Application Of Fibrin Sealant Research Articles

Application of platelet-rich plasma in rectovaginal fistulas in the patients with ulcerative colitis

BackgroundThere is a need for other than surgical methods of therapy for small and low rectovaginal fistulas (RVF) in the course of inflammatory bowel diseases (IBD), such as application of fibrin sealants, stem cells, biological therapy, or platelet-rich plasma. The aim of this study was to evaluate the results of the treatment after local application of PRP in aforementioned fistulas, exclusively in the patients with ulcerative colitis (UC).Patients and methodsMedical records of 13 patients with small and low-lying, active RVF in the course of UC, and after restorative proctocolectomy for UC were evaluated. Curettage of fistulous tracts was performed with the following application of PRP in all patients.ResultsComplete closure of RVF was achieved after the first injection in 4 patients, 3 women healed their fistulas following the second application, and two of them closed RVF after 3 injections. To sum up, the complete closure of RVF was achieved in 9 (69%) patients. Fistulas remained closed from 6 to 12 months.ConclusionsThe application of PRP in small, low, and recurrent IBD anal fistulas is effective, simple, and safe with an acceptable rate of healing. This therapy might also precede any further, surgical methods of treatment.

PSU6 Cost-Eectiveness Analysis of the Application of Porcine-Derived Fibrin Sealant for the Treatment of IntraOperative Cerebrospinal Fluid Leak in China

Cerebrospinal fluid leak (CSFL) after craniotomy may incur serious sequelae, such as meningitis and hematoma. A porcine-derived fibrin sealant (FS) has been introduced and used in conjunction with sutures for dural closure at hospitals in China. This study aimed to evaluate the cost-effectiveness of using FS for the treatment of intraoperative CSFL. A decision tree was constructed in R 3.6.3 to assess the cost-effectiveness of using FS with sutures compared to sutures alone for treatment of intra-operative CSFL from the perspective of the Chinese healthcare system. Efficacy and safety information were extracted from a randomized, single-blinded clinical trial comparing the two interventions (NCT03110783). Costs were obtained through the analysis of real-world databases of provincial procurement costs. All costs were converted to USD based on the published exchange rate on 12/23/2020 (6.5400 RMB to 1 USD). The effectiveness of the interventions was measured both as the success rate of CSFL treatment and as the reduction of postoperative complications. The CSFL treatment success rate was higher in patients using FS with sutures than using sutures alone (97.8% vs. 49.2%). Postoperative complication rates were lower for the group with FS (9.5% vs. 14.5%). Higher costs for using FS ($248.5 vs. $7.7) were offset by savings from higher treatment success rate and lower post-operative complication rates. The FS group saved $375.0 in additional CSFL repairs compared to the sutures group ($18.1 vs. $393.0), and $66.7 in treatment for complications ($131.9 vs. $198.6). Total costs per patient were lower by $200.8 in the FS plus suture group ($398.5 vs. $599.3). The cost effectiveness analysis demonstrated that using FS with sutures could provide improved clinical outcomes at reduced costs. FS used in combination with sutures was the dominant strategy vs sutures alone for the treatment of intra-operative CSFL.

Fibrin Sealants and Axillary Lymphatic Morbidity: A Systematic Review and Meta-Analysis of 23 Clinical Randomized Trials.

Simple SummaryAxillary dissection is a highly mobile procedure with severe lymphatic consequences. The off-label application of fibrin sealants in the axilla, with the sole aim to eliminate dead space and to provoke sealing of the disrupted lymphatic vessels at the end of axillary dissection, is an experimental procedure to reduce lymphatic morbidity. The aim of our systematic review and meta-analysis is to investigate the effects of fibrin sealants on lymphatic morbidity after axillary dissection. Our results show that this experimental procedure is able to decrease the total axillary drainage output, the number of days before the axillary drainage is removed, and the length of hospital stay. However, no effects on the occurrence rate of axillary lymphocele or on the surgical site complications rate were demonstratedBackground: use of fibrin sealants following pelvic, paraaortic, and inguinal lymphadenectomy may reduce lymphatic morbidity. The aim of this meta-analysis is to evaluate if this finding applies to the axillary lymphadenectomy. Methods: randomized trials evaluating the efficacy of fibrin sealants in reducing axillary lymphatic complications were included. Lymphocele, drainage output, surgical-site complications, and hospital stay were considered as outcomes. Results: twenty-three randomized studies, including patients undergoing axillary lymphadenectomy for breast cancer, melanoma, and Hodgkin’s disease, were included. Fibrin sealants did not affect axillary lymphocele incidence nor the surgical site complications. Drainage output, days with drainage, and hospital stay were reduced when fibrin sealants were applied (p < 0.0001, p < 0.005, p = 0.008). Conclusion: fibrin sealants after axillary dissection reduce the total axillary drainage output, the duration of drainage, and the hospital stay. No effects on the incidence of postoperative lymphocele and surgical site complications rate are found.

