Fibrin sealant use for minimising peri-operative allogeneic blood transfusion

Effect of topical application of autologous platelet gel on sternal wound infection after cardiac surgery: A meta-analysis

Following heart operation, a severe life-threatening complication has been identified by investigators who have recently discovered that local application of platelet-rich plasma (PRP) can lower the rate of wound infection in heart surgery. Nevertheless, due to the low quality of these trials, we have tried to perform high-quality meta-analyses to prove the efficacy of PRP in heart surgery for post-operative wound infections. In this study, five randomised controlled trials (RCTs) were chosen from three databases, and there were 1005 studies to analyse the data. Among 181 cases, PRP was applied to the surgical site, and 205 in the control group. Both the CI and the OR or the average difference (MD) were computed with either a fixed or random-effect model. A meta-analysis of the data was carried out with RevMan 5.3. The results showed that there were no statistically significant differences in the incidence of post-operative surgical site infection (SSI) in control group compared to those treated with PRP gel (OR, 0.97; 95% CI, 0.38, 2.47; p = 0.95); In the heart operation, the local application of PRP gel decreased the rate of drainage after operation (MD, -217.82; 95% CI, -335.38, -100.26; p = 0.0003); The operation time of the PRP gel was not significantly different from that of the control group (MD, 12.65; 95% CI, -2.95, 28.24; p = 0.11). Contrary to earlier research, the application of autoplatelet gel in heart surgery did not seem to decrease operative site infections after the operation, but it did decrease the amount of postoperative drainage. Nevertheless, because of the limited number of RCTs in this meta-analysis, caution should be exercised in their treatment. More high-quality randomised, large-sample trials are required to further confirm the findings.

Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis

BACKGROUND

Hip and knee replacement surgery is a well-established means of improving quality of life, but is associated with a significant risk of bleeding. One-third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care.

OBJECTIVES

To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta-analysis (NMA) methodology.

SEARCH METHODS

We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We included RCTs of people undergoing elective hip or knee surgery only. We excluded non-elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non-fibrin sealants.

DATA COLLECTION AND ANALYSIS

We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all-cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received.

MAIN RESULTS

We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra-articularly and orally at a total dose of greater than 3 g pre-incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate-certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre-incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low-certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low-certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low-certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low-certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low-certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all-cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low-certainty evidence). This was followed by TXA given intravenously and intra-articularly at a total dose of 2 g pre-incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low-certainty evidence) and TXA given intravenously and intra-articularly, total dose greater than 3 g pre-incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low-certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low-certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials).

AUTHORS' CONCLUSIONS

We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra-articular, oral and intravenous, or intravenous and intra-articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review.

Biosubstitutes for dural closure: Unveiling research, application, and future prospects of dura mater alternatives

The dura mater, as the crucial outermost protective layer of the meninges, plays a vital role in safeguarding the underlying brain tissue. Neurosurgeons face significant challenges in dealing with trauma or large defects in the dura mater, as they must address the potential complications, such as wound infections, pseudomeningocele formation, cerebrospinal fluid leakage, and cerebral herniation. Therefore, the development of dural substitutes for repairing or reconstructing the damaged dura mater holds clinical significance. In this review we highlight the progress in the development of dural substitutes, encompassing autologous, allogeneic, and xenogeneic replacements, as well as the polymeric-based dural substitutes fabricated through various scaffolding techniques. In particular, we explore the development of composite materials that exhibit improved physical and biological properties for advanced dural substitutes. Furthermore, we address the challenges and prospects associated with developing clinically relevant alternatives to the dura mater.

Recent trends in perioperative blood transfusion during elective kidney transplantation

Background

Accurately predicting the demand for blood transfusions is crucial for blood banks. Given the potential for emergency situations, it is imperative that blood banks maintain a sufficient inventory of blood products. In this study, we examined the use of perioperative transfusions in patients undergoing elective kidney transplants.

Methods

Data on all complement-dependent cytotoxicity-crossmatched assays between 2013 and 2022 were collected. We excluded repeated assays and patients who did not undergo kidney transplantation. Transfusion records and transfusion adverse reactions were reviewed retrospectively.

Results

In total, 30 patients underwent elective kidney transplantation from 2013 to 2022. The mean age of the patients was 48.1±9.7 years. The male-to-female ratio was 1.5:1. Four patients received transfusions intraoperatively, whereas eight patients were transfused postoperatively. The postoperative hemoglobin level of the transfusion group (n=9, 8.9±1.3) was significantly lower than that of the nontransfusion group (n=21, 10.4±1.2). The most commonly transfused blood product intraoperatively was leuko-reduced filtered red blood cells, followed by fresh frozen plasma. When the study period was divided into two halves based on the time of operation, the first half showed a higher number of significant transfusions.

Conclusions

In most elective kidney transplant cases, surgery was conducted without the need for blood transfusion. The timing of transfusion, when necessary, shifted from during the operation to after the operation. The implementation of patient blood management, coupled with advancements in surgical techniques, appears to have impacted the pattern of perioperative transfusion.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures

BACKGROUND

Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications.

OBJECTIVES

To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones.

SEARCH METHODS

We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data.

MAIN RESULTS

We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence).  It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence).  We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect.  Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants).  All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo   Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here.

