The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms

Real-life practice of reflectance confocal microscopy in France: A prospective multicenter study

BACKGROUND

Studies demonstrating the potential utility of reflectance confocal microscopy (RCM) have been performed under experimental conditions.

OBJECTIVE

To provide an overview of RCM practice in real-life.

METHODS

A multicenter, prospective study carried out in 10 university dermatology departments in France.

RESULTS

Overall, 410 patients were enrolled. One-half of the patients (48%) were referred by private practice dermatologists. They were referred for diagnosis (84.9%) or presurgical mapping (13%). For diagnosis, the lesions were located on the face (62%), arms and legs (14.9%), and trunk (13.6%), and presurgical mapping was almost exclusively on the face (90.9%). Among those referred for diagnosis, the main indication was suspicion of a skin tumor (92.8%). Of these, 50.6% were spared biopsies after RCM. When RCM indicated surgery, histology revealed malignant lesions in 72.7% of cases. The correlation between RCM and histopathology was high, with a correlation rate of 82.76% and a kappa coefficient of 0.73 (0.63; 0.82).

LIMITATIONS

This study was performed in the settings of French tertiary referral hospitals.

CONCLUSION

This study shows that in real-life RCM can be integrated into the workflow of a public private network, which enables a less invasive diagnostic procedure for patients.

The role of sealants for achieving anastomotic hemostasis in vascular surgery

BACKGROUND

During vascular interventions, connections that link arteries, veins, or synthetic grafts, which are known as an 'anastomosis', may be necessary. Vascular anastomoses can bleed from the needle holes that result from the creation of the anastomoses. Various surgical options are available for achieving hemostasis, or the stopping of bleeding, including the application of sealants directly onto the bleeding vessels or tissues. Sealants are designed for use in vascular surgery as adjuncts when conventional interventions are ineffective and are applied directly by the surgeon to seal bleeding anastomoses. Despite the availability of several different types of sealants, the evidence for the clinical efficacy of these hemostatic adjuncts has not been definitively established in vascular surgery patients.

OBJECTIVES

To evaluate the benefits and harms of sealants as adjuncts for achieving anastomotic site hemostasis in patients undergoing vascular surgery.

SEARCH METHODS

The Cochrane Vascular Information Specialist conducted systematic searches of the following databases: the Cochrane Vascular Specialised Register via the Cochrane Register of Studies; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE via Ovid; Embase via Ovid ; and CINAHL via EBSCO. We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for clinical trials. Reference lists of included trials and relevant reviews were also searched. The latest search date was 6 March 2023.

SELECTION CRITERIA

We included randomized controlled trials that compared fibrin or synthetic sealant use with alternative interventions (e.g. manual compression, reversal of anticoagulation) for achieving anastomotic-site hemostasis in vascular surgery procedures. We included participants who underwent the creation of an anastomosis during vascular surgery. We excluded non-vascular surgery patients.

DATA COLLECTION AND ANALYSIS

We have used standard Cochrane methods. Our primary outcomes were time to hemostasis, failure of hemostatic intervention, and intraoperative blood loss. Our secondary outcomes were operating time, death from bleeding complications up to 30 days, postoperative bleeding up to 30 days, unplanned return to the operating room for bleeding complications management up to 30 days, quality of life, and adverse events. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We found 24 randomized controlled trials that included a total of 2376 participants who met the inclusion criteria. All trials compared sealant use with standard care controls, including oxidized cellulose, gelatin sponge, and manual compression. All trials were at high risk of performance bias, detection bias, and other sources of bias. We downgraded the certainty of evidence for risk of bias concerns, inconsistency, imprecision and possible publication bias. Combining data on time to hemostasis showed that sealant use may reduce the mean time to hemostasis compared to control (mean difference (MD) -230.09 seconds, 95% confidence interval (CI) -329.24 to -130.94; P < 0.00001; 7 studies, 498 participants; low-certainty evidence). Combining data on failure of hemostatic intervention showed that sealant use may reduce the rate of failure compared to control, but the evidence is very uncertain (risk ratio (RR) 0.46, 95% CI 0.35 to 0.61; P < 0.00001; 17 studies, 2120 participants; very low-certainty evidence). We did not detect any clear differences between the sealant and control groups for intraoperative blood loss (MD -32.69 mL, 95% CI -96.21 to 30.83; P = 0.31; 3 studies, 266 participants; low-certainty evidence); operating time (MD -18.72 minutes, 95% CI -40.18 to 2.73; P = 0.09; 4 studies, 436 participants; low-certainty evidence); postoperative bleeding (RR 0.78, 95% CI 0.59 to 1.04; P = 0.09; 9 studies, 1216 participants; low-certainty evidence), or unplanned return to the operating room (RR 0.27, 95% CI 0.04 to 1.69; P = 0.16; 8 studies, 721 participants; low-certainty evidence). No studies reported death from bleeding or quality of life outcomes.

