Efficacy of TachoSil a fibrin-based haemostat in different fields of surgery- a systematic review

Endoscopic transsphenoidal surgery reconstruction using the fibrin sealant patch Tachosil®

INTRODUCTION

The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach.

MATERIALS AND METHODS

All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil® at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil® was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak.

RESULTS

A total of 52 primary procedures where Tachosil® was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% (n = 4), with all cases having had a Tachosil® overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil® patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil®.

CONCLUSIONS

We believe this to be the largest case series evaluating the endoscopic use of Tachosil® in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil® may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks.

Fibrin Sealant TISSEEL Lyo as a haemostatic agent in vascular surgery: Results of randomized, controlled, patient-blinded, multicentre clinical study in the Russian population

BACKGROUND

This phase III, controlled, patient-blinded, multicentre study in two parallel, equal-sized treatment groups compared the efficacy and safety of TISSEEL Lyo, fibrin sealant versus Manual Compression (MC) with surgical gauze pads for use as a haemostatic agent in patients who underwent vascular surgery in Russia.

METHODS

Adult patients, both genders, who received peripheral vascular expanded polytetrafluoroethylene conduits and had suture line bleeding after surgical haemostasis were enrolled. Patients were randomized to be treated with TISSEEL Lyo or MC. The bleeding needed additional treatment and had to be assessed as grade 1 or 2 bleeding according to the Validated Intraoperative Bleeding scale. The primary efficacy endpoint was the proportion of patients achieving haemostasis at 4 min after treatment application (T4) at the study suture line, which was maintained until the closure of the surgical wound. The secondary efficacy endpoints included the proportion of patients achieving haemostasis at 6 min (T6) and 10 min (T10) after treatment application at the study suture line, which was maintained until closure of the surgical wound, as well as the proportion of patients with intraoperative and postoperative rebleeding. Safety outcomes included incidence of adverse events (AEs), surgical site infections and graft occlusions.

RESULTS

A total of 110 patients were screened; 104 patients were randomized: (TISSEEL Lyo: 51 [49%] patients; MC: 53 [51%] patients). T4 haemostasis was achieved in 43 (84.3%) patients in the TISSEEL Lyo group and in 11 (20.8%) patients in the MC group (p < 0.001). Significantly more patients in TISSEEL Lyo group achieved the haemostasis at T6 (relative risk (RR) of achieving haemostasis 1.74 [95% confidence interval (CI) 1.37; 2.35]) and T10 (RR 1.18 [95% CI 1.05; 1.38]) versus MC. No one had intraoperative rebleeding. Postoperative rebleeding was reported only in one patient in the MC group. No treatment-emergent serious AEs (TESAEs) related to TISSEEL Lyo/MC, TESAEs leading to withdrawal and TESAEs leading to death were reported in patients during the study.

CONCLUSIONS

Data demonstrated TISSEEL Lyo had clinically and statistically significant superiority to MC as a haemostatic agent in vascular surgery at all measured time points including 4, 6 and 10 min and had proven to be safe.

Collagen fleece (Tachosil®) for treating testis torsion: A case report

BACKGROUND

Testicular torsion is an emergent disease in urology, and there has been discussion of the treatment of testicular torsion. Testicular decompression has been established as a critical treatment for testicular compartment syndrome (TCS), which occurs after detorsion in a patient who is diagnosed with testis torsion. Until now, testicular fasciotomy and incision of tunica albuginea with tunica vaginalis flap (TVF) graft have been suggested for decompression, and some studies about the efficacy of TVF were reported. However, this method is time consuming and needs meticulous technique, so other methods such as orchio-septopexy are suggested. The objective of this clinical case report was to propose new surgical method using collagen fleece (Tachosil^®) instead of tunica vagina flap.

CASE SUMMARY

A 5-year-old boy with scrotal pain visited our hospital 24 h after symptom onset. After history taking, physical examination, and scrotum ultrasonography, he was diagnosed with testis torsion. Emergency surgery was performed after diagnosis. Following the incision of scrotum and fasciotomy, we covered his tunica albuginea with collagen fleece called Tachosil^® instead of covering with TVF.

CONCLUSION

Short-term follow-up showed normal blood flow in testis without a TCS. This is the first case report of using Tachosil^® in testicular torsion surgery, and its advantages were already reported in other surgeries like Peyronie’s disease. Our case suggests this new technique is an appropriate method because of its advantages including its cost-effective and time-saving characteristics. The main limitation is the short follow-up, so more studies are needed to provide a high level of evidence about its efficacy and safety.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most frequent and potentially life-threatening complications following pancreatic surgery. Fibrin sealants have been used in some centres to reduce POPF rate. However, the use of fibrin sealant during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2020.

OBJECTIVES

To evaluate the benefits and harms of fibrin sealant use for the prevention of POPF (grade B or C) in people undergoing pancreatic surgery compared to no fibrin sealant use.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 09 March 2023, together with reference checking, citation searching, and contacting study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 14 RCTs, randomising 1989 participants, comparing fibrin sealant use versus no fibrin sealant use for different locations: stump closure reinforcement (eight trials), pancreatic anastomosis reinforcement (five trials), or main pancreatic duct occlusion (two trials). Six RCTs were carried out in single centres; two in dual centres; and six in multiple centres. One RCT was conducted in Australia; one in Austria; two in France; three in Italy; one in Japan; two in the Netherlands; two in South Korea; and two in the USA. The mean age of the participants ranged from 50.0 years to 66.5 years. All RCTs were at high risk of bias. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included eight RCTs involving 1119 participants: 559 were randomised to the fibrin sealant group and 560 to the control group after distal pancreatectomy. Fibrin sealant use may result in little to no difference in the rate of POPF (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.73 to 1.21; 5 studies, 1002 participants; low-certainty evidence) and overall postoperative morbidity (RR 1.20, 95% CI 0.98 to 1.48; 4 studies, 893 participants; low-certainty evidence). After fibrin sealant use, approximately 199 people (155 to 256 people) out of 1000 developed POPF compared with 212 people out of 1000 when no fibrin sealant was used. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto odds ratio (OR) 0.39, 95% CI 0.12 to 1.29; 7 studies, 1051 participants; very low-certainty evidence) and total length of hospital stay (mean difference (MD) 0.99 days, 95% CI -1.83 to 3.82; 2 studies, 371 participants; very low-certainty evidence). Fibrin sealant use may reduce the reoperation rate slightly (RR 0.40, 95% CI 0.18 to 0.90; 3 studies, 623 participants; low-certainty evidence). Serious adverse events were reported in five studies (732 participants), and there were no serious adverse events related to fibrin sealant use (low-certainty evidence). The studies did not report quality of life or cost-effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included five RCTs involving 519 participants: 248 were randomised to the fibrin sealant group and 271 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF (RR 1.34, 95% CI 0.72 to 2.48; 3 studies, 323 participants; very low-certainty evidence), postoperative mortality (Peto OR 0.24, 95% CI 0.05 to 1.06; 5 studies, 517 participants; very low-certainty evidence), reoperation rate (RR 0.74, 95% CI 0.33 to 1.66; 3 studies, 323 participants; very low-certainty evidence), and total hospital cost (MD -1489.00 US dollars, 95% CI -3256.08 to 278.08; 1 study, 124 participants; very low-certainty evidence). After fibrin sealant use, approximately 130 people (70 to 240 people) out of 1000 developed POPF compared with 97 people out of 1000 when no fibrin sealant was used. Fibrin sealant use may result in little to no difference both in overall postoperative morbidity (RR 1.02, 95% CI 0.87 to 1.19; 4 studies, 447 participants; low-certainty evidence) and in total length of hospital stay (MD -0.33 days, 95% CI -2.30 to 1.63; 4 studies, 447 participants; low-certainty evidence). Serious adverse events were reported in two studies (194 participants), and there were no serious adverse events related to fibrin sealant use (very low-certainty evidence). The studies did not report quality of life. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two RCTs involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto OR 1.41, 95% CI 0.63 to 3.13; 2 studies, 351 participants; very low-certainty evidence), overall postoperative morbidity (RR 1.16, 95% CI 0.67 to 2.02; 2 studies, 351 participants; very low-certainty evidence), and reoperation rate (RR 0.85, 95% CI 0.52 to 1.41; 2 studies, 351 participants; very low-certainty evidence). Fibrin sealant use may result in little to no difference in the total length of hospital stay (median 16 to 17 days versus 17 days; 2 studies, 351 participants; low-certainty evidence). Serious adverse events were reported in one study (169 participants; low-certainty evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report POPF, quality of life, or cost-effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealant use may result in little to no difference in the rate of POPF in people undergoing distal pancreatectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF in people undergoing pancreaticoduodenectomy. The effect of fibrin sealant use on postoperative mortality is uncertain in people undergoing either distal pancreatectomy or pancreaticoduodenectomy.

