Use Of Sealant Research Articles

Feedback on the use of three surgical sealants for preventing prolonged air leak after robot-assisted anatomical lung resection.

Prolonged air leak (PAL) is the most common complication after lung resection. Several surgical sealants have been developed to reduce PAL, including fibrin-based (FS), polyethylene glycol-based (PEGS) and polyglycolic acid-based (PGAS) sealants. In this work we report our experience of surgical sealant use after robot-assisted lung resection. A 7-year retrospective study was conducted, including patients who had robot-assisted lobectomy or segmentectomy. Data were collected using a prospective national database. The use of surgical sealants was recorded in traceability sheets. PAL occurred in 60 of the 299 patients included. American Society of Anesthesiologists score (ASA) and index of prolonged air leak (IPAL) were higher for patients with sealants. In this group, operative time, chest drain duration and length of stay were significantly longer. PAL occurrence was significantly associated to sealant in univariate analysis (odds ratio =1.88, 95% CI: 1.07 to 3.36, P=0.03) but the association was slightly decreased when adjusting on IPAL and ASA score (Odds ratio =1.70, 95% CI: 0.94 to 3.10, P=0.08). Comparing sealants, more segmentectomies were performed in patients with PGAS (P=0.0013) and their operative time was shorter (P=0.0002). PAL occurrences were not different. Length of stay (P=0.0045) and operative time (P=0.0002) were longer in patients with PEGS who had more postoperative complications (P=0.024). This study did not identify a positive effect of surgical sealants for preventing PAL. However it highlighted the need to rationalize their use.

The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy.

The aim of this study was to elucidate the impact of intraoperative blood loss on outcomes following pancreatoduodenectomy (PD). The negative impact of intraoperative blood loss on outcomes in PD has long been suspected but not well characterized, particularly those factors that may be within surgeons' control. From 2001 to 2015, 5323 PDs were performed by 62 surgeons from 17 institutions. Estimated blood loss (EBL) was discretized (0 to 300, 301 to 750, 751 to 1300, and >1300 mL) using optimal scaling methodology. Multivariable regression, adjusted for patient, surgeon, and institutional variables, was used to identify associations between EBL and perioperative outcomes. Factors associated with both increased and decreased EBL were elucidated. The relative impact of surgeon-modifiable contributors was estimated through beta coefficient standardization. The median EBL of the series was 400 mL [interquartile range (IQR) 250 to 600]. Intra-, post-, and perioperative transfusion rates were 15.8%, 24.8%, and 37.2%, respectively. Progressive EBL zones correlated with intra- but not postoperative transfusion in a dose-dependent fashion (P < 0.001), with a key threshold of 750 mL EBL (8.14% vs 40.9%; P < 0.001). Increasing blood loss significantly correlated with poor perioperative outcomes. Factors associated with increased EBL were trans-anastomotic stent placement, neoadjuvant chemotherapy, pancreaticogastrostomy reconstruction, multiorgan or vascular resection, and elevated operative time, of which 38.7% of the relative impact was "potentially modifiable" by the surgeon. Conversely, female sex, small duct, soft gland, minimally invasive approach, pylorus-preservation, biological sealant use, and institutional volume (≥67/year) were associated with decreased EBL, of which 13.6% was potentially under the surgeon's influence. Minimizing blood loss contributes to fewer intraoperative transfusions and better perioperative outcomes for PD. Improvements might be achieved by targeting modifiable factors that influence EBL.