Evaluation of Fibrin Sealant in Prevention of Cervical Anastomotic Leakage After McKeown Esophagectomy: A Single-Center, Retrospective Study.

Anastomotic leakage remains an issue after esophagectomy for patients with esophageal or esophagogastric junction cancer. Previous studies have indicated that the intraoperative application of fibrin sealant may reduce the incidence of postoperative anastomotic leakage. This retrospective study was aimed to evaluate the efficacy and safety of fibrin sealant in the prevention of anastomotic leakage in patients undergoing McKeown esophagectomy. We designed a single-center, retrospective study. Between January 2018 and December 2019, 227 patients with esophageal or esophagogastric junction cancer undergoing McKeown esophagectomy performed by our team were retrospectively identified, of whom 86 patients were included in the FS group and 141 patients were included in the control group. Intraoperatively, 2.5 ml of porcine fibrin sealant was applied circumferentially to the cervical anastomosis after the anastomosis was created in the FS group. The primary outcome was the incidence of cervical anastomotic leakage within the first three months after surgery. The differences in baseline clinical characteristics between the two groups were not significant except for a history of drinking. In the FS group, the postoperative cervical anastomotic leakage rate was lower (FS group: 4.7% [4 of 82] vs. control group: 19.9% [28 of 141], p < 0.01). Multivariate logistic regression showed that the intraoperative application of fibrin sealant was an independent protective factor for anastomotic leakage (OR 0.169, 95% CI 0.055-0.515, p=0.002). The intraoperative application of fibrin sealant could possibly prevent cervical anastomotic leakage after McKeown esophagectomy with satisfactory safety. Further prospective clinical trials are warranted.

Corroboration Development and Regulatory approval of Fibrin Sealant

Objective&#x0D; Finding the relation between scientific evidence development and regulatory approval of medical devices in existing markets, USA (United states of America) and EU (European Union)&#x0D; Design&#x0D; To understand this relation, we used evidence development of fibrin sealant as a case study. In general fibrin sealant is a good case study because there is a lot of information available about it.&#x0D; A systematic review method based on the Cochrane handbook was used to find the evidence development regarding fibrin sealant. We investigated different indications of fibrin sealant, the year of publication, and the phases in clinical trials. To find the procedures and requirements of the approval for fibrin sealant, we searched the government website of their regulatory agencies FDA (Food and Drug Administration), EMA (European Medicine Agency), and CFDA (China Food and Drug Administration).&#x0D; Results&#x0D; The relation between evidence development and approval, we found that the cumulative publications of fibrin sealant increased almost in a straight line from 1998 to 2019. Regarding the applications of fibrin sealant, in the first four years after 1998, no new applications were approved, the next four years, two applications were approved, in the four years after that, there were four new applications.&#x0D; Conclusions&#x0D; In the first years, the amount of new approved applications is very low, compared to the amount of new publications, but afterwards it goes much faster. Even though fibrin sealant seems to be a Medical Device, the regulatory approval takes time to catch up. For the future research, it would be interesting to also include sales data of fibrin sealant to analyse how sales data influences the medical device companies’ strategies for publication and market approval.

Autologous fibrin sealant application in cardiac surgery - a single-centre observational study.

