Efficacy of fibrin sealant in thyroid surgery. Is drainage still necessary?

INTRODUCTION

The routinely use of drains in thyroid surgery is a traditional and well-defined method, even if there is no clear evidence of significant improvement in patients outcomes. Aim of our study is to define the feasibility, safety and cost- effectiveness of fibrin sealant in total thyroidectomy in order to overcome the use of drains.

MATERIALS AND METHODS

We enrolled 262 patients (45 men and 217 women, mean age 54.7 yrs) undergone total thyroidectomy in University Hospital of Palermo (Italy), between July 2015 and October 2017. We randomized patients into group A (drain) and group B (no drain, fibrin sealant application).

RESULTS

We registered statistical difference between the two groups in mean operative time, visual analogue scale of pain, post-operative stay, incidence of seromas and/or deep and superficial hematomas, re-operation and wound infection (reduced in the fibrin sealant group). No significant difference have been found in intraoperative blood loss, postoperative cough, post-operative use of analgesic and in incidence of hypoparathyroidism or recurrent palsy.

CONCLUSIONS

Our study demonstrates that there is no evidence that the use of suction drains improves patients outcome and that routinely use of fibrin sealant can be advocated in thyroid surgery as an adjunct to a good surgical procedure.

KEY WORDS

Complication, Drainage, Fibrin Sealant, Thyroidectomy.

Use of a Sprayed Fibrin Hemostatic Sealant after Laser Therapy for Hereditary Hemorrhagic Telangiectasia Epistaxis

Background

Hereditary hemorrhagic telangiectasia (HHT) is a relatively common autosomal dominant condition. Epistaxis is a frequent manifestation, often occurring daily and requiring iron and blood transfusions. Surgery often is bloody and difficult. The aim of this study was to evaluate the effectiveness of a sprayed fibrin, hemostatic sealant in preventing postoperative epistaxis after laser treatment of nasal mucosa in HHT. Fibrin sealant was compared with nasal packing for likelihood of postoperative epistaxis and financial impact including material costs and hospitalization fees.

Methods

Retrospective review was performed of 64 individual laser treatments for epistaxis in HHT patients at the University of California, San Diego, Medical Center between 2002 and 2005. Nasal packing was used in 30 procedures and fibrin sealant was used in 34 procedures.

Results

Six of 30 (20%) procedures using postoperative nasal packing required admission with an average hospital expense of $5914. One of 34 patients (3%) in the fibrin sealant group required hospitalization (p = 0.04).

Conclusion

Aerosolized fibrin sealant prevents postoperative epistaxis after nasal laser treatment in HHT patients. Compared with traditional nasal packing we found improved patient comfort and recovery with substantial cost savings.

[Medical and economic impact of a haemostatic sealant on the rate of transfusion after total knee arthroplasty]

OBJECTIVES

Blood loss reduction in total knee arthroplasty (TKA) contributes to the prevention of morbidity and mortality and in the management of health care costs. Fibrin haemostatic sealant have controversial effectiveness in reducing postoperative blood loss and transfusion requirements. Our study evaluated the medical and economic benefits of this treatment with the assumption that it decreases the frequency of blood transfusion after TKA.

METHODS AND PATIENTS

Our single-center and randomized study included 60 patients pose unilateral primary TKA for osteoarthritis. Distribution was done in 2 groups of 30 patients each. Group 1 patients treated with a dose of 5 mL Evicel®, compared to untreated group 2. Were collected the number of patients transfused. The treatment cost was compared to the sealant cost.

RESULTS

Results are not statistically significant. Two patients were transfused in group 1 and 3 in group 2 (P=0.64). The treatment cost for 30 patients is 13,500 €, for a savings of cells packed at 187 €, an additional cost of 13,313 € in group 1.

CONCLUSION

The use of fibrin haemostatic sealant in TKA did not induce a significant difference in terms of blood or transfusion savings, with a significant cost. We do not recommend its routine use in TKA.

