The application of TachoSil® for sealing colorectal anastomosis: a feasibility study

Early Esophageal Perforation Following Anterior Cervical Discectomy and Fusion Treated With Controlled Esophageal Fistula and TachoSil® Coverage: A Case Report

Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure. One of its most feared complications is esophageal injury (EI). There is no standard approach on how to treat these injuries. TachoSil® (Corza Medical GmbH, Düsseldorf, Germany) is a fibrinogen-containing patch that has been used in various surgical areas. Here, we present a 68-year-old male patient who was diagnosed with an EI with secondary surgical site infection following a three-level ACDF (C4/5, C5/6, and C6/7). Initially, the patient underwent incision and drainage (I&D) of the surgical site abscess, primary repair of the esophageal tear, and esophageal catheter placement to create a controlled esophagocutaneous fistula. Postoperatively, he was diagnosed with a leak and underwent a second I&D procedure. The primary repair of the EI was augmented with a TachoSil patch, and the patient was started on glycopyrrolate. The site of EI was well-sealed with no re-leaks, and the patient was discharged after he had completed a course of intravenous (IV) antibiotics and had been on parenteral nutrition for a total of 40 days. This case shows that the use of TachoSil to augment the repair of ACDF-associated EI, and glycopyrrolate to decrease salivation could decrease the risk of leak and enhance the healing process. This is an observation that needs to be scrutinized in future studies.

Collagen patch cover facilitates recovery of bowel function after laparoscopic colectomy

BACKGROUND

Numerous factors can influence bowel movement recovery and anastomotic healing in colorectal surgery, and poor healing can lead to severe complications and increased medical expenses. Collagen patch cover (CPC) is a promising biomaterial that has been demonstrated to be safe in animal models and has been successfully applied in various surgical procedures in humans. This study.

METHODS

A retrospective review of medical records from July 2020 to June 2022 was conducted to identify consecutive patients who underwent laparoscopic colectomy. Patients who received CPC at the anastomotic site were assigned to the collagen group, whereas those who did not receive CPC were assigned to the control group.

RESULTS

Data from 241 patients (collagen group, 109; control group, 132) were analyzed. Relative to the control group, the collagen group exhibited a faster recovery of bowel function, including an earlier onset of first flatus (2.93 days vs. 3.43 days, p < 0.01), first defecation (3.73 days vs. 4.18 days, p = 0.01), and oral intake (4.30 days vs. 4.68 days, p = 0.04). CPC use was also associated with lower use of postoperative intravenous analgesics. The complication rates in the two groups did not differ significantly.

CONCLUSIONS

CPCs can be safely and easily applied to the anastomotic site during laparoscopic colectomy, and can accelerate bowel movement recovery. Further studies on the effectiveness of CPCs in colorectal surgery involving larger sample sizes are required.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT05831956 (26/04/2023).

Clinical results after external reinforcement of colorectal anastomosis: a systematic review

OBJECTIVE

The aim of this review is to describe and assess the existing methods to cover colorectal anastomoses with biomaterials and their clinical impact in reducing anastomotic leakage (AL).

SUMMARY BACKGROUND DATA

The most serious complication in colorectal surgery is AL. Despite improvements in its diagnosis and management, AL remains an unresolved issue. To prevent its appearance and clinical consequences, different external reinforcement techniques with synthetic or biomaterials have been described.

METHODS

A systematic review search of the available literature until June 2022 was performed, looking for all literature regarding external reinforcement of colonic or colorectal anastomoses. After the review process, a classification of materials was proposed into solid and liquid materials, and an assessment of their clinical impact was performed. The study protocol has been registered at PROSPERO and has been reported in the line with PRISMA and AMSTAR Guidelines 11,12 .

RESULTS

Ninety-seven articles that fulfilled inclusion criteria, were identified and revised. Overall, 18 of the selected articles focused on human clinical trials and 79 on animal models. Only fibrin sealants, collagen patches, and omentoplasty have shown positive results in humans.

CONCLUSIONS

Fibrin sealants, collagen patches, and omentoplasty are, so far, the most studied biomaterials. However, further studies are required to confirm these findings before definite recommendations can be made.

