Fibrinkleber und Serombildung nach Abdominoplastik

BACKGROUND: Seroma formation is one of the most frequent complications following abdominoplasty. The effect of intraoperative fibrin sealant on the formation of seroma was investigated in patients who had an abdominoplasty. The relevance of slow vs accelerated fibrin polymerization was determined. MATERIAL AND METHODS: Two different thrombin concentrations (4 IE vs 500 IE thrombin/ml) of fibrin sealant were used in two groups of 20 patients each. The control group consisted of 20 patients with abdominoplasties without fibrin glue adhesion. RESULTS: The group with slow-reacting fibrin sealant (4 IE) had a significantly lower rate of seroma formation than both the high concentration fibrin group and controls (P<0.032 and P<0.018, respectively). In addition, the amount of postoperative drainage was significantly lower in the low-dose group (P<0.000). Patients with seroma had a significantly higher weight of resected tissue (P<0.04). The amount of postoperative drainage, age, and body/mass index had no significant effect on the prevalence of complications. CONCLUSION: The use of slow reacting, low-dose fibrin glue demonstrated a protective effect against the formation of seroma following abdominoplasty. The amount of postoperative drainage was significantly lower.     

Omental packing for the transected surface remnant liver after major hepatectomy

To avoid intraabdominal abscess and biliary fistula, which may lengthen hospital stay or result in lethal complications after major hepatic resection, it is important to control postoperative bleeding and bile leakage. We employed a technique for preventing postoperative bleeding and bile leakage, using omental packing with fibrin glue for the transected surface of the remnant liver after hepatic resection. This procedure was employed in 50 patients who underwent major hepatic resection. There was no postoperative bleeding or biliary fistula, and drain tubes were removed within 5 days in all patients. Omental packing with fibrin glue could be a very useful procedure of preventing postoperative biliary fistula, bleeding, and abscess after major hepatic resection.     

Biliary complications during liver resection

Biliary complications after hepatectomy may lead to sepsis, liver failure, and death. Measures to detect biliary injury after liver transection may reduce such morbidity. The aim of this study was to investigate the trend of biliary complications after hepatectomy during the last 10 years and assess the efficacy of intraoperative measures (methylene blue test, cholangiography, fibrin glue application) for reducing postoperative biliary complications. This is a retrospective study of 616 consecutive patients who underwent hepatectomy in our institution from January 1989 to September 1998. The study period was divided into the first 5 years and the second 5 years for comparison. The hospital mortality rate was 6%. It was significantly reduced during the second 5-year period (3.3% vs. 10.6%; p= 0.0002). The postoperative biliary leakage rate was 5.5% and was also reduced during the second 5-year period (3.5% vs. 9.8%; p= 0.004). Postresection methylene blue tests were performed more frequently during the second 5-year period than the first (63% vs. 28%; p= 0.0001). The postoperative biliary leakage rate was reduced by the methylene blue test (3.6% vs. 7.3%; p < 0.05) but not by application of fibrin glue (7.2% vs. 4.2%) or postresection cholangiography. However, among the 60 patients with a positive methylene blue test, postoperative biliary leakage still occurred in 10% of them after the leakage sites were sutured. In conclusion, the biliary complication rate is decreasing. Only the postresection methylene blue test, but not postresection cholangiography or application of fibrin glue, helps to reduce the postoperative biliary leakage rate.     

Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? results of a prospective randomized trial