An autologous blood-derived patch as a hemostatic agent: evidence from thromboelastography experiments and a porcine liver punch biopsy model

Perioperative bleeding is a common complication in surgeries that increases morbidity, risk of mortality, and leads to increased socioeconomic costs. In this study we investigated a blood-derived autologous combined leukocyte, platelet, and fibrin patch as a new means of activating coagulation and maintaining hemostasis in a surgical setting. We evaluated the effects of an extract derived from the patch on the clotting of human blood in vitro, using thromboelastography (TEG). The autologous blood-derived patch activated hemostasis, seen as a reduced mean activation time compared to both non-activated controls, kaolin-activated samples, and fibrinogen/thrombin-patch-activated samples. The accelerated clotting was reproducible and did not compromise the quality or stability of the resulting blood clot. We also evaluated the patch in vivo in a porcine liver punch biopsy model. In this surgical model we saw 100% effective hemostasis and a significant reduction of the time-to-hemostasis, when compared to controls. These results were comparable to the hemostatic properties of a commercially available, xenogeneic fibrinogen/thrombin patch. Our findings suggest clinical potential for the autologous blood-derived patch as a hemostatic agent.

A calcium and zinc composite alginate hydrogel for pre-hospital hemostasis and wound care

We developed, characterized, and examined the hemostatic potential of sodium alginate-based Ca²⁺ and Zn²⁺ composite hydrogel (SA-CZ). SA-CZ hydrogel showed substantial in-vitro efficacy, as observed by the significant reduction in coagulation time with better blood coagulation index (BCI) and no evident hemolysis in human blood. SA-CZ significantly reduced bleeding time (≈60 %) and mean blood loss (≈65 %) in the tail bleeding and liver incision in the mice hemorrhage model (p ≤ 0.001). SA-CZ also showed enhanced cellular migration (1.58-fold) in-vitro and improved wound closure (≈70 %) as compared with betadine (≈38 %) and saline (≈34 %) at the 7th-day post-wound creation in-vivo (p < 0.005). Subcutaneous implantation and intra-venous gamma-scintigraphy of hydrogel revealed ample body clearance and non-considerable accumulation in any vital organ, proving its non-thromboembolic nature. Overall, SA-CZ showed good biocompatibility along with efficient hemostasis and wound healing qualities, making it suitable as a safe and effective aid for bleeding wounds.

A new hemostatic agent composed of Zn2+-enriched Ca2+ alginate activates vascular endothelial cells in vitro and promotes tissue repair in vivo

To control capillary bleeding, surgeons may use absorbable hemostatic agents, such as Surgicel® and TachoSil®. Due to their slow resorption, their persistence in situ can have a negative impact on tissue repair in the resected organ. To avoid complications and obtain a hemostatic agent that promotes tissue repair, a zinc-supplemented calcium alginate compress was developed: HEMO-IONIC®. This compress is non-absorbable and is therefore removed once hemostasis has been achieved. After demonstrating the hemostatic efficacy and stability of the blood clot obtained with HEMO-IONIC, the impact of Surgicel, TachoSil, and HEMO-IONIC on cell activation and tissue repair were compared (i) in vitro on endothelial cells, which are essential to tissue repair, and (ii) in vivo in a mouse skin excision model. In vitro, only HEMO-IONIC maintained the phenotypic and functional properties of endothelial cells and induced their migration. In comparison, Surgicel was found to be highly cytotoxic, and TachoSil inhibited endothelial cell migration. In vivo, only HEMO-IONIC increased angiogenesis, the recruitment of cells essential to tissue repair (macrophages, fibroblasts, and epithelial cells), and accelerated maturation of the extracellular matrix. These results demonstrate that a zinc-supplemented calcium alginate, HEMO-IONIC, applied for 10 min at the end of surgery and then removed has a long-term positive effect on all phases of tissue repair.

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A new Zn2+ enriched Ca2+ alginate hemostatic agent, HEMO-IONIC, has been developed.

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Non-absorbable, it achieves hemostasis with no foreign bodies left in the wound.

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HEMO-IONIC stimulates endothelial cell migration in vitro and angiogenesis in vivo.

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HEMO-IONIC, removed 10 min after application, promotes all stages of tissue repair.

