Surgical Glue Research Articles

Rapidly light-activated surgical protein glue inspired by mussel adhesion and insect structural crosslinking

Currently approved surgical tissue glues do not satisfy the requirements for ideal bioadhesives due to limited adhesion in wet conditions and severe cytotoxicity. Herein, we report a new light-activated, mussel protein-based bioadhesive (LAMBA) inspired by mussel adhesion and insect dityrosine crosslinking chemistry. LAMBA exhibited substantially stronger bulk wet tissue adhesion than commercially available fibrin glue and good biocompatibility in both in vitro and in vivo studies. Besides, the easily tunable, light-activated crosslinking enabled an effective on-demand wound closure and facilitated wound healing. Based on these outstanding properties, LAMBA holds great potential as an ideal surgical tissue glue for diverse medical applications, including sutureless wound closures of skin and internal organs.

Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study.

Fistula is the main complication of laparoscopic sleeve gastrectomy (LSG), for which healing is difficult to achieve. The aims of the study were to evaluate the efficacy of interventional endoscopy for post-LSG fistula treatment, to evaluate various endoscopic techniques used and identify their complications, and to identify predictive factors of healing following endoscopic treatment. This retrospective multicenter study included patients with post-LSG fistula. Therapeutic procedures were evaluated, taking into account complications and healing times. Endoscopic procedures were considered to have promoted healing if no other surgical procedure was performed. Predictive factors of healing were identified by univariate and multivariate analysis. A total of 110 patients were included, of whom 6 (5.5 %) healed spontaneously, 81 (73.6 %) healed following endoscopic treatment, and 19 (17.3 %) healed following surgery. Healing rates following endoscopic treatment were 84.4 % in the first 6 months of treatment (65/77), 52.4 % for treatment lasting 6 - 12 months (11/21), and 41.7 % after 12 months of treatment (5/12). A drainage procedure (surgical, endoscopic, or percutaneous) was performed in 92 patients (83.6 %). A total of 177 esogastric stents were placed in 88 patients (80.0 %). Surgical debridement, clip placement, glue sealing, and plug placement were also performed. Multivariate analysis identified four predictive factors of healing following endoscopic treatment: interval < 21 days between fistula diagnosis and first endoscopy (P = 0.003), small fistula (P = 0.01), interval between LSG and fistula ≤ 3 days (P = 0.01), no history of gastric banding (P = 0.04). Endoscopic treatment facilitated healing of post-LSG fistula in 74 % of patients. Early endoscopic treatment increased the likelihood of success, and was most effective during the first 6 months of management. After this point, surgical treatment should be considered.

Fixation of Light Weight Polypropylene Mesh with n-Butyl-2-cyanocrylate in Pelvic Floor Surgery: Experimental Design Approach in Sheep for Effectiveness Evaluation.

Objective. The aim of this study was to find a proper experimental design and to evaluate n-butyl-2-cyanoacrylate (Histoacryl) as a fixation method for a light-weight and large pore PP mesh (Synthetic PP Mesh-1) using the sheep as an animal model. Methods. Posterior vaginal implantation by means of episiotomy was used to implant 8 ewes which were evaluated macroscopically and histologically at 3 months (n = 4) and 6 months (n = 4) post-surgery. In previous pilot studies anterior vaginal implantation was evaluated, as well as different synthetic mesh materials, sizes and fixation methods (n = 1 to 3) during three weeks. In all cases a clinical evaluation of the animal was performed. Results. A reduction in the mesh size (Synthetic PP Mesh-1) together with precise application of the surgical glue Histoacryl to fix the mesh yielded significantly better histocompatibility results (P < 0.01) compared to larger size or other fixation methods. Conclusion. The combination of Synthetic PP Mesh-1 with Histoacryl offered a high degree of graft integration without vaginal ulceration and a minimal foreign body reaction, being the sheep a proper animal model to test these types of medical devices.

Complete thymectomy in adult rats with non-invasive endotracheal intubation.