Despite substantial improvements in perioperative mortality, complications, and specifically the development of a pancreatic fistula, remain a common occurrence after pancreaticoduodenectomy. It was the objective of this study to evaluate the role of fibrin glue sealant as an adjunct to decrease the rate of pancreatic fistula after pancreaticoduodenectomy. One hundred twenty-five patients were randomized after pancreaticoduodenal resection only if, in the opinion of the surgeon, the pancreaticojejunal anastomosis was at high risk for development of a pancreatic anastomotic leak. After completion of the pancreaticojejunal anastomosis, the patients were randomized to topical application of fibrin glue sealant to the surface of the anastomosis or no such application. The primary postoperative end points in this study were pancreatic fistula, total complications, death, and length of hospital stay. A total of 59 patients were randomized to the fibrin glue arm, whereas 66 patients were randomized to the control arm and did not receive fibrin glue application. The pancreatic fistula rate in the fibrin glue arm of the study was 26% vs. 30% in the control group (p = not significant [NS]). The mean length of postoperative stay for all patients randomized was similar (fibrin glue = 12.2 days, control = 13.6 days) and the mean length of stay for patients in whom pancreatic fistula developed was also not different (fibrin glue = 18.9 days, control = 21.7 days). There were no differences with respect to total complications or specific complications such as postoperative bleeding, infection, or delayed gastric emptying. These data demonstrate that the topical application of fibrin glue sealant to the surface of the pancreatic anastomosis in this patient population undergoing high-risk pancreaticojejunal anastomosis did not reduce the incidence of pancreatic fistula or total complications after pancreaticodudodenectomy. There seems to be no benefit regarding the use of this substance in this setting. Presented at the Forty-Fifth Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation). This work was supported in part by the Haemacure Company and Baxter Health Care.     

Platelet gel and fibrin sealant reduce allogeneic blood transfusions in total knee arthroplasty

BACKGROUND: Total knee arthroplasty (TKA) is often associated with a considerable amount of post-operative blood loss, necessitating the transfusion of allogeneic blood, which can add to the complications. Optimization of strategies to reduce the need for blood transfusion is desired. This study was designed to evaluate the efficacy of autologous platelet gel and fibrin sealant in unilateral TKA. METHODS: Consecutive patients were operated on and assigned to the study and control groups. Study group patients (n = 85) were operated on according to our standard TKA protocol, with the application of autologous platelet gel and fibrin sealant on the wound tissues at the end of surgery. Eighty patients were operated on according to the same protocol, but without the use of platelet gel and fibrin sealant, and served as the control group. All blood transfusions, occurrence of wound leakage, wound healing disturbances and incidences of post-operative infections were recorded. RESULTS: Patients in the treatment group had a significantly higher post-operative haemoglobin level (11.3 vs. 8.9 g/dl, respectively) and a decreased need for allogeneic blood products (0.17 vs. 0.52 units, respectively) than those in the control group (P < 0.001). The incidences of wound leakage and wound healing disturbance were significantly less (P < 0.001) in patients managed with platelet gel and fibrin sealant. Four patients in the control group, who received blood products, developed wound infection. The hospital stay was decreased by 1.4 +/- 1.5 days for patients in the treatment group (P < 0.001). CONCLUSION: Peri-operatively applied platelet gel and fibrin sealant may reduce the incidence of allogeneic blood transfusions and complications associated with TKA.     

The effect of fibrin sealant combined with fibrinolysis inhibitor on reducing the amount of lymphatic leakage after axillary evacuation in breast cancer. A prospective randomized clinical trial.

BACKGROUND AND AIMS: One third of women undergoing mastectomy with axillary evacuation for primary breast cancer suffer from postoperative seromas leading to unnecessary costs and complications such as infections and new operations. Different methods to prevent seroma formation have been tried without permanent success. The aim of this prospective randomised study was to examine the effect of fibrin sealant with fibrinolysis inhibitor firstly on the reduction of the amount of lymphatic leakage after axillary evacuation and secondly on the reduction of days with drains and postoperative seroma punctures. METHODS: 40 patients with primary breast cancer were prospectively randomised to the treatment group (n = 19) getting fibrin glue combined with fibrinolysis inhibitor (aprotinin) sprayed into the axillary fossa and to the control group (n = 21). RESULTS: There were no differences in the incidence of postoperative seromas between the groups. However, the seromas were easier to treat if fibrin clue was used. Total quantity (mean+/-SD) of lymphorrhea and total number of aspirations (mean+/-SD) were almost twice as high in the patients of the control group compared to those having fibrin sealant. In the treatment group seromas resolved after one or occasionally after two aspirations in 71 % of patients, while in the control group 90 % of patients needed three or more aspirations. CONCLUSION: Potentially, fibrin sealant combined with fibrinolysis inhibitor might be used for the treatment of post- axillary evacuation lymphorrhea and seroma.     

