Estimating the pathogen safety of manufactured human plasma products: application to fibrin sealants and to thrombin

Application of adhesives in the treatment of cartilage repair

From degeneration causing intervertebral disc issues to trauma‐induced meniscus tears, diverse factors can injure the different types of cartilage. This review highlights adhesives as a promising and rapidly implemented repair strategy. Compared to traditional techniques such as sutures and wires, adhesives offer several advantages. Importantly, they seamlessly connect with the injured tissue, deliver bioactive substances directly to the repair site, and potentially alleviate secondary problems like inflammation or degeneration. This review delves into the cutting‐edge advancements in adhesive technology, specifically focusing on their effectiveness in cartilage injury treatment and their underlying mechanisms. We begin by exploring the material characteristics of adhesives used in cartilage tissue, focusing on essential aspects like adhesion, biocompatibility, and degradability. Subsequently, we investigate the various types of adhesives currently employed in this context. Our discussion then moves to the unique role adhesives play in addressing different cartilage injuries. Finally, we acknowledge the challenges currently faced by this promising technology.

A review of platelet-rich plasma for enteric fistula management

Enteric fistula (EF), a serious complication after abdominal surgery, refers to unnatural communication between the gastrointestinal tract and the skin or other hollow organs. It is associated with infection, massive fluid/electrolyte loss, and malnutrition, resulting in an unhealed course. Despite advances in surgical techniques, wound care, infection control, and nutritional support, EF remains associated with considerable morbidity and mortality. Autologous platelet-rich plasma (PRP) containing elevated platelet concentrations has been proposed to promote healing in many tissues. However, the mechanism of action of PRP in EF treatment remains unclear owing to its complicated clinical manifestations. In this review, we summarized the clinical approaches, outlined the principal cytokines involved in the healing effects, and discussed the advantages of PRP for EF therapy. In addition, we defined the mechanism of autologous PRP in EF management, which is essential for further developing EF therapies.

A sealant with a hemostatic mechanism independent of the blood coagulation function was effective in both elective and emergency surgery for thoracic aorta

OBJECTIVES

Matsudaito is a unique surgical sealant with a powerful hemostatic effect that works independent of a patient's blood coagulation function. Because of its mechanism, this sealant is expected to be particularly useful in patients with a poor blood coagulation function, such as in cases of acute aortic syndrome requiring emergency surgery. We, therefore, evaluated the hemostatic static effect of the sealant in both emergency and elective surgery of the thoracic aorta.

METHODS

We used data obtained from post-marketing surveillance of the sealant. Patients who underwent replacement of the thoracic aorta were enrolled. The hemostatic effect was evaluated as effective if a further hemostatic procedure was not performed after applying the sealant.

RESULTS

From 46 hospitals in Japan, a total of 542 patients (327 elective and 215 emergency cases) were enrolled. Hospital mortality was 4.0% and 11.6% in elective and emergency cases, respectively (p < 0.05). Among the 1039 anastomoses (609 elective and 430 emergency cases), effective hemostasis was confirmed in 436 (71.6%) elective and 259 (60.2%) emergency cases. The data from the clinical trial of the sealant showed a hemostatic rate of 44.4% in elective control cases without the sealant.

CONCLUSION

Given that the hemostatic rate in emergency surgery with the sealant seemed to be better than that in elective surgery without the sealant (determined from the clinical trial), we concluded that the sealant was effective in both emergency and elective thoracic surgery of the aorta.

An Instant Underwater Tissue Adhesive Composed of Catechin-Chondroitin Sulfate and Cholesterol-Polyethyleneimine

Due to the safety issue and poor underwater adhesion of current commercially available bioadhesives, they are hard to apply to in vivo physiological environments and more diverse medical use conditions. In this study, a novel and facile bioadhesive for underwater medical applications are designed based on the coacervation of electrostatic interactions and hydrophobic interactions, with the introduction of catechin as a provider of catechol moieties for adhesion to surrounding tissues. The orange-colored bio-adhesive, named PcC, is generated within seconds by mixing catechin-modified chondroitin sulfate and cholesterol chloroformate-modified polyethyleneimine with agitation. In vitro mechanical measurements prove that this novel PcC bio-adhesive is superior in underwater adhesion performance when applied to cartilage. Animal experiments in a rat mastectomy model and rat cartilage graft implantation model demonstrate its potential for diverse medical purposes, such as closing surgical incisions, reducing the formation of seroma, and tissue adhesive applied in orthopedic or cartilage surgery.

A comparative study of conventional intermarginal split lamella with labial mucous membrane graft versus sutureless procedure using fibrin sealant to manage major trichiasis

OBJECTIVE

In the intermarginal split lamella with labial mucous membrane graft procedure to manage major trichiasis, the graft is usually sutured in the receptor bed using 6-0 polyglactin sutures. We aimed to compare the use of fibrin sealant to seal the graft to the receptor bed versus the conventional technique using sutures.

METHODS

This is a retrospective comparative study of patients who underwent conventional intermarginal split lamella with labial mucous membrane graft or sutureless procedure using fibrin sealant (Tisseel, Baxter Healthcare Corp) between 2016 and 2021. Etiology of the trichiasis, procedure duration, postoperative discomfort and edema, complications, and follow-up period were extracted from these patients' charts.

RESULTS

Twenty-seven eyelids from 19 patients underwent the procedure: twelve patients underwent the sutureless procedure, while seven underwent the conventional procedure. Mean follow-up was 8.4 ± 2.9 months and 13.7 ± 6.5 months for the sutureless and conventional groups, respectively. Patients who underwent the sutureless procedure reported no postoperative foreign body sensation, while 71.4% of patients who underwent the conventional procedure reported some degree of ocular discomfort. In the sutureless group, operating time and postoperative edema were significantly reduced. Labial mucous membrane graft dehiscence was observed in one eyelid (8.3%) on the first postoperative day in the sutureless group. No dehiscence was observed in the conventional technique group.

CONCLUSION

The use of fibrin sealant showed to be a good alternative to conventional absorbable sutures. Advantages include expedited operating time, decreased postoperative discomfort, and expedite postoperative recovery.

