Massive Swelling of Surgicel® Fibrillar™ Hemostat after Spinal Surgery. Case Report and a Review of the Literature

Hypersensitive Reaction of Oxidized Regenerated Cellulose Powder in Total Knee Arthroplasty

The powdered form of oxidized regenerated cellulose (ORC powder) is a widely used biodegradable hemostatic material in the field of surgery. There are several reports of its effectiveness and safety; however, excessive foreign body reactions remain a concern for surgeons in total knee arthroplasty (TKA). A 70-year-old woman who underwent unilateral TKA using ORC powder to control perioperative blood loss exhibited a skin rash around her operated knee at six days postoperatively. These reactions were potentially hypersensitive to ORC powder. After receiving antiallergic medication for 18 days, the skin rash disappeared. Although there are several reports on the safety of ORC powder, inadequate intraoperative lavage of the product may induce hypersensitive reactions such as skin rash.

The Safety and Efficacy of Microporous Polysaccharide Hemospheres in Terms of the Complication Rates in Total Hip Arthroplasty for Femoral Neck Fractures: A Control-Matched Retrospective Cohort

AIMS

This study aimed to assess the safety and efficacy of microporous polysaccharide hemospheres (MPSHs) in managing blood loss and reducing the risk of postoperative haematoma and early periprosthetic joint infection (PJI) following total hip arthroplasty (THA) for femoral neck fracture (FNF), in the context of the existing treatment challenges.

METHODS

A control-matched retrospective analysis of 163 patients undergoing unilateral primary THA for displaced FNF between 2020 and 2023 was performed. The study group consisted of 74 patients who received MPSH administered intraoperatively. The control group consisted of 89 patients who received no topical haemostatics. One-to-one case-control matching between groups was performed. The primary outcome was a perioperative change in the haematologic values (haemoglobin, red blood cell count, haematocrit, platelet concentration) and transfusion rate. The secondary outcomes were the incidence of postoperative local haematoma formation, prolonged wound secretion, surgical site infection (SSI), and PJI within 3 months of surgery.

RESULTS

Our analysis found no statistically significant differences in the haematologic parameters between the control and study cohorts. The changes in the haemoglobin concentration were not significant between the control group (3.18 ± 1.0 g/dL) and the treatment group (2.87 ± 1.15 g/dL) (p = 0.3). There were no significant differences (p = 0.24) in the haematocrit and red blood cell concentration (p = 0.15). The platelet levels did not significantly differ (p = 0.12) between the groups. Additionally, we found no significant discrepancy in the incidence of early PJI or blood transfusion rates between the groups. No adverse effects following MPSH use were recorded in the study group.

CONCLUSIONS

Routine use of MPSH in THA for FNF management appears to be safe, with no observed adverse events related to Arista® use. Although there was a tendency towards reduced blood loss in the Arista® AH group, MPSH did not significantly impact bleeding complications, local haematoma formation, or subsequent PJI.

A contemporary systematic review of the complications associated with SURGICEL

BACKGROUND

This review aims to summarize the findings from recent literature (2010-2022) reporting on complications that resulted from the surgical use of SURGICEL for intraoperative hemostasis.

METHODS

A literature search was conducted using the MEDLINE (OVID), Embase, and Cochrane Central Register of Controlled Trials - CENTRAL (OVID) databases. The studies were sorted into case reports and other study types for data extraction. Covidence was used for data extraction and statistics were descriptive.

RESULTS

Of the total 560 articles screened, 73 papers were selected for a full-text review and 70 studies were included in this review. A total of 7,242 participants were included in the studies (case studies n = 93, others n = 7149). 67/70 of the included studies reported complications when SURGICEL was used intraoperatively. Reported complications included: SURGICEL induced masses (granulomas, abscesses, hematomas, cysts) (n = 25), hemorrhagic complications (n = 12), masses misdiagnosed as tumors, cardiovascular, nervous system, and hepatobiliary complications, pain, and infections. Other complications included: fistulas, erectile dysfunction, chorioamnionitis, swelling, urinary leak, renal failure, and anaphylaxis.

CONCLUSIONS

Publications reporting on complications associated with the use of SURGICEL intraoperatively have continued to emerge. Future studies should compare how the types and rates of complications compare between SURGICEL and alternative hemostatic agents.

