Bioglue: a review of the use of this new surgical adhesive in thoracic surgery

Bioadhesive patch as a parenchymal sparing treatment of acute traumatic pulmonary air leaks

INTRODUCTION

Traumatic pulmonary injuries are common in chest trauma. Persistent air leaks occur in up to 46% of patients depending on injury severity. Prolonged leaks are associated with increased morbidity and cost. Prior work from our first-generation pectin patches successfully sealed pulmonary leaks in a cadaveric swine model. We now test the next-generation pectin patch against wedge resection in the management of air leaks in anesthetized swine.

METHODS

A continuous air leak of 10% to 20% percent was created to the anterior surface of the lung in intubated and sedated swine. Animals were treated with a two-ply pectin patch or stapled wedge resection (SW). Tidal volumes (TVs) were recorded preinjury and postinjury. Following repair, TVs were recorded, a chest tube was placed, and animals were observed for presence air leak at closure and for an additional 90 minutes while on positive pressure ventilation. Mann-Whitney U test and Fisher's exact test used to compare continuous and categorical data between groups.

RESULTS

Thirty-one animals underwent either SW (15) or pectin patch repair (PPR, 16). Baseline characteristics were similar between animals excepting baseline TV (SW, 10.3 mL/kg vs. PPR, 10.9 mL/kg; p = 0.03). There was no difference between groups for severity of injury based on percent of TV loss (SW, 15% vs. PPR, 14%; p = 0.5). There was no difference in TV between groups following repair (SW, 10.2 mL/kg vs. PPR, 10.2 mL/kg; p = 1) or at the end of observation (SW, 9.8 mL/kg vs. PPR, 10.2 mL/kg; p = 0.4). One-chamber intermittent air leaks were observed in three of the PPR animals, versus one in the SW group ( p = 0.6).

CONCLUSION

Pectin patches effectively sealed the lung following injury and were noninferior when compared with wedge resection for the management of acute traumatic air leaks. Pectin patches may offer a parenchymal sparing option for managing such injuries, although studies evaluating biodurability are needed.

The Effects of Using Bioglue in Nasal Septal Surgery

OBJECTIVES

Nasal septal surgery is one of the most common surgical procedure performed by otolaryngologists. Nasal packs are used for bleeding control, prevention of septal hematoma, replacement of mucoperichondrial flaps, and stabilization of the septum after nasal septal surgery. The aim of this study was to investigate the effects of albumin-glutaraldehyde-based tissue adhesive (Bioglue), which can be used as an alternative to nasal pack on the nasal septum after experimental nasal septum surgery.

METHODS

A total of 16 female Wistar albino rats were randomly separated into the study group (n = 10) and the control group (n = 6). After raising the mucoperichondrial flap on one side of the septum, Bioglue was used to fix the mucoperichondrial flap over the septal cartilage ın the study group and nasal packs (Merocel) were used for fixation in the control group. The rats were sacrificed at 2 and 4 weeks after septoplasty. All the tissue samples were evaluated under light microscope by the same pathologist in respect of foreign-body reaction, degree of inflammation, granulation tissue, fibrosis, cartilage damage, and cilia and goblet cell damage. In the control group, the Merocel packs were removed after 2 days and the groups were compared in terms of hematoma.

RESULTS

No hematoma was observed in any group. Septal perforation was determined in all the study group participants and loss of cilia and goblet cells and foreign-body reaction were found in 8 samples of the study group participants and in none of the control group.

CONCLUSIONS

The results of this study show that Bioglue caused segmental cartilage injury; therefore, it may not suitable for use following septal surgery.