AUTHORS' CONCLUSIONS

Based on meta-analysis of 24 trials with 2376 participants, our review demonstrated that sealant use for achieving anastomotic hemostasis in vascular surgery patients may result in reduced time to hemostasis, and may reduce rates of hemostatic intervention failure, although the evidence is very uncertain, when compared to standard controls. Our analysis showed there may be no differences in intraoperative blood loss, operating time, postoperative bleeding up to 30 days, and unplanned return to the operating room for bleeding complications up to 30 days. Deaths and quality of life could not be analyzed. Limitations include the risk of bias in all studies. Our review has demonstrated that using sealants may reduce the time required to achieve hemostasis and the rate of hemostatic failure. However, a significant risk of bias was identified in the included studies, and future trials are needed to provide unbiased data and address other considerations such as cost-effectiveness and adverse events with sealant use.

Revolutionizing diagnostic pathology: The emergence and impact of artificial intelligence-what doesn't kill you makes you stronger?

This study explored the integration and impact of artificial intelligence (AI) in diagnostic pathology, particularly dermatopathology, assessing its challenges and potential solutions for global health care enhancement. A comprehensive literature search in PubMed and Google Scholar, conducted on March 30, 2023, and using terms related to AI, pathology, and machine learning, yielded 44 relevant publications. These were analyzed under themes including the evolution of deep learning in pathology, AI's role in replacing pathologists, development challenges of diagnostic algorithms, clinical implementation hurdles, strategies for practical application in dermatopathology, and future prospects of AI in this field. The findings highlight AI's transformative potential in pathology, underscore the need for ongoing research, collaboration, and regulatory dialogue, and emphasize the importance of addressing the ethical and practical challenges in AI implementation for improved global health care outcomes.

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.

Modelling the Cost-Effectiveness of Diagnostic Tests

Diagnostic tests are used to determine whether a disease or condition is present or absent in a patient, who will typically be suspected of having the disease or condition due to symptoms or clinical signs. Economic evaluations of diagnostic tests (e.g. cost-effectiveness analyses) can be used to determine whether a test produces sufficient benefit to justify its cost. Evidence on the benefits conferred by a test is often restricted to its accuracy, which means mathematical models are required to estimate the impact of a test on outcomes that matter to patients and health payers. It is important to realise the case for introducing a new test may not be restricted to its accuracy, but extend to factors such as time to diagnosis and acceptability for patients. These and other considerations may mean the common modelling approach, the decision tree, is inappropriate for underpinning an economic evaluation. There are no consensus guidelines on how economic evaluations of diagnostic tests should be conducted-this article attempts to explore the common challenges encountered in economic evaluations, suggests solutions to those challenges, and identifies some areas where further methodological work may be necessary.

A comparative high-resolution physicochemical analysis of commercially available fibrin sealants: Impact of sealant osmolality on biological performance

Fibrin sealants are well-established components of the surgical toolbox, especially in procedures that harbor a high risk of perioperative bleeding. Their widespread use as hemostats, sealants or tissue-adhesives in various surgical settings has shown that the choice of the appropriate sealant system affects the clinical outcome. While many studies have compared the hemostatic efficiency of fibrin sealants to that of other natural or synthetic sealants, there is still limited data on how subtle differences in fibrin sealant formulations relate to their biological performance. Here, we performed an in-depth physicochemical and biological characterization of the two most commonly used fibrin sealants in the US and Europe: TISSEEL™ ("FS") and VISTASEAL™/VERASEAL™ ("FS+Osm"). Our chemical analyses demonstrated differences between the two sealants, with lower fibrinogen concentrations and supraphysiological osmolality in the FS+Osm formulation. Rheological testing revealed FS clots have greater clot stiffness, which strongly correlated with network density. Ultrastructural analysis by scanning electron microscopy revealed differences between FS and FS+Osm fibrin networks, the latter characterized by a largely amorphous hydrogel structure in contrast to the physiological fibrillar network of FS. Cytocompatibility experiments with human fibroblasts seeded on FS and FS+Osm fibrin networks, or cultured in presence of sealant extracts, revealed that FS+Osm induced apoptosis, which was not observed with FS. Although differential sealant osmolality and amounts of fibrinogen, as well as the presence of Factor XIII or additives such as antifibrinolytics, may explain the mechanical and structural differences observed between the two fibrin sealants, none of these substances are known to cause apoptosis at the respective concentrations in the sealant formulation. We thus conclude that hyper osmolality in the FS+Osm formulation is the primary trigger of apoptosis-a mechanism that should be evaluated in more detail, as it may affect the cellular wound healing response in situ.

