Fibrin Glue Injection Research Articles

Abstract 394: Resolution of Bilateral Subdural Hematomas Following Pseudomeningocele‐Induced Intracranial Hypotension Treated with Fibrin Sealant

Introduction CSF leaks lead to intracranial hypotension and is being increasingly diagnosed as a cause of headaches. These leaks may present simply as a headache but can also lead to severe neurological complications, such as brainstem herniation, bilateral subdural hematomas, and cranial nerve palsies. We present a case of a dural tear that resulted in a pseudomeningocele, which was treated successfully with fibrin sealant. Presentation A 67‐year‐old patient presented to the emergency department with a headache that had worsened acutely over the past 4 days, following several months of less severe symptoms. A CT scan of the head revealed isodense to hypodense components on the right and mixed attenuation components on the left, suggesting a subdural hematoma with mild mass effect. An MRI of the brain, both with and without contrast, showed subacute to chronic subdural hematomas with an acute component on the left side. The MRI also indicated diffuse smooth thickening and enhancement of the dura, drooping of the splenium, flattening of the ventral pons, and reduced ponto‐mamillary distance. A whole‐spine MRI, although motion‐degraded, did not reveal any CSF leak. The patient underwent an epidural blood patch placement to address the suspected CSF leak, but their headache did not improve. A repeat CT scan of the head showed mild worsening of the bilateral hematomas and midline shift. A dynamic myelogram revealed a ventral filling defect likely due to a T5‐T6 central and left paracentral disc extrusion, which was the origin of the dural tear and led to the development of a pseudomeningocele. The patient then received a CT‐guided transfemoral fibrin glue injection at T5/T6. Following this procedure, the patient experienced improvement in their headaches, and follow‐up images showed stable findings at 2 and 4 weeks. A repeat CT scan of the head at 10 weeks demonstrated significant improvement in the bilateral subdural hematomas. Discussion Treatment for CSF leaks ranges from simple observation to surgical repair in refractory and complicated cases. Typically, an epidural blood patch is the first‐line treatment and often resolves the headache. However, some cases remain refractory depending on the etiology of the CSF leak. Several endovascular treatments are under development, including embolization for CSF‐venous fistulas and fibrin sealant for other cases. Fibrin glue, a pharmaceutical product composed of human thrombin and fibrinogen, is introduced into the epidural space under image guidance. Fibrin sealant placement is a safe procedure and has emerged as a viable alternative for refractory cases.

Traitement des fistules anales réfractaires à l’Infliximab au cours de la maladie de Crohn : Mise au point

Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab. Update on the different therapeutic alternatives for anal fistula in Crohn's disease after failure of Infliximab. A research in the medical literature on PubMed and Google Scholar was carried out. We included cohort studies, reviews and randomized double-blinded therapeutic trials. Case reports and fundamental research studies have been excluded. Anti-TNF therapy, notably Infliximab remain the therapeutic option of choice. Since Infliximab efficacy has been estimated at 60%, with a significant loss-of response rate, new therapeutic strategies have been evaluated and may offer new opportunities for the management of anal fistulas: for example, Ustekinumab could be effective after failure of anti-TNF therapy, although further studies are required. Recent guidelines suggest that injection of mesenchymal stem cells is an effective and safe treatment for complex fistulas. Other surgical options have been proposed, such as endorectal advancement flap, fibrin glue injection, anal fistula plug and ligation of the intersphincteric fistula tract, but all with limited and debatable efficacy. Given the failure rate of all these options, new strategies are currently being evaluated. Anal fistulas in Crohn's disease are a real therapeutic challenge. New medical and surgical therapies are currently being evaluated, with promising results.

Acute Variceal Hemorrhage in Germany-A Nationwide Study of 65,357 Hospitalized Cases: Variceal Hemorrhage in Germany.