Medical Adhesives and Their Role in Laparoscopic Surgery—A Review of Literature

Laparoscopic surgery is undergoing rapid development. Replacing the traditional method of joining cut tissues with sutures or staples could greatly simplify and speed up laparoscopic procedures. This alternative could undoubtedly be adhesives. For decades, scientists have been working on a material to bond tissues together to create the best possible conditions for tissue regeneration. The results of research on tissue adhesives achieved over the past years show comparable treatment effects to traditional methods. Tissue adhesives are a good alternative to surgical sutures in wound closure. This article is a review of the most important groups of tissue adhesives including their properties and possible applications. Recent reports on the development of biological adhesives are also discussed.

Fibrin Sealants: Challenges and Solutions

Intraoperative bleeding and postoperative bleeding are major surgical complications. Tissue sealants, hemostats, and adhesives provide the armamentarium for establishing hemostatic balance, including the tissue sealant fibrin. Fibrin sealants combine advantages including instantaneous effect, biocompatibility, and biodegradability. However, several challenges remain. This review summarizes current fibrin product generations and highlights new trends and potential strategies for future improvement.

The past, present, and future of enzyme-based therapies

Enzyme-based therapeutics (EBTs) have the potential to tap into an almost unmeasurable amount of enzyme biodiversity and treat myriad conditions. Although EBTs were some of the first biologics used clinically, the rate of development of newer EBTs has lagged behind that of other biologics. Here, we review the history of EBTs, and discuss the state of each class of EBT, their potential clinical advantages, and the unique challenges to their development. Additionally, we discuss key remaining technical barriers that, if addressed, could increase the diversity and rate of the development of EBTs.

Tissue Adhesives: From Research to Clinical Translation

Sutures, staples, clips and skin closure strips are used as the gold standard to close wounds after an injury. In spite of being the present standard of care, the utilization of these conventional methods is precarious amid complicated and sensitive surgeries such as vascular anastomosis, ocular surgeries, nerve repair, or due to the high-risk components included. Tissue adhesives function as an interface to connect the surfaces of wound edges and prevent them from separation. They are fluid or semi-fluid mixtures that can be easily used to seal any wound of any morphology - uniform or irregular. As such, they provide alternatives to new and novel platforms for wound closure methods. In this review, we offer a background on the improvement of distinctive tissue adhesives focusing on the chemistry of some of these products that have been a commercial success from the clinical application perspective. This review is aimed to provide a guide toward innovation of tissue bioadhesive materials and their associated biomedical applications.

Topical Hemostatic Agents at Time of Obstetric and Gynecologic Surgery: ACOG Committee Opinion, Number 812

There are three broad categories of hemostatic agents: 1) caustic, 2) physical, and 3) biologic. Because of the paucity of data on the use of topical hemostatic agents in gynecologic and obstetric surgery, indications for use are extrapolated from data on the use of these agents in other types of surgeries and are based on expert opinion. Topical hemostatic agents can be a useful adjunct to assist in the management of intraoperative bleeding in select circumstances. Topical hemostatic agents most commonly are used in situations where the use of electrocautery or sutures for hemostatic control of surgical bleeding is not ideal or safe, including bleeding in areas with nearby vulnerable structures or in the presence of diffuse bleeding from peritoneal surfaces or cut surfaces of solid organs. When managing intraoperative bleeding, there is no substitute for meticulous surgical technique. When possible, the surgeon should attempt to control intraoperative bleeding with sutures, clips, or electrosurgery before the use of hemostatic agents. It is essential for surgeons to understand the appropriate use, contraindications, and cost of these agents in order to make the most informed decision for patient care.

Use of fibrin adhesive for preventing pharyngocutaneous fistula in total laryngectomy

BACKGROUND

Minimizing pharyngocutaneous fistula after total laryngectomy is a perpetual focus for head and neck surgeons. Multiple intrinsic and extrinsic factors have been implicated in the wound healing process. Activated fibrin glue uniquely promotes healing as a tissue adhesive as well as a biochemical growth factor.

METHODS

We present a pilot case series of total laryngectomy with simple pharyngeal closure with a single surgeon. Fibrin tissue adhesive was incorporated in all patients along with standardized pre-operative, operative, and post-operative care. Outcomes measured included pharyngocutaneous fistula rate, perioperative complications, and other wound complications as well as long term swallowing function and voice rehab outcomes. We also present a review of the literature for the theoretical basis of using fibrin glue as well as other similar applications.

RESULTS

Fibrin tissue adhesive was successfully used in 18 consecutive patients undergoing total laryngectomy and pharyngoplasty. Despite the presence of a variety of wound healing risk factors including prior radiation and tobacco use, there were no pharyngocutaneous fistulas or other significant wound problems. No locoregional or free tissue overlay flap was done.

CONCLUSION

Fibrin tissue glue is a readily available, easily applied, and cost-effective adjunct that may reduce pharyngocutaneous fistula.

Recent Advances in Tissue Adhesives for Clinical Medicine

Tissue adhesives have attracted more attention to the applications of non-invasive wound closure. The purpose of this review article is to summarize the recent progress of developing tissue adhesives, which may inspire researchers to develop more outstanding tissue adhesives. It begins with a brief introduction to the emerging potential use of tissue adhesives in the clinic. Next, several critical mechanisms for adhesion are discussed, including van der Waals forces, capillary forces, hydrogen bonding, static electric forces, and chemical bonds. This article further details the measurement methods of adhesion and highlights the different types of adhesive, including natural or biological, synthetic and semisynthetic, and biomimetic adhesives. Finally, this review article concludes with remarks on the challenges and future directions for design, fabrication, and application of tissue adhesives in the clinic. This review article has promising potential to provide novel creative design principles for the generation of future tissue adhesives.

Evaluation of Cumulative and Conditional Antibiotic Release from Vancomycin-Embedded Fibrin Sealant and Its Antibacterial Activity : An In Vitro Study

Objective

Fibrin sealants have been used for hemostasis, sealant for cerebrospinal fluid leakage, and adhesive barrier in neurosurgery. Further, as its clinical use and role of an effective drug delivery vehicle have been proposed. This study was performed to measure antibacterial activity and continuous local antibiotic release from different concentrations of vancomycin-impregnated fibrin sealant in vitro.