Fibrin sealant in general surgery. Personal experience and literary review

In consideration of the use of fibrin glue in a general surgery department, authors analyze their last two years series. Operations on liver and biliary ducts, bowel and proctologic surgery, thyroid and breast surgery, abdominal wall hernias, fistulas and difficult wounds are considered with a literary review on fibrin sealant.

Use of tissue sealant for day surgery parotidectomy

OBJECTIVES

To evaluate the use of tissue sealant in facilitating day surgery parotidectomy without the use of surgical drains and to consider the potential economic benefit using this technique.

STUDY DESIGN AND SETTING

Prospective cohort study of 21 patients undergoing parotidectomy for nonmalignant disease in a university hospital. Surgery as a day procedure without the use of surgical drains was planned. The costs associated with parotidectomy, including the use of tissue sealant and its delivery system, versus in-patient admission with a drain were calculated and compared.

METHODS AND OUTCOME MEASURES

Parotidectomy was undertaken by one surgeon. Prior to wound closure, the skin flap and wound bed were approximated using Tisseel tissue sealant (Baxter Corp., Mississauga, ON). Data regarding the costs of the tissue sealant, the delivery system, and hospital in-patient stay were obtained to enable an economic comparison. Patients were followed to assess surgical outcome and document any complications.

RESULTS

There were no major surgical complications. One patient required admission for control of postoperative nausea. None of the patients felt that discharge had been premature. The estimated cost advantage of this technique applied to institutions in Canada was $1,775 per case.

CONCLUSIONS

Parotidectomy can be undertaken safely in a day surgery setting without the need for surgical drains. The increased cost associated with the use of tissue sealant compared with surgical drains is greatly overshadowed by the economic advantage of undertaking day surgery. There is a significant potential cost saving to the health care system.

[The influence of application of resorbable fibrinogen-collagen patches on the costs of selected procedures in thoracic surgery]

The application of fibrinogen-collagen patch to air tight closure of the lung parenchyma after pulmonary surgery is profitable for the patients but relatively high price of this product may cause a surgeons' hesitation before using it.

THE AIM OF THE STUDY

To compare the total costs of treatment of two subgroups of patients in whom, during the same surgical procedure, the fibrinogen-collagen patches were applicated or not to achieve air tight closure of the lung surface.

MATERIAL AND METHODS

A total costs of treatment of 122 patients were analyzed. The operations performed were as follows: bullectomy in pulmonary emphysema (n=31), decortication and empyemectomy (n= 16), partial pulmonary resection with coexisting diffuse pleural adhesions (n=75). In 58 patients the surface of the lung was sutured manually or by staplers but in 64 cases fibrinogen-collagen patches were used additionally.

RESULTS

The costs of the surgical procedure were higher in the sub-group of patients in whom fibrinogen-collagen patches were applicated. However, in these patients the hospital stay was shorter and the costs of laboratory tests and x-ray examinations performed after surgery were lower in comparison with patients operated on in traditional way.

CONCLUSION

Application of a relatively expensive product - fibrinogen-collagen patch to seal the lung parenchyma does not cause the increase of the total cost of the treatment.

Laparoscopic repair of inguinal hernias using an intraperitoneal onlay mesh technique and a Parietex composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results

INTRODUCTION

Laparoscopic repair of inguinal hernias is usually achieved by totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) techniques. The intraperitoneal onlay mesh (IPOM) could be an interesting alternative as it is much easier to perform and faster to execute. This technique is subject to correct selection of indications and to demonstration of its safety.

MATERIALS AND METHODS

From January 2003 to January 2006 we performed 61 laparoscopic hernia procedures on 60 selected patients (60 males with a mean age of 60 and mean weight of 76 kg) with an IPOM technique combining the Parietex composite mesh (12 cm circular model) and a fibrin glue (Tissucol) for its fixation. The glue was diluted to increase fixation time and applied to the mesh prior to positioning on the hernia defect.

