Evaluation of the efficacy and safety of endoscopic band ligation in the treatment of bleeding from mild to moderate gastric varices type 1

BACKGROUND

According to practice guidelines, endoscopic band ligation (EBL) and endoscopic tissue adhesive injection (TAI) are recommended for treating bleeding from esophagogastric varices. However, EBL and TAI are known to cause serious complications, such as hemorrhage from dislodged ligature rings caused by EBL and hemorrhage from operation-related ulcers resulting from TAI. However, the optimal therapy for mild to moderate type 1 gastric variceal hemorrhage (GOV1) has not been determined. Therefore, the aim of this study was to discover an individualized treatment for mild to moderate GOV1.

AIM

To compare the efficacy, safety and costs of EBL and TAI for the treatment of mild and moderate GOV1.

METHODS

A clinical analysis of the data retrieved from patients with mild or moderate GOV1 gastric varices who were treated under endoscopy was also conducted. Patients were allocated to an EBL group or an endoscopic TAI group. The differences in the incidence of varicose relief, operative time, operation success rate, mortality rate within 6 wk, rebleeding rate, 6-wk operation-related ulcer healing rate, complication rate and average operation cost were compared between the two groups of patients.

RESULTS

The total effective rate of the two treatments was similar, but the efficacy of EBL (66.7%) was markedly better than that of TAI (39.2%) (P < 0.05). The operation success rate in both groups was 100%, and the 6-wk mortality rate in both groups was 0%. The average operative time (26 min) in the EBL group was significantly shorter than that in the TAI group (46 min) (P < 0.01). The rate of delayed postoperative rebleeding in the EBL group was significantly lower than that in the TAI group (11.8% vs 45.1%) (P < 0.01). At 6 wk after the operation, the healing rate of operation-related ulcers in the EBL group was 80.4%, which was significantly greater than that in the TAI group (35.3%) (P < 0.01). The incidence of postoperative complications in the two groups was similar. The average cost and other related economic factors were greater for the EBL than for the TAI (P < 0.01).

CONCLUSION

For mild to moderate GOV1, patients with EBL had a greater one-time varix eradication rate, a greater 6-wk operation-related ulcer healing rate, a lower delayed rebleeding rate and a lower cost than patients with TAI.

Incidence of Skin Sensitivity Following Dermabond Application in Pediatric Orthopedic Surgery

BACKGROUND

Dermabond (Dermabond; Ethicon, Sommerville, NJ), is a skin adhesive commonly utilized in pediatric orthopedic surgery for postoperative wound care. Few studies have examined outcomes of Dermabond exposure in children. The purpose of this study is to estimate the incidence of skin reactions following Dermabond exposure in pediatric orthopedic surgery and investigate potential risk factors associated with Dermabond sensitivity.

METHODS

This was a retrospective study of a level-one pediatric trauma center. All orthopaedic surgeries in 2019 were screened for Dermabond application. Three surgeons with the highest rates of Dermabond application defined our cohort. Out of 2990 surgeries in 2019, the 3 surgeons performed 234 surgeries with Dermabond. Postoperative reactions and repeat Dermabond exposures were collected for these 234 patients. Subjects with known allergies to Dermabond were excluded. Reactions were defined. as discoloration, irritation, and wound dehiscence. Significant differences between patients with repeat Dermabond exposures and those without were determined using χ 2 analysis. Associations between patient characteristics and sensitivity were determined using logistic regression analysis. P values less than 0.05 were considered significant.

RESULTS

In all, 234 patients were included for analysis. The mean age at surgery was 12.5 years (SD 6.1), and 39% (92/234) of the cohort was male. Thirty-two patients (14%) experienced skin reactions during the study period (95% CI=7%-19%). Reactions most frequently included. erythema (10/32; 31%) and itchiness (10/32; 31%). Reactions were most frequently treated with oral antibiotics, Benadryl, or a dressing change. Of 144 patients with 1 Dermabond exposure, 17 (12%) experienced reactions (95% CI=7%-18%). Of 128 patients experiencing a repeat Dermabond exposure, 27 (21%) experienced reactions (95% CI=19%-34%, P =0.03). Age, surgical procedure, and surgical location were not, associated with a variable rate of sensitivity.

CONCLUSIONS

Sensitivity to Dermabond after pediatric orthopedic surgery occurred at a higher rate than seen in adults, and patients with multiple Dermabond exposures experienced significantly higher sensitivity than patients with a single exposure. Increased awareness of this potential complication is needed to help inform decisions regarding Dermabond's application in pediatric orthopedics.

Outcomes of 2-octyl cyanoacrylate skin adhesives following musculoskeletal oncology surgery: A STROBE-compliant observational study

ABSTRACT

2-octyl cyanoacrylate (2OCA) is a high-viscosity medical-grade tissue adhesive that is routinely used. However, no studies have evaluated its use in musculoskeletal surgery.We enrolled 99 patients who underwent musculoskeletal surgery. 2OCA was chosen for wound closure and was performed by a specific surgeon for all patients. The drying times for the adhesive were recorded, and photographs were obtained intra-operatively. Posttreatment follow-up consisted of queries regarding pain level and recording incisional dehiscence, wound infection, hematoma, and incisional bleeding. Data collection was performed postoperatively at 48 hours, 5 to 10 days, 14 days, and 30 days. Other adverse events were documented.2OCA was applied to 110 incisions in 99 patients, comprising 62 female and 37 male patients. The mean age of patients was 50.41 (±16.83) years; mean incision length was 10.24 (±5.7) cm, and the mean pain score using a visual analogue scale was 2.37 on a postoperative day 7. The mean drying time was 1.81 (±0.59) minutes; 91 (91%) patients reported excellent and superior satisfaction, and the remaining patients reported "good" (6%) and "fair" (2%) satisfaction. The percentages of dehiscence, hematoma and keloid formation were considerably low.In this study, 2OCA was safe for musculoskeletal oncology surgical incisions. The incidence of postoperative adverse events was low. However, some patients develop hematomas. Postoperative pain was low, and patient satisfaction was high. 2OCA can be a practical alternative to traditional suture closure for skin incisions after musculoskeletal surgery.