IntroductionTo minimize the risk of blood loss and post-transfusion complications in patients undergoing cardiovascular surgery, different strategies are used.AimTo analyse the efficacy of the intraoperative use of autologous fibrin glue to seal suture lines of cardiac and vascular structures.Material and methodsThe early results of 62 patients who underwent complex cardiac operations in extracorporeal circulation were analysed. In a half of them Vivostat autologous fibrin sealant in addition to the routine haemostatic agents was applied (study group), whereas in the second group (matched-pair control group) only standard haemostatics were used. Among many other factors, special attention was paid to postoperative drainage and blood products used.ResultsThe mean age of the patients and prevalence of comorbidities did not differ between groups. Generally, in the study group fewer haemostatic agents were used. For example, Preveleak tissue glue was applied in 3.2% of studied cases compared to one third of control patients (p = 0.008). The thoracic drainage on either day 0 or day 1 was also similar. The number of patients who received blood products did not differ between groups. More importantly, there were no significant differences in in-hospital mortality and prevalence of other postoperative complications.ConclusionsIn this study it was found that application of autologous fibrin glue was safe and might limit use of standard haemostatic agents. Taking into account the lack of potential threats related to the transmission of infections and immune responses, it may be an interesting alternative to the previously used local haemostatics.

Efficacy of Fibrin Sealant in Reducing Complication Risk After Bariatric Surgery: a Systematic Review and Meta-analysis.

Complications including staple-line leakage and bleeding may occur after sleeve gastrectomy and Roux-en-Y gastric bypass. In this meta-analysis, the efficacy of fibrin sealant in strengthening the staple line and reducing complication risk after bariatric surgery was evaluated. We searched PubMed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) published up to October 2020. Pooled estimates of the outcomes were computed using a random effects model. The primary outcomes were bleeding and leakage; secondary outcomes were gastric stricture, length of hospital stay, reoperation rate, and total operation time. In total, 9 RCTs including 2136 patients were reviewed. Our meta-analysis revealed that compared with controls, fibrin sealants decreased incidence of bleeding significantly (risk ratio [RR] = 0.42; 95% confidence interval [CI], 0.18-0.97), but did not demonstrate significant differences in reducing the incidence of leakage (RR = 0.62; 95% CI, 0.23-1.73), gastric stricture (RR = 1.16; 95% CI, 0.46-2.91), reoperation rate (RR = 0.85; CI, 0.14-5.14), or length of hospital stay (weighted mean difference = 0.62; 95% CI, - 0.31 to 1.55). Compared with oversewing, fibrin sealant use reduced the operation time; however, their efficacies in reducing the incidence of postoperative bleeding and leakage did not differ significantly. Although applying fibrin sealants to the staple line in bariatric surgery may provide favorable results, but it may not reduce postoperative leakage and stricture incidence significantly. Nevertheless, the application of fibrin sealants as a method for reducing risks of complications after bariatric surgery warrant further investigation.

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

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

Percutaneous application of fibrin sealant in surgically recalcitrant urinomas following oncocytoma resection

Surgical application of fibrin sealant is well established as a hemostatic agent. However, reports of its percutaneous application and its uses within the urinary tract are limited. Presented below are two patients with recalcitrant urinomas despite diversion therapy following partial nephrectomy for oncocytomas. Both patients were successfully treated with percutaneous application of fibrin sealant via a sheath at the time of percutaneous perinephric drain removal. Follow-up imaging demonstrated resolution of the urinomas with stabilization of creatinine. Percutaneous application of fibrin sealant may be considered as an alternative treatment for recalcitrant urinomas prior to surgical intervention, though more studies are required to confirm its effectiveness and safety.

Costs Analysis of Fibrin Sealant for Prevention of Anastomotic Leakage in Lower Colorectal Surgery.

IntroductionPostoperative anastomotic leaks remain a common and serious complication of colorectal surgeries and are a major cause of mortality and morbidity of these procedures. Anastomotic leaks (AL) have been extensively studied; however, there has been no significant reduction in their prevalence over time. In addition, there is a significant economic burden from AL attributed to the need for repeat surgery, radiologic intervention and lengthened hospital stay. We conducted a comparative cost analysis of patients undergoing colorectal surgery with anastomosis, with the application of fibrin sealant (FS) to the sutured anastomosis versus not treating the sutured anastomosis with FS.MethodsThe deterministic decision-tree model was populated with clinical data including operating room time, hospitalization days, occurrence of AL, need for revision surgery, blood products and radiologic interventions to treat the AL in lower colorectal surgery. A systematic literature review was conducted to identify appropriate studies with these variables.ResultsThe average cost per case treated lower colorectal surgery with fibrin sealant glue 10 mL Tisseel® and those not treated with a fibrin sealant after suturing the anastomoses was €3233 and €4130, respectively, for resource expenses paid by the healthcare system. This would suggest potential savings of €897 per surgery, achieved through the application of FS to the sutured anastomosis for preventing AL following colorectal surgery.ConclusionApplication of FS to the sutured anastomosis in lower colorectal surgery resulted in a decrease in post-operative AL, and cost savings based on a reduction in hospitalization days, a reduction needing: revision surgery, radiologic intervention and blood products to treat AL.