The use of state-of-the-art haemostatic materials in gastrointestinal surgery

Haemostatic materials such as: gelatine sponges, oxygenated cellulose meshes, tissue sealants, collagen matrices with human thrombin and fibrinogen are gaining on popularity in gastrointestinal surgery, especially in colorectal surgery. We searched for available scientific publications in the Pubmed and Cochrane database on the use of individual hemostatic materials in the field of gastrointestinal surgery. The analysis focused on the assessment of the safety of the use of individual materials in terms of the rate of bleeding complications and the rate of anastomotic leakage cases. The use of haemostatic materials has for years been a recognized method of reducing the rate of intra- and postoperative complications, both in gastrointestinal surgery and in other surgical specialties. Based on the available studies, it can be concluded that the use of hemostatic materials such as matrices, sponges and adhesives in gastrointestinal surgery, even in patients at high risk of anastomotic leakage and bleeding complications, reduces the incidence of complications. The growing popularity of haemostatics and sealants in surgery means that they are currently used in a wide range of indications, and surgeons are more and more willing to use them even in case of standard surgical procedures, which is reflected in the available studies. Choosing a haemostat should be a conscious decision, taking into account the site and type of bleeding, mechanism of action, ease of use, efficacy, safety, and price, among others.

Human fibrinogen and thrombin patch for extraluminal protection of intestinal anastomosis

In spite of recent advances regarding equipment and surgical techniques in colorectal surgery, rates of anastomotic dehiscence (AD) have remained stable throughout the years. The development of products to protect anastomosis aiming the reduction of AD rates has shown to be promising. Human fibrinogen and thrombin patch (HFTP Tachosil®) have been used in experimental studies in animals and small case series in humans, with promising results. In this study, the authors describe the technique of HFTP use in details, aiming the protection of colorectal anastomosis, and retrospectively demonstrate the preliminary results in a pilot case series. HFTP was used in 4 patients submitted to conventional surgery. The procedures performed were: left colon resection, segmental colectomy (both for colorectal cancer), enteral anastomosis for fistula closure and right ileocolectomy. Anastomotic healing and absence of complications were observed in 3 patients, and the patient submitted to right ileocolectomy developed AD and died after reoperation. The use of HFTP is safe and can be indicated in selected cases. However, AD can occur even after the use of this strategy. Randomized controlled trials with larger samples of patients are needed in order to properly define the real benefits of this strategy in dehiscence prevention

Is Circular Fibrin Sealing of Low Rectal Anastomosis Able to Prevent Leakage in 21-Day Follow-up? Randomized Experimental Trial in Pigs

Purpose. Clinically apparent anastomotic leakage (AL) after low anterior rectal resection (LAR; <7 cm from anal verge) using circular double-stapled anastomosis without defunctioning stoma is up to 37.5%. However, it is unclear whether there is reduction of LAR after 21 postoperative days without defunctioning stoma but with extraluminal anastomotic application of fibrin sealant. Methods. Forty-eight-week-old pigs underwent LAR and circular double-stapled anastomosis in end-to-end technique (descendo-rectostomy). Animals were randomized into therapy and control group (cg). Therapy group (n = 20) received additional extraluminal circular anastomotic application of fibrin sealant. Objective was to assess incidence of clinically apparent and nonclinically apparent leakage through the 21st postoperative day. Remaining animals were sacrificed on the 21st day, and anastomotic region was analyzed. In case of earlier diagnosed AL, animals were sacrificed. Results. In cg, we observed clinically and nonclinically AL in 20% (n = 4). No animal was identified with a nonclinical-apparent leakage in this group, and all 4 animals with leakages presented clinical signs. In the therapy group, no animal (0/20) developed clinically apparent leakage signs. There were no leakages in this group, but 3 animals had ulcerative lesions without leak and without clinical signs. These lesions were observed intraluminally at crossing of staple lines after 21 days. In one of these animals, incomplete leakage was observed, blocked by fibrin sealant. Conclusion. In circular stapled colorectal anastomosis, circular fibrin glue sealant successfully protected anastomotic intraluminal wall defects at crossing of staple lines, reducing leakage rate from 20% to 0% (cg vs therapy group) after 21 postoperative days.

Anastomotic leaks in gastrointestinal surgery and their prevention

Anastomotic leak in the gastrointestinal tract is one of the most important complications of resection. They are the main cause of reoperation, their occurrence worsens the prognosis of the patient, increasing the proportion of direct mortality, as well as being a significant risk factor for recurrence of cancer. The risk of leaks within the gastrointestinal tract is greatly varied, depending on the location and extent of the resection, but also on patient, disease or a surgical procedure, including surgeon. To determine the potential risk of leakage can be significant for introduction some prophylactic actions. Some of them have the character of general recommendations, as proper nutrition of the patient in the perioperative period, while another part is directly connected to the surgical procedure. The second group includes protective stoma, the use of tissue glues, insertion transrectal drain for rectal anastomosis decompression, the use of stents or the use of collagen matrix coated with fibrinogen and thrombin. Important to reduce the proportion of leaks can be more precise and targeted prophylactic recommendations, based on the individualized determination of risk factors leaks. Further research for this purpose are necessary for this purpose, the big hope can be associated with data obtained through mobile applications.