Thymectomy in neonatal rodents is an established and reliable procedure for immunological studies. However, in adult rats, complications of hemorrhage and pneumothorax from pleural disruption can result in a significant mortality rate. This protocol is a simple method of rat thymectomy that utilizes a mini-sternotomy and endotracheal intubation. Intubation is accomplished with a non-invasive and easily reproducible method and allows for positive pressure ventilation to prevent pneumothorax and a controlled airway that allows sufficient time for careful thymus dissection to minimize pleural disruption. A 1.5 cm sternal incision decreases contact with mediastinal vessels and pleura, while still providing full visualization of the thymus. Following exposure of the mediastinum, the thymus is removed by blunt dissection under magnification. The pleural space is then sealed by suture closure of the pre-tracheal muscles followed by the application of surgical glue. The thorax is then closed by suture closure of the sternum, followed by suture closure of the skin. All thymectomies were complete as evidenced by immunohistochemical (IHC) staining of mediastinal tissue, and absence of naïve T-cells by flow cytometry, and the procedure had a 96% survival rate. This method is suitable when complete thymectomy with minimal complications is desired for further immunological studies in athymic adult rats.

330. A surgical glue, cyanoacrylate-based, for the prevention of bilomas post major liver resection

330. A surgical glue, cyanoacrylate-based, for the prevention of bilomas post major liver resection

A human case study demonstrating the safety and effectiveness of laparoscopic surgical glue injection hernioplasty for pediatric indirect inguinal hernia

The purpose of this pediatric case report was to provide clinical evidence supporting the safety and effectiveness of laparoscopic surgical glue injection hernioplasty (LSGIH) in humans for indirect inguinal hernia repair. We performed LSGIH on a female newborn for a right indirect inguinal hernia that was incidentally discovered during a laparoscopic right salphingo-oophorectomy for prenatal right ovarian cyst torsion. Under laparoscopic control, the internal ring was closed by injection of Histoacryl into the internal opening of the patent processus vaginalis. One month later, the patient underwent another laparoscopic operation due to torsion of a newly developed contralateral ovarian cyst. During the second operation, we were able to clearly observe the previous LSGIH site. Despite partial absorption of the injected Histoacryl , the opening of the internal ring remained closed without any evidence of adhesions. This case supports LSGIH as a simple, safe, and useful technique for pediatric inguinal hernioplasty. However, more clinical trials should be performed to confirm the long-term reliability and safety of LSGIH in humans.

Prevalence of Surgical Site Infection Comparing Postoperative Negative Pressure and Conventional Dressings

Purpose The purpose of this study was to compare the prevalence of surgical site infection (SSI) between children whose umbilical incision was covered with a negative pressure or conventional dressing following laparoscopic surgery. Background Covering surgical incisions provides reinforcement to wound closures, a surface to absorb exudate, and a barrier against bacteria to prevent SSIs. A conventional practice for laparoscopic procedures is to cover umbilical incisions with adhesive strips and/or surgical glue. Postoperative SSI is common and can lead to slowed healing and poor outcomes. Negative pressure dressings applied postsurgically may prevent infection by providing a better barrier to bacteria. However, there is limited data available to indicate which umbilical incision dressings are associated with fewer SSIs. Design This study used a retrospective comparative design. Sample/Setting Following institutional review board approval, the electronic medical records of 486 children, with mean age of 11.7 years, ranging from 1 month to 20 years, 58% male, 84% White race, and who had a laparoscopic appendectomy in a large medical center, were queried. Procedures Documentation of postoperative SSI, age, race, gender, BMI, laparoscopic procedure, and umbilical or periumbilical incision information was collected and analyzed. Findings Ten patients acquired SSI; the rate was not statistically significant. Those with vacuum dressings were more likely to have single port laparoscopic appendectomy and a transumbilical incision. There were no statistically significant correlations among the other variables. Implications Although preventing SSI is important, in this sample few infections were found. Therefore, a simple umbilical vacuum dressing offers a safe and attractive alternative to conventional postoperative dressings.

Cyanoacrylate Surgical Glue for Mesh Fixation in Laparoscopic Total Extraperitoneal Hernia Repair

In an attempt to find the ideal surgical technique for mesh fixation during laparoscopic total extraperitoneal inguinal hernia repair, we evaluate the use of a synthetic surgical glue (N-butyl-cyanoacrylate-Glubran 2) in an effort to reduce postoperative pain and the complications associated with the use of staples. We have prospectively evaluated 61 consecutive patients (73 hernias) with a minimum follow-up period of 18 months and an average of 29.7 months, without any significant complications present. The majority (59%) only required low dosages of painkillers during the first 24 hours after surgery and have not experienced any cases of chronic pain or recurring hernias in the time period described. On the basis of this initial experience, the use of the surgical glue used to repair inguinal hernias with the laparoscopic total extraperitoneal technique has been proved to be a simple and effective surgical method for mesh fixation.