Postoperative contact dermatitis caused by skin adhesives used in orthopedic surgery: Incidence, characteristics, and difference from surgical site infection

Skin adhesives are used to close clean surgical wounds. We aimed to investigate the incidence of skin adhesive-related contact dermatitis and the characteristics that differentiate it from a surgical site infection.We retrospectively analyzed patients whose surgical wound was closed using a liquid skin adhesive (Dermabond Prineo skin closure system, Ethicon, NJ) by a single surgeon between March 2018 and June 2020. Medical records were reviewed to evaluate complications indicating contact dermatitis, including wound infections and hematomas.We included 143 patients (men, 59; women, 84; mean age, 60.8 years). No patient had an early surgical site infection or wound dehiscence, but 4 (2.8%) developed postoperative contact dermatitis (week 7, 1; week 4, 2; day 9, 1). Manifestations included eczema and pruritus, without local heat or wound discharge. All cases resolved without complications, including infection.Contact dermatitis occurred in 2.8% of patients who received liquid skin adhesive, and the symptoms differed from those of surgical site infection. Patients should be informed about the risk of contact dermatitis before applying a liquid skin adhesive.

Liver retraction using n-butyl-2-cyanoacrylate glue during laparoscopic cholecystectomy

There might be a thick "protrusion" in the visceral surface of hepatic quadrate lobe during the laparoscopic cholecystectomy (LC), which affects the surgical fields and consequently triggers high risks of biliary tract injury. Although n-butyl-2-cyanoacrylate (NBCA) glue has been applied to laparoscopic upper abdominal surgery for liver retraction, there is still no consensus on its safety and feasibility in LC. In this study, we investigated the safety, feasibility, and effectiveness of liver retraction using NBCA glue for these patients which have the thick "protrusion" on the square leaf surface of the liver during LC.Fifty-seven patients presenting thick "protrusion" hepatic quadrate lobe were included in our retrospective study. We performed LC in the presence of NBCA glue (n = 30, NBCA group) and absence of NBCA glue (n = 27, non-NBCA group), respectively. NBCA was used to fix the thick "protrusion" of the liver leaves to the hepatic viscera surface, which contributed to the revelation of the gallbladder triangle. The operation time, blood loss, postoperative hospitalization, and liver function were compared between the 2 groups.Both the groups' patients accomplished the operation in the laparoscopy. There was no mortality and no additional incision during operation. No severe complications including bile duct injury were available after surgery and no postoperative NBCA-related complications occurred after 9- to 30 months' follow-up. The time of operation in NBCA group showed significant decrease compared with that of non-NBCA group (48.33 ± 16.15 vs 65.00 ± 22.15 minutes, P < .01). There were no significant differences in blood loss, postoperative hospital stays, and the preoperative and postoperative liver function between the two groups (P > .05). Besides, no significant differences were noticed in major clinical characteristics between the 2 groups (P > .05).Liver retraction using NBCA during LC for thick "protrusion" hepatic quadrate lobe patients is safe, effective, and feasible.

Allergic Contact Dermatitis to Dermabond Prineo After Elective Orthopedic Surgery

The Dermabond Prineo skin closure system (Ethicon, Somerville, New Jersey) is a wound closure device that combines a 2-octyl cyanoacrylate liquid adhesive and a self-adhesive polyester mesh. Although cyanoacrylates traditionally have been associated with low rates of sensitization, allergic contact dermatitis (ACD) to Dermabond products is being increasingly reported after orthopedic surgery. The authors describe the first case series of ACD to Dermabond Prineo where patch testing confirmed the diagnosis in all patients. Six patients who had suspected Dermabond Prineo ACD after lower limb orthopedic surgery were assessed. Of these patients, 5 had itching within 4 days of surgery and rash within 5 days. All 5 of these patients reported previous exposure to Dermabond products. All patients had removal of the adhesive and mesh earlier than planned and were treated with corticosteroids. In addition, 4 patients received systemic antibiotics; however, only 1 had a microbiologically confirmed superficial skin infection. In all patients, the dermatitis resolved within 2 weeks of dressing removal, with no adverse effect on the orthopedic outcome. Patch testing showed positive reactions to Dermabond Prineo glue for all patients. Orthopedic surgeons should be aware of the potential for ACD to Dermabond Prineo, especially among patients with previous exposure to Dermabond products. The authors discuss the risk factors for ACD to Dermabond Prineo in the orthopedic cohort and provide recommendations for prevention and management. [Orthopedics. 2020;43(6):e515-e522.].

Fibrin and Thrombin Sealants in Vascular and Cardiac Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

In vascular and cardiac surgery, the ability to maintain haemostasis and seal haemorrhagic tissues is key. Fibrin and thrombin based sealants were introduced as a means to prevent or halt bleeding during surgery. Whether fibrin and thrombin sealants affect surgical outcomes is poorly established. A systematic review and meta-analysis was performed to examine the impact of fibrin or thrombin sealants on patient outcomes in vascular and cardiac surgery.

DATA SOURCES

Cochrane CENTRAL, Embase, and MEDLINE, as well as trial registries, conference abstracts, and reference lists of included articles were searched from inception to December 2019.

REVIEW METHODS

Studies comparing the use of fibrin or thrombin sealant with either an active (other haemostatic methods) or standard surgical haemostatic control in vascular and cardiac surgery were searched for. The Cochrane risk of bias tool and the ROBINS-I tool (Risk Of Bias In Non-randomised Studies - of Interventions) were used to assess the risk of bias of the included randomised and non-randomised studies; quality of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Two reviewers screened studies, assessed risk of bias, and extracted data independently and in duplicate. Data from included trials were pooled using a random effects model.

RESULTS

Twenty-one studies (n = 7 622 patients) were included: 13 randomised controlled trials (RCTs), five retrospective, and three prospective cohort studies. Meta-analysis of the RCTs showed a statistically significant decrease in the volume of blood lost (mean difference 120.7 mL, in favour of sealant use [95% confidence interval {CI} -150.6 - -90.7; p < .001], moderate quality). Time to haemostasis was also shown to be reduced in patients receiving sealant (mean difference -2.5 minutes [95% CI -4.0 - -1.1; p < .001], low quality). Post-operative blood transfusions, re-operation due to bleeding, and 30 day mortality were not significantly different for either RCTs or observational data.

CONCLUSION

The use of fibrin and thrombin sealants confers a statistically significant but clinically small reduction in blood loss and time to haemostasis; it does not reduce blood transfusion. These Results may support selective rather than routine use of fibrin and thrombin sealants in vascular and cardiac surgery.

