Oxidized cellulose (Surgicel) granuloma mimicking a primary ovarian tumor

Oxidised cellulose-based reaction mimicking a suspicious ovarian mass: a case report and a systematic review

Oxidised regenerated cellulose was introduced 60 years ago to control diffuse bleeding from large surfaces. Although considered safe and effective, foreign body reactions can mimic suspicious masses in several organs. We describe the third case, reported in PubMed, of an oxidised regenerated cellulose-based granuloma mimicking a suspicious ovarian tumour on MRI. During surgery, the diagnosis was suspected by granulomatous tissue and confirmed by pathology. The follow-up after the excision was uneventful. Although a rare complication, physicians should be aware of this presentation and of the recommendation to remove excess Surgicel after the bleeding has stopped.

Surgicel® Granuloma Mimicking Recurrent Thyroid Tumor After Thyroidectomy: A Case Report and Literature Review

Oxidized regenerated cellulose, commonly known by the brand name Surgicel®, is a hemostatic agent widely used in various surgical procedures. While it is generally considered safe and effective, there have been reports of complications associated with its use, including the formation of pseudotumoral lesions. This article presents a case of a patient who developed a Surgicel® granuloma in the thyroid bed, mimicking a recurrent tumor. Surgicel® is known to cause a chronic inflammatory reaction, leading to foreign body giant cell formation and fibroblastic proliferation. Fine-needle aspiration (FNA) cytology is a valuable diagnostic tool for identifying pseudotumoral lesions caused by oxidized cellulose. The characteristic appearance of oxidized cellulose fragments and the presence of a granulomatous reaction can help distinguish these lesions from tumor recurrence or abscesses. To prevent Surgicel® granuloma, it is recommended to use the minimal amount necessary to achieve hemostasis. It is also important to document its use in the operative report. In cases where a recurrent mass lesion is suspected postoperatively, a comprehensive medical history, imaging studies, and FNA are essential for accurate diagnosis and management. This case report highlights the importance of considering Surgicel®-induced granuloma in the differential diagnosis of recurrent thyroid-bed tumors. A correct diagnosis can help avoid unnecessary aggressive interventions, particularly in cancer patients.

FDG PET/CT Features of Polysaccharide-Based Hemostatic Agent: Chronic Inflammatory Changes Can Mimic Metastatic Lesions

PURPOSE

To prevent hemorrhagic complications, hemostatic agents (HAs) have been widely used in recent years. The use of HAs can lead to false-positive results on postoperative imaging. There exists only 1 study in the literature evaluating these applications during surgical procedures. Therefore, we aimed to evaluate the postoperative imaging features of polysaccharide-based HAs in thoracic surgery patients who have had 18F-FDG PET/CT scans.

PATIENTS AND METHODS

Two hundred nine consecutive patients who underwent thoracic surgery were enrolled in this study. A topical polysaccharide-based HA was applied to the surgical bed for all of the patients. The patients diagnosed with cancer were followed up with subsequent thoracic CT scans, and 42 of these patients were also imaged with 18F-FDG PET/CT, which then comprised the main study group. Due to suspicion of metastasis, 19/42 patients were reoperated or rebiopsied. The latest histopathological findings were accepted as criterion standard, and previous FDG PET/CT images were retrospectively reevaluated.

RESULTS

Polysaccharide-based HAs that appear as amorphous basophilic material were identified in histopathological samples of 11/19 patients. Lymphocytes, plasma cells, and histiocytes, which formed foreign body reaction and/or foreign body granuloma, indicating the presence of chronic inflammation, were seen in all of the samples. 18F-FDG PET/CT showed increased FDG uptake in all of these lesions.

CONCLUSIONS

Despite the inconsistency of the literature, polysaccharide-based HAs can be demonstrated in human surgical specimens as amorphous basophilic materials even after a long time from the initial surgical procedure. These agents almost always cause chronic inflammatory changes. In addition, these agents may mimic "false-positive" findings on postoperative FDG PET/CT scans.

Bolster material granuloma masquerading as recurrent renal cell carcinoma following partial nephrectomy

Nephron sparing surgery has seen a phenomenal rise in its application over the past few decades. The use of Surgicel and gel foam for closure of defect created after partial nephrectomy has become a routine practice at many centers. In this case report, we describe radiological artifact secondary to a surgical bolster mimicking a residual disease or an early recurrence in the kidney. This case highlights two facts; first, reapproximation of the renal tissue is best done without the use of Surgicel bolsters. Second, bolsteroma should always be kept in mind as a differential diagnosis in a case where computed tomography (CT) imaging is showing early recurrence. If the surgeon is sure about the surgical margins being negative and the CT image shows a bolsteroma, the patient should be observed and a repeat scan should be done at 3–6 months, which would show regression or disappearance of the lesion proving it to be an artifact rather than malignant lesion.