Severe dermatitis from Dermabond®surgical glue

Severe dermatitis from Dermabond^®surgical glue

Somatotopic Changes in the Nucleus Ambiguus After Section and Regeneration of the Recurrent Laryngeal Nerve of the Rat

Changes in motoneurons innervating laryngeal muscles after section and regeneration of the recurrent laryngeal nerve (RLN) are far from being understood. Here, we report the somatotopic changes within the nucleus ambiguus (Amb) after the nerve injury and relates it to the resulting laryngeal fold impairment. The left RLN of each animal was transected and the stumps were glued together using surgical fibrin glue. After several survival periods (1, 2, 4, 8, 12, 16 weeks; at least six rats at each time point) the posterior cricoarytenoid (PCA) and thyroarytenoid (TA) muscles were injected with fluorescent-conjugated cholera toxin and the motility of the vocal folds evaluated. After section and subsequent repair of the RLN, no movement of the vocal folds could be detected at any of the survival times studied and the somatotopy and the number of labeled motoneurons changed. From 4 wpi award, the somatotopy was significantly disorganized, with the PCA motoneurons being located rostrally relative to their normal location. A rostrocaudal overlap between the two pools of motoneurons supplying the PCA and TA muscles was observed from 2 wpi onwards. Hardly any labeled neurons were found in the contralateral Amb in any of the experimental groups. An injury of the RLN leads to a reinnervation of the denervated motor endplates of PCA and TA. However, misdirected axons sprout and regrowth from the proximal stump to the larynx. As a result, misplaced innervation of muscles results in a lack of functional recovery of the laryngeal folds movement following a RLN injury.

Erratum to: The use of surgical glue in acute type A aortic dissection

Erratum to: The use of surgical glue in acute type A aortic dissection

A Blood-Resistant Surgical Glue for Minimally Invasive Repair of Vessels and Heart Defects

Currently, there are no clinically approved surgical glues that are nontoxic, bind strongly to tissue, and work well within wet and highly dynamic environments within the body. This is especially relevant to minimally invasive surgery that is increasingly performed to reduce postoperative complications, recovery times, and patient discomfort. We describe the engineering of a bioinspired elastic and biocompatible hydrophobic light-activated adhesive (HLAA) that achieves a strong level of adhesion to wet tissue and is not compromised by preexposure to blood. The HLAA provided an on-demand hemostatic seal, within seconds of light application, when applied to high-pressure large blood vessels and cardiac wall defects in pigs. HLAA-coated patches attached to the interventricular septum in a beating porcine heart and resisted supraphysiologic pressures by remaining attached for 24 hours, which is relevant to intracardiac interventions in humans. The HLAA could be used for many cardiovascular and surgical applications, with immediate application in repair of vascular defects and surgical hemostasis.

Incidence, management, and outcomes of the arteriovenous fistula complicating transvenous lead extraction

An arteriovenous (AV) fistula is an infrequently reported complication of transvenous lead extraction (TLE), but may be under-recognized. To determine the incidence, management, and outcomes of the AV fistula complicating TLE. All TLE procedures from July 2001 to December 2012 were reviewed. Of 2471 patients who underwent TLE, the AV fistula occurred in 8 (0.3%; 6 pacemaker and 2 implantable cardioverter-defibrillator) procedures. Patients who developed an AV fistula had longer lead implant duration (11.8 [interquartile range 7.7] vs 5.2 [interquartile range 7.0] years) and were more likely to have required a powered sheath (8 of 8 [100%] vs 1392 of 2463 [56.5%]) compared to those who did not. Other procedural and demographic details did not discriminate. All patients had a continuous bruit along the anterior chest wall. Catheter angiography was more sensitive (100%) than computed tomography (75%) or ultrasound (25%) for confirming the diagnosis and identifying the vessels involved. One fistula closed spontaneously, while others were closed with covered stents (4) or surgical glue (1). One attempt at closure failed, and one was diagnosed postmortem. Mortality related to the AV fistula was 3 of 8 (37.5%). Patients who died all had structural heart disease. In the 5 patients with normal hearts, the AV fistula was well tolerated for up to 2 years. An AV fistula is an infrequent, though possibly under-recognized, complication of TLE. It requires a high index of suspicion for early diagnosis, may present late, and may be associated with significant morbidity and mortality in patients with structural heart disease.

The use of surgical glue in acute type A aortic dissection

Acute type A aortic dissection (AAAD) remains a lethal disease. With advances in operative methods and perioperative management, surgical outcomes continue to improve, but in-hospital mortality still ranges from 10 to 30% in most series. The surgical technique of choice for aortic root repair remains controversial. Surgical glue created a breakthrough in surgery for acute aortic dissection. We review the surgical techniques with the use of surgical glue for AAAD.