AUTHORS' CONCLUSIONS

We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration).  We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

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

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

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Systematic Review of Topical Hemostatic Agent Use in Minimally Invasive Gynecologic Surgery

Background and Objectives:

To perform a systematic review of articles evaluating hemostatic effectiveness and peri-operative outcomes when topical hemostatic agents (HA) are used in minimally invasive gynecologic surgeries (MIGS) for benign conditions.

Methods:

Studies published through March 31, 2017 were retrieved through PubMed, EMBASE, Cochrane, and ClinicalTrials.gov to identify all eligible studies. No studies were excluded based on publish date. All comparative studies or case series with >10 participants reporting use of at least one topical HA in MIGS for benign conditions were included as long as full-text articles were available and written in English. Studies were excluded if surgery was done for malignancy or completed via an open approach. Articles that included multiple surgical subspecialties were excluded if data related to MIGS was unable to be isolated. Evaluation for eligibility and data extraction was performed by three independent reviewers. Quality of evidence was also assessed by each reviewer.

Results:

From 132 articles, a total of 8 studies were included in this systematic review. We found that use of fibrin sealant decreased time to hemostasis, postoperative hemoglobin drop, and estimated blood loss (EBL) compared with bipolar energy and reduced the overall operative time in laparoscopic myomectomy. When fibrin sealant use at time of myomectomy was compared to bipolar energy there was no significant difference in the rate of postoperative complications. Furthermore, there was less of a decrease in anti-Mullerian hormone (AMH) level when a thrombin-gelatin matrix was used compared to bipolar energy on ovarian tissue.

Conclusion:

Application of topical HA in MIGS can reduce operative time, blood loss, and ameliorate damage to ovarian function. However, more data needs to be gathered for use of HA during different types of gynecologic procedures (adnexal surgery, myomectomy, and hysterectomy) to provide better quality evidence to guide their use.

Pro-coagulant haemostatic factors for the prevention and treatment of bleeding in people without haemophilia

BACKGROUND

Some hospital patients may be at risk of or may present with major bleeding. Abnormalities of clotting (coagulation) are often recorded in these people, and the traditional management has been with transfusions of blood components, either to prevent bleeding (prophylactic) or to treat bleeding (therapeutic). There is growing interest in the use of targeted therapies with specific pro-coagulant haemostatic (causing bleeding to stop and to keep blood within a damaged blood vessel) factor concentrates in place of plasma.

OBJECTIVES

To assess the effects and safety of pro-coagulant haemostatic factors and factor concentrates in the prevention and treatment of bleeding in people without haemophilia.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (2018, issue 3), MEDLINE (from 1948), Embase (from 1974), CINAHL (from 1938), PubMed (publications in process to 18 April 2018), PROSPERO, Transfusion Evidence Library (from 1950), LILACS (from 1980), IndMED (from 1985), KoreaMed (from 1934), Web of Science Conference Proceedings Citation Index (from 1990) and ongoing trial databases to 18 April 2018.

SELECTION CRITERIA

We included RCTs that compared intravenous administration of a pro-coagulant haemostatic factor concentrate, either with placebo, current best or standard treatment, or another pro-coagulant haemostatic factor concentrate for prevention or treatment of bleeding. There was no restriction on the types of participants. We excluded studies of desmopressin, tranexamic acid and aminocaproic acid and use of pro-coagulant haemostatic factors for vitamin K over-anticoagulation.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodological procedures.

MAIN RESULTS

We identified 31 RCTs with 2392 participants and 22 ongoing trials. There were 13 therapeutic RCTs that randomised 1057 participants (range from 20 to 249 participants) and 18 prophylactic trials that randomised 1335 participants (range 20 to 479 participants). The pro-coagulant haemostatic factor concentrate was fibrinogen in 23 trials, Factor XIII in seven trials and pro-thrombin complex concentrates (PCC) in one trial.Seventeen trials had industrial funding or support, eight studies either did not declare their funding or were unclear about their source of funding and six studies declared non-industrial funding sources.Certainty in the evidence and included study biasOur certainty in the evidence, using GRADE criteria, ranged from very low to high across all outcomes. We assessed most outcomes as being of low certainty. Risks of bias were a concern in many of the RCTs; randomisation methodology was unclear in 15 RCTs, with allocation concealment unclear in 14 RCTs and at high risk of bias in five RCTs. The blinding status of outcome assessors was unclear in 13 RCTs and at high risk of bias in five RCTs, although most outcomes in these trials were objective and not prone to observer bias. Study personnel were often unblinded or insufficient information was available to assess their level of blinding (five RCTs were at unclear risk and seven at high risk of bias).Primary outcomesAll-cause mortality was reported by 21 RCTs, arterial thromboembolic events by 22 RCTs, and venous thromboembolic events by 21 RCTs.Fibrinogen concentrate: prophylactic trials with inactive comparator (nine RCTs)The trials had heterogeneous clinical settings and outcome time points, so we did not pool the data. Compared to placebo, there was no evidence that prophylactic fibrinogen concentrate reduced all-cause mortality (4 RCTs; 248 participants). Compared to inactive comparators there was low- to moderate-quality evidence that prophylactic fibrinogen concentrate did not increase the risk of arterial or venous thromboembolic complications (7 RCTs; 398 participants).Fibrinogen concentrate: prophylactic trials with active comparator (two RCTs)There was no mortality or incidence of thromboembolic events in these two RCTs (with 57 participants).Fibrinogen concentrate: therapeutic trials with inactive comparator (eight RCTs)The trials had heterogeneous surgical settings and outcome time points, so we pooled data for subgroups only. Compared to an inactive comparator, there was no evidence (quality ranging from low to high) that fibrinogen concentrate reduced all-cause mortality in actively bleeding participants (7 RCTs; 724 participants). Compared to inactive comparators there was no evidence that the use of fibrinogen concentrate in active bleeding increased arterial (7 RCTs; 607 participants) or venous (6 RCTs; 562 participants) thromboembolic events.Fibrinogen concentrate: therapeutic trials with active comparator (four RCTs)We did not pool the outcome data, as they were not measured at comparable time points. Compared to other active pro-coagulant agents, there was no evidence (very low to moderate quality) that fibrinogen concentrate reduced all-cause mortality in actively bleeding participants (4 RCTs; 220 participants). There was no evidence that fibrinogen concentrate increased the risk of arterial (3 RCTs; 126 participants) or venous (4 RCTs; 220 participants) thromboembolic events.FactorXIII: Prophylactic trials with inactive comparator (six trials)The trials were heterogeneous in their surgical settings and time points for outcome analysis, so we pooled data for subgroups only. Compared to an inactive comparator, there was no evidence that prophylactic Factor XIII reduced all-cause mortality (5 RCTs; 414 participants). There was no evidence (very low to low quality) of a difference in the arterial or venous event rate between Factor XIII and inactive comparators (4 trials; 354 participants).FactorXIII: therapeutic trials with inactive comparator (one trial)There was no mortality or incidence of thromboembolic events in this trial.Prothrombin complex concentrate (PCC): prophylactic trials with inactive comparator (one trial)There was no evidence (moderate quality) that PCC reduced all-cause mortality (1 trial; 78 participants). No thromboembolic complications were reported in this trial.