Background: Acute variceal hemorrhage (AVH) is a frequent cause of upper gastrointestinal bleeding (UGIB) in liver cirrhosis. Most cases require urgent endoscopic intervention due to potentially life-threatening courses. Different endoscopic hemostasis techniques can be used, in particular endoscopic variceal ligation (EVL) and endoscopic sclerotherapy (EST), depending on the bleeding side (esophageal, fundal, and gastric) as well as radiological interventions (e.g., embolization and transjugular intrahepatic portosystemic shunt [TIPS]). This study aimed to investigate trends in incidence, treatment modalities, and outcome parameters, such as in-hospital mortality and adverse events in Germany. Methods: We evaluated the current epidemiological trends, therapeutic strategies, and in-hospital mortality of AVH in Germany based on the standardized hospital discharge data provided by the German Federal Statistical Office from 2010 to 2019. Results: A total of 65,357 AVH cases, predominately males (68.3%), were included in the analysis. The annual incidence rate (hospitalization cases per 100,000 persons) was 8.9. The in-hospital mortality was 18.6%. The most common underlying disease was alcohol-related liver cirrhosis (60.6%). The most common clinical complication was bleeding anemia (60.1%), whereas hypovolemic shock (12.8%) was the less frequent. In esophageal variceal hemorrhage (EVH), EVL was the most frequently performed endoscopic therapy, while in gastric variceal hemorrhage (GVH), EST and fibrin glue injection were the most commonly performed therapies. EVL showed the lowest in-hospital mortality (12.3%) in EVH, while EST showed favorable results (14% in-hospital mortality) in GVH. Combination therapies overall showed a higher in-hospital mortality and were more frequent in GVH. The presence of hypovolemic shock, AKI, sepsis, artificial ventilation, ARDS, bleeding anemia, hepatic encephalopathy, and male sex was associated with a significantly worse outcome. Conclusion: Our study provides detailed insight into the incidence, patient-related risk factors, endoscopic treatment, and in-hospital mortality in a sizeable AVH collective in Germany. These data might help improve risk stratification and treatment strategies for AVH patients in the future.

Abstract 284: Renal Contrast Excretion After Myelography: A Valuable Tool in The Diagnosis of Cerebrospinal‐Venous Fistulae

Introduction Cerebrospinal‐venous fistulae (CSF‐VFs) represent a pathologic, low‐flow direct connection between the intrathecal space, usually at the level of a diverticular dilation of a nerve root sleeve, and the thoracolumbar venous system. They can cause CSF hypovolemia resulting in an often‐debilitating intracranial hypotension syndrome. Lateral decubitus CT or DSA myelography (CTM, DSM) are the gold‐standard modalities for diagnosing these entities. Their high spatial and temporal resolution allows visualization of the abnormal connection between the two spaces. Yet, the small size and low flow make CSF‐VFs radiographically subtle, and may not be consistently visualized even after a correctly‐performed CTM/DSM, requiring repeated invasive procedures to definitively establish or exclude their presence. Opacification of the renal excretory system 30‐60 minutes after lateral decubitus myelograms is thought to be a highly sensitive and specific indirect sign of the presence of a CSF‐VF 1,2, as this amount of time is considered insufficient to allow arachnoid reabsorption of contrast. Renal pelvises hyperdensity or its absence after a negative decubitus CTM/DSM can prompt further myelographic investigation or definitively rule out the presence of a CSF‐VF on the side of the examination, respectively. Methods We present three patients with severely symptomatic CSF‐VFs treated at our hospital between 2021 and 2023. All patients were females (range: 50‐60 years old). All three patients underwent bilateral diagnostic lateral decubitus DSM/CTM. Exams were performed at least 72 hours apart in order to allow complete clearance of intrathecal contrast. After each myelographic acquisition, patients remained in the lateral decubitus position until abdominal CT imaging was performed at 30 and 45 minutes to detect the presence of contrast in the renal collecting system. Results Patients 1 and 2, had a CSF‐VF between nerve root dural diverticula and the azygos system that was directly visualized on lateral decubitus CTM (patient 1: right T10‐T11, patient 2: left T8‐T9). Contrast was detectable in the renal pelvises after myelography was performed on the affected side, and not detectable after the contralateral investigation. One fistula was treated via CT‐guided targeted blood patch and fibrin glue injection and the other via endovascular Onyx embolization of the tributary Intercostal veins. Patient 3 had an extremely slow flow CSF‐VF at the right T11‐12 level that was identified only after 5 right‐sided decubitus myelograms with both modalities. The repeated exams were based on the presence of contrast in the renal pelvises after each right‐sided procedure and on the absence of renal opacification after the left‐sided myelograms. Eventually, a CSF‐VF was identified. Successful Onyx embolization of the foraminal veins of the R T11‐12 levels was performed. All three patients had complete resolution of symptoms. Conclusion Contrast presence in the renal excretory system after a lateral decubitus CTM/DSM is a potentially highly sensitive and specific indirect diagnostic sign that can establish or exclude the presence of a CSF‐VF on the examined side. It could be particularly helpful when the fistula is not initially detected, as it can prompt aggressive continuation of the myelographic work‐up. Similarly, it can exclude its presence on one side, sparing the patient invasive and low yield diagnostic procedures.