Intraoperative Application of Fibrin Sealant does not Reduce the Duration of Closed Suction Drainage Following Radical Axillary Lymph Node Dissection in Melanoma Patients: A Prospective Randomized Trial in 58 Patients

BACKGROUND: Patients suffering from malignant melanoma often require radical lymph node dissection of the axillary nodal basin. The effects of intraoperative application of fibrin sealant following radical axillary lymph node dissection (RALND) on the incidence of postoperative lymphatic secretion are discussed. To study the effect of intraoperatively applied fibrin sealant following RALND a randomized patient-blinded trial was carried out. METHODS: Fifty-eight patients with axillary lymph node metastases of malignant melanoma underwent therapeutic RALND and were randomized into two groups: 29 patients received 2 cc of fibrin glue intraoperatively and 29 patients were only irrigated with 0.9% saline. The amount of drainage was recorded every 24 h. The main outcome criterion was the duration of drain placement in the wound. Minor criteria were the total amount of fluid and the length of hospital stay. Statistical analysis was performed using Spearman's log-rank correlation and paired t-test. RESULTS: There was no significant difference between the nonfibrin group 5 days (range = 3.6-5.7 days) and the fibrin group 5 days (range = 4.1-8.5 days) (p = 0.701). The total amount of fluid for the nonfibrin group (410 cc, range = 362-727 cc) and that for the fibrin group (503 cc, range = 369-1098 cc) (p = 0.605) and the length of postoperative hospital stay of 6 days (range = 5.4-7) vs. 7 days (range = 5.9-10.7), respectively, were not different between both groups (p = 0.387). CONCLUSION: Considering our study results, we cannot recommend the use of 2 cc of fibrin glue intraoperatively in the prevention of lymphatic secretion in patients undergoing RALND for metastatic melanoma.     

Does fibrin sealant reduce drain output and allow earlier removal of drainage catheters in women undergoing operation for breast cancer?

Serosanguinous drainage after mastectomy and axillary lymph node dissection has traditionally been treated with the temporary use of closed suction drainage catheters. Use of drainage catheters is associated with wound infection, discomfort, nerve injury, and impaired arm movement. Commercially produced fibrin sealant has been proposed to reduce postoperative serosanguinous collections. We hypothesized that the intraoperative application of low-dose (2-5 cm3) fibrin sealant would reduce serosanguinous drainage and allow earlier removal of closed suction drainage catheters after operation for breast cancer. Fifty-five women with known breast cancer underwent either total mastectomy, modified radical mastectomy, or isolated level I and II axillary lymph node dissection. Twenty-six patients were treated with fibrin sealant and 29 served as control subjects. The application of fibrin sealant resulted in a significant reduction in overall duration catheters were needed (7 vs 8.3 days; P = 0.05). More importantly fibrin sealant reduced the time until 24-hour drain output was less than 30 cm3 (4.9 vs 6.2 days). Additionally fibrin sealant application resulted in a 60 per cent reduction in overall drainage amount after total mastectomy and a 32 per cent reduction after modified radical mastectomy. The application of fibrin sealant after axillary lymph node dissection did not decrease overall drainage amount. In conclusion fibrin sealant reduces serosanguinous drainage after total mastectomy and modified radical mastectomy and may allow earlier removal of closed suction drainage catheters.     

经T管窦道生物蛋白胶植入协助治疗拔T管后胆漏

目的 研究经腹腔镜胆总管切开取石T管引流术（LCTD）后,拔除T管出现胆漏的处理办法;在临床常规方法的基础上,探讨生物蛋白胶封堵T管窦道漏口的可行性。方法 研究对象为LCTD术后,拔除T管出现胆漏的患者36例,按照随机分组原则分为2组。对照组18例,拔除T管出现胆漏后,行禁食水、胃肠减压、抑酸、抑酶、抗感染治疗,同时经胆道镜T管窦道尿管置入或经十二指肠镜鼻胆管引流;研究组18例,拔除T管出现胆漏后,除禁食水、胃肠减压、抑酸、抑酶、抗感染治疗、经胆道镜T管窦道尿管置入或经十二指肠镜鼻胆管引流外,经胆道镜从T管窦道置入生物蛋白胶堵漏,封闭窦道撕裂或未完全愈合处。统计、对比两组患者的病情恢复情况。结果 对照组单纯使用T管窦道尿管置入或鼻胆管引流,腹膜炎体征恢复慢,治疗时间长,费用高,其中2例患者行二次手术;研究组在使用T管窦道尿管置入或鼻胆管引流的基础上,加用生物蛋白胶封堵窦道漏口,腹膜炎体征恢复快,治疗时间短,费用低,无二次手术患者。两组比较,各指标差异有统计学意义（P＜0.05）。结论 对于拔除T管后出现胆漏的患者,除禁食水、胃肠减压、抑酸、抑酶、抗感染、再次T管窦道置入尿管引流或鼻胆管引流外,联合胆道镜植入生物蛋白胶堵漏治疗拔T管后胆漏,较单纯使用尿管引流或鼻胆管引流效果更好,恢复快,费用低,值得推广。     