Collagen-bound fibrin sealant (TachoSil®) for dural closure in cranial surgery: single-centre comparative cohort study and systematic review of the literature

Cerebrospinal fluid (CSF) leakage is a well-known complication of craniotomies and there are several dural closure techniques. One commonly used commercial product as adjunct for dural closure is the collagen-bound fibrin sealant TachoSil®. We analysed whether the addition of TachoSil has beneficial effects on postoperative complications and outcomes. Our prospective, institutional database was retrospectively queried, and 662 patients undergoing craniotomy were included. Three hundred fifty-two were treated with dural suture alone, and in 310, TachoSil was added after primary suture. Our primary endpoint was the rate of postoperative complications associated with CSF leakage. Secondary endpoints included functional, disability and neurological outcome. Systematic review according to PRISMA guidelines was performed to identify studies comparing primary dural closure with and without additional sealants. Postoperative complications associated with CSF leakage occurred in 24 (7.74%) and 28 (7.95%) procedures with or without TachoSil, respectively (p = 0.960). Multivariate analysis confirmed no significant differences in complication rate between the two groups (aOR 0.97, 95% CI 0.53–1.80, p = 0.930). There were no significant disparities in postoperative functional, disability or neurological scores. The systematic review identified 661 and included 8 studies in the qualitative synthesis. None showed a significant superiority of additional sealants over standard technique regarding complications, rates of revision surgery or outcome. According to our findings, we summarize that routinary use of TachoSil and similar products as adjuncts to primary dural sutures after intracranial surgical procedures is safe but without clear advantage in complication avoidance or outcome. Future studies should investigate whether their use is beneficial in high-risk settings.

Effectiveness of the Fibrinogen-Thrombin-Impregnated Collagen Patch in the Prevention of Postoperative Complications after Parotidectomy: A Single-Blinded, Randomized Controlled Study

We investigated whether a fibrinogen-thrombin collagen sponge patch reduces postoperative complications of parotid gland surgery. This single-blinded, randomized controlled study included 165 patients who underwent parotid surgery for benign tumors (2018–2019) at a tertiary center. Primary outcomes were postoperative drain amount, days until drain removal, and discharge. Patients were scheduled for follow-up at 1 and 4 weeks, and 3 months after surgery. Complications including surgical site infection, pain, seroma, sialocele, salivary fistula, facial nerve palsy, Frey’s syndrome with subjective symptoms, and facial asymmetry were analyzed. After identifying confounding variables, multivariate approaches were used. Histologic analysis was performed in a mouse model of salivary gland surgery. In total, 162 patients (77, fibrinogen-thrombin collagen patch group; 85, controls) were included, with no significant between-group differences other than resected tissue. Among postoperative total drain amount and days until drain removal and discharge, the only postoperative total drain was significantly lower in the patch group than in the control group in the adjusted model. Additionally, although validation through robust trials with longer follow-up is needed, we found the potential benefit of the fibrinogen patch on Frey’s syndrome and facial asymmetry. In conclusion, fibrinogen-thrombin-impregnated collagen patches in parotidectomy can reduce postoperative drainage and improve outcomes.

MRI appearance of adjunct surgical material used in spine surgery

BACKGROUND CONTEXT

Early postoperative MR images are frequently necessary after spine surgery. The appearance of commonly used adjunct hemostatic agents and dural sealants in MR images has not been systematically evaluated.

PURPOSE

The purpose of this experimental study was to systematically analyze and describe the characteristics of the most commonly applied hemostatic agents and dural sealants in spine surgery on early postoperative MR images.

STUDY DESIGN

Cadaver Study METHODS: Four commonly applied dural sealants (Duraseal, Bioglue, Tachosil, Tisseel) and five commonly used hemostatic agents (Surgiflo, Bonewax, , Spongostan, Gelfoam, Avitene) were investigated. The experimental setting involved a human cadaver where a standard left-sided laminotomy was performed on nine levels of the thoracolumbar spine, and the materials were separately applied and mixed with fresh blood or water for hemostatic and dural sealants, respectively. The cadaver model was scanned at a 3 Tesla MRI and the imaging findings for all materials were compared to the surrounding tissue and systematically reported.

RESULTS

All investigated dural sealants and hemostatic agents were distinguishable from the surrounding tissue on MR images with different appearances on the MR sequences. A detailed atlas for the identification of the materials in postoperative spine MRI was established.

CONCLUSION

Commonly used hemostatic agents and dural sealants can be successfully identified on early postoperative spine MRI.

CLINICAL SIGNIFICANCE

Knowledge about MRI appearances of commonly used adjunct surgical materials helps in interpretation of postoperative imaging and supports clinical decision making.

A novel hybrid technique for the repair of an atrioesophageal fistula post-atrial radiofrequency ablation

An atrioesophageal fistula is an uncommon complication of atrial ablation with a mortality rate of 40-100%. Uniform treatment guidelines have yet to be established. Herein, we illustrate the successful surgical management of an atrioesophageal fistula, avoiding the need for an oesophageal surgical intervention by sealing and clipping of the oesophagus. This novel single-step hybrid approach combining cardiac surgical and gastroenterological techniques provides a less aggressive strategy with potentially a more favourable prognosis.

The Contribution of a Collagen Patch Coated With Fibrin Glue in Sealing Upper Gastrointestinal Defects: An Experimental Study

BACKGROUND/AIM

We aimed to evaluate the safety and efficacy of sealing primary upper gastrointestinal (GI) perforations with a collagen patch coated with fibrin glue (Tachosil^®).

MATERIALS AND METHODS

Thirty New Zealand rabbits were used in this study. An iatrogenic gastric perforation was created, and primary repair was performed on the control group. Tachosil^®, without suturing the deficit, was used in the intervention group.

RESULTS

Leakage was observed in 3 (20%) and 2 rabbits (13.3%) in the control and intervention group, respectively; however, the difference was not statistically significant (p=0.62). Moreover, adhesions formed in 10/15 and all rabbits in the intervention and control group, respectively (p=0.014); however, based on the Zuhlke adhesion's classification, there was no statistically significant difference between the two groups.

CONCLUSION

A collagen patch coated with fibrin glue is not a replacement but can be considered a safe option for the reinforcement of suturing, preventing leakages in the upper GI tract.

Randomized clinical trial and meta-analysis of the impact of a fibrin sealant patch on pancreatic fistula after distal pancreatectomy: CPR trial

BACKGROUND

Postoperative pancreatic fistula (POPF) remains the main cause of morbidity in patients after distal pancreatectomy. The objective of this study was to investigate whether an absorbable fibrin sealant patch could prevent POPF after distal pancreatectomy.

METHODS

A multicentre, patient-blinded, parallel-group randomized superiority trial was performed in seven Dutch hospitals. Allocation was done using a computer-generated randomization list with a 1 : 1 allocation ratio and concealed varying permuted block sizes. Pancreatic stump closure with a fibrin patch was compared with standard treatment in patients undergoing distal pancreatectomy. The primary endpoint was the development of grade B/C POPF. A systematic review and meta-analysis was performed which combined the present findings with all available evidence.

RESULTS

Between October 2010 and August 2017, 247 patients were enrolled. Fifty-four patients (22.2 per cent) developed a POPF, 25 of 125 patients in the patch group versus 29 of 122 in the control group (20.0 versus 23.8 per cent; P = 0·539). No related adverse effects were observed. In the meta-analysis, no significant difference was seen between the patch and control groups (19.7 versus 22.0 per cent; odds ratio 0.89, 95 per cent c.i. 0.60 to 1.32; P = 0·556).