RESULTS

Mean operative time was 10 minutes. Mean hernia diameter was 2.5 cm (+/- 0.8 cm). 10 hernias were direct, 51 were indirect and 10 out of 61 were recurrent. We did not convert any of the laparoscopic procedures. Mean hospital stay was one day; mean recovery time for working and general physical activities was five days. Patients were checked after one week, 1-3-6 months and 1-2 years. Average follow up time was 23.7 months. 1.6 % of patients showed short-term complications: one trocar site haematoma. No additional complications were reported; particularly, we had no recurrence, no seroma, no mesh migration, and no bowel obstruction or fistula.

CONCLUSION

Results of this study show intraperitoneal (IP) tolerance to this kind of mesh and the safety of its fixation with Tissucol. The absence of recurrence and complications could be a good reason to extend the indication of IPOM hernia repair. However, these preliminary results should be confirmed by longer follow-up.

Application of fibrin glue sealant after hepatectomy does not seem justified: results of a randomized study in 300 patients

OBJECTIVE

To evaluate the efficacy, amount of hemorrhage, biliary leakage, complications, and postoperative evolution after fibrin glue sealant application in patients undergoing liver resection.

SUMMARY BACKGROUND DATA

Fibrin sealants have become popular as a means of improving perioperative hemostasis and reducing biliary leakage after liver surgery. However, trials regarding its use in liver surgery remain limited and of poor methodologic quality.

PATIENTS AND METHODS

A total of 300 patients undergoing hepatic resection were randomly assigned to fibrin glue application or control groups. Characteristics and debit of drainage and postoperative complications were evaluated. The amount of blood loss, measurements of hematologic parameters liver test, and postoperative evolution (particularly involving biliary fistula and morbidity) was also recorded.

RESULTS

Postoperatively, no differences were observed in the amount of transfusion (0.15 +/- 0.66 vs. 0.17 +/- 0.63 PRCU; P = 0.7234) or in the patients that required transfusion (18% vs. 12%; P = 0.2), respectively, for the fibrin glue or control group. There were no differences in overall drainage volumes (1180 +/- 2528 vs. 960 +/- 1253 mL) or in days of postoperative drainage (7.9 +/- 5 vs. 7.1 +/- 4.7). Incidence of biliary fistula was similar in the fibrin glue and control groups, (10% vs. 11%). There were no differences regarding postoperative morbidity between groups (23% vs. 23%; P = 1).

CONCLUSIONS

Application of fibrin sealant in the raw surface of the liver does not seem justified. Blood loss, transfusion, incidence of biliary fistula, and outcome are comparable to patients without fibrin glue. Therefore, discontinuation of routine use of fibrin sealant would result in significant cost saving.

Cost-effectiveness of cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion: a systematic review and economic model

OBJECTIVES

To compare patient outcomes, resource use and costs to the NHS and NHS Blood Transfusion Authority (BTA) associated with cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion.

DATA SOURCES

Electronic databases covering the period 1996-2004 for systematic reviews and 1994-2004 for economic evidence.

REVIEW METHODS

Existing systematic reviews were updated with data from selected randomised controlled trials (RCTs) that involved adults scheduled for elective non-urgent surgery. Any resource use or cost data were extracted for potential use in populating an economic model. Relative risks or weighted mean difference of each outcome for each intervention were assessed, taking into account the number of RCTs included in each outcome and intervention and the presence of any heterogeneity. This allowed indirect comparison of the relative effectiveness of each intervention when the intervention is compared with allogeneic blood transfusion. A decision analytic model synthesised clinical and economic data from several sources, to estimate the relative cost-effectiveness of cell salvage for people undergoing elective surgery with moderate to major expected blood loss. The perspective of the NHS and patients and a time horizon of 1 month were used. The economic model was developed from reviews of effectiveness and cost-effectiveness and clinical experts. Secondary analysis explored the robustness of the results to changes in the timing and costs of cell salvage equipment, surgical procedure, use of transfusion protocols and time horizon of analysis.