Open Inguinal Hernia Repair: A Network Meta-analysis Comparing Self-Gripping Mesh, Suture Fixation, and Glue Fixation

The most troublesome complications of inguinal hernia repair are recurrent herniation and chronic pain. A multitude of technological products dedicated to abdominal wall surgery, such as self-gripping mesh (SGM) and glue fixation (GF), were introduced in alternative to suture fixation (SF) in the attempt to lower the postoperative complication rates. We conducted an electronic systematic search using MEDLINE databases that compared postoperative pain and short- and long-term surgical complications after SGM or GF and SF in open inguinal hernia repair. Twenty-eight randomized controlled trials totaling 5495 patients met the inclusion criteria and were included in this network meta-analysis. SGM and GF did not show better outcomes in either short- or long-term complications compared to SF. Patients in the SGM group showed significantly more pain at day 1 compared to those in the GF group (VAS score pain mean difference: - 5.2 Crl - 11.0; - 1.2). The relative risk (RR) of developing a surgical site infection (RR 0.83; Crl 0.50-1.32), hematoma (RR 1.9; Crl 0.35-11.2), and seroma (RR 1.81; Crl 0.54-6.53) was similar in SGM and GF groups. Both the SGM and GF had a significantly shorter operative time mean difference (1.70; Crl - 1.80; 5.3) compared to SF. Chronic pain and hernia recurrence did not statistically differ at 1 year (RR 0.63; Crl 0.36-1.12; RR 1.5; Crl 0.52-4.71, respectively) between SGM and GF. Methods of inguinal hernia repair are evolving, but there remains no superiority in terms of mesh fixation. Ultimately, patient's preference and surgeon's expertise should still lead the choice about the fixation method.

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.

Mechanochemical ablation versus cyanoacrylate adhesive for the treatment of varicose veins: study protocol for a randomised controlled trial

BACKGROUND

Thermal ablation techniques have become the first-line treatment of truncal veins in the management of chronic venous disease (CVD). Despite excellent outcomes, these methods are often associated with pain; generally due to their use of heat and the necessity of fluid infiltration around the vein. More recently, novel non-thermal techniques, such as mechanochemical ablation (MOCA) and cyanoacrylate adhesive (CAE) have been developed to overcome these unwelcome effects. So far, the novel techniques have been found to have similar efficacy to thermal methods, yet no direct comparisons between the non-thermal treatment techniques have been conducted to date, giving rise to this study.

METHODS/DESIGN

This is a prospective, multicentre, randomised clinical trial, recruiting patients with truncal saphenous incompetence. Patients will be randomised to undergo either MOCA or CAE truncal ablation, followed by treatment of any varicosities. All patients will be required to wear compression stockings for 4 days post intervention. The primary outcome measure is the pain score immediately following completion of truncal ablation, measured by a 100-mm Visual Analogue Scale (VAS). The secondary outcomes are entire treatment pain scores, clinical scores, quality of life scores, occlusion rates, time to return to usual activities/work at 2 weeks, 3, 6 and 12 months. Re-intervention rate will be considered from the third month. Cost-effectiveness will be assessed for each intervention at 12 months. The study is powered to detect a mean 10-mm difference in maximum pain score. Allowing for loss to follow-up, the total target recruitment is 180 patients.

DISCUSSION

The study will be the first study to compare MOCA against CAE and is designed to determine which method causes less pain. Completion of this study is expected to be the end of 2019.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03392753 . Registered on 17 November 2017.

2-Octylcyanoacrylate for the prevention of anastomotic leak

BACKGROUND

Anastomotic leak after colorectal surgery is a significant cause of morbidity and mortality. The aim of this study was to evaluate the impact of a reinforced colo-colonic anastomosis with tissue adhesive, 2-octylcyanoacrylate (2-OCA), on the integrity of anastomotic healing as measured by anastomotic bursting pressure.

METHODS

Sixty-eight female Sprague-Dawley rats underwent a rectosigmoid colon transection and a sutured end-to-end anastomosis followed by randomization to receive no further intervention or reinforcement with the tissue adhesive, 2-OCA. After seven postoperative days, a macroscopic assessment of the anastomosis, mechanical assessment to determine anastomotic bursting pressure, and a detailed semi-quantitative histopathologic healing assessment were performed.

RESULTS

Thirty-four animals were randomized to each group. Study characteristics did not differ between the groups. There was also no difference in the degree of adhesions present postoperatively. Although there was no difference between the net proximal and distal luminal areas in the two groups (0.37 cm²versus 0.55 cm², P = 0.26), the 2-OCA group exhibited evidence of stricture in 15% of anastomoses as compared with 3% in the suture-only group (P < 0.0001). Histologically, the presence of only fibroblasts density was statistically more evident in the 2-OCA group compared with the sutured-only anastomosis (P = 0.0183). There was not a significant increase in mechanical strength in the 2-OCA group (238.9 mm Hg) versus in the suture-only group (231.8 mm Hg). There was no difference in the rate of anastomotic leak in the 2-OCA as compared with the suture-only group (9.1 versus 8.8%).

CONCLUSIONS

Application of 2-OCA to reinforce a colo-colonic anastomosis clinically provides no benefit to its mechanical strength and detrimentally increases the rate of obstruction and/or stricture in this in vivo model.

Biomechanical and Histologic Evaluation of LifeMesh™: A Novel Self-Fixating Mesh Adhesive

Mesh fixation with the use of adhesives results in an immediate and total surface area adhesion of the mesh, removing the need for penetrating fixation points. The purpose of this study was to evaluate LifeMesh™, a prototype mesh adhesive technology which coats polypropylene mesh. The strength of the interface between mesh and tissue, inflammatory responses, and histology were measured at varying time points in a swine model, and these results were compared with sutures. Twenty Mongrel swine underwent implantation of LifeMesh™ and one piece of bare polypropylene mesh secured with suture (control). One additional piece of either LifeMesh™ or control was used for histopathologic evaluation. The implants were retrieved at 3, 7, and 14 days. Only 3- and 7-day specimens underwent lap shear testing. On Day 3, LifeMesh™ samples showed considerably less contraction than sutured samples. The interfacial strength of Day 3 LifeMesh™ samples was similar to that of sutured samples. At seven days, LifeMesh™ samples continued to show significantly less contraction than sutured samples. The strength of fixation at seven days was greater in the control samples. The histologic findings were similar in LifeMesh™ and control samples. LifeMesh™ showed significantly less contraction than sutured samples at all measured time points. Although fixation strength was similar at three days, the interfacial strength of LifeMesh™ remained unchanged, whereas sutured controls increased by day 7. With histologic equivalence, considerably less contraction, and similar early fixation strength, LifeMesh™ is a viable mesh fixation technology.

Contact Dermatitis Reaction to 2-Octyl Cyanoacrylate Following 3 Orthopedic Procedures

Two-octyl cyanoacrylate is a popular skin adhesive used for closing surgical incisions. Since Food and Drug Administration approval in 1998, the few reports of adverse reactions following its use have primarily been limited to the nonorthopedic literature. The authors present a case series of contact dermatitis associated with 2-octyl cyanoacrylate following orthopedic surgery and a review of the literature on the diagnosis and treatment of this complication. All 3 patients presented with blistering around their incisions within 2 weeks of surgery and responded to treatment involving removal of the offending agent and use of oral diphenhydramine and hydroxyzine and topical triamcinolone. One case was complicated by a draining hematoma, requiring irrigation and debridement. Complete resolution occurred in all cases. This case series is intended to increase awareness in the orthopedic community of allergic contact dermatitis to 2-octyl cyanoacrylate and its appropriate treatment. [Orthopedics. 2018; 41(2):e289-e291.].

