Fibrin Glue Patch Research Articles

Management of persistent air leak in Neonates: A case series

Background: Autologous blood patch pleurodesis (ABPP) has been used in adults as an efficient and safe technique to address persistent air leak (PAL). A fibrin glue patch is also an alternative, but its elevated cost and technique can limit its routine use. Evidence of their use in the pediatric population, specifically in the neonatal age is scant. Case Presentation: We share our management experience in a series of 3 cases. The first 2 were treated exclusively with ABPP and showed clinical and radiographic improvement. The 3rd case, due to the persistence of the air leak, required extended thoracotomy and fibrin patch placement. Conclusion: The use of ABPP as an alternative for the treatment of neonates with PAL is a safe and efficient technique. The procedure is replicable and can be done at the bedside at a low cost. A fibrin glue patch should be considered as an alternative option when ABPP fails to resolve the leak.

Popping the balloon: Abrupt onset of a spinal CSF leak and spontaneous intracranial hypotension in idiopathic intracranial hypertension, a case report.

Spontaneous intracranial hypotension (SIH) is a debilitating neurologic condition that is often thought of as separate from idiopathic intracranial hypertension (IIH). The unique case presented here details a spontaneous spinal cerebrospinal fluid (CSF) leak that developed abruptly following a CSF pressure elevating maneuver in a patient with pre-existing intracranial hypertension, raising the possibility of a causative link between the two conditions. A 40-year-old woman with symptomatic IIH developed a dural tear of a thoracic spinal nerve root sleeve during an episode of Valsalva maneuver leading to a CSF leak and development of symptomatic SIH. This was successfully treated with epidural blood and fibrin glue patch and the patient is now symptom-free. The implication of a possible causative link between elevated CSF pressure and subsequent development of dural rupture and SIH raises important questions regarding the pathophysiology of SIH in some cases. Furthermore, it suggests that there could be a potential prophylactic benefit of CSF pressure lowering medications in preventing the development of SIH in patients with IIH.

Multiple epidural fibrin glue patches in a patient with spontaneous intracranial hypotension - A case report -

Multiple epidural fibrin glue patches in a patient with spontaneous intracranial hypotension - A case report -

Direct suture technique of normal gland edge on the incised dura margin to repair the intraoperative cerebrospinal fluid leakage from the arachnoid recess during transsphenoidal pituitary tumor surgery.

During transsphenoidal surgery for pituitary adenomas with large suprasellar extension, cerebrospinal fluid (CSF) leakage commonly develops from a defect at the arachnoid recess between the resected dura margin and the anterior edge of a normal pituitary gland (type 1 CSF leakage). To evaluate the usefulness of a direct suture technique of the normal gland edge on the incised dural margin to repair intraoperative CSF leakage from the arachnoid recess. Between November 2005 and December 2012, 861 patients with pituitary adenomas were operated on with transsphenoidal surgery, and intraoperative CSF leakage was encountered in 432 patients. Type 1 CSF leakage developed in a total of 122 patients, and their defects were repaired with the direct suture technique in 51 patients, whereas a fleece-coated fibrin glue patch alone was applied onto the defect in the other 71 patients. This direct suture technique required an additional 5 to 20 minutes in most cases. We experienced no case of postoperative CSF rhinorrhea in the 51 patients whose defects were repaired by the direct suture technique and only 1 case of CSF rhinorrhea in 71 patients whose defects were repaired with a fleece-coated fibrin glue patch alone. There was no statistical difference in the outcome between 2 groups. Postoperative lumbar CSF drainage was not performed in any case. Our 2 different repair techniques for arachnoid recess tears are very reliable methods for managing this type of CSF leakage. The direct suture technique may be more appropriate for type 1 CSF leakage with a wider gap and more prominent CSF leakage.

Large-volume blood patch to multiple sites in the epidural space through a single-catheter access site for treatment of spontaneous intracranial hypotension.