RESULTS

Overall, 668 studies were identified electronically for the update of the two systematic reviews. This included five RCTs, of which two were cell salvage and three preoperative autologous donation (PAD). Five published systematic reviews were identified for antifibrinolytics, fibrin sealants and restrictive transfusion triggers, PAD plus erythropoietin, erythropoietin alone and acute normovolaemic haemodilution (ANH). Twelve published studies reported full economic evaluations. All but two of the transfusion strategies significantly reduced exposure to allogeneic blood. The relative risk of exposure to allogeneic blood was 0.59 for the pooled trials of cell salvage (95% confidence interval: 0.48 to 0.73). This varied by the type and timing of cell salvage and type of surgical procedure. For cell salvage, the relative risk of allogeneic blood transfusion was higher in cardiac surgery than in orthopaedic surgery. Cell salvage had lower costs and slightly higher quality-adjusted life years compared with all of the alternative transfusion strategies except ANH. The likelihood that cell salvage is cost-effective compared with strategies other than ANH is over 50%. Most of the secondary analyses indicated similar results to the primary analysis. However, the primary and secondary analyses indicated that ANH may be more cost-effective than cell salvage.

CONCLUSIONS

The available evidence indicates that cell salvage may be a cost-effective method to reduce exposure to allogeneic blood transfusion. However, ANH may be more cost-effective than cell salvage. The results of this analysis are subject to the low quality and reliability of the data used and the use of indirect comparisons. This may affect the reliability and robustness of the clinical and economic results. There is a need for further research that includes adequately powered high-quality RCTs to compare directly various blood transfusion strategies. These should include measures of health status, health-related quality of life and patient preferences for alternative transfusion strategies. Observational and tracking studies are needed to estimate reliably the incidence of adverse events and infections transmitted during blood transfusion and to identify the lifetime consequences of the serious hazards of transfusion on mortality, health status and health-related quality of life.

Fibrin glue for securing the mesh in laparoscopic totally extraperitoneal inguinal hernia repair: a study with a 40-month prospective follow-up period

BACKGROUND

Anchoring the mesh in laparoscopic totally extraperitoneal groin hernia repair (TEP) with human fibrin glue has theoretical advantages. However, these have been supported and reported previously only in animal studies. Before the initiation of large patient trials, the authors wanted to confirm the feasibility, assess the costs, and rule out any flagrant short- and long-term adverse effects of fibrin glue usage in a small series of patients.

METHODS

Nine consecutive TEP repairs with fibrin glue mesh fixation were performed. The perioperative and postoperative outcomes at 1, 16, and 40 months were compared with those for a control group of 96 stapled repairs.

RESULTS

Gluing was easy and is less expensive than stapling. No fibrin glue-related adverse effects were found. The overall outcome was similar to that for stapled repairs, with no indication that the glued repairs were inferior.

CONCLUSIONS

Fibrin glue seems to be a reasonable, feasible, and maybe even competitive alternative to the standard tissue-penetrating mesh fixation. The results of this study justify launching larger trials.

Drug Targets in Colonoscopic Polypectomy: Biological Sealants with Special Reference to Fibrin-Glue (Tissucol)

The increasing outpatient use of colonoscopy in the diagnostic study and prophylaxis of colon diseases has allowed early identification of polypoid neoformations, thus indicating their increased incidence during the asymptomatic phase. In this respect, the application of biological sealants immediately before the polypectomy has represented a novel therapeutic strategy in the treatment of these preneoplastic lesions. The injection of biological sealants with needle under the polyp peduncle or sub-mucosa has demonstrated a protective action on the electrocoagulated area, an anti-haemorrhagic effect owing to the strengthened seal of the eschar that is formed, and a facilitated tissue regeneration, respectively. The author report his experience acquired over the past five years with regard to the use of biological sealant in colonoscopic polypectomy and conclude that biological sealants, a human fibrin glue, which utilises components of the human plasma, may allow a more generous removal of neoformations, the absence of post-polypectomy complications and, consequently, the dramatic reduction of time of patient's admission in the hospital. In fact, all patients were discharged after two hours from polypectomy, thus implying a better quality of life for patients, in the absence of post-operative complications and a reduction of non-medical costs.

