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Orădan AV, Dindelegan GC, Vinaşi RC, Muntean MV, Dindelegan MG, Chiriac L, Volovici V. Reduction of Anastomotic Time Through the Use of Cyanoacrylate in Microvascular Procedures. Plast Surg (Oakv) 2022; 30:335-342. [PMID: 36212098 PMCID: PMC9537713 DOI: 10.1177/22925503211019619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/16/2021] [Indexed: 11/03/2023] Open
Abstract
Background: Ever since the description of the first microvascular anastomosis, numerous alternative methods have been described to the classical approach. Tissue adhesive has shown promising result in previous studies and can be a fast and efficient alternative which still requires more studies to allow its clinical implementation. Methods: A randomized comparative experimental study was conducted on rats' femoral arteries and an end-to-end anastomosis was performed in order to compare 2 anastomosis techniques. In one group, a simple interrupted suture was utilized, whereas in the second group a combination between fewer sutures and tissue adhesive was used. The anastomotic time, total operative time, blood flow velocity before, immediately after and 48 hours after the procedure, as well as an independent grading of the anastomosis immediately after the procedure were performed. Magnetic resonance imaging (MRI) was performed in order to assess the degree of stenosis. After euthanasia, histology and scanning electron microscopy (SEM) were performed on the vessels in order to assess possible complications. Results: A total of 24 anastomoses were performed, of which 12 with a classic technique and 12 with an adhesive technique. All the anastomoses were patent with a significant reduction of anastomotic and total operative time. The grading of the anastomoses showed better results in the classic suture group. The blood flow velocities were not statistically significant between the 2 groups. On MRI there was one stenotic anastomosis, whereas histology and SEM showed more complications on the adhesive group. Conclusion: Anastomotic times were significantly lower with a non-significant trend toward more thrombotic complications in the adhesive group. Further improvement of the glue properties and refinement of the technique will likely make it a viable alternative to interrupted suturing in the future.
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Affiliation(s)
- Alex V. Orădan
- Department of Plastic Surgery, Clinical Rehabilitation
Hospital, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - George C. Dindelegan
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- First Surgical Clinic, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ramona C. Vinaşi
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Neuroscience, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maximilian V. Muntean
- Department of Plastic Surgery, “Prof. Dr. I. Chiricuta”
Institute of Oncology, “Iuliu Hatieganu” University of Medicine and
Pharmacy, Cluj-Napoca, Romania
| | - Maximilian G. Dindelegan
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Otorhinolaryngology, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Liviu Chiriac
- National Magnetic Resonance Center, Faculty of Physics,
Babeş-Bolyai University, Cluj Napoca, Romania
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The
Netherlands
- Center for Medical Decision Making, Department of Public
Health, Erasmus MC University Medical Center, Rotterdam, The
Netherlands
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Scott BB, Randolph MA, Guastaldi FPS, Wu RC, Redmond RW. Light-Activated Vascular Anastomosis. Surg Innov 2022:15533506221104382. [DOI: 10.1177/15533506221104382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. There have been few advances in technique since vascular anastomosis was performed with silk suture on a curved needle in 1902. This technique results in disruption of the endothelium with exposed intraluminal suture, both of which may lead to thrombocyte aggregation, intimal hyperplasia, and vascular stenosis. A variety of alternative techniques have been explored, with limited success. Photochemical tissue bonding (PTB) is a light-activated methodology of rapidly cross-linking tissue interfaces at the molecular level. Herein, we describe a new technique for anastomosis of venous interposition graft in an ovine model of femoral artery bypass utilizing PTB. Methods. Polypay specific pathogen free sheep (n = 5; 40-45 kg) underwent femoral artery bypass utilizing saphenous vein. The femoral artery was transected and reversed saphenous vein was implanted as an interposition graft. The proximal anastomosis was created as a vein-over-artery cuff utilizing PTB, and the distal anastomosis was created with standard interrupted 8-0 polypropylene suture. Four weeks post-index operation, femoral angiogram was performed to evaluate patency, tortuosity, and luminal diameter. All bypass grafts were harvested and longitudinal and transverse histological sections from the proximal anastomosis were analyzed. Results. The PTB anastomoses (n = 5) were immediately watertight and patent. All animals survived the 28-day study duration. Angiography revealed patent grafts with no aneurysm or stenosis (n = 5). Histologic examination revealed integration of the venous endothelium with the arterial adventitia. Conclusion. Photochemical tissue bonding creates an immediate strong, watertight vascular anastomosis that can withstand physiologic arterial pressure and remains patent at 28 days without the need for intraluminal suture.