CONCLUSION

Application of a fibrin patch to the pancreatic stump does not reduce the incidence of POPF in distal pancreatectomy. Future studies should focus on alternative fistula mitigation strategies, considering pancreatic neck thickness and duct size as risk factors. Trial registration number NL5876 (Netherlands Trial Registry).

Corrective surgery using a gridiron incision for abdominal pain caused by a folded ovary in the third trimester of pregnancy

Introduction

Sonography and magnetic resonance imaging (MRI) may be helpful to obtain an accurate diagnosis of acute abdominal pain in pregnancy. Adnexal torsion presenting in the first or second trimester can be confirmed and treated through laparoscopic surgery; however laparoscopic surgery in the third trimester can be difficult owing to the large uterus, and a gridiron incision can be useful.

Case Report/Case presentation

An 18-year-old gravida 1, para 0 (G1P0) woman at 30 + 4 weeks of gestation presented with sudden-onset cyclic pain in the right lower quadrant. Abdominal ultrasonography showed a normal appendix, and MRI showed a normal appendix and normal ovaries. The patient’s prominent tender point was marked and compared with the MR images, which confirmed the mark as the position of the right ovary. Laparotomy was performed through a gridiron incision, and a folded right ovary was identified. The ovary was unfolded, and TachoSil® and Surgicel® were used to maintain the unfolded position. The patient’s pain resolved, and her postoperative course was uneventful. She delivered a healthy, 2540-g male baby at 35 weeks’ gestation.

Discussion/Conclusions

A gridiron incision was useful to treat a folded ovary in the third trimester and to evaluate the adnexa and minimize uterine manipulation.

Human fibrinogen and thrombin patch for extraluminal protection of intestinal anastomosis

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

Hemostatic agents for prehospital hemorrhage control: a narrative review

Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma. A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival. A literature search was performed through PubMed, Scopus, and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents, prehospital, battlefield or combat dressings, and prehospital hemostatic resuscitation, followed by cross-reference searching. Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted. Based on these findings, this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings. These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action. Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants have been used in some centers to reduce postoperative pancreatic fistula. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2018.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched trial registers and the following biomedical databases: the Cochrane Library (2019, Issue 2), MEDLINE (1946 to 13 March2019), Embase (1980 to 11 March 2019), Science Citation Index Expanded (1900 to 13 March 2019), and Chinese Biomedical Literature Database (CBM) (1978 to 13 March 2019).

SELECTION CRITERIA

We included all randomised controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included 12 studies involving 1604 participants in the review. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included seven studies involving 860 participants: 428 were randomised to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence) or length of hospital stay (MD 0.99 days, 95% CI -1.83 to 3.82; 371 participants; two studies; very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included four studies involving 393 participants: 186 were randomised to the fibrin sealant group and 207 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (16.7% versus 11.7%; RR 1.14, 95% CI 0.28 to 4.69; 199 participants; two studies; very low-quality evidence). We are uncertain whether fibrin sealants reduce postoperative mortality (0.5% versus 2.4%; Peto OR 0.26, 95% CI 0.05 to 1.32; 393 participants; four studies; low-quality evidence) or length of hospital stay (MD 0.01 days, 95% CI -3.91 to 3.94; 323 participants; three studies; very low-quality evidence). There is probably little or no difference in overall postoperative morbidity (52.6% versus 50.3%; RR 1.04, 95% CI 0.87 to 1.24; 323 participants; three studies; moderate-quality evidence) between the groups. We are uncertain whether fibrin sealants reduce reoperation rate (5.2% versus 7.7%; RR 0.74, 95% CI 0.33 to 1.66; 323 participants; three studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two studies involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (median 16 to 17 days versus 17 days; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study (169 participants; low-quality evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.

Wound healing effect of regenerated oxidized cellulose versus fibrin sealant patch: An in vivo study

Background

Topical hemostatic agents are used when ligation, electrocauterization, or other conventional hemostatic methods are impractical. Because a hemostatic agent is a foreign body, it can cause foreign body reactions, inflammation, and infections that can interfere with the wound healing process. Therefore, we should select hemostatic agents after considering their effects on wound healing. Here, we compared the effects of hemostatic agents on wound healing in a rectus abdominis muscle defect in rats.

Methods

Twelve Sprague Dawley rats were subjected to creation of a 6 × 6 mm defect in the rectus abdominis muscle and divided into four groups: control group; group A, Tachosil fibrin sealant patch; group B, Surgicel Fibrillar oxidized regenerated cellulose; and group C, Surgicel Snow oxidized regenerated cellulose. For the histologic analysis, biopsies were performed on the 3rd, 7th, and 27th days.

Results

The foreign body reaction was the weakest in group A and most significant in group C. The inflammatory cell infiltration was the weakest in group A and similar in groups B and C. Muscle regeneration differed among periods. The rats in group A were the most active initially, while those in group C showed prolonged activity.

Conclusion

Tachosil and Surgicel administration increased inflammation via foreign body reactions, but the overall wound healing process was not significantly affected. The increased inflammation in the Surgicel groups was due to a low pH. We recommend using Tachosil, because it results in less intense foreign body reactions than Surgicel and faster wound healing due to the fibrin action.

Comparison of the sonographic findings in laparoscopic cholecystostomy with and without hemostatic agent on 45-day follow-up of patients attending hospital

Introduction:

Cholelithiasis is one of the most prevalent pathological conditions, and elective laparoscopic cholecystostomy with and without hemostatic agent (HA) is the therapeutic approach to its treatment. This research study aimed to compare the sonographic findings of patients who underwent cholecystostomy with and without HA use.

Materials and Methods:

This cross-sectional, descriptive-analysis study was conducted by available nonprobability sampling technique, and according to Cochran Formula, 144 patients, who underwent laparoscopic cholecystostomy, were recruited and divided into two groups including a group of 85 patients with HA use and a group of 59 patients without HA use. Patients in each group had sonography on discharge date and 15, 30, and 45 days after the surgery. Data were collected and entered in SPSS-24 software; meanwhile, descriptive statistics was used to analyze Chi-square test, Fisher's exact test, and Friedman and Wilcoxon nonparametric test.

Findings:

The results of the study showed that the presence of echogenic mass with reverberation artifact (abscess mucosa) on 15- and 30-day follow-up sonography of patients, who underwent laparoscopic cholecystostomy, were significantly higher in patients with HA than in the group without HA (P < 0.05), and on 45-day follow-up sonography, there was no significant correlation regarding the presence of echogenic mass with reverberation artifact (abscess mucosa) and fluid in the two groups (P > 0.05). Besides, HA density significantly decreases in individuals over time (P < 0.05); however, there was no significant differences between HA reduction rate and gender (P > 0.05).

Conclusion:

These findings might be the indication of HA agents’ effect on surgical operations and their resemblance to abscess. Due to the possibility of temporary immune responses to HA, as an external object, it is necessary, in vital pathologies, to pay close attention to what differentiates the normal imaging appearance in follow-up sonography.