Goals, challenges and strategies for wound and bleeding management in total knee arthroplasty: A modified Delphi method

BACKGROUND

Surgical techniques related to soft tissue management play critical roles in optimizing surgical outcomes and patient satisfaction in total knee arthroplasty (TKA). Despite the importance of wound closure and bleeding management approaches, no published guidelines/consensus are available.

METHODS

Twelve orthopedic surgeons participated in a modified Delphi panel consisting of 2 parts (each part comprising two rounds) from September-October 2018. Questionnaires were developed based on published evidence and guidelines on surgical techniques/materials. Questionnaires were administered via email (Round 1) or at a face-to-face meeting (subsequent rounds). Panelists ranked their agreement with each statement on a five-point Likert scale. Consensus was achieved if ≥70% of panelists selected 4/5, or 1/2. Statements not reaching consensus in Round 1 were discussed and repeated or modified in Round 2. Statements not reaching consensus in Round 2 were excluded from the final consensus framework.

RESULTS

Consensus was reached on 13 goals of wound management. Panelists agreed on 38 challenges and 71 strategies addressing surgical techniques or wound closure materials for each tissue layer, and management strategies for blood loss reduction or deep vein thrombosis prophylaxis in TKA. Statements on closure of capsular and skin layers, wound irrigation, dressings and drains required repeat voting or modification to reach consensus.

CONCLUSION

Consensus from Asia-Pacific TKA experts highlights the importance of wound management in optimizing TKA outcomes. The consensus framework provides a basis for future research, guidance to reduce variability in patient outcomes, and can help inform recommendations for wound management in TKA.

Prevention of postoperative anemia in hip hemiarthroplasty for femoral neck fractures: comparison between local haemostatic agents

Background

Tranexamic acid and fibrin sealant have been shown to be effective in reducing the need for transfusion after hip fracture surgery.

Objective

The aim of this study was to evaluate the efficacy of local haemostatic agents to reduce the need of postoperative transfusion in elederly patients after hip hemiarthroplasty.

Methods

All patients admitted to our institution with a diagnosis of proximal femur fracture from September 2018 to March 2021 were involved. Inclusion criteria were: diagnosis of femoral neck fracture, classified as AO 31B2-3, surgical treatment with hip hemiarthroplasty, hemoglobinemia on admission > 8 gr/dL. Patients were divided in four groups.

Results

EVICEL was used on 25 patients, TRANEX was used on 52 patients, standard hemostatic care was used on 73 patients, while post-surgical drain was used on 21 patients. 3 patients were transfused in the EVICEL group while 26 patients were transfused in the control group (p 0,0404), there was also statistical significant difference in the need of perioperative transfusion between EVICEL group and drain group with 10 patients transfused (p 0,0102). Statistical significant differences was found about haemoglobin variation in the first post-operative day between TRANEX group and control group (p 0,000155) and between TRANEX group and drain group (p 0,013) and also between TRANEX group and control group in the third post-operative day (p 0,0004).

Conclusion

This study demonstrates that the use of both fibrin sealant or TXA can reduce total blood loss and the need of transfusions in geriatric population with intracapsular femur fracture.

Systematic review on active treatment for urinary fistula after partial nephrectomy

INTRODUCTION

Urinary fistula is expected to become more frequent in urological practice as a result of expanding indication of partial nephrectomy given it's oncological results equivalent to those of radical nephrectomy but at a lower risk of progression to chronic kidney disease, lower cardiovascular morbidity, and overall mortality.

OBJECTIVES

Review and compare different techniques of contemporary active management for urinary fistula after partial nephrectomy.