Use of Oxidized Regenerated Cellulose as a Hemostatic Agent in Neurosurgery: Appraisals and Recommendations to Prevent Postoperative Complications and Facilitate Follow-Up

Neurosurgical hemostasis can be performed with bipolar coagulation and with the support of several dedicated biomaterials including oxidized regenerated cellulose (ORC; e.g., Surgicel®, Johnson & Johnson, New Brunswick, NJ, USA). Oxidized regenerated cellulose is a sterile absorbable fibrous biomaterial that has become a major local hemostatic agent thanks to its ease of use, favorable biocompatibility and bioabsorption characteristics. However, some postoperative issues associated with its use, such as allergic reaction, seroma, foreign-body reaction with compressive neuropathies and misdiagnosis during follow-up, have been reported. These complications could compromise clinical outcomes with a negative impact on patient quality of life and sometimes require risky major surgical procedures. An understanding of the specific properties of ORC combined with adequate surgical expertise and compliance with some basic rules are needed to optimize clinical outcomes and minimize postoperative issues.

A Comparative Efficacy Evaluation of Recombinant Topical Thrombin (RECOTHROM®) With A Gelatin Sponge Carrier Versus Topical Oxidized Regenerated Cellulose (TABOTAMP®/SURGICEL®) In A Porcine Liver Bleeding Model

PURPOSE

Topical hemostatic agents can be classified as active or passive. This study compared the hemostatic efficacy of an active agent, recombinant thrombin (RECOTHROM^® [rT]) plus gelatin sponge carrier versus a passive agent, oxidized regenerated cellulose (TABOTAMP^®/SURGICEL^® [ORC]), in a porcine liver abrasion model.

MATERIALS AND METHODS

Eight pigs were used, four of them were heparinized. A total of 80 liver lesions were created, 40 of them in heparinized pigs. Lesions were treated with rT plus gelatin sponge or ORC. Bleeding rate was quantified before treatment by applying pre-weighed gauze. Time to hemostasis was assessed visually for 10 minutes.

RESULTS

Seven of the 80 lesions were excluded for having initial bleeding rates exceeding the target of 10 g/min. Sixteen and 20 lesions were treated with rT plus gelatin sponge and 19 and 18 lesions were treated with ORC, in non-heparinized and heparinized animals, respectively. Time to hemostasis (median [IQR]) was significantly shorter with rT plus gelatin sponge (30 [30,30] seconds) in heparinized and non-heparinized animals versus ORC in non-heparinized (180 [120,210] seconds) and heparinized animals (215 [135,345] seconds); P < 0.0001 for both comparisons. In heparinized animals, ORC took longer to achieve hemostasis, with treatment failure in 2/18 lesions. Time to hemostasis with ORC was longer for lesions in heparinized animals with initial bleeding rates of >5-10 g/min (285 [225,394] seconds) versus ≤5 g/min (175 [108,290] seconds).

CONCLUSIONS

In this model, rT plus gelatin sponge carrier (active) was a more effective hemostat than ORC (passive) in both heparinized and non-heparinized animals.

The safety and benefit of using oxidized regenerated cellulose to position free flap pedicle in head and neck reconstruction

BACKGROUND

Oxidized regenerated cellulose (ORC; Surgicel®; Ethicon, Neuchâtel, Switzerland) is an absorbable hemostatic agent used for hemostasis in operation, although some surgeons use it to position free flap pedicles. The increasing risk of vessel compromise is a huge concern. However, no scientific data to date demonstrate the safety and benefit of using ORC in microvascular surgery. In the present study, we compared the outcome of microvascular head and neck reconstruction with and without pedicle placement using ORC.

MATERIALS AND METHODS

From January 2015 to December 2017, we reviewed patients undergoing microvascular surgery with free fibular osteocutaneous flap in our hospital. The patients were divided into the ORC group and non-ORC group and their baseline characteristics and outcomes were compared.

RESULTS

In total, there were 27 patients in the ORC group and 67 in the non-ORC group. The non-ORC group had significantly higher cigarette consumption (70.4% vs. 89.6%; p = .022). The outcome of the ORC group was better regarding arterial thrombosis (0% vs. 3%), flap failure (0% vs. 4.5%), hematoma (7.4% vs. 10.4%), and wound complications (25.9% vs. 44.8%). The ORC group had a worse result than the non-ORC group for vein thrombosis (7.4% vs. 4.5%) and duration of hospitalization (24.111 days vs. 23.627 days). However, none of above results was significant.

CONCLUSIONS

Though this study was underpowered to detect the differences, the results showed a trend toward better outcomes of flaps and wounds in the ORC group. It seems that using ORC in this field is safe and beneficial.

Systematic Review of Topical Hemostatic Agent Use in Minimally Invasive Gynecologic Surgery

Background and Objectives:

To perform a systematic review of articles evaluating hemostatic effectiveness and peri-operative outcomes when topical hemostatic agents (HA) are used in minimally invasive gynecologic surgeries (MIGS) for benign conditions.

Methods:

Studies published through March 31, 2017 were retrieved through PubMed, EMBASE, Cochrane, and ClinicalTrials.gov to identify all eligible studies. No studies were excluded based on publish date. All comparative studies or case series with >10 participants reporting use of at least one topical HA in MIGS for benign conditions were included as long as full-text articles were available and written in English. Studies were excluded if surgery was done for malignancy or completed via an open approach. Articles that included multiple surgical subspecialties were excluded if data related to MIGS was unable to be isolated. Evaluation for eligibility and data extraction was performed by three independent reviewers. Quality of evidence was also assessed by each reviewer.