A single institution experience in the treatment of fistula in ano using diode laser (fistula laser closure): short-term outcomes

Introduction Management of the perianal fistula has been always a challenge for colorectal surgeons especially when the external sphincter is involved. Several minimally invasive procedures emerged as an alternative to the traditional surgical approach as fibrin glue injection, ligation of the intershpincteric track (LIFT) and injection of platelet-rich plasma (PRP). Recently, the use of diode laser in proctology has emerged as an alternative to conventional surgical treatment. The laser beam causes shrinkage and sealing of the fistulous track that depends on the power and the duration of laser light application. Patients and methods This study was carried out on 69 patients with perianal fistula in the Gastrointestinal Surgery Unit, General Surgery Department, Tanta University Hospitals, during the study period from February 2021 to December 2022. Patients underwent fistula laser closure (FILAC) using a diode laser, radial fibers, wavelength 1470 nm, and 10 watts of power. Results Sixty nine patients underwent fistula laser closure. The success rate was 74%. There was significance between recurrence and posterior position of the fistulous track of the intersphincteric type. Also, there was significance between recurrence and cases who had a caliber track more than 7 mm but there was no significance between recurrence and length of the track. The procedure was associated with minimal postoperative pain, long period of postoperative discharge, short hospital stay, and early return to normal activities. Conclusion Diode laser is a safe minimally invasive and effective procedure for the treatment of straight non branched short track fistula with some considerations as the caliber track should not exceed 7 mm and the posterior intersphincteric fistula should be treated by lay open fistulotomy. The procedure is also associated with less postoperative pain, early return to normal activities, and minimal recurrence rate but high cost remains a limitation.

Role of EhretialaevisRoxb.. (Ajan Vruksha/Khandu Chakka) Medicated Thread in Fistula- In- Ano: - Randomised Clinical Trial

Ehretialaevisroxb. is a traditional herbal plant used for various purposes, mainly wound healing and pain relief. This plant isalso known as AjanVruksha and commercially known as Khandu Chakk. Wound healing & pain relief activities of Ehretialaevisroxb.(AjanVruksha/Khandu Chakka) are used for making a novel herbal medicated thread in fistula- in- ano to avoid the untoward effects oftraditional Ksharsutra, commonly used in Ayurved practice for Fistula-in ano management. Fistula in ano is the abnormal tract having oneopening inside the anal canal and one opening at the perianal skin. Many modalities are available for the treatment of fistula in ano, likeKsharsutra, fistulotomy, fibrin glue injection, and fistula plug. Sometimes there are many tracts. Novel herbal thread comprisesehretialaevisroxb., Achyranthesaspera Linn., Ficusracemosa. A novel herbal thread was applied in group A of 75 patients and in group B of 75patients, a conventional thread was applied. The study is based on a superior clinical trial. To determine the efficacy of the compositionof the present invention, the clinical parameters of pain, bleeding, discharge, itching, tenderness, hyper granulation, and unit cutting timewere evaluated after every week. The novel thread was found more efficient in pain relief, discharge, etching, cutting rate, bleeding, andhyper granulation, than a conventional thread in this study. We aim to provide a medicated thread for fistula-in- ano, which canovercome deficiencies associated with the known arts and provide effective and safe treatment for affected patients. And to achieve thisaim, our objectives are to assess the efficacy of Novel Medicated thread and Conventional Ksharsutra in promoting healing in fistula- inano,along with comparing the efficacy of both threads.