Use of a fibrinogen-thrombin sponge in rhinoplasty

BACKGROUND

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

[Use of topical haemostatic agents in cardiovascular surgery]

The problem of haemostasis in cardiovascular surgery is of current concern. Recent trends are towards increased use of topical haemostatic agents. Tachocomb has been used for more than 30 years in abdominal surgery and oncology. The purpose of the present publication is to analyse the literature data and formulate the indications for the use of Tachocomb in cardiovascular surgery. Multicenter randomized and local studies have demonstrated efficacy of Tachocomb in treatment of surgical haemorrhage in operations on the heart, thoracic aorta, carotid arteries and lower-limb arteries, resulting in significantly decreased time to achieve haemostasis, decreased volume of blood loss and haemotrasfusion, as well as reduced frequency of complications. Also shown was economic efficacy, including a shortened length of patients' hospital stay. This is followed by describing a wide spectrum of examples of alternative use of Tachocomb, including its use for seamless closure of defects of cardiac chamber walls, aero- and lymphostasis, prevention of formation of commissures. Convincing experimental and clinical results make it possible to formulate a series of indications for the use of Tachocomb in cardiovascular surgery.

Nanostructured fibrin agarose hydrogel as a novel haemostatic agent

Blood loss remains a major concern during surgery and can increase the morbidity of the intervention. The use of topical haemostatic agents to overcome this issue therefore becomes necessary. Fibrin sealants are promising haemostatic agents due to their capacity to promote coagulation, but their effectiveness and applicability need to be improved. We have compared the haemostatic efficacy of a novel nanostructured fibrin‐agarose hydrogel patch, with (c‐NFAH) or without cells (a‐NFAH), against two commercially available haemostatic agents in a rat model of hepatic resection. Hepatic resections were performed by making short or long incisions (mild or severe model, respectively), and haemostatic agents were applied to evaluate time to haemostasis, presence of haematoma, post‐operative adhesions to adjacent tissues, and inflammation factors. We found a significantly higher haemostatic success rate (time to haemostasis) with a‐NFAH than with other commercial haemostatic agents. Furthermore, other relevant outcomes investigated were also improved in the a‐NFAH group, including no presence of haematoma, lower adhesions, and lower grades of haemorrhage, inflammation, and necrosis in histological analysis. Overall, these findings identify a‐NFAH as a promising haemostatic agent in liver resection and likely in a range of surgical procedures.

Agentes hemostáticos tópicos em cirurgia: revisão e perspectivas

RESUMO A hemostasia tem papel crítico e importância fundamental em todos os procedimentos cirúrgicos. Seu manejo possui diversos pontos chaves, que se iniciam por boa técnica operatória e adequado suporte anestésico. Determinadas situações, como hemorragias graves resultantes de trauma penetrante, por exemplo, não dependem exclusivamente do controle da equipe cirúrgica e necessitam do apoio de novas soluções que diminuam ou controlem a hemorragia. Desde os tempos antigos, um marco da medicina é atuar no controle da hemorragia e, mais recentemente, na facilitação da hemostasia pela aplicação de agentes tópicos, seja por compressão manual ou agentes modernos. Na última década, o número de diferentes agentes hemostáticos tópicos cresceu drasticamente. Para que o cirurgião moderno escolha o agente correto no momento correto, é essencial que conheça o mecanismo de ação, entenda a eficácia e os possíveis efeitos adversos relacionados a cada agente. Assim, a grande variedade de hemostáticos tópicos, somada à ausência de um artigo de revisão na literatura nacional sobre este tópico, nos estimulou a elaborar este manuscrito. Aqui relatamos uma revisão detalhada sobre os agentes hemostáticos tópicos mais comumente utilizados nas especialidades cirúrgicas.

Functional outcomes after glossectomies: Pilot study on use of a thrombin-fibrinogen biosponge (TachoSil)

OBJECTIVE

The aim of this study was to investigate whether the use of a thrombin-fibrinogen biosponge (TachoSil) has any advantage in tongue healing.

STUDY DESIGN

A retrospective study with 30 patients treated with partial glossectomy (below half a tongue) was designed. We compared the results from a group using the biosponge (n =15 patients) and a control group (n = 15). Variables taken into consideration were bolus clearance, frenulum flexibility, and oral transit time. With these parameters, we formulated a "tongue remaining functional" (TRF) scale to assess tongue functionality after the surgery. We also evaluated long-term quality of life by using the Functional Intraoral Glasgow Scale (FIGS).

RESULTS

In this study, TRF score, bolus clearance, oral transit time, and frenulum flexibility were significantly improved in the biosponge group. However, there were no differences between the 2 groups in the FIGS scores.

CONCLUSIONS

The use of the biosponge in this pilot study showed positive long-term effects in lingual healing and functionality after partial glossectomies.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2016.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched trial registers and the following biomedical databases: the Cochrane Library (2018, Issue 4), MEDLINE (1946 to 12 April 2018), Embase (1980 to 12 April 2018), Science Citation Index Expanded (1900 to 12 April 2018), and Chinese Biomedical Literature Database (CBM) (1978 to 12 April 2018).

SELECTION CRITERIA

We included all randomized controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included 11 studies involving 1462 participants in the review.Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomyWe included seven studies involving 860 participants: 428 were randomized to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence). There is probably little or no difference in length of hospital stay between the groups (12.1 days versus 11.4 days; MD 0.32 days, 95% CI -1.06 to 1.70; 755 participants; four studies; moderate-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomyWe included three studies involving 251 participants: 115 were randomized to the fibrin sealant group and 136 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (1.6% versus 6.2%; RR 0.25, 95% CI 0.01 to 5.06; 57 participants; one study; very low-quality evidence). Fibrin sealants may lead to little or no difference in postoperative mortality (0.1% versus 0.7%; Peto OR 0.15, 95% CI 0.00 to 7.76; 251 participants; three studies; low-quality evidence) or length of hospital stay (12.8 days versus 14.8 days; MD -1.58 days, 95% CI -3.96 to 0.81; 181 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (33.7% versus 34.7%; RR 0.97, 95% CI 0.65 to 1.45; 181 participants; two studies; very low-quality evidence), or reoperation rate (7.6% versus 9.2%; RR 0.83, 95% CI 0.33 to 2.11; 181 participants; two studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomyWe included two studies involving 351 participants: 188 were randomized to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (17.0 days versus 16.5 days; MD 0.58 days, 95% CI -5.74 to 6.89; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study: more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.

Impact of a Surgical Sealing Patch on Lymphatic Drainage After Axillary Dissection for Breast Cancer: The SAKK 23/13 Multicenter Randomized Phase III Trial

BACKGROUND

Several studies and a meta-analysis showed that fibrin sealant patches reduced lymphatic drainage after various lymphadenectomy procedures. Our goal was to investigate the impact of these patches on drainage after axillary dissection for breast cancer.

