Surgical adhesive increases burst pressure and seals leaks in stapled gastrojejunostomy. Surg Obes Relat Dis. 2010;6:498-501. [PMID: 20176513 DOI: 10.1016/j.soard.2009.11.016]

Effects of cyanoacrylate on leakage pressures of cooled canine cadaveric jejunal enterotomies

OBJECTIVE

To compare the intraluminal initial and maximal pressures of enterotomies closed using three different techniques (single-layer appositional continuous closure; closure with cyanoacrylate; a single-layer appositional closure augmented with cyanoacrylate) in a cooled canine cadaveric jejunal model and to report the initial leak location in all samples.

STUDY DESIGN

Experimental, ex-vivo study.

SAMPLE POPULATION

Grossly normal chilled small intestine segments from three canine cadavers.

METHODS

A total of 45 chilled jejunal segments (n = 15 segments/group) were assigned to a handsewn group (HSE), a cyanoacrylate only group (CE) and a handsewn and cyanoacrylate group (HS + CE). A 2 cm antimesenteric enterotomy was performed and closure with one of the above techniques. Initial leakage pressures (ILP), maximal intraluminal pressures (MIP) and initial leakage location were recorded by a single observer.

RESULTS

Handsewn enterotomies leaked at higher ILP when augmented with cyanoacrylate (83.3 ± 4.6 mmHg, p < .001) compared to both the HSE group (43.8 ± 5.3 mmHg) and the CE group (18.6 ± 3.5 mmHg). Those sealed with cyanoacrylate only leaked at a lower MIP compared with the other groups (p < .001). Maximal intraluminal pressures did not differ between handsewn enterotomies, whether augmented or not (p = .19).

CONCLUSION

Reinforcement of a sutured enterotomy closure with cyanoacrylate was easy to perform and resulted in significantly increased initial leak pressures in cadaveric jejunum.

CLINICAL SIGNIFICANCE

The increased leakage pressures achieved by reinforcing enterotomies with cyanoacrylate could consequently reduce the incidence of postoperative intestinal leakage following an enterotomy and may result in reduced patient morbidity or mortality.

The Effects of Using Bioglue in Nasal Septal Surgery

OBJECTIVES

Nasal septal surgery is one of the most common surgical procedure performed by otolaryngologists. Nasal packs are used for bleeding control, prevention of septal hematoma, replacement of mucoperichondrial flaps, and stabilization of the septum after nasal septal surgery. The aim of this study was to investigate the effects of albumin-glutaraldehyde-based tissue adhesive (Bioglue), which can be used as an alternative to nasal pack on the nasal septum after experimental nasal septum surgery.

METHODS

A total of 16 female Wistar albino rats were randomly separated into the study group (n = 10) and the control group (n = 6). After raising the mucoperichondrial flap on one side of the septum, Bioglue was used to fix the mucoperichondrial flap over the septal cartilage ın the study group and nasal packs (Merocel) were used for fixation in the control group. The rats were sacrificed at 2 and 4 weeks after septoplasty. All the tissue samples were evaluated under light microscope by the same pathologist in respect of foreign-body reaction, degree of inflammation, granulation tissue, fibrosis, cartilage damage, and cilia and goblet cell damage. In the control group, the Merocel packs were removed after 2 days and the groups were compared in terms of hematoma.

RESULTS

No hematoma was observed in any group. Septal perforation was determined in all the study group participants and loss of cilia and goblet cells and foreign-body reaction were found in 8 samples of the study group participants and in none of the control group.

CONCLUSIONS

The results of this study show that Bioglue caused segmental cartilage injury; therefore, it may not suitable for use following septal surgery.

Polymeric Tissue Adhesives

Polymeric tissue adhesives provide versatile materials for wound management and are widely used in a variety of medical settings ranging from minor to life-threatening tissue injuries. Compared to the traditional methods of wound closure (i.e., suturing and stapling), they are relatively easy to use, enable rapid application, and introduce minimal tissue damage. Furthermore, they can act as hemostats to control bleeding and provide a tissue-healing environment at the wound site. Despite their numerous current applications, tissue adhesives still face several limitations and unresolved challenges (e.g., weak adhesion strength and poor mechanical properties) that limit their use, leaving ample room for future improvements. Successful development of next-generation adhesives will likely require a holistic understanding of the chemical and physical properties of the tissue-adhesive interface, fundamental mechanisms of tissue adhesion, and requirements for specific clinical applications. In this review, we discuss a set of rational guidelines for design of adhesives, recent progress in the field along with examples of commercially available adhesives and those under development, tissue-specific considerations, and finally potential functions for future adhesives. Advances in tissue adhesives will open new avenues for wound care and potentially provide potent therapeutics for various medical applications.