Does autologous fibrin sealant (vivostat©) reduce the incidence of postoperative pancreatic fistula after distal pancreatectomy? – a matched pairs analysis

Background Postoperative pancreatic fistula (POPF) is the most common complication following distal pancreatectomy. This retrospective study investigated the effects of autologous fibrin sealant (Vivostat©) in reducing the incidence of POPF after distal pancreatectomy. Methods A matched pairs analysis was performed to compare the incidence of clinically relevant POPF of 41 patients who underwent a distal pancreatectomy with application of autologous fibrin sealant (Vivostat©) with a historical control group. Results Clinically relevant POPF were present in 11 patients in the study group (27%) and in 13 patients in the control group (32%, p = .639). No patient of the study group required emergency angiographic treatment for postoperative hemorrhage due to POPF, whereas three patients were identified in the control group (7%, p = .079). Conclusions POPF cannot be prevented under treatment with autologous fibrin sealant (Vivostat©). We observed the tendency of a lower rate of postoperative pancreatic hemorrhage due to POPF. However, prospective randomized controlled studies are required.

Prospective comparative study of hypospadias surgical repair with and without the use of fibrin sealant

Background: Hypospadias is the most common congenital malformation of the penis, affecting about 4-6 males per 1000 male births, and ranging in severity from a urethral meatus that is slightly off-center to a meatus in the perineal area, The aim of this study was to evaluate whether the application of fibrin sealant over the suture lines of neo-urethra reduces complications and improve overall outcome in children hypospadias repair.1,2 Methods: It was a prospective comparative study conducted in a tertiary care center (Department of pediatric surgery - Menoufia University), we included the patients age more than 6 months and less than 4 years presented with hypospadias to our department in this study. A total 30 patients of coronal, sub coronal, mid shaft hypospadias and distal hypospadias were studied and were divided into two groups, group (A) 15 cases and group (B) 15 cases. All patients underwent a tabularized incised plate (TIP) repair with a Dartos vascularized pedicle flap to cover the neo-urethra, In group (B) a thin layer of fibrin sealant applied over the suture line of neo-urethra but no sealant was used in group (A).Results: Postoperative surgical complications: urethra cutaneous fistula, flap dehiscence, flap necrosis and urethral stricture were recorded. Urethrocutaneous fistula flap dehiscence and flap necrosis were lower in group (B) patients. There was no significant difference in postoperative urethral stricture between two groups. Conclusions: Use of fibrin sealant in hypospadias repair is safe and can reduce complications.

Is Circular Fibrin Sealing of Low Rectal Anastomosis Able to Prevent Leakage in 21-Day Follow-up? Randomized Experimental Trial in Pigs.

Purpose. Clinically apparent anastomotic leakage (AL) after low anterior rectal resection (LAR; <7 cm from anal verge) using circular double-stapled anastomosis without defunctioning stoma is up to 37.5%. However, it is unclear whether there is reduction of LAR after 21 postoperative days without defunctioning stoma but with extraluminal anastomotic application of fibrin sealant. Methods. Forty-eight-week-old pigs underwent LAR and circular double-stapled anastomosis in end-to-end technique (descendo-rectostomy). Animals were randomized into therapy and control group (cg). Therapy group (n = 20) received additional extraluminal circular anastomotic application of fibrin sealant. Objective was to assess incidence of clinically apparent and nonclinically apparent leakage through the 21st postoperative day. Remaining animals were sacrificed on the 21st day, and anastomotic region was analyzed. In case of earlier diagnosed AL, animals were sacrificed. Results. In cg, we observed clinically and nonclinically AL in 20% (n = 4). No animal was identified with a nonclinical-apparent leakage in this group, and all 4 animals with leakages presented clinical signs. In the therapy group, no animal (0/20) developed clinically apparent leakage signs. There were no leakages in this group, but 3 animals had ulcerative lesions without leak and without clinical signs. These lesions were observed intraluminally at crossing of staple lines after 21 days. In one of these animals, incomplete leakage was observed, blocked by fibrin sealant. Conclusion. In circular stapled colorectal anastomosis, circular fibrin glue sealant successfully protected anastomotic intraluminal wall defects at crossing of staple lines, reducing leakage rate from 20% to 0% (cg vs therapy group) after 21 postoperative days.