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Affiliation(s)
- Benjamin B. Scott
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
- Plastic Surgery Research Laboratory, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Mark A. Randolph
- Plastic Surgery Research Laboratory, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Fernando P. S. Guastaldi
- Skeletal Biology Research Center, Department of Oral and Maxillofacial Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Ruby C. Wu
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Robert W. Redmond
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Atam C, Orhan Z, Toplu G, Serin M, Karaduman ZO, Öztürk A. Comparison of peripheral nerve repair using ethyl-cyanoacrylate and conventional suture technique in a rat sciatic nerve injury model. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:330-336. [PMID: 32544069 DOI: 10.5152/j.aott.2020.03.156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to compare the outcomes of primary nerve repair using either ethyl-cyanoacrylate or conventional microsuture technique in a rat peripheral nerve injury model. METHODS In this study, a total of 30 Wistar Albino rats weighing between 220 and 275 g were used. The rats were randomly divided into three groups (10 in each), including one control (group 1) and two experimental groups (group 2, conventional microsuture repair; group 3, cyanoacrylate repair). In each group, the sciatic nerve was identified and transected. No further intervention was performed in group 1. The nerve was repaired using the epineural technique with a 10/0 atraumatic nylon in group 2 and synthetic cyanoacrylate adhesive in group 3. At the fifth postoperative week, needle electromyography (EMG) was performed to measure distal latency, combined muscle action potential (CMAP), and motor nerve conduction velocity (MNCV). Following the EMG recordings, animals were euthanized. Nerve samples were collected to evaluate vacuolar degeneration, fibrosis, and foreign body reaction histopathologically. RESULTS In the EMG analysis, mean distal latency was significantly shorter in group 1 (0.85±0.09 ms) than in groups 2 (1.17±0.25 ms) (p=0.0052) and 3 (1.14±0.14 ms) (p=0.0026) while no significant differences existed between groups 2 and 3 (p>0.9999). The mean CMAP was greater in group 1 (10.5±0.35 mV) than in groups 2 (2.86±1.28 mV) (p=0.011) and 3 (2.16±1.34 mV) (p=0.0002), but there was no significant difference between groups 2 and 3 (p>0.9999). The mean MNCV was 53.5±5.95, 39.62±7.31, and 39.84±4.73 mm/sec in groups 1, 2, and 3, respectively. There was a significant difference between groups 1 and 2 (p=0.0052) and between 1 and 3 (p=0.0026), but not between 2 and 3 (p>0.9999). In the histopathological evaluation, the mean vacuolar degeneration score was 0, 2.12, and 1.88 in groups 1, 2, and 3, respectively. No obvious difference was observed between groups 2 and 3 (p=0.743). The mean fibrosis score was 0, 1.62, and 1.77 in groups 1, 2, and 3, respectively. There was no significant difference between groups 2 and 3 (p=0.888). The mean foreign body reaction score was 0, 2.5, and 2.44 in groups 1, 2, and 3, respectively. No difference was present between groups 2 and 3 (p=0.743). CONCLUSION Primary nerve repair using the cyanoacrylate adhesive may provide similar electrophysiological and histopathological results as compared to the conventional microsuture repair.
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Affiliation(s)
- Camettin Atam
- Clinic of Orthopedics and Traumatology, Kırklareli State Hospital, Kırklareli, Turkey
| | - Zafer Orhan
- Department of Orthopedics and Traumatology, Düzce University, School of Medicine, Düzce, Turkey
| | - Gaye Toplu
- Deparment of Plastic Surgery, Health Sciences University, İstanbul Training and Research Hospital, İstanbul, Turkey
| | - Merdan Serin
- Deparment of Plastic Surgery, Health Sciences University, İstanbul Training and Research Hospital, İstanbul, Turkey
| | - Z Okan Karaduman
- Department of Orthopedics and Traumatology, Düzce University, School of Medicine, Düzce, Turkey
| | - Ayhan Öztürk
- Deparment of Neurology, Düzce University, School of Medicine, Düzce, Turkey
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Wang X, Yan Y, Zhang R, Fan Y, Cui F, Feng Q, Liang X. Anastomosis of Small Arteries Using a Soluble Stent and Bioglue. J BIOACT COMPAT POL 2016. [DOI: 10.1177/0883911504046678] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A soluble intralumenal stent for vascular anastomosis was prepared from glucose, dextran-40 and disodium (1–4)-2-deoxy-2-sulfoamino-ß-D-glucopyranuronan (S-chitosan). The in vitro and in vivo solubility of the stent was tested. Animal tests were carried out using femoral arteries of rabbits. In comparison with the previously reported data for poly(ethylene glycol), (PEG) and sugar stents, the S-chitosan containing stent (S-sugar stent) had a shorter dissolution time and a higher vessel patency rate that led to a higher rabbit survival rate. Neither irritation nor thrombosis, due to the introduction of S-sugar stent, was observed from histological sections 2 months after the anastomosis. This S-chitosan containing sugar stent is a promising candidate for fast sutureless anastomosis of vessels in non-trauma surgery.
