Matula / Steiger Hemostasis and Fleece-Bound Sealing in Neurosurgery

1. Auflage 2005
ISBN: 978-3-13-257978-1
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 104 Seiten, ePub

Presentation of surgical treatment techniques of fleece-bounded tissue sealing - mostly intraoperative pictures - deliberate minimal use of radiological pictures. This compact text is intended to serve as an atlas or guide to using the above techniques. Results are presented briefly in tabular form.

Christian Matula

Zielgruppe

Ärzte

Autoren/Hrsg.

Matula, Christian

Steiger, Christina N.

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin

Inhaltsverzeichnis

1 Introduction
The History of Tissue Sealing and Hemostasis
The General Use of Fibrin Glues and Collagen Sponge
The General Use of the Fixed Combination of Collagen Sponge and Tissue Glue
2 General Remarks
The Fixed Combination of Collagen Sponge and Clotting Factors
Composition of TachoSil®
Product Characteristics
Mode of Action
General Indications in Neurosurgery
Macroscopical and Histological Reaction and Postmortem Findings
Experimental Evaluation of the Structure of the Tissue Glue–Coated Collagen in MRI Scans
3 Special Remarks
The Tissue Glue–Coated Collagen Sponge in Hemostasis and Tissue Sealing
Cranial Applications
Case Reports on the Use of Fleece-Bound Sealing in Cranial Neurosurgery
4 Results
General Remarks
Material-Related Results
Cranial Applications
Spinal Applications
Acceptance and Contentment
5 Summary and Conclusion

Leseproben

1 Introduction

The History of Tissue Sealing and Hemostasis

Since the beginning of surgery, bleeding, especially parenchymal bleeding, has always been a major problem, which was not solved satisfactorily until early in the last century. In general, various methods were attempted which fall into one of the three different categories: Mechanical, thermal, and biochemical. The use of thermal energy to accomplish hemostasis was even known in ancient Egypt. Galen caused this practice to become the primary method until Paré re-discovered the principle of ligature in the 16th century. In the late 1920s Bovie and Cushing worked on electrocoagulation and so thermal hemostasis returned to prominence, where it has remained until now. Today, the electric scalpel, the bipolar coagulator, and different lasers are widely used to achieve hemostasis during surgical procedures. The principle of mechanically induced hemostasis has been known since prehistoric times, but until the 16th century and Paré nobody used the method of ligature to stop bleeding from individual blood vessels. In 1892 Horsly invented bone wax in order to prevent bone bleeding.

Various mechanical devices have been developed since then and are used in surgical hemostasis today. Nevertheless thermal and mechanical blood coagulation have been a great improvement in surgery and can be used successfully. Unfortunately they show huge disadvantages in sensitive areas and in parenchymal bleeding. (Bio-)Chemical hemostasis has proved to be a great advantage in such situations. It originated at the time of Hippocrates with the use of caustics like copper sulfate which were not specific in action, reached a peak during the Middle Ages, and ceased after the recovery of ligation. Since these caustics caused an indiscriminate amorphous destruction of all protein elements, the resulting hemostasis was of poor quality and very unreliable.

In 1886 gelatin entered the market and with this substance began the evolution of biochemical hemostasis as we know it today. It was Bergel who first reported the clinical application of fibrin powder in 1909, which was followed by many reports of the ability of fibrin to control parenchymal bleeding. Methods for the purification of thrombin were described in 1938 by Seegers et al. and two years later human fibrinogen and thrombin became available. During World War II these two substances were used to enhance adhesion of skin grafts in soldiers who had sustained severe burn injuries. At that time fibrin foam, which had the appearance of a sponge, was produced. It consisted of fibrinogen which, after exposure to thrombin, was agitated, frozen, and dried. After its reconstitution with a solution of thrombin it was ready for use. More than 500 patients suffering parenchymal bleeding during neurosurgery were treated with this foam. At the same time thick, durable fibrin/glycerol-containing films were produced. These films were sufficiently stable to undergo sterilization and so they were used in almost 100 patients. After the War, human thrombin was replaced by bovine thrombin because human thrombin was known to be a risk factor in transmission of hepatitis. Although bovine thrombin replaced human thrombin, no fibrin sealant was developed until 1970 (by Helene Matras), and the first fibrin glue became available in 1978.