Influence of fibrin glue on seroma formation after breast surgery

BACKGROUND

This study was designed to determine the effectiveness of Hemaseel APR fibrin sealant versus conventional drain placement in the prevention of seromas after breast procedures.

METHODS

A prospective, randomized, controlled study of subjects who were randomized into control (drain) and experimental (fibrin) groups was conducted.

RESULTS

Analysis of 82 patients showed similarly matched groups. Seroma formation rate was 45.5% in the control group and 36.8% in the fibrin glue group (P = 0.43). The rate of wound complications was similar. Aspirate volumes were significantly greater in the fibrin glue group. Drain placement saved patients >366 US dollars over fibrin glue.

CONCLUSIONS

Although use of fibrin sealant resulted in a nonsignificant decrease in seroma formation rate compared with that of drain placement, the higher cost involved, cumbersome technique, and higher aspirate volumes tend to indicate that there is no advantage to using fibrin glue over drain placement with the technique described.

Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? Results of a prospective randomized trial

Despite substantial improvements in perioperative mortality, complications, and specifically the development of a pancreatic fistula, remain a common occurrence after pancreaticoduodenectomy. It was the objective of this study to evaluate the role of fibrin glue sealant as an adjunct to decrease the rate of pancreatic fistula after pancreaticoduodenectomy. One hundred twenty-five patients were randomized after pancreaticoduodenal resection only if, in the opinion of the surgeon, the pancreaticojejunal anastomosis was at high risk for development of a pancreatic anastomotic leak. After completion of the pancreaticojejunal anastomosis, the patients were randomized to topical application of fibrin glue sealant to the surface of the anastomosis or no such application. The primary postoperative end points in this study were pancreatic fistula, total complications, death, and length of hospital stay. A total of 59 patients were randomized to the fibrin glue arm, whereas 66 patients were randomized to the control arm and did not receive fibrin glue application. The pancreatic fistula rate in the fibrin glue arm of the study was 26% vs. 30% in the control group (p = not significant [NS]). The mean length of postoperative stay for all patients randomized was similar (fibrin glue = 12.2 days, control = 13.6 days) and the mean length of stay for patients in whom pancreatic fistula developed was also not different (fibrin glue = 18.9 days, control = 21.7 days). There were no differences with respect to total complications or specific complications such as postoperative bleeding, infection, or delayed gastric emptying. These data demonstrate that the topical application of fibrin glue sealant to the surface of the pancreatic anastomosis in this patient population undergoing high-risk pancreaticojejunal anastomosis did not reduce the incidence of pancreatic fistula or total complications after pancreaticodudodenectomy. There seems to be no benefit regarding the use of this substance in this setting.

Use of Tisseel fibrin sealant in neurosurgical procedures: incidence of cerebrospinal fluid leaks and cost-benefit analysis in a retrospective study

OBJECTIVE

To determine the clinical efficacy and cost effectiveness of using the fibrin sealant (FS) Tisseel (Baxter Healthcare Corp., Deerfield, IL) for patients undergoing anterior cranial base, infratemporal, and retromastoid surgical procedures.

METHODS

A retrospective review was performed, comparing two matched populations of patients who underwent surgical procedures using anterior cranial, infratemporal, or retromastoid approaches to intracranial pathological lesions. The incidences of cerebrospinal fluid (CSF) leaks in matched groups treated with the FS Tisseel or treated without FS were compared. The costs of Tisseel use were examined in comparison with the costs of postoperative management of CSF leaks and/or tension pneumocranium with spinal drainage and occasionally surgical reexploration, when lumbar drainage failed.