Agentes hemostáticos tópicos em cirurgia: revisão e perspectivas

RESUMO A hemostasia tem papel crítico e importância fundamental em todos os procedimentos cirúrgicos. Seu manejo possui diversos pontos chaves, que se iniciam por boa técnica operatória e adequado suporte anestésico. Determinadas situações, como hemorragias graves resultantes de trauma penetrante, por exemplo, não dependem exclusivamente do controle da equipe cirúrgica e necessitam do apoio de novas soluções que diminuam ou controlem a hemorragia. Desde os tempos antigos, um marco da medicina é atuar no controle da hemorragia e, mais recentemente, na facilitação da hemostasia pela aplicação de agentes tópicos, seja por compressão manual ou agentes modernos. Na última década, o número de diferentes agentes hemostáticos tópicos cresceu drasticamente. Para que o cirurgião moderno escolha o agente correto no momento correto, é essencial que conheça o mecanismo de ação, entenda a eficácia e os possíveis efeitos adversos relacionados a cada agente. Assim, a grande variedade de hemostáticos tópicos, somada à ausência de um artigo de revisão na literatura nacional sobre este tópico, nos estimulou a elaborar este manuscrito. Aqui relatamos uma revisão detalhada sobre os agentes hemostáticos tópicos mais comumente utilizados nas especialidades cirúrgicas.

Effects of albumin/glutaraldehyde glue on healing of colonic anastomosis in rats

AIM

To evaluate the effect of local surgical adhesive glue (albumin/glutaraldehyde-Bioglue) on the healing of colonic anastomoses in rats.

METHODS

Forty Albino-Wistar male rats were randomly divided into two groups, with two subgroups of ten animals each. In the control group, an end-to-end colonic anastomosis was performed after segmental resection. In the Bioglue group, the anastomosis was protected with extraluminar application of adhesive glue containing albumin and glutaraldehyde. Half of the rats were sacrificed on the fourth and the rest on the eighth postoperative day. Anastomoses were resected and macroscopically examined. Bursting pressures were calculated and histological features were graded. Other parameters of healing, such as hydroxyproline and collagenase concentrations, were evaluated. The experimental data were summarized and computed from the results of a one-way ANOVA. Fisher’s exact test was applied to compare percentages.

RESULTS

Bursting pressures, adhesion formation, inflammatory cell infiltration, and collagen deposition were significantly higher on the fourth postoperative day in the albumin/glutaraldehyde group than in the control group. Furthermore, albumin/glutaraldehyde significantly increased adhesion formation, inflammatory cell infiltration, neoangiogenesis, and collagen deposition on the eighth postoperative day. There was no difference in fibroblast activity or hydroxyproline and collagenase concentrations.

CONCLUSION

Albumin/glutaraldehyde, when applied on colonic anastomoses, promotes their healing in rats. Therefore, the application of protective local agents in colonic anastomoses leads to better outcomes.

Surgical glue in laparoscopic sleeve gastrectomy: An initial experience and cost-effectiveness analysis

RATIONALE, AIMS, AND OBJECTIVES

Laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric procedures. Gastric leaks and bleeding are the most frequent complications, associated with a high clinical and economic burden. The best method of staple line reinforcement in LSG is debated. Surgical glue is one of the options available. The aim of this study was to assess the safety, efficiency, and relative cost-effectiveness of surgical glue used to perform LSG in morbid obese adults as compared with standard stapling.

METHODS

A prospective, observational, and comparative before-after study was conducted. All consecutive patients undergoing LSG at Montpellier University Hospital in 2011 and 2012 were included and treated according to 2 groups: standard stapling (n = 99, group 1) and surgical glue reinforcement (n = 94, group 2). Clinical and economic outcomes were measured after 6 months.