AUTHORS' CONCLUSIONS

The paucity of good-quality comparable evidence precludes the drawing of conclusions for clinical practice. Further research is required to determine the risk-to-benefit ratio of these interventions. The sample sizes of future RCTs would need to be greatly increased to detect a reduction in mortality or thromboembolic events between treatment arms. To improve consistency in outcome reporting, the development of core outcome sets is essential and may help address a number of the limitations identified in this review.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

BACKGROUND

Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use.

OBJECTIVES

To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults.

DATA SOURCES

Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms.

REVIEW METHODS

This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis.

RESULTS

We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I² = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I² = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays.

LIMITATIONS

It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available.

CONCLUSIONS

The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020710.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A hospital cost analysis of a fibrin sealant patch in soft tissue and hepatic surgical bleeding

Background

Despite hemostat use, uncontrolled surgical bleeding is prevalent. Drawbacks of current hemostats include limitations with efficacy on first attempt and suboptimal ease-of-use. Evarrest^® is a novel fibrin sealant patch that has demonstrated high hemostatic efficacy compared with standard of care across bleeding severities. The objective of this study was to conduct a hospital cost analysis of the fibrin sealant patch versus standard of care in soft tissue and hepatic surgical bleeding.

Methods

The analysis quantified the 30-day costs of each comparator from a hospital perspective. Published US unit costs were applied to resource use (ie, initial treatment, retreatment, operating time, hospitalization, transfusion, and ventilator) reported in four trials. A “surgical” analysis included resources clinically related to the hemostatic benefit of the fibrin sealant patch, whereas a “hospital” analysis included all resources reported in the trials. An exploratory subgroup analysis focused solely on coagulopathic patients defined by abnormal blood test results.

Results

The surgical analysis predicted cost savings of $54 per patient with the fibrin sealant patch compared with standard of care (net cost impact: −$54 per patient; sensitivity range: −$1,320 to $1,213). The hospital analysis predicted further cost savings with the fibrin sealant patch (net cost impact of −$2,846 per patient; sensitivity range: −$1,483 to −$5,575). Subgroup analyses suggest that the fibrin sealant patch may provide dramatic cost savings in the coagulopathic subgroup of $3,233 (surgical) and $9,287 (hospital) per patient. Results were most sensitive to operating time and product units.

Conclusion

In soft tissue and hepatic problematic surgical bleeding, the fibrin sealant patch may result in important hospital cost savings.

Fibrin Sealants in Dura Sealing: A Systematic Literature Review

Background

Fibrin sealants are widely used in neurosurgery to seal the suture line, provide watertight closure, and prevent cerebrospinal fluid leaks. The aim of this systematic review is to summarize the current efficacy and safety literature of fibrin sealants in dura sealing and the prevention/treatment of cerebrospinal fluid leaks.

Methods

A comprehensive electronic literature search was run in the following databases: Cochrane Database of Systematic Reviews, Cochrane Central Resister of Controlled Trials, clinicaltrials.gov, MEDLINE/PubMed, and EMBASE. Titles and abstracts of potential articles of interest were reviewed independently by 3 of the authors.