METHODS

A systematic literature search on the MEDLINE database was conducted in March 2020, combining the terms: "urine leak", "urine leakage", "urinary leak" and "urinary fistula", with: "partial nephrectomy", "nephron sparing surgery" and "renal sparing surgery". This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only articles related to active treatment were eligible. Abstracts in English and Spanish from the last two decades were screened. No restriction based on study design nor the length of follow-up.

PRIMARY OUTCOMES

1) Leak resolution rate 2) Time course of leak resolution and 3) Number of interventions needed for resolution.

RESULTS

Multiple studies were found. There were no randomized controlled trials. Urinary fistula can be solved in many ways with active treatment, with a high success rate (97.5%), an average of 1.4 intervention-per-patients and a mean time for leak resolution of 11 days (median of 3 days).

CONCLUSION

There is a high risk of bias due to the study's methodology. There is a broad range of effective alternatives and various approaches to solve urinary fistula in an appropriate timing.

Perioperative anaphylaxis to fibrin sealants in children with Noonan Syndrome: A retrospective study

BACKGROUND

In the diagnosis of perioperative anaphylaxis, it is essential to define its cause to prevent future reexposures, especially in children with Noonan Syndrome who are characterized by a large number of systemic features and wide-ranging dysmorphia. From an oral surgeon's point of view, apart from an increased risk of tumor incidence, diverse hematologic anomalies are of high concern.

OBJECTIVE

Perioperative management of such patients often requires the use of fibrin sealants, which contain aprotinin. A certain number of anaphylaxis cases have been observed in our daily practice during such treatment, which was the reason for this evaluation.

METHODS

The study was conducted to retrospectively review perioperative anaphylaxis grade II and above in children with Noonan Syndrome who underwent surgeries in the Department of Oral Surgery, Medical University of Lodz, between 2006 and 2021.

RESULTS

Out of the 16 cases of suspected anaphylaxis to aprotinin, 14 were observed in children with Noonan Syndrome. The postoperative serologic screening revealed positive results for qualitative aprotinin-specific immunoglobulin (Ig) G, highly elevated quantitative aprotinin-specific IgG, and slightly elevated aprotinin-specific IgE antibodies. Interestingly, previous aprotinin administration or contact in the past 12 months was excluded.

CONCLUSION

Given that fibrin sealants are typically used in various surgical practices and although the anaphylaxis reactions in such cases are rare, it is essential to be cautious in patients with RASopathies who are at a high risk of developing anaphylaxis.

Safety and efficacy of sFilm-FS, a novel biodegradable fibrin sealant, in Göttingen minipigs

Bleeding during surgical procedures is a common complication. Therefore, hemostatic agents have been developed to control bleeding, and fibrin sealants have several benefits. sFilm-FS is a novel fibrin sealant that comprises a biodegradable co-polymeric film embedded with human fibrinogen and thrombin. Herein, the safety and efficacy of sFilm-FS were compared using a liver and spleen puncture model of Göttingen minipigs with those of the standard hemostatic techniques (control animals) and EVARREST^®, a reference fibrin sealant. Hemostasis and reduced blood loss were more effectively achieved with sFilm-FS than with the standard techniques in the control animals and comparable to those achieved with EVARREST^®. No treatment-related adverse effects were observed in any of the groups. Histopathological evaluation indicated that sFilm-FS was slightly and moderately reactive at the liver puncture site and spleen, respectively, compared with the standard techniques in the control animals. These changes are expected degradation reactions of the co-polymeric film and are not considered as adverse events. No treatment-related abnormalities were noted in the other evaluated organs. Additionally, no evidence of local or systemic thromboses was noted. These results support the use of sFilm-FS for hemostasis in humans.

Postoperative bleeding in essential thrombocytosis patients with colorectal cancer: Case report and literature review

Introduction and importance

Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by increased platelet count and a high risk of bleeding or thrombotic events due to platelet dysfunction. Patients with ET are treated according to their risk of complications with cytoreductive or anti-aggregant treatment. Neither guidelines for oncologic patients nor perioperative management of patients with ET have been determined.

Case presentation

A 41-year-old female patient with ET who had alternating constipation and diarrhea was referred after a screening colonoscopy diagnosing a locally advanced rectosigmoid junction colon adenocarcinoma with liver metastases. Systemic preoperative chemotherapy was indicated. The patient underwent laparoscopic low anterior resection plus volume-preserving right lobectomy of the liver. Postoperative bleeding of the internal iliac artery (IIA) associated with hematoma at the lower pelvic cavity was diagnosed and treated by interventional radiology; the patient was discharged without other complications 16 days after surgery.