Hemostatic Agents in Orthopedic Surgery

Controlling blood loss is a crucial aspect of orthopedic surgery. Hemostatic agents can be used intraoperatively in combination with antifibrinolytics as part of an overall strategy to limit blood loss. Several new hemostatic agents have recently come to the market designed specifically for vascular surgery but have found uses in other surgical fields, including orthopedics. This article reviews the mechanisms of action and best uses of various mechanical hemostats, active hemostats, flowable hemostats, and fibrin sealants for achieving hemostasis in orthopedic surgery. Mechanical and active hemostats have been reported to successfully decrease blood loss from cancellous bone, capillaries, and venules. Flowable hemostats are generally favorable for use in small spaces where the swelling capabilities of mechanical and active hemostats can be detrimental to surrounding structures. Sealants are best used for closing defects in tissues.

Complications of oxidised regenerated cellulose at Caesarean section: A report of two cases

Two patients underwent surgical deliveries within four months of one another at a single maternity unit. Both patients had complications of infection-like symptoms such as offensive vaginal discharge and pyrexia, months following their caesarean sections resulting in further surgery. The incidents were thought to be secondary to woven oxidised regenerated cellulose (ORC) use. ORC must be used according to its relevant product literature which can vary between brands. Surgeons must keep abreast of changes to the haemostatic material provided to them and therefore the properties of each type, especially when faced with bleeding not suitable for suturing or electrocautery.

Hemostats in Spine Surgery: Literature Review and Expert Panel Recommendations

Bleeding in spine surgery is a common occurrence but when bleeding is uncontrolled the consequences can be severe due to the potential for spinal cord compression and damage to the central nervous system. There are many factors that influence bleeding during spine surgery including patient factors and those related to the type of surgery and the surgical approach to bleeding. There are a range of methods that can be employed to both reduce the risk of bleeding and achieve hemostasis, one of which is the adjunct use of hemostatic agents. Hemostatic agents are available in a variety of forms and materials and with considerable variation in cost, but specific evidence to support their use in spine surgery is sparse. A literature review was conducted to identify the pre-, peri-, and postsurgical considerations around bleeding in spine surgery. The review generated a set of recommendations that were discussed and ratified by a wider expert group of spine surgeons. The results are intended to provide a practical guide to the selection of hemostats for specific bleeding situations that may be encountered in spine surgery.

Variants of Oxidized Regenerated Cellulose and Their Distinct Effects on Neuronal Tissue

Based on oxidized regenerated cellulose (ORC), several hemostyptic materials, such as Tabotamp^®, Equicel^® and Equitamp^®, have been developed to approach challenging hemostasis in neurosurgery. The present study compares ORC that differ in terms of compositions and properties, regarding their structure, solubility, pH values and effects on neuronal tissue. Cytotoxicity was detected via DNA-binding fluorescence dye in Schwann cells, astrocytes, and neuronal cells. Additionally, organotypic hippocampal slice cultures (OHSC) were analyzed, using propidium iodide, hematoxylin-eosin, and isolectin B₄ staining to investigate the cellular damage, cytoarchitecture, and microglia activation. Whereas Equicel^® led to a neutral pH, Tabotamp^® (pH 2.8) and Equitamp^® (pH 4.8) caused a significant reduction of pH (p < 0.001). Equicel^® and Tabotamp^® increased cytotoxicity significantly in several cell lines (p < 0.01). On OHSC, Tabotamp^® and Equicel^® led to a stronger and deeper damage to the neuronal tissue than Equitamp^® or gauze (p < 0.01). Equicel^® increased strongly the number of microglia cells after 24 h (p < 0.001). Microglia cells were not detectable after Tabotamp^® treatment, presumably due to an artifact caused by strong pH reduction. In summary, our data imply the use of Equicel^®, Tabotamp^® or Equitamp^® for specific applications in distinct clinical settings depending on their localization or tissue properties.

The effect of chemical and structural modifiers on the haemostatic process and cytotoxicity of the beta-chitin patch

Beta-chitin patch has previously been proven to be an effective haemostat, but whether modifying the patch affects its efficacy and safety, remains unanswered. In this study, the patch was modified using polyethylene oxide, Pluronic-F127, calcium, increased thickness or polyphosphate, and their effect on the process of haemostasis and cytotoxicity was tested and compared with standard-of-care, Surgicel and FloSeal. Whole blood collected from volunteers was applied to the patches to test their whole blood clotting and thrombin generation capacities, whilst platelet isolates were used to test their platelet aggregation ability. The fluid absorption capacity of the patches was tested using simulated body fluid. Cytotoxicity of the patches was tested using AlamarBlue assays and PC12 cells and the results were compared with the standard-of-care. In this study, beta-chitin patch modifications failed to improve its whole blood clotting, platelet aggregation and thrombin generation capacity. Compared to non-modified patch, modifications with polyethylene oxide or calcium reduced platelet aggregation and thrombin generation capacity, while increasing the thickness or adding polyphosphate decreased platelet aggregation capacity. The cytotoxicity assays demonstrated that the beta-chitin patches were non-toxic to cells. In vivo research is required to evaluate the safety and efficacy of the beta-chitin patches in a clinical setting.