The recent progress of tissue adhesives in design strategies, adhesive mechanism and applications

Tissue adhesives have emerged as an effective method for wound closure and hemostasis in recent decades, due to their ability to bond tissues together, preventing separation from one tissue to another. However, existing tissue adhesives still have several limitations. Tremendous efforts have been invested into developing new tissue adhesives by improving upon existing adhesives through different strategies. Therefore, highlighting and analyzing these design strategies are essential for developing the next generation of advanced adhesives. To this end, we reviewed the available strategies for modifying traditional adhesives (including cyanoacrylate glues, fibrin sealants and BioGlue), as well as design of emerging adhesives (including gelatin sealants, methacrylated sealants and bioinspired adhesives), focusing on their structures, adhesive mechanisms, advantages, limitations, and current applications. The bioinspired adhesives have numerous advantages over traditional adhesives, which will be a wise direction for achieving tissue adhesives with superior properties.

Efficacy of the Novel Medical Adhesive, MAR-VIVO-107, in an Acute Porcine Liver Resection Model

BACKGROUND

Despite modern surgical techniques, insufficient hemostasis after liver trauma is still a major cause of morbidity and mortality after injury. Therefore, efficient hemostatic agents are indicated. In this study, we evaluated the hemostatic efficacy of a novel synthetic wound adhesive (MAR-VIVO-107) based on polyurethane/polyurea, compared with a widely used fibrin adhesive (Tisseel).

MATERIALS AND METHODS

Twelve German Landrace pigs were randomly assigned to 2 groups. The animals were operated under sterile conditions. A midline laparotomy was performed and the left liver lobe was isolated and resected, using a surgical scissor, in order to induce hepatic trauma. MAR-VIVO-107 or Tisseel was applied to the resected area. The animals were monitored for 60 minutes; thereafter, they were sacrificed under anesthesia. Blood and tissue samples were collected pre- and postresection for biochemical and hematological analyses.

RESULTS

MAR-VIVO-107 versus Tisseel (mean ± SD, P value)-postsurgical survival rate was 100% in both groups. Bleeding time was significantly higher in Tisseel compared with MAR-VIVO-107 (10.3 ± 5.0 vs 3.7 ± 1.5 minutes, P = .0124). In trend, blood loss was less in the MAR-VIVO-107 group (54.3 ± 34.9 vs 105.5 ± 65.8 g, P = .222). Aspartate transaminase levels were significantly lower in the MAR-VIVO-107 group when compared with the Tisseel group (39.0 ± 10.0 vs 72.4 ± 23.4 U/L, P = .0459).

CONCLUSION

The efficacy of MAR-VIVO-107 and comparable performance to the gold standard fibrin have been shown under pre-clinical conditions. MAR-VIVO-107 permits hemorrhage control within seconds, even in wet environment.

The role of BioGlue in thoracic surgery: a systematic review

BACKGROUND

BioGlue is a commonly used sealant in thoracic surgery. Prolonged air leak and presence of bronchopleural fistulae (BPF) are often encountered in clinical practice. We therefore, investigated the role and the efficacy of BioGlue in these scenarios.

METHODS

A systematic review was conducted by searching Medline [1966-2016] and Cochrane Central Register of Controlled Trials (CENTRAL) [1999-2016] along with reference lists of the included studies. Included studies reported on thoracic surgery operations and use of BioGlue in thoracic surgical procedures, whereas excluded studies met at least one of the following criteria: non-English language studies, non-human population, studies on surgical specialties other than Thoracic surgery, reviews and meta-analyses and sealants other than BioGlue.

RESULTS

Twelve studies with a total number of 194 patients were included. Amongst them, 178 were treated for alveolar air leaks (AAL), 14 for BPF and 2 for lymphatic leaks. BioGlue was utilized at the time of initial operation in 172 (96.7%) patients for AAL, while at secondary intervention in 13 (92.9%) for BPF and 1 (50%) for lymphatic leak. In terms of AAL, only 2 out of 4 studies showed statistically significant reduction in duration of air leak, duration of intercostal drainage and length of stay (LOS) when BioGlue was applied. No complications were encountered after using BioGlue in sealing BPF, apart from the re-application of BioGlue in 3 cases.