Results:

From 132 articles, a total of 8 studies were included in this systematic review. We found that use of fibrin sealant decreased time to hemostasis, postoperative hemoglobin drop, and estimated blood loss (EBL) compared with bipolar energy and reduced the overall operative time in laparoscopic myomectomy. When fibrin sealant use at time of myomectomy was compared to bipolar energy there was no significant difference in the rate of postoperative complications. Furthermore, there was less of a decrease in anti-Mullerian hormone (AMH) level when a thrombin-gelatin matrix was used compared to bipolar energy on ovarian tissue.

Conclusion:

Application of topical HA in MIGS can reduce operative time, blood loss, and ameliorate damage to ovarian function. However, more data needs to be gathered for use of HA during different types of gynecologic procedures (adnexal surgery, myomectomy, and hysterectomy) to provide better quality evidence to guide their use.

Intracranial foreign material granulomas after cranial surgery

BACKGROUND

Various synthetic materials are used in neurosurgery and left in place intentionally during surgery for several purposes such as hemostasis, dural closure, or cranioplasty. Although leaving such substances in surgical sites is considered safe, in general, foreign body granuloma may occur months or years after intracranial surgery. Thus, far relatively little is known about treatment and outcome of such lesions.

METHODS

A systematic review of 3466 histopathological examinations after cranial surgeries achieved over a 13-year period was performed. After excluding patients with Teflon granulomas or infection, a total of 12 patients with foreign body granulomas induced by synthetic material used in a prior surgery were identified. Patient records, imaging studies, and histopathological data were analyzed. Furthermore, postoperative outcome was assessed.

RESULTS

Mean age at the second surgery was 51 years (range, 11-68 years). The median time between the primary and the secondary surgery was 13 months (range, 1-545 months). Eight patients (75%) presented with signs and symptoms related to the foreign body granulomas. Total resection of the foreign body granulomas was performed in all patients. The granulomas were induced by oxidized cellulose polymer (n = 6), suture material (n = 3), Gelfoam (n = 1), methylmethacrylate (n = 1), and bone wax (n = 1). The mean postoperative follow-up time was 54 months (range 1-137 months). There was symptomatic improvement in all instances. Imaging studies did not demonstrate any recurrence.

CONCLUSION

Despite its rarity, foreign body granuloma should be taken into consideration in the differential diagnosis of intracranial mass lesions especially in cases of suspected tumor recurrence after prior surgery. The pathogenesis of foreign body granuloma still needs further clarification. Our study demonstrates that they have good prognosis after surgical removal.

Hemostatic Agents and Tissue Sealants: Potential Mimics of Abdominal Abnormalities

OBJECTIVE

Topical tissue sealants and hemostatic agents, seen on postoperative imaging in a variety of intraabdominal and pelvic locations, have the potential to be mistaken for abdominal abnormalities, especially if the radiologist is not aware of the patient's surgical history. The normal appearance of these agents may mimic abscesses, tumors, enlarged lymph nodes, or retained foreign bodies. Therefore, it is important to be familiar with their typical imaging appearances and to review the surgical records when needed to avoid misdiagnoses. The purpose of this article is to increase the radiologist's familiarity with various types of topical tissue sealants and hemostatic agents used during surgical and percutaneous procedures in the abdomen and pelvis along with their radiologic appearances.

CONCLUSION

Various types of hemostatic agents are now commonly used during surgery and percutaneous procedures in the abdomen and pelvis, and it is important to recognize the various appearances of these agents. Although there are suggestive features outlined in this article, the most important factor for the radiologist is to be aware of the patient's history and the possibility that a hemostatic agent may be present. On postoperative imaging, hemostatic agents may mimic abscesses, tumors, enlarged lymph nodes, or retained foreign bodies, and accurate diagnosis can save a patient unnecessary treatment. It is therefore crucial to incorporate knowledge of the patient's surgical history with recognition of the typical imaging appearances of hemostatic agents and other pseudolesions to avoid misdiagnoses.

Practical Suggestions for Prevention of Complications Arising from Oxidized Cellulose Retention: A Case Report and Review of the Literature

BACKGROUND Bleeding is a major intraoperative complication during surgical procedures. When conventional methods such as ligature and diathermocoagulation are ineffective for bleeding management, hemostatic agents should be used. Oxidized cellulose is one of the major hemostatic agents used worldwide. Oxidized cellulose is often left in situ after hemostasis because of its high level of reabsorption that lasts up to 8 weeks. However, 38 cases of retaining-associated complications are reported in the literature. CASE REPORT A 51-year-old male patient presented in our emergency department with acute abdominal pain, nausea, and vomiting. The patient had been admitted in our department for laparoscopic cholecystectomy for acute cholecystitis 25 months previously. Abdominal ultrasound and CT scan showed the presence of a cystic circular mass, with homogeneous fluid content, close to the surgical clips of the previous surgery, resembling a "neogallbladder". Laparoscopic abdominal exploration and drainage were performed. Histological examination reported protein-based amorphous material with rare lymphocytes and macrophages. Culturing was negative for bacterial growth. The patient was discharged uneventfully on the 4 th postoperative day. The primary surgical report was evaluated with evidence of application of Gelita-Cel ® Standard for hemostatic purposes. Results of 12-month follow-up were normal. CONCLUSIONS Herein, we report the first case of a complication associated with the use of Gelita-Cel ® Standard. We reviewed the literature to better define the purpose and limits of oxidized cellulose use as a hemostatic agent. Despite the fundamental role of oxidized cellulose as a hemostatic agent, we provide some practical suggestions to prevent the reported severe complications and surgical overtreatments.