Octyl-2-cyanoacrylate Tissue Glue (Dermabond) versus Monocryl 6 × 0 Sutures in Lip Closure

Objective:

To assess the value of octyl-2-cyanoacrylate tissue glue in lip closure versus Monocryl stitches.

Design:

Closure of a cleft lip can be done using transcutaneous Monocryl 6 × 0 sutures or using octyl-2-cyanoacrylate tissue glue (Dermabond). In 15 consecutive patients, the cleft lip was closed with Monocryl 6 × 0 and in another 15 consecutive patients, Dermabond was applied. Outcome parameters were complications, satisfaction of the parents with the cosmetic result, and the cosmetic result as judged by professionals. Satisfaction of the parents was assessed using a questionnaire and a visual analog scale. The cosmetic result as judged by professionals was measured by rating standardized pictures according to a visual analog scale.

Setting:

A tertiary referral center for children with craniofacial anomalies.

Results:

Complications were equal in both patient groups (p = .273). Satisfaction of the parents, as well as the professionals, with the cosmetic result did not show significant differences between the Monocryl 6 × 0 and the Dermabond groups (p = .922 and .983, respectively). However, parents were significantly more positive about the cosmetic result than the professionals were (p = .000).

Conclusion:

The results of lip closure using Dermabond tissue glue equal the cosmetic results of lip closure using transcutaneous Monocryl 6 × 0 sutures.

A mixed-methods feasibility and external pilot study to inform a large pragmatic randomised controlled trial of the effects of surgical wound dressing strategies on surgical site infections (Bluebelle Phase B): study protocol for a randomised controlled trial

BACKGROUND

Surgical site infections (SSIs) are common, occurring in up to 25% of > 4 million operations performed in England each year. Previous trials of the effect of wound dressings on the risk of developing a SSI are of poor quality and underpowered.

METHODS/DESIGN

This study is a feasibility and pilot trial to examine the feasibility of a full trial that will compare simple dressings, no dressing and tissue-glue as a dressing. It is examining the overall acceptability of trial participation, identifying opportunities for refinement, testing the feasibility of and validating new outcome tools to assess SSI, wound management issues and patients' wound symptom experiences. It is also exploring methods for avoiding performance bias and blinding outcome assessors by testing the feasibility of collecting wound photographs taken in theatre immediately after wound closure and, at 4-8 weeks after surgery, taken by participants themselves or their carers. Finally, it is identifying the main cost drivers for an economic evaluation of dressing types. Integrated qualitative research is exploring acceptability and reasons for non-adherence to allocation. Adults undergoing primary elective or unplanned abdominal general surgery or Caesarean section are eligible. The main exclusion criteria are abdominal or other major surgery less than three months before the index operation or contraindication to dressing allocation. The trial is scheduled to recruit for nine months. The findings will be used to inform the design of a main trial.

DISCUSSION

This pilot trial is the first pragmatic study to randomise participants to no dressing or tissue-glue as a dressing versus a simple dressing. Early evidence from the ongoing pilot shows that recruitment is proceeding well and that the interventions are acceptable to participants. Combined with the qualitative findings, the findings will inform whether a main, large trial is feasible and, if so, how it should be designed.

TRIAL REGISTRATION

ISRCTN49328913 . Registered on 20 October 2015.

Fibrin glue for pilonidal sinus disease

BACKGROUND

Pilonidal sinus disease is a common condition that mainly affects young adults. This condition can cause significant pain and impairment of normal activities. No consensus currently exists on the optimum treatment for pilonidal sinus and current therapies have various advantages and disadvantages. Fibrin glue has emerged as a potential treatment as both monotherapy and an adjunct to surgery.

OBJECTIVES

To assess the effects of fibrin glue alone or in combination with surgery compared with surgery alone in the treatment of pilonidal sinus disease.

SEARCH METHODS

In December 2016 we searched: the Cochrane Wounds Specialised Register; CENTRAL; MEDLINE; Embase and CINAHL Plus. We also searched clinical trials registries and conference proceedings for ongoing and unpublished studies and scanned reference lists to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only. We included studies involving participants of all ages and studies conducted in any setting. We considered studies involving people with both new and recurrent pilonidal sinus. We included studies which evaluated fibrin glue monotherapy or as an adjunct to surgery.

DATA COLLECTION AND ANALYSIS

Two study authors independently extracted data and assessed risk of bias. We used standard methods expected by Cochrane.

MAIN RESULTS

We included four RCTs with 253 participants, all were at risk of bias. One unpublished study evaluated fibrin glue monotherapy compared with Bascom's procedure, two studies evaluated fibrin glue as an adjunct to Limberg flap and one study evaluated fibrin glue as an adjunct to Karydakis flap.For fibrin glue monotherapy compared with Bascom's procedure, there were no data available for the primary outcomes of time to healing and adverse events. There was low-quality evidence of less pain on day one after the procedure with fibrin glue monotherapy compared with Bascom's procedure (mean difference (MD) -2.50, 95% confidence interval (CI) -4.03 to -0.97) (evidence downgraded twice for risk of performance and detection bias). Fibrin glue may reduce the time taken to return to normal activities compared with Bascom's procedure (mean time 42 days with surgery and 7 days with glue, MD -34.80 days, 95% CI -66.82 days to -2.78 days) (very low-quality evidence, downgraded as above and for imprecision).Fibrin glue as an adjunct to the Limberg flap may reduce the healing time from 22 to 8 days compared with the Limberg flap alone (MD -13.95 days, 95% CI -16.76 days to -11.14 days) (very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and imprecision). It is uncertain whether use of fibrin glue affects the incidence of postoperative seroma (an adverse event) (risk ratio (RR) 0.27, 95% CI 0.05 to 1.61; very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and imprecision). There was low-quality evidence that fibrin glue, as an adjunct to Limberg flap, may reduce postoperative pain (median 2 versus 4; P < 0.001) and time to return to normal activities (median 8 days versus 17 days; P < 0.001). The addition of fibrin glue to the Limberg flap may reduce the length of hospital stay (MD -1.69 days, 95% CI -2.08 days to -1.29 days) (very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and for unexplained heterogeneity).A single RCT evaluating fibrin glue as an adjunct to the Karydakis flap did not report data for the primary outcome of time to healing. It is uncertain whether fibrin glue with the Karydakis flap affects the incidence of postoperative seroma (adverse event) (RR 3.00, 95% CI 0.67 to 13.46) (very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and for imprecision). Fibrin glue as an adjunct to Karydakis flap may reduce length of stay but this is highly uncertain (mean 2 days versus 3.7 days; P < 0.001, low-quality evidence downgraded twice for risk of selection, performance and detection bias).