CONCLUSIONS

Although BioGlue has been shown to be efficient in treating AAL, it should be used with caution against BPF, despite encouraging preliminary results. Potential adverse effects must always be taken into consideration. Future randomized controlled trials are warranted in an attempt to establish its benefit in current clinical practice.

A review of the postoperative lymphatic leakage

Lymphatic complications are rare, but well-known phenomena, and have been described by many researchers. However, many diagnoses of lymphatic complications are found confusing due to different definition. A literature search in Pubmed was performed for studies postoperative lympatic complications. These complications divided into two parts: lymphatic leakage and lymphatic stasis. This review is about lymphatic leakage, especially, postoperative lymphatic leakage due to the injury of lymphatic channels in surgical procedures. According to polytrophic consequences, many types of postoperative lymphatic leakage have been presented, including lymph ascites, lymphocele, lymphorrhea, lymphatic fistula, chylous ascites, chylothorax, chyloretroperitoneum and chylorrhea. In this review, we focus on the definition, incidence and treatment about most of these forms of lymphatic complications to depict a comprehensive view of postoperative lymphatic leakage. We hold the idea that the method of treatment should be individual and personal according to manifestation and tolerance of patient. Meanwhile, conservative treatment is suitable and should be considered first.

Improved application technique of albumin-glutaraldehyde glue for repair of superficial lung defects

Background

Albumin-glutaraldehyde glue has gained widespread acceptance for treatment of alveolar air leaks (AAL) in thoracic surgery. As liquid run-off during application is detrimental to its sealing efficacy, we developed a modified technique and assessed it in vitro.

Methods

Caudal lobes of freshly excised swine lungs (n = 20) were intubated and ventilated. A standardized focal superficial parenchymal defect (40 × 25 mm) was created on the inflated lung. AAL was assessed under exposure to increasing inspired tidal volume (TVi). Lung lobes were randomly selected and subjected to either a standard sealing suggested by the manufacturer (control group) or a modified technique relying on placement of a square silicone frame around the lesion site (study group). AAL was subsequently assessed until burst failure occurred and the occuring lesions length was recorded on the inflated lung to evaluate elasticity of underlying tissue.

Results

Superficial parenchymal defects resulted in AAL increasing with ascending TVi. AAL prior to sealant application was comparable in both groups. An application error occurred once in our control group. At TVi = 400, 500, 600 and 700 ml, the albumin-glutaraldehyde glue achieved complete sealing in 10, 10, 9 and 8 lungs respectively in our study group, as opposed to 9, 7, 6 and 4 lobes in the control group. The required mean burst pressure was significantly higher in our study group (41.0 ± 1.0 vs. 37.5 ± 4.2 cmH₂O, p = 0.0195), but there was no difference in expansion of covered defect between both groups (1.0 ± 0.4 vs. 1.5 ± 1.7 mm, p = 0.3772).

Conclusions

Our tests suggest that frame-assisted sealant application might prevent glue run-off and thus improves its sealing efficacy. We encourage further investigation of this technique in well-designed, controlled clinical trials.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-016-0544-6) contains supplementary material, which is available to authorized users.

Effect of the Bioadhesive, BioGlue, on Impaired Colonic Anastomose Healing in Rats

Colonic anastomotic leakage is still a problem in general surgery practice. We sought to investigate the effect of a new tissue adhesive, BioGlue, on the healing of normal and impaired colonic anastomoses. Sixty-four rats were randomized into 4 groups. In all animals, a 1-cm segment of the left colon was resected, and an end-to-end sutured anastomosis was created. Animals were then divided into 2 groups: normal and impaired anastomosis. These 2 groups were further subdivided into 2 additional groups: animals that received BioGlue and those that did not. All rats received intraperitoneal injections of either 0.9% NaCl or 5-fluorouracil (5-FU). Anastomotic evaluation was done 7 days after surgery. Macroscopic healing, mechanical strength, and histopathologic healing parameters were evaluated. Leakage of the anastomosis was significantly higher in rats in the impaired group compared with those in the BioGlue groups (P = 0.043). The adhesion formation score was significantly higher in rats in the impaired anastomosis group compared with the other groups. Bursting pressures were significantly lower in the impaired anastomosis group than in the other ones (P = 0.001). Neoangiogenesis and fibroblast activity were different among the groups (P = 0.001). Inflammatory cell infiltration and collagen deposition did not differ among the groups (P = 0.07). Immediate postoperative intraperitoneal administration of 5-FU after colonic anastomosis inhibits intestinal wound healing. Covering colon anastomoses with BioGlue after suturing conferred beneficial effect on healing.

