with subcutaneous implantation of Histoacryl.

The effect of fibrin glue and peritoneal grafts in the prevention of intraperitoneal adhesions

We studied the effect of fibrin sealant and peritoneal grafts applied by fibrin glue on adhesion formation in the rat. Sealing and patching of ischaemic lesions of the uterus resulted in a significant increase in adhesion formation. We conclude, that fibrin sealant and peritoneal grafts can not be given general approval for prophylaxis of intraperitoneal adhesions.

Fibrin glue as a biologic vascular patch--a comparative study

Fibrin glue is a biologic two component hemostatic adhesive. Fibrin glue acts as an effective vascular plus after arterial injury without suture at pressures twice systolic. It is also effective on vein at physiologic pressures, however, venous distensibility precludes its efficacy beyond these limits. Recent studies have documented its utility as a preclot material on vascular grafts and as a seal for sutured vascular anastomoses. This study was designed to characterize the glue's sealant ability when applied to open arterial and venous injuries, and to compare its efficacy with currently available hemostatic agents. Segments of canine peripheral artery and vein were isolated and perforated with a 16-gauge needle. This injury was treated by random application of either fibrin sealant (FS), oxidized cellulose (OC), microcrystalline collagen (MC), or MC plus thrombin (MCT). Five minutes after patch application, intralumenal pressure was increased progressively with saline infusion to ascertain bursting threshold. The arterial bursting threshold was significantly higher for FA (250 +/- 59.7 mm Hg) than for OC (12.5 +/- 6.1 mm Hg), MC (17.2 +/- 21.9 mm Hg) or MCT (10.8 +/- 13.8 mm Hg) (P less than 10(6)). The bursting threshold of FS applied to vein (17.5 +/- 11.7) was not significantly different from other agents (P less than 0.05).

Hemisplenectomy using a hand-held CO2 laser. An experimental study

Hemisplenectomy was performed in mongrel dogs using a hand held CO2 laser. Cutting and hemostasis were performed by a laser beam with a high concentration power--about 6kW/mm2--at the focal spot, and residual bleeding was controlled by using a defocused beam. The cutting action was improved by temporary closing of the arterial vessels and by injecting adrenaline into the splenic artery to produce a relatively dry surface. The surgical procedure was free of mortality or morbidity. Histological studies revealed a brand of fibrous tissue at the cut surface, without apparent abnormalities in the splenic parenchyma beneath the section. Activity of the residual half spleen was shown by postoperative technetium scan and by the fact that Howell-Jolly bodies appeared in peripheral blood only after resection of the remaining half spleen.

Malign effects of splenectomy--the place of conservative treatment

In this review article the incidence is discussed of overwhelming post-splenectomy infection (OPSI), which is especially likely to occur in children and when splenectomy is carried out for haematological disorders. Long-term broad spectrum antibiotics or the use of polyvalent pneumococcal vaccine are often advocated as prophylactic measures under these circumstances.

After mild splenic trauma, conservative surgery or partial splenectomy may be indicated in some cases. Where trauma is more severe and the spleen cannot safely be preserved there may be a place for autotransplantation of splenic slices, for example into a pocket of omentum, and there is some experimental support for this technique.

Attempts to bypass the need for splenectomy in splenic injury

Within the last decade spleen salvage has been a controversial issue. Only recently, with the advances and utilization of modern technology in surgery, spurred by a better understanding of this immunologically important organ, preservation has become a reality. Numerous approaches have been suggested. Reported is a simple method of applying a new agent, Fibrin Seal (FS), to control hemorrhage from splenic injury. In a controlled study using 14 mongrel dogs, it is compared to the hemostatic ability of cryoprecipitate with thrombin and Avitene. FS is an adhesive material with hemostatic qualities consisting of fibrinogen, factor XIII, antiplasmin, cold-insoluble globulin, and platelet growth factor. FS appears to have cohesive and adhesive properties that result in more efficient hemostasis than the controls. FS conforms to the spleen surface, allowing manipulation of the organ without dislodgement of the coagulum. Follow-up laparotomy showed minimal tissue reaction. On the basis of these data, consideration of FS as an important hemostatic agent warrants clinical investigation.