Effect of routine fibrin glue use on the duration of air leaks after lobectomy

The effectiveness of fibrin glue as a sealant to reduce postoperative air leaks after pulmonary lobectomy was evaluated in 28 consecutive patients between November 1988 and May 1989. A fibrin glue spray was used in 14 patients, and 14 patients served as controls. Assignment of either group was made before thoracotomy. Nine male and 5 female patients with a mean age of 63.8 years were in the fibrin glue experimental group, and 8 male and 6 female patients with a mean age of 59 years, in the control group. An equal number of complete and incomplete fissures were in each group. All fissures were handled in the same way (stapled). Two milliliters of fibrin glue was applied through a double-syringe delivery system and sprayed on the staple line and any cut surface of the inflated lung just before thoracotomy closure. The fibrin glue-treated group had a mean air leak duration of 2.3 +/- 3.7 days, chest tube drains for 6 +/- 4.1 days, and a postoperative hospitalization of 9.8 +/- 3.1 days. The control group had a mean air leak duration of 3.3 +/- 3.3 days (p = 0.94), chest tube drains for 5.9 +/- 3.9 days (p = 0.95), and a postoperative hospitalization of 11.5 +/- 3.9 days (p = 0.21). We conclude that the routine use of a fixed quantity of fibrin glue is not effective in reducing the duration of air leaks, chest tube drainage, or hospitalization after uncomplicated pulmonary lobectomy.     

Use of fibrin sealant to reduce bloody drainage and hemoglobin loss after total knee arthroplasty: a brief note on a randomized prospective trial.

BACKGROUND: A phase-III trial that included fifty-three patients undergoing unilateral primary total knee arthroplasty with cement was conducted to investigate the hemostatic efficacy of fibrin sealant. METHODS: Following cementing of the joint, 10 mL of fibrin sealant was sprayed onto the wound before tourniquet deflation and wound closure. No placebo was used in the control group. All patients received drains. RESULTS: Within twelve hours after the surgery, the amount of bloody drainage was 184.5 +/- 28.9 mL (mean and standard error) in the fibrin-sealant group (information available for twenty-three patients) and 408.3 +/- 54.6 mL in the control group (information available for twenty-three patients) (p = 0.002, after adjustment for variance in the time that the drainage was measured). On the first postoperative day, the hemoglobin level had decreased by 20.1 +/- 2.1 g/L in the fibrin-sealant group (information available for twenty-two patients) and by 27.3 +/- 2.1 g/L in the control group (information available for twenty-four patients). After adjustment for baseline values, the decrease in the hemoglobin level was 28.9% less in the fibrin-sealant group than in the control group (p = 0.005, 95% confidence limits = 10.2, 43.7). There were no seroconversions in the fibrin-sealant group. CONCLUSION: These results suggest that fibrin sealant can safely reduce bloody drainage following total knee arthroplasty while maintaining higher hemoglobin levels.     