Clinical discussion

ET has been related to the development of hematologic complications or second non-hematologic malignancies. A systematic review was conducted to seek guidance for the management of such patients in the perioperative period. Special perioperative care must be taken, and complications management should avoid further hemorrhages or cloth formation.

Conclusion

Under oncologic and hematological guidance, minimally invasive surgery and non-invasive management of complications are advised in the lack of published perioperative management guidelines of ET patients with colorectal cancer.

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Essential thrombocythemia (ET) is a rare clonal myeloproliferative disorder.

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ET can manifest as hemorrhage, thrombosis, and functional microvascular symptoms.

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Cytoreductive treatment and anti-aggregants are indicated in ET with a high risk of complications.

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Colorectal cancer, with its surgical and oncologic treatment, may increase the risk of adverse vascular events.

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Perioperative management of patients with ET has not been determined.

Anaphylaxis after injecting a hemostatic agent containing gelatin into vertebral bone under pressure-a warning

STUDY DESIGN

Case series.

PURPOSE

The use of topical hemostatic agents is common in spinal deformity surgery. While beneficial, emerging case data shows gelatin-containing agents causing intra-operative complications. We present two patients who developed anaphylaxis after injection of these gelatin-containing hemostatic agents into the vertebral body using manual pressure. In the literature, while anaphylactic reactions associated with the use of animal-derived gelatin has been implicated; the risk of injecting these products into the closed vascular cavity of the vertebral body with subsequent embolization into systemic circulation bears emphasis. This report is to meant to make the surgical team aware of the risks of injecting hemostatic agents using manual pressure into the vertebral body and to highlight a plausible mechanism for the phenomenon.

METHODS

Two children with spinal deformity undergoing posterior spinal fusion procedures with the use of gelatin-containing hemostatic agents injected into the vertebral body through the pedicle are described.

RESULTS

Both patients had gelatin-containing hemostatic agent solution injected under manual pressure through the vertebral pedicle to prevent excessive bleeding. Anaphylaxis occurred soon thereafter, resulting in emergent cessation of the surgery and initiation of medical resuscitation. In both cases, tryptase levels obtained just after the event were elevated.

CONCLUSION

Patients with an allergy to or prior history of exposure to zoologic products undergoing spine surgery may be at risk of anaphylaxis if the gelatin-containing hemostatic agent is injected under manual pressure into the closed space of the vertebral body. This allows rapid entry into the venous circulation. We recommend that the surgeon perform a thorough history of a patient's allergies and use extreme caution when injecting these topical hemostatic products into the vertebral body.

LEVEL OF EVIDENCE

IV.

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

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

Deep learning extended depth-of-field microscope for fast and slide-free histology

Traditional microscopy suffers from a fixed trade-off between depth-of-field (DOF) and spatial resolution—the higher the desired spatial resolution, the narrower the DOF. We present DeepDOF, a computational microscope that allows us to break free from this constraint and achieve >5× larger DOF while retaining cellular-resolution imaging—obviating the need for z-scanning and significantly reducing the time needed for imaging. The key ingredients that allow this advance are 1) an optimized phase mask placed at the microscope aperture; and 2) a deep-learning-based algorithm that turns sensor data into high-resolution, large-DOF images. DeepDOF offers an inexpensive means for fast and slide-free histology, suited for improving tissue sampling during intraoperative assessment and in resource-constrained settings.

Microscopic evaluation of resected tissue plays a central role in the surgical management of cancer. Because optical microscopes have a limited depth-of-field (DOF), resected tissue is either frozen or preserved with chemical fixatives, sliced into thin sections placed on microscope slides, stained, and imaged to determine whether surgical margins are free of tumor cells—a costly and time- and labor-intensive procedure. Here, we introduce a deep-learning extended DOF (DeepDOF) microscope to quickly image large areas of freshly resected tissue to provide histologic-quality images of surgical margins without physical sectioning. The DeepDOF microscope consists of a conventional fluorescence microscope with the simple addition of an inexpensive (less than $10) phase mask inserted in the pupil plane to encode the light field and enhance the depth-invariance of the point-spread function. When used with a jointly optimized image-reconstruction algorithm, diffraction-limited optical performance to resolve subcellular features can be maintained while significantly extending the DOF (200 µm). Data from resected oral surgical specimens show that the DeepDOF microscope can consistently visualize nuclear morphology and other important diagnostic features across highly irregular resected tissue surfaces without serial refocusing. With the capability to quickly scan intact samples with subcellular detail, the DeepDOF microscope can improve tissue sampling during intraoperative tumor-margin assessment, while offering an affordable tool to provide histological information from resected tissue specimens in resource-limited settings.

