Product comparison model in otolaryngology: Equivalency analysis of absorbable hemostatic agents after endoscopic sinus surgery

Review of Evidence Supporting the Arista™ Absorbable Powder Hemostat

Background

Uncontrolled and diffuse bleeding is a dreaded event during open and laparoscopic surgery that may lead to postoperative complications, obstruction of the surgical field that reduces visualization, and prolonged operating times. Powder hemostats can be used to control bleeding and are easy to use, have a safe profile, and can achieve broad coverage area at a low cost.

Methods

A strategic literature search of peer-reviewed, English language studies was conducted to capture evidence on the clinical efficacy and safety of a Microporous Polysaccharide Hemosphere (MPH) based Hemostat (Arista™ Absorbable Hemostat (Arista™ AH)).

Results

Six preclinical studies were found which supported the use of MPH in various animal models of laparoscopic and open surgery, all of which demonstrated its safety and efficacy. Five single-arm and 11 comparative clinical studies similarly supported the efficacy and safety of MPH in various surgery types, including cardiac, renal, and dermatologic surgery.

Conclusion

Published evidence supports the safe and effective use of MPH across a variety of surgical settings.

Self-assembling RADA16 peptide hydrogel supports hemostasis, synechiae reduction, and wound healing in a sheep model of endoscopic nasal surgery

OBJECTIVES

Complications of endoscopic sinus/nasal turbinate surgery include postoperative hemorrhage, synechiae formation, and poor wound healing. Our primary objectives were to evaluate whether a topical hydrogel based on self-assembling RADA16 peptides: i) reduces bleeding and synechiae formation, and ii) supports wound healing, using a sheep nasal surgery model.

METHODS

Thirty sheep received endoscopic surgery-created bilateral nasal mucosal injuries on the middle turbinate/opposing septum. Injuries were randomly assigned RADA16, Gelatin-thrombin, or no treatment. Outcomes included intra-operative hemostasis, scar tissue/synechiae formation and wound healing at 2 weeks and the 6-week study terminus, and histopathology.

RESULTS

Intra-operative hemostasis time improved with RADA16 and Gelatin-thrombin versus Control wounds (139.7±56.2 s, 145.4±58.1 s, and 224.0±69.9 s, respectively; p < 0.0001 for both comparisons). Two-week synechiae scores (maximum 4 points) were similar in Controls (2.9±1.8 points) and Gelatin-thrombin (3.1±1.6 points) wounds (p > 0.05), but were reduced in RADA16 sites by 91% versus Controls and 92% versus Gelatin-thrombin treatment (0.3±0.6 points; p < 0.0001 for both comparisons). Six-week synechiae scores were similar in Control (1.1±1.7 points) and Gelatin-thrombin (1.7±2.0 points) wounds (p > 0.05), but reduced 100% in RADA16-treated wounds. Synechiae occurred in fewer RADA16-treated sites at 2 weeks (20%) versus Gelatin-thrombin (80%) and Controls (75%; p < 0.01) and at 6 weeks (0%, 50% and 35%, respectively; p < 0.01). RADA16 was associated with significantly lower 6-week histopathology scores, driven by reduced submucosal fibrosis and angiogenesis.

CONCLUSION

Although RADA16 and Gelatin-thrombin similarly accelerated hemostasis in this sheep endoscopic sinus surgery model, only RADA16 reduced postoperative synechiae formation at 2 weeks with an absence of synechiae at 6 weeks. Histology suggested RADA16 enhanced mucosal regeneration.

Maximizing Postoperative Recovery: The Role of Functional Biomaterials as Nasal Packs-A Comprehensive Systematic Review without Meta-Analysis (SWiM)

Numerous biomaterials have been developed over the years to enhance the outcomes of endoscopic sinus surgery (ESS) for patients with chronic rhinosinusitis. These products are specifically designed to prevent postoperative bleeding, optimize wound healing, and reduce inflammation. However, there is no singular material on the market that can be deemed the optimal material for the nasal pack. We systematically reviewed the available evidence to assess the functional biomaterial efficacy after ESS in prospective studies. The search was performed using predetermined inclusion and exclusion criteria, and 31 articles were identified in PubMed, Scopus, and Web of Science. The Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess each study's risk of bias. The studies were critically analyzed and categorized into types of biomaterial and functional properties, according to synthesis without meta-analysis (SWiM) guidelines. Despite the heterogeneity between studies, it was observed that chitosan, gelatin, hyaluronic acid, and starch-derived materials exhibit better endoscopic scores and significant potential for use in nasal packing. The published data support the idea that applying a nasal pack after ESS improves wound healing and patient-reported outcomes.