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Affiliation(s)
- Xiaohong Wang
- Biomanufacture Laboratory, Department of Mechanical Engineering, Tsinghua University, Beijing, 100084, P.R.China
| | | | - Renji Zhang
- Biomanufacture Laboratory, Department of Mechanical Engineering, Tsinghua University, Beijing, 100084, P.R.China
| | | | | | - Q.L. Feng
- Department of Materials Science & Engineering, Tsinghua University, Beijing, 100084, P.R.China
| | - X.D. Liang
- General Hospital of People’s Liberation Army, Beijing, 100854, P.R. China
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Saito Y, Kubota K, Okada A, Deguchi T, Kuroda J, Nitori N, Kadomura T, Yoshida M, Kitajima M. Introduction of 2-octyl cyanoacrylate (Dermabond ®) for incisional hernia mesh repair. Surg Today 2016; 46:123-128. [PMID: 25860590 DOI: 10.1007/s00595-015-1161-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 03/03/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE We developed a new technique, sutureless mesh fixation, using 2-octyl cyanoacrylate (Dermabond®, a surgical tissue adhesive) for incisional hernia repair. The objective of this article is to introduce the new technique and to examine whether the technique provides sufficient resistance to abdominal pressure. METHODS We conducted two tests using a porcine model, a traction experiment and artificial pneumoperitoneum test. In the traction experiment, the adherence properties of Dermabond® with mesh and peritoneum were examined using a tissue fragment from a pig. In the artificial pneumoperitoneum test, which used an incisional hernia porcine model, mesh was implanted on the peritoneum in the abdominal cavity with Dermabond®. It was then determined whether sutureless mesh fixation could bear artificial abdominal air pressure. RESULTS In the traction experiment, Dermabond®, which bonded the mesh to the peritoneum, tolerated pressure up to 2.45 × 103 mmHg. In the artificial pneumoperitoneum test, the mesh was strongly fastened to the peritoneum by means of only Dermabond®, and there was little air circulation even without closing the wound over the mesh. CONCLUSIONS Sutureless mesh fixation with Dermabond® is technically feasible and promises to provide sufficient resistance to abdominal pressure.
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Affiliation(s)
- Yoshiyuki Saito
- Department of Surgery Gastroenterology Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo, 108-8329, Japan.
| | - Keisuke Kubota
- Department of Surgery, St. Luke's International Hospital, 9-1, Akashi-cho, Chuo City, Tokyo, 104-8560, Japan
| | - Akihiro Okada
- Department of Surgery Gastroenterology Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Tomoaki Deguchi
- Department of Surgery Gastroenterology Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Junko Kuroda
- Department of Surgery Gastroenterology Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Nobuhiro Nitori
- Department of Surgery Gastroenterology Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Tomohisa Kadomura
- Department of Surgery Gastroenterology Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Masashi Yoshida
- Department of Surgery Gastroenterology Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Masaki Kitajima
- Department of Surgery Gastroenterology Center, International University of Health and Welfare Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo, 108-8329, Japan
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Kubrusly LF, Formighieri MS, Lago JVM, Graça YLSDS, Sobral ACL, Lago MM. Comparison of polyurethane with cyanoacrylate in hemostasis of vascular injury in guinea pigs. Braz J Cardiovasc Surg 2015; 30:119-26. [PMID: 25859876 PMCID: PMC4389526 DOI: 10.5935/1678-9741.20140125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 12/22/2014] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the behavior of castor oil-derived polyurethane as a hemostatic agent and tissue response after abdominal aortic injury and to compare it with 2-octyl-cyanoacrylate. METHODS Twenty-four Guinea Pigs were randomly divided into three groups of eight animals (I, II, and III). The infrarenal abdominal aorta was dissected, clamped proximally and distally to the vascular puncture site. In group I (control), hemostasis was achieved with digital pressure; in group II (polyurethane) castor oil-derived polyurethane was applied, and in group III (cyanoacrylate), 2-octyl-cyanoacrylate was used. Group II was subdivided into IIA and IIB according to the time of preparation of the hemostatic agent. RESULTS Mean blood loss in groups IIA, IIB and III was 0.002 grams (g), 0.008 g, and 0.170 g, with standard deviation of 0.005 g, 0.005 g, and 0.424 g, respectively (P=0.069). The drying time for cyanoacrylate averaged 81.5 seconds (s) (standard deviation: 51.5 seconds) and 126.1 s (standard deviation: 23.0 s) for polyurethane B (P=0.046). However, there was a trend (P=0.069) for cyanoacrylate to dry more slowly than polyurethane A (mean: 40.5 s; SD: 8.6 s). Furthermore, polyurethane A had a shorter drying time than polyurethane B (P=0.003), mean IIA of 40.5 s (standard deviation: 8.6 s). In group III, 100% of the animals had mild/severe fibrosis, while in group II only 12.5% showed this degree of fibrosis (P=0.001). CONCLUSION Polyurethane derived from castor oil showed similar hemostatic behavior to octyl-2-cyanoacrylate. There was less perivascular tissue response with polyurethane when compared with cyanoacrylate.
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Liang X, Cai H, Hao Y, Sun G, Song Y, Chen W. Sciatic nerve repair using adhesive bonding and a modified conduit. Neural Regen Res 2014; 9:594-601. [PMID: 25206861 PMCID: PMC4146232 DOI: 10.4103/1673-5374.130099] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2014] [Indexed: 11/05/2022] Open
Abstract
When repairing nerves with adhesives, most researchers place glue directly on the nerve stumps, but this method does not fix the nerve ends well and allows glue to easily invade the nerve ends. In this study, we established a rat model of completely transected sciatic nerve injury and repaired it using a modified 1 cm-length conduit with inner diameter of 1.5 mm. Each end of the cylindrical conduit contains a short linear channel, while the enclosed central tube protects the nerve ends well. Nerves were repaired with 2-octyl-cyanoacrylate and suture, which complement the function of the modified conduit. The results demonstrated that for the same conduit, the average operation time using the adhesive method was much shorter than with the suture method. No significant differences were found between the two groups in sciatic function index, motor evoked potential latency, motor evoked potential amplitude, muscular recovery rate, number of medullated nerve fibers, axon diameter, or medullary sheath thickness. Thus, the adhesive method for repairing nerves using a modified conduit is feasible and effective, and reduces the operation time while providing an equivalent repair effect.