Comparison of fibrin sealants in peripheral vascular surgery: A systematic review and network meta-analysis

Background

Evidence comparing fibrin sealants (FSs) in surgery are limited. This study evaluated the efficacy and safety of FSs, and manual compression in peripheral vascular surgery.

Methods

A systematic review of randomized trials was conducted in Medline, Embase, and Cochrane databases within the last 15 years. Data were available to conduct a network meta-analysis (NMA) in peripheral vascular surgery. Fibrin sealant treatment arms were further broken-down and assessed by clotting time (i.e., 2-min [2C] or 1-min [1C]). The primary efficacy outcome was the proportion of patients achieving hemostasis by 4 min (T4). Treatment-related serious and non-serious adverse events (AEs) were qualitatively assessed.

Results

Five studies (n = 693), were included in the NMA. Results predicted VISTASEAL 2C, followed by EVICEL 1C, had the highest probability of achieving T4. Compared with manual compression, significant improvements in T4 were found with VISTASEAL 2C (relative risk [RR] = 2.67, 95% CrI: 2.13–3.34), EVICEL 1C (RR = 2.58, 95% CrI: 2.04–3.23), VISTASEAL 1C (RR = 2.00, 95% CrI: 1.45–2.65), and TISSEEL 2C (RR = 1.99, 95% CrI: 1.48–2.60). TISSEEL 1C was not significantly different than manual compression (RR = 1.40, 95% CrI: 0.70–2.33). Among FSs, VISTASEAL 2C was associated with a significant improvements in T4 compared with VISTASEAL 1C (RR = 1.33, 95% CrI: 1.02–1.82), TISSEEL 2C (RR = 1.34, 95% CrI: 1.05–1.77), and TISSEEL 1C (RR = 1.90, 95% CrI: 1.18–3.74). Treatment-related serious and non-serious AE rates were typically lower than 2%.

Conclusions

In peripheral vascular surgeries, VISTASEAL 2C and EVICEL 1C were shown to have the highest probabilities for achieving rapid hemostasis among the treatments compared. Future studies should expand networks across surgery types as data become available.

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Fibrin sealants can control perioperative bleeding, yet comparative evidence is limited.

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This network meta-analysis compared fibrin sealants and compression in peripheral vascular surgery.

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VISTASEAL and EVICEL had the highest probability of achieving hemostasis by 4 min.

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These results show differences exist between fibrin sealants in peripheral vascular surgery.

Fibrin sealant reduces need for transfusions after hip hemiarthroplasty for femoral neck fractures

INTRODUCTION

Every year more than 300,000 proximal femur fractures are diagnosed. Their number will double within 30 years. In femoral neck fractures treated with hip hemiarthroplasty 90-days mortality is 29.5-51.6%. Haemorrhage is one amongst other complications that is associated with increasing postoperative mortality. Transfusion rate in these patients ranges from 25.7% to 39%. Blood transfusions expose to complications. Fibrin sealants are useful in reducing perioperative need for transfusions, total blood loss, blood loss from drainage. The aim of this study is to assess whether the use of a fibrin sealant during hip hemiarthroplasty implant reduces the need for transfusion.

PATIENT AND METHODS

All patients admitted with a proximal femur fracture from September 2018 to May 2019 were reviewed. Inclusion criteria were: femoral neck fracture AO 31B2-3, hip hemiarthroplasty. Exclusion criteria were: previous surgery on the affected hip, coagulation disorders, hematopoietic disorders. Patients were divided in fibrin sealant group and control group. All patients underwent partial hip replacement through a posterolateral approach. 4 ml of fibrin sealant (EVICEL, Omrix Biopharmaceuticals, Diegem, Belgium) were sprayed on the soft tissues of patients included in the fibrin sealant group. Primary outcome of our study was need for perioperative transfusion. Secondary outcomes were: mean red blood cell transfused volume, variations in haematocrit and haemoglobin and total blood volume loss.