Use of Glubran 2 in uvulopalatoplasty, an alternative to sutures to improve surgical outcome

Uvulopalatoplasty is one of the most common surgeries for snoring and obstructive sleep apnea. The usual way of approximating the edges of the soft palate is the use of sutures, which influences the quality of healing and the severity of postoperative pain. To present our experience in using the tissue glue "N-butyl-2-cyanoacrylate (Glubran 2)" in uvulopalatoplasty and its effect on the operative technique and postoperative results. Between January 2009 and February 2011, 54 patients fitting certain preoperative criteria were treated with this technique and with a minimum follow-up period of 6 months. N-butyl-2-cyanoacrylate was used in uvulopalatoplasty for the treatment of snoring. The main outcome measures were the stability of soft palatal tissues to which the glue was applied, the degree of postoperative pain in comparison with the use of sutures, the morphology of the newly formed soft palate, and postoperative side effects and complications. The technique for the use of surgical glue is described in detail. Fifty-four patients completed the study. Complete healing of the edge of the newly formed soft palate without displacement or delayed postoperative palatal fibrosis was achieved with the use of N-butyl-2-cyanoacrylate. Postoperative pain was significantly reduced with the use of surgical glue. N-butyl-2-cyanoacrylate (Glubran 2) is an effective alternative for surgical sutures in uvulopalatoplasty. As compared to sutures, this tissue glue had the advantages of achieving better surgical outcomes.

EComment. Management of percutaneous coronary intervention complications

We read with great interest the article by Almdahl et al., regarding the cardiac surgical outcome of patients with complications of percutaneous coronary intervention (PCI) [1]. Complications of PCI include perforation (of the coronary artery or ventricle), retained wires, dissection, bleeding (subepicardial or not), tamponade and myocardial ischaemia or infarction [1, 2]. There is an angiographic classification of three types of coronary artery perforation post PCI according to Ellis et al. [3]. In Type I, the angiographic findings are consistent with extraluminal crater with no contrast extravasation. In Type II the contrast extravasation is limited to ‘blushing’ in the myocardial or epicardial fat. In Type III there is a contrast extravasation through frank (>1 mm) perforations or Type III ‘cavity spilling’ extravasation into either the left ventricle, the coronary sinus, any of the cardiac chambers, or the pericardium [3]. This classification is quite important as a useful tool for the diagnosis, management and prognosis of this potentially severe complication. Type I perforations are associated with the lowest incidence of tamponade (8%) with no reported incidence of myocardial infarction or mortality. As a result, the vast majority (85%) of Type I are treated conservatively. Type II perforations show a higher incidence of tamponade and myocardial infarction (13% and 14%, respectively) with no reported mortality, and conservative treatment is successful in 90% of cases. In contrast, Type III perforations have a high morbidity with a much higher incidence of tamponade and myocardial infarction (63% and 50%, respectively) and conservative treatment has been reported to be successful in only 44% of cases, with a mortality independent of treatment in 19% of cases [2, 3]. Shimony et al., in their recent systematic review and meta-analysis (16 studies, 197 061 PCIs), reported that the incidence of PCI complications was 0.43%. Furthermore, the tamponade rates were 0.4%, 3.3% and 45.7% for patients with Ellis classes I to III coronary artery perforations, respectively [4]. It is important to take into consideration the fact that currently (to the best of our knowledge), no established protocol guidelines exist regarding management strategies for PCI complications [2–4]. According to the suggested algorithm of Shimony et al., which is consistent with our department's practice as well, all these patients should be under continuous monitoring and assessment (sequential echocardiography studies). In the case of haemodynamic instability (mainly Ellis class III), the patient is either initially treated conservatively under the care of the cardiologists [pericardiocentesis (definitive or bridging treatment for open surgical intervention), heparin reversal, discontinuation of IIb/IIIa inhibitors/bivalirudin, prolonged balloon inflation for 5 to 15 minutes, embolization, polytetrafluoroethylene-covered stent etc], or surgically by the cardiac surgeons [4]. Surgical management is not standardized and depends on the surgical anatomy, patient co-morbidities and clinical condition. Surgical reports include simple suturing of the perforation, ligation of bleeding vessels, pericardial patch application, surgical glues, CABG (on or off CBP) with and without endarterectomy, stent removal, or vein patch [1–5]. Conflict of interest: none declared

Use of N-Butyl Cyanoacrylate With Metacryloxisulfolane (Glubran 2) Surgical Glue for Flapless Closure of Oroantral Communication