Use of oxidized regenerated cellulose to achieve hemostasis during laparoscopic cholecystectomy: a retrospective cohort analysis

OBJECTIVE

Laparoscopic cholecystectomy is the first-choice treatment for symptomatic cholelithiasis. Though generally safe, this procedure is not without complications, with bleeding the most frequent cause of conversion to open cholecystectomy. Oxidized regenerated cellulose (ORC) added to conventional hemostatic strategies, is widely used to control bleeding during surgery despite limited evidence supporting its use. This retrospective study analyzed patients undergoing laparoscopic cholecystectomy in an Italian center over a 16-month period, between October 2014 and February 2016, who experienced uncontrollable bleeding despite the use of conventional hemostatic strategies, requiring the addition of ORC gauze (Emosist®).

RESULTS

Of the 530 patients who underwent laparoscopic cholecystectomy, 24 (4.5%) had uncontrollable bleeding from the liver bed. Of these, 62.5% had acute cholecystitis and 33.3% chronic cholecystitis; 1 patient was diagnosed with gallbladder carcinoma, postoperatively. Most patients had comorbidities, 16.7% had liver cirrhosis, and 37.5% used oral anticoagulants. The application of ORC rapidly controlled bleeding in all patients. Patients were discharged after a mean duration of 2.2 days. ORC was easy to use and well tolerated. Bleeding complications remain a relevant issue in laparoscopic cholecystectomy. ORC was able to promptly stop bleeding not adequately controlled by conventional methods and appears, therefore, to be a useful hemostat.

Subhepatic mass occurrence after using oxidized and regenerated cellulose polymer in laparoscopic cholecystectomy: a case series

BACKGROUND

Oxidized regenerated cellulose (ORC) is a bioabsorbable surgical hemostatic. We present the first prospective case series of circumscribed mass occurrence after using ORC in laparoscopic cholecystectomy.

METHODS

Tabotamp (Ethicon, Inc., Somerville, NJ) in the form of tightly woven knitted patches was used to achieve hemostasis in 83 patients submitted to LC.

RESULTS

A subhepatic mass was detected in five patients and radiologic characteristics were described. Abdominal contrast enhanced CT showed a heterogeneous soft-tissue mass. NMR was performed in one patient and showed a T2-weighted hyperintense mass.

CONCLUSION

ORC retention after surgery is not uncommon at long-term follow-up. The radiologic characteristics of a suspected ORC retention mass can differentiate it from a neoplastic lesion, so that surgery can be avoided.

Surgicel® granuloma mimicking ovarian cancer: A case report

Surgicel^® is an absorbable sterile mesh composed of oxidized cellulose that is used to control intraoperative capillary or venous bleeding, due to its capacity to bind hemoglobin, thus allowing the formation of an artificial clot. In the present study, a large granuloma mimicking ovarian cancer, which developed following placement of a Surgicel^® sponge during a combined pubovaginal sling procedure and cystocele repair, is reported. The aim of the present case report is to emphasize the fact that hemostatic measures should be removed following their use, and to alert surgeons to the risk of using and leaving in situ oxidized cellulose. Furthermore, accurate evaluation of the surgical history of the patient should always be performed prior to attempting surgery.

A Novel Hemostatic Patch That Stops Bleeding in Cardiovascular and Peripheral Vascular Procedures

BACKGROUND

Achieving hemostasis during surgery is a common challenge across surgical specialties and procedures, including cardiovascular and peripheral vascular procedures. Although several hemostatic agents are available, they all become less effective as bleeding becomes more vigorous. Veriset™ hemostatic patch is a topical hemostatic agent that has been approved for use on solid organs and in soft tissue. The primary aim of these studies was to assess the safety of Veriset hemostatic patch during cardiovascular and peripheral vascular procedures.

METHODS

Adult domestic swine were given intraoperative anticoagulation and systemic antiplatelet therapy, and then underwent a variety of cardiovascular coronary artery bypass graft (CABG anastomosis and aortotomy closure) and peripheral vascular (carotid arteriotomy with patch angioplasty) procedures. Bleeding was identified or created from each anastomotic site and was brisk in many cases. Veriset hemostatic patch, Surgicel(®) Nu-Knit(®) absorbable hemostat, or standard of care treatment was applied topically to the site of bleeding, and time to hemostasis was monitored for each animal. Animals were assessed during and after the surgical procedure to determine the effects of treatment on vessel diameter, clinical laboratory parameters, and host tissue response and/or tissue integration.