RESULTS

Patients who received the FS Tisseel exhibited no detectable postoperative CSF leaks or tension pneumocranium. Patients who did not receive Tisseel demonstrated 4 to 16% incidences of postoperative leaks, depending on the surgical approach used. The costs of treating those leaks far exceeded the costs of using Tisseel, even if it were used indiscriminately for all patients.

CONCLUSION

This retrospective review indicates that the FS Tisseel reduces the incidence of postoperative CSF leaks and tension pneumocranium while reducing overall management costs. Further prospective study is needed to determine which patients can benefit most from FS use.

From clinical evidence to everyday practice: implementing findings from a cost-effectiveness analysis for endoscopic injection therapy for upper-gastrointestinal bleeding

BACKGROUND

A previous upper-gastrointestinal bleeding trial showed that patients treated with repeated fibrin glue injection for upper-gastrointestinal bleeding have significantly less rebleeding than those treated with polidocanol.

OBJECTIVE

To analyse the cost and effectiveness of repeated fibrin glue injection and to investigate whether these results change physicians' attitudes.

DESIGN

A retrospective random sample of five hospitals from the previous study, collection of cost identification, and follow-up data on 320 patients (155 in the polidocanol group, 165 in the fibrin glue group).

METHODS

An incremental cost-effectiveness analysis and comparison of outcomes was performed using chi-squared tests and Kaplan-Meier survival analysis. A survey was carried out using a questionnaire in the five hospitals on local guidelines for management of ulcer bleeding, and its results were analysed qualitatively. The measure of effectiveness is the number of prevented rebleedings. Further variables were length of hospital stay and length of intensive care unit (ICU) stay.

RESULTS

The cost for the prevention of one additional rebleeding by repeated fibrin glue treatment amounts to 14,316 +/- 4981 euros (incremental cost-effectiveness ratio). There were no significant differences in length of stays in ICU or in hospital. The physicians did not change their management plans for patients with upper-gastrointestinal bleeding. In a survey, it was seen that other factors, such as local guidelines, attitudes towards new treatment options, and ease of handling of drugs, are more important than a result of a single study for a behavioural change of the doctors.

CONCLUSIONS

The study was not designed prospectively to address a pharmacoeconomic question. As relevant variables (e.g. length of ICU stay) could not be reliably ascertained retrospectively, this may lead to biased estimates of the incremental cost-effectiveness ratio.

[Endoscopic treatment of intestinal anastomotic leakage in low anterior resection of the rectum by using fibrin adhesive. Our experience]

BACKGROUND

Personal experience about treatment of anastomotic leakage in low anterior resection of the rectum by using human fibrin adhesive "Tissucol" is reported.

METHODS

Eight cases of anastomotic leakage treated with using human fibrin adhesive "Tissucol", are analyzed in a retrospective study. Patients had three/six months-one year follow up. Treatment with human fibrin adhesive "Tissucol" was performed in our Endoscopic ambulatory. Six cases had either an immediate resolution or an ambulatorial follow-up; in 2 cases only, general complications forced to a prolonged hospital stay. The study concerns 58 patients subjected to low anterior resection of the rectum and endoscopic treatment of 8/58 patients with anastomotic leakage. Fistulas were sealed with human fibrin adhesive "Tissucol" by using flexible endoscope. Anastomotic leakage identification leakage was made and low anterior resection of the rectum and sealing with human fibrin adhesive "Tissucol" were performed.

RESULTS

Complete sealing of fistula and rectum patent.

CONCLUSIONS

The excellent results obtained with this non invasive and fast treatment, easily practicable even in ambulatorial regimen, lead the authors to consider it effective and as first-choice treatment of this dangerous complication. The cost/benefit ratio is favorable if compared with the long hospital stay required for other treatments, which also present loaded high morbidity and mortality.

