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Yoshihara H, Karakostas J, Hayes W. Efficacy of patch technique for dural tear repair using hydrogel sealant: a pilot study. Spine J 2023; 23:1563-1567. [PMID: 37369254 DOI: 10.1016/j.spinee.2023.06.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND CONTEXT Dural tear is one of the common complications of lumbar spine surgery. Suture repair is often difficult due to the requirement of meticulous suture technique in limited space. Dural tear repair is particularly challenging in minimally invasive spine surgery. The patch technique, applying patch material and glue without suture, is an alternative method for dural tear repair. PURPOSE To verify the efficacy of patch technique for dural tear repair using polyethylene glycol hydrogel sealant and to compare patch materials. STUDY DESIGN/SETTING Basic research. METHODS There were three study groups: Group 1 (control group, n=4) had hydrogel sealant alone, Group 2 (n=8) had collagen sheet patch and hydrogel sealant, Group 3 (n=8) had mesh sheet patch and hydrogel sealant. A 4-mm durotomy was made in a piece of bovine dura using an arterial punch. Patch material (collagen or mesh sheet) was placed over the dural tear with 2 mm margin and then sprayed with hydrogel sealant. The pressure in the system was increased by 10 mm Hg and monitored. When the leakage occurred, the pressure threshold was measured. RESULTS The mean pressure threshold for leakage was 32.5 (Standard deviation=15.0), 66.3 (37.0), and 88.8 (27.5) mm Hg for Group 1, 2 and 3, respectively. The mean pressure threshold for leakage for Group 3 was significantly higher than that for Group 1 (p<.05). There was no significant difference in the mean pressure threshold for leakage between Groups 1 and 2, and Groups 2 and 3. CONCLUSIONS Patch technique using mesh sheet and hydrogel sealant demonstrated significantly higher mean pressure threshold for leakage compared with hydrogel sealant alone. CLINICAL SIGNIFICANCE Patch technique using mesh sheet and hydrogel sealant without suture is potentially a reasonable option for dural tear repair in lumbar spine surgery.
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Affiliation(s)
| | - Jonathan Karakostas
- Department of Orthopedic Surgery & Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Westley Hayes
- Department of Orthopedic Surgery & Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
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Han GY, Hwang SK, Cho KH, Kim HJ, Cho CS. Progress of tissue adhesives based on proteins and synthetic polymers. Biomater Res 2023; 27:57. [PMID: 37287042 DOI: 10.1186/s40824-023-00397-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/17/2023] [Indexed: 06/09/2023] Open
Abstract
In recent years, polymer-based tissue adhesives (TAs) have been developed as an alternative to sutures to close and seal incisions or wounds owing to their ease of use, rapid application time, low cost, and minimal tissue damage. Although significant research is being conducted to develop new TAs with improved performances using different strategies, the applications of TAs are limited by several factors, such as weak adhesion strength and poor mechanical properties. Therefore, the next-generation advanced TAs with biomimetic and multifunctional properties should be developed. Herein, we review the requirements, adhesive performances, characteristics, adhesive mechanisms, applications, commercial products, and advantages and disadvantages of proteins- and synthetic polymer-based TAs. Furthermore, future perspectives in the field of TA-based research have been discussed.
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Affiliation(s)
- Gi-Yeon Han
- Program in Environmental Materials Science, Department of Agriculture, Forestry and Bioresources, Seoul National University, Seoul, 08826, Korea
| | - Soo-Kyung Hwang
- Research Institute of Agriculture and Life Sciences, Seoul National University, Seoul, 08826, Korea
| | - Ki-Hyun Cho
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, 03080, Korea
| | - Hyun-Joong Kim
- Program in Environmental Materials Science, Department of Agriculture, Forestry and Bioresources, Seoul National University, Seoul, 08826, Korea.
- Research Institute of Agriculture and Life Sciences, Seoul National University, Seoul, 08826, Korea.
| | - Chong-Su Cho
- Research Institute of Agriculture and Life Sciences, Seoul National University, Seoul, 08826, Korea.
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Xue W, Shi W, Kuss M, Kong Y, Alimi OA, Wang H, DiMaio DJ, Yu C, Duan B. A Dual-network Nerve Adhesive with Enhanced Adhesion Strength Promotes Transected Peripheral Nerve Repair. ADVANCED FUNCTIONAL MATERIALS 2023; 33:2209971. [PMID: 36816838 PMCID: PMC9937437 DOI: 10.1002/adfm.202209971] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Indexed: 05/02/2023]
Abstract
Peripheral nerve transection has a high prevalence and results in functional loss of affected limbs. The current clinical treatment using suture anastomosis significantly limits nerve recovery due to severe inflammation, secondary damage, and fibrosis. Fibrin glue, a commercial nerve adhesive as an alternative, avoids secondary damage but suffers from poor adhesion strength. To address their limitations, a highly efficacious nerve adhesive based on dual-crosslinking of dopamine-isothiocyanate modified hyaluronic acid and decellularized nerve matrix is reported in this paper. This dual-network nerve adhesive (DNNA) shows controllable gelation behaviors feasible for surgical applications, robust adhesion strength, and promoted axonal outgrowth in vitro. The in vivo therapeutic efficacy is tested using a rat-based sciatic nerve transection model. The DNNA decreases fibrosis and accelerates axon/myelin debris clearance at 10 days post-surgery, compared to suture and commercial fibrin glue treatments. At 10 weeks post-surgery, the strong adhesion and bioactivity allow DNNA to significantly decrease intraneural inflammation and fibrosis, enhance axon connection and remyelination, aid motor and sensory function recovery, as well as improve muscle contraction, compared to suture and fibrin treatments. Overall, this dual-network hydrogel with robust adhesion provides a rapid and highly efficacious nerve transection treatment to facilitate nerve repair and neuromuscular function recovery.
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Affiliation(s)
- Wen Xue
- Department of Internal Medicine, Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
| | - Wen Shi
- Department of Internal Medicine, Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
| | - Mitchell Kuss
- Department of Internal Medicine, Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
| | - Yunfan Kong
- Department of Internal Medicine, Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
| | - Olawale A Alimi
- Department of Internal Medicine, Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
| | - Hanjun Wang
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
| | - Dominick J DiMaio
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
| | - Cunjiang Yu
- Department of Biomedical Engineering, Pennsylvania State University, University Park, Pennsylvania 16802, USA
| | - Bin Duan
- Department of Internal Medicine, Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
- Department of Mechanical and Materials Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska 68588, USA
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McDowell MM, Jacobs RC, Valappil B, Abou-Al-Shaar H, Zenonos GA, Wang EW, Snyderman CH, Gardner PA. Dural Sealants Do Not Reduce Postoperative Cerebrospinal Fluid Leak after Endoscopic Endonasal Skull Base Surgery. J Neurol Surg B Skull Base 2022; 83:589-593. [PMID: 36393876 PMCID: PMC9653287 DOI: 10.1055/s-0042-1743558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 01/30/2022] [Indexed: 10/18/2022] Open
Abstract
Abstract
Introduction The application of cranial tissue sealants to assist with postoperative closure is widespread, but data are lacking regarding its utility in endoscopic endonasal surgery (EEA). A prospective study was conducted to assess the effect of sealant usage on postoperative cerebrospinal fluid (CSF) leak rate following standard reconstruction.
Methods A prospective trial of sealant usage after endoscopic endonasal skull base surgery was performed from May 2016 to June 2019 at a tertiary referral cranial base center. This study enrolled 300 consecutive adult and pediatric patients with skull base pathology who underwent EES in which an intraoperative CSF leak occurred. Patients were sequentially stratified into equally sized groups who did or did not receive sealant as part of their reconstruction.
Results Three hundred consecutive adult and pediatric patients were enrolled in the study and had a confirmed intraoperative CSF leak. The intervention cohort with sealant (first 150 patients) had 21 postoperative CSF leaks (14% rate) compared with 9 postoperative CSF leaks (6% rate) in the control group without sealant (p = 0.02). On multivariate analysis, sealant usage was associated with a higher rate of postoperative CSF leak (odds ratio [OR] = 2.7; p = 0.025). Male gender (OR = 2.4; p = 0.04) and high-flow intraoperative CSF leak (OR = 3.1; p = 0.038) were also found to be associated with postoperative CSF leak.
Conclusion Among all patients undergoing EES with an intraoperative CSF leak, the addition of sealant to standard closure techniques did not reduce the rate of postoperative CSF leaks.
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Affiliation(s)
- Michael M. McDowell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Rachel C. Jacobs
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Benita Valappil
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Georgios A. Zenonos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Eric W. Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Carl H. Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Paul A. Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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Marom N, Ode G, Coxe F, Jivanelli B, Rodeo SA. Current Concepts on Tissue Adhesive Use for Meniscal Repair-We Are Not There Yet: A Systematic Review of the Literature. Am J Sports Med 2022; 50:1442-1450. [PMID: 33856859 DOI: 10.1177/03635465211003613] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tissue adhesives (TAs) represent a promising alternative or augmentation method to conventional tissue repair techniques. In sports medicine, TA use has been suggested and implemented in the treatment of meniscal tears. The aim of this review was to present and discuss the current evidence and base of knowledge regarding the clinical usage of TAs for meniscal repair. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic literature search was performed using the PubMed, Embase, and Cochrane Library databases for studies reporting on clinical outcomes of TA usage for meniscal repair in humans in the English language published before January 2020. RESULTS Ten studies were eligible for review and included 352 meniscal repairs: 94 (27%) were TA-based repairs and 258 (73%) were combined suture and TA repairs. Concomitant anterior cruciate ligament reconstruction was performed in 224 repairs (64%). All included studies utilized fibrin-based TA. Of the 10 studies, 9 were evidence level 4 (case series), and 8 reported on a cohort of ≤40 meniscal repairs. Rates of meniscal healing were evaluated in 9 of 10 studies, with repair failure seen in 39 repairs (11%). CONCLUSION The use of TAs, specifically fibrin-based TAs, for meniscal repair shows good results as either an augmentation or primary repair of various configurations of meniscal tears. However, this review reveals an absence of comparative high-quality evidence supporting the routine use of TAs for meniscal repair and emphasizes the lack of an ideal TA designed for that purpose. Further high-quality research, basic science and clinical, will facilitate the development of new materials and enable testing their suitability for use in meniscal repair.