Methods

Antibacterial activity was investigated by disk diffusion test by measuring the diameter of the growth inhibition zone of bacteria (methicillin-resistant Staphylococcus aureus, ATCC29213) from vancomycin-embedded fibrin sealant disc diluted at five different concentrations (C1–C5; 8.33, 4.167, 0.83, 0.083, and 0.0083 mg/disc, respectively). Continuous and conditioned release of vancomycin concentration (for 2 weeks and for 5 days, respectively) were also measured using high-performance liquid chromatography (HPLC) method. To mimic the physiologic wound conditions with in vitro, conditioned vancomycin release in phosphate buffer solution (PBS) was measured and replaced PBS for five consecutive days, half a day or completely daily.

Results

In the disk diffusion test, the mean diameters of bacterial inhibition zone were 2.54±0.07 cm, 2.61±0.12 cm, and 2.13±0.15 cm (C1, C2, and C3 respectively) but 1.67±0.06 cm and 1.23±0.15 cm in C4 and C5, respectively. Continuous elution test elicited the peak release of vancomycin from the fibrin sealant at 48 hours, with continued release until 2 weeks. However, conditioned vancomycin release decreased to half or more on day 2, however, the sustainable release was measured over the therapeutic dose (10–20 μg/mL) for 5 days and 4 days in assays of half and total exchange of PBS.

Conclusion

This study suggests that fibrin sealant can provide an efficient vehicle for antibiotic drug release in a wide range of neurosurgical procedures and the safe and effective therapeutic dose will be at the concentration embedded of 4.167 mg/disc or more of vancomycin.

Use of a fibrinogen-thrombin sponge in rhinoplasty

BACKGROUND

Although several methods have been described to address nasal dorsum augmentation and smoothing of irregularities in rhinoplasty, establishing the ideal method has proven controversial.

OBJECTIVE

Here, we introduce a novel technique of cartilage grafting for nasal dorsum augmentation by wrapping cartilage in a fibrinogen- and thrombin-coated collagen patch called TachoSil®.

MATERIAL AND METHODS

In a pilot study comprising ten cases, the use of the collagen patch was examined in various indications in rhinoplasty. Patients were clinically monitored for up to 8 months and photometric and sonographic documentation was performed pre- and postoperatively.

RESULTS

In nine patients, the collagen patch was used for fixation of cartilage grafts in different indications: saddle nose deformities (n = 5), open roof (n = 1), nasal dorsum irregularities (n = 3). A diced cartilage graft enclosed by a bilayer of TachoSil® was applied in seven patients. Solid pieces of cartilage were either embedded in a bilayer of the collagen patch (n = 1) or covered by a monolayer (n = 1). Moreover, the collagen patch alone served as a soft tissue support in one patient with thin skin. Six patients were revision cases. All patients had uneventful healing without adverse events such as allergic reactions and infections.

CONCLUSION

The collagen patch TachoSil® is eligible for various indications in rhinoplasty. It is a useful material predominantly for nasal dorsum augmentation by sandwiching diced or solid cartilage in the collagen patch, leading to better graft fixation and precise profile shaping. At the same time, TachoSil® helps with blood control. Follow-up studies will be performed to assess the material's long-term behavior.

A totally recombinant fibrin matrix for mesenchymal stem cell culture and delivery

Mesenchymal stem cells (MSCs) have been widely studied for tissue engineering and treating diseases in laboratories, clinical trials, and clinics. Fibrin matrices are often used to culture MSCs or increase the retention of MSCs at the injection site. However, fibrins made with the human plasma derived fibrinogen have high cost and risk of human pathogen transmission. In this article, we studied if fibrin matrices made with recombinant human fibrinogen, recombinant human thrombin, and recombinant human factor XIII could be used to culture and deliver MSCs. We systematically investigated the relationships between the fibrin matrix formulation, its nanostructure, and the behaviors of the cells in the matrix including the cell morphology, viability, and growth. We found that the fibrinogen concentration significantly affected the matrix structure and cell behaviors. We then used an optimized fibrin matrix to deliver human MSCs into mice subcutaneously. We found that the matrix could significantly enhance the retention of MSCs at the injection site. To our best knowledge, this is the first study on using fibrin matrices made with entirely recombinant proteins for culturing and delivering MSCs. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 106A: 3135-3142, 2018.

Cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery (CAGE CUP): study protocol of a randomised controlled trial

INTRODUCTION

Pterygium is a non-cancerous growth of the conjunctival tissue over the cornea that may lead to visual impairment in advanced stages, restriction of ocular motility, chronic inflammation and cosmetic concerns. Surgical removal is the treatment of choice, but recurrence of pterygium is a frequent problem. It has been previously shown that fibrin glue may result in less recurrence and may take less time than sutures for fixing the conjunctival graft in place during pterygium surgery. However, fibrin glue is a biological material and it carries the risk of transmitting infectious agents from pooled and single-donor blood donors and anaphylaxis in susceptible individuals. Cauterisation is another surgical option, and it would be advantageous to know whether cauterisation may be superior surgical option compared with fibrin glue. This protocol describes the rationale and design of the randomised controlled trial (RCT) in which we will compare cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery.

METHODS AND ANALYSES

This will be a parallel group RCT comparing cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery. Computer-generated randomisation will be used, and allocation concealment will be conducted using sequentially numbered opaque sealed envelopes. Surgeons will not be blinded to the procedures, but participants, other investigators and outcome assessors will be blinded. Adult participants with primary pterygium operated in a tertiary hospital in Split, Croatia, will be included. Primary outcome will be recurrence of pterygium, defined as any regrowth of tissue from the area of excision across the limbus onto the cornea after 180 days.

ETHICS AND DISSEMINATION

The trial was approved by the ethics review board of the University Hospital Split (500-03/17-01/68). Results will be disseminated at conferences and through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03321201; Pre-results.

Novel synthetic adhesive as an effective alternative to Fibrin based adhesives

AIM

To compare a novel, fully synthetic, polyurethane based glue (MAR-1) to fibrin sealant in a partial liver resection rat model.

METHODS

After 50% resection of the lateral left liver lobe in male Wistar rats (n = 7/group/time point), MAR-1, Fibrin or NaCl was applied. After 14, 21 and 90 postoperative days, sealant degradation, intra-abdominal adhesions were scored, and histological examination of liver tissue was performed.