Tissucol application in dermolipectomy and incisional hernia repair

Biological adhesives have a lot of applications in surgical procedures. Here we present a prospective study with the aim of analyzing results of the application of Tissucol between the muscle layers and subcutaneous tissue after incisional hernia repair with polypropylene mesh and associated dermolipectomy. We assess clinical and technical parameters, local morbidity, and hospital stay. Fifty-six patients were divided into two groups. Patients with whom we used fibrin glue were older, with more obesity (P < 0.005) with associated diseases, and their incisional hernias were larger and more complicated to repair. Patients in the Tissucol group developed less local morbidity (hematomas or abscesses; P < 0.01), had a shorter mean hospital stay (P < 0.01), and required less wound care. The use of Tissucol improves the results of surgical repair of large abdominal incisional hernias repaired by mesh placement and dermolipectomy, and it decreases global morbidity and hospital stay are reduced.

The use of fibrin glue in refractory coagulopathic epistaxis

Epistaxis can be particularly difficult to treat when a patient has a coagulopathy, even if the area bleeding is visible. Where routine measures fail to arrest the bleeding (e.g., nasal cautery and packing), the application of fibrin glue is successful in stopping the bleeding without having to address the underlying coagulopathy. Ten patients with epistaxis secondary to an underlying coagulopathy were treated by local application of fibrin glue to the area bleeding. The bleeding stopped immediately in all patients when the fibrin glue was applied. No patients suffered complications. Fibrin glue application should be considered as a cost-effective means of controlling epistaxis from an identifiable area in the nasal cavity in patients with a coagulopathy.

Safety and efficacy of currently available fibrin tissue adhesives

PURPOSE

The purpose of this study is to review preparation methods, bonding power, preparation time, and costs associated with currently available autologous and homologous fibrin tissue adhesive preparations.

METHODS

Two autologous fibrin tissue adhesive preparations (AFTA-A and AFTA-E), a single-donor homologous preparation, and 2 multiple-donor pooled homologous fibrin tissue adhesives, Vi-Guard and Tisseel, were evaluated and compared in relation to bonding power, preparation time, cost, bicompatibility, and biodegradability.

RESULTS

Vi-Guard and Tisseel showed significantly greater bonding strengths than their single-donor counterparts. AFTA-C offers the quickest preparation time. All preparations were found to be similar in biocompatibility and biodegradability in soft tissue tests. Histology showed no infection or tissue reaction from adhesive exposure in any of the preparations.

CONCLUSION

The optimal choice of a fibrin tissue adhesive is determined by the particular clinical indication. Currently available fibrin tissue adhesives vary appreciably in their bonding strength, cost, level of exposure risk, and preparation methods and times. Autologous preparations, which offer optimal safety, lack the strength and availability characteristics found with the multiple-donor preparations.

The use of fibrin glue as an operative sealant in dental extraction in bleeding disorder patients

Controlling haemorrhage by using a celluloid splint as an adjunctive therapy in patients with bleeding disorders is very beneficial in dental extraction. However, this technique still requires specific replacement therapy. The use of fibrin glue as a local treatment in dental extraction, without the use of any blood product replacement, recommended to improve efficiency in controlling haemorrhage during dental extraction. This method was modified using a combination of celluloid splint and fibrin glue for use in dental extraction in bleeding disorder patients. It was found that this method was effective in controlling bleeding, was cost effective, did not require replacement therapy and posed no risk of viral transmission.

[Endoscopic hemostasis in bleeding gastroduodenal ulcer--a contribution to the cost aspect]

Endoscopic injections of fibrin glue for the treatment of gastroduodenal ulcer hemorrhage have been increasingly used instead of sclerosing agents since 1987. Sclerosants have the drawback that they themselves have tissue-destroying or rather ulcerogenic effects. A difficult form of administration and a relatively high price are set against the good biological properties of the fibrin glue. In a randomized study comparing fibrin glue with polidocanol there was a statistically significant lower rebleeding rate in the fibrin group. The data of this study were analysed with regard to economic aspects. They showed an improved cost-benefit and cost-effectiveness ratio of the fibrin glue compared with polidocanol.