RESULTS

Application of Veriset hemostatic patch had no effect on vessel diameter, similar to Surgicel Nu-Knit absorbable hemostat and standard of care treatment. Approximately 28 days after application, Veriset hemostatic patch and Surgicel Nu-Knit absorbable hemostat were completely absorbed, with no impact on serum chemistry profiles. Furthermore, Veriset hemostatic patch was as effective or more effective than Surgicel Nu-Knit absorbable hemostat when applied during carotid arteriotomy (30.0 ± 0.0 sec vs. 163.6 ± 86.9 sec, P < 0.001) and CABG anastomosis (91.9 ± 66.0 sec vs. 207.5 ± 159.2 sec, P = 0.053).

CONCLUSIONS

Veriset hemostatic patch exhibits similar safety as Surgicel Nu-Knit absorbable hemostat, with effectiveness against cardiovascular and peripheral vascular bleeding. If these preclinical results are confirmed in clinical trials, this highly effective patch with a topical application requiring less than 30 seconds is likely to prove useful in many clinical settings.

Intraovarian oxidized cellulose (Surgicel) mimicking acute ovarian pathology after recent pelvic surgery

Oxidized regenerated cellulose (Ethicon Surgicel) is often used during surgery to achieve hemostasis. The appearance of Surgicel on postoperative computed tomography (CT) may be mistaken for abscess. Meanwhile, the literature regarding its ultrasound appearance remains scant. We report the CT and sonographic appearances of Surgicel in the right ovary of a 21-year-old woman presenting to the emergency department with pelvic pain 7 days after ovarian cystectomy. The patient was discharged home with only supportive measures, and follow-up ultrasound obtained 26 days later demonstrated resolution of the sonographic abnormality. This case stresses the importance of familiarity with common imaging appearances of topical hemostatic agents and the need to correlate radiologic findings with the patient's clinical condition and prior operative reports to identify patients suitable for conservative management.

Evaluation of the biological tolerability of the starch-based medical device 4DryField® PH in vitro and in vivo a rat model

PURPOSE

To evaluate in vitro cytotoxicity/biocompatibility as well as in vivo tolerability of the novel polysaccharide 4DryField® PH, certified for haemostasis and adhesion prevention.

METHODS

In vitro cytotoxicity/viability testing according to ISO EN 10,993 using murine and human tumour cell lines incubated with 4DryField® PH (PlantTec Medical GmbH). Using a rat model the impact of 4DryField® PH on animals viability and in vivo effects were macro- and micropathologically assessed.

RESULTS

In vitro testing revealed no cytotoxic effect of 4DryField® PH nor enhancement of viability to tumour cell lines. In vivo viability of rats was unimpaired by 4DryField® PH. Bodyweight loss in animals with abdominal injury plus treatment with 4DryField® PH was in the range of controls and less than in injured rats without treatment. At day 7 after surgery no formation of adhesions, neither macroscopic nor histological remnants nor signs of foreign body reaction were present in animals without injury. In animals with peritoneal injury and 4DryField® PH application, histopathological observation revealed minor residuals of polysaccharide in the depth of wound cavity embedded in a thickened subperitoneal layer; however, with a suggested intact neoperitoneum. The presence of mononuclear cells surrounding polysaccharide particles in varying states of degradation was observable as well.

CONCLUSION

4DryField® PH is not cytotoxic and does not enhance viability of tumour cell lines. High dose of 4DryField® PH of 1.09 g/kg bodyweight is well tolerated and reduces weight loss in animals with peritoneal injury. The biocompatibility of 4DryField® PH can be rated as being excellent.

Safety and effectiveness of a synthetic hemostatic patch for intraoperative soft tissue bleeding

Background

Continuous bleeding after using conventional hemostatic methods involving energy, sutures, or clips, is a serious and costly surgical complication. Many topical agents have been developed to promote intraoperative hemostasis, but improvement is needed in both decreasing time to hemostasis and increasing ease of use. Veriset™ hemostatic patch is CE-marked for controlling bleeding on the liver and in soft tissue. In the current study, we aimed to gather further evidence for the safety and effectiveness of Veriset™ hemostatic patch in soft tissue bleeding during a variety of surgical procedures.

Methods

Thirty patients scheduled for nonemergency surgery, each with an intraoperative soft tissue bleeding site, were treated with Veriset™ hemostatic patch. Time to hemostasis was monitored, and adverse events were assessed during the 90 days after surgery.

Results

When Veriset™ hemostatic patch was used, hemostasis occurred within 5 minutes in 29/30 (96.7%) subjects and within 1 minute in 21/30 (70.0%) subjects. No device-related serious adverse events were recorded during the 30 days after surgery, and no reoperations for device-related bleeding complications were performed during the 5 days after surgery.

Conclusions

Veriset™ hemostatic patch is a safe and effective hemostat for controlling soft tissue bleeding during a variety of surgical procedures.

Surgicel application in intracranial hemorrhage surgery contributed to giant-cell granuloma in a patient with hypertension: case report and review of the literature

BACKGROUND

Surgicel is an oxidized cellulose preparation that is widely applied in neurosurgery due to its hemostatic effect and good tissue compatibility. Tumor-like lesions induced by Surgicel application in cerebral surgery have been rarely reported, especially for intracranial hemorrhage debridement surgery in patients with hypertension.