Results

A total of 1006 database records and additional records were identified. After screening for duplicates and relevance, a total of 78 articles were assessed by the investigators for eligibility. Thirty-eight were excluded and the full-text of 40 articles were included in the qualitative synthesis. Seven of these included only safety data and were included in the safety assessment. The remaining 33 articles included findings from 32 studies that enrolled a total of 2935 patients who were exposed to fibrin sealant. Among these 33 studies there were only 3 randomized controlled trials, with the remaining being prospective cohort analysis, case controlled studies, prospective or retrospective case series. One randomized controlled trial, with 89 patients exposed to fibrin sealant, found a greater rate of intraoperative watertight dura closure in the fibrin sealant group than the control group (92.1% versus 38.0%, p<0.001); however, post-operative cerebrospinal fluid leakage occurred in more fibrin sealant than control patients (6.7% versus 2.0%, p>0.05). Other clinical trials evaluated the effect of fibrin sealant in the postoperative prevention of cerebrospinal fluid leaks. These were generally lower level evidence studies (ie, not prospective, randomized, controlled trials) that were not designed or powered to demonstrate a significant advantage to fibrin sealant use. Two small case series studies evaluated the effect of fibrin sealants in persistent cerebrospinal fluid leak treatment, but did not establish firm efficacy conclusions. Specific adverse reports where fibrin sealants were used for dura sealing were limited, with only 8 cases reported in neurosurgical procedures since 1987 and most reporting only a speculative relationship/association with fibrin sealant exposure.

Conclusions

A major finding of this systematic literature review is that there is a paucity of randomized studies that have evaluated the effectiveness and safety of fibrin sealants in providing intraoperative watertight dura closure and post-operative cerebrospinal fluid leakage. Among the limited studies available, evidence from a single randomized, controlled trial indicates that fibrin sealants provide a higher rate of intraoperative watertight closure of the dura suture line than control, albeit with a higher rate of postoperative cerebrospinal fluid leakage. Evidence from non-randomized, controlled trials suggests that fibrin sealants may be effective in preventing cerebrospinal fluid leaks with an acceptable safety profile. There is a substantial need for randomized, controlled clinical trials or well-designed prospective observational trials where the conduct of a randomized trial is not feasible to fully assess the impact of fibrin sealant utilization on the rates of intraoperative dura closure, postoperative cerebrospinal leakage, and safety.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Variation in hospital resource use and cost among surgical procedures using topical absorbable hemostats

Background

Adjunctive hemostats are used to assist with the control of intraoperative bleeding. The most common types are flowables, gelatins, thrombins, and oxidized regenerated celluloses (ORCs). In the US, Surgicel^® products are the only US Food and Drug Administration-approved ORCs.

Objective

To compare the outcomes of health care resource utilization (HRU) and costs associated with using ORCs compared to other adjunctive hemostats (OAHs are defined as flowables, gelatins, and topical thrombins) for surgical procedures in the US inpatient setting.

Patients and methods

A retrospective, US-based cohort study was conducted using hospital inpatient discharges from the 2011–2012 calendar years in the Premier Healthcare Database. Patients with either an ORC or an OAH who underwent a cardiovascular procedure (valve surgery and/or coronary artery bypass graft surgery), carotid endarterectomy, cholecystectomy, or hysterectomy were included. Propensity score matching was used to create comparable groups of ORC and OAH patients. Clinical, economic, and HRU outcomes were compared.

Results

The propensity score matching created balanced patient cohorts for cardiovascular procedure (22,718 patients), carotid endarterectomy (10,890 patients), cholecystectomy (6,090 patients), and hysterectomy (9,348 patients). In all procedures, hemostatic agent costs were 28%–56% lower for ORCs, and mean hemostat units per discharge were 16%–41% lower for ORCs compared to OAHs. Length of stay and total procedure costs for patients treated with ORCs were lower for carotid endarterectomy patients (0.3 days and US$700) and for cholecystectomy patients (1 day and US$3,350) (all P<0.001).

Conclusion

Costs and HRU for patients treated with ORCs were lower than or similar to patients treated with OAHs. Proper selection of the appropriate hemostatic agents has the potential to influence clinical outcomes and treatment costs.

Health and economic outcomes associated with uncontrolled surgical bleeding: a retrospective analysis of the Premier Perspectives Database

Background

Bleeding remains a common occurrence in surgery. Data describing the burden of difficult-to-control bleeding and topical absorbable hemostat use are sparse. This study was conducted to estimate the clinical and economic impact that remains associated with uncontrolled surgical bleeding, even when hemostats are used during surgery.

Methods

This US retrospective analysis used the Premier Perspectives Database. Hospital discharges from 2012 were used to identify patients treated with hemostats during eight surgery types. Patients were included if they were ≥18 years, had an inpatient hospitalization with one of the eight surgeries, and received a hemostat on the day of surgery. Patients were stratified by procedure and presence or absence of major bleeding (uncontrolled) despite hemostat use. Outcomes were all-cause hospitalization costs, hemostat costs, length of stay, reoperation, and surgery-related complications (eg, mortality). Statistical significance was tested through chi-square or t-tests. Multivariate analyses were conducted for all-cause costs and length of stay using analysis of covariance.

Results

Among 25,048 procedures, major bleeding events occurred in 14,251 cases. Despite treatment with hemostats, major bleeding occurred in 32%–68% of cases. All-cause costs were significantly higher in patients with uncontrolled bleeding despite hemostat use versus controlled bleeding (US$24,203–$61,323 [uncontrolled], US$14,420–$45,593 [controlled]; P<0.001). Hemostat costs were significantly greater in the uncontrolled bleeding cohort for all surgery types except cystectomy and pancreatic surgery. Reoperation and mortality rates were significantly higher in the uncontrolled bleeding cohort in all surgical procedures except cystectomy and radical hysterectomy.