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Affiliation(s)
- Xiangdang Liang
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, China
| | - Hongfei Cai
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, China
| | - Yongyu Hao
- Wei Zikeng Clinic of General Armament Department of Chinese PLA, Beijing, China
| | - Geng Sun
- Department of Orthopedics, 252 Hospital of Chinese PLA, Hebei Province, China
| | - Yaoyao Song
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, China
| | - Wen Chen
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, China
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Pratt GF, Rozen WM, Westwood A, Hancock A, Chubb D, Ashton MW, Whitaker IS. Technology-assisted and sutureless microvascular anastomoses: evidence for current techniques. Microsurgery 2011; 32:68-76. [PMID: 22121054 DOI: 10.1002/micr.20930] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 05/12/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Since the birth of reconstructive microvascular surgery, attempts have been made to shorten the operative time while maintaining patency and efficacy. Several devices have been developed to aid microsurgical anastomoses. This article investigates each of the currently available technologies and attempts to provide objective evidence supporting their use. METHODS Techniques of microvascular anastomosis were investigated by performing searches of the online databases Medline and Pubmed. Returned results were assessed according to the criteria for ranking medical evidence advocated by the Oxford Centre for Evidence Based Medicine. Emphasis was placed on publications with quantifiable endpoints such as unplanned return to theatre, flap salvage, and complication rates. RESULTS There is a relative paucity of high-level evidence supporting any form of assisted microvascular anastomosis. Specifically, there are no randomized prospective trials comparing outcomes using one method versus any other. However, comparative retrospective cohort studies do exist and have demonstrated convincing advantages of certain techniques. In particular, the Unilink™/3M™ coupler and the Autosuture™ Vessel Closure System® (VCS®) clip applicator have been shown to have level 2b evidence supporting their use, meaning that the body of evidence achieves a level of comparative cohort studies. CONCLUSION Of the available forms of assisted microvascular anastomoses, there is level 2b evidence suggesting a positive outcome with the use of the Unilink™/3M™ coupler and the Autosuture™ VCS® clip applicator. Other techniques such as cyanoacrylates, fibrin glues, the Medtronic™ U-Clip®, and laser bonding have low levels of evidence supporting their use. Further research is required to establish any role for these techniques.
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Affiliation(s)
- George F Pratt
- Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Melbourne, Vic., Australia
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Bot GM, Bot KG, Ogunranti JO, Onah JA, Sule AZ, Hassan I, Dung ED. The use of cyanoacrylate in surgical anastomosis: an alternative to microsurgery. J Surg Tech Case Rep 2011; 2:44-8. [PMID: 22091332 PMCID: PMC3214492 DOI: 10.4103/2006-8808.63727] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
To present anastomosis with cyanoacrylate as a cheap, simple, fast, and available technique for anastomosis in urological, vascular, gynecological, and general surgical procedures. This method may in the future be a good alternative to microsurgery, particularly in centers where facilities are unavailable and the financial implication is unbearable for the patient. Cyanoacrylate is an adhesive or glue that is available in different chemical forms ranging from ethylcyanoacrylate (superglue) to Isobutylcyanoacrylate and octylcyanoacrylate (dermerbond), which is in clinical use. Anastomosis with cyanoacrylate requires the application of stay sutures, a luminal stent and the subsequent application of the adhesive. The adhesives with lower molecular weights produce a rigid and patent region of anastomosis, while the higher molecular compounds produce a consistency close to the normal tissue. This technique presents a surgical method that is socially, culturally, and ethically acceptable, which is affordable to a larger majority of patients in our subregion. Cyanoacrylate anastomosis may in the future present a fast, convenient, simple, and affordable option in the treatment of patients requiring anastomosis. In our subregion where the socio-cultural, psychological, and economic burden of failed anastomosis is high, associated with the low per capital income, this may be a novel option for the management of urogynecological, vascular, neurosurgical, and general surgical procedures requiring either microscopic or macroscopic anastomosis.
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Affiliation(s)
- G M Bot
- Department of Surgery, Jos University Teaching Hospital, Plateau State, Nigeria
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Abstract
Researchers have made numerous attempts to shorten anastomosis duration since Jacobson first used the term microvascular surgery in 1960. However, none of these alternatives has its combination of facility, low cost, reliability, durability, and high success rate. This study aimed to shorten the anastomosis duration, especially in operations that require multiple anastomoses, and the authors performed experimental anastomoses with the fish-mouth technique using fibrin glue. This technique first involves 2 longitudinal incisions made 180 degrees apart in the shape of a fish mouth at each vessel end, thus creating a pair of equal-sized, full-thickness flaps on both vessels. These incisions, equal in length, were as long as the radius of the vessel. Two simple stay-sutures placed on the corners of the flap bases and vessels were approximated. Then, the anastomosis site was sealed with fibrin glue. Both control and experimental groups are consisted of 32 rats. This study assessed and statistically evaluated the groups with biopsies on days 3, 7, 14, and 21 and also assessed patency rates, microaneurysm formation, histologic healing patterns, and operation duration. The present study concluded that anastomosis with fish-mouth technique using fibrin glue takes less time, requires fewer sutures, decreases the amount of foreign materials in direct contact with the blood stream, creates less foreign-body reaction in the vessel wall, and everts contact surfaces. With these advantages, this technique provides a reliable and successful alternative, especially in operations requiring multiple anastomoses.