METHODS

In a phase III superiority trial, we randomized patients undergoing breast-conserving surgery at 14 Swiss sites to receive versus not receive three large TachoSil^® patches in the dissected axilla. Axillary drains were inserted in all patients. Patients and investigators assessing outcomes were blinded to group assignment. The primary endpoint was total volume of drainage.

RESULTS

Between March 2015 and December 2016, 142 patients were randomized (72 with TachoSil^® and 70 without). Mean total volume of drainage in the control group was 703 ml [95% confidence interval (CI) 512-895 ml]. Application of TachoSil^® did not significantly reduce the total volume of axillary drainage [mean difference (MD) -110 ml, 95% CI -316 to 94, p = 0.30]. A total of eight secondary endpoints related to drainage, morbidity, and quality of life were not improved by use of TachoSil^®. The mean total cost per patient did not differ significantly between the groups [34,253 Swiss Francs (95% CI 32,625-35,880) with TachoSil^® and 33,365 Swiss Francs (95% CI 31,771-34,961) without, p = 0.584]. In the TachoSil^® group, length of stay was longer (MD 1 day, 95% CI 0.3-1.7, p = 0.009), and improvement of pain was faster, although the latter difference was not significant [2 days (95% CI 1-4) vs. 5.5 days (95% CI 2-11); p = 0.2].

CONCLUSIONS

TachoSil^® reduced drainage after axillary dissection for breast cancer neither significantly nor relevantly.

Efficacy of fibrin-sealants in reducing biliary leakage following laparoscopic common bile duct exploration

INTRODUCTION

In spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy.

METHODS

We report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group.

RESULTS

Thirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P=.338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P=.020), which was a protective factor with an odds ratio of 10.5.

CONCLUSION

Fibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE.

Potent Hemostatic Efficacy of a Novel Recombinant Fibrin Sealant Patch (KTF-374) in Rabbit Bleeding Models

PURPOSE

Fibrin sealants are used for hemostasis during surgery. Commercially available fibrin sealants are made of materials of human or animal origin. We developed a novel recombinant fibrin sealant patch (KTF-374) that has thin and flexible properties. This study evaluated the hemostatic efficacy of KTF-374 for various patterns of bleeding in rabbits, as compared with that of the existing fibrin-coated collagen fleece (FCCF).

MATERIALS AND METHODS

Test hemostats used were KTF-374 and FCCF. Laparotomy was performed under general anesthesia in rabbits. We created wounds in the liver, caudal vena cava, and ventral aorta under anticoagulating conditions with heparin. Test hemostats were then applied to the wound site and compressed manually for 3 min. Hemostatic efficacy was evaluated with the success rate of hemostasis at 3 min.

RESULTS

In all bleeding models, the success rate of hemostasis was significantly higher with KTF-374 than FCCF. The hemostatic success rate of KTF-374 and FCCF was 100% vs. 25% (p = .007) in the partial hepatectomy model (n = 8); 100% vs. 12.5% (p = .001) in the caudal vena cava resection model (n = 8); and 100% vs. 25% (p = .004) in the ventral aortic puncture model (n = 8). The wound site could clearly be recognized through the patch after the application of KTF-374 but not FCCF.

CONCLUSIONS

These results suggest that KTF-374 possesses more potent hemostatic properties than FCCF for various patterns of bleeding. KTF-374 is a promising hemostat due to its potent efficacy and good visibility of the wound site through the patch.

Use of fibrinogen and thrombin sponge in pediatric split liver transplantation

Purpose:

To analyze the use of this sponge in pediatric patients undergoing split-liver transplantation.

Methods:

Retrospective study, including 35 pediatric patients undergoing split-liver transplantation, divided into two groups according to the use of the sponge: 18 patients in Group A (no sponge) and 17 in Group B (with sponge).

Results:

The characteristics of recipients and donors were similar. We observed greater number of reoperation due to bleeding in the wound area in Group A (10 patients - 55.5%) than in Group B (3 patients - 17.6%); p = 0.035. The median volume of red blood cells transfused in Group A was significantly higher (73.4 ± 102.38 mL/kg) than that in Group B (35.1 ± 41.67 mL/kg); p = 0.048. Regarding bile leak there was no statistical difference.

Conclusion:

The use of the human fibrinogen and thrombin sponge, required lower volume of red blood cell transfusion and presented lower reoperation rates due to bleeding in the wound area.

Developing a tissue glue by engineering the adhesive and hemostatic properties of metal oxide nanoparticles

Despite decades of research, wound complications remain a major cause of postoperative mortality, especially in the face of multiple comorbidities. Addressing the issue of anastomotic leakages and impaired wound healing from a new angle is of great interest with the prospect of having direct impact on patient outcome. Recently, aqueous suspensions of silica and iron oxide nanoparticles have been employed to connect biological tissue by serving as an adhesive layer eventually leading to macroscopic gluing of tissue. In this work, we explore the prospects of this effect by introducing bioactive tissue adhesives composed of nanoparticles produced via scalable and sterile flame spray pyrolysis. We investigate six different metal oxides on cytocompatibility, hemostatic activity and adhesive properties in a small intestine lap joint model. While bioglass nanoparticles show exceptionally strong procoagulant and adhesive properties, the cell membrane integrity is impaired at high particle concentrations. Interestingly, when bioglass is combined with ceria, a material that has well-documented cytoprotective effects, the resulting hybrid particles exhibit the same beneficiary effects as bioglass while featuring superior cytocompatibility. Taken together, we demonstrate highly modular synthesis of nanoparticles expressing adhesive properties in conjunction with tailored bioactivity. Such bioactive nanoparticles as adhesion nuclei in wound healing have a wide range of potential applications in surgical wound care and regenerative medicine.

Fibrinogen-Based Collagen Fleece Graft Myringoplasty for Traumatic Tympanic Membrane Perforation

Background and Objectives

The aim of this study was to investigate how fibrinogen-based collagen fleece (Tachocomb®) graft myringoplasty (FCGM), performed under microscopic guidance, improves both hearing and tympanic membrane tissue repair in patients with traumatic tympanic membrane perforation (TMP).

Subjects and Methods

Between August 2009 and March 2015, a total of 52 patients with traumatic TMP visited the department of otorhinolaryngology at a secondary medical center. Twenty-nine of these underwent FCGM under microscopic guidance in our outpatient clinic. For each patient, we recorded the location and size of the perforation, the time elapsed from the onset of TMP until the myringoplasty, and the hearing level both before and after myringoplasty.

Results

The TMP closed completely in all cases (29 of 29 patients). After myringoplasty, the postoperative air-bone gap (ABG) differed significantly from the preoperative ABG. Three of the 29 patients (10.3%) experienced complications. Specifically, 2 presented with otorrhea after FCGM, but conservative management led to improvement without recurrence of perforation. One patient showed delayed facial palsy 1 week after the procedure. The condition of this patient also improved and the palsy was not permanent.

Conclusions

FCGM may be an effective treatment option in case of traumatic TMP. The procedure requires no hospitalization, and can be used to avoid traditional tympanoplasty.