Effectiveness of Fibrin Sealant Application on the Development of Staple Line Complications After Sleeve Gastrectomy: A Prospective Randomized Trial.

Evaluate the effectiveness of the use of fibrin sealant (FS) for preventing the development of staple line complications (SLCs) after sleeve gastrectomy (SG). There is no consensus on the best means of preventing SLCs after SG. This was a prospective, intention-to-treat, randomized, 2 center study of a group of 586 patients undergoing primary SG (ClinicalTrials.gov identifier: NCT01613664) between March 2014 and June 2017. The 1:1 randomization was stratified by center, age, sex, gender, and body mass index, giving 293 patients in the FS group and 293 in the control group (without FS). The primary endpoint (composite criteria) was the incidence of SLCs in each of the 2 groups. The secondary criteria were the mortality rate, morbidity rate, reoperation rate, length of hospital stay, readmission rate, and risk factors for SLC. There were no intergroup differences in demographic variables. In an intention-to-treat analysis, the incidence of SLCs was similar in the FS and control groups (1.3% vs 2%, respectively; P = 0.52). All secondary endpoints were similar: complication rate (5.4% vs 5.1%, respectively; P = 0.85), mortality rate (0.3% vs 0%, respectively; P = 0.99), GL rate (0.3% vs 1.3%, respectively; P = 0.18), postoperative hemorrhage/hematoma rate (1% vs 0.7%, respectively; P = 0.68), reoperation rate (1% vs 0.3%, respectively; P = 0.32). Length of stay was 1 day in both groups (P = 0.89), and the readmission rate was similar (5.1% vs 3.4%, respectively; P = 0.32). No risk factors for SLCs were found. The incidence of postoperative SLCs did not appear to depend on the presence or absence of FS.

Autologous Activated Fibrin Sealant for the Esophageal Anastomosis: A Feasibility Study

BackgroundEsophageal cancer is surgically treated by means of an esophagectomy. However, esophagectomies are associated with high morbidity rates with dehiscence of the anastomosis occurring in 19% of these procedures in the Netherlands. Application of a fibrin sealant may improve mechanical strength of the anastomosis. The aim of this study was to determine the technical feasibility of the application of an autologous fibrin sealant by aerosolized spraying on esophageal anastomoses. MethodsThis study was designed as a single-center feasibility study. Patients undergoing elective minimal invasive esophageal surgery with the creation of a thoracic or a cervical anastomosis were eligible. Fibrin sealant (Vivostat) was applied to the anastomosis intraoperatively. Feasibility was measured using a nine-item checklist, designed for intraoperative application. ResultsIn total, fifteen patients, between the ages of 43-79 y, were included in this study. One procedure scored eight out of nine points on the feasibility checklist, so application was considered as unsuccessful. The other fourteen procedures obtained a 100% score and were documented as successful procedures. Together, this led to a success rate of 93%. Grade III anastomotic leakage occurred in one of the fifteen patients (6.7%). ConclusionsThis study showed that application of fibrin sealant on esophageal anastomoses is technically feasible and safe. Future studies may investigate the possible protective effects of fibrin sealant application on the development of anastomotic leakage. NCT03251040.

Assessment of Migration of Human MSCs through Fibrin Hydrogels as a Tool for Formulation Optimisation.