Spontaneous intracranial hypotension can be a therapeutic challenge to the treating physician. In this study, we present our experience with the administration of a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site. A retrospective review was conducted of patients with spontaneous intracranial hypotension who underwent a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site from 2010 to 2012. Patient demographic data, clinical charts, indications for treatment, radiographic images, procedure notes, and postprocedure hospital course were reviewed. Overall, 9 patients were identified who underwent 20 blood patch procedures. Patients were selected to undergo the large-volume procedure either because they had a failed site-directed epidural blood patch or if imaging demonstrated multiple possible leak sites. There were 6 women and 3 men, with an average age of 33.5 years. The mean volume of blood injected per procedure was 54.1 mL (median=55 mL; range=38-70 mL). All patients had an orthostatic headache as one of their presenting symptoms; 22% also presented with neurocognitive decline and behavioral changes; 89% of patients had improvement or resolution of their symptoms; and 80% of patients who had a previously failed site-directed epidural blood or fibrin glue patch improved with a large volume catheter-directed blood patch. Our experience supports the use of a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site for the treatment of spontaneous intracranial hypotension. Additionally, our results indicate a role for this procedure in refractory cases of spontaneous intracranial hypotension.

Alternative treatment of intracranial hypotension presenting as postdural puncture headaches using epidural fibrin glue patches: two case reports

Introduction: Intracranial hypotension is a neurologic syndrome characterized by orthostatic headaches and, radiographically, by dural thickening and enhancement as well as subdural collections. Several of etiologies exist, including surgical dural violations, lumbar puncture, or spontaneous cerebrospinal fluid leak. Current management includes conservative management consisting of bed rest, caffeine, and hydration. When conservative management fails, open surgical or percutaneous options are considered. Currently, the gold standard in percutaneous management of intracranial hypotension involves the epidural injection of autologous blood. Recently, some therapies for intracranial hypotension have employed the use of epidural fibrin glue. Case Presentation: Two cases of patients with persistent postdural puncture headaches are presented. Epidural fibrin glue injection alleviated the orthostatic headaches of two patients with intracranial hypotension. Conclusion: Although consideration must be afforded for the potential risks of viral transmission and aseptic meningitis, the utilization of epidural fibrin glue injection as an alternative or adjunct to the epidural blood patch in the treatment of intracranial hypotension should be further investigated.

Fibrin Glue to Treat Spinal Fluid Leaks Associated with Intrathecal Drug Systems

Intrathecal drug delivery systems (IDDSs) are used to treat resistant pain states as well as intractable spasticity via medication delivery into the spinal fluid. Risks associated with implantation of these devices include infection, bleeding, intrathecal granuloma formation, and neurologic sequelae similar to other neuraxial procedures. Intrathecal catheter placement creates the additional risk of persistent spinal fluid leak, which can lead to postdural puncture headaches as well as seroma formation and may require subsequent surgical exploration or explantation. This retrospective case series examines 3 patients at a single institution with persistent spinal fluid leak after IDDS placement (and explantation in one case) resulting in headache and/or seroma formation that were treated with epidural fibrin glue. Three patients underwent IDDS implantation with baclofen for spasticity. In 1 patient, a cerebral spinal fluid leak developed at 1-week postoperatively. After several unsuccessful epidural blood patches and surgical exploration with a catheter revision, she was ultimately treated successfully with a fibrin glue patch. The second patient received an IDDS and did well until a seroma developed 1year later. He was likewise treated with an epidural fibrin glue patch after 2 failed blood patches. In a third patient, a spinal fluid leak developed after explantation of an IDDS and was treated with an epidural fibrin glue patch as initial therapy.

Post Dural Puncture Headache Following Intrathecal Drug Delivery System Placement

Background: Placement of an intrathecal drug delivery system (IDDS) may provide substantial benefit to certain patients. However, placement of these devices is not without complications, and minimal data exist describing the rates of these complications. Specifically, there is a paucity of data describing the incidence of post dural puncture headache (PDPH) following IDDS placement. Objectives: The aim of this study was to identify the incidence and treatment course of PDPH following placement of an IDDS in a retrospective review. Study Design: Retrospective assessment of medical records. Setting: Department of Pain Medicine and Anesthesiology, Mayo Clinic, Rochester, MN. Methods: Following IRB approval, 319 IDDS surgical reports in 285 patients were identified retrospectively over a 20 year study time period. We report demographic information, number of dural punctures, techniques for sealing dural leak, details, and treatment course of PDPH in this population. Results: Symptoms of PDPH were recognized in 73 individual cases (23% of total procedural volume). Younger patient age was the only statistically significant characteristic in predicting development of a PDPH. There were no statistically significant differences found in regards to other risk factors for PDPH development or treatment strategy employed. Seventy-nine percent of PDPH patients were successfully managed with conservative non-interventional therapies (bedrest, IV fluids, analgesics, antiemetics), while 21% required progression to epidural blood or fibrin glue patch procedures for full resolution of symptoms. Limitations: Limitations include the retrospective design of the study as well as the potential for undocumented or improperly documented surgical techniques and/or events. Conclusion: Though the development of PDPH after IDDS implantation was found to be fairly common (23% incidence), the majority of these patients had self-limited symptoms that resolved with conservative medical management. Epidural blood patch or application of epidural fibrin glue was therapeutically successful for the remainder of PDPH patients who were refractory to conservative measures. Key words: Pain, intrathecal drug delivery system, pain pump, morphine, baclofen, postdural puncture headache, spinal headache