Conclusion

Uncontrolled intraoperative bleeding despite hemostat use is prevalent and associated with significantly higher hospital costs and worse clinical outcomes across several surgical procedures compared to controlled bleeding. There is an unmet need for newer hemostats that can more effectively control bleeding, improve outcomes, and reduce hospital resource use.

Current Status of Hemostatic Agents and Sealants in Urologic Surgical Practice

There has been a recent and near exponential increase in the use of hemostatic agents and sealants to supplement the rapidly evolving methods in the surgical management of urologic patients. This article reviews the use of hemostatic agents and sealants in current urologic practice.

Fibrin sealants and topical agents in hepatobiliary and pancreatic surgery: a critical appraisal

INTRODUCTION

Fibrin sealants and topical hemostatic agents have been used extensively in hepatobiliary and pancreatic (HPB) surgery to promote coagulation and clot formation decreasing the need for allogeneic blood transfusion and to act as tissue sealants, ideally preventing biliary, enteric, and pancreatic leaks.

RESULTS

Current literature has demonstrated some favorable outcomes using many different products for application in the field of HPB surgery. However, critical findings exist demonstrating lack of reproducible efficacy or benefit. In all, many clinical trials have demonstrated effectiveness of fibrin sealants and other agents at reducing the need for intraoperative and postoperative blood transfusion. Ability to effectively seal tissues providing biliostatic effect or preventing postoperative fistula formation remains debated as definitive evidence is lacking.

CONCLUSIONS

In the following invited review, we discuss current literature describing the use of topical agents and fibrin sealants in liver and pancreas surgery. We summarize major contemporary clinical trials and their findings regarding the use of these agents in HPB surgery and provide evidence from the preclinical literature as to the translation of these products into the clinical arena.

Fibrin sealants and topical agents in hepatobiliary and pancreatic surgery: a critical appraisal

INTRODUCTION

Fibrin sealants and topical hemostatic agents have been used extensively in hepatobiliary and pancreatic (HPB) surgery to promote coagulation and clot formation decreasing the need for allogeneic blood transfusion and to act as tissue sealants, ideally preventing biliary, enteric, and pancreatic leaks.

RESULTS

Current literature has demonstrated some favorable outcomes using many different products for application in the field of HPB surgery. However, critical findings exist demonstrating lack of reproducible efficacy or benefit. In all, many clinical trials have demonstrated effectiveness of fibrin sealants and other agents at reducing the need for intraoperative and postoperative blood transfusion. Ability to effectively seal tissues providing biliostatic effect or preventing postoperative fistula formation remains debated as definitive evidence is lacking.

CONCLUSIONS

In the following invited review, we discuss current literature describing the use of topical agents and fibrin sealants in liver and pancreas surgery. We summarize major contemporary clinical trials and their findings regarding the use of these agents in HPB surgery and provide evidence from the preclinical literature as to the translation of these products into the clinical arena.

The impact of blood management on length of stay after primary total knee arthroplasty

The current study investigates the impact of patient factors, surgical factors, and blood management on postoperative length of stay (LOS) in 516 patients who underwent primary total knee arthroplasty. Age, gender, type of anticoagulation, but not body mass index (BMI) were found to be highly significant predictors of an increased LOS. Allogeneic transfusion and the number of allogeneic units significantly increased LOS, whereas donation and/or transfusion of autologous blood did not. Hemoglobin levels preoperatively until 48 hours postoperatively were negatively correlated with LOS. After adjusting for confounding factors through Poisson regression, age (p = 0.001) and allogeneic blood transfusion (p = 0.002) were the most significant determinants of LOS. Avoiding allogeneic blood plays an essential role in reducing the overall length of stay after primary total knee arthroplasty.

[Patient Blood Management : three pillar strategy to improve outcome through avoidance of allogeneic blood products]

Blood transfusions are commonly viewed as life-saving interventions; however, current evidence shows that blood transfusions are associated with a significant increase of morbidity and mortality in a dose-dependent relationship. Not only explanatory models of basic research but also the results from randomized controlled trials suggest a causal relationship between blood transfusion and adverse outcome. Therefore, it can be claimed that the current state of science debunks the long held belief in the so-called life-saving blood transfusion by exposing the potential for promoting disease and death. Adherence to the precautionary principle and also the fact that blood transfusions are more costly than previously assumed require novel approaches in the treatment of anemia and bleeding. Patient Blood Management (PBM) allows transfusion rates to be dramatically reduced through correcting anemia by stimulating erythropoiesis, minimization of perioperative blood loss and harnessing and optimizing the physiological tolerance of anemia. A resolution of the World Health Assembly has endorsed PBM and therefore morbidity and mortality should be significantly reduced by lowering of the currently high blood utilization rate of allogeneic blood products in Austria, Germany and Switzerland.

Ten-year follow-up on Dutch orthopaedic blood management (DATA III survey)

INTRODUCTION

Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. This survey was conducted to assess the current use of perioperative blood-saving measures and to compare it with prior results.

MATERIALS AND METHODS

All departments of orthopaedic surgery at Dutch hospitals were sent a follow-up survey on perioperative blood-saving measures, and data were compared to the results of two surveys conducted 5 and 10 years earlier.

RESULTS

The response rate was 94 out of 108 departments (87%). Most departments used erythropoietin prior to hip and knee replacements at the expense of preoperative autologous blood donation. The use of intraoperative autologous retransfusion in revision hip (56 vs. 54%) as well as revision knee arthroplasty (26 vs. 24%), was virtually unchanged. Postoperative autologous retransfusion is still used by the majority of departments after both primary arthroplasty and revision of hip (58/53%) and knee (65/61%).