CASE PRESENTATION

This case report describes a rare case in which Surgicel application led to a foreign body reaction, contributing to the development of an intracranial giant-cell granuloma. A 49-year-old female hypertensive patient was diagnosed with intracranial hemorrhage. She was treated with debridement surgery that employed Surgicel application. Although a satisfactory hemostatic effect was achieved, the patient was diagnosed with epilepsy 6 months later. Subsequent magnetic resonance imaging revealed an intracranial space-occupying lesion. After undergoing en bloc resection of the lesion, the patient was diagnosed with a Surgicel-related intracranial giant-cell granuloma by histopathology.

CONCLUSIONS

Application of Surgicel during intracranial hemorrhage debridement surgery may be associated with a risk of granuloma development due to formation of a tumor-like space-occupying lesion in the surgery bed. Even a low risk of tumor development implies a need for caution when applying Surgicel, especially when solely used to achieve a hemostatic effect.

The effects of surgicel and bone wax hemostatic agents on bone healing: An experimental study

BACKGROUND

The biological effects of hemostatic agends on the physiological healing process need to be tested. The aim of this study was to assess the effects of oxidized cellulose (surgicel) and bone wax on bone healing in goats' feet.

MATERIALS AND METHODS

Three congruent circular bone defects were created on the lateral aspects of the right and left metacarpal bones of ten goats. One defect was left unfilled and acted as a control; the remaining two defects were filled with bone wax and surgicel respectively. The 10 animals were divided into two groups of 5 animals each, to be sacrificed at the 3(rd) and 5(th) week postoperatively. Histological analysis assessing quality of bone formed and micro-computed tomography (MCT) measuring the quantities of bone volume (BV) and bone density (BD) were performed. The results of MCT analysis pertaining to BV and BD were statistically analyzed using two-way analysis of variance (ANOVA) and posthoc least significant difference tests.

RESULTS

Histological analysis at 3 weeks showed granulation tissue with new bone formation in the control defects, active bone formation only at the borders for surgicel filled defects and fibrous encapsulation with foreign body reaction in the bone wax filled defects. At 5 weeks, the control and surgicel filled defects showed greater bone formation; however the control defects had the greatest amount of new bone. Bone wax filled defects showed very little bone formation. The two-way ANOVA for MCT results showed significant differences for BV and BD between the different hemostatic agents during the two examination periods.

CONCLUSION

Surgicel has superiority over bone wax in terms of osseous healing. Bone wax significantly hinders osteogenesis and induces inflammation.

Bedside bleeding control, review paper and proposed algorithm

Bleeding is a common occurrence in practice, but occasionally it may be challenging issue to overcome. It can come from numerous sources such as, trauma, during or post-surgical intervention, disorders of platelet and coagulation factors and increased fibrinolysis, wounds and cancers. This paper was inspired from our experience with a patient admitted to a local long term acute care facility with a large fungating right breast cancerous wound. During her hospital stay spontaneous bleeding from her breast cancerous mass was encountered and became more frequent and significant over the period of her stay. Different hemostatic technologies were used to control her bleeding. We felt that it was important to share our experience with our colleagues to help with potential similar situation that they may face.

Oxidized regenerated cellulose imitating pelvic abscess

BACKGROUND

Oxidized regenerated cellulose is a topical hemostatic agent that is used commonly in abdominal and pelvic surgery. Although oxidized regenerated cellulose mimicking an abscess has been reported after different operations, little is known about its side effects after gynecologic surgery.

CASES

Two women were diagnosed with postoperative abscess and intra-abdominal oxidized regenerated cellulose was identified as an abscess or as part of an abscess on computed tomography imaging. Both women recovered after treatment with antibiotics with and without drainage.

CONCLUSION

Oxidized regenerated cellulose may be mistaken for an abscess or as part of an abscess on imaging studies. It is important to reveal information about oxidized regenerated cellulose use to the imaging department.

Oxidized cellulose (Surgicel) based reaction post thyroidectomy mimicking an abscess: A case report

INTRODUCTION

Surgicel (oxidized cellulose) is used for intra-operative haemostasis and adhesion prevention. Previously local tissue reactions to oxidized cellulose have been reported at many surgical sites, but not in the head and neck.

PRESENTATION OF CASE

A 56 year old lady presented 30 days following total thyroidectomy with wound swelling and erythema. Multiple sinuses were noted within the wound, through which oxidized cellulose partially extruded. Following removal of the un-absorbed material the symptoms resolved over 3 days.

DISCUSSION

The absence of any systemic symptoms confirm that this was most likely a type four hypersensitivity reaction. The removal of the unabsorbed material was a further unique part of this case.

CONCLUSION

We present the first head and neck reaction to oxidized cellulose. This report serves to remind head and neck surgeons of the potential for local tissue reactions to this material.