Control of cell migration is fundamental to the performance of materials for cell delivery, as for cells to provide any therapeutic effect, they must migrate out from the delivery material. Here the influence of fibrinogen concentration on the migration of encapsulated human mesenchymal stem cells (hMSCs) from a cell spheroid through fibrin hydrogels is tracked over time. Fibrin was chosen as a model material as it is routinely employed as a haemostatic agent and more recently has been applied as a localised delivery vehicle for potential therapeutic cell populations. The hydrogels consisted of 5 U/mL thrombin and between 5 and 50 mg/mL fibrinogen. Microstructural and viscoelastic properties of different compositions were evaluated using SEM and rheometry. Increasing the fibrinogen concentration resulted in a visibly denser matrix with smaller pores and higher stiffness. hMSCs dispersed within the fibrin gels maintained cell viability post-encapsulation, however, the migration of cells from an encapsulated spheroid revealed that denser fibrin matrices inhibit cell migration. This study provides the first quantitative study on the influence of fibrinogen concentration on 3D hMSC migration within fibrin gels, which can be used to guide material selection for scaffold design in tissue engineering and for the clinical application of fibrin sealants.

The Effects of Bougie Diameters on Tissue Oxygen Levels After Sleeve Gastrectomy: A Randomized Experimental Trial

Background:Staple-line leak is the most frightening complication of laparoscopic sleeve gastrectomy and several predisposing factors such as using improper staple sizes regardless of gastric wall thickness, narrower bougie diameter and ischemia of the staple line are asserted.Aims:To evaluate the effects of different bougie diameters on tissue oxygen partial pressure at the esophagogastric junction after sleeve gastrectomy.Study Design:A randomized and controlled animal experiment with 1:1:1:1 allocation ratio.Methods:Thirty-two male Wistar Albino rats were randomly divided into 4 groups of 8 each. While 12-Fr bougies were used in groups 1 and 3, 8-Fr bougies were used in groups 2 and 4. Fibrin sealant application was also carried out around the gastrectomy line after sleeve gastrectomy in groups 3 and 4. Burst pressure of gastrectomy line, tissue oxygen partial pressure and hydroxyproline levels at the esophagogastric junction were measured and compared among groups.Results:Mortality was detected in 2 out of 32 rats (6.25%) and one of them was in group 2 and the cause of this mortality was gastric leak. Gastric leak was detected in 2 out of 32 rats (6.25%). There was no significant difference in terms of burst pressures, tissue oxygen partial pressure and tissue hydroxyproline levels among the 4 groups.Conclusion:The use of narrower bougie along with fibrin sealant has not had a negative effect on tissue perfusion and wound healing.

Minimally Invasive Fibrin Sealant Application in Pilonidal Sinus: A Comparative Study.

The aim of this study was to compare the filling of the pilonidal sinus tract with fibrin sealant (FS) against tract excision and primary closure (PC) as the primary procedure. Details of all patients who underwent treatment for a symptomatic first episode of pilonidal sinus disease between January 2011 and December 2015 were prospectively recorded in a custom database. Patients underwent PC (n=17) or FS (n=17) according to patient preference. Prior surgical treatment and ongoing infection precluded entry. Patients were treated with antibiotics if presenting with infection. Outcomes measured were recurrence, further procedures, outpatient attendances and length of follow-up to resolution. 34 consecutive patients [FS vs. PC: male n=15 vs. 12 p=0.398; mean age 29 (SEM 12) vs. 30 (SEM 15) p=0.849] were included. Treated preoperative infections were similar FS (n=5) vs. PC (n=12) (p=0.038, chi-squared test). FS cohort had more sinuses FS median (range) 2 (1-4) vs. PC 1 (1-3) (p=0.046). Postoperative outcomes: recurrence rate FS (n=5) vs. PC (n=4) (p=0.629); infection rate FS (n=1) vs. PC (n=8) (p=0.045); total number of operations required FS 1 (1-2) vs. PC 1 (1-4) (p=0.19); total number of outpatient attendance FS 2 (1-7) vs. PC 3 (1-16) (p=0.629); follow-up FS 129 days ± 33 vs. PC 136 ± 51 (p=0.914). Fibrin sealant is not inferior to excision followed by primary closure.