Reinforcement of intrathoracic oesophago-gastric anastomosis with fibrin sealant (Tisseel®) in oesophagectomy for cancer: A prospective comparative study

PurposeFibrin sealant (Tisseel) is a human protein and thrombin soluble fibrinogen that has been indicated for reinforcement of gastro-intestinal anastomoses to prevent leakage. The objective of this study is to examine the impact of fibrin sealant regarding anastomotic leak, following Ivor-Lewis procedure. MethodsThis is a prospective comparative study on 2-stage oesophagectomy for cancer of the distal oesophagus or oesophagogastric junction. N = 57 individuals were randomly subjected; n = 22 patients to Tisseel in combination to surgical anastomosis versus n = 35 patients to surgical anastomosis alone. The test of probability was assessed through Chi-Square, independent samples paired T-Test and Log-Rank analysis. ResultsOf the 57 cases included, 56 underwent hybrid and 1 open oesophagectomy. In the Tisseel group, n = 5(22.7%) developed anastomotic leak comparing to n = 3(8.6%) of the control group. No statistically significant difference in leak rate was shown between the two groups; the test of probability was rejected. ConclusionsOur results are not supportive of Tisseel tissue sealing property on the intrathoracic oesophago-gastric anastomosis and fibrin sealant's use cannot be justified.

Postoperative hemorrhage complications following the Whipple procedure.

Although the Whipple operation is an essential surgical technique, its high morbidity (30% to 60%) and mortality (5%) are problems to be addressed. The incidence of postoperative hemorrhage has been reported between 5% and 16% in the literature. In this study, the data and results regarding postoperative hemorrhage complications from our clinic were evaluated. The files of 185 patients who had undergone Whipple operation in our hospital in the last five years were evaluated retrospectively, and the causes of hemorrhage were attempted to be determined. It was found that 6 out of the 13 (7%) patients who had hemorrhage died. In six of there 13 cases, hemorrhage occurred due to fistulas from the portal vein, gastroduodenal artery, and pancreatic arteries at variable periods. Two cases were found to have developed disseminated intravascular coagulation as a result of sepsis. Early intervention was performed in two cases who bled from the meso veins and in one case who bled from the portal vein. Laparotomy and hemostasis were performed in a patient who bled from the gastric anastomosis line. In a patient who had been taking low molecular weight heparin, bleeding from the drains and nasogastric tube stopped following the cessation of the drug. Preventive procedures such as connection of the vascular structures, use of vascular sealants, omental patching during surgery, and reducing the risk of complications by using somatostatin analogs were performed to prevent hemorrhages after Whipple operations. In addition to standard methods, angiography and embolization have emerged as effective methods in the diagnosis and treatment of hemorrhages. Furthermore, determination and elimination of independent risk factors, such as jaundice, affecting fistula formation and bleeding in the perioperative period, is important for prevention.

Dural sealants for the management of cerebrospinal fluid leakage after intradural surgery: current status and future perspectives

ABSTRACTIntroduction: Cerebrospinal fluid leakage is a complication after intradural surgery and is associated with severe secondary complications like compromised wound healing and meningitis. Dural sealants are meant to augment the primary dural closure in order to achieve a watertight closure.Areas covered: This review summarizes the efficacy of currently available dural sealants. Potential future improvements and biomaterials are discussed.Expert opinion: The use of a dural sealant seems to be the logical method to prevent CSF leakage. However, based on the efficacy of currently available dural sealants according to systematic reviews and in vitro studies, a significant effective dural sealant seems is still lacking. A new dural sealant has to be thoroughly assessed before clinical application in in vitro, in vivo and clinical trials. A new research area within sealant development might be the introduction of dural sealants with both antimicrobial and analgesic properties.

Role of Porcine Fibrin Sealant in the Prevention of Cervical Anastomotic Leakage After Esophagectomy for Esophageal or Esophagogastric Junction Cancer (PLACE020): A Phase 2, Single-Arm, Prospective Study