Oxidized regenerated cellulose granuloma mimicking recurrent mass lesion after laparoscopic nephron sparing surgery

INTRODUCTION

Achieving hemostasis in laparoscopic nephron sparing surgery (LNSS), a technically demanding procedure, is challenging. Absorbable hemostatic agents, such as oxidized regenerated cellulose (ORC) are frequently used for hemostasis in laparoscopic nephron sparing surgery. Retention of this material is a very rare situation.

PRESENTATION OF THE CASE

We are presenting a case of ORC granuloma after nephron sparing surgery for renal cell carcinoma (RCC) mimicking recurrent renal mass. A 50-year-old woman diagnosed with upper pole renal mass underwent laparoscopic nephron sparing surgery. Oxidized regenerated cellulose was used to achieve hemostasis for an oozing from the perirenal tissue. Resection confirmed RCC. Imaging at 6th month follow-up revealed a lesion with contrast enhancement at the location of the adrenal gland. Positron emission tomography suggested inflammation or metastasis. Histopathological evaluation of the mass revealed foreign body granuloma.

DISCUSSION

Laparoscopic nephron sparing surgery is becoming a standardized treatment of select renal tumors. Hemostatic agents, such as ORC, are frequently used to minimize complications in LNSS. In case of ORC application, which is completely absorbed in 8 weeks, to or to a location with close proximity to the primary resection site, surgical granuloma formation should be considered. However its use should not be discouraged and biopsy may be considered for definitive diagnosis.

CONCLUSION

Oxidized regenerated cellulose granuloma may mimic different entities such as including invasive carcinoma. Thus it is of utmost importance, if ORC was used during LNSS, the location and use of this material should be noted precisely.

CT appearances following laparoscopic partial nephrectomy for renal cell carcinoma using a rolled cellulose bolster

Abstract Purpose: To describe the evolving computed tomography (CT) appearances of a cellulose surgical bolster used as a hemostatic agent in patients who undergo laparoscopic partial nephrectomy for renal cell carcinoma. Materials and methods: We retrospectively reviewed the follow-up CT studies of 33 patients with stage T1N0M0 renal carcinoma who underwent laparoscopic partial nephrectomy using a rolled, oxidized, regenerated cellulose sheet sutured in place as a bolster in the parenchymal defect. Thirteen patients undergoing laparoscopic partial nephrectomy without the use of a bolster were also evaluated to differentiate imaging features. Results: The bolster-related masses were significantly larger than those seen in the non-bolster patients. There was a decrease in size of the post-operative bolster-related mass with time. The bolster shape evolved with time, initially appearing oval, and becoming irregular with decreasing size. Equivocal increase in attenuation of 10–20 HU was seen in 6 patients. Increase in attenuation of greater than 20 HU was seen in 3 patients. There was no evidence of tumor recurrence in any of the patients. Invagination of fat was seen in two bolster-related masses at 18 months or greater. Conclusions: Cellulose bolster has a variable appearance on follow-up CT exams. Evolutionary features include reduction in bolster size and shape with time leading finally to non-visualization. Bolster enhancement can mimic abscesses and tumor recurrence.

Topical haemostatic agents

BACKGROUND

A variety of local haemostatic agents is now available to stop troublesome bleeding. These agents are indicated for use during surgical interventions where conventional methods of haemostasis are not applicable because of the site of surgery or the degree of bleeding.

METHOD

A literature search using the PubMed and ISI Web of Knowledge databases identified relevant studies on topical haemostatic agents. Manufacturers' recommendations were also sought through commercial websites.

RESULTS AND CONCLUSION

A significant body of evidence now exists to support the use of topical haemostatic agents in a wide variety of clinical situations. The advantages and disadvantages of many of these agents are highlighted.

Use of oxidized cellulose for corporal body grafting and suture-less correction of severe penile chordee: an experimental study in rabbits

OBJECTIVE

To evaluate the efficacy of oxidized cellulose, Surgicel(TM) (Johnson & Johnson Medical, New Brunswick, NJ, USA) for patching defects in the tunica albuginea in a rabbit model, with a future application to correct chordee.

MATERIALS AND METHODS

The study comprised nine New Zealand white male rabbits; a rectangular 15 x 5-mm defect was created in the ventral tunica albuginea that was covered by Surgicel. The skin was closed with no catheters left in situ after the procedure. The rabbits were killed in groups of three at 2, 6 and 12 weeks after surgery. The evaluation included cavernosography and histopathological examination of sections of the penis stained with haematoxylin and eosin, and Masson's trichrome.

RESULTS

No deaths were caused by the procedure, and none of the rabbits developed bleeding or haematoma after surgery. Cavernosography at 2 weeks showed contrast medium leaking from the site of the Surgicel, but at 6 and 12 weeks all rabbits had a straight erection with patent corpora and no evidence of narrowing or venous leak. Histopathological evaluation revealed evidence of the remnants of Surgicel surrounded by acute inflammatory cell infiltrate with early neovascularization at 2 weeks. At 6 and 12 weeks, there was complete normal regeneration of the tunica albuginea with no foreign-body reaction.

CONCLUSIONS

In this pilot study, Surgicel had a clear haemostatic effect when covering a defect in the tunica albuginea. Moreover, normal tunica albuginea regenerated by 6 weeks and was maintained at 12 weeks. These results suggest that Surgicel might be considered a safe and effective grafting material for tunica albuginea substitution, including the surgical management of penile chordee.