[The use of fibrin tissue adhesive in parenchymal organs of the abdomen. An experimental study in rabbits and dogs (author's transl)]

In rabbits and dogs standardized lesions of the liver, kidney, and spleen were treated by application of human fibrinogen tissue adhesive. In all cases this procedure resulted in a complete control of bleeding as well as a stable and lasting closure of the wounds. During the postoperative observation time of one month, the fibrinogen tissue adhesive was initially infiltrated by leucocytes and macrophages and subsequently resorbed by a granulating tissue, characterized by the early appearance of numerous fibroblasts. Our clinical experience, until now, confirms these promising experimental results.

Ligation of the splenic artery; effects on the injured spleen and its function

Treatment of splenic trauma by ligating the splenic artery was studied on 28 dogs. Bleeding was arrested, and the animals under experimentation tolerated the ligation of the splenic artery without complications. The histology of the spleen showed no abnormalities 2 mo after the experiment. The traumatized area of the spleen had healed. The platelets and reticulocytes were temporarily increased. The hemotocrit values, WBC counts, and serum immunoglobulin M, remained within normal levels. Bone marrow smears, and scintigrams of the spleen were normal. Ligation of the splenic artery, combined with splenorrhaphy, was also successfully used in children with splenic trauma involving major segmental vessels.

Preservation of the injured spleen

Experience with suture repair of splenic lacerations in 14 children and 8 adults is reported. The youngest patient was 3 days old and the oldest 60 years. Adequate healing was confirmed by postoperative splenic scans with or without arteriography. The 2 deaths in this series were not related to the splenic repair and were due to associated major injuries. The course of illness in the remaining 20 survivors did not reveal a failure of this technique or a complication related to the use of this conservative approach. It is expected that salvage of the traumatized spleen will eliminate the risk of fulminant postoperative infections that may be fatal.

Surgical technic for treatment of splenic rupture

In nine baboons and one dog, a technic for suturing the injured spleen and also providing immediate control of hemorrhage is described. By placing Silastic strips along the wound edges of the transverse incision into the spleen and along the surface and bottom edges of the wound after resection, it was possible to control bleeding with deep U sutures passing through the Silastic bolsters and the spleen tissue. The procedure appears to provide a reliable method of salvaging splenic tissue and thus avoiding the hazard of postsplenectomy sepsis.

Splenic function following experimental dearterialization injury in the suckling rat

An experimental splenic dearterilization injury was created in 1-wk-old rats to study the effect of vascular trauma on splenic function. Splenic weight significantly decreased 1 wk following injury but returned to control values within a month. Total splenic nuclear activity diminished initially but increased to above control values 1 mo after injury, and finally returned to normal at 2 mo. Survival rate after an intraperitoneal challenge with pneumococcus in groups 1 wk following total splenectomy and partial dearterlization was not significantly different than controls. This study confirmed the clinical impression that vascular injury to the spleen causes only a transient impariment of splenic size and function and provides further incentive to perform splenorrhaphy following splenic trauma.

Are hemisplenectomy and/or primary splenic repair feasible?

Following splenectomy, infant rats are at risk when challenged with pneumococcus. Mortality was 85% in splenectomized rats and 6.6% in controls. Rats subjected to a standardized splenic trauma had a 16% mortality when left untreated and a zero mortality with operative therapy by splenectomy, hemisplenectomy, or primary splenic repair. Hemisplenectomy and primary splenic repair are indeed feasible in rats with resultant splenic tissue showing a normal histologic appearance. Hemisplenectomized infant rats, when subjected to pneumococcal challenge, had a 15% mortality compared to 85% for splenectomized infant rats. This suggests that the repaired spleen retains its very important immunologic abiltiy to resist infection. Despite differences in species and organ sizes and shapes, these data suggest that partial splenectomy and primary splenic repair may be attractive alternatives to splenectomy in instances of trauma and inadvertant operative injury.