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Affiliation(s)
- Niv Marom
- Department of Orthopaedic Surgery, Meir Medical Center, Kfar Saba, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabriella Ode
- Department of Orthopaedics, Prisma Health-Upstate, Greenville, South Carolina, USA
| | - Francesca Coxe
- Sports Medicine Institute, Hospital for Special Surgery, New York, USA
| | - Bridget Jivanelli
- Kim Barrett Memorial Library, Hospital for Special Surgery, New York, USA
| | - Scott A Rodeo
- Sports Medicine Institute, Hospital for Special Surgery, New York, USA
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Feler J, Sun F, Bajaj A, Hagan M, Kanekar S, Sullivan PLZ, Fridley JS, Gokaslan ZL. Complication Avoidance in Surgical Management of Vertebral Column Tumors. Curr Oncol 2022; 29:1442-1454. [PMID: 35323321 PMCID: PMC8947448 DOI: 10.3390/curroncol29030121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 11/23/2022] Open
Abstract
The surgical management of spinal tumors has grown increasingly complex as treatment algorithms for both primary bone tumors of the spine and metastatic spinal disease have evolved in response to novel surgical techniques, rising complication rates, and additional data concerning adjunct therapies. In this review, we discuss actionable interventions for improved patient safety in the operative care for spinal tumors. Strategies for complication avoidance in the preoperative, intraoperative, and postoperative settings are discussed for approach-related morbidities, intraoperative hemorrhage, wound healing complications, cerebrospinal fluid (CSF) leak, thromboembolism, and failure of instrumentation and fusion. These strategies center on themes such as pre-operative imaging review and medical optimization, surgical dissection informed by meticulous attention to anatomic boundaries, and fastidious wound closure followed by thorough post-operative care.
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Affiliation(s)
- Joshua Feler
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Felicia Sun
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Ankush Bajaj
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
| | - Matthew Hagan
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
| | - Samika Kanekar
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
| | - Patricia Leigh Zadnik Sullivan
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Jared S. Fridley
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Ziya L. Gokaslan
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
- Correspondence:
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Kinaci A, Bergmann W, van Thoor S, Redegeld S, van der Zwan A, van Doormaal TPC. Safety and biodegradability of a synthetic dural sealant patch (Liqoseal) in a porcine cranial model. Animal Model Exp Med 2021; 4:398-405. [PMID: 34977491 PMCID: PMC8690992 DOI: 10.1002/ame2.12184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/09/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Liqoseal consists of a watertight layer of poly(ester)ether urethane and an adhesive layer containing polyethylene glycol-N-hydroxysuccinimide (PEG-NHS). It is designed to prevent cerebrospinal fluid (CSF) leakage after intradural surgery. This study assessed the safety and biodegradability of Liqoseal in a porcine craniotomy model. Methods In 32 pigs a craniotomy plus durotomy was performed. In 15 pigs Liqoseal was implanted, in 11 control pigs no sealant was implanted and in 6 control pigs a control dural sealant (Duraseal or Tachosil) was implanted. The safety of Liqoseal was evaluated by clinical, MRI and histological assessment. The degradation of Liqoseal was histologically estimated. Results Liqoseal, 2 mm thick before application, did not swell and significantly was at maximum mean thickness of 2.14 (±0.37) mm at one month. The foreign body reaction induced by Liqoseal, Duraseal and Tachosil were comparable. Liqoseal showed no adherence to the arachnoid layer and was completely resorbed between 6 and 12 months postoperatively. In one animal with Liqoseal, an epidural fluid collection containing CSF could not be excluded. Conclusion Liqoseal seems to be safe for intracranial use and is biodegradable. The safety and performance in humans needs to be further assessed in clinical trials.
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Affiliation(s)
- Ahmet Kinaci
- Department of Neurology and Neurosurgery, Brain CenterUniversity Medical Centre UtrechtUtrechtThe Netherlands
- Brain Technology InstituteUtrechtThe Netherlands
| | - Wilhelmina Bergmann
- Division of PathologyFaculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | | | | | - Albert van der Zwan
- Department of Neurology and Neurosurgery, Brain CenterUniversity Medical Centre UtrechtUtrechtThe Netherlands
- Brain Technology InstituteUtrechtThe Netherlands
| | - Tristan P. C. van Doormaal
- Department of Neurology and Neurosurgery, Brain CenterUniversity Medical Centre UtrechtUtrechtThe Netherlands
- Brain Technology InstituteUtrechtThe Netherlands
- Department of NeurosurgeryClinical Neuroscience CenterUniversity Hospital ZurichZurichSwitzerland
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Park J, Kim Y, Chun B, Seo J. Rational engineering and applications of functional bioadhesives in biomedical engineering. Biotechnol J 2021; 16:e2100231. [PMID: 34469052 DOI: 10.1002/biot.202100231] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 12/31/2022]
Abstract
For the past decades, several bioadhesives have been developed to replace conventional wound closure medical tools such as sutures, staples, and clips. The bioadhesives are easy to use and can minimize tissue damage. They are designed to provide strong adhesion with stable mechanical support on tissue surfaces. However, this monofunctionality of the bioadhesives hinders their practical applications. In particular, a bioadhesive can lose its intended function under harsh tissue environments or delay tissue regeneration during wound healing. Based on several natural and synthetic biomaterials, functional bioadhesives have been developed to overcome the aforementioned limitations. The functional bioadhesives are designed to have specific characteristics such as antimicrobial, cell infiltrative, stimuli-responsive, electrically conductive, and self-healing to ensure stability under harsh tissue conditions, facilitate tissue regeneration, and effectively monitor biosignals. Herein, we thoroughly review the functional bioadhesives from their fundamental background to recent progress with their practical applications for the enhancement of tissue healing and effective biosignal sensing. Furthermore, the future perspectives on the applications of functional bioadhesives and current challenges in their commercialization are also discussed.
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Affiliation(s)
- Jae Park
- Biological Interfaces and Sensor Systems Laboratory, School of Electrical and Electronic Engineering, Yonsei University, Seoul, Republic of Korea
| | - Yeonju Kim
- Biological Interfaces and Sensor Systems Laboratory, School of Electrical and Electronic Engineering, Yonsei University, Seoul, Republic of Korea
| | - Beomsoo Chun
- Biological Interfaces and Sensor Systems Laboratory, School of Electrical and Electronic Engineering, Yonsei University, Seoul, Republic of Korea
| | - Jungmok Seo
- Biological Interfaces and Sensor Systems Laboratory, School of Electrical and Electronic Engineering, Yonsei University, Seoul, Republic of Korea
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Kinaci A, van Thoor S, Redegeld S, Tooren M, van Doormaal TPC. Ex vivo evaluation of a multilayered sealant patch for watertight dural closure: cranial and spinal models. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2021; 32:85. [PMID: 34297226 PMCID: PMC8302489 DOI: 10.1007/s10856-021-06552-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Cerebrospinal fluid leakage is a frequent complication after cranial and spinal surgery. To prevent this complication and seal the dura watertight, we developed Liqoseal, a dural sealant patch comprising a watertight polyesterurethane layer and an adhesive layer consisting of poly(DL-lactide-co-ε-caprolactone) copolymer and multiarmed N-hydroxylsuccinimide functionalized polyethylene glycol. We compared acute burst pressure and resistance to physiological conditions for 72 h of Liqoseal, Adherus, Duraseal, Tachosil, and Tisseel using computer-assisted models and fresh porcine dura. The mean acute burst pressure of Liqoseal in the cranial model (145 ± 39 mmHg) was higher than that of Adherus (87 ± 47 mmHg), Duraseal (51 ± 42 mmHg) and Tachosil (71 ± 16 mmHg). Under physiological conditions, cranial model resistance test results showed that 2 of 3 Liqoseal sealants maintained dural attachment during 72 hours as opposed to 3 of 3 for Adherus and Duraseal and 0 of 3 for Tachosil. The mean burst pressure of Liqoseal in the spinal model (233 ± 81 mmHg) was higher than that of Tachosil (123 ± 63 mmHg) and Tisseel (23 ± 16 mmHg). Under physiological conditions, spinal model resistance test results showed that 2 of 3 Liqoseal sealants maintained dural attachment for 72 hours as opposed to 3 of 3 for Adherus and 0 of 3 for Duraseal and Tachosil. This novel study showed that Liqoseal is capable of achieving a strong watertight seal over a dural defect in ex vivo models.
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Affiliation(s)
- A Kinaci
- Department of Neurology and Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
- Brain Technology Institute, Utrecht, The Netherlands
| | - S van Thoor
- Brain Technology Institute, Utrecht, The Netherlands
| | - S Redegeld
- Brain Technology Institute, Utrecht, The Netherlands
| | - M Tooren
- Polyganics BV, Groningen, The Netherlands
| | - T P C van Doormaal
- Department of Neurology and Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands.
- Brain Technology Institute, Utrecht, The Netherlands.