Importance of Multimodal Spinal Cord Monitoring and Hemodynamic Augmentation during High Thoracic Ventral Dural Tear Repair Using the Posterior Approach

AbstractCerebrospinal fluid (CSF) leakage due to large ventral dural tears (VDT) often requires surgical intervention. Surgical closure of a high thoracic VDT is challenging and associated with high morbidity, especially if it is performed after multiple epidural blood patch (EBP)/fibrin glue injections. A 44-year-old woman was diagnosed with spontaneous intracranial hypotension due to VDT at T1-T2, causing CSF leakage. Multiple EBP and fibrin glue injections failed to treat her symptoms; hence, the patient underwent surgical closure using the posterior approach. The patient was anesthetized using standard anesthetic drugs and was maintained under total intravenous anesthesia to facilitate continuous motor-evoked potential (MEP) monitoring. The surgical course was complicated by bleeding, hypotension, and MEP loss. Continuous MEP monitoring, effective team communication, quick restoration of blood pressure(BP) and BP augmentation with fluid, blood, and vasopressor helped to restore the MEP back to baseline. Hence, the patient recovered without neurological morbidity. This case report highlights the importance of adequate vascular access, multimodal spinal cord monitoring, and BP augmentation during a high thoracic VDT repair.

794 Interventional Approaches to Symptomatic Tarlov Cysts: a Five-year Institutional Experience

INTRODUCTION: Tarlov cysts are perineural collections of cerebrospinal fluid most often affecting sacral nerve roots. Up to 4.6% of the general population has one or more Tarlov cysts, with 20% of cysts becoming symptomatic, causing back pain, extremity paresthesias and weakness, bladder/bowel dysfunction, and sexual dysfunction. The most effective treatment of symptomatic Tarlov cysts, with options including nonsurgical management, cyst aspiration and injection of fibrin glue, cyst fenestration, and nerve root imbrication, is debated. METHODS: Retrospective chart review was conducted for 50 patients with Tarlov cysts seen at our institution in the last 5 years. Clinical outcome was determined based on improvement in one or more symptoms. RESULTS: 36 patients with symptomatic Tarlov cysts were identified.The average age of patients with symptomatic Tarlov cysts was 55.67 years (range, 2–77). Common symptoms were back pain/sacrococcygeal (94.4%), radiculopathy (66.7%), and bladder/bowel dysfunction (33.3%). 12% of patients had underlying connective tissue disorders (CTD), 44% of patients had bilateral cysts, and 16% of patients had cysts in multiple regions. 47.2% of patients with symptomatic Tarlov cysts were managed nonsurgically; 50% were managed with CT-guided aspiration of the cyst with or without injection of fibrin glue. Of patients treated interventionally, 47.4% saw lasting clinical improvement, with the most improvement in patients after aspiration with fibrin glue injection, 10.5% saw improvement for ≥ 6 months, and 36.8% saw no improvement or temporary improvement for < 6 months. CONCLUSIONS: Patients with symptomatic Tarlov cysts who underwent cyst aspiration with injection of fibrin glue saw the most clinical improvement. As a significant portion of patients with Tarlov cysts have CTD, evaluation by rheumatology may be warranted.

Evaluation of a modified subchondroplasty technique in an equine full-thickness cartilage defect model: a pilot study

To perform a pilot study with the intent of assessing the feasibility of a modified subchondroplasty (mSCP) technique in a validated preclinical equine model of full-thickness articular cartilage loss and evaluate the short-term patient response to the injected materials. 3 adult horses. Two 15-mm-diameter full-thickness cartilage defects were created on the medial trochlear ridge of each femur. Defects were treated with microfracture and then filled by 1 of 4 techniques: (1) autologous fibrin graft (FG) via subchondral injection of fibrin glue (FG), (2) autologous fibrin graft via direct injection of FG, (3) subchondral injection of a calcium phosphate bone substitute material (BSM) with direct injection of FG, and (4) untreated control. Horses were euthanized after 2 weeks. Patient response was evaluated via serial lameness examination, radiography, magnetic resonance imaging, computed tomography, gross evaluation, microcomputed tomography, and histopathology. All treatments were successfully administered. The injected material perfused through the underlying bone into the respective defects without adversely affecting the surrounding bone and articular cartilage. Increased new bone formation was seen at the margins of the trabecular spaces containing BSM. There was no treatment effect on the amount or composition of tissue within defects. The mSCP technique was a simple, well-tolerated technique in this equine articular cartilage defect model without significant adverse effects to host tissues after 2 weeks. Larger studies with long-term follow-ups are warranted.