RESULTS

(Mean ± SEM) (MAR-1 vs Fibrin vs NaCl). Bleeding mass was significantly higher in NaCl (3.36 ± 0.51 g) compared to MAR-1 (1.44 ± 0.40 g) and Fibrin (1.16 ± 0.32 g). At 14 and 90 d, bleeding time was significantly lower in MAR-1 (6.00 ± 0.9 s; 13.57 ± 3.22 s) and Fibrin (3.00 ± 0.44 s; 22.2 ± 9.75 s) compared to NaCl (158.16 ± 11.36 s; 127.5 ± 23.3 s). ALT levels were significantly higher in MAR-1 (27.66 ± 1 U/L) compared to Fibrin (24.16 ± 0.98 U/L) and NaCl (23.85 ± 0.80 U/L). Intrabdominal adhesions were significantly lower in MAR-1 (11.22% ± 5.5%) compared to NaCl (58.57% ± 11.83%). Degradation of the glue was observed and MAR-1 showed almost no traces of glue in the abdominal cavity as compared to the Fibrin (10% ± 5% 14 d; 7% ± 3% 21 d). Survival showed no significant differences between the groups.

CONCLUSION

Compared to Fibrin, MAR-1 showed similar hemostatic properties, no adverse effects, and is biocompatible. Further studies on adhesion strength and biodegradability of synthetic sealants are warranted.

HESTAT: Study protocol for a phase II/III, randomized, placebo-controlled, single blind study to evaluate the new hemostatic agent TT-173 in total knee arthroplasty

BACKGROUND

Several hemostatic treatments intended to reduce the bleeding associated to total knee arthroplasty have been investigated with varying degrees of success. TT-173 is a new topical agent based on recombinant tissue factor that activates the extrinsic pathway of coagulation. This trial aim is to evaluate the efficacy and safety of TT-173 in total knee arthroplasty.

METHODS/DESIGN

This is a phase II/III, sequential, simple blind, randomized, multicenter, placebo controlled and parallel clinical trial that will recruit 189 evaluable patients. Those randomized to treatment group will receive 2mg of TT-173 over the surgical surfaces of the knee. Control patients will receive physiologic saline. The follow up will consist in 6 visits during a period of 35 (±7) days. Primary endpoints will be the total blood loss and the incidence and severity of adverse events. Secondary and exploratory endpoints will include drainage production, decrease in hemoglobin level, transfusion ratio, analytical alterations, pain intensity, motion range, immunogenicity of TT-173 and the occurrence of systemic absorption. At the end of phase II, results will be evaluated by an independent committee that will recommend the continuation or the discontinuation of the trial.

DISCUSSION

The design proposed maximizes the safety of the participants, avoids the risk of bias derived from the limitations of masking and enable the eventual discontinuation of the trial if this is recommended by the Interim Analysis Committee. If TT-173 proves its efficacy and safety in this indication, it would become a useful tool to improve the bleeding control in total knee arthroplasty.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02687399. Registered the 9th of February 2016.

Isolation, Characterization and Evaluation of Collagen from Jellyfish Rhopilema esculentum Kishinouye for Use in Hemostatic Applications

Hemostat has been a crucial focus since human body is unable to control massive blood loss, and collagen proves to be an effective hemostat in previous studies. In this study, collagen was isolated from the mesoglea of jellyfish Rhopilema esculentum Kishinouye and its hemostatic property was studied. The yields of acid-soluble collagen (ASC) and pepsin-soluble (PSC) were 0.12% and 0.28% respectively. The SDS-PAGE patterns indicated that the collagen extracted from jellyfish mesoglea was type I collagen. The lyophilized jellyfish collagen sponges were cross-linked with EDC and interconnected networks in the sponges were revealed by scanning electron microscope (SEM). Collagen sponges exhibited higher water absorption rates than medical gauze and EDC/NHS cross-linking method could improve the stability of the collagen sponges. Compared with medical gauze groups, the blood clotting indexes (BCIs) of collagen sponges were significantly decreased (P < 0.05) and the concentration of collagen also had an influence on the hemostatic property (P < 0.05). Collagen sponges had an improved hemostatic ability compared to the gauze control in tail amputation rat models. Hemostatic mechanism studies showed that hemocytes and platelets could adhere and aggregate on the surface of collagen sponge. All properties make jellyfish collagen sponge to be a suitable candidate used as hemostatic material and for wound healing applications.

Refining the risk estimate for transfusion-transmission of occult hepatitis B virus

BACKGROUND AND OBJECTIVES

We previously published a model to estimate the residual risk (RR) for occult hepatitis B infection (OBI) in the absence of universal anti-HBc testing. To incorporate new information on the epidemiology of OBI, we describe model refinements and estimate a more accurate HBV RR due to OBI in Australia.

MATERIALS AND METHODS

In our original model, the OBI risk, p(OBI), was defined by the rate of 'non-detection' by the HBV DNA screening test in use, p(NAT non-detection), and the average infectivity of blood components from OBI donors, p(transmission). We revised the model by integrating three refinements: that donations with anti-HBs levels of >10 IU/l, or donations solely for manufactured plasma products, be excluded from the risk calculation, and an updated estimate of p(transmission).

RESULTS

Refining our OBI RR model resulted in a more than 10-fold reduction in the reported RR risk to recipients from OBI in our donor population. Based on the use of a common data set, the mean OBI RR risk decreased from 1 in 374 354 donations (95% CI: 1 in 191 940-1 072 681) to 1 in 3 984 033 (95% CI: 1 in 1 146 188-65 268 257) for the refined model.

CONCLUSION

Our model refinements provide a more realistic measure of the HBV RR in the donor population. Unlike the previous model, the new model demonstrates that the risk of HBV due to OBI in the Australian blood donor population is negligible, and further potentially cost-ineffective risk management strategies are not currently warranted.

Efficacy of Human Fibrinogen-Thrombin Patch (TachoSil) Clinical Application in Upper Gastrointestinal Cancer Surgery

BACKGROUND

Previous studies investigated the efficacy and applicability of tissue adhesives in gastrointestinal surgery while no evidence is available to date about a novel compound, TachoSil (Takeda, Zurich, Switzerland). The primary aim of this observational study was to assess the effect of new fibrin sealant on the incidence of postoperative complications in a homogeneous group of patients submitted to upper gastrointestinal surgery for cancer.