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10
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Diab A, Al-Shami H, Negida A, Gadallah A, Farag H, Elkadi DM, Gaber MM, Ebada MA. Efficacy and safety of polyethylene glycol dural sealant system in cranial and spinal neurosurgical procedures: Meta-analysis. Surg Neurol Int 2021; 12:182. [PMID: 34084610 PMCID: PMC8168650 DOI: 10.25259/sni_132_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/16/2021] [Indexed: 11/25/2022] Open
Abstract
Background: We aimed to assess the efficacy of polyethylene glycol (PEG) dura sealant to achieve watertight closure, prevention of cerebrospinal fluid (CSF) leak and to investigate its possible side effects. Methods: We searched Medline (through PubMed), Scopus, and the Cochrane Library through December 2019. We included articles demonstrating cranial or spinal procedures with the use of PEG material as a dural sealant. Data on intraoperative watertight closure, CSF leak, and surgical complications were extracted and pooled in a meta-analysis model using RevMan version 5.3 and OpenMeta (Analyst). Results: Pooling the controlled trials showed that PEG resulted in significantly more intraoperative watertight closures than standard care (risk ratio [RR] = 1.44, 95% confidence interval [CI] [1.24, 1.66]). However, the combined effect estimate did not reveal any significant difference between both groups in terms of CSF leaks, the incidence of surgical site infections, and neurological deficits (P = 0.7, 0.45, and 0.92, respectively). On the other hand, pooling both controlled and noncontrolled trials showed significance in terms of leak and neurological complications (RR = 0.0238, 95% CI [0.0102, 0.0373] and RR = 0.035, 95% CI [0.018, 0.052]). Regarding intraoperative watertight closure, the overall effect estimate showed no significant results (RR=0.994, 95% CI [0.986, 1.002]). Conclusion: Dura seal material is an acceptable adjuvant for dural closure when the integrity of the dura is questionable. However, marketing it as a factor for the prevention of surgical site infection is not scientifically proved. We suggest that, for neurosurgeons, using the dural sealants are highly recommended for duraplasty, skull base approaches, and in keyhole approaches.
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Affiliation(s)
- Ahmed Diab
- Department of Medicine, Demerdash Hospital, Cairo, Egypt
| | - Hieder Al-Shami
- Department of Neurosurgery, Al-Ahly Bank Hospital, Nasr City, Egypt
| | - Ahmed Negida
- Department of Medicine, Zagazig University Hospitals, Zagazig, Egypt
| | | | - Hossam Farag
- Department of Medicine, Zagazig University Hospitals, Zagazig, Egypt
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Bovone G, Dudaryeva OY, Marco-Dufort B, Tibbitt MW. Engineering Hydrogel Adhesion for Biomedical Applications via Chemical Design of the Junction. ACS Biomater Sci Eng 2021; 7:4048-4076. [PMID: 33792286 DOI: 10.1021/acsbiomaterials.0c01677] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hydrogel adhesion inherently relies on engineering the contact surface at soft and hydrated interfaces. Upon contact, adhesion normally occurs through the formation of chemical or physical interactions between the disparate surfaces. The ability to form these adhesion junctions is challenging for hydrogels as the interfaces are wet and deformable and often contain low densities of functional groups. In this Review, we link the design of the binding chemistries or adhesion junctions, whether covalent, dynamic covalent, supramolecular, or physical, to the emergent adhesive properties of soft and hydrated interfaces. Wet adhesion is useful for bonding to or between tissues and implants for a range of biomedical applications. We highlight several recent and emerging adhesive hydrogels for use in biomedicine in the context of efficient junction design. The main focus is on engineering hydrogel adhesion through molecular design of the junctions to tailor the adhesion strength, reversibility, stability, and response to environmental stimuli.
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Affiliation(s)
- Giovanni Bovone
- Macromolecular Engineering Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, 8092 Zurich, Switzerland
| | - Oksana Y Dudaryeva
- Macromolecular Engineering Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, 8092 Zurich, Switzerland
| | - Bruno Marco-Dufort
- Macromolecular Engineering Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, 8092 Zurich, Switzerland
| | - Mark W Tibbitt
- Macromolecular Engineering Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, 8092 Zurich, Switzerland
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Chen K, Lin Q, Wang L, Zhuang Z, Zhang Y, Huang D, Wang H. An All-in-One Tannic Acid-Containing Hydrogel Adhesive with High Toughness, Notch Insensitivity, Self-Healability, Tailorable Topography, and Strong, Instant, and On-Demand Underwater Adhesion. ACS APPLIED MATERIALS & INTERFACES 2021; 13:9748-9761. [PMID: 33591721 DOI: 10.1021/acsami.1c00637] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Hydrogels that are mechanically tough and capable of strong underwater adhesion can lead to a paradigm shift in the design of adhesives for a variety of biomedical applications. We hereby innovatively develop a facile but efficient strategy to prepare hydrogel adhesives with strong and instant underwater adhesion, on-demand detachment, high toughness, notch-insensitivity, self-healability, low swelling index, and tailorable surface topography. Specifically, a polymerization lyophilization conjugation fabrication method was proposed to introduce tannic acid (TA) into the covalent network consisting of polyethylene glycol diacrylate (PEGDA) of substantially high molecular weight. The presence of TA facilitated wet adhesion to various substrates by forming collectively strong noncovalent bonds and offering hydrophobicity to allow water repellence and also provided a reversible cross-link within the binary network to improve the mechanical performance of the gels. The long-chain PEGDA enhanced the efficacy and stability of TA conjugation and contributed to gel mechanics and adhesion by allowing chain diffusion and entanglement formation. Moreover, PEGDA/TA hydrogels were demonstrated to be biocompatible and capable of accelerating wound healing in a skin wound animal model as compared to commercial tissue adhesives and can be applied for the treatment of both epidermal and intracorporeal wounds. Our study provides new, critical insight into the design principle of all-in-one hydrogels with outstanding mechanical and adhesive properties and can potentially enhance the efficacy of hydrogel adhesives for wound healing.
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Affiliation(s)
- Kaiwen Chen
- Key State Laboratory of Fine Chemicals, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, High-tech District, Dalian 116024, P.R. China
| | - Qiaoxia Lin
- Department of Biomedical Engineering, Research Center for Nano-biomaterials & Regenerative Medicine, College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, PR China
| | - Libin Wang
- Key State Laboratory of Fine Chemicals, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, High-tech District, Dalian 116024, P.R. China
| | - Zhumei Zhuang
- Key State Laboratory of Fine Chemicals, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, High-tech District, Dalian 116024, P.R. China
| | - Yang Zhang
- Laboratory of Regenerative Biomaterials, Department of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen 518037, P.R. China
| | - Di Huang
- Department of Biomedical Engineering, Research Center for Nano-biomaterials & Regenerative Medicine, College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, PR China
| | - Huanan Wang
- Key State Laboratory of Fine Chemicals, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, High-tech District, Dalian 116024, P.R. China
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Abstract
Polymeric tissue adhesives provide versatile materials for wound management and are widely used in a variety of medical settings ranging from minor to life-threatening tissue injuries. Compared to the traditional methods of wound closure (i.e., suturing and stapling), they are relatively easy to use, enable rapid application, and introduce minimal tissue damage. Furthermore, they can act as hemostats to control bleeding and provide a tissue-healing environment at the wound site. Despite their numerous current applications, tissue adhesives still face several limitations and unresolved challenges (e.g., weak adhesion strength and poor mechanical properties) that limit their use, leaving ample room for future improvements. Successful development of next-generation adhesives will likely require a holistic understanding of the chemical and physical properties of the tissue-adhesive interface, fundamental mechanisms of tissue adhesion, and requirements for specific clinical applications. In this review, we discuss a set of rational guidelines for design of adhesives, recent progress in the field along with examples of commercially available adhesives and those under development, tissue-specific considerations, and finally potential functions for future adhesives. Advances in tissue adhesives will open new avenues for wound care and potentially provide potent therapeutics for various medical applications.
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Affiliation(s)
- Sungmin Nam
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
| | - David Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
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Yan T, Kameda S, Suzuki K, Kaiju T, Inoue M, Suzuki T, Hirata M. Minimal Tissue Reaction after Chronic Subdural Electrode Implantation for Fully Implantable Brain-Machine Interfaces. SENSORS 2020; 21:s21010178. [PMID: 33383864 PMCID: PMC7795822 DOI: 10.3390/s21010178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/12/2020] [Accepted: 12/25/2020] [Indexed: 11/16/2022]
Abstract
There is a growing interest in the use of electrocorticographic (ECoG) signals in brain–machine interfaces (BMIs). However, there is still a lack of studies involving the long-term evaluation of the tissue response related to electrode implantation. Here, we investigated biocompatibility, including chronic tissue response to subdural electrodes and a fully implantable wireless BMI device. We implanted a half-sized fully implantable device with subdural electrodes in six beagles for 6 months. Histological analysis of the surrounding tissues, including the dural membrane and cortices, was performed to evaluate the effects of chronic implantation. Our results showed no adverse events, including infectious signs, throughout the 6-month implantation period. Thick connective tissue proliferation was found in the surrounding tissues in the epidural space and subcutaneous space. Quantitative measures of subdural reactive tissues showed minimal encapsulation between the electrodes and the underlying cortex. Immunohistochemical evaluation showed no significant difference in the cell densities of neurons, astrocytes, and microglia between the implanted sites and contralateral sites. In conclusion, we established a beagle model to evaluate cortical implantable devices. We confirmed that a fully implantable wireless device and subdural electrodes could be stably maintained with sufficient biocompatibility in vivo.