Incidence and management of bile leakage after hepatic resection for malignant hepatic tumors

BACKGROUND: Bile leakage is one of the frequent and disturbing complications of hepatic resection. STUDY DESIGN: Clinical records of the 363 patients who underwent hepatic resections without biliary reconstruction for hepatic cancers between January 1994 and June 2001 were reviewed. Postoperative bile leakage was defined as continuous drainage with a bilirubin concentration of 20 mg/dL or 1,500 mg/d lasting 2 days. Leakage that continued longer than 2 weeks or that required surgical intervention was defined as uncontrollable. Differences in incidence and frequency of uncontrollable leakage for the different types of hepatic resection, tumors, and underlying liver disease were investigated. Outcomes after treatment for uncontrollable bile leakage were also reviewed. RESULTS: Postoperative bile leakage occurred in 26 of 363 patients (7.2%). Although the incidence in patients with cholangiocellular carcinoma (3/9 [33%]) was higher (p = 0.03) than in patients with hepatocellular carcinoma, rates of occurrence were similar among the different types of hepatic resection and underlying liver disease. Eight of the 26 patients (31%) had uncontrollable leakage. Two patients required reoperation to control leakage; one of these developed hepatic failure and died 2 months after surgery. Four patients underwent endoscopic nasobiliary drainage 21 to 34 days after hepatectomy, and the leakage resolved within 3 to 21 days. Fibrin glue sealing was effective in two patients whose leaking bile ducts were not connected to the common bile duct. CONCLUSIONS: Although meticulous surgical technique can minimize the risk of postoperative bile leakage, some instances of leakage are unavoidable. Nonsurgical treatments, such as nasobiliary drainage or fibrin glue sealing, are preferable to reoperation.     

Clinical study of bioabsorbable PGA sheets for suture reinforcement and use as artificial pleura]

Bioabsorbable PGA non-woven fabric sheets were used to treat 103 patients who underwent pulmonary surgery in three hospitals, and their handleability, applicability, drainage time after surgery and subsequent side effects were studied. For suture reinforcement, these sheets showed satisfactory handleability, applicability and effectiveness for hemostasis and prevention of air leakage at the suture sites. Since this material has good compatibility with fibrin glue, use of these two materials in combination reduced both the operation time and postoperative drainage period. For small fistula and pleural defects, attachment of the sheets with fibrin glue to create an artificial pleura was sufficient for prevention air leakage without suturing. No side effects or complications were observed, and the postoperative courses of all 103 patients were uneventful. These findings suggest that PGA sheets are acceptable for suture reinforcement in the pulmonary surgery, and that when used with fibrin glue, can simplify surgery for emphysematous lung disease and shorten the period of postoperative air leakage.     

DOES FIBRIN SEALANT DECREASE IMMEDIATE URINARY LEAKAGE FOLLOWING RADICAL RETROPUBIC PROSTATECTOMY?

PURPOSE: We determined the effectiveness of fibrin sealant in decreasing postoperative urinary leakage following radical retropubic prostatectomy performed by 1 surgeon at Washington Hospital Center. MATERIALS AND METHODS: Between April and November 2003 our group treated 32 consecutive patients with prostate cancer with radical retropubic prostatectomy. The first 16 patients (control) underwent the Walsh described technique and the second group of 16 patients had an additional application of fibrin sealant around the urethro vesical anastomosis. Postoperative drain output was measured every 8 hours. The results of the 2 groups were compared. RESULTS: The Blake drain was removed after 4 nursing shifts (times 1 through 4) in 81% (13 of 16) of the control group and in 100% (16 of 16) of the fibrin sealant group. The fibrin sealant group had significantly less drainage output overall compared with the control group (p = 0.005). The drainage output from each group decreased with time at a significant rate independent of each other (p <0.001), and there was a larger difference (p = 0.04) in output between groups at times 1 and 2 compared with times 3 and 4. There was no relationship between the amount of urinary drainage and drain output. There was no immediate morbidity associated with the use of fibrin sealant. CONCLUSIONS: The application of fibrin sealant to the urethro vesical anastomosis during radical retropubic prostatectomy does decrease postoperative drain output. With earlier drain removal, patients would benefit from less discomfort and from skilled nursing requirements. In select patients early drain removal could accelerate discharge home.     