Background: Surgery is the primary treatment for esophageal or esophagogastric junction cancer (EC or EJC), but anastomotic leakage (AL) remains problematic. The use of fibrin sealant (FS) may reduce the incidence of AL. We aimed to assess the efficacy and safety of the application of porcine FS in the prevention of cervical AL for patients with EC or EJC. Methods: In this phase 2, single-arm, prospective study, we recruited patients aged 18-80 years with resectable EC or EJC, clinically staged as T1-4aN0-3M0. An open or minimally invasive McKeown esophagectomy was performed with circular stapled anastomosis. After anastomosis, 2·5 ml of porcine FS was applied circumferentially. The primary endpoint was the proportion of patients with AL within 3 months. Findings: From Jun 4, 2018, to Dec 29, 2018, 57 patients were enrolled, including 47 patients with thoracic EC and five with EJC. At the data cutoff date (Mar 31, 2019), two (3·5%) of the 57 patients had developed cervical AL. One (1·8%) patient was diagnosed with gastric fistula. The incidence of anastomotic stricture and other major postoperative complications was 1·8% and 17·5%, respectively. The median time needed to initiate oral feeding after operation was eight days (IQR 7·0-9·0). No adverse events related to FS were recorded. No deaths occurred within 90 days after surgery. Interpretation: Perioperative sealing with porcine FS is safe and shows promise for the prevention of AL after esophagectomy in patients with resectable EC or EJC. Further phase 3 study is warranted. Trial Registration Number: This study is registered at ClinicalTrials.gov, number NCT03529266. Funding Statement: The study was supported in part by grants from the Fundamental Research Funds for the Central Universities [grant number: 17ykzd30], the National Natural Science Foundation of China [grant number: 81402003], and the Guangdong Esophageal Cancer Institute Science and Technology Program [grant number: M201601]. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study obtained the approval from the ethics committee at Sun Yat-sen University Cancer Center and was done according to the provisions of the Declaration of Helsinki and Good Clinical Practice guidelines.

Histopathological effects of modern topical sealants on the liver surface after hepatectomy: an experimental swine study

The present study aimed to determine the impact of different sealant materials on histopathological changes to the liver surface after liver resection. Thirty-six landrace pigs underwent left anatomical hemihepatectomy and were assigned to a histopathological control group (HPC, n = 9) with no bleeding control, a clinically simulated control group (CSC, n = 9) with no sealant but bipolar cauterization and oversewing of the liver surface, and two treatment groups (n = 9 each) with a collagen-based sealant (CBS) or a fibrinogen-based sealant (FBS) on resection surface. After postoperative day 6, tissue samples were histologically examined. There were no significant differences in preoperative parameters between the groups. Fibrin production was higher in sealant groups compared with the HPC and CSC groups (both p < 0.001). Hepatocellular regeneration in sealant groups was higher than in both control groups. A significantly higher regeneration was seen in the FBS group. Use of sealants increased the degree of fibrin exudation at the resection plane. Increased hepatocellular necrosis was seen in the CBS group compared with the FBS group. The posthepatectomy hepatocellular regeneration rate was higher in the FBS group compared with the CBS group. Randomized studies are needed to assess the impact of sealants on posthepatectomy liver regeneration in the clinical setting.

Estudo prospectivo sobre o impacto do uso do selante de fibrina humano livre de agentes estabilizadores de coágulo na artroplastia total de joelho

Objective The present study aimed to evaluate the results of the intraoperative topical use of a human fibrin sealant free of clot-stabilizing agents in total knee arthroplasties (TKAs), looking for differences between groups regarding blood loss, transfusion requirement, length of hospital stay, pain perception, range of motion (ROM), and incidence of complications. Methods We have analyzed prospectively an intervention group with 32 patients (Sealant) and a control group with 31 patients (Control) with symptomatic knee osteoarthritis who underwent TKA. Results The results were similar between the groups regarding visible blood loss in the drain in 24 hours (Control, 276.5 mL ± 46.24 versus Sealant, 365.9 mL ± 45.73), total blood loss in 24 hours (Control, 930 mL ± 78 versus Sealant, 890 mL ± 67) and in 60 hours after surgery (Control, 1,250 mL ± 120 versus Sealant, 1,190 mL ± 96), blood transfusion requirement (which occurred only in 1 control patient), length of hospital days stay (Control, 5.61 ± 0.50 versus Sealant, 4.81 ± 0.36), postoperative pain, and ROM. Sealant use was not related to wound healing complications, to infection, or to deep venous thrombosis. Conclusion We have concluded that the hemostatic agent composed of human fibrin was not effective in reducing bleeding volume and blood transfusion requirement, nor it interfered with hospital length of stay, pain perception, and ROM. Its use was not related to any complications.

Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review

BackgroundStaple-line leaks following laparoscopic sleeve gastrectomy (LSG) remain a concerning complication. Staple-line buttressing is largely adopted as an acceptable reinforcement but data regarding leaks have been equivocal. This study compared staple-line leaks in five reinforcement options during LSG: no reinforcement (NO-SLR), oversewing (suture), nonabsorbable bovine pericardial strips (BPS), tissue sealant or fibrin glue (Seal), or absorbable polymer membrane (APM).MethodsThis systematic review study of articles published between 2012 and 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Variables of interest included leak rates, bleeding, and complications in addition to surgical and population parameters. An independent Fisher’s exact test was used to compare the number of patients with and without leaks for the different reinforcement options.ResultsOf the 1633 articles identified, 148 met inclusion criteria and represented 40,653 patients. Differences in age (older in APM; p = 0.001), starting body mass index (lower in Suture; p = 0.008), and distance from pylorus (closer in BPS; p = 0.04) were observed between groups, but mean bougie size was equivalent. The overall leak rate of 1.5% (607 leaks) ranged from 0.7% for APM (significantly lower than all groups; p ≤ 0.007 for next lowest leak rate) to 2.7% (BPS).ConclusionsThis systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement. Variation in surgical technique may also contribute to leak rates.

Fissure sealants or fluoride varnish? Routines and attitudes among dental health personnel in Norway.

To investigate routines and attitudes among dentists and dental hygienists concerning use of fissure sealants and fluoride varnish for non-operative management of occlusal caries. All dentists and dental hygienists working in child dental care in three counties in Norway were invited to answer a questionnaire on routines for use of fissure sealants and fluoride varnish. Nine statements regarding attitudes towards use of sealants were scored using a five-point Likert scale. Multivariable logistic regression analyses were performed to assess indicators associated with reported routines for use of sealants and varnish. The study was approved by the Norwegian Centre for Research Data. In total 142 of 189 (75%) dentists and dental hygienists answered the questionnaire. The majority of the respondents, n = 83 (59%), reported to prefer fissure sealants while fluoride varnish was preferred by 57 (41%) of the respondents. Frequent use of fissure sealants was reported by 58 (41%) and frequent use of varnish by 104 (74%) of the respondents. Most (n = 104, 74%), used sealants on specific indications, and 89 (64%) opened fissures only when suspecting dentine caries. Preferred method and routines for occlusal caries management differed between counties (p < 0.05). Almost all clinicians agreed with the statement that sealants are protective against caries, while statements regarding costs, technique sensitivity and children's cooperation revealed some concerns regarding fissure sealing. Fissure sealants were the preferred method for occlusal caries management despite reported concerns related to technical aspects and patient cooperation. County-level variation in frequency of sealant use was observed.

SEAL Cambodia—Evaluation of a modified protocol for placement of Fuji VII® Fissure Sealants at one and two years