RESULTS

Eighty-one consecutive patients were enrolled. EVICEL was used on 19 patients, standard haemostatic care on 62 patients. Two patients were transfused in the fibrin sealant group, 22 in the control group (p 0,0371). Mean transfused volume was 21,05 ml in the fibrin sealant group and 116,16 ml in the control group (p 0,0017). No significant difference could be found in haematocrit and haemoglobin variation and total blood loss.

DISCUSSION

A reduction in transfusional need with the use of fibrin sealants was reported in studies on total hip arthroplasty and was confirmed by our study.

CONCLUSION

EVICEL reduces need for transfusion in patients undergoing hip hemiarthroplasty for a femoral neck fracture. It must be held among the options when a stricter control on transfusional requirement is needed.

Reflectance confocal microscopy: Principles, basic terminology, clinical indications, limitations, and practical considerations

Reflectance confocal microscopy (RCM) is a noninvasive imaging tool used for in vivo visualization of the skin. It has been extensively studied for use in the evaluation of equivocal cutaneous neoplasms to decrease the number of biopsy procedures in patients with benign lesions. Furthermore, its applications are broadening to include presurgical cancer margin mapping, tumor recurrence surveillance, monitoring of ablative and noninvasive therapies, and stratification of inflammatory disorders. With the approval of category I Current Procedural Terminology reimbursement codes for RCM image acquisition and interpretation, use of this technology has been increasingly adopted by dermatologists. The first article in this 2-part continuing medical education series highlights basic terminology, principles, clinical applications, limitations, and practical considerations in the clinical use of RCM technology.

Surgical applications of intracorporal tissue adhesive agents: current evidence and future development

Introduction: Traditional mechanical closure techniques pose many challenges including the risk of infection, tissue reaction, and injury to both patients and clinicians. There is an urgent need to develop tissue adhesive agents to reform closure technique. This review examined a variety of tissue adhesive agents available in the market in an attempt to gain a better understanding of intracorporal tissue adhesive agents as medical devices.Areas covered: Fundamental principles and clinical determinants of the tissue adhesives were summarized. The available tissue adhesives for intracorporal use and their relevant clinical evidence were then presented. Lastly, the perspective of future development for intracorporal tissue adhesive were discussed. Clinical evidence shows current agents are efficacious as adjunctive measures to mechanical closure and these agents have been trialed outside of clinical indications with varied results.Expert opinion: Despite some advancements in the development of tissue adhesives, there is still a demand to develop novel technologies in order to address unmet clinical needs, including low tensile strength in wet conditions, non-controllable polimerization and sub-optimal biocompatibility. Research trends focus on producing novel adhesive agents to remit these challenges. Examples include the development of biomimetic adhesives, externally activated adhesives, and multiple crosslinking strategies. Economic feasibility and biosafety are limiting factors for clinical implementation.

Improvement of diagnostic confidence and management of equivocal skin lesions by integration of reflectance confocal microscopy in daily practice: Prospective study in 2 referral skin cancer centers

BACKGROUND

Reflectance confocal microscopy (RCM) allows accurate, noninvasive, in vivo diagnosis for skin cancer. However, its impact on physicians' diagnostic confidence and management is unknown.

OBJECTIVES

We sought to assess the physicians' diagnostic confidence and management before and after RCM of equivocal skin lesions.

METHODS

Prospective, 2-center, observational study. During clinical practice, 7 dermatologists recorded their diagnostic confidence level (measured in a scale from 0 to 10), diagnosis, and management before and after RCM of clinically/dermoscopically equivocal lesions that raised concern for skin cancer. We also evaluated the diagnostic accuracy before and after RCM.

RESULTS

We included 272 consecutive lesions from 226 individuals (mean age, 53.5 years). Diagnostic confidence increased from 6.2 to 8.1 after RCM (P < .001) when RCM confirmed or changed the diagnosis. Lesion management changed in 33.5% cases after RCM (to observation in 51 cases and to biopsy/excision in 31 cases). After RCM, the number needed to excise was 1.2. Sensitivity for malignancy before and after RCM was 78.2% and 85.1%, respectively. Specificity before and after RCM was 78.8% and 80%, respectively.

LIMITATIONS

Small sample size, real-life environment, and different levels of expertise among RCM users.