CONCLUSIONS

Currently, just as in 2007, the majority of Dutch orthopaedic departments uses erythropoietin, normothermia and postoperative autologous retransfusion with hip and knee arthroplasty. Intraoperative retransfusion is used mainly with hip revision arthroplasty. Other effective blood management modalities such as tranexamic acid have not been widely implemented.

Fibrin sealants or cell saver eliminate the need for autologous blood donation in anemic patients undergoing primary total knee arthroplasty

INTRODUCTION

Reducing allogeneic blood transfusions remains a challenge in total knee arthroplasty. Patients with preoperative anemia have a particularly high risk for perioperative blood transfusions.

MATERIALS AND METHODS

176 anemic patients (Hb < 13.5 g/dl) undergoing total knee replacement were prospectively evaluated to compare the effect of a perioperative cell saver (26 patients), intraoperative fibrin sealants (5 ml Evicel, Johnson & Johnson Wound Management, Ethicon, Somerville, NJ) (45 patients), preoperative autologous blood donation (PABD) (21 patients), the combination of fibrin sealants and preoperative autologous blood donation (44) and no intervention (40 patients) on perioperative blood loss and transfusion requirements.

RESULTS

All protocols resulted in significant reduction of allogeneic blood transfusions. Transfusion rates were similar with the use of PABD (19%), Evicel (18%), and cell saver (19%), all significantly lower than the control group (38 %, p < 0.05). Combining Evicel with PABD resulted in significantly higher wastage of autologous units (p < 0.05) with no significant reduction in allogeneic transfusion rate (14%). The use of fibrin sealant resulted in a significant reduction of blood loss compared to the PABD group (603 vs. 810 ml, p < 0.005) as well as the control group (603 vs. 822 ml, p < 0.005).

CONCLUSIONS

While PABD proved to be the most cost-effective treatment option in anemic patients, fibrin sealants and cell saver show similar reduction in allogeneic transfusion rates compared to controls. The combination of fibrin sealants and PABD is not cost-effective and increases the number of wasted units.

Patterns of use of hemostatic agents in patients undergoing major surgery

BACKGROUND

Although a number of prohemostatic agents that are applied intraoperatively have been introduced to minimize bleeding, little is known about the patterns of use and the factors that influence use. We examined the use of hemostatic agents in patients undergoing major surgery.

METHODS

All patients who underwent major general, gynecologic, urologic, cardiothoracic, or orthopedic surgery from 2000-2010 who were recorded in the Perspective database were analyzed.

RESULTS

Among 3,633,799 patients, hemostatic agents were used in 30.3% (n = 1,102,267). The use of hemostatic agents increased from 28.5% in 2000 to 35.2% in 2010. Over the same period, the rates of transfusion declined for pancreatectomy (-14.4%), liver resection (-15.0%), gastrectomy (-11.7%), prostatectomy (-6.6%), nephrectomy (-4.6%), hip arthroplasty (-10.4%), and knee arthroplasty (-6.6%). Over the same time period, the transfusion rate increased for colectomy (6.0%), hysterectomy (3.7%), coronary artery bypass graft (8.4%), valvuloplasty (4.2%), lung resection (1.9%), and spine surgery (1.6%). Transfusion remained relatively stable for thyroidectomy (0.2%).

CONCLUSIONS

The use of hemostatic agents has increased rapidly even for surgeries associated with a small risk of transfusion and bleeding complications. In addition to patient characteristics, surgeon and hospital factors exerted substantial influence on the allocation of hemostatic agents.

Newer hemostatic agents used in the practice of dermatologic surgery

Minor postoperative bleeding is the most common complication of cutaneous surgery. Because of the commonality of this complication, hemostasis is an important concept to address when considering dermatologic procedures. Patients that have a bleeding diathesis, an inherited/acquired coagulopathy, or who are on anticoagulant/antiplatelet medications pose a greater risk for bleeding complications during the postoperative period. Knowledge of these conditions preoperatively is of the utmost importance, allowing for proper preparation and prevention. Also, it is important to be aware of the various hemostatic modalities available, including electrocoagulation, which is among the most effective and widely used techniques. Prompt recognition of hematoma formation and knowledge of postoperative wound care can prevent further complications such as wound dehiscence, infection, or skin-graft necrosis, minimizing poor outcomes.

Evolution of the role of army transfusion services in the management of trauma patients and battle casualties with massive hemorrhage

Providing blood at the times of national emergencies and war-like scenarios is a challenge to the blood transfusion services. The dictum should be adequate bleeding, minimum storage time, quick transportation and maximum utilization of blood as soon as possible. For the successful implementation of its role, forward transfusion services should be fully mobile with integral transportation and communication systems. Supplementation of blood supplies has to be prompt, & for this adequate air transport facilities will have to be established. A rational approach to using blood products in patients with bleeding, requires an understanding of the principles of managing hemorrhagic shock. The main priorities are controlling hemorrhage and restoring adequate oxygen delivery to the tissues. Surgical control and treatment of coagulopathy are required to stop hemorrhage in these patients. Resuscitation with fluids and red cells are necessary to improve perfusion and oxygen delivery to tissues. Once patients are resuscitated and further bleeding is stopped, use of conservative transfusion triggers is recommended to avoid excessive transfusion and adverse outcomes. A host of new technologies are being developed that have the potential of reducing blood loss. These will help in reducing the transfusion requirements in trauma patients with massive hemorrhage.