Fibrin glue as a novel therapy for contracted socket in comparison to mitomycin-c and triamcinolone acetonide at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia

Background: Contracted socket is still a major problem for patients with anophthalmia. The main factor for this condition is inflammation and fibrosis, which result in conjunctival shortening. Myofibroblasts that express α-SMA are the primary mediators of anophthalmic socket contraction. Methods: One healthy eye of a New Zealand white rabbit were randomly selected for evisceration and divided into four treatment groups, each with five rabbits. Each rabbit in the group received a single subconjunctival injection of a different agent. Group, I was the control group that received no injection, Group II received MMC 0.4 mg/ml, Group III received TCA 40 mg/ml, and Group 4 received fibrin glue. After 14 days, the animals were euthanized, and conjunctival samples were submitted for histopathological analysis. A monoclonal α-SMA antibody was applied, and pathologists provided the IRS score for each sample. The differences in α-SMA expression were statistically analyzed with a significant level of p <0.05 Result: All groups displayed a statistically significant decrease in α-SMA expression compared to the control group (p<0.05) as sorting as MMC group with p=0.007, TCA group with p=0.007, and fibrin glue with p= 0.009. MMC was the most effective at reducing α-SMA (p=0.004). Surprisingly, there were no statistically significant differences between MMC, TCA, and fibrin glue when they were evaluated independently. Conclusion: A single subconjunctival injection of fibrin glue may be used as a novel treatment to prevent socket contracture in actively healing sockets.

Fibrin glue injection method for complex fistula after laparoscopic distal pancreatectomy: a case report

BackgroundPancreatic fistula is the most problematic complication in pancreatectomy. Although drainage can be used to relieve this complication, pancreatic surgeons often encounter refractory pancreatic fistula. Fibrin glue injection, with the use of a twofold diluted solution B and a double-lumen tube, was found effective in treating this complicated pancreatic fistula.Case presentationWe report the case of a 64-year-old Japanese man who underwent laparoscopic distal pancreatectomy for pancreatic tail cancer. After initial drainage of the pancreatic fistula diagnosed 4 days postoperatively, on day 134, refractory pancreatic fistula was observed using contrast-enhanced computed tomography. We used fibrin glue injection, with a twofold diluted solution containing thrombin and calcium chloride and a double-lumen tube, for treating the refractory fistula; the fluid drainage was almost stopped with no fever or abdominal pain. No recurrence of pancreatic cancer has been observed since the procedure.ConclusionsFibrin glue injection was effective for complicated pancreatic fistula after distal pancreatectomy. Using a twofold diluted solution B containing thrombin and calcium chloride and a double-lumen tube makes possible the thorough injection of fibrin glue.

Cervical cerebrospinal fluid venous fistula with syringomyelia treated with suboccipital decompression: illustrative case.

BACKGROUNDCerebrospinal fluid (CSF) venous fistulas are a recently discovered and underdiagnosed cause of spontaneous spinal CSF leak, which may lead to spontaneous intracranial hypotension. Most cases occur in the thoracic spine, and only 2 cases were reported in the cervical spine. Treatments include the epidural blood patch, fibrin glue injection, and surgical ligation of the fistula.OBSERVATIONSThe authors report the treatment of a C6–7 CSF venous fistula, for which direct ligation was not feasible, with suboccipital decompression, leading to the complete resolution of the symptoms. Based on the clinical course and outcome in our patient, the authors summarize the previous theory and propose a hypothesis for the pathophysiology of headache and other symptoms in patients with CSF venous fistulas.LESSONSThe symptoms of CSF venous fistulas may be linked not only to intracranial hypotension but also to the altered CSF dynamics induced by tonsillar herniation. Suboccipital decompression should be considered as a potential treatment option, especially in patients with Valsalva-induced headache who show a poor response to surgical ligation, patients in whom surgical ligation is not feasible, and patients with foramen magnum obstruction. Further investigation of the pathophysiology of CSF venous fistulas is warranted and should be performed in the future.

Rescue fibrin glue-infiltrating hemostasis combined with hepatorrhaphy to control intractable postoperative bleeding from the liver cut surface.