Current and Alternative Therapies for Nasal Mucosa Injury: A Review

Nasal mucosa injury can be caused by trauma, radiotherapy, chronic infection such as sinusitis, and post sinus surgery. The rate of healing and its treatment are important in the recovery of patients especially in post sinus surgery, which introduces new injuries. In this review, the current knowledge in terms of the mechanism underlying nasal wound healing was initially discussed. The currently available treatment options for enhancement of wound healing following sinus surgery were discussed and these had included intravenous antibiotics or steroids, various nasal sprays, and nasal packing. In addition, emerging alternative therapies in nasal mucosa wound healing such as herbal medicine and the advancement of regenerative medicine therapies such as stem cells and their byproducts were also discussed. Despite the various available treatment options for wound healing in nasal mucosa, rigorous strong evidence of their efficacy is gravely warranted in order to recommend them as part of the treatment modality.

Analysis of Absorbable Hemostatic Packing Compared to Physiologic Hemostasis in Functional Endoscopic Sinus Surgery With or Without Septoplasty

Background

There currently are no randomized studies examining if absorbable hemostatic packing (AHP) results in better objective and subjective outcomes than physiologic healing in sinus surgery with or without septoplasty.

Objective

The objective of this study is to examine outcomes after functional endoscopic sinus surgery (FESS) with or without septoplasty with the use of AHP versus physiologic hemostasis and healing.

Methods

A prospective randomized control trial was performed at 2 tertiary academic institutions. Fifty-nine patients undergoing bilateral FESS with or without septoplasty were enrolled and randomized to receive AHP in 1 middle meatus and no packing contralaterally. Subjective outcomes (pain, bleeding, obstruction, discharge) on self-reported visual analog scale questionnaires were tabulated on postoperative days 0, 1, 7, and 14 by the patient. Endoscopic outcomes (synechiae formation, edema, infection, granulation, debridement, crusting) were measured at 1 week, 2 weeks, and 6 weeks postoperatively by their surgeon.

Results

No significant differences were identified in subjective or endoscopic outcomes with AHP use. Concurrent septoplasty patients with AHP experienced no sustainable difference in subjective or endoscopic outcomes compared to septoplasty control. No sustainable differences were found among the types of AHP or the 2 surgeons.

Conclusion

This first reported prospective randomized study of patients with nonstrict selection criteria found AHP made no significant difference on subjective and objective postoperative outcomes as compared to physiologic hemostasis. Previous AHP-specific studies have shown differences in carefully selected patient groups. Generalizing study-proved benefits of specific AHP to all AHP is shown to be not appropriate.

In vitro analysis of growth patterns of invasive fungal species on commonly used endonasal hemostatic agents

OBJECTIVE

Previous studies have not examined the potential role of endonasal hemostatic agents in facilitating growth of fungal species. We aim to determine the possibility of these to serve as a nutrient source for fungal growth.

METHODS

Cultures of Aspergillus, Fusarium, and Mucor were harvested and placed in solution in sterile saline at standardized high and low concentrations. Thrombin gelatin matrix, carboxyl methylcelluose, and potato starch derivative agents were prepared following manufacturer instructions and applied to two separate Petri dishes per agent. Each substrate was then inoculated with either high or low concentrations of fungal species. Negative and positive control plates with each organism were included. Dishes were sealed, incubated, and examined daily for fourteen days for microscopic and macroscopic growth.

RESULTS

Thrombin gelatin matrix was relatively resilient to growth, although Fusarium growth was noted on all packing material by day three. Carboxyl methylcellulose also supported growth of high-concentration Mucor appreciated on day five. The potato starch derivative supported fulminant growth of all fungal species.

CONCLUSIONS

Endonasal hemostatic agents may be nutrient sources that facilitate growth of fungal species. This may be a consideration in a surgeon's decision to use a hemostatic agent. Prompt initial post-operative debridement may be warranted in select patients. Our findings serve as a model for further testing of fungal growth on other hemostatic materials. Future studies are needed to confirm the clinical significance of these findings in vivo.

Influence of chitosan-based dressing on prevention of synechia and wound healing after endoscopic sinus surgery: A meta-analysis

INTRODUCTION

Endoscopic sinus surgery (ESS) has had many complications, e.g., synechia formation. This meta-analysis investigated the effect of a novel chitosan-based dressing on prevention of synechia and wound healing after ESS.