Laparoscopic management of perforated peptic ulcer using combined suturing and fibrin glue patch

Background: Duodenal perforation is a common complication of duodenal ulcer. Treatment for perforated peptic ulcer can be performed by laparoscopy in 85% of cases, making it possible to avoid a median laparotomy which can lead to wound infection and late incisional hernia. Methods: Twenty-four patients with perforated peptic ulcer were planned to be treated laproscopically, three of whom were excluded from the study (one patient with previous upper abdominal operations, one with bleeding peptic ulcer and the third one had evidence of gastric outlet obstruction).The study started.from January 2009 till December 2010.Five patients were operated in Ain Shams University hospitals (Egypt) and sixteen patients were operated upon in Kingdom of Saudi Arabia. Mean age was (38.1±10.3), diagnosis of perforated peptic ulcer was reached usual by clinical examination, laboratory investigations, plain X-ray chest, abdomen and abdominal U/S. One case was misdiagnosed originally as acute appendicitis.All operations were performed by laparoscopy; closing the perforation with intra-corporeal sutures and application of fibrin glue patch. Results: Mean operating time was 65 minutes. All procedures included suturing of the perforation with application of fibrin glue patch with peritoneal toilet and suction drain.Mean hospital stay was 3.5days. All patients had no serious postoperative complications apart from three patients, two of them developed chest infection and the third patient had postoperative leak and peritonitis. Conclusion: Laparoscopic closure of peptic ulcer is safe with short hospital stay and early return to work.

Hand-Assisted Laparoscopic Partial Nephrectomy Without Formal Collecting System Closure: Perioperative Outcomes in 104 Consecutive Patients

Laparoscopic partial nephrectomy (LPN) paralleling open techniques, particularly closure of the collecting system, can be technically challenging for the novice laparoscopist. We describe operative results and complications of a single surgeon, retrospectively reviewed series using a simplified method of hand assistance and a fibrin glue patch for hemostasis without formal collecting system closure. We identified 104 consecutive patients between September 2003 and January 2009 who underwent hand-assisted laparoscopic partial nephrectomy (HALPN). Our technique involves routine hilar clamping after isolation of the tumor and mobilization of the kidney. After resection of the mass, a fibrin glue patch is placed within the surgical defect and secured with bolstering sutures. No attempt is made to suture the collecting system, nor are ureteral catheters placed when the collecting system is entered during resection of the tumor. Mean tumor size was 2.8 cm (median 2.5 cm, range 0.7-7.0 cm). With hilar clamping, warm ischemia time averaged 24.5 minutes (range 11-39 min). Estimated blood loss averaged 220 mL (range 50-1500 mL), and five (4.8%) patients received transfusions either intraoperatively or postoperatively. Urine leak occurred in 1.9% (n=2) of patients overall and 4.3% (2/47) of patients with documented collecting system entry. Both urine leaks resolved with conservative management only. HALPN without formal collecting system closure is a safe and effective technique with similar urine leak and transfusion rates compared with other series. This technique may allow more urologists to perform minimally invasive partial nephrectomy or to do so with potentially shorter ischemia times.