The role of hemostatic devices in neurosurgery. A systematic review

Hemostasis represents a fundamental step in every surgical procedure. During neurosurgical procedures, proper and robust hemostasis into confined spaces can significantly reduce the odds of perioperative complications. Over the decades, multiple methods have been applied, and several medical devices have been developed to promote and guarantee proper hemostasis. This study presents a systematic review of the most used intraoperative hemostatic methods and devices in neurosurgery. Insightful research was performed on the PubMed database according to the PRISMA guidelines. This comprehensive review of scientific literature represents a synoptic panel where the most used intraoperative hemostatic methods and devices available today in neurosurgery are classified and described.

Polymeric Tissue Adhesives

Polymeric tissue adhesives provide versatile materials for wound management and are widely used in a variety of medical settings ranging from minor to life-threatening tissue injuries. Compared to the traditional methods of wound closure (i.e., suturing and stapling), they are relatively easy to use, enable rapid application, and introduce minimal tissue damage. Furthermore, they can act as hemostats to control bleeding and provide a tissue-healing environment at the wound site. Despite their numerous current applications, tissue adhesives still face several limitations and unresolved challenges (e.g., weak adhesion strength and poor mechanical properties) that limit their use, leaving ample room for future improvements. Successful development of next-generation adhesives will likely require a holistic understanding of the chemical and physical properties of the tissue-adhesive interface, fundamental mechanisms of tissue adhesion, and requirements for specific clinical applications. In this review, we discuss a set of rational guidelines for design of adhesives, recent progress in the field along with examples of commercially available adhesives and those under development, tissue-specific considerations, and finally potential functions for future adhesives. Advances in tissue adhesives will open new avenues for wound care and potentially provide potent therapeutics for various medical applications.

Advances in Topical Hemostatic Agent Therapies: A Comprehensive Update

Severe hemorrhage causes significant metabolic and cellular dysfunction secondary to deficient tissue perfusion and oxygen delivery. If bleeding continues, hemodynamic destabilization, hypoxemia, multiple organ failure, and death will occur. Techniques employed to promote hemostasis include surgical suture ligatures, cautery, chemical agents, self-assembling nanoparticles, and physical methods, like mechanical pressure. Improved understanding of the natural clotting cascade has allowed newly designed agents to become more targeted for clinical and military use. Topically-applied hemostatic agents have enormous clinical applications in achieving hemostasis. This manuscript describes currently available and developing topical hemostatic materials, including topical active agents, mechanical agents, synthetic/hemisynthetic hemostatic agents, and external hemostatic dressings for clinical practice.

Perioperative outcomes and hospital costs associated with flowable gelatin hemostatic matrix for lumbar surgeries in real world hospital setting

Background: Efficient hemostasis during lumbar surgery (LS) is associated with better perioperative outcomes. Flowable gelatin hemostatic matrix (FGHM) is a new type of absorbable hemostatic agent, which is effective to control bleeding during spinal surgery. This study aimed to assess the impact of FGHM on perioperative outcomes and hospital costs associated with LS. Methods: This study retrospectively analyzed medical and billing records of patients who underwent LS for spinal degenerative disease in a Chinese tertiary care hospital from 2014 to 2016. The identified patients were further stratified into a FGHM group (n = 108) (using the combination of FGHM and gelatin sponge) and a historical control group (using oxidized cellulose and/or collagen, n = 82) for the adjusted comparisons of the perioperative outcomes using a propensity score matching method. Multiple generalized linear regression was conducted to assess the impact of using FGHM on total hospitalization costs. Results: Comparisons of 64 propensity score matched pairs showed a significantly lower blood transfusion rate (34.4% vs 64.1%, p = 0.005), lower blood transfusion volume (182.7 ± 312.4 vs 301.3 ± 281.0 mL, p = 0.045), reduced post-surgery drainage tube placement rate (82.8% vs 93.8%, p = 0.046), and shorter post-operative days on antibiotics (6.0 ± 2.6 vs 7.1 ± 2.4 days, p = 0.010) in the FGHM group. Although with a relatively high acquisition price, the use of FGHM for hemostasis in LS did not increase the total hospitalization costs (coefficient = -0.001, p = 0.972). Conclusions: The use of FGHM in LS improved perioperative outcomes related to hemostatic effects without increasing overall hospital costs in a real-world hospital setting.