METHODS

Two cohorts of 28 and 34 patients undergoing upper gastrointestinal for surgery were compared. In the first cohort, the anastomotic site was treated with TachoSil fibrinogen-thrombin-collagen patches and in the second no collagen sponge or any other hemostatic sealant was used. Postoperative complications and outcomes as well as postoperative biochemical parameters were analyzed.

RESULTS

Postoperative complications occurred in 12 patients (35.3%) and 2 patients (7.1%) in control and collagen sponge group respectively (χ² = 3.539, p < 0.05), with no anastomotic leakage in the collagen sponge group. A binary logistic regression analysis showed that the nonuse of collagen sponge [odds ratio (OR) = 0.025, 95% confidence interval (CI) = 0.001-0.457, p = 0.01] was independently associated with postoperative complication occurrence.

CONCLUSIONS

The addition of fibrinogen-thrombin-collagen sponge patch may reduce postoperative complication rate after upper gastrointestinal surgery for cancer. Further study to delineate the role of TachoSil in gastrointestinal surgery are also needed to demonstrate improved effectiveness and applicability.

Evaluating the use of fibrin glue for sealing low-output enterocutaneous fistulas: study protocol for a randomized controlled trial

Background

The management of an enterocutaneous fistula poses a significant challenge to surgeons and is often associated with a costly hospital stay and long-term discomfort. The use of fibrin glue in the fistula tract has been shown to promote closure of low output enterocutaneous fistulas. Our previous nonrandomized study demonstrated that autologous platelet-rich fibrin glue treatment significantly decreased time to fistula closure and promoted closure rates. However, there are several limitations in the study, which may lead to bias in our conclusion. Thus, a multicenter, randomized, controlled clinical trial is required.

Methods/Design

The study is designed as a randomized, open-label, three-arm, multicenter study in nine Chinese academic hospitals for evaluating the efficacy and safety of fibrin glue for sealing low-output fistulas. An established number of 171 fistula patients will undergo prospective random assignment to autologous fibrin glue, commercial porcine fibrin sealants or drainage cessation (1:1:1). The primary endpoint is fistula closure time (defined as the interval between the day of enrollment and day of fistula closure) during the 14-day treatment period.

Discussion

To our knowledge, this is the first study to evaluate the safety and efficacy of both autologous and commercial fibrin glue sealing for patients with low-output volume fistulas.

Trial registration

NCT01828892. Registration date: April 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0966-9) contains supplementary material, which is available to authorized users.

Experiences with TachoSil® in microneurosurgery

BACKGROUND

We analyze our experience of using TachoSil® (Takeda Austria GmbH: Linz, Austria) in microneurosurgical procedures as a hemostat and also as a sealant to patch dural defects.

MATERIALS AND METHODS

Beginning on January 1, 2012, we prospectively analyzed 100 consecutive surgeries where TachoSil was used. The patient group included 58 women (58 %) and 42 men (42 %); the mean age was 52 years (range, 3-85 years). Indications for surgery included removal of the tumor (53 cases; 53 %), clipping of the cerebral arterial aneurysm (31 cases; 31 %), and treatment of other pathologies, including AVM (four cases; 4 %), cavernomas (four cases; 4 %), spinal tumor, and traumatic subdural hematoma. Patients received postoperative care according to local neurosurgical department protocol, including a postoperative CT scan after each craniotomy. Primary assessment of the wound took place during the hospital stay as well as at discharge or transfer to a rehabilitation unit. Mean follow-up time was 4 months (range, 1-12 months).

RESULTS

None of the patients developed postoperative hematoma after craniotomy or spinal procedure. At primary assessment during hospital stay, 93 patients (93 %) had had no wound-related problems over the normal course of healing. No case registered any liquor leak from the wound, and none of the patients showed any signs of allergic response related to TachoSil usage. At the last follow-up, 96 patients (96 %) experienced uneventful wound healing, and in four patients (4 %), superficial wound infection was successfully treated with oral antibiotics.

CONCLUSIONS

Our results indicate that TachoSil can serve in neurosurgical practice at no additional risks. TachoSil proved to be an effective hemostat, sealant, and adhesive in either cranial or spinal procedures.

Results from a First-in-Human Trial of a Novel Vascular Sealant

Background

Suture hole bleeding from synthetic grafts presents a hemostatic challenge. The designs of many vascular sealants are not optimal (non-adherence to wet surfaces, excessive swelling, inflexible). PreveLeak™ (formerly ArterX^®) is a polyaldehyde–bovine serum albumin-based sealant whose efficacy, safety, and performance were evaluated in this first-in-human study.

Materials and methods

A prospective, single-arm, multicenter study was performed in patients undergoing open vascular reconstructions with prosthetic grafts. Sealant was applied to the suture line after completion of the anastomosis. The primary endpoint was the incidence of immediate sealing (without clinically significant bleeding) upon clamp release. Secondary endpoints were time to sealing, safety, and assessment of product performance.

Results

Fifty-six anastomoses were performed in 32 patients. Grafts were Dacron (66% of sites), polytetrafluoroethylene (PTFE; 32%), or both Dacron and PTFE (2%). The femoral artery was the most common site of anastomosis (41% of sites). Immediate sealing after clamp release was achieved at all anastomoses (100%); 93% had no bleeding and 7% had oozing. No rebleeding occurred during 10 min of observation. The three most common adverse events were graft or bypass occlusion (n = 5 patients), infection (n = 4), and seroma (n = 3); none were device related. The sealant was considered easy to apply, quickly forming a soft gel, and adhering to tissue and grafts.

Conclusion

PreveLeak effectively sealed anastomotic suture lines during vascular reconstruction procedures and was considered easy to use. Adverse events were consistent with those commonly observed in patients undergoing surgical procedures. These results provided the support for conducting a larger controlled clinical trial.