Management strategies of intercavernous sinus bleeding during transsphenoidal surgery

Transsphenoidal surgery has been well established as an effective primary treatment for tumours of the sellar region. During the dural opening, the prominent intercavernous sinus poses limitations for this approach and may contribute to incomplete tumour resections. Based on our experience from 940 cases of conventional transsphenoidal surgery, we have developed a stepwise protocol for achieving bleeding control in 72 cases (7.7%) that had prominent anterior intercavernous sinus. A custom-made 45-degree right- or left-angled bipolar coagulator (38 cases) or Landolt bipolar coagulator (29 cases; Aesculp, Tuttlingen, Germany) was inserted into the small dural opening, and both of the dural layers were coagulated together so that the potential space between the endoosteal layer and meningeal layer could be sealed, and the dural opening could be extended. When the anterior portion of the medial wall of the cavernous sinus was accidentally opened, we then placed a small piece of oxidised regenerated cellulose (Surgicel; Johnson & Johnson, North Yorkshire, UK) at the opening of the medial wall of the cavernous sinus and coagulated both dural layers together starting from the sellar floor side with a custom-made 45-degree angled bipolar coagulator. For the relatively large opening of the cavernous sinus, a microfibrillar collagen haemostat (Avitene; MedChem Products, Woburn, MA) or fleece-coated fibrin glue (TachoComb; Nycomed Austria, Linz, Austria) patch was applied over the opened cavernous sinus with gentle compression and was found to be effective in most cases. Rarely, direct suture of the opened medial wall of the cavernous sinus was necessary in five cases. We describe a stepwise approach to overcome unusual bleedings from the prominent intercavernous sinus during conventional transsphenoidal surgery. Our surgical experience reveals that these methods can be very effective for the control of sinus bleeding.

Pseudomeningocele after lumbar discectomy treated with fibrin glue and epidural blood patch - A case report -

Pseudomeningocele is rare complication after lumbar discectomy. Most pseudomeningoceles are asymptomatic, but sometimes can cause headaches, infection, back pain, and radicular pain. Treatment modalities include conservative management, epidural blood patch, lumbar subarachnoid drainage, and surgery. We report a successful treatment of pseudomeningocele with epidural blood and fibrin glue patch, which did not treated with conservative management and epidural blood patch alone.

Is use of epidural fibrin glue patch in patients with metastatic cancer appropriate?

Is use of epidural fibrin glue patch in patients with metastatic cancer appropriate?

The Effect of Fibrin Glue Patch in an In vitro Model of Postdural Puncture Leakage

The Effect of Fibrin Glue Patch in an In vitro Model of Postdural Puncture Leakage

The Effect of Fibrin Glue Patch in an In vitro Model of Postdural Puncture Leakage

We studied the possibility of stopping a continuing transdural leakage with fibrin glue, a biologic adhesive, in an in vitro model. The model was made by sealing the bottom of a tube filled with saline to a height of 50 cm with a human lyophilized dural specimen. Dural punctures were performed with a 17-gauge Tuohy needle. The needle was then withdrawn, and 0.8 mL of fibrin glue was injected through the same needle to seal the defect. The column was refilled 3 min after sealing. The pressure in the intrathecal chamber was measured during the procedure. Macroscopic and microscopic histological studies of the dura and the fibrin plug were performed. In the five cases studied, the leak was sealed by the fibrin plug at closing pressures of 25-35 cm H2O, and no further leakage was detected after refilling. The dural specimens showed a fibrin glue plug stuck at the edges of the hole. We conclude that fibrin glue stops leakage of fluid from dural holes created by a 17-gauge Tuohy needle in an in vitro pressurized model. We explored the possibility of repairing a cerebrospinal fluid leak produced by an accidental dural puncture during epidural anesthesia by percutaneously injecting tissue adhesive in vitro. This technique seems promising for the prophylaxis and treatment of the headache associated with this leakage but requires further study in vivo.

Comparative Transoral Dural Closure Techniques: A Canine Model

A watertight dural closure is difficult to achieve after transoral-transclival operation for ventral intradural lesions at the craniocervical junction. These procedures have a high morbidity and mortality from cerebrospinal fluid (CSF) fistula, meningitis, and abscess. We used a canine model to test three different techniques of dural closure after transoral intradural operation: primary suture closure, laser patch weld, and fibrin glue patch closures. The primary suture closure technique was inadequate. All eight leaked CSF at the time of operation, and five had radiographic leaks and were incompetent at autopsy. All seven of the laser closures leaked CSF at operation, yet only one was incompetent at autopsy. The fibrin glue technique was superior and provided a solid seal at operation, even with repeated Valsalva maneuvers to 40 mm Hg. The immediate and persistent seal at operation is clinically significant because it may prevent CSF leak, meningitis, and abscess formation in human patients after transoral surgery. Fibrin glue is excellent for repairing complex dural defects and merits evaluation in clinical trials.