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Affiliation(s)
- Tianfang Yan
- Department of Neurological Diagnosis and Restoration, Osaka University Graduate School of Medicine, Suita 565-0871, Japan; (T.Y.); (S.K.)
| | - Seiji Kameda
- Department of Neurological Diagnosis and Restoration, Osaka University Graduate School of Medicine, Suita 565-0871, Japan; (T.Y.); (S.K.)
- Global Center for Medical Engineering and Informatics, Osaka University, Suita 565-0871, Japan
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita 565-0871, Japan
| | - Katsuyoshi Suzuki
- Ogino Memorial Laboratory, Nihon Kohden Corporation, Tokorozawa 359-0037, Japan;
| | - Taro Kaiju
- Center for Information and Neural Networks, National Institute of Information and Communications Technology, Suita 565-0871, Japan; (T.K.); (M.I.); (T.S.)
| | - Masato Inoue
- Center for Information and Neural Networks, National Institute of Information and Communications Technology, Suita 565-0871, Japan; (T.K.); (M.I.); (T.S.)
| | - Takafumi Suzuki
- Center for Information and Neural Networks, National Institute of Information and Communications Technology, Suita 565-0871, Japan; (T.K.); (M.I.); (T.S.)
| | - Masayuki Hirata
- Department of Neurological Diagnosis and Restoration, Osaka University Graduate School of Medicine, Suita 565-0871, Japan; (T.Y.); (S.K.)
- Global Center for Medical Engineering and Informatics, Osaka University, Suita 565-0871, Japan
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita 565-0871, Japan
- Correspondence:
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Sun F, Bu Y, Chen Y, Yang F, Yu J, Wu D. An Injectable and Instant Self-Healing Medical Adhesive for Wound Sealing. ACS APPLIED MATERIALS & INTERFACES 2020; 12:9132-9140. [PMID: 32058692 DOI: 10.1021/acsami.0c01022] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Designing versatile functional medical adhesives with injectability, self-healing, and strong adhesion is of great significance to achieve desirable therapeutic effects for promoting wound sealing in healthcare. Herein, a self-healing injectable adhesive is fabricated by physical interaction of polyphenol compound tannic acid (TA) and eight-arm poly(ethylene glycol) end-capped with succinimide glutarate active ester (PEG-SG). The hydrogen bonding induced from the structural unit (-CH2-CH2-O-) of PEG and catechol hydroxyl (-OH) of TA, accompanied by ester exchange between N-hydroxysuccinimide (-NHS) and amino (-NH2) of proteins, contributes to self-healing ability and rapid strong adhesion. Notably, the PEG/TA adhesive can repeatedly adhere to rigid porcine tissues, close the coronary artery under a large incision tension, and bear a heavy load of 2 kg. By exhibiting shear-thinning and anti-swelling properties, the PEG/TA adhesive can be easily applied through single-syringe extrusion onto various wounds. The single-channel toothpaste-like feature of the adhesive ensures its storage hermetically for portable usage. Moreover, in vivo operation and histological H&E staining results indicate that the PEG/TA adhesive greatly accelerates wound healing and tissue regeneration in a rat model. With the specialty of injectability, instant self-healing, and long-lasting strong adhesion to facilitate excellent therapeutic effects, the multifunctional PEG/TA adhesive may provide a new alternative for self-rescue and surgical situations.
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Affiliation(s)
- Feifei Sun
- Beijing National Laboratory for Molecular Sciences , Institute of Chemistry, Chinese Academy of Sciences , Beijing 100190 , China
| | - Yazhong Bu
- Beijing National Laboratory for Molecular Sciences , Institute of Chemistry, Chinese Academy of Sciences , Beijing 100190 , China
| | - Yourong Chen
- Knee Surgery Department of the Institute of Sports Medicine , Peking University Third Hospital , Beijing 100191 , China
| | - Fei Yang
- Beijing National Laboratory for Molecular Sciences , Institute of Chemistry, Chinese Academy of Sciences , Beijing 100190 , China
| | - Jiakuo Yu
- Knee Surgery Department of the Institute of Sports Medicine , Peking University Third Hospital , Beijing 100191 , China
| | - Decheng Wu
- Beijing National Laboratory for Molecular Sciences , Institute of Chemistry, Chinese Academy of Sciences , Beijing 100190 , China
- Department of Biomedical Engineering , Southern University of Science and Technology , Shenzhen , Guangdong 518055 , China
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Xu C, Zhao J, Gong Q, Chen S. Sustained release of vancomycin from bacterial cellulose membrane as dural substitutes for anti-inflammatory wound closure in rabbits. J Biomater Appl 2020; 34:1470-1478. [PMID: 32070189 DOI: 10.1177/0885328220908027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Chen Xu
- Shanghai Sixth People's Hospital, Shanghai JiaoTong University, Shanghai, China
| | - Jianwei Zhao
- Shanghai Sixth People's Hospital, Shanghai JiaoTong University, Shanghai, China
| | - Qiuyuan Gong
- Shanghai Sixth People's Hospital, Shanghai JiaoTong University, Shanghai, China
| | - Shiwen Chen
- Shanghai Sixth People's Hospital, Shanghai JiaoTong University, Shanghai, China
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17
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Lewis KM, Sweet J, Wilson ST, Rousselle S, Gulle H, Baumgartner B. Safety and Efficacy of a Novel, Self-Adhering Dural Substitute in a Canine Supratentorial Durotomy Model. Neurosurgery 2019; 82:397-406. [PMID: 28575349 PMCID: PMC6018778 DOI: 10.1093/neuros/nyx216] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 04/04/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leaks increase postoperative risk for complication, likelihood of reoperation, and costs. OBJECTIVE To investigate a novel, self-adhering polyethylene glycol-coated collagen pad (PCC) as a dural substitute relative to Duragen XS (DGX; Integra LifeSciences Corporation, Plainsboro, New Jersey) and as a dural sealant relative to Tachosil (Takeda Austria GmbH, Linz, Austria), a fibrinogen and thrombin-coated collagen pad (FTC). METHODS A canine supratentorial durotomy surgical model was used to investigate the safety and efficacy of PCC. For safety, 4 animals were bilaterally treated with DGX or PCC and recovered for 1, 8, or 16 wk; total 24 animals. Each animal underwent physical and neurological examinations weekly and 16-wk animals underwent a magnetic resonance imaging (MRI) examination at each time point. For efficacy, 9 animals were unilaterally treated with FTC or PCC and underwent a burst pressure test intraoperatively or 14 d postoperatively; total 36 animals. RESULTS In the safety study, no abnormal clinical signs or changes were noted on physical and neurological examinations, or in clinical pathology, CSF analysis or histopathology of DGX or PCC-treated animals. No consistent signs of cerebral compression, CSF leak, hemorrhage, or hydrocephalus were noted on MRI. In the efficacy study, no significant difference was found between FTC and PCC at each time point or overall (13.9 vs 12.3 mm Hg, n = 18 per group, P = .46). CONCLUSION PCC is safe for use as a dural substitute and effective as a dural sealant. The novel, self-adhering combination of a polyethylene glycol-based sealant and a collagen pad may offer unique benefits to the advancement of duraplasty.
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Affiliation(s)
| | | | | | | | - Heinz Gulle
- Baxter Medical Products GmbH, Vienna, Austria
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18
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Kinaci A, Van Doormaal TP. Dural sealants for the management of cerebrospinal fluid leakage after intradural surgery: current status and future perspectives. Expert Rev Med Devices 2019; 16:549-553. [DOI: 10.1080/17434440.2019.1626232] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Ahmet Kinaci
- Department of Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
- Brain Technology Institute, Utrecht, The Netherlands
| | - Tristan P.C. Van Doormaal
- Department of Neurosurgery, Brain Center Rudolph Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
- Brain Technology Institute, Utrecht, The Netherlands
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19
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Du X, Wu L, Yan H, Qu L, Wang L, Wang X, Ren S, Kong D, Wang L. Multifunctional Hydrogel Patch with Toughness, Tissue Adhesiveness, and Antibacterial Activity for Sutureless Wound Closure. ACS Biomater Sci Eng 2019; 5:2610-2620. [DOI: 10.1021/acsbiomaterials.9b00130] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Xinchen Du
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin 300071, P. R. China
| | - Le Wu
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin 300071, P. R. China
| | - Hongyu Yan
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin 300071, P. R. China
| | - Lijie Qu
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin 300071, P. R. China
| | - Lina Wang
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin 300071, P. R. China
| | - Xin Wang
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin 300071, P. R. China
| | - Shuo Ren
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin 300071, P. R. China
| | - Deling Kong
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin 300071, P. R. China
| | - Lianyong Wang
- Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin 300071, P. R. China
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20
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Eles JR, Vazquez AL, Kozai TDY, Cui XT. Meningeal inflammatory response and fibrous tissue remodeling around intracortical implants: An in vivo two-photon imaging study. Biomaterials 2018; 195:111-123. [PMID: 30634095 DOI: 10.1016/j.biomaterials.2018.12.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/15/2018] [Accepted: 12/28/2018] [Indexed: 12/21/2022]
Abstract
Meningeal inflammation and encapsulation of neural electrode arrays is a leading cause of device failure, yet little is known about how it develops over time or what triggers it. This work characterizes the dynamic changes of meningeal inflammatory cells and collagen-I in order to understand the meningeal tissue response to neural electrode implantation. We use in vivo two-photon microscopy of CX3CR1-GFP mice over the first month after electrode implantation to quantify changes in inflammatory cell behavior as well as meningeal collagen-I remodeling. We define a migratory window during the first day after electrode implantation hallmarked by robust inflammatory cell migration along electrodes in the meninges as well as cell trafficking through meningeal venules. This migratory window attenuates by 2 days post-implant, but over the next month, the meningeal collagen-I remodels to conform to the surface of the electrode and thickens. This work shows that there are distinct time courses for initial meningeal inflammatory cell infiltration and meningeal collagen-I remodeling. This may indicate a therapeutic window early after implantation for modulation and mitigation of meningeal inflammation.
