APPLICATION OF RECENT SEALING MATERIALS IN SURGERY

Abstract

The surgical suture, both when realized with the traditional threads and with the most modern mechanical staplers, represents the “classic” method for wound repair. All surgeons, however, sometimes have to deal with wounds hard to recover because, due to stretching and ischemic events of variable extent, complications such as hematomas, granulomata, dehiscences and fistulae may occur, impairing the tissue healing. Therefore, the ideal solution would be to have wound healing with no need of sutures, capable to sustain a certain mechanical stretching and with optimal conditions for a rapid recovery without leaving foreign substances in the wound area. On the other hand this concept, even in an empiric way, was already known by the ancient doctors of Great Greece who used vegetal resins for wound healing purposes. Topical hemostats, sealants, and adhesives are increasingly popular elements of the surgical toolbox. Hemostats are capable of clotting blood; sealants can provide a sealing barrier in the presence or absence of blood; and adhesives bond tissues together. Fibrin sealant is the only material available in the United States today that is approved by the Food and Drug Administration (FDA) for indications in all three of these categories. Fibrin glues are hemostatic and adhesive agents used in surgery. They are derived principally from products of human plasma. Composed of fibrinogen, thrombin, factor XIII, antifibrinolytic agent (aprotinin) and calcium chloride, they reproduce the final steps in the coagulation cascade, generating a stable fibrin-clot, stopping loss of blood flow and helping in the normal healing process. Clots formed by these agents are similar to normal clots and thus are naturally degraded by corporal enzymes. This glue has mainly been used in surgery for hemostasis, suture support and tissue adhesion. It is also used to obtain hemostasis in hemorrhagic fields, especially in situations where sutures are not appropriate, to reduce blood flow of solid organs, to seal anastomoses or filtrations of hollow organs, and to replace sutures in surgical procedures, especially when these are difficult or impossible. Fibrin sealant is now approved by the FDA for multiple indications, including hemostasis in a broad variety of surgical specialities, colon sealing at the time of colostomy closure, and skin graft adhesive attachment at the time of burn wound grafting. The use of these sealants is indicated in almost every surgical specialty including without exception endoscopic procedures where hemostatic activity is required such as cavity sealing, tissue adhesion, and support for healing wounds. Fibrin sealant has been studied and used extensively across a wide range of surgical procedures in different surgical specialties. The majority of studies, case series, and case reports published during the past 5 years confirm the effectiveness and safety of fibrin sealant as a hemostatic agent, sealant, and adhesive. Based on studies and other reports published within the last 5 years, the use of fibrin sealant appears to be increasing for tissue sealing, although it is also used extensively for hemostasis and tissue adhesion.

Fibrin sealant has been used widely in general surgery.More than half of the published reports since 2000 discuss its use for closure of gastrointestinal fistulas, including anorectal, colorectal, gastrocutaneous, esophagogastrointestinal, intractable complex, pancreatic, perineal, and gastrojejunal fistulas. Fibrin sealant has been used as a sphincter-sparing treatment of anal fistulas for many years, with success rates ranging from 0% to 100%. Most studies have shown that fibrin sealant reduces lymphatic drainage, serosanguineous drainage, and seroma formation after mastectomy. It has also been used in esophageal rupture, hernia repair, pancreatic resection, upper gastrointestinal bleeding (administered by endoscopic injection), and pilonidal sinus excision. It was also found to be an effective alternative to sutures in an animal model of colonic anastomosis and to strengthen the anastomotic site after suturing. In laparoscopic extraperitoneal inguinal hernia repair, it was more effective than prosthetic mesh alone and as effective as staples for mesh fixation without the complications associated with staple use. It is also used to stop bleeding in liver trauma and for treatment of splenic injuries from blunt or penetrating trauma to the abdomen when control of bleeding by conventional surgical techniques is ineffective or impractical. In cardiovascular surgeries recently reported studies have shown that fibrin sealant has been used effectively for hemostasis in patients undergoing replacement of the ascending aorta, and to improve hemostasis during PTFE graft placement for vascular access for dialysis or after suturing of PTFE femoral artery grafts.