RESULTS

The duration of intervention was significantly shorter in group 2 (68 vs 82 minutes, P = .001). There was no significant difference regarding complications, but leaks in group 1 were more severe. Group 2 was also associated with a reduced initial length of stay (4.8 vs 5.2 days, P = .01). Six-month readmissions and total length of stay were also shorter in group 2 (5.5 vs 6.1 days, P = .003). Surgical glue use was associated with a significant reduction in the initial inpatient cost (€5488 vs €6152, P = .005) and in the 6-month total inpatient cost, including readmissions (€6006 vs €6754, P = .005). The incremental cost of glue to avoid a severe complication was -€5446.33 (95 confidence interval, -8202.01 to -2690.66).

CONCLUSIONS

Surgical glue might be a safe and cost-effective intervention in laparoscopic sleeve gastrectomy.

The Physiological Incubation Biosimulator (PIBS): An Improved Ex Vivo Experimental Setup for the Mechanical Stability of Biological Sealants in Surgical Procedures

BACKGROUND

Tissue-bound fibrin sealants are used in a wide array of surgical procedures. The microenvironmental interaction between sealant and application site is often poorly evaluated due to a lack of suitable experimental models.

METHODS

A physiological incubation biosimulator (PIBS) was developed to test biological sealants in an ex vivo setup under physiological conditions comparable to the microenvironment at application site (temperature, humidity, pressure). PIBS was validated by a study on the effectiveness of TachoSil for leak closure at pancreatic resection sites. Defined defects in a thoracic membrane of porcine origin were sealed by TachoSil. Integrity of the sealing was tested in the presence of active pancreatic fluid over 60 minutes. Heat-inactivated pancreatic fluid and electrolyte solution served as controls. The time to leakage was recorded and experimental groups were analyzed by Kaplan-Meier analysis.

RESULTS

PIBS produced reliable results. TachoSil lead to a leakage rate of 96% after incubation with active pancreatic fluid (p = 34), which was significantly higher compared with heat-inactivated pancreatic fluid (p = 34, 52%) or electrolyte solution (p = 20, 19%).

CONCLUSION

PIBS is an effective tool to evaluate microenvironmental effects on the adhesive strength of biomaterials. Tissue sealing effect of TachoSil is diminished in a "pancreatic" microenvironment rich with pancreatic enzymes. Our results might therefore explain the reason of the findings of randomized controlled trials recently published on this subject.

Fibrinogen-thrombin collagen patch reinforcement of high-risk colonic anastomoses in rats

AIM

To evaluate the effectiveness of human fibrinogen-thrombin collagen patch (TachoSil^®) in the reinforcement of high-risk colon anastomoses.

METHODS

A quasi-experimental study was conducted in Wistar rats (n = 56) that all underwent high-risk anastomoses (anastomosis with only two sutures) after colectomies. The rats were divided into two randomized groups: Control group (24 rats) and treatment group (24 rats). In the treatment group, high-risk anastomosis was reinforced with TachoSil^® (a piece of TachoSil^® was applied over this high-risk anastomosis, covering the gap). Leak incidence, overall survival, intra-abdominal adhesions, and histologic healing of anastomoses were analyzed. Survivors were divided into two subgroups and euthanized at 15 and 30 d after intervention in order to analyze the adhesions and histologic changes.

RESULTS

Overall survival was 71.4% and 57.14% in the TachoSil^® group and control group, respectively (P = 0.29); four rats died from other causes and six rats in the treatment group and 10 in the control group experienced colonic leakage (P > 0.05). The intra-abdominal adhesion score was similar in both groups, with no differences between subgroups. We found non-significant differences in the healing process according to the histologic score used in both groups (P = 0.066).

CONCLUSION

In our study, the use of TachoSil^® was associated with a non-statistically significant reduction in the rate of leakage in high-risk anastomoses. TachoSil^® has been shown to be a safe product because it does not affect the histologic healing process or increase intra-abdominal adhesions.

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.

Use of bioabsorbable staple reinforcement material in side-to-side anastomoses: Suture line reinforcement of the weak point of the anastomosis

BACKGROUND

Few studies have been designed regarding optimal reinforcement of the crotch of a side-to-side anastomosis. The purpose of this study was to clarify the weak point of the side-to-side anastomosis and to evaluate the effect of bioabsorbable reinforcement material.

METHODS

Fresh pig small bowel was used for all experiments. A side-to-side anastomosis was performed using a linear stapler, and the burst pressure of the anastomosis was measured. Three separate experiments were done. In experiment 1, the weak point and the burst pressure of that point were defined. In experiment 2, the burst pressure of the side of the anastomosis was measured. In experiment 3, we evaluated the effect of Neoveil(®) to strengthen the weak point of the anastomosis.