Various topical hemostatic agents can help induce coagulation at the liver cut surface. However, hemostasis is usually ineffective in controlling bleeding. We present a case of rescue fibrin glue-infiltrating hemostasis combined with hepatorrhaphy to manage intractable postoperative bleeding from the liver cut surface. The case was a 56-year-old male patient with hepatocellular carcinoma in hepatitis B virus-associated cirrhotic liver. The patient was administered warfarin because of graft replacement of the ascending aorta and hemi-arch one year earlier. After warfarin was discontinued, segment VII partial hepatectomy was performed according to standard procedures. However, considerable bleeding occurred during and after hepatectomy. Bleeding from the liver cut surface was controlled over one hour using surface coagulation and topical application of four kinds of hemostatic agents. However, active abdominal bleeding led to reoperation soon after the hepatectomy. During the reoperation, we identified diffuse oozing from the edge of the liver cut surface which was difficult to control. Thus, we performed direct parenchymal injection of fibrin glue at the bleeding points using 12 fibrin glue kits which induced complete hemostasis. Because the patient would undergo anticoagulation again soon after the operation, we also performed hepatorrhaphy. The patient recovered uneventfully after the reoperation. He has been doing well for six months without complications. In conclusion, fibrin glue-infiltrating hemostasis effectively controlled intractable bleeding from the hepatic cut surface in our case. Thus, it can be considered as an optional method for rescue hemostasis.

Retrograde endoscopic assisted percutaneous treatment of urinary fistulas after partial nephrectomy

Background. Urinary fistulas (UFs) are one of the most significant complications after partial nephrectomy. Placement of an ureteral stent eliminates urine extravasation in the majority of patients. However, some of them have persistent UFs despite upper urinary tract drainage. Such cases require retrograde injection of fibrin glue into the renal cavity through a ureteroscope or via the percutaneous approach. Some authors reported cases of simultaneous use of 2 stents and percutaneous cryoablation of the fistula, but these techniques are rare and, therefore, it is problematic to evaluate their efficacy.Objective: to evaluate the results of the new treatment method for the elimination of persistent UFs using the retrograde endoscopic percutaneous approach.Materials and methods. This study included 5 patients (3 males and 3 females) with UFs developed after kidney resection. Mean age of the patients was 55.8 years. The tumor size was 2.5 to 4.8 cm; mean R.E.N.A.L. score was 7.8. All patients had earlier undergone minimally invasive partial nephrectomy; the time between surgery and UF development varied between 3 and 10 days. Four out of 5 patients had a large amount of discharge from their paranephral drainage system, examination of which confirmed high creatinine level. Patients underwent flexible ureteropyelography in the lithotomy position. During this procedure, we identified the damaged calyx and then performed percutaneous puncture targeting the distal end of the endoscope at this calyx, ensuring that the tip of the needle appeared in the paranephral cavity in front of the injured calyx. Using the flexible ureteroscope, we inserted the needle into the pelvis, dilated the puncture opening along the string, and installed a nephrostomy drainage system (12 Fr). Then the endoscope was removed and the ureter was additionally drained with a stent. The stent was removed after 8-10 days with subsequent antegrade pyelography. If there was no extravasation, the nephrostomy tube was removed and the patient was discharged from hospital to continue treatment in outpatient settings.Results. All patients with UFs resulting from partial nephrectomy was successfully operated on. No complications were registered. The mean surgery time was 45.0 ± 20.5 min (range: 40-65 min). Only two patients had some discharge from the fistula within 1 day after nephrostomy tube removal and it stopped without any additional interventions. Three patients had their fistula healed immediately. The treatment efficacy during the whole follow-up period of 18 ± 4 months (range: 6-26 months) was 100 %.Conclusion. Ureteral stenting ensures elimination of UFs in the majority of patients after partial nephrectomy. In individuals with persistent UFs, retrograde endoscopic percutaneous drainage of the pelvicalyceal system is the method of choice, because it allows rapid and effective treatment of UFs.

Urinary fistulas after partial nephrectomy in renal cell carcinoma

Urinary fistulas after partial nephrectomy are rare complications of this operation. There are various reasons for their development, prevention and treatment. This review analyzes the results of the cases' prevalence of urine leakage after partial nephrectomy with various approaches, occurrence's predictors of urinary fistulas, possible ways of their intraoperative prevention and treatment methods. The obtained data show that the size of tumors, their endophytic nature and proximity to the kidney pelvicalyceal system, as well as suturing of its defect, can be predictors of the development of urinary fistulas (UFs). Some authors point to the influence of long ischemia time and high blood loss on the occurrence of UFs. The main method of treating UFs is ureteral stenting or percutaneous drainage of the kidney pelvicalyceal system. For long-term persistent UFs, the method of choice can be simultaneous introduction of 2 stents, retrograde or percutaneous injection of fibrin glue, percutaneous cryoablation of the UFs.