Repair of transperineal recto-urethral fistula using a fibrin sealant haemostatic patch

AIM

Recto-urethral fistula (RUF) is a rare complication of radical prostatectomy. We report a transperineal approach using a fibrin sealant haemostatic patch.

METHOD

Five consecutive patients who developed RUF following radical prostatectomy had a direct transperineal repair with a haemostatic patch (TachoSil®) and were assessed at a median follow-up of 35.5 (21-45) months.

RESULTS

There were no early postoperative complications. The average length of hospital stay was 5 (4-7) days. One patient developed recurrence 4 weeks after removal of the urethral catheter. Following healing in four patients the stoma was reversed at a median interval of 3 months, and 9.5 (7-10) months following the prostatic surgery. In the four patients with successful closure there was no case of recurrence or anorectal or urinary dysfunction at a median follow-up of 35.5 (21-45) months.

CONCLUSION

Direct transperineal repair of RUF reinforced with a fibrin haemostatic patch of TachoSil is safe and effective.

[Use of absorbable fibrin sealant patch to strengthen the gastrointestinal anastomosis performed on patients with peritoneal carcinomatosis treated with intention to cure by debulking surgery and intraoperative hyperthermic intraperitoneal chemotherapy]

BACKGROUND

Peritoneal disseminated disease, regardless of its origin, should currently be considered a locoregional disease stage, and thus a candidate for an intention to treat therapeutic option with debulking surgery and hyperthermic intraperitoneal chemotherapy.

OBJECTIVE

To determine whether or not the collagen sponge with fibrinogen 5.5mg and thrombin 2IU, applied as a tissue sealant and gastrointestinal reinforcement sutures, contributes to the reduction of anastomotic leak.

MATERIAL AND METHODS

Quasi-experimental, comparative, prospective, case/control study conducted on patients with peritoneal carcinomatosis of colorectal origin, operated on in our Peritoneal Cancer Surgery Unit from 2011 to April 2014. The study included 73 patients, 43 (59%) men and 30 (41%) women with peritoneal carcinomatosis of colorectal origin, candidates for debulking surgery and hyperthermic intraperitoneal chemotherapy. Gastrointestinal anastomoses were performed on 49 (67%) patients. These patients were randomised into 2 groups: A control (27) and B hypothesis (22) reinforced with sponge suture.

RESULTS

The total number of anastomoses performed was 49 (mean: 1.9), with 27 in the control group A (mean: 1.88) and 22 in B (mean: 2.16). The debulkings achieved were: complete debulking 0.38 (77.5%), complete debulking 1: 7 (14.8%), and 4 (8.1%) did not undergo hyperthermic intraperitoneal chemotherapy due to complete debulking>2. Intestinal fistula: 3 cases (6.1%) in A group vs 0 in B.

CONCLUSIONS

In our series, the use of a fibrinogen and thrombin sponge has contributed to a significant reduction in the risk of gastrointestinal fistulas in high risk oncology patients.

An Experimental Study on the Use of Calcium Alginate to Heal Colonic Anastomoses

BACKGROUND

Anastomotic leak is considered the major complication following abdominal surgery. In recent years, the use of a variety of sealing materials for the prevention of leaks has been analyzed. Different biomaterials have been employed as scaffolds to favour tissue repair and regeneration. Among these materials we must mention alginate, a natural polymer with different applications as temporary supporting matrix. The aim of the present study is to evaluate the behavior of both alginate-impregnated sutures and lyophilized alginate sponges in the healing process of colonic anastomes using an experimental animal model.

MATERIAL AND METHODS

A preliminary study was undertaken to select the adequate scaffold. Animals (n = 45) were distributed into three groups: control (colonic anastomosis using non-continuous 5-0 Polyglactin 910 suture), suture (colonic anastomosis using suture impregnated with alginate gel at 4%) and sponge (colonic anastomosis using suture reinforced with lyophilized alginate sponge). The macroscopic and histological variables were assessed at 4, 8 and 12 days after surgical intervention.

RESULTS

No statistically significant differences have been observed between the groups during the analysis of macroscopic variables. Animals with sponge implantation showed a greater degree of epithelial reepithalization, less acute and chronic inflammation and greater collagen deposit.