But not only bleeding, liquid-tight and airtight wound sealing was also hard to achieve. Especially dural sealing has always been a major problem. The first step toward dural sealing was made in 1890 when Beach suggested gold foil as a dural substitute. Five years later, Abbe used rubber to fill dural defects. In 1924 Wilder Pen-field stated that neurosurgeons needed an absorbable membrane that disappears after 30 days. In 1956 dense connective tissue grafts were introduced in neurosurgery. Among them were allogenic ones like fascia lata and dura mater and xenogenic ones like bovine dura mater. Two years later, Sharkey et al. and Campbell et al. reported on the use of cadaveric human dura mater. This substance has not only been used in neurosurgery but also in urology and maxillofacial surgery. Since cadaveric human dura mater rarely causes immune-mediated inflammatory reactions or other complications, it was long seen as an ideal dural substitute. The most famous and most dangerous but very rare complication is the transmission of Creutzfeldt–Jakob disease. In 1967 Lee et al. reported on the use of silicon-coated Dacron as a dural substitute. The material is inexpensive; it causes minimal tissue reaction and carries no risk of transmissible disease. But despite its advantages, silastic dural graft has turned out not to be the ideal dural substitute due to its various complications. In 1979 Vicryl mesh was developed and one year later it became available on an experimental basis. Five years later, Maurer and McDonald investigated the effectiveness of Vicryl meshes and came to the conclusion that they had the potential for an ideal dural substitute. However, what they criticized was that watertight dural closure could not be achieved in all cases. In 1983 xenogenic bovine pericardium came on the market. It was used by neurosurgeons, ophthalmologists, abdominal surgeons, and otorhinolaryngologists. Eight years later, a thinner, more pliable and flexible material, xenogenic ovine pericardium, was developed.

Biosynthetic cellulose has also been used as a dural substitute after good results were achieved with this substance as a dermal substitute in burn victims, as dermal protection in varicose leg wounds, and as a hemostatic agent in experimental liver surgery. Only transient and mild postoperative symptoms have been observed. As autopsies have shown, the graft was accepted well and fibrosis, which caused adherence to the scull but not to the cortex, occurred only rarely. Another possibility for dural closure is a cellular human dermis which was first used in 1995. Here also very good results were achieved and no adhesion formation was reported.

A very promising substance is collagen sponge. It is absorbable and since it needs to be highly purified, not pyrogenic, and without telopeptides it does not induce a host inflammatory response. Due to its structure it can absorb fluid without increasing its volume. From animal trials and from clinical case reports we know that it reduces postoperative adhesion. In contrast to other substances it does not cause cortical scarring and is resistant to secondary infection. Furthermore, the collagen sponge has a hemostatic effect. A huge advantage is the standardized production, its easy handling, and its ability to adapt to the shape of the dural defect. In contrast to most dural substitutes, it does not need to be sutured. A big improvement was achieved, as studies have shown no cerebrospinal fluid (CSF) leakage in patients undergoing neurosurgical procedures where collagen sponges have been applied together with fibrin glue.

Although many substances have been tested, none of them was ideal for stopping bleeding and achieving liquid-tight and airtight defect sealing.

Therefore, one can say that the development of the ready-to-use fixed combination of collagen carrier and clotting factors in dried form (TachoComb) at the beginning of the 1990 s was an enormous step forward.

The General Use of Fibrin Glues and Collagen Sponge

Fibrinogen-based adhesives and collagen sponges are widely used in various surgical disciplines in many situations. Both substances can be applied alone, but often a combination has proved to be useful. If fibrin glue is used alone different application forms are possible.

– Firstly, it can be applied with an application needle or with an application catheter. However, a concomitant problem is that of early clot formation, resulting in obstruction of the needle or catheter.

– Secondly, the fibrin glue can be applied as a spray. Here the strength of the glue seems to be reduced, probably caused by the preliminary activation of fibrinogen and thrombin to smallest fibrin clots during application, as well as in the mixing chamber of the applicator or during the spraying phase itself.

– In the case of the first two methods, the components of the glue are applied simultaneously leaving open the option of sequential application, where each area that should be glued is covered with one component of the glue.

– Finally, both coated surfaces are brought together. However, since it is almost impossible to achieve the exact equivalent amount of each component using this technique, the strength of the glue is reduced here also.

– Another possibility is the use of a collagen sponge on which the fibrin glue can be applied. But, as with the other methods, difficulties have been encountered in trying to find the right proportions of the components.

– Finally, a collagen sponge can also be used on its own.

Fibrin glues have proved to be helpful in various surgical disciplines. In abdominal surgery fibrin glue can be applied to protect leakages or it can be sprayed onto surfaces to achieve hemostasis without risk of abscess formation like, for example, on resected liver surfaces. If conventional methods are not sufficient, post–liver biopsy bleeding can be stopped by injecting fibrin sealant into or near to the biopsy site. In liver traumas, quick and efficient hemostasis is necessary to stabilize a patient. Fibrin glues have shown to be helpful for gentle, effective, and long-lasting hemostasis.

In pulmonary surgery, fibrin glues can be used together with conventional sutures to reduce the incidence of bronchopleural or pulmonary air leakage. Even though studies show an improvement in the patient's condition and a decrease...

Über Autor(innen)

Christian Matula