PEDIATRIC LIVER TRANSPLANTATION WITH EX-SITU LIVER TRANSECTION AND THE APPLICATION OF THE HUMAN FIBRINOGEN AND THROMBIN SPONGE IN THE WOUND AREA

Background

Surgical strategy to increase the number of liver transplants in the pediatric population is the ex-situ liver transection (reduction or split). However, it is associated with complications such as hemorrhage and leaks. The human fibrinogen and thrombin sponge is useful for improving hemostasis in liver surgery.

Aim

Compare pediatric liver transplants with ex-situ liver transection (reduction or split) with or without the human fibrinogen and thrombin sponge.

Methods

Was performed a prospective analysis of 21 patients submitted to liver transplantation with ex-situ liver transection with the application of the human fibrinogen and thrombin sponge in the wound area (group A) and retrospective analysis of 59 patients without the sponge (group B).

Results

The characteristics of recipients and donors were similar. There were fewer reoperations due to bleeding in the wound area in group A (14.2%) compared to group B (41.7%, p=0.029). There was no difference in relation to the biliary leak (group A: 17.6%, group B: 5.1%, p=0.14).

Conclusion

There was a lower number of reoperations due to bleeding of the wound area of ​​the hepatic graft when the human fibrinogen and thrombin sponge were used.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Efficacy of TachoSil, a Fibrin-Based Hemostat, for Anterior Lumbar Spine Surgery

Study Design

Retrospective case series.

Purpose

To examine the efficacy of TachoSil for vessel injury in 6 patients who underwent anterior lumbar fusion surgery (ALF).

Overview of Literature

ALF for the lumbar spine has a high rate of success, although intraoperative concerns and iatrogenic complications are known, and injury of a major vessel is sometimes a complication. The efficacy of TachoSil, a fibrin-based hemostat, has been reported for several types of surgery; however, use of TachoSil for ALF surgery has not been described. Here, we report on the efficacy of TachoSil in 6 patients, who underwent ALF after vascular surgeons having difficulty in repairing vessels.

Methods

Two man and 4 women with average age of 50.8±10.9 (mean±standard deviation) were diagnosed with a vertebral tumor (2 patients), L4 degenerative spondylolisthesis (2 patients), and L5 spondylolytic spondylolisthesis (2 patients) and underwent ALF. The blood vessels injured included the common iliac vein in 2 patients and a branch of a segmental artery from the aorta in 4 patients. We consulted a vascular surgeon to suture or repair the vessels during surgery, and although the vascular surgeon attempted to address the injuries, suturing or repair was not possible in these cases. For this reason, we used TachoSil to repair the injury in the vessels walls or to stop the bleeding.

Results

Time to pressure hemostasis using TachoSil was 34±12 minutes, and total blood loss was 1,488±1,711 mL. Nevertheless, all vessel injuries were controlled by the use of TachoSil.

Conclusions

We recommend the use of TachoSil for vessel injuries that vascular surgeons cannot suture or repair during ALF surgery.

Adhesive and robust multilayered poly(lactic acid) nanosheets for hemostatic dressing in liver injury model

Freestanding biodegradable nanosheets composed of poly(l-lactic acid) (PLLA) have been developed for various biomedical applications. These nanosheets exhibit unique properties such as high adhesiveness and exquisite flexibility; however, they burst easily due to their nanometer thickness. We herein describe a freestanding, multilayered nanosheet composed of PLLA fabricated using a simple combination procedure: (i) multilayering of PLLA and alginate, (ii) gelation of the alginate layers, (iii) fusion-cut sealing, and (iv) elution of the alginate layers. The multilayered nanosheets not only reinforced the bursting strength but also provided a high level of adhesive strength. In fact, they were found to show potential as a hemostatic dressing, and they tended to show reduced tissue adhesion that accompanies liver injury. Therefore, we propose this biomaterial as a candidate for an alternative to conventional therapy in hemorrhage. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1747-1757, 2017.

Effectiveness of Tachosil(®) in the prevention of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis

PURPOSE

Postoperative pancreatic fistula (POPF) is a frequent and clinically relevant problem after distal pancreatectomy. A variety of methods have been tested in the attempt to prevent POPF, most of them without convincing results.

METHODS

A systematic literature search was conducted in PubMed, Embase and the Cochrane Library to identify clinical studies comparing pancreatic stump closure with the addition of Tachosil(®) to conventional stump closure. The identified studies were critically appraised, and meta-analyses were performed using a random-effects model. Dichotomous data were pooled using odds ratios, and weighted mean differences were calculated for continuous outcomes, together with the corresponding 95 % confidence intervals.

RESULTS

Four studies (two randomised controlled trials and two retrospective clinical studies) reporting data from 738 patients were included in the meta-analysis. Overall POPF, clinically-relevant POPF, mortality, reoperations, intraoperative blood loss and length of hospital stay did not differ significantly between conventional closure and additional covering of the pancreatic stump with Tachosil(®). A sensitivity analysis of only randomised controlled trials confirmed the results.

CONCLUSIONS

The application of Tachosil(®) to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay. Future research should concentrate on novel methods of pancreatic stump closure to prevent POPF after distal pancreatectomy.

Effectiveness of Tachosil(®) in the prevention of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis

PURPOSE

Postoperative pancreatic fistula (POPF) is a frequent and clinically relevant problem after distal pancreatectomy. A variety of methods have been tested in the attempt to prevent POPF, most of them without convincing results.

METHODS

A systematic literature search was conducted in PubMed, Embase and the Cochrane Library to identify clinical studies comparing pancreatic stump closure with the addition of Tachosil(®) to conventional stump closure. The identified studies were critically appraised, and meta-analyses were performed using a random-effects model. Dichotomous data were pooled using odds ratios, and weighted mean differences were calculated for continuous outcomes, together with the corresponding 95 % confidence intervals.

RESULTS

Four studies (two randomised controlled trials and two retrospective clinical studies) reporting data from 738 patients were included in the meta-analysis. Overall POPF, clinically-relevant POPF, mortality, reoperations, intraoperative blood loss and length of hospital stay did not differ significantly between conventional closure and additional covering of the pancreatic stump with Tachosil(®). A sensitivity analysis of only randomised controlled trials confirmed the results.

CONCLUSIONS

The application of Tachosil(®) to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay. Future research should concentrate on novel methods of pancreatic stump closure to prevent POPF after distal pancreatectomy.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched The Cochrane Library (2015, Issue 7), MEDLINE (1946 to 26 August 2015), EMBASE (1980 to 26 August 2015), Science Citation Index Expanded (1900 to 26 August 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 26 August 2015).