Use of Monsel solution to treat obstetrical hemorrhage: a review and comparison to other topical hemostatic agents

Peripartum hemorrhage accounts for 8% of maternal deaths in the United States, and nearly 27% worldwide. A growing need exists for tactics to spare morbidity given a rise of abnormal placentation that contributes to excessive blood loss at the time of delivery. Approaches such as compression sutures, balloon tamponade, and pelvic artery embolization are not without side effects and potential implications for future fertility. The use of topical hemostatic agents has become widespread in gynecologic and obstetric surgery despite a paucity of distinct studies in the field, and may allow providers to increasingly avoid cesarean hysterectomy. A variety of topical hemostatic agents exist along a wide cost continuum, each characterized by specific efficacy, advantages, drawbacks, and often gaps in long-term data to support safety and impact on future fertility. Herein, we comprehensively review these agents and illustrate a nontraditional use of Monsel solution applied directly to the placental bed in a case of focal placenta accreta. This ultimately contributed to successful uterine preservation with no known adverse sequelae. Monsel solution may have a role in establishing hemostasis in the setting of abnormal placentation, and may be a particularly attractive alternative in resource-poor nations.

Hemostatic glues in tonsillectomy: A systematic review

OBJECTIVES/HYPOTHESIS

The aim of this study was to compare use of hemostatic glues to conventional techniques of intraoperative hemostasis for tonsillectomy.

STUDY DESIGN

A systematic review of the literature and meta-analysis.

METHODS

All published prospective controlled trials that compared hemostatic glues to conventional techniques of hemostasis were identified. We performed a meta-analysis of articles comparing fibrin sealant to electrocautery, and of those comparing electrocautery to electrocautery plus fibrin hemostasis.

RESULTS

Seven studies were identified that made qualifications for review, with a total of 748 patients. Outcome measures were postoperative hemorrhage recorded by investigators, and visual analogue scores of pain for day 1, day 3, and day 10 postoperatively. Use of fibrin sealant was not associated with a reduction in hemorrhage rates following tonsillectomy when compared to electrocautery (pooled relative risk [RR] 0.315; 95% confidence intervals [CI]: 0.047-2.093, 224 patients). No statistical difference in bleeding rate was seen between electrocautery hemostasis alone, compared to electrocautery with fibrin sealant (pooled RR 1.742; 95% CI: 0.433-7.005, 108 patients). No statistically significant difference in pain was identified.

CONCLUSIONS

Pain and bleeding are significant causes of morbidity post-tonsillectomy. We conclude that there is no significant evidence to support hemostatic glues over current techniques for reducing severity of these outcomes. Consequently, we do not recommended hemostatic glues for routine use in current clinical practice. Studies were generally of low quality and inadequately powered to detect a statistical difference, even when pooled. We advocate further research to facilitate future meta-analysis.

In vivo study of novelly formulated porcine-derived fibrinogen as an efficient sealant

Fibrinogen has been used as surgical sealant in the clinical setting for decades. The application of human plasma-derived fibrinogen is limited due to high cost and the risk of prion and virus infection. We developed a novel arginine-formulated fibrinogen from cryoprecipitates of porcine plasma. This porcine-derived fibrinogen exhibited excellent stability during sterilization and better hemostatic efficacy than a leading commercial hemostatic product in a nonlethal hemorrhage model. Therefore, it has the potential to be more economical and readily available while having a decreased risk of human blood-borne pathogen transmission.

Safety and efficacy of a novel, dry powder fibrin sealant for hemostasis in hepatic resection

BACKGROUND/AIMS

Fibrocaps is a dry powder fibrin sealant containing human plasma-derived fibrinogen and thrombin. The safety, efficacy, and application methods for Fibrocaps were evaluated in an exploratory, first-in-human, noncomparative, clinical study.

METHODS

Patients with minor bleeding/oozing after elective partial hepatic resection had Fibrocaps applied to the bleeding site either directly from the vial or from a spray device, with manual pressure applied using a cellulose, collagen, or gelatin sponge, if needed. Safety was evaluated at screening and postoperative days 1, 2, and 5, and weeks 4 and 12. The formation of anti-thrombin antibodies was assessed at baseline, and after 4 and 12 weeks. Time to hemostasis (TTH) within 10 min was determined.

RESULTS

Twenty-nine patients were treated with Fibrocaps; 6 experienced serious adverse events that were not related to the course of treatment. Adverse events occurring in >10% of patients were nausea, constipation, hypotension, obstipation, hypokalemia, and postoperative pain. Most adverse events were mild or moderate in severity. No patient developed anti-thrombin antibodies. The percentage of patients who achieved hemostasis was 93%; the median TTH was 3.8 min (range 0.3-10.3). Manual pressure was applied with Fibrocaps in 19 patients and considered beneficial in most.

CONCLUSION

Fibrocaps was well tolerated in patients undergoing elective hepatic resection and resulted in rapid hemostasis. These safety and efficacy results support further clinical testing of this ready-to-use fibrin sealant as an adjunct to surgical hemostasis.

Strategies to reduce pancreatic stump complications after open or laparoscopic distal pancreatectomy

Fibrin sealants could potentially protect against the occurrence of pancreatic fistula after distal pancreatectomy (DP). Fourteen relevant clinical studies (11 open and 3 laparoscopic DP) were identified using an extensive customized literature search, including 4 randomized controlled trials. Data from the 1 prospective randomized controlled trial with reasonable patient numbers found that fibrin reinforcement of the pancreatic stump suture line in open DP was associated with a significant reduction in fistula rate compared with suturing alone. Three other studies failed to show a significant difference in fistula rate. Two small scale nonrandomized retrospective studies each reported a reduced fistula rate associated with use of fibrin sealant in laparoscopic DP. On the basis of the current studies to evaluate the use of fibrin sealants in open and laparoscopic DP, application of fibrin glue to the pancreatic stump could help to reduce the incidence of troublesome pancreatic fistulas associated with this procedure.

Use of Tissue Glues in Endoscopic Pituitary Surgery: A Cost Comparison

Background:

Post-operative cerebrospinal fluid (CSF) leaks are a common complication of endoscopic pituitary surgery and account for a significant proportion of hospital costs associated with this procedure. Tisseel® is a tissue glue commonly used as an adjunct in dural repair but is not optimal for this purpose. DuraSeal® has several properties advantageous for dural repair but is not widely accepted in Canada partly due to its increased cost.

Objective:

A cost analysis of DuraSeal® versus Tisseel® in endoscopic pituitary surgery.

Methods:

A cost analysis was performed based on typical endoscopic pituitary surgery cases performed at our tertiary care institution. Operating room, hospital admission, and surgical sealant costs were obtained directly while estimates of patient recovery time and post-operative CSF leak rates were based on consensus values reported in the literature. Outcomes were reported for various possible clinical scenarios of sealant use.