Usefulness of a New Gelatin Glue Sealant System for Dural Closure in a Rat Durotomy Model

Watertight dural closure is imperative after neurosurgical procedures, because inadequately treated leakage of cerebrospinal fluid (CSF) can have serious consequences. We used a rat durotomy model to test the usefulness of a new gelatin glue as a dural sealant in a rat model of transdural CSF leakage. All rats were randomly divided into one of the following three treatment groups: no application (control group: N = 18), application of fibrin glue (fibrin glue group: N = 18), and application of the new gelatin glue (new gelatin glue group: N = 18). The craniotomy side was re-opened, and CSF leakage was checked and recorded at 1, 7, and 28 days postoperatively. The new gelatin glue was adequate for stopping CSF leakage; no leakage was observed at postoperative days 1 or 7, and leakage was observed in only one rat at postoperative day 28. This result was statistically significant when compared to the control group (P = 0.002, P = 0.015, P = 0.015, respectively). The pathologic score of the new gelatin group was not different from that of the control or fibrin glue groups. We conclude that our new gelatin glue provides effective watertight closure 1, 7, and 28 days after operation in the rat durotomy model.     

Comparison of a new fibrin sealant with standard topical hemostatic agents

BACKGROUND: Bleeding following liver resection continues to be a significant morbidity of the procedure. Fibrin sealants represent an improvement over conventional topical hemostatic agents, because they contain components that actively form clot. However, most available agents contain nonhuman protein, which represents an immunologic risk. HYPOTHESIS: An investigational surgical fibrin sealant (Crosseal; American Red Cross, Washington, DC) composed of human clottable proteins and human thrombin is more effective than standard topical hemostatic agents in reducing the time required to achieve hemostasis after liver resection. DESIGN: Prospective, randomized, controlled trial. SETTING: Fifteen major referral centers in the United States and the United Kingdom. METHODS: After liver resection using standard surgical techniques, 121 patients seen between May 1999 and May 2000 were randomized to treatment with a 2-component fibrin sealant (n=58) or to standard topical hemostatic agents, used singly or in combination (n=63). Up to 10 mL of Crosseal was administered by a spray applicator, as recommended by the manufacturer, whereas agents used in the control group were applied according to their instructions for use. MAIN OUTCOME MEASURES: The primary outcome measured was time to hemostasis. Secondary outcomes measured included blood loss between application of the hemostatic agent and closure of the abdomen, duration of postoperative biliary drainage, and the occurrence of complications, defined a priori as reoperation for any reason, development of abdominal fluid collections, or bilious appearance of drained fluid for at least 1 day postoperatively. RESULTS: The mean time to hemostasis was 282 seconds with Crosseal, compared with 468 seconds with standard agents (2-sided; P =.06), for the 116 efficacy-evaluable patients. Hemostasis was achieved within 10 minutes in 53 patients (91.4%) treated with the study fibrin sealant and in 44 control patients (69.8%) (2-sided; P =.003). Intraoperative blood loss was similar in the 2 groups. In the Crosseal group, the percentage of patients developing postoperative complications was 17.2%, compared with 36.5% in the control group (2-sided; P =.02). CONCLUSIONS: Compared with the use of standard topical hemostatic agents, Crosseal fibrin sealant significantly reduced the time to achieve hemostasis following liver resection. Patients treated with the new fibrin sealant also experienced significantly fewer postoperative complications.     

腹腔镜在肝脏外伤中的诊断和治疗应用(附43例报告)

目的 探讨腹腔镜在肝脏外伤中的应用价值。方法 回顾分析我院自2005年1月~2011年1月的43例在腹腔镜下进行诊断和治疗肝外伤临床资料。结果 35例在腹腔镜下分别采用单纯腹腔引流、电凝辅以生物蛋白胶或明胶海绵填压及间断缝合,均止血成功。9例中转开腹。无术后死亡,并发胆瘘2例。出院后2~4周复查B超,无肝脓肿和腹腔脓肿。结论 应用腹腔镜下诊断和治疗肝外伤是可行和安全的。     

Therapeutic fistuloscopy: an alternative approach in the management of postoperative fistulas