SELECTION CRITERIA

We included all randomized controlled trials that compared fibrin sealant group (fibrin glue or fibrin sealant patch) versus control group (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

We included nine trials involving 1095 participants who were randomized to the fibrin sealant group (N = 550) and the control group (N = 545) after pancreatic surgery. All of the trials were at high risk of bias. There was no evidence of differences in overall postoperative pancreatic fistula (fibrin sealant 29.6%; control 31.0%; RR 0.93, 95% CI 0.71 to 1.21; P = 0.58; nine studies; low-quality evidence), postoperative mortality (3.1% versus 2.1%; Peto OR 1.29, 95% CI 0.59 to 2.82; P = 0.53; eight studies; very low-quality evidence), overall postoperative morbidity (29.6% versus 28.9%; RR 1.04, 95% CI 0.82 to 1.32; P = 0.77; five studies), reoperation rate (8.7% versus 10.7%; RR 0.80, 95% CI 0.53 to 1.21; P = 0.29; five studies), or length of hospital stay (12.9 days versus 13.1 days; MD -0.73 days, 95% CI -2.20 to 0.74; P = 0.331; six studies) between the groups. The proportion of postoperative pancreatic fistula that was clinically significant was not mentioned in most trials. On inclusion of trials that clearly distinguished clinically significant fistulas, there was inadequate evidence to establish the effect of fibrin sealants on clinically significant postoperative pancreatic fistula (9.4% versus 13.4%; RR 0.72, 95% CI 0.42 to 1.21; P = 0.21; three studies). Quality of life and cost effectiveness were not reported in any of the trials.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants do not seem to prevent postoperative pancreatic fistula in people undergoing pancreatic surgery.

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

BACKGROUND

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Novel porous silica granules for instant hemostasis

Granulation is one of the most feasible methods to improve hemostatic efficacy by stabilize the capillary structure of silica particles. Its usability was improved significantly through granulation by enhancing flowability and eliminating dust.

Prevention of fluid effusion in kidney transplantation with the use of hemostatic biomaterials

BACKGROUND

Fluid effusion (blood, lymph, or urine) in kidney transplantation may give rise to several complications, directly, such as hematoma, seroma, lymphocele, and/or urinoma, or consequently, such as increased infection risk, longer hospital stay, graft compression--with or without functional impairment--and necessity of further hospitalizations. The aim of this study was to evaluate effectiveness of hemostatic biomaterials in prevention of fluid effusions, especially lymphocele in kidney transplant patients.

METHODS

We selected 40 patients who underwent kidney transplantation from 2009 to 2012 in which we used hemostatic biomaterials, and compared their results with those of other transplant patients from our center in which we did not used these biomaterials. Evaluated parameters were: fluid effusion, graft function, quality and quantity of drainage, blood count, and operative time.

RESULTS

There was no difference in operative time. The incidence of complications on which biomaterials can have a role decreased; particularly, we observed a reduction from 24.21% to 7.5% of fluid effusions (lymphocele). There was no evidence of complications due to biomaterials.

CONCLUSIONS

Hemostasis is important in surgery, and in kidney transplantations lymphostasis also has a significant role. In addition to the traditional hemostatic methods, recently some biomaterials, with the purpose of providing atraumatic hemostasis, were added. In our experience they are easy to use, and their use has proved to be effective for both hemostasis and lymphostasis with consequent reduction of fluid effusions.

Experiences with TachoSil® in microneurosurgery

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The use of a biologic topical haemostatic agent (TachoSil(®)) for the prevention of postoperative bleeding in patients on antithrombotic therapy undergoing thyroid surgery: A randomised controlled pilot trial

INTRODUCTION

Anticoagulants and antiplatelet agents are well-known risk factors for post-operative bleeding. The aim of this prospective, randomized pilot study was to evaluate the effectiveness of a topical haemostatic agent, namely TachoSil, for the prevention of postoperative bleeding in patients on antithrombotic therapy undergoing thyroidectomy. Perioperative management and some distinctive aspects of cervical haematomas were also discussed.

METHODS

Between January 2012 and May 2014, all patients taking vitamin K antagonists (VKAs) or acetyl salicylic acid (ASA) scheduled for total thyroidectomy were enrolled and randomly allocated to group 1 (standard haemostasis) and group 2 (standard haemostasis + TachoSil). Antithrombotic drugs were always suspended prior to surgery and, when indicated, replaced by bridging anticoagulation with low-molecular-weight heparin. The primary endpoint was the incidence of postoperative cervical haematomas.

RESULTS

A total of 70 patients were included in the study, representing 8.5% (70/820) of all patients who underwent thyroidectomies in the same period. The overall rate of post-operative cervical haematoma was 7.1% (5/70) and reached 14.8% (4/27) in patients on VKA therapy. All but one occurred more than 24 h after surgery (32nd hour, 8th, 10th, and 13th days). Group 1 (37 patients) and group 2 (33 patients) were well-matched according to clinical and demographic features. Postoperative haematoma was observed in 2/37 patients (5.4%) recruited in the Group 1 and 3/33 patients (9.1%) recruited in the Group 2 (P = 0.661).

CONCLUSIONS

Patients taking antithrombotic drugs represent a major problem in thyroid surgery. The incidence of bleeding after thyroidectomy is significantly high and the use of TachoSil do not seem effective in preventing its occurrence. However, larger multicenter study is needed to confirm these results.

Attenuation measurements show that the presence of a TachoSil surgical patch will not compromise target irradiation in intra-operative electron radiation therapy or high-dose-rate brachytherapy

Background

Surgery of locally advanced and/or recurrent rectal cancer can be complemented with intra-operative electron radiation therapy (IOERT) to deliver a single dose of radiation directly to the unresectable margins, while sparing nearby sensitive organs/structures. Haemorrhages may occur and can affect the dose distribution, leading to an incorrect target irradiation. The TachoSil (TS) surgical patch, when activated, creates a fibrin clot at the surgical site to achieve haemostasis. The aim of this work was to determine the effect of TS on the dose distribution, and ascertain whether it could be used in combination with IOERT. This characterization was extended to include high dose rate (HDR) intraoperative brachytherapy, which is sometimes used at other institutions instead of IOERT.

Methods

CT images of the TS patch were acquired for initial characterization. Dosimetric measurements were performed in a water tank phantom, using a conventional LINAC with a hard-docking system of cylindrical applicators. Percentage Depth Dose (PDD) curves were obtained, and measurements made at the depth of dose maximum for the three clinically used electron energies (6, 9 and 12MeV), first without any attenuator and then with the activated patch of TS completely covering the tip of the IOERT applicator. For HDR brachytherapy, a measurement setup was improvised using a solid water phantom and a Farmer ionization chamber.

Results

Our measurements show that the attenuation of a TachoSil patch is negligible, both for high energy electron beams (6 to 12MeV), and for a HDR ¹⁹²Ir brachytherapy source. Our results cannot be extrapolated to lower beam energies such as 50 kVp X-rays, which are sometimes used for breast IORT.

Conclusion

The TachoSil surgical patch can be used in IORT procedures using 6MeV electron energies or higher, or HDR ¹⁹²Ir brachytherapy.