To present first experience of the use N-butyl cyanoacrylate with metacryloxisulfolane (Glubran 2) synthetic surgical glue, in the nonsurgical closure of oroantral communication (OAC). Two OACs, created after the exodontia of tooth 27 in 2 female patients, were sealed and closed with Glubran 2 surgical glue and monitored OACs, until the epithelization of the sockets was ended successfully. Two months postclosure of OACs, the sealed OACs were evaluated on the panoramic image and Water's view radiography. The extraction wounds with OACs were monitored until 23rd and 25th postinterventional days, when epithelization of socket ended successfully. On the panoramic image and Water's view radiography, there were no radiological signs of maxillary sinus pathoses. Glubran 2 can be successfully applied in the closure of OAC from 3 to 5 mm in diameter.

Aortic redissection after glue repair: a rare echocardiographic finding.

A 66-year-old male patient underwent supracoronary ascending aortic grafting and resuspension of the incompetent aortic valve because of a type A aortic dissection. Three months later, he presented with ongoing low-grade fever and sternal wound discharge. Wound and blood cultures were positive for methicillinresistant Staphylococcus aureus. Sinography was consistent with mediastinitis and infection of the vascular prosthesis. Magnetic resonance angiography and computed tomography angiography showed redissection at the distal anastomotic site extending down to the abdominal aorta and both of the common iliac arteries. Transesophageal echocardiography (TEE) findings were equivocal (Fig. 1). We considered the possibility of vegetation on the vascular graft. After a 6-week-long unsuccessful treatment with intravenous antibiotics, the patient was referred for redo surgery. Surgical findings included: (1) dehiscence of the distal anastomotic site and (2) a piece of surgical adhesive (BioGlue , CryoLife, Inc., Kennesaw, GA), which was used during the first operation, found protruding into the false aortic lumen (Fig. 2). This piece of surgical glue produced the rare echocardiographic picture seen on TEE.

Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia: the United States human experience

From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic transesophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility, and efficacy of TEEM in a series of patients with achalasia. Under institutional review board approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, between age 18 and 50 years, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical comorbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 o'clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastroesophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm below the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure, the mucosal incision was closed longitudinally with endoscopic clips and surgical glue. Five patients underwent TEEM, with no perioperative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first postoperative day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach, and absence of leaks. All patients were discharged on the second postoperative day on liquid diet. Two patients reported transient heartburn, which were well controlled with medications. The average preoperative GERD-HRQL was 20, which improved to 11.3 at 7 days postoperative and 2 at 30 days postoperative. To date, three patients have already returned for their 6-month follow-up, reporting adequate swallowing and low LES pressures on esophageal manometry (their mean preoperative LES resting pressure was 36.46 mmHg and residual pressure was 43.16 mmHg, whereas the 6-month follow-up mean LES resting pressure was 10.06 mmHg and residual pressure was 0.43 mmHg). TEEM seems to be safe, feasible, and effective for the treatment of patients with achalasia. Long-term data are still necessary for wide-spread utilization of this novel technique.

Hemostatic Effect of New Surgical Glue in Animal Partial Nephrectomy Models

To evaluate the hemostatic effect of newly developed medical adhesive in animal partial nephrectomy models. A total of 30 experimental rabbits were used in the first study. After clamping the renal vessels, partial nephrectomy was performed up to the opening of the calices. Bioglue was applied to the resection stumps using the new glue (group 1, n = 10) or fibrin glue (group 2, n = 10) for 2 minutes, and the blood loss was measured after unclamping the vessels. Simple unclamping without glue (group 3, n = 10) was also evaluated. For the second study, we used 9 dogs with blood pressure monitoring. After preparation similar to that for the first study, the new glue was applied in 3 dogs (group 4), fibrin glue in 3 dogs (group 5) and no glue in 3 dogs (group 6). Histologic evaluation was performed at 7 days and 1 month after surgery. The mean blood loss was significantly less in group 1 (1.45 g) than in groups 2 (6.59 g) and 3 (19.77 g; P <.001 for both). It was also significantly less in group 4 (12.5 g) than in group 5 (182.5 g; P <.001). Group 4 maintained their initial blood pressure throughout the study, but a significant decrease was observed in group 5. No hematoma was observed at day 7. The new glue showed acceptable hemostasis when applied to the resection stumps after partial nephrectomy in both the rabbit and the dog models. These findings indicate that it could be useful for hemostasis after partial nephrectomy.