RESULTS

The weak point of the side-to side anastomosis was the crotch and the burst pressure was 39.8 ± 5.7 mmHg. The burst pressure of the side of the anastomosis was 109.9 ± 7.9 mmHg. This was significantly higher than the burst pressure of the crotch (P = 0.008). The burst pressure of the crotch in the group with Neoveil(®) was 83.3 ± 14.9 mmHg. This pressure was significantly higher than the group with no Neoveil(®) reinforcement (P = 0.001).

CONCLUSION

These findings suggest that the use of Neoveil(®) as a buttressing material is associated with reinforced staple lines and increased crotch burst pressures compared to non-buttressed staple lines. Neoveil(®) was found to perform comparably to clinically available buttress materials in this ex vivo model. Reinforcement of the weak point of the side-to-side anastomosis with Neoveil(®)may lead to fewer anastomotic leaks.

Can tissue adhesives and platelet-rich plasma prevent pharyngocutaneous fistula formation?

OBJECTIVE

One of the frequently encountered disorders of wound healing following laryngectomy is pharyngocutaneous fistula. However, although studies have been performed with the aim of prevention of pharyngocutaneous fistulae, there are very few studies with tissue adhesives and platelet-rich plasma. In this study, our aim was to investigate the histopathologic changes in wound healing caused by various tissue adhesives and platelet-rich plasma, together with their effects on prevention of pharyngocutaneous fistula.

METHODS

40 male rats were randomly divided into five groups: control, platelet-rich plasma, fibrin tissue adhesive, protein-based albumin glutaraldehyde and synthetic tissue adhesive groups. The pharyngotomy procedure was performed and was sutured. Except the control group, tissue adhesives and platelet-rich plasma were applied. Then, the skin was sutured. On the seventh day, the rats were sacrificed. The skin was opened and pharyngotomy site was assessed in terms of fistulae. The pharyngeal suture line was evaluated histopathologically by using Ehrlich Hunt scale.

RESULTS

Inflammatory infiltration was found to be higher in "platelet-rich plasma" group than "fibrin tissue adhesive" and "synthetic tissue adhesive" groups. The fibroblastic activity of "platelet-rich plasma", "fibrin tissue adhesive" and "protein-based albumin glutaraldehyde" groups was higher than the control group. The positive changes created by platelet-rich plasma and fibrin tissue adhesive at the histopathologic level were found together with no detected fistula. Among the study groups, there was no statistical difference for pharyngeal fistula development. This result may be obtained by the small number of animal experiments.

CONCLUSION

These results shed light on the suggestion that platelet-rich plasma and fibrin tissue adhesive can be used in clinical studies to prevent pharyngocutaneous fistula.

Clinical applications of surgical adhesives and sealants

In the United States and Europe, the number of topical adhesives, surgical sealants, and hemostats approved for use in the surgical setting is ever expanding although no single device fills all medical and surgical needs to replace sutures. As more surgical procedures are performed through laparoscopic and robotic approaches, these devices are becoming more important, and current research is focused on solving the limitations of conventional wound treatments. This review article discusses clinical applications of various biologically derived and synthetic products that are currently available to surgeons and those that are in development.

Endoscopic full-thickness resection and clip defect closure in the colon with the new FTRD system: experimental study

BACKGROUND

The benefit of endoscopic full-thickness resection is the improved diagnostic work-up with an integral wall specimen which allows a precise determination of the tumor or its precursor and its infiltration depth into the wall.

MATERIALS AND METHODS

A new endoscopic full-thickness resection device (FTRD), which is a combination of a modified over-the-scope-clip (OTSC) system with an electrocautery snare, has been tested in an experimental setting. In eleven pigs, divided into three groups, endoscopic full-thickness resection was performed in the colon at one or two sites, respectively. Seven days (n = 7) or 28 days (n = 4) after the intervention, the animals were euthanized following endoscopic examination of the resection and clip application sites. Furthermore, two different clips were tested during these animal trials in order to evaluate the most effective clip design.

RESULTS

The average diameter of the tissue resected with the FTRD was 3.1, 3.6, and 5.4 cm in the three groups. On follow-up endoscopy 7 days after the intervention, fibrin coating and stool residues were found at all clips, causing minor inflammatory reactions. However, the colon wall under the clip was non-inflamed. After 28 days, the serosa had primarily healed in all cases. There were also stool residues at all clips; however, no acute inflammatory reactions were seen anymore, due to complete healing. Histological assessment did not show any signs of dehiscence in the region of the scar, or ischemia in the clip area. In addition, no wound infections, such as abscess formation, were observed.