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Miyamoto S, Sakuraba M, Asano T, Tsuchiya S, Hamamoto Y, Onoda S, Tomori Y, Yasunaga Y, Harii K. Optimal technique for microvascular anastomosis of very small vessels: Comparative study of three techniques in a rat superficial inferior epigastric arterial flap model. J Plast Reconstr Aesthet Surg 2010; 63:1196-201. [DOI: 10.1016/j.bjps.2009.05.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Revised: 05/01/2009] [Accepted: 05/27/2009] [Indexed: 11/15/2022]
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“Lid technique”: cyanoacrylate-assisted anastomosis of small-sized vessels. J Plast Reconstr Aesthet Surg 2009; 62:1205-9. [DOI: 10.1016/j.bjps.2007.12.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Revised: 11/16/2007] [Accepted: 12/18/2007] [Indexed: 11/18/2022]
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Güneren E, Odaci E, Yildiz L, Akbaş H, Eroğlu L, Kaplan S. Use of longitudinal invaginating matrix sutures in microarterial sleeve anastomoses. ACTA ACUST UNITED AC 2009; 38:1-4. [PMID: 15074715 DOI: 10.1080/02844310310010571] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A different approach to end in end anastomosis was tested to minimise the undesirable traits of classic and sleeve (telescoping) methods. Our approach aimed to maintain full contact at the level of the anastomosis by using longitudinal matrix sutures as a new invaginating suture technique in microarterial sleeve anastomosis. Classic end-to-end anastomosis with seven to eight stitches, Lauritzen's end-in-end anastomosis with four stitches, and our modified end-in-end anastomosis with two horizontal matrix sutures were made in 10, 20, and 25 rat femoral arteries, respectively. Nine, 17, and 18, respectively were patent at early evaluation; and eight, 13, and 14 at the time of late evaluation. There was no significant difference in between the patency rates of the groups. Histopathological examination showed large strictures and the formation of intra-luminal organised thrombus with thin intramural fibrin precipitation in occluded specimens. The longitudinal matrix sutures in the sleeve anastomoses, which passed through all layers of the vascular wall, injured the intima (a vertical rupture) and constricted the lumen.
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Affiliation(s)
- Ethem Güneren
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Ondokuz Mayis University, Kurupelit, Samsun, Turkey.
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De Somer F, Delanghe J, Somers P, Debrouwere M, Van Nooten G. Mechanical and chemical characteristics of an autologous glue. J Biomed Mater Res A 2008; 86:1106-12. [DOI: 10.1002/jbm.a.31705] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Van Nooten GJ, Somers P, Forsyth R, Narine K, Van Belleghem Y, Jacobs S, De Somer F. Autologous glue: part of the sticky mystery unraveled. J Thorac Cardiovasc Surg 2007; 134:415-23. [PMID: 17662782 DOI: 10.1016/j.jtcvs.2007.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 03/16/2007] [Accepted: 04/02/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the safety and efficacy of an autologous surgical tissue adhesive. METHODS Autologous glue was made out of canine concentrated plasma proteins mixed with 7.5% glutaraldehyde. Tensile strength and cytotoxicity of the autologous glue were tested. In a dog model, 8 transectioned iliac arteries were reanastomosed by using the animal's glue as the sole fixation method. After 120 days, all animals were angiographically controlled for patency and killed for histologic and immunohistochemical examination of the anastomosis. RESULTS The autologous glue showed sufficient tensile strength (557 +/- 135 N/mm2). The elasticity of the glue is influenced by variations of concentrations in both proteins and glutaraldehyde. Glutaraldehyde remained cytotoxic, even at low concentrations of 2.5%. All operative procedures were successful. Angiographs performed before animal death showed all but 1 vessel to be patent and showed manifest compression signs in 3 anastomoses. Histological examination revealed only a foreign-body reaction adjacent to the surface of the glue. The autologous glue does not trigger any immune response on immunochemistry. Because fibroblastic neo-endothelial lining was near to normal, potential glutaraldehyde leaching does not seem too harmful for the vascular juncture in the dog model. CONCLUSIONS Autologous glutaraldehyde glue has been used successfully as a vascular adhesive. In contrast to our previous studies with heterologous glue, we did not find a fierce acute inflammatory reaction indicating immune triggering. Nevertheless, glutaraldehyde remains a cytotoxic cross-linker. It is yet not known whether autologous glutaraldehyde glue can be used safely in clinical practice.
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Abstract
UNLABELLED Hand suture microanastomosis is a difficult procedure. This report describes a simplified microanastomosis using cuff and glue apparatus. MODEL Vena cava and intestine of rat were sectioned. The distal margin was introduced into an everted cuff covering the outer wall and fixed to the base of the tube by three stitches. The proximal segment was inserted into the cuff system and an encircling ligature was performed to attach both margins to the cuff. Proximal margin below ligature was pulled up exposing both intimae where glue was deposited. The proximal margin was pulled down, sealing the borders by glue adhesion. Ligatures fixing the system were sectioned and the cuff was removed. Anastomosis acquired a waveform shape, obtaining ideal intima-intima union and improving the healing process. After short training, this anastomosis can be performed within 10 min. This technique avoids cuff foreign body reaction, simplifies microanastomosis research, and may improve glue technology for tissue anastomosis.