AUTHORS' CONCLUSIONS

Current evidence is uncertain regarding any benefits associated with fibrin glue either as monotherapy or as an adjunct to surgery for people with pilonidal sinus disease. We identified only four RCTs and each was small and at risk of bias resulting in very low-quality evidence for the primary outcomes of time to healing and adverse events. Future studies should enrol many more participants, ensure adequate randomisation and blinding, whilst measuring clinically relevant outcomes.

Fibrin glue versus sutures for conjunctival autografting in primary pterygium surgery

BACKGROUND

Pterygium, a growth of the conjunctiva over the cornea, is a progressive disease leading in advanced stages to visual impairment, restriction of ocular motility, chronic inflammation and cosmetic concerns. Surgical removal is the treatment of choice, but recurrence can be a problem. Currently the best surgical option in terms of recurrence is conjunctival autograft. To date the most common surgical methods of attaching conjunctival autografts to the sclera are through suturing or fibrin glue. Each method presents its own advantages and disadvantages. Sutures require considerable skill from the surgeon and can be associated with a prolonged operation time, postoperative discomfort and suture-related complications, whereas fibrin glue may give a decreased operation time, improve postoperative comfort and avoid suture-related problems.

OBJECTIVES

To assess the effectiveness of fibrin glue compared to sutures in conjunctival autografting for the surgical treatment of pterygium.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2016), Embase (January 1980 to October 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 14 October 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in any setting where fibrin glue was compared with sutures to treat people with pterygium.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results, assessed trial quality, and extracted data using standard methodological procedures expected by Cochrane. Our primary outcome was recurrence of pterygium defined as any re-growth of tissue from the area of excision across the limbus onto the cornea. The secondary outcomes were surgical time and complication rate. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

We included 14 RCTs conducted in Brazil, China, Egypt, India, Malaysia, New Zealand, Philippines, Saudi Arabia, Sweden and Turkey. The trials were published between 2004 and 2016, and were assessed as a mixture of unclear and low risk of bias with three studies at high risk of attrition bias. Only adults were enrolled in these studies.Using fibrin glue for the conjunctival autograft may result in less recurrence of pterygium compared with using sutures (risk ratio (RR) 0.47, 95% CI 0.27 to 0.82, 762 eyes, 12 RCTs; low-certainty evidence). If pterygium recurs after approximately 10 in every 100 surgeries with sutures, then using fibrin glue may result in approximately 5 fewer cases of recurrence in every 100 surgeries (95% CI 2 fewer to 7 fewer cases). Using fibrin glue may lead to more complications compared with sutures (RR 1.92; 95% CI 1.22 to 3.02, 11 RCTs, 673 eyes, low-certainty evidence). The most common complications reported were: graft dehiscence, graft retraction and granuloma. On average using fibrin glue may mean that surgery is quicker compared with suturing (mean difference (MD) -17.01 minutes 95% CI -20.56 to -13.46), 9 RCTs, 614 eyes, low-certainty evidence).

AUTHORS' CONCLUSIONS

The meta-analyses, conducted on people with pterygium in a hospital or outpatient setting, show fibrin glue may result in less recurrence and may take less time than sutures for fixing the conjunctival graft in place during pterygium surgery. There was low-certainty evidence to suggest a higher proportion of complications in the fibrin glue group.

New materials in embolizations

Percutaneous, catheter-directed embolotherapy is an established interventional technique for the management of many vascular disorders. For more than three decades, typical embolization devices included macro and microcoils, polyvinyl alcohol microparticles, glue and certain liquids such as absolute alcohol. In the past decade, however, several new embolic devices and refinements of existing embolic devices have arrived on the market and a number of clinical studies have demonstrated their added value. In this review article, these new embolic devices and their typical indications will be discussed, as well as the results of studies involving the embolic devices.

Early Failure of Surgical Angioplasty with Tissue Glue: A Word of Caution

A 43-year-old woman with critical stenosis of the left main stem was managed with saphenous vein angioplasty using BioGlue. She developed severe myocardial ischemia postoperatively, probably due to external compression exerted on the patch by the adhesive material, and required emergency coronary artery bypass grafting.

Effect of Tissue Adhesives on Seroma Incidence After Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Tissue adhesives (TAs) are widely utilized in abdominoplasty to reduce postoperative seroma. However, current literature regarding TAs in abdominoplasty is limited to small studies and the findings of single institutions.

OBJECTIVES

The authors reviewed the current literature regarding the effects of TAs on seroma formation and other endpoints following abdominoplasty, and summarized the types of TAs and application techniques that have been described to date.

METHODS

A systematic review of the Medline, Embase, Web of Science, and Cochrane databases was conducted to identify randomized controlled trials (RCTs) in which the numbers of patients who experienced seroma after abdominoplasty were indicated. The Cochrane Collaboration's tool for assessing risk of bias was applied.

RESULTS

Seven studies were included in a descriptive review, 5 of which were RCTs. Data from the 5 RCTs were pooled for a meta-analysis. Patients who received TAs following abdominoplasty had a similar incidence of seroma compared with patients who did not receive TAs. However, the total drainage volume was significantly lower for patients who received TAs.

CONCLUSIONS

There is a paucity of high-quality evidence to support the delivery of TAs to prevent seroma formation after abdominoplasty. Well-designed RCTs are needed to assess with confidence the overall effects of TAs in abdominoplasty.

LEVEL OF EVIDENCE

2 Therapeutic.

In situ precision electrospinning as an effective delivery technique for cyanoacrylate medical glue with high efficiency and low toxicity

The side effects or toxicity of cyanoacrylate used in vivo have been argued since its first application in wound closure. We propose an airflow-assisted in situ precision electrospinning apparatus as an applicator and make a detailed comparison with traditional spraying via in vitro and in vivo experiments. This novel method can not only improve operational performance and safety by precisely depositing cyanoacrylate fibers onto a wound, but significantly reduce the dosage of cyanoacrylate by almost 80%. A white blood cell count, liver function test and histological analysis prove that the in situ precision electrospinning applicator produces a better postoperative outcome, e.g., minor hepatocyte injury, moderate inflammation and the significant ability for liver regeneration. This in situ precision electrospinning method may thus dramatically broaden both civilian and military applications of cyanoacrylates.