Histological analysis of human diced cartilage grafts

BACKGROUND

Grafting the radix and dorsum of the nose has been controversial and the plastic surgery community has recently revisited diced cartilage grafts. Previous articles by the authors reported clinical failures of diced cartilage-Surgicel-wrapped grafts and the successful implementation of diced cartilage-fascia-wrapped grafts for rhinoplasty procedures. This article investigates four means of radix and dorsum augmentation, including banked and fresh septum.

METHODS

Twenty-seven human specimens were taken from rhinoplasty patients: six failed diced cartilage-Surgicel-wrapped grafts, eight diced cartilage-fascia-wrapped grafts, and 13 specimens of fresh cartilage or previously placed cartilage grafts. All were stained with hematoxylin and eosin, Masson's trichrome, safranin-O, glial fibrillary acidic protein, and Evans' van Gieson stains and analyzed for chondrocyte viability, matrix proteins, and regenerative potential of the cartilage.

RESULTS

The diced cartilage-Surgicel-wrapped grafts showed disorganized fibrosis, loss of nuclei in chondrocyte lacunae, and negative glial fibrillary acidic protein staining. All specimens contained remnants of Surgicel and evidence of foreign body reaction. The diced cartilage-fascia-wrapped grafts showed normal histologic characteristics, healthy cartilage pieces with viable chondrocytes in their lacunae, positive glial fibrillary acidic protein staining, and organized capsule of fibrosis surrounding the cartilage pieces. The fascia was viable and showed an organized architecture distinctly different from the disorganized scar tissue of the diced cartilage-Surgicel-wrapped grafts.

CONCLUSIONS

Given the histologic findings, diced cartilage-Surgicel-wrapped grafts absorbed due to foreign body reaction. Diced cartilage-fascia wrapped grafts survived and demonstrated normal cartilage viability. According to the clinical performance and analysis of these grafts, diced cartilage-fascia is the most reliable way to augment the nasal dorsum and radix with autologous diced cartilage.

Diced cartilage grafts in rhinoplasty surgery

The use of diced cartilage grafts in rhinoplasty surgery was recently revived by Erol with the publication of his technique for "Turkish delight" grafts (i.e., diced cartilage grafts wrapped in Surgicel). The present study details the authors' experience with 50 consecutive diced cartilage grafts used in three configurations during a prospective study of 50 primary and secondary aesthetic rhinoplasty procedures performed by the senior author (Daniel). Part I consists of 22 diced cartilage grafts wrapped in Surgicel and placed in the radix (n = 14), radix/upper dorsum (n = 4), and full-length dorsum (n = 4). All grafts were performed adhering meticulously to Erol's technique without modification. This portion of the study was halted abruptly at 4 months because of the unexpected absorption and clinical failure of all diced cartilage grafts wrapped in Surgicel. Subsequently, five patients had revision surgery, and biopsy specimens were taken at the prior grafting site and analyzed histologically. After this clinical failure, part II of the study began, consisting of 20 patients who had diced cartilage grafts wrapped in fascia. The range of applications was comparable: radix (n = 12), radix/dorsum (n = 3), and full-length dorsum (n = 5). Because of our prior practice of overcorrecting by 20 percent with diced cartilage grafts wrapped in Surgicel, we had excessive amounts of material in six of our initial diced cartilage wrapped in fascia radix grafts, but no subsequent grafts. The overcorrections were easily reduced at 6 weeks to 11 months postoperatively using a pituitary rongeur under local anesthesia, and the material was sent for histologic analysis. Minimum 1-year follow-up of all 20 cases has shown maintenance of the grafts without evidence of absorption. Part III of this study comprised eight patients who had diced cartilage grafts without a fascial covering placed throughout the nose, including on the sides of osseocartilaginous rib grafts to the dorsum. At 14 months, there was no evidence that any of these grafts had been absorbed. Histologic analysis of the biopsy specimens from the diced cartilage grafts wrapped in Surgicel showed evidence of fibrosis and lymphocytic infiltrates with small amounts of Surgicel visible on birefringent microscopy. Remnants of cartilage were present but were metabolically inactive on the basis of negative glial fibrillary acidic protein staining. Control specimens of fresh septal cartilage and banked septal cartilage were remarkably similar to each other and demonstrated normal cartilage architecture and cellular activity. The diced cartilage grafts wrapped in fascia showed coalescence of the diced cartilage into a single cartilage mass, with viable cartilage cells and normal metabolic activity on the basis of glial fibrillary acidic protein staining. All of the diced cartilage grafts wrapped in Surgicel absorbed and failed to correct the clinical problem for which they were performed. All of the diced cartilage grafts wrapped in fascia and pure diced cartilage grafts did correct the clinical deformities and appear to have survived completely. The diced cartilage grafts wrapped in fascia placed along the dorsum were distinctly palpable throughout the postoperative period, as was one prior case with a 6-year follow-up. The authors' clinical experience confirms the experimental studies of Yilmaz et al. that question the use of Surgicel for wrapping diced cartilage grafts in clinical rhinoplasty surgery.