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Affiliation(s)
- J R Eles
- Bioengineering, University of Pittsburgh, United States; Center for the Neural Basis of Cognition, University of Pittsburgh and Carnegie Mellon University, United States
| | - A L Vazquez
- Bioengineering, University of Pittsburgh, United States; Center for the Neural Basis of Cognition, University of Pittsburgh and Carnegie Mellon University, United States; Radiology, University of Pittsburgh, United States
| | - T D Y Kozai
- Bioengineering, University of Pittsburgh, United States; Center for the Neural Basis of Cognition, University of Pittsburgh and Carnegie Mellon University, United States; McGowan Institute for Regenerative Medicine, University of Pittsburgh, United States; NeuroTech Center of the University of Pittsburgh Brain Institute, United States; Center for Neuroscience, University of Pittsburgh, United States
| | - X T Cui
- Bioengineering, University of Pittsburgh, United States; Center for the Neural Basis of Cognition, University of Pittsburgh and Carnegie Mellon University, United States; McGowan Institute for Regenerative Medicine, University of Pittsburgh, United States.
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Heher P, Ferguson J, Redl H, Slezak P. An overview of surgical sealant devices: current approaches and future trends. Expert Rev Med Devices 2018; 15:747-755. [DOI: 10.1080/17434440.2018.1526672] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Philipp Heher
- Austrian Cluster for Tissue Regeneration, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology/AUVA Research Center, Vienna, Austria
| | - James Ferguson
- Austrian Cluster for Tissue Regeneration, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology/AUVA Research Center, Vienna, Austria
| | - Heinz Redl
- Austrian Cluster for Tissue Regeneration, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology/AUVA Research Center, Vienna, Austria
| | - Paul Slezak
- Austrian Cluster for Tissue Regeneration, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology/AUVA Research Center, Vienna, Austria
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Li F, Truong VX, Fisch P, Levinson C, Glattauer V, Zenobi-Wong M, Thissen H, Forsythe JS, Frith JE. Cartilage tissue formation through assembly of microgels containing mesenchymal stem cells. Acta Biomater 2018; 77:48-62. [PMID: 30006317 DOI: 10.1016/j.actbio.2018.07.015] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/14/2018] [Accepted: 07/09/2018] [Indexed: 01/06/2023]
Abstract
Current clinical approaches to treat articular cartilage degeneration provide only a limited ability to regenerate tissue with long-term durability and functionality. In this application, injectable bulk hydrogels and microgels containing stem cells can provide a suitable environment for tissue regeneration. However insufficient cell-cell interactions, low differentiation efficiency and poor tissue adhesion hinder the formation of high-quality hyaline type cartilage. Here, we have designed a higher order tissue-like structure using injectable cell-laden microgels as the building blocks to achieve human bone marrow-derived mesenchymal stem cell (hBMSC) long-term maintenance and chondrogenesis. We have demonstrated that a 4-arm poly(ethylene glycol)-N-hydroxysuccinimide (NHS) crosslinker induces covalent bonding between the microgel building blocks as well as the surrounding tissue mimic. The crosslinking process assembles the microgels into a 3D construct and preserves the viability and cellular functions of the encapsulated hBMSCs. This assembled microgel construct encourages upregulation of chondrogenic markers in both gene and glycosaminoglycan (GAG) expression levels. In addition, the regenerated tissue in the assembled microgels stained positively with Alcian blue and Safranin O exhibiting unique hyaline-like cartilage features. Furthermore, the immunostaining showed a favourable distribution and significantly higher content of type II collagen in the assembled microgels when compared to both the bulk hydrogel and pellet cultures. Collectively, this tissue adhesive hBMSC-laden microgel construct provides potential clinical opportunities for articular cartilage repair and other applications in regenerative medicine. STATEMENT OF SIGNIFICANCE A reliable approach to reconstruct durable and fully functional articular cartilage tissue is required for effective clinical therapies. Here, injectable hydrogels together with cell-based therapies offer new treatment strategies in cartilage repair. For effective cartilage regeneration, the injectable hydrogel system needs to be bonded to the surrounding tissue and at the same time needs to be sufficiently stable for prolonged chondrogenesis. In this work, we utilised injectable hBMSC-laden microgels as the building blocks to create an assembled construct via N-hydroxysuccinimide-amine coupling. This crosslinking process also allows for rapid bonding between the assembled microgels and a surrounding tissue mimic. The resultant assembled microgel-construct provides both a physically stable and biologically dynamic environment for hBMSC chondrogenesis, leading to the production of a mature hyaline type cartilage structure.
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Effectiveness of Dural Sealants in Prevention of Cerebrospinal Fluid Leakage After Craniotomy: A Systematic Review. World Neurosurg 2018; 118:368-376.e1. [PMID: 29969744 DOI: 10.1016/j.wneu.2018.06.196] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Cerebrospinal fluid (CSF) leakage is one of the most challenging complications in neurosurgery. We sought to evaluate the efficacy of dural sealants in preventing CSF leakage after cranial surgery. METHODS A literature search was performed in the PubMed, Embase, and Cochrane databases. The inclusion criteria were defined to include articles describing regular cranial procedures combined with the use of any dural sealant reporting CSF leakage. The primary outcome was CSF leakage (pseudomeningocele formation or incisional CSF leakage), secondary outcomes were pseudomeningocele formation, incisional CSF leakage, and surgical-site infection. RESULTS Twenty articles were included. Ten of these were comparative studies (sealant vs. no sealant) including 3 randomized controlled trials. In the 20 articles, a total of 3682 surgical procedures were reported. The number of CSF leakages in general did not differ between the sealant group (8.2%) and control group (8.4%), risk ratio (RR) 0.84 (0.50-1.42), I2 = 56%. Exclusion of non-randomized controlled trials did not alter the results. Meta-analyses for secondary outcomes showed no difference between number of incisional CSF leakage, RR 0.30 (0.05-1.59), I2 = 38%. Also, no difference was found in the pseudomeningocele formation, RR 1.50 (0.43-5.17), I2 = 0%. Surgical-site infection was seen less in the sealant group (1.0%) compared with the control group (5.6%), RR 0.25 (0.13-0.48), I2 = 0%. CONCLUSIONS This systematic review showed that dural sealants did not reduce the number of CSF leaks in general, the number of incisional CSF leaks alone, or the number of pseudomeningocele formations alone. However, dural sealants reduced the risk of surgical-site infection.
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Kalsi P, Thom M, Choi D. Histological effects of fibrin glue and synthetic tissue glues on the spinal cord: are they safe to use? Br J Neurosurg 2017; 31:695-700. [DOI: 10.1080/02688697.2017.1359491] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Pratipal Kalsi
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, UK
- Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Maria Thom
- Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Neuropathology, National Hospital for Neurology and Neurosurgery, London, UK
| | - David Choi
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, UK
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Jiang YY, Zhu YJ, Li H, Zhang YG, Shen YQ, Sun TW, Chen F. Preparation and enhanced mechanical properties of hybrid hydrogels comprising ultralong hydroxyapatite nanowires and sodium alginate. J Colloid Interface Sci 2017; 497:266-275. [DOI: 10.1016/j.jcis.2017.03.032] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/27/2017] [Accepted: 03/05/2017] [Indexed: 11/25/2022]
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Degenhart AD, Eles J, Dum R, Mischel JL, Smalianchuk I, Endler B, Ashmore RC, Tyler-Kabara EC, Hatsopoulos NG, Wang W, Batista AP, Cui XT. Histological evaluation of a chronically-implanted electrocorticographic electrode grid in a non-human primate. J Neural Eng 2016; 13:046019. [PMID: 27351722 DOI: 10.1088/1741-2560/13/4/046019] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Electrocorticography (ECoG), used as a neural recording modality for brain-machine interfaces (BMIs), potentially allows for field potentials to be recorded from the surface of the cerebral cortex for long durations without suffering the host-tissue reaction to the extent that it is common with intracortical microelectrodes. Though the stability of signals obtained from chronically implanted ECoG electrodes has begun receiving attention, to date little work has characterized the effects of long-term implantation of ECoG electrodes on underlying cortical tissue. APPROACH We implanted and recorded from a high-density ECoG electrode grid subdurally over cortical motor areas of a Rhesus macaque for 666 d. MAIN RESULTS Histological analysis revealed minimal damage to the cortex underneath the implant, though the grid itself was encapsulated in collagenous tissue. We observed macrophages and foreign body giant cells at the tissue-array interface, indicative of a stereotypical foreign body response. Despite this encapsulation, cortical modulation during reaching movements was observed more than 18 months post-implantation. SIGNIFICANCE These results suggest that ECoG may provide a means by which stable chronic cortical recordings can be obtained with comparatively little tissue damage, facilitating the development of clinically viable BMI systems.