Poloxamer bioadhesive hydrogel for buccal drug delivery: Cytotoxicity and trans-epithelial permeability evaluations using TR146 human buccal epithelial cell line

A salbutamol sulfate (SS)-Poloxamer bioadhesive hydrogel specially developed for buccal administration was investigated by studying interactions with TR146 human buccal epithelium cells (i.e. cellular toxicity (i) and trans-epithelial SS diffusion (ii)). The assessment of cell viability (MTT, Alamar Blue), membrane integrity (Neutral Red), and apoptosis assay (Hoechst 33342), were performed and associated to Digital Holographic Microscopy analysis. After the treatment of 2h, SS solution induced drastic cellular alterations that were prevented by hydrogels in relation with the concentrations of poloxamer and xanthan gum. The formulation containing P407 19%/P188 1%/Satiaxane 0.1% showed the best tolerance after single and multiple administrations and significantly reduced the trans-epithelial permeability from 5.00±0.29 (×10(3)) (SS solution) to 1.83±0.22 cm/h. Digital Holographic Microscopy images in good agreement with the viability data confirmed the great interest of this direct technique. In conclusion, the proposed hydrogels represent a safe and efficient buccal drug delivery platform.

Resection of Ileoinguinal and Ileohypogastric Nerves Combined with Gluing in Modified Lichtenstein Repair

We conducted a cohort trial to investigate the relevance of resection of the ilioinguinal and iliohypogastric nerves in combination with mesh fixation with BioGlue™ (CryoLife® Inc., Kennsaw, Georgia) in modified Lichtenstein repair to the development of chronic pain and hernia recurrence.1 In all, 430 patients underwent Lichtenstein repair. In 247 patients the mesh was fixed by means of glue, and in 183 patients it was fixed with conventional sutures. In all cases the inguinal nerves N. ilioinguinalis and N. iliohypogastricus were located and resected after identification to prevent nerve reaction to the mesh. The pain intensity was measured with a numeric analogous scale (NAS) 24 hours after surgery. All complications were recorded with a follow-up of up to 5 years. There was a significantly lower pain intensity level in the gluing group compared with the suture group 24 hours after surgery (0.016 t test). The level was 3.8±2.4 in bilateral hernia and 3.3±2.1 in unilateral hernia in the gluing group. It was 4.7±3.3 in unilateral and 3.7±2.2 in bilateral hernia in the suture group. The cut-suture time was lower in the gluing group. There were no severe pain syndromes (NAS≥4) in the gluing group and only 1.1% in the suture group. There was a higher incidence of non-bacterial wound infections in the gluing group (3.6%) than in the suture group (1.1%). The rate of recurrence after 5 years amounted to 2.0% in the gluing group and 2.2% in the suture group. The technique of using BioGlue™ for mesh fixation combined with systematic nerve dissection reduces acute and chronic postoperative pain after modified Lichtenstein repair. Only 2 of 430 patients suffered from severe chronic pain. Combined gluing and systematic resection of the inguinal nerves is more comfortable than standard Lichtenstein repair.

The use of "2-octyl cyanoacrylate" as skin adhesive in pediatric and congenital cardiac surgery

AIM

The aim of this paper was to evaluate the safety and cost-effectiveness of "2-octyl-cyanoacrylate" as skin adhesive in congenital heart surgery.

METHODS

From April 2010 to December 2011, we collected data from 300 patients who underwent cardiac surgery for congenital heart disease. We divided our population into 3 groups: group-1 (N.=100):"2-octyl-cyanoacrylate" has been used to replace the intra-dermal suture line; group-2 (N.=100):"2-octyl-cyanoacrylate" has been utilized as a barrier ("add-on measure") in addition to the intra-dermal suture line, group-3 (N.=100) with a standard intra-dermal suture line.

RESULTS

Median age of patients was 1.36 years. One-hundred and thirty-nine patients were younger than 12 months and 56 older than 16 years. There were 11 wound dehiscence (3.6%) (2 in group-1 and 9 in group-3, P=0.001) and 1 superficial wound infection (group-1). Six patients (2%) required surgical wound revision (2 in group-1 and 4 in group-3, P=NS). Wound complication was significantly associated to delayed sternal closure (3/12 patients, 25% versus 13/288 patients, 4.5%) (P=0.04). Median cost (intra-/postoperative) for wound treatment was lower in group-1 and 2 (19±5.5 and 23.9±7.4 € respectively) when compared to Group-3 (26.7±3.2) (P<0.0001).

CONCLUSION

The use of "2-octyl-cyanoacrylate" proved to be safe and effective; the "add-on measure" strategy provided the best cost-effective solution.

Ureteral obstruction following partial nephrectomy: can it be caused by fibrin glue?

Fibrin sealants are widely used during partial nephrectomy, however reports regarding the potential complications associated with their use are limited. We present the case of a 67-year-old male who developed delayed ureteral obstruction without hydronephrosis following partial nephrectomy in a solitary kidney. We hypothesize that the obstruction and absence of hydronephrosis were caused by extrinsic compression and subsequent inflammation due to the fibrin glue. Our report underscores the importance of a high index of suspicion for obstruction when acute kidney injury occurs following partial nephrectomy when fibrin glue is used, even in the absence of collecting system dilatation.

Octyl-2-cyanoacrylate adhesive for skin closure: eight years experience

Cyanoacrylate skin adhesive is increasingly used to ensure and stabilize wound closures. One of the documented favorable effects of these glues is to limit the risk of a surgical site infection by physically isolating the wound.

PATIENTS AND METHODS

From January 2005 to January 2013, 900 patients requiring surgical treatment in the Structure of Plastic Surgery of the University of Sienna were enrolled for the study and divided in two groups; 450 patients treated with glue versus 450 controls.

RESULTS

The cohort of patients treated with glue had lower incidence of wound infection and wound dehiscence. Approximately 375 work-hours were economized.

CONCLUSION

Octyl-2-cyanoacrylate is a valuable aid for ensuring the success of surgery by reducing surgical site infections. The use of octyl-2-cyanoacrylate is easy, guarantying a major superficial protection without relevant contraindications and with evident saving of time and resources.

Allergic contact dermatitis to 2-octyl cyanoacrylate

Cyanoacrylates are widely used as topical skin adhesives in emergency departments, clinics, and operating rooms. We report 4 patients who developed allergic contact dermatitis (ACD) following postsurgical closure with 2-octyl cyanoacrylate. These patients were challenged with a novel method of use testing to confirm sensitivity to 2-octyl cyanoacrylate. The popularity of skin adhesives makes this emerging allergen worthy of examination. It is possible that cyanoacrylate allergy currently is underrecognized.