CONCLUSIONS

This study demonstrates the safety and efficacy of the clip-and-cut technique using the new FTRD system. With the device, a local full-thickness colon resection can be easily created, and the resulting wall defect is reliably sealed by the endoluminal application of a modified OTSC clip.

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.

A highly elastic and adhesive gelatin tissue sealant for gastrointestinal surgery and colon anastomosis

BACKGROUND

We describe the development of a highly elastic and adhesive surgical tissue sealant, based on photochemically crosslinked gelatin, for sealing sutured incisions in the gastrointestinal (GI) tract in a rabbit surgical model and in a canine colon anastomosis study.

METHODS

The study included in vitro assessment of mechanical parameters of the tissue sealant and in vivo analysis of burst strength and histology at 24 h, 3 days and 7 days post surgery, in a rabbit model, to assess progress of wound healing at the suture sites. Utility of this sealant to repair and seal a lower colonic resection and anastomosis procedure in a canine model was also investigated.

RESULTS

We show that a photopolymerised gelatin tissue sealant provides effective sealing of GI incisions and facilitates wound healing with no evidence of inflammation up to 28 days post-surgery. Blending of derivatised gelatin with underivatised gelatin allowed tuning of elasticity and elastic modulus of the photopolymerised sealant to suit surgical applications. High tissue adhesive strength was maintained at all blend ratios and exceeded 100 kPa.

CONCLUSIONS

This highly elastic and adhesive photopolymerised gelatin tissue sealant offers a number of advantages over currently available sealants suitable for GI surgical procedures.

A new biodegradable adhesive for protection of intestinal anastomoses. Preliminary communication

BACKGROUND AND AIMS

Anastomotic leaks continue to be a devastating complication for patients and surgeons worldwide. The few surgical adhesives available to date have not achieved the desired clinical results. The purpose of this experimental study was to determine if Pebisut® applied to intestinal suture lines provides increased resistance and protection during the critical days of healing.

METHODS

Intestinal lesions were caused in rats and dogs and a new biodegradable adhesive (Pebisut®) (patent granted in the European Union 07808494.4-1219, 01.12.2010, in Mexico P.C.T./MX/a/2009/001737, 16.02.2009, pending in the U.S.P.T.O. 60/762,136, 26.01.2006) was applied to compare the resistance of suture lines using bursting pressures and histologically.

RESULTS

Under acute and chronic conditions, Pebisut® strengthened and made the suture lines more resistant, while histologically penetrating and sealing them. The adhesive disappears within 2-3 weeks and is well tolerated by the intestinal tissues.

CONCLUSIONS

This biodegradable adhesive provides greater resistance, temporarily protects suture lines and may prevent anastomotic leaks.

Isocyanate-functional adhesives for biomedical applications. Biocompatibility and feasibility study for vascular closure applications

Biodegradable isocyanate-functional adhesives based on poly(ethylene glycol)-adipic acid esters were synthesized, characterized, and evaluated in vitro and in vivo. Two types of formulations, P2TT and P2MT, were developed by functionalization with 2,4-tolylene diisocyanate (TDI) or 4,4'-methylene-bis(phenyl isocyanate) (MDI), respectively, and branching with 1,1,1-trimethylolpropane (TMP). The biocompatibility of the synthesized adhesive formulations was evaluated as per ISO 10993. Cytotoxicity, systemic toxicity, pyrogenicity, genotoxicity (reverse mutation of Salmonella typhimurium and Escherichia coli), hemolysis, intracutaneous reactivity, and delayed-type hypersensitivity were evaluated. All formulations met the requirements of the conducted standard tests. The biological behavior and ability of the adhesive formulations to close an arteriotomy and withstand arterial pressure following partial approximation with a single suture were evaluated in a rat abdominal aorta model. Animals were evaluated at 1, 2, 3, and 4 weeks after surgery. Macroscopic and histopathologic evaluation of explanted arteries suggested that the P2TT formulation had better in vivo performance than the P2MT formulation. Additionally, the P2TT formulation resulted in less tissue reaction than P2MT formulation. To our knowledge, this is the first study demonstrating the potential of this new class of isocyanate-functional degradable adhesives for vascular applications.