CONCLUSIONS

The use of lyophilized alginate sponges to reinforce colonic anastomoses in an animal model reduces inflammation and promotes the earlier formation of greater collagen deposits without increasing the number of adhesions or the incidence of stenosis.

Technical Feasibility of TachoSil Application on Esophageal Anastomoses

Purpose. Sealing esophageal anastomoses with a sealant patch (TachoSil) containing human fibrinogen and thrombin may improve mechanical strength. The aim was to evaluate the technical feasibility of the application of a sealant patch in upper gastrointestinal surgery. Methods. In total 15 patients, 18–80 years old, undergoing thoracolaparoscopic esophagectomy with esophagogastrostomy or laparoscopic total gastrectomy with esophagojejunostomy was included. Different techniques of anastomotic TachoSil patch application were tested and recorded on video. Results. TachoSil was successfully applied to the esophagogastrostomy (n = 11) and to the esophagojejunostomy (n = 4). A median of 2 (1–6) attempts was necessary to reach successful application. The median duration was 7 (3–26) minutes before successful application was accomplished. The best technique in esophagectomy was the application of TachoSil with the use of 2 cellophane sheets. For total gastrectomy, the patch was folded into a harmonica shape and wrapped around the esophagojejunostomy. Although not significant, the number of attempts and time to success showed a decreasing trend along with the increased experience. Conclusion. Application of TachoSil as a sealant of esophageal anastomoses was technically feasible. Future studies may investigate the value of TachoSil application on the prevention of anastomotic leakage.

Clinical applications of surgical adhesives and sealants

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

Decreased leakage rate of colonic anastomoses by tachosil coating: an experimental study

Colorectal anastomotic coating has been proposed as a means to lower the leakage rate. Prior to clinical testing, coating materials need thorough experimental evaluation to ensure safety and efficacy. The aim of this study was to evaluate Tachosil as an anastomotic coating agent. Technically insufficient colon anastomoses were created in 80 C57BL/6 mice, and in half of the animals the anastomoses were covered with Tachosil. The animals were examined for clinical signs of anastomotic leakage, and the breaking strength of the anastomoses was evaluated. The number of leakages was reduced by Tachosil coating (10/40 versus 20/40 in controls; P=0.037). However, more cases of large bowel obstruction were found in the Tachosil group (12/40 versus 0/40 in controls; P<0.0005). Breaking strength was comparable between the Tachosil and control groups (0.49 N versus 0.52 N, respectively; P=0.423). Clinical studies are needed to clarify the efficacy of Tachosil anastomotic coating.

Risk factors for postoperative CSF leakage after elective craniotomy and the efficacy of fleece-bound tissue sealing against dural suturing alone: a randomized controlled trial

OBJECT

Cerebrospinal fluid leakage is an immanent risk of cranial surgery with dural opening. Recognizing the risk factors for this complication and improving the technique of dural closure may reduce the associated morbidity and its surgical burden. The aim of this paper was to investigate whether the addition of TachoSil on top of the dural suture reduces postoperative CSF leakage compared with dural suturing alone and to assess the frequency and risk factors for dural leakage and potentially related complications after elective craniotomy.

METHODS

The authors conducted a prospective, randomized, double-blinded single-center trial in patients undergoing elective craniotomy with dural opening. They compared their standard dural closure by running suture alone (with the use of a dural patch if needed) to the same closure with the addition of TachoSil on top of the suture. The primary end point was the incidence of CSF leakage, defined as CSF collection or any open CSF fistula within 30 days. Secondary end points were the incidence of infection, surgical revision, and length of stay in the intensive care unit (ICU) or intermediate care (IMC) unit. The site of craniotomy, a history of diabetes mellitus, a diagnosis of meningioma, the intraoperative need of a suturable dural substitute, and blood parameters were assessed as potential risk factors for CSF leakage.

RESULTS

The authors enrolled 241 patients, of whom 229 were included in the analysis. Cerebrospinal fluid leakage, mostly self-limiting subgaleal collections, occurred in 13.5% of patients. Invasive treatment was performed in 8 patients (3.5%) (subgaleal puncture in 6, lumbar drainage in 1, and surgical revision in 1 patient). Diabetes mellitus, a higher preoperative level of C-reactive protein (CRP), and the intraoperative need for a dural patch were positively associated with the occurrence of the primary end point (p = 0.014, 0.01, and 0.049, respectively). Cerebrospinal fluid leakage (9.7% vs 17.2%, OR 0.53 [95% CI 0.23-1.15], p = 0.108) and infection (OR 0.18 [95% CI 0.01-1.18], p = 0.077) occurred less frequently in the study group than in the control group. TachoSil significantly reduced the probability of staying in the IMC unit for 1 day or longer (OR 0.53 [95% CI 0.27-0.99], p = 0.048). Postoperative epidural hematoma and empyema occurred in the control group but not in the study group.