Mechanical strength and rheological properties of tissue adhesives with regard to colorectal anastomosis: an ex vivo study

OBJECTIVE

To compare mechanical strength and rheology of existing tissue adhesives in a clinically relevant test setup with regard to colorectal anastomosis.

BACKGROUND

Little is known on the mechanical strength of tissue adhesives directly after application. Furthermore, rheological profiling may be important in understanding mechanical performance and explaining differences between adhesives. This study provides new data on the mechanical strength and rheology of a comprehensive list of tissue adhesives with regard to colorectal adhesiveness.

METHODS

Twelve surgical tissue adhesives were included: 4 cyanoacrylate adhesives (CA), 2 fibrin glues (FG), 3 polyethylene glycol (PEG) adhesives, and 3 albumin-based (AB) adhesives. Tubular rat colonic segments were glued together. Tensile (T), shear (S), and peel (P) strength were measured. Shear storage (G') and shear loss (G″) moduli were also evaluated.

RESULTS

CA adhesives were stronger than AB (T: P = 0.017; S: P = 0.064; P: P < 0.001), which, in turn, were stronger than PEG (T: P < 0.001; S: P < 0.001; P: P = 0.018). PEG were stronger than FG for shear (P = 0.013) and comparable for tensile and peel strength (P > 0.05). Within-group variation was smallest for CA. Mechanical strength correlated strongly between performed tests. Rheological properties (G' and G″) correlated strongly with mechanical strength for all adhesives combined.

CONCLUSIONS

CA adhesives are the strongest and most homogenous group in terms of mechanical strength. Hydrogels (FG, AB) are heterogeneous, with lower mechanical strength than CA. FG are mechanically the weakest adhesives. Rheological profiles correlate to mechanical strength and may be useful for predicting mechanical performance.

Interventional radiologic management and treatment of enterocutaneous fistulae

Enterocutaneous fistulae (ECFs) are abnormal sinus tract communications between the alimentary system and skin surface that can cause significant management problems and cost to the health care system. Interventional radiology can play an important role in diagnosis and treatment when conventional measures fail and additional surgery is difficult or poses a high risk. The management of patients with fistulae requires operator ingenuity and dedication, a multidisciplinary team approach, and an understanding of the pathophysiology. This article reviews the major issues in ECF management and the role of interventional radiology.

Novel technique to appose flaps using the BioGlue in the external dacryocystorhinostomy

PURPOSE

To introduce the sutureless technique to appose flaps using the BioGlue composed of bovine serum albumin (45%) and glutaraldehyde (10%) in the external dacryocystorhinostomy (DCR).

METHODS

The clinical chart was reviewed, retrospectively. The authors studied 31 case series of 30 patients who underwent the external DCR using the BioGlue in the step of apposing flaps. Instead of the suture technique, BioGlue was applied to appose flaps. Other steps were performed in the similar fashion to the conventional external DCR. And also, authors studied 31 case series of 30 patients who underwent the external DCR with conventional suture technique.

RESULTS

Mean follow-up period is 12.5 months in study group and 12.6 months in control group. During mean follow up, 3 cases of membrane formation were observed, and patency of the anastomosis was kept well established in 28 cases (90%) in both groups.

CONCLUSIONS

Sutureless apposition of flaps using the BioGlue can be an alternative method for the conventional suture technique in the external DCR. Also, it is easy and safe procedure to perform.