Fibrin sealants in orthopaedic surgery: practical experiences derived from use of QUIXIL® in total knee arthroplasty

BACKGROUND

Total knee arthroplasty is associated with a significant postoperative blood loss even without any form of perioperative anticoagulation.

METHODS

The potential role of QUIXIL(®), a fibrin sealant used in orthopaedic surgery to control blood loss and avoid blood transfusions in patients undergoing total knee arthroplasty was evaluated in a prospective randomized trial with twenty-four patients diagnosed with primary osteoarthritis of the knee.

RESULTS

Results showed that application of 2 ml QUIXIL(®) adds costs to treatment without reducing the number of transfused red blood cell counts and postoperative haemoglobin loss. However, significant lower levels of postoperative fluid loss (P = 0.026) was detected in QUIXIL(®) treated patients.

CONCLUSION

Regarding cost effectiveness and benefit no indication for the use of 2 ml QUIXIL(®) fibrin sealant in standard knee arthroplasty could be proofed statistically.

Fibrin sealant (evicel® [quixil®/crosseal™]): a review of its use as supportive treatment for haemostasis in surgery

Evicel® is a fibrin sealant consisting of two components, human clottable protein (predominantly human fibrinogen) and human thrombin. It is indicated as supportive treatment in patients undergoing surgery when control of bleeding by standard surgical techniques is ineffective or impractical. Evicel® is a new formulation of the previously available fibrin sealant Quixil® (in the EU) or Crosseal™ (in the US). Evicel® differs from Quixil®/Crosseal™ in that its fibrinogen component does not contain the antifibrinolytic agent tranexamic acid, which is potentially neurotoxic, resulting in Quixil®/Crosseal™ being contraindicated for use in neurosurgery. The removal of tranexamic acid did not affect the haemostatic efficacy or longevity of Evicel® fibrin clots and allowed the sealant to be granted an expanded indication. Evicel® and Quixil®/Crosseal™ are easy to use and, since they do not contain synthetic or bovine aprotinin, have a reduced potential for hypersensitivity reactions. This article reviews the pharmacological properties, clinical efficacy and tolerability of Evicel® and its previous formulation as supportive treatment for haemostasis in surgery. In clinical studies, Evicel® and Quixil®/Crosseal™ were generally well tolerated and effective haemostatic agents for adjunctive use in various types of surgeries when conventional methods were impractical or ineffective in controlling bleeding. Two pivotal, randomized studies showed that Evicel® was significantly more effective than manual compression in patients undergoing vascular surgery, and significantly more effective than Surgicel® in patients undergoing retroperitoneal or intra-abdominal surgery, as assessed by the proportion of patients achieving haemostasis. In another similarly designed pivotal study in patients undergoing liver resection, Crosseal™ was significantly more effective than standard haemostatic agents (e.g. Surgicel®), as assessed by the mean time to haemostasis. The incidences of treatment-emergent adverse events in these studies were generally similar between the Evicel® or Crosseal™ groups and the comparator groups. Quixil® was also generally well tolerated and an effective haemostatic agent in endonasal surgeries, and tonsillectomies and/or adenoidectomies, with some benefit of treatment with Evicel® or Quixil® also observed in orthopaedic surgeries. Although additional comparative studies with other haemostatic agents would help to definitively position Evicel® with respect to these agents, current evidence suggests that Evicel® is useful in surgeries for improving haemostasis where standard surgical techniques are insufficient.

Measurement of joint effusion and haematoma formation by ultrasound in assessing the effectiveness of drains after total knee replacement: A prospective randomised study

We prospectively randomised 78 patients into two groups, 'drains' or 'no drains' to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient. Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing.

Dutch orthopedic blood management surveys 2002 and 2007: an increasing use of blood-saving measures

BACKGROUND

Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. The surveys were developed to assess the use of blood-saving measures in orthopedic surgery in the Netherlands in 2002 and 2007.

STUDY DESIGN AND METHODS

In 2002 and 2007, a questionnaire on blood management measures after several orthopedic procedures was sent to all Dutch orthopedic departments (110 and 96, respectively).

RESULTS

The response was 79% in 2002 and 84% in 2007. The use of preoperative autologous blood donation remained virtually unchanged in 2002 versus 2007 for both hip (10.9 and 10.5%) and knee (5.7 and 8.2%) arthroplasty. In 2007, there was a substantial increase in departments using erythropoietine for hip (31.6–66.1%) as well as knee (24.0–55.5%) arthroplasty. There was an increase of the use of autologous retransfusion of intraoperatively suctioned washed blood in hip (20.3–28.4%) as well as knee arthroplasty (8.9–16.1%) over the 5-year period, but it was predominantly used in revision hip arthroplasty (54.3%). The use of postoperative autologous retransfusion of filtered drained wound blood increased dramatically in 5 years time in hip (11.5–51.0%) and knee arthroplasty (15.9–59.3%).

CONCLUSION

There is an evident increase in the preoperative use of erythropoietin and the postoperative use of autologous retransfusion of drained blood among Dutch orthopedic departments. There appears to be an increasing awareness and positive attitude among Dutch orthopedic surgeons to implement perioperative blood-saving measures.

Topical haemostatic agents in liver surgery: do we need them?