ObjectivesIn order to address the severe caries burden among Cambodian children and limited access to dental care this study had two objectives: (1) To evaluate the caries preventive effect of hand-mixed GIC Fissure Sealants (FS) placed on first permanent molars of 6–8 year-old Cambodian children using two protocols in the SEAL Cambodia Project and (2) validate the SEAL Cambodia population-based intervention. MethodsThe study had four groups, two cohorts, and investigated two clinical protocols (original and modified) for FS placement to compare caries preventive fraction. Three groups were followed up at 1y and two were followed up at 2y. The modified protocol involved control of the temperature of the material, the timing of mixing and placement, and adjustment of the occlusion. Data analysis examined differences in caries incidence by group. ResultsAt 1 and 2 y, 62.8%, and 68.0% follow-up rates were achieved, respectively. The baseline mean dmft for the first and second cohorts was 8.0 (SD 3.9) and 9.9 (SD 4.3) respectively. The original protocol did not render a statistically significant preventive benefit. A preventive fraction of 89.1% at 1 y and 32.3% at 2 y was achieved using the modified protocol in the second cohort (P < 0.05). Children with baseline dmft> 8 realised half the preventive fraction at 2 y compared to those with dmft <8 (22.3% and 45.8% respectively). ConclusionsThe modified FS protocol increased the caries preventive effect, although it was lower than that reported in other studies. Clinical significanceThis study builds evidence for the use of glass ionomer cement Fissure Sealants (FS) for the prevention of caries at a population level. It showed that improving the field-based clinical protocol for application of FS had a large impact on clinical success.

Effects and results of fibrin sealant use in laparoscopic sleeve gastrectomy

Background: Leakage and bleeding after LSG are very serious feared complications. The aim of this study was to review the clinical evidence after using fibrin sealant in standard LSG.Methods: Morbidly obese patients who underwent standard technique of LSG with using fibrin sealant were included in the study. Data concerning patient demographic variables [age, gender, body mass index (BMI, kg/m2), and comorbid conditions], previous surgeries, postoperative complications and postoperative readmissions were collected.Results: In total, 100 patients who underwent LSG, 51.6 % of the patients had obesity-related comorbid conditions with a BMI >35 kg/m². The mean age of the patients was 42 ± 13 years. All operations were completed laparoscopically. The mean operative time was 60 ± 12 min. No leakage was detected in the intra-operative methylene blue test. The mean hospital stay was 5 ± 2 days. Staple-line leakage, twist and stricture were not observed.No mortality were noted.Conclusion: This retrospective study shows that bariatric surgeons should consider using standard surgical surgery in LSG to reduce postoperative complications. Fibrin glue is a reliable and useful tool for strengthening the staple line and can prevent potential twist of the stomach.

Heterologous fibrin sealant potentiates axonal regeneration after peripheral nerve injury with reduction in the number of suture points

The use of suture associated with heterologous fibrin sealant has been highlighted for reconstruction after peripheral nerve injury, having the advantage of being safe for clinical use. In this study we compared the use of this sealant associated with reduced number of stitches with conventional suture after ischiatic nerve injury. 36 Wistar rats were divided into 4 groups: Control (C), Denervated (D), ischiatic nerve neurotmesis (6 mm gap); Suture (S), epineural anastomosis after 7 days from neurotmesis, Suture + Fibrin Sealant (SFS), anastomosis with only one suture point associated with Fibrin Sealant. Catwalk, electromyography, ischiatic and tibial nerve, soleus muscle morphological and morphometric analyses were performed. The amplitude and latency values of the Suture and Suture + Fibrin Sealant groups were similar and indicative of nerve regeneration.The ischiatic nerve morphometric analysis in the Suture + Fibrin Sealant showed superior values related to axons and nerve fibers area and diameter when compared to Suture group. In the Suture and Suture + Fibrin Sealant groups, there was an increase in muscle weight and in fast fibers frequency, it was a decrease in the percentage of collagen compared to group Denervated and in the neuromuscular junctions, the synaptic boutons were reestablished.The results suggest a protective effect at the lesion site caused by the fibrin sealant use. The stitches reduction minimizes the trauma caused by the needle and it accelerates the surgical practice. So the heterologous fibrin sealant use in nerve reconstruction should be considered.

High Abundance of Unintentionally Produced Tetrachlorobiphenyls (PCB47/48/75, 51, and 68) in the Atmosphere at a Regional Background Site in East China.