Use of BioGlue Surgical Adhesive in Hypospadias Repair

PURPOSE

To prospectively evaluate the efficacy of albumin glutaraldehyde tissue adhesive (BioGlue) in the surgical treatment of patients with hypospadias.

MATERIALS AND METHODS

Two groups of 20 patients each who underwent hypospadias repair were included in the study. In the first group we utilized BioGlue as an additional protective layer to the suture line of the neo-urethra, while patients in the second group were operated on utilizing a routine surgical technique.

RESULTS

There were no statistical differences between patients from the 2 groups in terms of surgical complications. Urethrocutaneous fistula was revealed in 4 (20%) patients after repair with BioGlue and in 3 (15%) patients from the control group (p = 0.686), suture line breakdown in 4 (20%) and in 1 (5%) patients (p = 0.478), meatal stenosis in 1 (5%) and in 1 (5%) patient (p = 1). Furthermore more patients in the BioGlue group (n = 12, 60%) demonstrated poor cosmetic results compared to the control group where most patients - 19 (95%) had acceptable cosmetic outcomes (p = 0.007).

CONCLUSIONS

Our data showed no benefits of BioGlue use in hypospadias repair.

Tissue adhesives in otorhinolaryngology

The development of medical tissue adhesives has a long history without finding an all-purpose tissue adhesive for clinical daily routine. This is caused by the specific demands which are made on a tissue adhesive, and the different areas of application. In otorhinolaryngology, on the one hand, this is the mucosal environment as well as the application on bones, cartilage and periphery nerves. On the other hand, there are stressed regions (skin, oral cavity, pharynx, oesophagus, trachea) and unstressed regions (middle ear, nose and paranasal sinuses, cranial bones). But due to the facts that adhesives can have considerable advantages in assuring surgery results, prevention of complications and so reduction of medical costs/treatment expenses, the search for new adhesives for use in otorhinolaryngology will be continued intensively. In parallel, appropriate application systems have to be developed for microscopic and endoscopic use.

Surgical sealant for preventing air leaks after pulmonary resections in patients with lung cancer

BACKGROUND

Postoperative air leak is a frequent complication after pulmonary resection for lung cancer. It may cause serious complications, such as empyema, or prolong the need for chest tube and hospitalization. Different types of surgical sealants have been developed to prevent or to reduce postoperative air leaks. A systematic review was therefore undertaken to evaluate the evidence on their effectiveness.

OBJECTIVES

To evaluate the effectiveness of surgical sealants in preventing or reducing postoperative air leaks after pulmonary resection for lung cancer.

SEARCH STRATEGY

We searched the electronic databases MEDLINE (1966 to September 2008), EMBASE (1974 to September 2008), and the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library, Issue 3, 2008) and listed references. We hand searched conference proceedings to identify published and unpublished trials.

SELECTION CRITERIA

We included randomized controlled clinical trials in which standard closure techniques plus a sealant were compared with the same intervention with no use of any sealant in patients undergoing elective pulmonary resection provided that a large proportion of the patients studied had undergone pulmonary resection for lung cancer.

DATA COLLECTION AND ANALYSIS

Four reviewers independently selected the trials to be included in the review, assessed methodological quality of each trial and extracted data using a standardized form. Because of several limitations, narrative synthesis was used at this stage.

MAIN RESULTS

Sixteen trials, with 1642 randomized patients in total were included. In thirteen trials there were differences between treatment and control patients in reducing postoperative air leaks. This reduction proved to be significant in six trials. Three trials showed a significant reduction in time to chest drain removal in the treatment group. In two trials, the percentage of patients with persistent air leak was significantly smaller in the treatment group. Finally, three trials including 352 patients showed a statistically significant reduction in length of hospital stay.

AUTHORS' CONCLUSIONS

Surgical sealants reduce postoperative air leaks and time to chest drain removal but this reduction is not always associated with a reduction in length of postoperative hospital stay. Therefore, systematic use of surgical sealants with the objective of reducing hospital stay cannot be recommended at the moment. More and larger randomized controlled clinical trials are needed.