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Affiliation(s)
- Flávio Henrique Ferreira Galvão
- Experimental Microvascular Laboratory of Transplantation and Liver Surgery Discipline, University of São Paulo School of Medicine, São Paulo, Brazil.
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18
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Abstract
In our experimental study of a new microvascular anastomosis technique, we divided 30 Wistar albino rats into 2 groups. We performed the classic interrupted suture anastomosis technique in group 1 (n = 15) and our new technique, using 3 horizontal mattress sutures, in group 2 (n = 15). We checked patency immediately following anastomosis, at the end of the first hour, and at the end of the third week postanastomosis. While the patency rates for both techniques were 100% at the end of the first hour, the respective values were 100% and 93.4% by the end of the third week. Using light microscopy, lumen patency, intimal and medial damage, inflammation, and granulation were evaluated histopathologically. The mean anastomosis time for the experimental group (15 minutes) was shorter than that for the classic group (mean 21 minutes), and the difference was statistically significant (P < 0.01), while the difference between the patency rates was not significant (P = 0.05). Therefore, provided that the incisions are made correctly, our microvascular anastomosis technique using 3 horizontal mattress sutures can be used in experimental and clinical studies.
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Affiliation(s)
- Ibrahim Orak
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey.
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Bahten LCV, Noronha LD, Silveira F, Nicollelli G, Longhi P, Pantanali CAR. Estudo da cicatrização nas lesões traumáticas esplênicas utilizando octil-2-cianoacrilato e fio de poliglecaprone 25. Rev Col Bras Cir 2006. [DOI: 10.1590/s0100-69912006000300009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Estudar comparativamente a cicatrização e a formação de aderências em baço de ratos submetidos à trauma operatório e corrigidos utilizando octil-2-cianoacrilato (DE) e fio de poliglecaprone 25 (CA). MÉTODO: 30 ratos machos Wistar foram separados em três grupos de 10 animais, anestesiados de acordo com as normas do COBEA, submetidos à laparotomia xifopúbica e com uma tesoura Metzenbaum, foi realizada uma lesão esplênica com 4mm de profundidade, na borda anti-hilar do pólo inferior do baço. No Grupo CA, suturou-se a lesão com pontos contínuos de poliglecaprone 25; no Grupo DE, com octil-2-cianoacrilato e no Grupo CO, não houve sutura. Após 14 dias, os ratos foram submetidos à eutanásia e as aderências anotadas em protocolo próprio. O estudo anatomopatológico foi realizado nas colorações hematoxilina-eosina e Picro-Sirius, sendo do tipo fechado, duplo-cego. RESULTADOS: O Grupo DE apresentou menos aderências e menor reação de cicatrização tipo corpo estranho que o CA. Ambos mostram quantidade semelhante de colágeno jovem e maduro. CONCLUSÕES: O octil-2-cianoacrilato provocou menos aderências macroscópicas que o fio de poliglecaprone corado e não induziu cicatrização com reação de corpo estranho, mostrando-se efetivo no reparo das lesões traumáticas esplênicas, em ratos.
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20
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Fehm NP, Vatankhah B, Dittmar MS, Tevetoglu Y, Retzl G, Horn M. Closing microvascular lesions with fibrin sealant-attached muscle pads. Microsurgery 2006; 25:570-4. [PMID: 16184526 DOI: 10.1002/micr.20165] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Fibrin sealants are used in a variety of surgical procedures, mainly for purposes of hemostasis and assisted wound healing. The combined use of fibrin sealant and autologous muscle pads for hemostasis was not reported previously. Arterial incisions in the common carotid artery in rats were closed by the combined application of fibrin sealant and an autologous muscle pad. Postsurgical vessel patency and degree of stenosis were evaluated by color duplex sonography, computed tomography angiography, and postmortem histology. The combined application of muscle pad and fibrin sealant and achievement of hemostasis was feasible in all animals. Seventy-eight percent of animals showed no or only slight postsurgical vessel stenosis. Our method is simple and quick to perform, showing a high potential for hemostasis in microvascular lesions. Therefore, it might be used in future experimental studies for conservation of vessel patency after arterial catheterization and in experimental or clinical vascular surgery.
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Affiliation(s)
- Nando Percy Fehm
- Department of Neurology, University of Regensburg, Regensburg, Germany.
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21
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Abstract
The repair of peripheral nerves with sutures is time consuming. The aim of this study was to evaluate the benefits and functional outcome of repairing nerves with octyl 2-cyanoacrylate adhesive. The right peroneal nerve of 64 male, Lewis rats was sectioned and repaired. The rats were randomized into 3 experimental groups: A (n = 27), using only octyl 2-cyanoacrylate; B (n = 27), using 4, 10-0 nylon sutures; and C (n = 10), a sham operation. The recovery of nerve function was quantified through walking-track analyses; group A showed faster return of nerve function than B, especially at 15 days (P < 0.017). Histologic analysis showed a greater axonal regeneration in group A versus group B and no indication of tissue toxicity in group A. No dehiscence occurred during the 6-month study. Use of adhesive shortened the anastomosis time from 12 minutes to 4 minutes. These results indicate that the use of octyl 2-cyanoacrylate adhesive for nerve anastomoses is safe and effective and may have benefits compared with the use of sutures.