Fibrin sealant in surgery of patients with a hemorrhagic diathesis

The utilization of fibrin sealants in patients with hemostatic disorders has hitherto been very limited. Our experiences from 40 major and 8 minor surgical procedures, 10 circumcisions and 118 tooth extractions in 106 patients with hemophilia A, B or von Willebrand's disease, almost exclusively of the severe form, respectively, demonstrate the benefits regarding reduction of blood loss and requirements for systemic replacement therapy. The literature on the use of fibrin sealants in this group of patients, which mainly concerns dental procedures, is reviewed and compared with our data. The importance of the composition of the glue is also discussed in detail.

Cost evaluation of two methods of post tooth extraction hemostasis in patients on anticoagulant therapy

The classical management of patients on oral anticoagulant therapy included hospitalisation, cessation of the anticoagulant agent, and extraction of teeth when the prothrombine levels rise. This method was substituted in the High Risk Dental Clinic at Barzilai Medical Center in Ashkelon by use of a tissue sealant (Tisseel) which does not need hospitalisation nor cessation of the anticoagulant therapy. In comparing the last 23 sessions employing the former method to the first 23 sessions using the new method there were significant differences in the cost effectiveness for the health system, provider, insurer and patient. Despite the fact that from the health system point of view the new method is much more cost effective, there is no financial incentive for the provider (hospital) nor awareness on the part of the insurer (General Sick Fund) to embrace it and 'market' it.

Comparison of topical hemostatic agents in elective hepatic resection: a clinical prospective randomized trial

To compare the difference in efficacy of microcrystalline collagen powder (CL) and fibrin glue (FG) in elective hepatic resection, 62 patients (female 14, male 48) with ages ranging from 51 to 75 years were randomly allocated to receive either CL or FG as a topical agent during hepatectomy. There were no significant differences between the patients treated with CL (n = 31) and those treated with FG (n = 31) regarding sex, age, liver function, coagulation function, platelet counts, type of liver resection, and operative duration. A dry cut surface of the liver was obtained during surgery in 27 (87%) patients and 25 (81%) patients treated with CL and FG, respectively. Both CL and FG showed similar hemostatic effects. The CL and FG groups were not different in terms of postoperative rebleeding, bile leakage, or morbidity and mortality rates (6% vs. 6%, 6% vs. 6%, 45% vs. 39%, and 13% vs. 10%, respectively). Of the 52 patients with a dry cut surface of the liver during surgery, 3 patients in the CL group encountered rebleeding (n = 1) or bile leakage (n = 2) from the cut surface postoperatively, while no such complications were noted in the FG group. The results seem to favor FG for reliability in the postoperative period. The application of CL or FG may be better performed with consideration of the characteristics of each agent.

[Radical prostatectomy and biologic glue]

Fibrin glue (reconstituted fibrin glue-Tissu-col-Immuno-France) was used in 24 patients following radical prostatectomy with ilio-obturator lymphadenectomy (Group II) to improve haemostasis of the operative field, to decrease or eliminate lymphatic oozing and to promote healing of the urethrovesical anastomosis. The results in terms of duration of drainage, quantity of fluid evacuated by these drains, operative complications and length of hospital stay were compared to those obtained in 24 clinically identical patients operated previously without the use of fibrin glue (Group I). Although fibrin glue is easy to use, ensures a particularly dry operative field at the end of the operation and does not induce any infectious complications (abscess, hepatitis), it increases the cost of the operation (5 ml vial = 2,500 FF) and the use of this product does not reduce the drainage time (Group I: 7 +/- 4.6 days; Group II: 8.5 +/- 5.4 days) the volume of blood or lymphatic discharge (Group I: 500 +/- 570 ml; Group II: 660 +/- 825 ml) or the length of hospital stay (Group I: 16.5 +/- 4.8 days; Group II: 17.4 +/- 5.5 days). These results argue against the routine use of fibrin glue in radical prostatectomy.