A systematic review on the use of topical hemostats in trauma and emergency surgery

BACKGROUND

A wide variety of hemostats are available as adjunctive measures to improve hemostasis during surgical procedures if residual bleeding persists despite correct application of conventional methods for hemorrhage control. Some are considered active agents, since they contain fibrinogen and thrombin and actively participate at the end of the coagulation cascade to form a fibrin clot, whereas others to be effective require an intact coagulation system. The aim of this study is to provide an evidence-based approach to correctly select the available agents to help physicians to use the most appropriate hemostat according to the clinical setting, surgical problem and patient's coagulation status.

METHODS

The literature from 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] protocol. Sixty-six articles were reviewed by a panel of experts to assign grade of recommendation (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development and Evaluation] system, and a national meeting was held.

RESULTS

Fibrin adhesives, in liquid form (fibrin glues) or with stiff collagen fleece (fibrin patch) are effective in the presence of spontaneous or drug-induced coagulation disorders. Mechanical hemostats should be preferred in patients who have an intact coagulation system. Sealants are effective, irrespective of patient's coagulation status, to improve control of residual oozing. Hemostatic dressings represent a valuable option in case of external hemorrhage at junctional sites or when tourniquets are impractical or ineffective.

CONCLUSIONS

Local hemostatic agents are dissimilar products with different indications. A knowledge of the properties of each single agent should be in the armamentarium of acute care surgeons in order to select the appropriate product in different clinical conditions.

An Experimental Study of Histopathologic Effects of Hemostatic Agents Used in Spinal Surgery

OBJECTIVE

To evaluate and compare the histopathologic effects of various hemostatic agents used in spinal surgery on an experimental laminectomy model in rats.

METHODS

There were 110 rats randomly allocated into 11 groups, including sham, control, AnkaferdBlood Stopper (herbal hemostatic), SeraSeal (agar and bovine factor proteins), FLOSEAL (gelatin granules and thrombin), SURGIFLO (gelatin paste), HELITENE (absorbable collagen), Beriplast (fibrin sealant containing fibrinogen, factor XIII, and thrombin), TISSEEL (fibrin sealant), BLOODCARE (hemostatic powder), and SURGICEL (oxidized cellulose polymer) groups. Hemostatic agents were applied on the epidural region after laminectomy was performed until the identification of dura mater and nerve root. After a follow-up period of 12 weeks, rats were sacrificed, and histologic sections were performed proximal and distal to laminectomy zone. Groups were histopathologically compared in terms of chronic inflammation, fibrosis, and vascularization.

RESULTS

There was no difference between groups in terms of acute inflammation (P = 0.159). Chronic inflammation was more remarkable in the herbal hemostatic group (P = 0.036), and there was severe fibrosis in absorbable collagen hemostatic, fibrin sealant, and powder hemostatic agent groups (P < 0.001). Vascularity was more obvious in herbal hemostatic; fibrin sealant; absorbable collagen; fibrin sealant containing fibrinogen, factor XIII, and thrombin; hemostatic powder; and oxidized cellulose polymer groups (P < 0.001).

CONCLUSIONS

Hemostatic agents can cause notable histopathologic alterations, including inflammation, fibrosis, and vascularity. In this context, flowable hemostats such as gelatin granules and thrombin or gelatin paste seem to provide more promising results in spinal surgery.

The pressures of surgicel(®) in cardiac surgery

Surgicel® is bioabsorbable hemostatic mesh, frequently packed around oozing surgical bed. We report two morbidities due to it. Following transannular patch repair for Fallot's tetralogy, Surgicel® was packed around distal main pulmonary artery. Echocardiography in the intensive care unit (ICU) showed right ventricular dysfunction due to extrinsic obstruction and complete occlusion of left pulmonary artery (LPA) flows. Another patient with arterial switch operation had postoperative fibrillatory cardiac arrest, needing resuscitation with internal cardiac massage. The arrest was triggered by coronary ischemia due to periaortic compression. Both instances were caused by hygroscopic nature of Surgicel®, which absorbed blood, swelled, and compressed the luminal tissues.