Perspective: Early diagnosis and treatment of postoperative recurrent cerebrospinal fluid fistulas/ dural tears to avoid adhesive arachnoiditis.

Background: Intraoperative traumatic cerebrospinal fluid (CSF) fistulas/dural tears (DT) occur in up to 8.7–9.5% of primary lumbar surgical procedures. Further, they recur secondarily in between 8.1% and 17% of cases. It is critical to diagnose and treat these recurrent lumbar DT early (i.e. within 3–4 weeks of the index surgery) to avoid the evolution of adhesive arachnoiditis (AA), and its’ permanent neurological sequelae.Methods: Postoperative lumbar CSF fistulas/DT should be diagnosed on postoperative MR scans, and confirmed on Myelo-CT studies if needed. They should be definitively treated/occluded early on (e.g. within 3–4 postoperative weeks) to avoid the evolution of AA which can be readily diagnosed on MR studies, and corroborated, if warranted, on Myelo-CT examinations. The most prominent MR/Myelo-CT findings include; nerve roots aggregated in the central thecal sac, nerve roots peripherally scarred/adherent to the surrrounding meningeal wall (“empty thecal sac sign”), soft tissue masses in the subarachnoid space, and/or multiple loculated/scarred compartments.Results: Percutaneous interventional procedures (i.e. epidural blood patches, injection of fibrin glue (FG)/fibrin sealants (FS)) are rarely effective for treating postoperative recurrent lumbar CSF fistulas. Rather, direct surgical occlusion is frequently warranted including the use of; an operating microscope, adequate surgical exposure, 7-0 Gore-Tex sutures, muscle/dural patch grafts or suture anchors, followed by the application of microfibrillar collagen, and fibrin sealant/glue.Conclusion: Lumbar AA most commonly results from the early failure to diagnose and treat recurrent postoperative CSF fistulas. Since the clinical course of lumbar AA is typically one of progressive neurological deterioration, avoiding its’ initial onset is key.

Fibrin Glue-Kartogenin Complex Promotes the Regeneration of the Tendon-Bone Interface in Rotator Cuff Injury.

Objective Rotator cuff injury healing is problematic because the tendon-bone junction often forms cicatricial tissues, rather than fibrocartilage, which leads to mechanical impairment and is prone to redamage. Kartogenin (KGN) is a newly discovered small molecule compound which can induce cartilage formation through chondrogenesis of endogenous mesenchymal stem cells. Methods In this study, we used KGN with fibrin glue (FG) to repair the rotator cuff injury by promoting the formation of fibrocartilage at the tendon to bone interface. Firstly, we assessed the release rate of KGN from the FG-KGN complex and then created a rabbit rotator cuff tendon graft-bone tunnel model. The rabbits received saline, FG-KGN, or FG injections onto the tendon to bone interface after injury. Shoulder tissues were harvested at 6 and 12 weeks, and the sections were stained with HE and Safranin O/Fast green. The samples were assessed by histologic evaluation and biomechanical testing. Synovial mesenchymal stem cells derived from the synovial tissue around the rotator cuff were harvested for western blotting and qRT-PCR analysis. Results KGN was released rapidly from the FG-KGN complex during first 4 hrs and followed by a slow release until 7 days. The tendon graft-bone interface in the control (saline) group and the FG group was filled with scar tissue, rather than cartilage-like tissue, and only a small number of chondrocytes were found at the adjacent bone surface. In the FG-KGN group, the tendon to bone interface was fully integrated and populated by chondrocytes with proteoglycan deposition, indicating the formation of fibrocartilage-like tissues. At 12 weeks, the maximum tensile strength of the FG-KGN group was significantly higher than that of the FG and control groups (P < 0.01). The RNA expression levels of tendinous genes such as Tenascin C and the chondrogenic gene Sox-9 were substantially elevated in SMSCs treated with the FG-KGN complex compared to the other two groups. Conclusion These results indicated that fibrin glue is an effective carrier for KGN, allowing for the sustained release of KGN. The FG-KGN complex could effectively promote the regeneration and formation of fibrocartilage tissue of the tendon-bone interface in the rabbit rotator cuff tendon graft-bone tunnel model.