CONCLUSION

Physicians' diagnostic confidence and accuracy increased after RCM when evaluating equivocal tumors, frequently resulting in management changes while maintaining high diagnostic accuracy.

Fibrin-thrombin sealant does not reduce lymphocele formation in patients with inguinofemoral lymphadenectomy for vulvar cancer

Purpose: Inguinofemoral lymphadenectomy (IFLD) is associated with very high morbidity. Fibrin sealant patches are used in various surgical procedures to prevent hematomas and lymphoceles. Here, we report a single-institution experience of fibrin sealants after IFLD in vulvar cancer and give an overview of the current literature.

Patients and methods: We retrospectively analyzed outcome data on vulvar cancer patients who underwent bilateral IFLD between November 2014 and June 2016 at the University Hospital Basel. A fibrin sealant patch (Tachosil^®) was placed in one groin only. Postsurgical fluid collection and complications were compared between both groins; time courses of lymphocele formation were analyzed using a linear mixed-effects regression model.

Results: Postsurgical outcome of 11 consecutive patients with bilateral IFLD for vulvar cancer was assessed for a median follow-up of 32 days (range 12–77). Significantly larger lymphoceles were detected over time in the groin with the fibrin sealant patch (median 20 mL vs 5 mL without patch, p=0.002), and more punctures for symptomatic lymphocele were required on this side. The infection rate did not differ between sides.

Conclusion: Fibrin sealant patches should not routinely be used for prevention of lymphoceles after IFLD for vulvar cancer. They do not seem to reduce lymph collection, the need for puncture or the infection risk after lymphadenectomy in our experience and according to a general literature review.

Systematic review of fibrin glue in burn wound reconstruction

Background

In the reconstruction of burns using split-skin grafts (SSGs), fibrin glue can be used to improve graft take and reduce haematoma formation, although the efficacy and cost-effectiveness are unknown. This systematic review evaluated outcomes of fibrin glue compared with conventional SSG attachment techniques. Outcomes of interest included SSG take, haematoma formation, patient satisfaction and cost-effectiveness.

Methods

This PROSPERO-registered review was performed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA statement. Embase, PubMed, Cochrane and ClinicalTrial.gov databases were searched systematically. Observational and experimental studies comparing fibrin glue with other methods of SSG attachment in burn wounds were included. Risk of bias was assessed using the Cochrane risk-of-bias and Risk of Bias In Non-Randomized Studies – of Intervention tools. The quality of the evidence was assessed using the GRADE tool.

Results

Two RCTs and four observational studies were included. Graft take at day 5 was not significantly different between groups (3 studies, 183 individuals). Fibrin glue significantly reduced the risk of postoperative haematoma in two studies and reduced patient-reported pain in two studies, with suggested cost savings in four studies. All studies were at risk of methodological bias and the quality of the evidence was universally very low.

Conclusion

As the evidence is sparse, the quality very low and the risk of bias significant both within and across studies, it is not possible to make any recommendations regarding the use of fibrin glue in burn wounds.

Interrater and intrarater agreement of confocal microscopy imaging in diagnosing and subtyping basal cell carcinoma

BACKGROUND

Reflectance confocal microscopy (RCM) imaging can be used to diagnose and subtype basal cell carcinoma (BCC) but relies on individual morphologic pattern recognition that might vary among users.

OBJECTIVES

We assessed the inter-rater and intrarater agreement of RCM in correctly diagnosing and subtyping BCC.

METHODS

In this prospective study, we evaluated the inter-rater and intrarater agreement of RCM on BCC presence and subtype among three raters with varying experience who independently assessed static images of 48 RCM cases twice with four-week interval (T1 and T2). Histopathologic confirmation of presence and subtype of BCC from surgical excision specimen was defined as the reference standard.

RESULTS

The inter-rater agreement of RCM for BCC presence showed an agreement of 82% at T1 and 84% at T2. The agreements for subtyping BCC were lower (52% for T1 and 47% for T2). The intrarater agreement of RCM for BCC presence showed an observed agreement that varied from 79% to 92%. The observed agreements for subtyping varied from 56% to 71%.

CONCLUSIONS

In conclusion, our results show that RCM is reliable in correctly diagnosing BCC based on the assessment of static RCM images. RCM could potentially play an important role in BCC management if accurate subtyping will be achieved. Therefore, future clinical studies on reliability and specific RCM features for BCC subtypes are required.