A simplified technique for intrathoracic stomach repair: laparoscopic fundoplication with Vicryl mesh and BioGlue crural reinforcement

BACKGROUND

Laparoscopic repair of an intrathoracic stomach has been associated with a high recurrence rate. The use of biologic or synthetic mesh to reinforce the crural repair has been shown to reduce recurrence. This study aimed to assess a simplified technique for reinforcing the crural repair using absorbable Vicryl mesh secured with BioGlue during laparoscopic repair of an intrathoracic stomach.

METHODS

The charts of all patients who underwent laparoscopic repair of an intrathoracic stomach from June 2006 to March 2009 using the described technique were retrospectively reviewed. Intrathoracic stomach was defined as more than 50% of the stomach herniated into the chest. Follow-up assessment was routinely performed 1 year or more after surgery and included endoscopy, video esophagram, Bravo 48-h pH monitoring, and a gastroesophageal reflux disease (GERD)-health-related quality-of-life (HRQL) questionnaire.

RESULTS

A total of 35 patients (male:female = 10:25) with a mean age of 70 years (48-89 years) and a mean body mass index (BMI) of 30.4 kg/m(2) (20.4-44.8 kg/m(2)) underwent repair using this technique. The median operating time was 144 min (101-311 min), and the median hospital stay was 2 days (1-21 days). There were three conversions (8.6%) and one intraoperative complication (2.9%). Three patients (8.6%) experienced postoperative complications. No mesh-related complications occurred. Follow-up assessment 1 year or more after surgery was available for 21 of the 25 eligible patients [median follow-up period, 14 months (11-34 months)]. There were two recurrences (9.5%), one of them asymptomatic. The median GERD-HRQL score was 5 (2-28). Nearly all the patients (91.3%) were satisfied with the operation, and 96% would have it again.

CONCLUSION

Vicryl mesh secured with BioGlue is a simple and easy method for reinforcing the crural closure during laparoscopic repair of an intrathoracic stomach. The recurrence rate at 1 year is low and comparable with that of other series using biologic mesh secured with sutures or tacks.

Topical haemostatic agents

BACKGROUND

A variety of local haemostatic agents is now available to stop troublesome bleeding. These agents are indicated for use during surgical interventions where conventional methods of haemostasis are not applicable because of the site of surgery or the degree of bleeding.

METHOD

A literature search using the PubMed and ISI Web of Knowledge databases identified relevant studies on topical haemostatic agents. Manufacturers' recommendations were also sought through commercial websites.

RESULTS AND CONCLUSION

A significant body of evidence now exists to support the use of topical haemostatic agents in a wide variety of clinical situations. The advantages and disadvantages of many of these agents are highlighted.

Nerve and Conduction Tissue Injury Caused by Contact with BioGlue

BACKGROUND

BioGlue-a surgical adhesive composed of bovine albumin and glutaraldehyde-is commonly used in cardiovascular operations. The objectives of this study were to determine whether BioGlue injures nerves and cardiac conduction tissues, and whether a water-soluble gel barrier protects against such injury.

MATERIALS AND METHODS

In 18 pigs, diaphragmatic excursion during direct phrenic nerve stimulation was measured at baseline and at 3 and 30 min after nerve exposure to albumin (n = 3), glutaraldehyde (n = 3), BioGlue (n = 6), or water-soluble gel followed by BioGlue (n = 6). Additionally, BioGlue was applied to the cavoatrial junction overlying the sinoatrial node (SAN), either alone (n = 12) or after application of gel (n = 6).