Although polychlorinated biphenyls (PCBs) have been banned for several decades, they are still detected with elevated levels due to their unintentional production from combustion and industrial thermal processes (UP-PCBs). To investigate the composition and current levels of UP-PCBs and understand which sources are controlling PCB burdens in ambient atmosphere, air samples were collected from August 2012 to August 2015 at a background site in east China. An unexpected high abundance of PCB47+48+75 was observed to be the predominant congener with an average concentration of 786 ± 637 pg/m3. It accounted for 48 ± 16% of ΣPCBs, followed by PCB51 (10 ± 4%), PCB11 (8 ± 6%), and PCB68 (7 ± 3%). Seasonal variations with high levels in summer and lowest levels in winter were observed for PCB47+48+75, 51, and 68. These tetrachlorobiphenyl congeners were strongly correlated with temperature ( r2 > 0.7), suggesting the control of temperature-dependent volatilization processes from contaminated surfaces. The decreased occurrence of PCB47+48+75, 51, and 68 in commercial products and their negative correlations (| r| < 0.35) with polycyclic aromatic hydrocarbon (PAHs) and weak correlation with other PCB congeners suggested unique unintentional sources that differ from combustion and industrial thermal processes or pigment, such as the use of polymer sealant, for PCB47+48+75, 51, and 68 in the ambient air.

Use of a fibrin sealant within a blood-saving protocol in patients undergoing revision hip arthroplasty: effects on post-operative blood transfusion and healthcare-related cost analysis.

Blood transfusion and blood management are important aspects in orthopaedic surgery. Strategies include intra-operative and post-operative blood salvage and even the use of fibrin sealant in selected case. Objectives of the study were (1) to compare the total number of transfusions and the length of hospital stay in patients undergoing complete revision hip arthroplasty (RHA) with and without the use of a fibrin sealant (EVICEL®) and (2) to evaluate the possible role in cost savings of EVICEL® in association with the blood-saving protocol. Retrospective observational study evaluating patients undergoing complete RHA (stem + cup) with a blood-saving protocol with (n = 50) and without EVICEL® (n = 60). The outcome measures were: number of patients transfused (allogeneic red blood cells-RBC-and plasma), amount of blood/plasma transfusions, quantity of re-infused recycled blood, and length of hospital stay. An economic model was developed to assess the differences in costs between the two groups. EVICEL® reduced the number of transfused red blood cells and plasma (p < 0.001), and the hospital stay (p = 0.01) compared to control group. EVICEL® can induce a reduction in resource consumption with an average cost-savings of €1.676 per patient. EVICEL® may be effective in reducing red blood cells and plasma transfusion as well as hospital stay. The inclusion of EVICEL® in a blood-saving protocol seems to produce clinical efficacy and cost savings.

Tissue sealants for the prevention of lymphoceles after radical inguinal lymph node dissection in patients with melanoma: A systematic review and individual patient data meta-analysis.

Postoperative lymphoceles and further wound complications occur frequently after radical inguinal lymph node dissection (ILND). In various studies, tissue sealants have shown to reduce the incidence of postoperative morbidity. A systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of tissue sealants in reducing the incidence of postoperative lymphoceles following ILND in patients with melanoma was conducted. Individual patient data was requested to pool the data for meta-analysis appropriately. Thousand seven hundred twenty-nine manuscripts were screened for eligibility. Six RCTs published between 1986 and 2012 were identified including 194 patients for ILND. Only four RCTs were included in the meta-analysis. No study properly defined the term "lymphocele." Tissue sealants failed to influence the duration of drain placement (mean difference [MD] = -3.05 days; z = 1.18; P = 0.24), total drainage volume (MD = 598.39 mL; z = 1.49; P = 0.14), the incidence of postoperative seroma, wound infection and skin necrosis. No improvement was identified with the use of tissue sealants, however, a valid comparison of the results of included trials was difficult owing to the lack of a definition of the term "lymphocele." Other surgical techniques and trials using validated endpoint definitions are required to reevaluate these findings.