Systematic review and meta-analysis of fibrin sealants for patients undergoing pancreatic resection

INTRODUCTION

Post-operative pancreatic fistula (POPF) is a common complication after partial pancreatic resection, and is associated with increased rates of sepsis, mortality and costs. The role of fibrin sealants in decreasing the risk of POPF remains debatable. The aim of this study was to evaluate the literature regarding the effectiveness of fibrin sealants in pancreatic surgery.

METHODS

A comprehensive database search was conducted. Only randomized controlled trials comparing fibrin sealants with standard care were included. A meta-analysis regarding POPF, intra-abdominal collections, post-operative haemorrhage, pancreatitis and wound infections was performed according to the recommendations of the Cochrane collaboration.

RESULTS

Seven studies were included, accounting for 897 patients. Compared with controls, patients receiving fibrin sealants had a pooled odds ratio (OR) of developing a POPF of 0.83 [95% confidence interval (CI): 0.6-1.14], P = 0.245. There was a trend towards a reduction in post-operative haemorrhage (OR = 0.43 (95%CI: 0.18-1.0), P = 0.05) and intra-abdominal collections (OR = 0.52 (95%CI: 0.25-1.06), P = 0.073) in those patients receiving fibrin sealants. No difference was observed in terms of mortality, wound infections, re-interventions or hospital stay.

CONCLUSION

On the basis of these results, fibrin sealants cannot be recommended for routine clinical use in the setting of pancreatic resection.

Biocompatibility of a novel cyanoacrylate based tissue adhesive: cytotoxicity and biochemical property evaluation

Cyanoacrylate (CA) is most widely used as a medical and commercial tissue adhesive because of easier wound closure, good cosmetic results and little discomfort. But, CA-based tissue adhesives have some limitations including the release of cytotoxic chemicals during biodegradation. In previous study, we made prepolymerized allyl 2-CA (PACA) based tissue adhesive, resulting in longer chain structure. In this study, we investigated a biocompatibility of PACA as alternative tissue adhesive for medical application, comparing with that of Dermabond® as commercial tissue adhesive. The biocompatibility of PACA was evaluated for short-term (24 hr) and long-term (3 and 7 days) using conventional cytotoxicity (WST, neutral red, LIVE/DEAD and TUNEL) assays, hematoxylin-eosin (H&E) and Masson trichrome (MT) staining. Besides we examined the biochemical changes in cells and DNA induced by PACA and Dermabond® utilizing Raman spectroscopy which could observe the denaturation and conformational changes in protein, as well as disintegration of the DNA/RNA by cell death. In particular, we analyzed Raman spectrum using the multivariate statistical methods including principal component analysis (PCA) and support vector machine (SVM). As a result, PACA and Dermabond® tissue adhesive treated cells and tissues showed no difference of the cell viability values, histological analysis and Raman spectral intensity. Also, the classification analysis by means of PCA-SVM classifier could not discriminate the difference between the PACA and Dermabond® treated cells and DNA. Therefore we suggest that novel PACA might be useful as potential tissue adhesive with effective biocompatibility.

Imaging findings of extensive splenic infarction after cyanoacrylate injection for gastric varices--a case report

Endoscopic injection of N-Butyl-2-cyanoacrylate is a widely accepted treatment for esophagogastric varices. This procedure is commonly associated with minor complications which include transient pyrexia and abdominal discomfort. Serious vascular complications secondary to systemic embolization of cyanoacrylate have rarely been reported. We describe the CT findings of extensive splenic infarction in a patient following cyanoacrylate injection for gastric varices.

[Endoscopic sclerotherapy of gastric varices by tissue adhesives]

The diagnosis and treatment of gastric varices is a clinically concerned issue. With the development of endoscopic technology. The success rate of controlling bleeding from gastric and esophageal varices has been improved a lot. It is efficacious and safe to treat gastric and esophageal varices by endoscopic injection of tissue adhesives and to prevent re-bleeding. There is few acute and long-term complications of this modality. It has been the first line treatment for gastric varices.

CT portography with gastric variceal volume measurements in the evaluation of endoscopic therapeutic efficacy of tissue adhesive injection into gastric varices: a pilot study

BACKGROUND

N-butyl-2-cyanoacrylate (NBCA) injection is used for treating gastric varices (GV). Determining the degree of obliteration of GV is not readily evident at endoscopy.

AIMS

The aim of this study was to evaluate CT portography with gastric variceal volume calculations to assess endoscopic therapeutic efficacy of NBCA injection.

METHODS

The study design is a retrospective series pilot study. The setting is a single, tertiary care academic medical center. Ten patients underwent esophagogastroduodenoscopy (EGD) with NBCA injection of GV and had biphasic CT scans performed before and after injection therapy. Based on portal venous images, 3D reconstruction and semi-automated volume calculations of GV were performed. Pre and post injection GV volume calculations were compared.

RESULTS

The mean pre-procedure GV volume was 89.84 cm3. Eight patients had significant improvement in GV volume from pre-treatment versus post-treatment (95.65 cm3 vs. 49.65 cm3, P-value 0.04). Pre-procedure GV volume was not significantly different in patients treated for active hemorrhage versus no hemorrhage (101.66 cm3 vs. 72.11 cm3, P-value 0.33). Two patients had a subsequent GV hemorrhage after NBCA injection. The mean residual GV volume in these patients versus those that did not re-bleed was significantly more (127.77 cm3 vs. 38.00 cm3, P-value 0.005).

CONCLUSIONS

CT portography with measurement of GV volume is a potentially useful tool in determining the therapeutic efficacy NBCA injection of GV. Patients with higher residual GV volumes are at increased risk of hemorrhage and may benefit from repeat injection to reach ideal GV volumes.

Elasticity and safety of alkoxyethyl cyanoacrylate tissue adhesives

Cyanoacrylate glues are easily applied to wounds with good cosmetic results. However, they tend to be brittle and can induce local tissue toxicity. A series of cyanoacrylate monomers with a flexible ether linkage and varying side-chain lengths was synthesized and characterized for potential use as tissue adhesives. The effect of side-chain length on synthesis yield, physical and mechanical properties, formaldehyde generation, cytotoxicity in vitro and biocompatibility in vivo were examined. The incorporation of etheric oxygen allowed the production of flexible monomers with good adhesive strength. Monomers with longer side-chains were found to have less toxicity both in vitro and in vivo. Polymerized hexoxyethyl cyanoacrylate was more elastic than its commercially available and widely used alkyl analog 2-octyl cyanoacrylate, without compromising biocompatibility.