Fibrin glue: Novel submucosal injection agent for endoscopic submucosal dissection.

Background and study aims Adequate mucosal elevation by submucosal injection is crucial for patient safety and efficiency during endoscopic submucosal dissection (ESD). This study aimed to evaluate the efficacy of fibrin glue (FG) as a long-lasting submucosal injection agent and to evaluate the technical feasibility of FG injection for ESD. Materials and methods To compare the capabilities of different agents in maintaining submucosal evaluation, we injected FG, hyaluronic acid solution, and normal saline into the porcine gastric specimen that was incised into approximately 5 × 5 cm squares. Then, we measured the height of submucosal elevations over time. Moreover, three hypothetical lesions from the resected porcine stomach underwent ESD with FG injection. Thereafter, we conducted macroscopic and histopathologic analyses. Results FG maintained the greatest submucosal elevation among all the injection agents. Three ESD procedures were performed with en bloc resection. Both macroscopic and histopathologic findings showed a thick FG clot on the ulcers. Conclusions The FG solution can be potentially used as an ESD submucosal injection agent in an in vitro model.

Fibrin sealant injection through the drain with adjuvant compression as a treatment of groin lymphatic complications after vascular operation

Introduction: Groin lymphatic complications after femoral artery operations are rare, but if developed, they could be a source of severe complications that could be potentially fatal. The novel technique of combining compression and application of Tisseel sealant (Baxter AG, Vienna, Austria) to treat lymphatic fistulas in the groin region after common femoral artery exposure was evaluated. Material and methods: Twelve groins from eleven patients with groin lymphatic complications were enrolled into the study. Patients had femoral artery exposure during one of the following procedures: endovascular aortic aneurysm repair, thrombendarterectomy or extra-anatomic by-pass. Postoperatively, average lymphatic drainage through the drain was 140 ± 60 (range 48–300) mL per day. Intervention was performed at a median of 12 (9–23) days after operation. The drain was cut off close to the skin, a thin double-channel catheter was introduced as deep as possible through the drain and sealant was injected into the wound. Simultaneously, the remaining part of the drain was removed, the orifice in the skin was sutured and a compression dressing was kept in place for 24 hours. The median patient observation period was 13 months (range 2.5–23) and surveillance of the groin was performed using ultrasonography. Results: Early outcomes showed full technical success. None of the patients were readmitted due to lymphorrhea, infection or poor wound healing during follow-up. No lymphoceles were detected by ultrasonography. Conclusion: Fibrin glue injection augmented by compression is an effective method for treating postoperative lymphatic fistulas and to prevent lymphorrhagia and lymphocele formation in the groin region after femoral artery exposure.

Long-term efficacy of fibrin glue injection for perianal fistulas in patients with Crohn's disease.

The treatment of perianal fistulas in Crohn's disease remains challenging. Fibrin glue injection has previously shown short-term efficacy in a randomized controlled trial. No long-term data are available to assess the benefit of this treatment. This retrospective multicentre study included all patients with drained fistulas treated by at least one fibrin glue injection between January 2004 and June 2015 in three tertiary French centres. The primary end-point was the rate of complete clinical remission at 1year after injection defined by the closure of all fistula tracts with no need for iterative anal surgery or for optimization of immunosuppressants and/or biologics. In all, 119 patients (median age 33years, complex fistulas 65%, median previous anal surgery two, median Harvey Bradshaw score 3, immunosuppressants exposure 50%, anti-tumor necrosis factor exposure 60% with median time of administration of 1.1year) were analysed with a median follow-up of 18.3months. The complete clinical remission rate at 1year was 45.4%. The primary end-point was achieved in 63% of the cases in the combination therapy group and 37% in other patients. The only predictor of complete clinical remission at 1 year was combination therapy at the time of injection (P=0.01). The rate of early reintervention after glue injection was 2.5%. The cumulative incidence of iterative anal surgery and ostomy in the whole population was 54% and 5.6% respectively at 5 years. An adjunct of fibrin glue to conventional medical therapy may be an effective and safe treatment for perianal fistulas in patients with Crohn's disease.