RESULTS

Mean diaphragmatic excursions in the BioGlue and glutaraldehyde groups were lower at 3 min and 30 min than in the albumin group (P < 0.05). Mean excursions in the gel group were similar to those of the albumin group (P = 0.9). Five BioGlue pigs (83%) and one gel pig (17%) had diaphragmatic paralysis by 30 min (P < 0.05 and P = 0.3 versus albumin, respectively). Coagulation necrosis extended into the myocardium at the cavoatrial junction in all 12 BioGlue pigs but only two gel pigs (33%, P < 0.01). Two BioGlue pigs (17%), but no gel pigs, had focal SAN degeneration and persistent bradycardia (P < 0.01).

CONCLUSIONS

BioGlue causes acute nerve injury and myocardial necrosis that can lead to SAN damage. A water-soluble gel barrier is protective.

Use of a protein-based tissue adhesive as an aid for the surgical reconstruction of advanced and recurrent skin cancer tumors to the head and neck region: a technical report

BACKGROUND

Patients with advanced skin cancer present a unique challenge to neurosurgeons. Treatment involves aggressive surgical intervention and lengthy reconstructive procedures with considerable morbidity to obtain adequate and safe oncological margins. We reviewed our experience with BioGlue Surgical Adhesive, a protein-based adhesive, as an adjunct in free tissue transfer procedures to prevent CSF leakage and seroma formation.

METHODS

Between January 2000 and June 2004, 11 patients ranging in age from 32 to 87 years presented with advanced skin cancer tumors in the head and neck. Pathology included squamous (7) and basal (3) cell carcinoma and malignant schwannoma (1). Of the 11 patients, 8 had undergone previous surgery and/or radiation therapy. All were treated with a combination of craniotomy, skull base, and craniofacial approaches with reconstruction of the large defects using muscular or myocutaneous free flaps in a single operation. Fat, muscle, and a 1-mm epidural layer of BioGlue were used to seal the dural sutures and to obliterate any potential seroma-forming dead space.

RESULTS

A total of 6 patients underwent craniofacial resection with orbital exenteration and partial rhinectomy, whereas the remaining 5 underwent frontal, parietal, and/or occipital craniotomies. All patients required dural repair. Three patients required additional brain resection because of tumor infiltration. No patient developed a CSF leak or seroma. There were no adverse events related to the use of BioGlue. Three patients died of medical complications (pulmonary embolism, myocardial infarction, late-onset myelodysplasia). The remaining patients are alive, and our follow-up (range, 9-58 months) has revealed no recurrence or distal metastasis.

CONCLUSIONS

Advanced skin cancer tumors in the head and neck region are associated with complex and disfiguring surgical procedures with increased morbidity. We demonstrate that an adjunctive use of a sufficiently strong tissue adhesive can yield acceptable outcomes and minimize comorbidity in this challenging patient population.

BioGlue for prevention of postoperative cerebrospinal fluid leaks in transsphenoidal surgery: A case series

BACKGROUND

The efficacy of BioGlue (CryoLife, Inc, Atlanta, Ga) surgical adhesive in transsphenoidal surgery was assessed as an adjunct in the prevention of postoperative CSF leaks.

METHODS

All patients in whom BioGlue was used for an intraoperative skull base reconstruction were retrospectively identified. Intraoperative CSF leaks were graded according to size (grade 1, small weeping leak without obvious diaphragmatic defect; grade 2, moderate leak with a definite diaphragmatic defect; grade 3, large diaphragmatic and/or dural defect). CSF leak repair was tailored to CSF leak grade. BioGlue was applied as a reinforcement over collagen sponge as the last layer of the repair.

RESULTS

Over 28 months, a total of 282 patients underwent endonasal surgery. Of these patients, 124 (79 women; age range, 8-84 years), in 128 procedures, had an intraoperative CSF leak repair reinforced with BioGlue. Pathology included 80 pituitary adenomas, 11 craniopharyngiomas, 7 Rathke's cleft cysts, 6 chordomas, 5 meningiomas, 4 spontaneous CSF leaks, 3 arachnoid cysts, and 8 other parasellar pathologies. There were 62 (48.4%) grade 1, 41 (32.0%) grade 2, and 25 (19.5%) grade 3 leak repairs. The overall repair failure rate was 1.6% (2 cases), with the failures occurring in patients with grade 3 leaks, including 1 who developed meningitis; there was no failure of grades 1 and 2 leaks. The 2 failures were attributed largely to technical aspects of the repair rather than to failure of BioGlue per se.