Technical tips: Electrode safety in pediatric prolonged EEG recordings

Electrodes are an essential element of electroencephalography. Complications related to the use of recording electrodes are known to occur but not much is known about the mechanism, risk factors, and incidence of such complications. In this study, we wanted to identify the incidence and potential risk factors for electrode related skin injuries. We found that such injuries occur in 11.4% of children.

Histologic evaluation of absorbable and non-absorbable barrier coated mesh secured to the peritoneum with fibrin sealant in a New Zealand white rabbit model

PURPOSE

The purpose of this study is to evaluate the histologic response to fibrin sealant (FS) as an alternative fixation method for laparoscopic ventral hernia repair.

METHODS

One non-absorbable barrier mesh (Composix™) and three absorbable barrier meshes (Sepramesh™, Proceed™, and Parietex™ Composite) were used for the study, with uncoated macroporous polypropylene mesh (ProLite Ultra™) as the control. Three methods of fixation were used: #0-polypropylene suture + FS (ARTISS™, Baxter Healthcare Corp.), FS alone (ARTISS™), or tacks alone (n = 10 for each group). Two pieces of mesh (of dimensions 4 × 4-cm) were secured intraperitoneally in 75 New Zealand white rabbits. After 8 weeks, hematoxylin and eosin (H&E)-stained specimens were evaluated for host tissue response. Statistical significance (P < 0.05) was determined using a one-way analysis of variance (ANOVA) with Fisher's least significant difference (LSD) post hoc test.

RESULTS

Composix™ with FS only showed significantly greater cellular infiltration than with suture + FS (P = 0.0007), Proceed™ with FS only had significantly greater neovascularization than with suture + FS (P = 0.0172), and ProLite Ultra™ with suture + FS had significantly greater neovascularization than with tacks only (P = 0.046). Differences due to mesh type showed that Composix™ exhibited less extensive cellular infiltration (P ≤ 0.0032), extracellular matrix (ECM) deposition, and neovascularization, and demonstrated less inflammatory cells and more fibroblasts compared to the other meshes (P < 0.05).

CONCLUSIONS

FS did not have a significant histologic effect compared to tacks when utilized for the fixation of mesh to the peritoneum of New Zealand White rabbits. However, the mesh type did have a significant histologic effect. The permanent barrier mesh (Composix™) was associated with less histologic incorporation than absorbable barrier and macroporous meshes, as evidenced by lower levels of cellular infiltration, ECM deposition, and neovascularization, independent of the fixation method used.

Nitrogenous subcutaneous emphysema caused by spray application of fibrin glue during retroperitoneal laparoscopic surgery

We report a case of a patient treated by retroperitoneoscopic partial nephrectomy who developed nitrogenous subcutaneous emphysema (SCE) as a complication. The use of a nitrogen gas-pressured fibrin tissue adhesive applied as a spray caused excessively increased pressure in the closed retroperitoneal space and resulted in widespread SCE with protracted clinical course. To the best of our knowledge, this is the first report of nitrogenous SCE associated with pneumoperitoneum. The clinical significance of nitrogenous SCE is emphasized, and the risks associated with the use of fibrin glue as a spray during laparoscopic surgery are discussed.

Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate

BACKGROUND & AIMS

Endoscopic variceal obturation with tissue adhesive is used to control gastric variceal bleeding. We investigated the prevalence of serious complications from this therapy.

METHODS

We performed a retrospective analysis of complications that occurred in 753 patients with gastric variceal hemorrhages who were hospitalized in 2 tertiary referral hospitals. All patients received N-butyl-2-cyanoacrylate as therapy for endoscopic variceal obturation.

RESULTS

Complications occurred in 51 patients. Thirty-three patients experienced rebleeding because of early-onset (within 3 months) extrusion of the N-butyl-2-cyanoacrylate glue cast (4.4%), 10 patients developed sepsis (1.3%), and 5 patients developed distant embolisms (0.7%; 1 pulmonary, 1 brain, and 3 splenic). One patient had major gastric variceal bleeding after endoscopic variceal obturation (0.1%), 1 developed a large gastric ulcer (0.1%), and 1 had mesentery hematoma, hemoperitoneum, and infection in the abdominal cavity (0.1%). The complication-related mortality was 0.53% (3 deaths from sepsis and 1 death from rebleeding after early-onset glue cast extrusion).

CONCLUSIONS

The occurrence of complications after endoscopic variceal obturation with N-butyl-2-cyanoacrylate in gastric varices treatment is rare.

Tissue adhesive in ophthalmology

Tissue adhesive in ophthalmology is commonly used for corneal wound and restricted for superficial closure. Only synthetic adhesive available is butyl-2-cyanoacrylate. However, if it gets between the wound margins it inhibits healing by forming impervious barrier.

Long-term efficacy and safety of N-butylcyanoacrylate in endoscopic treatment of gastric varices

INTRODUCTION

Endoscopic glue (N-butyl-2-cyanoacrylate) injection has emerged as promising therapy for bleeding gastric varices (GV). We evaluated safety and long term efficacy of this technique in patients with portal hypertension and large bleeding GV.

PATIENT AND METHODS

170 patients (mean age 40.9 +/- 14y; 132 male; 142 had cirrhosis, 40 Child A, 62 Child B, 40 Child C) underwent glue injection into GV (F3 140, F2 30; fundal 114) as emergency procedure for active bleeding in 62 and electively for prevention of rebleeding in 108. Glue was injected intra-variceally under endoscopic vision, 0.5-4 ml/aliquot, repeated at 3 weeks till varices were eradicated/solidified. The efficacy was assessed by hemostasis at 48 h, primary, secondary, definitive success and treatment failure.

RESULTS

The overall hemostasis rate at 48h was 82.3% (51/62). Follow up was available in 158 patients for mean of 30.7 + 17.2 months. Repeat injections were performed in 76. The mean number of injections were 1.9 +/- 1.0 (1-4); total volume was 2.5 +/- 1.7 ml/patient. The status of GVs at last follow up was: disappeared in 32 (22.6%); F1 solidified in 46 (32.3%); F2 solidified in 64 (45.0%). Bleeding recurred in 14.5% (23/158); 60% within 2 weeks of injection. The primary, secondary and definitive success rates were 85.4% (135/158), 4.4% (7/158) and 89.9% (142/158) respectively and treatment failure rate was 10% (16/158). No significant complications were noticed except for injection site ulceration in 32. Twenty patients died on follow up (9 died of uncontrolled bleeding, 11 died of liver failure).

CONCLUSION

Endoscopic glue injection into bleeding GVs was effective in achieving hemostasis in 82% with a definitive success rate of 90% and had a good safety profile on long-term follow up.