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Affiliation(s)
- Angela Piñeros-Fernández
- Department of Plastic Surgery, University of Virginia Health System, Charlottesville, VA 22903-1351, USA
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22
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Ong YS, Yap K, Ang ESW, Tan KC, Ng RTH, Song IC. 2-Octylcynanoacrylate-assisted microvascular anastomosis in a rat model: long-term biomechanical properties and histological changes. Microsurgery 2004; 24:304-8. [PMID: 15274189 DOI: 10.1002/micr.20027] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The aim of this study was to establish the long-term biomechanical and histological properties of 2-octylcyanoacrylate-assisted microvascular anastomosis over conventional suture-only anastomosis in the laboratory rat model. The biomechanical and histological properties of three groups of vessels were compared: 1) vessels with 2-octylcyanoacrylate-assisted anastomoses (study group); 2) vessels with suture-only anastomoses (control group); and 3) normal unoperated vessels (sham group). In total, 144 adult rats were used, and these were studied at 1 week, 1 month, 3 months, and 6 months postanastomosis. At 6 months, the tensile strength of study vessels was significantly higher than control vessels. The stiffness of study and control vessels was similar at all time intervals. Histologically, there was no evidence that 2- octylcyanoacrylate caused toxicity to vessel walls, and there was less perivasacular foreign-body giant-cell reaction in the study group compared to the control group. Long-term follow-up showed that microvascular anastomosis with 2-octylcyanoacrylate in rat femoral arteries had superior tensile strength and similar stiffness to vessels anastomosed with sutures only, without adverse effects to surrounding tissues.
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Affiliation(s)
- Yee Siang Ong
- Department of Plastic Surgery, Singapore General Hospital, Singapore.
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Zeebregts CJ, Heijmen RH, van den Dungen JJ, van Schilfgaarde R. Non-suture methods of vascular anastomosis. Br J Surg 2003; 90:261-71. [PMID: 12594661 DOI: 10.1002/bjs.4063] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The main aim of performing a vascular anastomosis is to achieve maximal patency rates. An important factor to achieve that goal is to minimize damage to the vessel walls. Sutures inevitably induce vascular wall damage, which influences the healing of the anastomosis. Over time, several alternatives to sutures have become available. METHODS A Medline literature search was performed to locate English, German and French language articles pertinent to non-suture methods of vascular anastomosis. Manual cross-referencing was also performed and many historical articles were included. RESULTS AND CONCLUSION The non-suture techniques can be categorized into five groups based on the materials used: rings, clips, adhesives, stents and laser welding. With all these techniques a faster and less traumatic anastomosis can be made compared with sutures. However, each device is associated with technique-related complications. As a consequence, suturing continues to be the standard approach. The disadvantages of the non-suture techniques include: rigidity and a non-compliant anastomosis with rings; toxicity, leakage and aneurysm formation with adhesives; early occlusion with stents; cost, reduced strength in larger-sized vessels and demand for surgical skills with laser welding. Further refinement is needed before widespread adoption of these techniques can occur. Clips, however, may be particularly promising but long-term evaluation is required.
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Affiliation(s)
- C J Zeebregts
- Department of Surgery, University Hospital Groningen, Groningen, The Netherlands.
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24
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Abstract
Octyl-2-cyanoacrylate (Dermabond; Ethicon, Somerville, NJ) is a synthetic tissue adhesive recently approved for skin closure. This study was designed to assess its effectiveness for use in clefts lip repairs. Sixty-four patients with unilateral, bilateral, or midline cleft lip defects were repaired. The ages at repair ranged from 4 days to 19 months, with an average of 46.5 days. Follow-up ranged from 6 months to 3 years. No complications were found. Several advantages were observed: shorter operative time, formation of a protective barrier, simplified incision care, no need for suture removal, and improved scar outcome. This study supports octyl-2-cyanoacrylate as an alternative to skin sutures in primary cleft lip repair.
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Affiliation(s)
- William P Magee
- Eastern Virginia Medical School, Institute of Craniofacial and Plastic Surgery, Children's Hospital of the King's Daughters, Norfolk, VA, USA
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25
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Grummet JP, Costello AJ, Swanson DA, Stephens LC, Cromeens DM. Vesicourethral anastomosis with 2-octyl cyanoacrylate adhesive in an in vivo canine model. Urology 2002; 60:935-8. [PMID: 12429341 DOI: 10.1016/s0090-4295(02)01887-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of 2-octyl cyanoacrylate adhesive (OCA) in the formation of vesicourethral anastomoses. METHODS Open total prostatectomy was performed on 12 mongrel hounds. Of these, 8 had a vesicourethral anastomosis formed using OCA (4 with suture support and 4 sutureless). The remaining four anastomoses were conventionally formed using eight interrupted sutures. Acute leakage was tested intraoperatively. Before killing the hounds, the anastomosis of 1 animal in each group was assessed on postoperative days 3, 5, 7, and 14 by radiography. Each anastomotic specimen was then tested for leak pressure and examined histologically. RESULTS At intraoperative testing, one small leak was found in the sutureless OCA group. All other anastomoses were watertight intraoperatively. Radiographically, two leaks occurred in the OCA group with suture support, three leaks in the sutureless OCA group, and only one small localized leak in the control group. Only one of the eight anastomoses using OCA achieved a physiologic leak pressure greater than 70 mm Hg (one of these, however, could not be tested because of injury at the time the specimen was retrieved). The leak pressures of all four control-group anastomoses were 70 mm Hg or greater. Histologically, no significant differences were found in healing between the control and OCA anastomoses. CONCLUSIONS With or without suture support, OCA appears to be unsuitable for use in forming the large-diameter vesicourethral anastomosis required in radical prostatectomy.