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Affiliation(s)
- Alan D Degenhart
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA. Center for the Neural Basis of Cognition, Pittsburgh, PA, USA. Systems Neuroscience Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Modaresifar K, Azizian S, Hadjizadeh A. Nano/Biomimetic Tissue Adhesives Development: From Research to Clinical Application. POLYM REV 2016. [DOI: 10.1080/15583724.2015.1114493] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lewis KM, Kuntze CE, Gulle H. Control of bleeding in surgical procedures: critical appraisal of HEMOPATCH (Sealing Hemostat). MEDICAL DEVICES-EVIDENCE AND RESEARCH 2015; 9:1-10. [PMID: 26730213 PMCID: PMC4694675 DOI: 10.2147/mder.s90591] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The need for advanced hemostatic agents increases with the complexity of surgical procedures and use of anticoagulation and antiplatelet treatments. HEMOPATCH (Sealing Hemostat) is a novel, advanced hemostatic pad that is composed of a synthetic, protein-reactive monomer and a collagen backing. The active side is covered with a protein-reactive monomer: N-hydroxysuccinimide functionalized polyethylene glycol (NHS-PEG). NHS-PEG rapidly affixes the collagen pad to tissue to promote and maintain hemostasis. The combined action of the NHS-PEG and collagen is demonstrated to have benefit relative to other hemostatic agents in surgery and preclinical surgical models. This paper reviews the published investigations and case reports of the hemostatic efficacy of HEMOPATCH, wherein HEMOPATCH is demonstrated to be an effective, easy-to-use hemostatic agent in open and minimally invasive surgery of patients with thrombin- or platelet-induced coagulopathies.
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Affiliation(s)
- Kevin Michael Lewis
- Preclinical Safety and Efficacy, Baxter Healthcare Corporation, Deerfield, IL, USA
| | | | - Heinz Gulle
- Surgical Sciences and Engineering, Baxter Medical Products GmbH, Vienna, Austria
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First impressions about Adherus, a new dural sealant. J Appl Biomater Funct Mater 2015; 13:e372-5. [PMID: 26350346 DOI: 10.5301/jabfm.5000241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2015] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The aim of the study is to report our first impressions about Adherus, a novel dural sealant, used in neurosurgical endoscopic transnasal procedures. METHODS We retrospectively reviewed the clinical and surgical records of the first 11 patients with intraoperative high-flow cerebrospinal fluid leak treated with the aid of Adherus at our center between February and October 2014. The healing at the level of the dural plasty was monitored and evaluated radiologically and with regular endoscopic inspections. RESULTS With a median follow-up of 210 days, no postoperative CSF leak or surgical site infections were found in any of the cases. CONCLUSIONS Based on our preliminary experience, this new dural sealant seems to provide an effective aid in dural plasty during endoscopic transphenoidal procedures.
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Two-photon imaging of chronically implanted neural electrodes: Sealing methods and new insights. J Neurosci Methods 2015; 258:46-55. [PMID: 26526459 DOI: 10.1016/j.jneumeth.2015.10.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 10/12/2015] [Accepted: 10/15/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Two-photon microscopy has enabled the visualization of dynamic tissue changes to injury and disease in vivo. While this technique has provided powerful new information, in vivo two-photon chronic imaging around tethered cortical implants, such as microelectrodes or neural probes, present unique challenges. NEW METHOD A number of strategies are described to prepare a cranial window to longitudinally observe the impact of neural probes on brain tissue and vasculature for up to 3 months. RESULTS It was found that silastic sealants limit cell infiltration into the craniotomy, thereby limiting light scattering and preserving window clarity over time. In contrast, low concentration hydrogel sealants failed to prevent cell infiltration and their use at high concentration displaced brain tissue and disrupted probe performance. COMPARISON WITH EXISTING METHOD(S) The use of silastic sealants allows for a suitable imaging window for long term chronic experiments and revealed new insights regarding the dynamic leukocyte response around implants and the nature of chronic BBB leakage in the sub-dural space. CONCLUSION The presented method provides a valuable tool for evaluating the chronic inflammatory response and the performance of emerging implantable neural technologies.
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Annabi N, Yue K, Tamayol A, Khademhosseini A. Elastic sealants for surgical applications. Eur J Pharm Biopharm 2015; 95:27-39. [PMID: 26079524 PMCID: PMC4591192 DOI: 10.1016/j.ejpb.2015.05.022] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 05/25/2015] [Accepted: 05/27/2015] [Indexed: 12/21/2022]
Abstract
Sealants have emerged as promising candidates for replacing sutures and staples to prevent air and liquid leakages during and after the surgeries. Their physical properties and adhesion strength to seal the wound area without limiting the tissue movement and function are key factors in their successful implementation in clinical practice. In this contribution, the advances in the development of elastic sealants formed from synthetic and natural materials are critically reviewed and their shortcomings are pointed out. In addition, we highlight the applications in which elasticity of the sealant is critical and outline the limitations of the currently available sealants. This review will provide insights for the development of novel bioadhesives with advanced functionality for surgical applications.
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Affiliation(s)
- Nasim Annabi
- Department of Chemical Engineering, Northeastern University, Boston, MA 02115-5000, USA; Biomaterials Innovations Research Center, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA; Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA
| | - Kan Yue
- Biomaterials Innovations Research Center, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ali Tamayol
- Biomaterials Innovations Research Center, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ali Khademhosseini
- Biomaterials Innovations Research Center, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA; Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA; Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX, USA; Department of Physics, King Abdulaziz University, Jeddah 21569, Saudi Arabia.
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Dafford EE, Anderson PA. Comparison of dural repair techniques. Spine J 2015; 15:1099-105. [PMID: 23973097 DOI: 10.1016/j.spinee.2013.06.044] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Revised: 04/14/2013] [Accepted: 06/14/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Incidental durotomy occurs in 1% to 17% of lumbar spine surgery. This is treated with watertight suture repair, often combined with a sealant. PURPOSE To compare the hydrostatic strength of dural repair using various suture sizes, closure techniques, and adhesives. STUDY DESIGN A novel in vitro hydrostatic calf spine model. OUTCOME MEASURES Dural leakage as a function of hydrostatic pressure and leak area. METHODS We compared surgical repair between 5-0 surgilon and 6-0 prolene suture, continuous locked versus interrupted suture, and the effectiveness of three adhesives hydrogel, cyanoacrylate, and fibrin glue. The leakage flow rate was compared among suture groups using analysis of variance (ANOVA). The percent reduction of leak area was determined for the sealants and compared using ANOVA. The study was funded from an intramural departmental grant. RESULTS 6-0 Prolene was found to have significantly decreased leakage flow rate than 5-0 surgilon. We found no significant differences in the flow rate between the interrupted and continuous locked sutures. In most cases, leakage occurred from the needle holes around sutures. There was an 80% reduction in leak area with the hydrogel and cyanoacrylic sealants compared with only a 38% reduction with fibrin glue; however, there was no statistical difference between the leak rates using any of the sealants. CONCLUSION 6-0 Prolene using either interrupted or locked techniques was the best at creating watertight closure of an incidental durotomy. If a watertight seal cannot be obtained, a hydrogel or a fibrin sealant will immediately improve the strength of repair. Newer sutures that have a larger diameter of suture relative to needle should be developed for use in dural repair.
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Affiliation(s)
- Erica E Dafford
- Department of Orthopedic Surgery and Rehabilitation, University of Wisconsin, 1685 Highland Ave., 6th floor, Madison, WI 53705-2281, USA
| | - Paul A Anderson
- Department of Orthopedic Surgery and Rehabilitation, University of Wisconsin, 1685 Highland Ave., 6th floor, Madison, WI 53705-2281, USA.
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Abstract
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.
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Affiliation(s)
- Lindsey Sanders
- Department of Bioengineering, Clemson University, Clemson, South Carolina
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Abstract
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®.
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Xu C, Ma X, Chen S, Tao M, Yuan L, Jing Y. Bacterial cellulose membranes used as artificial substitutes for dural defection in rabbits. Int J Mol Sci 2014; 15:10855-67. [PMID: 24937688 PMCID: PMC4100185 DOI: 10.3390/ijms150610855] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 05/22/2014] [Accepted: 06/03/2014] [Indexed: 12/03/2022] Open
Abstract
To improve the efficacy and safety of dural repair in neurosurgical procedures, a new dural material derived from bacterial cellulose (BC) was evaluated in a rabbit model with dural defects. We prepared artificial dura mater using bacterial cellulose which was incubated and fermented from Acetobacter xylinum. The dural defects of the rabbit model were repaired with BC membranes. All surgeries were performed under sodium pentobarbital anesthesia, and all efforts were made to minimize suffering. All animals were humanely euthanized by intravenous injection of phenobarbitone, at each time point, after the operation. Then, the histocompatibility and inflammatory effects of BC were examined by histological examination, real-time fluorescent quantitative polymerase chain reaction (PCR) and Western Blot. BC membranes evenly covered the surface of brain without adhesion. There were seldom inflammatory cells surrounding the membrane during the early postoperative period. The expression of inflammatory cytokines IL-1β, IL-6 and TNF-α as well as iNOS and COX-2 were lower in the BC group compared to the control group at 7, 14 and 21 days after implantation. BC can repair dural defects in rabbit and has a decreased inflammatory response compared to traditional materials. However, the long-term effects need to be validated in larger animals.
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Affiliation(s)
- Chen Xu
- Department of Neurosurgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, China.
| | - Xia Ma
- School of Perfume and Aroma Technology, Shanghai Institute of Technology, Haiquan Road 100, Shanghai 201418, China.
| | - Shiwen Chen
- Department of Neurosurgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, China.
| | - Meifeng Tao
- School of Life Sciences and Biotechnology, Shanghai Jiaotong University, Dongchuan Road 800, Shanghai 200240, China.
| | - Lutao Yuan
- Department of Neurosurgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, China.
| | - Yao Jing
- Department of Neurosurgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai 200233, China.