Fibrin tissue sealant and minor skin grafts in burn surgery: A systematic review and meta-analysis

The indications for use of fibrin glue in skin grafting burn patients remains understudied. The purpose of this study is to review the efficacy of fibrin tissue sealant in skin graft adherence, establish guidelines for use of fibrin tissue sealant, and review the cost effectiveness of fibrin glue. Publications with the following criteria were included: comparative human studies, autologous skin grafts, and autologous or commercial fibrin sealant. Outcomes assessed included evidence of engraftment, wound closure, rates of hematoma/seroma, graft loss and infection. Meta-analysis obtained pooled odds ratios for outcomes of interest. Cost analysis was performed using data available in the literature. 7 studies and 751 interventions (fibrin) and controls (staples) were included in the final analysis. 67.6% grafts with fibrin were 100% adherent by one week, vs. 55.5% (OR 1.45, p = 0.086). Complete wound closure by one month was 80.2% with fibrin, vs. 73.3% (OR 1.34, p = 0.187). Hematoma/seroma occurred 38.2% with fibrin, vs. 64.7% (OR 0.487, p = 0.122). Graft loss was higher in the control group, 21% vs. 12.6% (OR 0.891, p = 0.604). Average cost of fibrin glue was $50 per ml, and averaged costs of stapler and staple remover was $30 USD ($10-50). Fibrin glue is as effective as staples for adhering skin grafts, and trends towards lower rates of hematoma/seroma. In topographically complex regions, fibrin glue may be a better choice for adherence of skin grafts.

Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy: Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group.

To identify a clinical fistula risk score following distal pancreatectomy. Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive. This multinational, retrospective study of 2026 DPs involved 52 surgeons at 10 institutions (2001-2016). CR-POPFs were defined by 2016 International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution. CR-POPF occurred following 306 (15.1%) DPs. Risk factors independently associated with CR-POPF included: age (<60 yrs: OR 1.42, 95% CI 1.05-1.82), obesity (OR 1.54, 95% CI 1.19-2.12), hypoalbuminenia (OR 1.63, 95% CI 1.06-2.51), the absence of epidural anesthesia (OR 1.59, 95% CI 1.17-2.16), neuroendocrine or nonmalignant pathology (OR 1.56, 95% CI 1.18-2.06), concomitant splenectomy (OR 1.99, 95% CI 1.25-3.17), and vascular resection (OR 2.29, 95% CI 1.25-3.17). After adjusting for inherent risk between cases by multivariable regression, the following were not independently associated with CR-POPF: method of transection, suture ligation of the pancreatic duct, staple size, the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide. Intraoperative drainage was associated with a greater fistula rate (OR 2.09, 95% CI 1.51-3.78) but reduced fistula severity (P < 0.001). From this large analysis of pancreatic fistula following DP, CR-POPF occurrence cannot be reliably predicted. Opportunities for developing a risk score model are limited for performing risk-adjusted analyses of mitigation strategies and surgeon performance.

Preliminary Report of the Use of Skin Sealant to Prevent Surgical Site Infection in Respiratory Surgery

Preliminary Report of the Use of Skin Sealant to Prevent Surgical Site Infection in Respiratory Surgery

Engineering a Multilayered Skin Substitute with Keratinocytes, Fibroblasts, Adipose-Derived Stem Cells, and Adipocytes.

A variety of skin substitutes that restore epidermal and dermal structures are currently available on the market. While the main focus in research and clinical application lies in dermal and epidermal substitutes, the development of a subcutaneous replacement, the hypodermis, is often neglected. This chapter describes the use of fibrin sealant as a hydrogel scaffold to generate a three-dimensional skin substitute. For the hypodermal layer adipose-derived stem cells (ASCs) and mature adipocytes are seeded within a fibrin hydrogel. On top, another fibrin clot with incorporated fibroblasts is placed for the construction of the dermal layer. Keratinocytes are added on top of the two-layered construct to form the epidermal layer. The three-layered construct is cultivated for up to 3weeks with keratinocytes being exposed to air according to the air-liquid interface cultivation model.