BACKGROUND/AIM: Since the treatment of postoperative fistulas remains a difficult problem, we applied endoscopic treatment in such 14 persistent fistulas. METHODS: Fourteen patients presented with postoperative fistulas: 7 patients (low-output group) due to residual cavity after liver hydatid disease surgery and 7 patients (high-output group) after small-bowel resection (n = 3), diverted duodenostomy (n = 1), vertical gastroplasty (n = 1), external pancreatic cyst drainage (n = 1), and transduodenal sphincteroplasty (n = 1). The therapeutic procedures included mechanical removal of silk sutures, necrotic material, and hydatid membranes in the low-output group and fibrin sealing in the high-output group. RESULTS: Fistuloscopy was performed 170-278 days (mean +/- SD 198.7 +/- 36.7 days) and 18-51 days (mean +/- SD 34.0 +/- 11.3 days) postoperatively in low- and high-output fistula patients, respectively, when the average daily output was 20-50 (32.8 +/- 12.5) ml and 200-1,000 (563.1 +/- 319.4) ml, respectively. The low-output group needed only one fistuloscopy session, while the other group required a median number of three sessions plus fibrin sealing, the total amount of fibrin glue used per patient being 2-14 (6.5 +/- 4.4) ml. No procedure-related complication occurred. All fistulas except one healed within 10-33 (21.8 +/- 7.9) days and 2-17 (9.2 +/- 5.1) days in low- and high-output groups, respectively. CONCLUSIONS: We believe fistuloscopy to be a useful tool in the management of gastrointestinal fistulas, but more experience should be gained in using this technique.     

Control of aerostasis in pulmonary metastasectomy by precision resection. Standard technique versus fibrin glue modification

The control of aerostasis after performing non-anatomical pulmonary resections constitutes a serious problem. The presence of an air leak in the postoperative period requires a prolonged thoracic drainage and consequently a longer hospital stay. The aim of our study was to evaluate the usefulness of fibrin glue and its effectiveness in the prevention of air leaks. At the Department of Thoracic Surgery of the National Cancer Institute of Milan, we conducted a case-control study in 90 patients submitted to metastasectomy for secondary lung cancer, removing multiple small nodules < or = 1.5 cm using the precision resection technique. We divided the patients into two groups, both of 45 subjects: group 1 treated with fibrin glue and group 2 submitted to cauterization of the pulmonary parenchyma. The patient characteristics were well matched for age, type of approach and operation, number of resections performed and type of pathology. The assessment parameters investigated were the duration of the air leak, expected complications, drainage time and length of hospital stay. In group 1 we performed fewer than 5 precision resections in 21 cases, from 5 to 10 in 16, and more than 10 in 8. In group 2 we executed fewer than precision resections in 21 cases, from 5 to 10 in 17, and more than 10 in 7. In group 1 the duration of the air leak was 2.93 +/- 1.91 days as against 6.95 +/- 7.01 days in group 2 (p = 0.000). In group 1 we had one complication (2%) (a long-term air leak lasting > 10 days), while in group 2 we had a long-term air leak in 11 cases (24%) (p = 0.000). Mean thoracic drainage time was 4.22 +/- 1.43 days in group 1, and 8.13 +/- 7.37 in group 2 (p = 0.000). The mean postoperative hospital stay was 6.22 +/- 1.43 days in group 1 compared to 10.13 +/- 7.37 days in group 2 (p = 0.000). In the group of patients treated with fibrin glue we obtained a significant reduction in drainage time, complications and postoperative hospital stay. The results of our experience show that the use of fibrin glue in non-anatomical resections with a high risk of developing air leakage is effective in reducing the expected complications, with a favourable impact also on the quality of life of patients with metasases.     

Endoscopic management of pancreatic fistulas secondary to intraabdominal operation

Background: Pancreatic fistulas may arise secondary to several disorders of the pancreas. Although ~70% of pancreatic fistulas close with nonoperative management, this course of treatment usually takes several weeks or even months. To reduce this long period, closures with fibrin glue have been attempted in the past. In this study, we describe the course, management, and outcome of eight patients with postoperative external pancreatic fistulas of the pancreatic body and tail that arose after oncologic operations in the upper abdomen. Methods: All eight cases were treated by external drainage, insertion of an endoprosthesis into the pancreatic duct, and closure of the fistula with fibrin glue. Results: Immediately after this intervention, secretion from the fistulas was absent in all cases. None of the patients developed abscesses, recurrent fistulas, or complications associated with the fibrin glue. Conclusion: The early endoscopic management of postoperative pancreatic fistula with an approach combining internal drainage of the pancreatic duct and external occlusion of the fistula with fibrin glue is expeditious and beneficial.