Results:

In a model where surgical sealant is employed only in high-risk cases, use of DuraSeal® allows for a yearly cost savings of at least $4486.72. If surgical sealant is used in all cases, regular use of DuraSeal® versus Tisseel® either marginally reduces yearly costs or increases them by a maximum of $7619.25, depending on the case volume and estimated post-operative CSF leak rate.

Conclusion:

In most clinical scenarios, use of DuraSeal® in endoscopic pituitary surgery may reduce overall yearly hospital costs compared to Tisseel®.

The FINISH-3 trial: a phase 3, international, randomized, single-blind, controlled trial of topical fibrocaps in intraoperative surgical hemostasis

BACKGROUND

This Phase 3, international, randomized, single-blind, controlled trial (FINISH-3) compared the efficacy and safety of Fibrocaps, a ready-to-use, dry-powder fibrin sealant containing human plasma-derived thrombin and fibrinogen, vs gelatin sponge alone for use as a hemostat for surgical bleeding in 4 indications (ie, spinal, hepatic, vascular, soft tissue dissection).

STUDY DESIGN

Adults with mild to moderate surgical bleeding (randomized 2:1; Fibrocaps vs gelatin sponge) were treated at a single bleeding site (day 1). Time to hemostasis (TTH) during 5 minutes was compared (log-rank statistic) within each indication. Safety follow-up continued to day 29.

RESULTS

Patients were treated (Fibrocaps, n = 480; gelatin sponge, n = 239) when undergoing spinal (n = 183), vascular (n = 175), hepatic (n = 180), or soft-tissue (n = 181) procedures. Fibrocaps was applied by spray device in 53% of all procedures (94% of hepatic and soft-tissue procedures). Fibrocaps significantly reduced TTH compared with gelatin sponge; estimated hazard ratios were 3.3, 2.1, 2.3, and 3.4 for the 4 surgical indications, respectively (each p < 0.001; primary end point). Fibrocaps significantly reduced median TTH for each indication (p < 0.001) and was superior for secondary efficacy end points of restricted mean TTH (p < 0.001) and probability of hemostasis at 3 (p < 0.001) and 5 (p ≤ 0.002) minutes. Adverse event incidences were generally similar between treatment arms. Non-neutralizing, anti-thrombin antibodies developed in 2% of Fibrocaps-treated and 3% of gelatin sponge-treated patients.

CONCLUSIONS

Fibrocaps was well tolerated and significantly reduced TTH relative to gelatin sponge alone in all 4 surgical indications. These findings demonstrate the broad utility of Fibrocaps as a hemostatic agent for mild to moderate surgical bleeding.

Fibrin sealants: surgical hemostat, sealant and adhesive

INTRODUCTION

Fibrin sealants (FS) have been approved for use in the United States since 1998. Since approval, they have been used in a wide variety of clinical settings and new products continue to be introduced.

AREAS COVERED

This review covers the literature supporting the USA FDA-approved indications for FS products produced by Baxter Corp. Literature review of PubMed, the Cochrane Library, FDA approval documents and product websites yielded information contained in this article. Mechanism of action, efficacy and safety of these products are covered.

EXPERT OPINION

FS are generally safe, popular and are used for a wide variety of off-label indications. Their use appears to be expanding rapidly. For many uses, including approved ones, large well-controlled trials are still needed. Additionally, cost-effectiveness data for these products would be a great benefit in guiding their future use.

Autologous platelet rich fibrin glue for sealing of low-output enterocutaneous fistulas: an observational cohort study

BACKGROUND

Glue sealing has become an alternative option for occlusion of enterocutaneous fistula (ECF) because of it minimal invasiveness and simplicity. This study aimed to determine efficacy and safety of autologous, platelet-rich fibrin glue (PRFG) in promoting closure of ECFs.

METHODS

This was a nonrandomized cohort study, recruiting patients who had low-output ECFs (<200 mL/24 h). Beside standard of care, patients were assigned to either the PRFG or control group. Clinical efficacy and safety were determined prospectively. Moreover, a well-balanced subcohort was generated by propensity score (PS) matching. Unadjusted and adjusted Cox proportional hazard models were employed to determine hazard ratios (HRs) of ECF closure in both cohorts.

RESULTS

From January 2008 to January 2012, 145 patients were enrolled initially, with 70 in the control group and 75 in the PRFG-treated group. Compared with the control group, patients in the PRFG group had lesser median time of fistula closure (7 vs 23 days; P = .0010). In addition, PRFG healed more fistulas within the first 28 days (77% vs 57%; P = .0127). For all fistulas included, PRFG-treated fistulas were 3.13 (95% confidence interval [CI], 1.82-5.36) times more likely to achieve closure than those with the non-PRFG approach in the adjusted Cox model. In a PS-matched cohort with 28 paired fistulas, HRs were 3.41 (95% CI, 1.91-6.07) for all fistulas regardless of location. No adverse events related to glue applications were observed.

CONCLUSION

Autologous PRFG seems to be safe and effective in the treatment of low-output ECFs, and can lessen closure times and promote closure rates.

Methods of haemostasis during liver resection--a UK national survey

BACKGROUND

Although haemorrhage is a major cause of morbidity and mortality in liver surgery, there is very little available guidance on its management.

METHODS

The aim of this study was to identify current practice in the UK in this regard. An online survey was created and hepatobiliary (HPB) specialists who were members of a specialist society and others who were known practitioners were invited by e-mail to complete the survey anonymously.

RESULTS

Fifty-one percent responded (n = 36/70), and most of these respondents worked at large HPB centres (>100 liver resections/year; n = 24, 66%). Not all questionnaires were fully completed by the individual surgeons. Thirty-eight percent of the surgeons routinely used Pringle's manoeuvre. Most surgeons used ligation of the inflow vessels (n = 16, 44%) and stapled the outflow vessels (n = 15, 42%). The Cavitron ultrasonic surgical aspirator (CUSA; 54%, 13/24) was preferred for parenchymal transection. The majority routinely used haemostatic adjuncts (n = 22, 62%), whilst 33% (n = 12) used them occasionally. Twenty-three (64%) felt manufactured haemostatic adjuncts played a major role in maintaining haemostasis and 19 preferred fibrin-based products.