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Affiliation(s)
- Jeremy P Grummet
- Division of Urology, Department of Surgery, University of Melbourne, Melbourne, Australia
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Buijsrogge MP, Verlaan CWJ, van Rijen MHP, Gründeman PF, Borst C. Coronary end-to-side sleeve anastomosis using adhesive in off-pump bypass grafting in the pig. Ann Thorac Surg 2002; 73:1451-6. [PMID: 12022532 DOI: 10.1016/s0003-4975(02)03423-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND In the exploration of facilitated coronary anastomosis strategies, we assessed a new octylcyanoacrylate adhesive in combination with a modified end-to-side sleeve anastomosis in off-pump bypass grafting in the pig. METHODS Sleeve-adhesive anastomoses (n = 20) were evaluated intraoperatively, at 3 days (n = 4), and at 5 weeks (n = 16) in an off-pump, low (< or = 15 mL/min; n = 10) and high flow (approximately 60 mL/min; n = 10) porcine bypass model. All anastomoses were examined by flow measurement, angiography, and histology. RESULTS Anastomosis construction took 8.5 minutes (6.7 to 10.2 minutes; median [15th to 85th percentile]). At 5 weeks, all anastomoses were fully patent (FitzGibbon grade A). The adhesive did not cause impaired vessel wall healing, but was surrounded by a focal acute and limited chronic (foreign body giant cells occasionally seen) inflammatory reaction at the adventitial application site. CONCLUSIONS Octyl-cyanoacrylate tissue adhesive combined with end-to-side internal mammary to coronary artery sleeve anastomosis construction proved to be feasible, even in low bypass graft flow conditions (< or = 15 mL/min; prothrombotic milieu) in the pig and deserves interest in exploration of facilitated anastomosis strategies in coronary artery bypass grafting.
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Affiliation(s)
- Marc P Buijsrogge
- Heart Lung Center Utrecht, University Medical Center Utrecht, The Netherlands
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Buijsrogge MP, Scheltes JS, Heikens M, Gründeman PF, Pistecky PV, Borst C. Sutureless coronary anastomosis with an anastomotic device and tissue adhesive in off-pump porcine coronary bypass grafting. J Thorac Cardiovasc Surg 2002; 123:788-94. [PMID: 11986608 DOI: 10.1067/mtc.2002.120336] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In the search for a facilitated coronary artery anastomosis, we assessed the feasibility of a hybrid anastomosis technique that used a prototype anastomotic device with an extraluminal frame (crinoline-like) and octyl-cyanoacrylate adhesive. METHODS During off-pump coronary artery bypass grafting in pigs (n = 8), a left internal thoracic artery-right coronary artery anastomosis was constructed and evaluated during the operation and at 5 postoperative weeks. The anastomosis was examined by flow measurement, angiography, intraluminal cast geometric analysis, and histologic analysis. RESULTS Anastomosis construction required 6.2 +/- 1.3 minutes (mean +/- SD). At 5 weeks all anastomoses were fully patent, with minor anastomotic diameter narrowing (median 16%, 15th-85th percentile 16%-26%). After 30-second graft occlusion, median peak hyperemic flow response was 5.0 (15th-85th percentile 4.4-6.5). As a result of complete, streamlining filling of anastomotic wall recesses by neointima formation, more intimal hyperplasia was found in the crinoline-adhesive anastomoses than in sutured control anastomoses. No excessive, lumen-narrowing neointima formation was observed, however. CONCLUSIONS The hybrid coronary anastomosis technique was feasible without any need for dedicated application tools. If technical improvements can be realized, the hybrid technique may provide an alternative to manual suturing.
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Affiliation(s)
- Marc P Buijsrogge
- Heart Lung Center Utrecht, University Medical Center Utrecht, The Netherlands
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28
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Abstract
The commercial introduction of octyl-2-cyanoacrylate as a medical-grade tissue adhesive was intended to be a rapid, painless, suture-free method for closure of simple lacerations and surgical wounds. The efficiency and therefore potential economic advantage of this material has led to further investigations of other possible indications. This glue has now been used in more than 100 different occasions for "off-label" applications including nailbed repair, skin graft fixation, temporary otoplasty, wound sealant, and other forms of wound closure. Complications are virtually nonexistent, and there has been no evidence of histotoxicity. The role of this material as an important reconstructive tool has not yet been delineated completely, but it appears to have no contraindications if used sensibly.
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Affiliation(s)
- G G Hallock
- Division of Plastic Surgery, The Lehigh Valley Hospitals, Allentown, PA, USA
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