METHODS

We systematically searched various medical literature data bases and included the randomized controlled trials (RCT) regarding the effect of novel chitosan-based dressing on ESS. The study outcomes included synechia, granulations, hemostasis, crusting scores, and infection.

RESULTS

Six RCTs, which involved 337 patients, were included in the meta-analysis. Compared with control intervention after ESS, chitosan-based gel dressing substantially inhibited synechia (risk ratio [RR] 0.28 [95% confidence interval {CI}, 0.15-0.54]; p = 0.0001), improved granulations (RR 1.47 [95% CI, 1.07-2.03]; p = 0.02), and hemostasis (RR 1.47 [95% CI, 1.07-2.03]; p = 0.02) but demonstrated no effect on crusting scores (standard mean difference -0.41 [95% CI, -1.06 to 0.23]; p = 0.21) and infection (RR 0.88 [95% CI, 0.51-1.52]; p = 0.64).

CONCLUSION

Compared with control intervention, chitosan-based dressing was associated with significantly reduced synechia and with increased granulations and hemostasis but showed no influence on crusting and infection after ESS.

Influence of hyaluronan nasal dressing on clinical outcome after endoscopic sinus surgery: A systematic review and meta-analysis

INTRODUCTION

Hyaluronan nasal dressing might be promising in promoting reepithelialization after endoscopic sinus surgery (ESS). However, the results remain controversial. We conducted a systematic review and meta-analysis to explore the effects of hyaluronan nasal dressing on clinical outcome after ESS.

METHODS

Medical literature data bases were systematically searched. Randomized controlled trials (RCT) that assessed the effect of hyaluronan nasal dressing on the outcome after ESS were included. The results were searched and data were extracted and assessed for quality. The primary outcome was reepithelization. Meta-analysis was performed by using the random-effect model.

RESULTS

Four RCTs, which involved 352 patients, were included in the meta-analysis. Overall, compared with control intervention, hyaluronan nasal dressing significantly promoted reepithelization (odds ratio [OR] 3.18 [95% confidence interval {CI}, 1.33-7.59]; p = 0.009) and reduced edema (OR 0.45 [95% CI, 0.23-0.89]; p = 0.02) after ESS. However, hyaluronan nasal dressing failed to reduce synechia (OR 0.45 [95% CI, 0.19-1.03]; p = 0.06), crust (OR 1.00 [95% CI, 0.20-5.09]; p = 1.00), and infection (OR 0.84 [95% CI, 0.46-1.53]; p = 0.56) compared with the control group in patients who underwent ESS.

CONCLUSION

Compared with "Control intervention" indicates standard nasal dressing without hyaluronan, resorbable hyaluronan nasal dressing could significantly improve reepithelization and decrease edema but had no influence on synechia, crust, and infection after ESS.

Efficacy of chitosan dressing on endoscopic sinus surgery: a systematic review and meta-analysis

Chitosan dressing might be promising to promote the recovery following endoscopic sinus surgery (ESS). However, the results remain controversial. We conducted a systematic review and meta-analysis to explore the influence of chitosan dressing on ESS. PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of chitosan dressing on endoscopic sinus surgery were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcomes were synechia and hemostasis. Meta-analysis was performed using random-effect model. Four RCTs involving 268 patients were included in the meta-analysis. Overall following ESS, compared with control intervention, chitosan dressing significantly reduced synechia (RR = 0.25; 95% CI 0.13-0.49; P < 0.0001) and promoted hemostasis (RR = 1.70; 95% CI 1.37-2.11; P < 0.00001), but showed no impact on granulations (RR = 1.18; 95% CI 0.72-1.95; P = 0.52), mucosal edema (RR = 0.88; 95% CI 0.60-1.29; P = 0.51), crusting (RR = 0.85; 95% CI 0.48-1.53; P = 0.60), and infection (RR = 0.88; 95% CI 0.51-1.52; P = 0.64). Compared to control intervention, chitosan dressing could significantly decrease edema and improve hemostasis, but had no effect on granulations, mucosal edema, crusting and infection.

Advances in Absorbable Biomaterials and Nasal Packing

Nasal biomaterials have been developed to improve postoperative outcomes after functional endoscopic sinus surgery (FESS). These products have been designed to overcome certain common complications in FESS, and to maximize patient comfort. This article evaluates the performance of nonabsorbable and absorbable packing with respect to these outcomes. The collected trials suggest superior performance of bioabsorbable packs compared with absorbable packs with respect to patient comfort. For hemostasis and wound healing, variation in performance metrics makes interstudy comparison difficult. Before further trials are conducted, consensus must be reached among rhinologists as to the proper method of evaluating these products.