CONCLUSIONS

Dural leakage after elective craniotomy/durotomy occurs more frequently in association with diabetes mellitus, elevated preoperative CRP levels, and the intraoperative need of a dural patch. This randomized controlled trial showed no statistically significant reduction of postoperative CSF leakage and surgical site infections upon addition of TachoSil on the dural suture, but there was a significant reduction in the length of stay in the IMC unit. Dural augmentation with TachoSil was safe and not related to adverse events. Clinical trial registration no. NCT00999999 ( http://www.ClinicalTrials.gov ).

Intraoperative bleeding and haemostasis during pelvic surgery for locally advanced or recurrent rectal cancer: a prospective evaluation

BACKGROUND

This study aimed to prospectively quantify the frequency of serious bleeding during pelvic surgery for locally advanced or recurrent rectal cancer and review the surgical methods used to control this.

METHODS

Consecutive cases of pelvic surgery for curative resection of locally advanced or recurrent rectal cancer were prospectively evaluated over a nine-month period. The procedures undertaken included multivisceral resections, sacrectomies or ultra-low anterior resections. Multivisceral resections were defined as pelvic exenterations, extra-levator abdominoperineal resections (ELAPER) and recurrent anterior resections. The primary endpoint was the proportion of patients sustaining major blood loss, defined as ≥1,000 ml. The secondary endpoint was the blood transfusion rate. Haemostatic adjunct use was recorded.

RESULTS

Twenty-six patients underwent surgery, comprising 11 pelvic exenterations, 3 ELAPERs, 1 recurrent anterior resection, 5 abdominosacral resections and 6 ultra-low anterior resections. The median intraoperative blood loss was 1,250 ml with 53.8 % of the patients sustaining a loss ≥1,000 ml. Fifty per cent of patients required a blood transfusion within 24 h, and one or more haemostatic adjuncts were necessary in 50 % of the cases. Adjuncts used included a fibrinogen/thrombin haemostatic agent in 38.5 % of patients, temporary intraoperative pelvic packing in 11.5 % of patients and preoperative internal iliac artery embolization in 7.7 % of patients.

CONCLUSIONS

This patient group is at a high risk of intraoperative haemorrhage, and such patients are high consumers of blood products. Haemostatic adjunct use is often necessary to minimize blood loss. We describe our local algorithm to assist in the assessment and intraoperative management of these challenging cases.

Effects of TachoSil and 5-fluorouracil on colonic anastomotic healing

BACKGROUND

The administration of intraperitoneal (IP) 5-fluorouracil (5-FU) during the early postoperative period after cytoreductive surgery can decrease local cancer recurrence but may also cause impairment of the anastomotic healing. This study examined the effects of the use of this therapy and of the anastomotic sealing with TachoSil, a fibrin-thrombin coated sealant (FTCS), on the healing of colon anastomoses.

MATERIALS AND METHODS

Forty male rats were divided into four groups (1-4, 10 rats each) that underwent transection and anastomosis of the left colon. The anastomoses were covered with FTCS in groups 2 and 4. Saline solution (2 mL/d-groups 1 and 2) or 5-FU (20 mg/kg/d; groups 3 and 4) was administered IP once daily for 3 d. Bursting pressure (BP) was recorded, and the anastomoses were examined macroscopically and graded histologically.

RESULTS

The relative weight loss was significantly higher in group 3 than in the other groups (P = 0.0004). Anastomotic dehiscence, postoperative adhesion formation, perianastomotic collections, and preanastomotic dilatation did not differ significantly among groups. BP was significantly lower in group 3 compared with all other groups (P = 0.001). Neoangiogenesis was significantly lower in group 3 compared with groups 1 and 2 (P = 0.05). Fibroblastic activity was significantly higher in group 1 compared with group 3 (P = 0.035). Inflammatory cell infiltration and collagen deposition did not differ significantly among groups.

CONCLUSIONS

Our results shown that the early postoperative IP chemotherapy with 5-FU impaired the healing of colon anastomoses. However, anastomotic sealing with FTCS reversed some of the negative effects of this therapy.