Cauda equina syndrome caused by retained hemostatic agents

We report a patient with cauda equina syndrome secondary to retained Surgicel (Ethicon: Johnson & Johnson Medical, Piscataway, NJ, USA) and Gelfoam (Pfizer, New York, NY, USA). Retained hemostatic agents such as these used in spinal surgery can create space occupying lesions that lead to neurological compromise. There are few reports of neurologic symptoms caused by hemostatic devices used in surgery despite their widespread use. Our patient had routine lumbar microdiscectomy with preexisting motor deficits, and the acute postoperative course was complicated by a decline in neurologic function. The findings at the time of reoperation confirmed compression due to Gelfoam and Surgicel in the spinal canal, and subjective and objective symptoms partially improved after reoperation.

Evaluation of resorption and biocompatibility of collagen hemostats in the spinal epidural space

BACKGROUND CONTEXT

Collagen hemostats have different characteristics depending on their properties and configuration. In vivo serial evaluation of local reactions because of placement of hemostats in the epidural space has not been reported.

PURPOSE

This study compared the resorption and biocompatibility of two types of collagen hemostats placed in the epidural space.

STUDY DESIGN

This in vivo study used experimental animals to evaluate collagen hemostats that were placed in the epidural space.

METHODS

A ligamentum flavum resection model was created in Japanese white rabbits (n=65). A microfibrillar collagen hemostat (MCH group, n=5), cotton-type collagen hemostat (CCH group, n=5) that was chemically cross-linked, or no hemostat (control group, n=4) was placed in the spinal epidural space. For histologic evaluation, each group was euthanized 1, 2, 4, and 8 weeks postoperatively (PO), and hematoxylin-eosin and immunohistochemical (IHC) staining for inflammatory cytokines (tumor necrosis factor [TNF]-α, interleukin [IL]-6), cyclooxygenase (COX)-2, and macrophages (CD68) was performed. To evaluate exudate accumulation and the degree of inflammation in the epidural space, magnetic resonance imaging at 7.04 T was serially performed in each group (n=3) under anesthesia and sedation.

RESULTS

The collagen hemostats in both groups were reabsorbed at 4 weeks PO. In the MCH group, there was inflammatory cell infiltration and granuloma formation around the hemostat, TNF-α-positive cells were seen up to 1 week, and IL-6-, COX-2-, and CD68-positive cells were seen at all evaluation times. In the CCH group, no inflammatory cell infiltration around the hemostat was observed, and IHC staining showed no positive cells at 4 weeks PO and later. T2*-weighted MR images showed significantly higher mean signal intensity of the epidural space in the MCH group than in the CCH group but only at 1 week PO (p<.05).

CONCLUSIONS

Resorption of both hemostats was similar. In the MCH group, there was intense tissue inflammation around the hemostatic material, and MR images showed high signal intensity because of exudate accumulation in the epidural space. This indicated a strong foreign-body reaction to the MCH, thus demonstrating a difference in biocompatibility with the CCH.

Swelling, sealing, and hemostatic ability of a novel biomaterial: A polyethylene glycol-coated collagen pad

Trends in the development of hemostatic agents are towards self-adhering pads. This study investigates a novel biomaterial made of a polyethylene glycol-coated collagen pad (PCC). The swelling and adherence of PCC were investigated in vitro, and the hemostatic and sealing ability was investigated in vivo. In vitro, the maximum swell of PCC submerged in human plasma for 24 h is 65%. The greatest swell was in thickness, averaging 24% to a mean thickness of 2.5 ± 0.19 mm (mean±SD) ( N = 20). PCC withstood clinically relevant pressures when applied to a collagen casing washed with bile, lymph, urine, saline, and cerebrospinal fluid mixed at 33% and 67% with blood. In vivo, PCC provided complete hemostasis when applied to severe, arterial bleeds of actively ventilated pulmonary parenchyma at 3, 5, 8, and 10 min after application in a heparinized porcine pulmonary segmentectomy model. The mean rate of bleeding was 17.7 ± 8.6 ml/min. The lungs were ventilated at 15 ± 4 breaths per min and an airway pressure of 19 ± 2 cm H2O. PCC had no incidence of hematoma and an 11% incidence of intraoperative air leak ( N = 36). These data are promising for future clinical application of a new versatile, self-adhering hemostatic sealing pad consisting of a polyethylene glycol-coated collagen.