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Saini A, Chauhan VS. Self-assembling properties of peptides derived from TDP-43 C-terminal fragment. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2014; 30:3845-3856. [PMID: 24559403 DOI: 10.1021/la404710w] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Two highly fibrillogenic peptide sequences (MNFGAFSINP and EDLIIKGISV) were previously reported in the C-terminal fragment (CTF) of TDP-43 (220-414), a protein recently implicated in neuro-degenerative diseases such as amyotrophic lateral sclerosis (ALS) and frontotemporal lobar degeneration (FTLD-U). It was observed that the sequences MNFGAFS and EDLIIKG harbor their respective fibrillogenic domains. Here, the self-assembling properties of peptides obtained by systematic deletion of residues from these two sequences were investigated with the help of light scattering, thioflavin T fluorescence, transmission electron microscopy, and circular dichroism spectroscopy. It was found that the pentapeptide NFGAF and the tetrapeptide DLII are the shortest fibrillogenic sequences from MNFGAFS and EDLIIKG, respectively. Structure function studies revealed that self-assembly of the peptides is largely governed by hydrophobic interactions. Both NFGAF and DLII formed hydrogels based on a complex fibrillar network, at relatively low concentrations, and of remarkable strength and stability. Of particular interest was DLII, a rare aliphatic tetrapeptide that formed a hydrogel at a concentration of 1 mg/mL in less than an hour. Interestingly, various other tetrapeptides based on DLII (YLII, KLII, NLII, and LIID) also formed hydrogels of comparable physical properties, suggesting that an amphipathic peptide design based on the hydrophobic LII motif and a single residue polar terminus is highly favorable for hydrogelation. Peptides discovered in this study, especially DLII and its variants, are some of the shortest ever reported to show such structural and functional features, suggesting that they can be useful templates for the design of peptide-based soft materials.
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Affiliation(s)
- Akash Saini
- International Centre for Genetic Engineering and Biotechnology, Aruna Asaf Ali Marg, New Delhi 110067, India
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Kawai H, Nakagawa I, Nishimura F, Motoyama Y, Park YS, Nakamura M, Nakase H, Suzuki S, Ikada Y. Effectiveness of a new gelatin sealant system for dural closure. Neurol Res 2014; 36:866-72. [PMID: 24601724 DOI: 10.1179/1743132814y.0000000342] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Watertight dural closure is imperative after neurosurgical procedures because inadequately treated leakage of cerebrospinal fluid (CSF) can have serious consequences. In this study, the authors test the use of a new gelatin glue as a dural sealant in in vitro and in vivo canine models of transdural CSF leakage. METHODS The in vitro model was sutured semicircles of canine dura mater and artificial dural substitute. The sutures were sealed with gelatin glue (n = 20), fibrin glue (n = 20), or a polyethylene glycol (PEG)-based hydrogel sealant (n = 20). Each sample was set in a device to measure water pressure, and pressure was increased until leakage occurred. Bonding strength was subjectively evaluated. The in vivo model was dogs who underwent dural excision and received either no sealant (control group; n = 5) or gelatin glue sealant (n = 5) before dural closure. Twenty-eight days post-surgery, the maximum intracranial pressure was measured at the cisterna magna using Valsalva maneuver and tissue adhesion was evaluated. RESULTS The water pressure at which leakage occurred in the in vitro model was higher with gelatin glue (76·5 ± 39·8 mmHg) than with fibrin glue (38·3 ± 27·4 mmHg, P < 0·001) or the PEG-based hydrogel sealant (46·3 ± 20·9 mmHg, P = 0·007). Bonding strength was higher for the gelatin glue than fibrin glue (P < 0·001) or PEG-based hydrogel sealant (P = 0·001). The maximum intracranial pressure in the in vivo model was higher for the gelatin glue group (59·0 ± 2·2 mmHg) than the control group (13·8 ± 4·0 mmHg, P < 0·001). Tissue adhesion was lower for the gelatin glue group than the control group (P = 0·005). DISCUSSION The new gelatin glue provides an effective watertight closure when used as an adjunct to sutured dural repair.
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Treasure TE, Dean JS, Gear RD. Craniofacial approaches and reconstruction in skull base surgery: techniques for the oral and maxillofacial surgeon. J Oral Maxillofac Surg 2014; 71:2137-50. [PMID: 24237775 DOI: 10.1016/j.joms.2013.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 08/05/2013] [Accepted: 08/05/2013] [Indexed: 10/26/2022]
Abstract
Skull base surgery (SBS) is considered the standard of care in treating benign and malignant lesions of the cranial base. SBS is a multidisciplinary team approach used to treat these complex lesions that may have intracranial extension. SBS can be broken down into 3 steps. Transfacial access is performed, followed by resection with sound oncologic principles, and then reconstruction of the cranial base and facial structures. Functional and esthetic concerns must be addressed by the surgeons. Oral and maxillofacial surgeons frequently perform elective facial osteotomies and treat victims of cranial base trauma. These same principles can be applied to SBS as a part of the skull base team.
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Affiliation(s)
- Trevor E Treasure
- Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Texas School of Dentistry, Houston, TX.
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Peng HT, Shek PN. Novel wound sealants: biomaterials and applications. Expert Rev Med Devices 2014; 7:639-59. [DOI: 10.1586/erd.10.40] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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JITO J, NITTA N, NOZAKI K. Delayed Cerebrospinal Fluid Leak after Watertight Dural Closure with a Polyethylene Glycol Hydrogel Dural Sealant in Posterior Fossa Surgery: Case Report. Neurol Med Chir (Tokyo) 2014; 54:634-9. [DOI: 10.2176/nmc.cr2013-0010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Junya JITO
- Department of Neurosurgery, Shiga University of Medical Science
| | - Naoki NITTA
- Department of Neurosurgery, Shiga University of Medical Science
| | - Kazuhiko NOZAKI
- Department of Neurosurgery, Shiga University of Medical Science
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Holowka EP, Bhatia SK. Hydrogel Materials. Drug Deliv 2014. [DOI: 10.1007/978-1-4939-1998-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Ito K, Horiuchi T, Oyanagi K, Nomiyama T, Hongo K. Comparative study of fibrin and chemical synthetic sealant on dural regeneration and brain damage. J Neurosurg Spine 2013; 19:736-43. [PMID: 24074508 DOI: 10.3171/2013.8.spine12998] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Several materials, such as polyethylene glycol (PEG) hydrogel and fibrin glue, have been used to seal dural incisions after brain and spinal surgeries. Although the use of PEG sealant is gaining popularity, it can be associated with postoperative cerebrospinal fluid leakage and infection. However, the reasons for this association are currently unknown. The present study aimed to investigate the effects of PEG sealant and fibrin glue on wound healing and brain damage in vivo. METHODS Oval-shaped bone defects and dural defects were created bilaterally over the parietal lobes of 22 Japanese white rabbits. The dural defects were covered with 0.5 ml of fibrin glue on one side and 0.5 ml of PEG sealant on the other side. Dural regeneration and brain damage were investigated in each harvested brain and dura mater using light microscopy. RESULTS Dural regeneration was more effective in the presence of fibrin glue than it was with PEG sealant (p = 0.014). Of the 22 rabbits, 11 showed thick (Grades ++ and +++) dural regeneration by 28 days postsurgery in the hemisphere where fibrin glue was used, whereas Grade +++ dural regeneration was not observed in the PEG hydrogel hemisphere, and only 4 rabbits showed Grade ++ regeneration. Abscess and granulation formation also tended to be more severe when PEG hydrogel sealant was used. No Grade ++ granulation/abscess formation was observed with fibrin glue, and Grade + was only observed in 13 of 22 rabbits. Conversely, with PEG hydrogel sealant, only 2 rabbits did not show granulation/abscess formation, and Grade +, ++, and +++ granulation/abscess formation was observed in 8, 7, and 5 rabbits, respectively. The extent of cortical damage was significantly greater in rabbits with abscesses and granulations, compared with rabbits without these lesions (p = 0.007). CONCLUSIONS Dural regeneration tended to occur more rapidly with fibrin glue, whereas granulation was more likely with PEG hydrogel sealant, which led to postoperative complications. Histological analysis indicated that PEG hydrogel sealant inhibited the normal tissue healing process and that outcomes were improved by the use of fibrin glue.
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Bai W, Wang X, Yuan W, Wang H, Wang Z. Application of PLGA/type I collagen/chitosan artificial composite dura mater in the treatment of dural injury. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2013; 24:2247-2254. [PMID: 23832452 DOI: 10.1007/s10856-013-4964-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 05/16/2013] [Indexed: 06/02/2023]
Abstract
To improve the safety of dura repair in neurological surgeries, a new poly (glycolide-co-lactide)/type I collagen/chitosan artificial composite dura mater was evaluated in a rabbit model with dura mater injury. Eighteen rabbits were randomized to 3 groups: rabbits with unclosed dura mater; rabbits with dura mater repaired by fascia and rabbits with dura mater repaired by the composite membrane. Modified combine behavior score were given at a series of time points and several cytokines were also determined to reflect the inflammatory conditions. Rabbits whose dura mater was repaired by composite membrane showed a similar recovery rate of neurological function and inflammatory condition compared with the rabbits whose dura mater was repaired by fascia. In addition, the rabbits with closed dura mater were better than ones with unclosed dura mater in the restore rate of neurological function as well as inflammatory reactions according to the statistical analysis. The new artificial membrane appears to be safe and efficient in the treatment of dura mater defect.