BACKGROUND

Worldwide, partial liver resections are increasingly being performed for primary or secondary hepatic malignancies. There are various techniques to reduce blood loss during liver surgery. Several topical haemostatic agents have been developed to improve haemostasis of the resection surface and these agents are used more and more, even although the true effects remain unclear.

METHODS

The present literature about the use of topical haemostatic agents in liver surgery was reviewed. Furthermore we conducted a Dutch national survey to explore the use of and belief in these agents in liver surgery.

RESULTS

The Dutch national survey among surgeons showed that topical haemostatic agents are frequently used not only to lower intra-operative blood loss or shorten time to haemostasis, but even more importantly, to reduce resection surface related complications such as bile leakage, postoperative haemorrhage and abscess formation. Although various topical haemostatic agents have been shown to reduce intra-operative time to haemostasis at the resection surface after liver resections, there is no scientific proof that these topical haemostatic agents really reduce resection surface related complications.

CONCLUSION

This review highlights the need for more randomized clinical trials to investigate the efficacy of topical haemostatic agents in reducing resection surface related complications.

Strategies for blood management in orthopaedic and trauma surgery

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.

[Changes in transfusion practice for surgery]

The context of transfusion has changed in recent years. Some data could lead to an increased demand: the risk of viral transmission has significantly decreased; a national survey has revealed that the mortality related to an insufficient or delayed transfusion was higher to the side effects of the transfusion itself. Some other data could decrease the demand: the preoperative use of EPO is now easier; the intraoperative use of antifibrinolytic has been shown to be efficient. The number of allogenic red blood cells units (RBCs) transfused each year in France regularly increases, while the transfusion of predeposited autologous blood is in sharp decline. However, in hospitals still using but reducing this technique, the consumption of allogenic RBCs does not increase and the transfusion of any blood (allogenic and/or autologous) decreases. The strategy is based on preoperative evaluation of usual blood loss and tolerable blood loss by accepting a reasonable risk of allogenic blood transfusion. Advances in public health seem to be found above all in the analysis of system failures.

An approach to transfusion and hemorrhage in trauma: current perspectives on restrictive transfusion strategies

Hemorrhagic shock is a leading cause of death in trauma patients. Surgical control of bleeding and fluid resuscitation with both crystalloid and blood products remain the mainstay of therapy for injured patients with bleeding. However, there has been a recent re-evaluation of transfusion practice. Both the fear of transmissible disease and the costs of transfusing blood products have led to increasingly restrictive transfusion practices. A small percentage of trauma patients require massive transfusion. These patients are complex and difficult to manage, and clinicians must act quickly to save them. There is little evidence to help guide clinical transfusion decisions in these patients. A rational approach to using blood products requires an understanding of the end points of resuscitation. Resuscitation with fluids and red cells is necessary to improve perfusion and oxygen delivery to tissues. Avoiding overtransfusion is key, however, because transfusion is also associated with significant risks. This trend toward reducing allogenic blood exposure will likely continue. New technologies that have the potential of reducing blood loss and transfusion requirements in trauma patients with massive bleeding are being developed, and similar old technologies are being reapplied.

Autologous Fibrin Glue Using the Vivostat System for Hemostasis in Laparoscopic Partial Nephrectomy

OBJECTIVES

Haemostasis remains the greatest challenge during laparoscopic partial nephrectomy. Use of fibrin sealant currently is increasing. We describe first a technique for achieving effective haemostasis during laparoscopic partial nephrectomy using the Vivostat system.

METHODS

Ten patients underwent laparoscopic partial nephrectomy. Autologous fibrin sealant was prepared with the Vivostat system and applied to the resection bed. This system is an automated medical device for the preparation of an autologous fibrin sealant, generating up to 5 ml of sealant from 120 ml of the patient's blood. The concentration of fibrin and the volume of sealant are stable; the sealant may be kept at room temperature for up to 8 hours before application without a loss of properties and effectiveness. The patients were evaluated for acute and delayed bleeding.

RESULTS

Mean patient's age was 54 years (range, 31-68). Haemostasis was immediate in all cases after application of the sealant for 1 to 2 minutes to the resection site; no additional haemostatic measures were required. Mean warm ischemia time was 23 minutes (range, 20-27); mean blood loss was 90 cc (range, 20-200). Pre-operative and post-operative serum haemoglobin did not differ significantly (mean, 14.9 vs 12.6g/dl) and creatinine values (mean, 0.91 vs 0.95 ng/ml). Mean operative time was 136 minutes (range, 60-180). No postoperative bleeding or other complications occurred.

CONCLUSIONS

In this study, immediate haemostasis was achieved and maintained after the kidney was reperfused. Our initial experience with the Vivostat system in laparoscopic partial nephrectomy has been encouraging.

Intraoperative blood management in joint replacement surgery

Interest is growing in blood conservation and avoidance of transfusion in patients undergoing orthopedic surgery, especially in the field of joint replacement. Several methods have proven successful in reducing intraoperative blood loss, which can translate into lessened allogeneic and autologous transfusion requirements. Available techniques include acute normovolemic hemodilution, hypotensive anesthesia, intraoperative blood salvage, specialized cautery, topical hemostatic agents, and pharmacologic agents given in the perioperative period. The greatest potential benefit arises in operations with greater expected blood loss or in special situations such as in patients with religious issues, bilateral joint replacement, coagulation disorders, or significant preoperative anemia.