Spleen-Preserving Laparoscopic Distal Pancreatectomy for Insulinoma in a Child

Introduction: Insulinomas are rare insulin-secreting neoplasms. Ten percent occur in the setting of multiple endocrine neoplasia-type 1 (MEN-1). This video presents the technical details of a spleen-preserving laparoscopic distal pancreatectomy in a child. Nowadays, the adoption of this approach is limited. Our aim is to bring this procedure closer to routine clinical practice. Operative Technique: A 13-year-old girl with neuroglycopenic symptoms for 6 months was referred to our institution for evaluation and management. The work-up demonstrated hyperinsulinemic hypoglycemia, a 3 cm lesion of the tail of the pancreas, a prolactinoma, and adenomas of two parathyroid glands (MEN-1). A four-trocar laparoscopic distal pancreatectomy was performed with the surgeon between the legs. We started with the division of the gastrocolic ligament using a 5 mm tissue-sealing device to enter the lesser sac. The stomach was retracted cephalad, allowing for a better exposure of the pancreatic tail. The peritoneum on the lower pancreatic margin was incised to get access to the retroperitoneal area. Retropancreatic attachments were dissected. With dissection advanced, the pancreas could be lifted up. The insulinoma became visible on the posterior margin and was well delimited with intraoperative palpation. The next step was dissection of the splenic vein on the superior border, embodied by the tail of the pancreas. Approaching small pancreatic vessels originating in the splenic vein is better performed with a hook monopolar electrocautery. We continued freeing toward the body of the pancreas. The peritoneum around the proximal splenic artery was also incised with the hook. If bleeding from the splenic vein is encountered, compression and application of fibrin sealant could provide hemostasis. A bleeding short vessel could be isolated, ligaclipped, oversewn, or coagulated. If bleeding is impossible to control, it is still possible to spare the spleen according to Warshaw's method (the splenic vessels are ligated and spleen becomes dependent on the short gastric vessels). Once the splenic vessels were retracted and the dissection completed, the umbilical 5-mm port was converted to a 12-mm port. The EndoGIA™ linear stapler was introduced and transection of the pancreas was performed using two 30 mm cartridges. The end of the proximal pancreas was over sewn to prevent pancreatic leak. The specimen was extracted in a retrieval bag through the umbilical port. A drain was left in situ. Results: The postoperative course was uneventful. No postoperative diabetes was observed and no treatment for hypoglycemia was necessary. Early oral feeding on postoperative day 2 was well tolerated. The drain was removed and the patient was discharged home in a good condition at postoperative day 5. Histology analysis confirmed the full resection of the intrapancreatic insulinoma but also revealed a second tumor more distally on the pancreatic tail. The patient remains asymptomatic 20 months after surgery. Conclusions: Spleen-preserving laparoscopic distal pancreatectomy is a feasible, effective, and safe procedure. Distal pancreatectomy is preferred to tumorectomy to avoid incomplete resection in cases of multifocal disease. Laparoscopy gives an excellent view of small vessels and has all the advantages of the mini-invasive surgery. Spleen preservation avoids the overwhelming postsplenectomy infection. No competing financial interests exist. Runtime of video: 5 mins 9 secs

Full endoscopic treatment of dural tears in lumbar spine surgery.

An incidental durotomy is a common complication of spinal surgery. Its treatment remains challenging, especially in endoscopic procedures. The objective of this study is to describe a technique for endoscopic dural closure which is safe and effective. From a prospective database all endoscopic spinal procedures with incidental durotomy were identified. Retrospectively, video recordings were analysed with a special reference to the applied technique of dural closure. Additionally 1, 6 and 12week follow-up examinations were evaluated for clinical outcome and associated complications. Out of 212 consecutive patients, an intraoperative dural tear was observed in nine patients (4.2%). A dural tear occurred in 1.1% of cases of lumbar disc herniation, in 7.9% of cases with lumbar spinal stenosis, in 37.5% of cases with a synovial cyst. An autologous muscle sample was harvested within the operative field and grafted at the dural defect in several layers. Fixation of the transplantation and watertight closure were achieved by the application of fibrin sealant with gelfoam. The mean time for dural closure was 209s (range 47-420s). Postoperatively no CSF fistula, no new deficits nor worsening of a pre-existing neurological deficit occurred. None of the patients had problems with wound healing, or discomfort which could be related to the CSF leak. Dural closure with an autologous muscle graft in combination with fibrin sealant patch is a fast, safe and alternative technique for the management of dural tear in microendoscopic surgery.