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Affiliation(s)
- Wanshan Bai
- Department of Orthopedic Surgery, Dongtai People's Hospital, No. 2 Kangfu West Road, Dongtai 224200, Jiangsu, China
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Nishimura K, Kimura T, Morita A. Watertight dural closure constructed with DuraSeal TM for bypass surgery. Neurol Med Chir (Tokyo) 2013; 52:521-4. [PMID: 22850505 DOI: 10.2176/nmc.52.521] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is a common procedure for the treatment of cerebral ischemia and is useful for cerebral aneurysms and tumors. The STA has to pass through the dura and the dura cannot be sutured tightly around the STA to prevent vessel narrowing, so subcutaneous cerebrospinal fluid (CSF) collection is common. This study analyzed the feasibility of using a synthetic dural sealant in the STA-MCA anastomosis to establish watertight closure. Twenty-four patients underwent STA-MCA anastomosis for cerebral ischemia or cerebral aneurysm. After creation of a standard STA-MCA anastomosis, the dura was reapproximated closely, leaving a small defect around the STA. Then, DuraSeal(TM) was sprayed over the dural defect, and a negative-pressure drain was positioned before closing the skin. Only two patients developed subcutaneous CSF collection, which was managed conservatively. The patency of the anastomosis was proven by magnetic resonance angiography in all cases, and no ischemic complication suggesting chemical spasm of the STA due to the sealant occurred. With DuraSeal(TM), watertight dural closure can be obtained easily and safely in bypass surgery.
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Affiliation(s)
- Kengo Nishimura
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
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Abstract
Nerve glue is an attractive alternative to sutures to improve the results of nerve repair. Improved axon alignment, reduced scar and inflammation, greater and faster reinnervation, and better functional results have been reported with the use of nerve glue. The different types of nerve glue and the evidence to support or oppose their use are reviewed. Although the ideal nerve glue has yet to be developed, fibrin sealants can be used as nerve glue in select clinical situations. Technology to allow suture-free nerve repair is one development that can potentially improve functional nerve recovery and the outcomes of upper extremity reconstruction.
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Affiliation(s)
- Raymond Tse
- Division of Plastic Surgery, Department of Surgery, University of Washington, WA 98105, USA.
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Neuman BJ, Radcliff K, Rihn J. Cauda equina syndrome after a TLIF resulting from postoperative expansion of a hydrogel dural sealant. Clin Orthop Relat Res 2012; 470:1640-5. [PMID: 21952743 PMCID: PMC3348307 DOI: 10.1007/s11999-011-2071-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND DuraSeal(™) (Coviden, Waltham, MA, USA), a hydrogel sealant, is primarily used as an adjunct to a dural repair. Its use has also been described to seal off an annulotomy after a transforaminal lumbar interbody fusion when recombinant human bone morphogenetic protein-2 (rhBMP-2) is used. This aids in the reduction of postoperative radiculitis caused by rhBMP-2. However, as a result of its hydrophilic properties, DuraSeal(™) has the potential to swell, which could lead to compression of the thecal sac. CASE DESCRIPTION We report a 57-year-old woman who developed cauda equina after a transforaminal lumbar 47 interbody fusion (TLIF) procedure in which the expansion of the DuraSeal(™) was believed to be the causative factor. The patient developed urinary retention, bowel incontinence, and paresthesias in the saddle region on postoperative Day 3. She underwent emergent exploration and decompression of the thecal sac. The gel-like DuraSeal™ material was causing significant compression of the thecal sac. LITERATURE REVIEW Multiple reports have documented that DuraSeal(™), used as an adjunct to dural repair, can swell leading to compression of the spinal cord and/or neural elements. Our case demonstrates the use of DuraSeal(™) both over a site of a dural repair and over an annulotomy site, through which a TLIF was performed, is associated with the risk of developing postoperative cauda equina syndrome as a result of swelling of the DuraSeal(™). CLINICAL RELEVANCE Those using DuraSeal™ to seal off the annulotomy after a TLIF procedure performed with rhBMP-2 should use the product with an understanding of the potential postoperative swelling of the product and resulting neurologic sequela, particularly if DuraSeal(™) is used concomitantly at the site of dural repair.
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Affiliation(s)
- Brian J. Neuman
- Thomas Jefferson University/Rothman Institute, 1015 Walnut Street, Curtis Building, Suite 801, Philadelphia, PA 19107 USA
| | - Kristen Radcliff
- Thomas Jefferson University/Rothman Institute, 1015 Walnut Street, Curtis Building, Suite 801, Philadelphia, PA 19107 USA
| | - Jeffery Rihn
- Thomas Jefferson University/Rothman Institute, 1015 Walnut Street, Curtis Building, Suite 801, Philadelphia, PA 19107 USA
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Tarapore PE, Mukherjee P, Mummaneni PV, Ames CP. The appearance of dural sealants under MR imaging. AJNR Am J Neuroradiol 2012; 33:1530-3. [PMID: 22460340 DOI: 10.3174/ajnr.a3078] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Dural sealants are an adjunct to obtain watertight closure after intradural procedures. This study aims to characterize the appearance on MR imaging of 3 commonly employed dural sealants: fibrin glue, PEGH, and BSAG. To this end, patients who underwent spinal intradural procedures that included the use of dural sealant during closure were identified retrospectively. Post-operative data on 15 patients, including complications such as pseudomeningocele formation and infection, were gathered. The appearance of dural sealants on follow-up MR imaging scans within 3 days of surgery was analyzed. Fifteen patients were identified (5 with fibrin glue, 5 with PEGH, and 5 with BSAG applied during closure) with appropriately timed post-operative MR imaging scans. All 3 substances were identifiable based on anatomic location and imaging characteristics on post-operative MR imaging in standard T1, T1 PGFS, and T2 FSE. Definite differentiation between CSF and fibrin glue or PEGH was not possible with the T1 or T1 PGFS, or with the T2 FSE. Differences in intensity between CSF and BSAG were also not significant on either T1 sequence, but they were statistically significant on the T2 FSE. All patients had an uneventful post-operative course, and no patients developed post-operative pseudomeningocele at 30 days. This study concludes that water-based dural sealants such as fibrin glue and PEGH are difficult to differentiate from CSF on standard T1, T1 PGFS and T2 FSE, while BSAG is easily recognized on the T2 FSE. Recognition of water-based sealants therefore requires communication between the neurosurgeon and the neuroradiologist to avoid post-operative misidentification.
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Affiliation(s)
- P E Tarapore
- Department of Neurological Surgery and Radiology, University of California, San Francisco, San Francisco, CA 94143, USA.
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Alizzi AM, Summers P, Boon VH, Tantiongco JP, Thompson T, Leslie BJ, Williams D, Steele M, Bidstrup BP, Diqer AMA. Reduction of Post-surgical Pericardial Adhesions Using a Pig Model. Heart Lung Circ 2012; 21:22-9. [DOI: 10.1016/j.hlc.2011.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 09/13/2011] [Accepted: 10/04/2011] [Indexed: 12/01/2022]
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Osbun JW, Ellenbogen RG, Chesnut RM, Chin LS, Connolly PJ, Cosgrove GR, Delashaw JB, Golfinos JG, Greenlee JDW, Haines SJ, Jallo J, Muizelaar JP, Nanda A, Shaffrey M, Shah MV, Tew JM, van Loveren HR, Weinand ME, White JA, Wilberger JE. A multicenter, single-blind, prospective randomized trial to evaluate the safety of a polyethylene glycol hydrogel (Duraseal Dural Sealant System) as a dural sealant in cranial surgery. World Neurosurg 2011; 78:498-504. [PMID: 22381303 DOI: 10.1016/j.wneu.2011.12.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 12/02/2011] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Incisional cerebrospinal fluid (CSF) leakage after cranial surgery is a significant cause of morbidity due to poor wound healing and infection, meningitis, and pseudomeningocele formation. Many common dural closure techniques, such as sutures, autologous grafts, gelatin or collagen sponges, and fibrin glues, are used to achieve watertight closure, although none are US Food and Drug Administration approved for this use. DuraSeal Dural Sealant System is a polyethylene glycol (PEG) hydrogel approved by the U.S. Food and Drug Administration for obtaining watertight dural closure when applied after standard dural suturing. This multicenter, prospective randomized study further evaluated the safety of a PEG hydrogel compared with common dural sealing techniques. METHODS A total of 237 patients undergoing elective cranial surgery at 17 institutions were randomized to dural closure augmented with the PEG hydrogel or a control "standard of care" dural sealing technique after Valsalva maneuver demonstrated an intraoperative nonwatertight dural closure. Data were collected on complications resulting in unplanned postoperative interventions or reoperations, surgical site infections, CSF leaks, and other neurological complications within 30 days. Surgeons also provided data on the ease of use of the dural sealing techniques, as well as preparation and application times. RESULTS The incidences of neurosurgical complications, surgical site infections, and CSF leaks were similar between treatment and control groups, with no statistically significant difference between the measures. In the PEG hydrogel group (n = 120), the incidence of neurosurgical complications was 5.8% (n = 7), the incidence of surgical site infections was 1.7% (n = 2), and the incidence of CSF leak was 0.8% (n = 1). In the control group (n = 117), the incidence of neurosurgical complications was 7.7% (n = 9), the incidence of surgical site infection was 2.6% (n = 3), and the incidence of CSF leak was 1.7% (n = 2). Sealant preparation time was less than 5 minutes in 96.6% of the PEG hydrogel group compared with 66.4% of controls (P < 0.001). The dural augmentation was applied in less than 1 minute in 85.7% of the PEG hydrogel group compared with 66.4% of the control group (P < 0.001). CONCLUSIONS The PEG hydrogel dural sealant used in this study has a similar safety profile to commonly used dural sealing techniques when used as dural closure augmentation in cranial surgery. The PEG hydrogel dural sealant demonstrated faster preparation and application times than other commonly used dural sealing techniques.
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Affiliation(s)
- Joshua W Osbun
- Department of Neurosurgery, The University of Washington and Harborview Medical Center, Seattle, WA, USA
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