CONCLUSIONS

BioGlue appears to be an effective adjunct in preventing postoperative CSF leaks after transsphenoidal surgery. However, careful attention to technical details of the repair is still required to prevent failures, especially when closing large dural and diaphragmatic defects.

Albumin-glutaraldehyde bioadhesive ("Bioglue") for prevention of postoperative complications after stapled hemorrhoidopexy: a randomized controlled trial

BACKGROUND

Hemorrhoidopexy using the circumferential stapler is an established method for surgical treatment of patients with prolapsing hemorrhoids. Despite its advantages, complications such as anal canal stenosis, hemorrhage and anastomosis leak with eventual intrapelvic sepsis can cause serious postoperative problems. The aim of this study was to evaluate the utility of a surgical adhesive, the biological albumin-glutaraldehyde glue "Bioglue", in reduction of these postoperative complications.

PATIENTS AND METHODS

Between January 2002 and November 2004, 200 patients undergoing stapled hemorrhoidopexy were enrolled in a prospective, randomized clinical trial. One hundred patients were randomly assigned to the control group; the study group consisted of 100 patients who received Bioglue in the mucosa anastomosis area. All patients received standardized postoperative analgesic, laxative and antibiotic treatment. We then evaluated the two groups for postoperative complications (after surgery and 6 months postoperatively).

RESULTS

From the control group (no Bioglue application), two patients presented with anal stenosis, two with hemorrhage, three had anastomosis leak and one had thrombosis, whereas none of the patients from the Bioglue group had any of these complications. Both groups had patients with severe postoperative pain (3 each) and fecal incontinence (1 patient each). The overall difference in the number of complications in the two groups was statistically significant (p < 0.05).

CONCLUSION

In this first study using Bioglue in patients undergoing circumferential stapled hemorrhoidopexy we have shown that application of the glue is effective in reducing postoperative complications.

A prospective, randomized, controlled trial of the effectiveness of BioGlue in treating alveolar air leaks

OBJECTIVE

The use of tissue glues has been advocated to reduce post-thoracotomy alveolar air leaks, but outcomes have been inconclusive. The aim of this study was to determine the effectiveness of BioGlue (CryoLife Europa Ltd, Hampshire, United Kingdom) in eliminating post-thoracotomy alveolar air leaks.

METHODS

A prospective, randomized, single-blind, controlled trial was conducted in which patients were stratified according to the severity of post-thoracotomy air leak that could not be controlled by conventional surgical techniques. They were allocated to a control arm (surgical treatment only) or an interventional arm (surgical treatment and BioGlue). Duration of air leak, intercostal drainage, and hospital stay comprised primary study end points.

RESULTS

From December 2002 to January 2005, 52 patients were randomized, 29 (56%) of whom were men. The mean age was 59 +/- 15 years, and other characteristics were comparable in both groups. Indications for surgery were malignancy in 46 patients (88%), carcinoid tumor in 2 patients (4%), and infective disease in 4 patients (8%). Patients in the BioGlue arm had shorter median duration of air leaks, 1 (0-2) versus 4 (2-6) days (P < .001); intercostal chest drainage, 4 (3-4) versus 5 (4-6) days (P = .012); and hospital stay, 6 (5-7) versus 7 (7-10) days (P = .004), compared with controls. No major complications were encountered using BioGlue.

CONCLUSIONS

This study demonstrates clear benefit from BioGlue in the treatment of alveolar air leaks through reduction of air leak duration, chest drainage time, and hospital stay. Systematic use of BioGlue may be warranted in adult thoracic surgical procedures (except pneumonectomy and decortication) when an air leak remains after all other steps to control it have failed.