Intraoperative haemostasis with new fibrin surgical sealant (Quixil®) in gynaecological oncology

Fibrin sealant (evicel® [quixil®/crosseal™]): a review of its use as supportive treatment for haemostasis in surgery

Evicel® is a fibrin sealant consisting of two components, human clottable protein (predominantly human fibrinogen) and human thrombin. It is indicated as supportive treatment in patients undergoing surgery when control of bleeding by standard surgical techniques is ineffective or impractical. Evicel® is a new formulation of the previously available fibrin sealant Quixil® (in the EU) or Crosseal™ (in the US). Evicel® differs from Quixil®/Crosseal™ in that its fibrinogen component does not contain the antifibrinolytic agent tranexamic acid, which is potentially neurotoxic, resulting in Quixil®/Crosseal™ being contraindicated for use in neurosurgery. The removal of tranexamic acid did not affect the haemostatic efficacy or longevity of Evicel® fibrin clots and allowed the sealant to be granted an expanded indication. Evicel® and Quixil®/Crosseal™ are easy to use and, since they do not contain synthetic or bovine aprotinin, have a reduced potential for hypersensitivity reactions. This article reviews the pharmacological properties, clinical efficacy and tolerability of Evicel® and its previous formulation as supportive treatment for haemostasis in surgery. In clinical studies, Evicel® and Quixil®/Crosseal™ were generally well tolerated and effective haemostatic agents for adjunctive use in various types of surgeries when conventional methods were impractical or ineffective in controlling bleeding. Two pivotal, randomized studies showed that Evicel® was significantly more effective than manual compression in patients undergoing vascular surgery, and significantly more effective than Surgicel® in patients undergoing retroperitoneal or intra-abdominal surgery, as assessed by the proportion of patients achieving haemostasis. In another similarly designed pivotal study in patients undergoing liver resection, Crosseal™ was significantly more effective than standard haemostatic agents (e.g. Surgicel®), as assessed by the mean time to haemostasis. The incidences of treatment-emergent adverse events in these studies were generally similar between the Evicel® or Crosseal™ groups and the comparator groups. Quixil® was also generally well tolerated and an effective haemostatic agent in endonasal surgeries, and tonsillectomies and/or adenoidectomies, with some benefit of treatment with Evicel® or Quixil® also observed in orthopaedic surgeries. Although additional comparative studies with other haemostatic agents would help to definitively position Evicel® with respect to these agents, current evidence suggests that Evicel® is useful in surgeries for improving haemostasis where standard surgical techniques are insufficient.

Endoscopic hemostasis with fibrin glue for refractory postsphincterotomy and postpapillectomy bleeding

BACKGROUND

Bleeding is a feared complication of endoscopic sphincterotomy and papillectomy. Fibrin glue has been proposed as an effective adjunct in securing hemostasis. However, its use has been limited by the risk of early occlusion of the injecting needle, and its role has not been defined in the setting of refractory post-ERCP bleeding. We present a modified technique of endoscopic hemostasis with diluted fibrin glue in the setting of postsphincterotomy and postpapillectomy bleeds.

OBJECTIVE

We aimed to verify that diluted fibrin glue can be easily and successfully injected and is effective in the endoscopic treatment of refractory post-ERCP bleeding.

DESIGN

Case series.

SETTING

A tertiary-care academic medical center.

PATIENTS

Six patients with refractory post-ERCP bleeding were treated (3 after sphincterotomy and 3 after papillectomy) with fibrin glue injection.

INTERVENTION

Endoscopic hemostasis with diluted fibrin glue injection.

MAIN OUTCOME MEASUREMENTS

Successful endoscopic hemostasis with diluted fibrin glue injection.

RESULTS

One session of fibrin glue injection stopped the refractory post-ERCP bleeding in all 6 patients.

LIMITATION

Small number of patients.

CONCLUSION

This case series provides evidence that our modified injection technique of diluted fibrin glue allowed an easy submucosal injection and may be considered to be an effective endoscopic modality to treat refractory post-ERCP bleeding.