CONCLUSION

The Pringle manoeuvre is a popular technique amongst specialist UK liver surgeons and the CUSA is used by nearly half of the surgeons. Despite the absence of definitive evidence for their benefit, manufactured haemostatic adjuncts are still widely used, especially the fibrin-based adjuncts.

Outcomes of using a sutureless bovine pericardial patch graft for Ahmed glaucoma valve implantation

OBJECTIVE

To evaluate the long-term outcomes of a surgical technique using a sutureless bovine pericardial patch graft for the implantation of an Ahmed glaucoma valve (AGV). 


METHODS

This was a pilot study on patients with primary open-angle glaucoma refractory to repeated surgical filtering procedures. All patients underwent AGV implant technique using a sutureless bovine pericardial patch graft. The pericardial membrane was cut using an ordinary corneal trephine with a diameter of 9.0 or 10.0 mm. The anterior part of the tube was covered with the graft and kept in place with fibrin glue. Subsequently, the cap was stitched all around the tube and the dissected conjunctiva was laid over it. Intraocular pressure (IOP) and complications were evaluated 1 week and 1, 3, 6, 12, and 24 months after surgery.


RESULTS

The procedure was used to treat 20 eyes of 20 consecutive patients (12 men and 8 women: mean age [SD] 64.8 [7.8] years). Mean IOP was 28.1 mm Hg (SD 4.9) at baseline and decreased to 14.9 mm Hg (SD 1.5) 24 months after surgery (p<0.001). The overall mean number of topical medications was 3.1 (SD 0.5) at baseline and decreased to 1.4 (SD 0.8) after 24 months (p<0.001). During follow-up, there was no conjunctival erosion, thinning of pericardial patch graft over the tube, or tube exposure; no signs of endophthalmitis were recorded.


CONCLUSIONS

The results suggest that the sutureless technique using a bovine pericardial graft patch is a safe and rapid procedure for AGV implantation.

[The use of haemostatic agents in Urology]

Intra- and post-operative bleedings are frequent complications of all surgical procedures and can represent a severe risk for patients. Beginning from the second half of the 20th century, with an important spur from the development of laparoscopy, great efforts were made in the field of surgical research, aiming at improving hemostatic techniques. The development of mechanical and thermic hemostatic devices, in addition to the improvement of new suturing materials, already improved the possibility of bleeding control; yet a very important contribution in this field has been represented by the introduction in the surgical setting of chemical/biological agents capable of empowering locally blood hemostatic capacity. Currently, there are more chemical hemostatic agents surgeons can make use of in order to minimize bleedings: we reviewed the most important classes, considered their advantages, disadvantages and risks, and tried to look forward to those that will offer, in our view, the best options - for surgeons and patients - for an efficient and safe prevention and control of surgical bleedings, either in open or minimally invasive surgery.

Conjunctival limbal autograft and allograft transplantation using fibrin glue

BACKGROUND AND OBJECTIVE

Conjunctival limbal autograft is the surgical treatment of choice for visually significant unilateral limbal stem cell deficiency. The use of fibrin glue, which has been reported extensively in pterygium and other conjunctival surgeries, has not been fully described in limbal stem cell transplantation.

PATIENTS AND METHODS

The authors reviewed 3 cases of conjunctival limbal autograft and 1 of living related conjunctival limbal allograft using only fibrin glue to secure the graft. Main outcome measures included ocular surface stability, visual acuity, and postoperative complications.

RESULTS

At most recent follow-up, all 4 patients (100%) maintained a stable ocular surface. Mean epithelial healing time was 10 days. Mean visual acuity improved from 20/400 to 20/53. All grafts were successful with no postoperative dislocations or displacements.

CONCLUSION

The findings demonstrate that fibrin glue can be used safely and effectively to secure conjunctival limbal grafts in limbal stem cell deficiency. This novel approach has the potential to decrease operative time, increase ease of technique, and improve patient comfort postoperatively.

A method to screen and evaluate tissue adhesives for joint repair applications

BACKGROUND

Tissue adhesives are useful means for various medical procedures. Since varying requirements cause that a single adhesive cannot meet all needs, bond strength testing remains one of the key applications used to screen for new products and study the influence of experimental variables. This study was conducted to develop an easy to use method to screen and evaluate tissue adhesives for tissue engineering applications.

METHOD

Tissue grips were designed to facilitate the reproducible production of substrate tissue and adhesive strength measurements in universal testing machines. Porcine femoral condyles were used to generate osteochondral test tissue cylinders (substrates) of different shapes. Viability of substrates was tested using PI/FDA staining. Self-bonding properties were determined to examine reusability of substrates (n = 3). Serial measurements (n = 5) in different operation modes (OM) were performed to analyze the bonding strength of tissue adhesives in bone (OM-1) and cartilage tissue either in isolation (OM-2) or under specific requirements in joint repair such as filling cartilage defects with clinical applied fibrin/PLGA-cell-transplants (OM-3) or tissues (OM-4). The efficiency of the method was determined on the basis of adhesive properties of fibrin glue for different assembly times (30 s, 60 s). Seven randomly generated collagen formulations were analyzed to examine the potential of method to identify new tissue adhesives.

RESULTS

Viability analysis of test tissue cylinders revealed vital cells (>80%) in cartilage components even 48 h post preparation. Reuse (n = 10) of test substrate did not significantly change adhesive characteristics. Adhesive strength of fibrin varied in different test settings (OM-1: 7.1 kPa, OM-2: 2.6 kPa, OM-3: 32.7 kPa, OM-4: 30.1 kPa) and was increasing with assembly time on average (2.4-fold). The screening of the different collagen formulations revealed a substance with significant higher adhesive strength on cartilage (14.8 kPa) and bone tissue (11.8 kPa) compared to fibrin and also considerable adhesive properties when filling defects with cartilage tissue (23.2 kPa).

CONCLUSION

The method confirmed adhesive properties of fibrin and demonstrated the dependence of adhesive properties and applied settings. Furthermore the method was suitable to screen for potential adhesives and to identify a promising candidate for cartilage and bone applications. The method can offer simple, replicable and efficient evaluation of adhesive properties in ex vivo specimens and may be a useful supplement to existing methods in clinical relevant settings.