Techniques of splenic preservation using fibrin glue

Fibrin glue (FG) was used to achieve hemostasis of 16 splenic injuries in 14 patients. The etiologies of injury included five gunshot wounds, two stab wounds, four iatrogenic injuries, and five patients with blunt splenic trauma. The intraoperative blood loss averaged 1.8 +/- 2.4 (SD) liters and patients were transfused 3 +/- 2 units of blood perioperatively. The amount of FG required to achieve splenic hemostasis averaged 11 +/- 8 ml and varied directly with the grade of injury. One patient with a splenic hilar vascular injury (Grade V) underwent splenectomy following failure to achieve complete hemostasis despite the use of 25 ml of FG. All other splenic injuries were successfully managed using less than 25 ml of FG. Postoperative computerized tomographic (CT) scanning, performed in ten patients, was negative for rebleeding or abscess formation. The overall splenic salvage rate was 86%. FG was effective in achieving hemostasis of both superficial and deep splenic injuries. Its use as an adjunct in trauma surgery should result in increased splenic salvage rates compared with that obtained using conventional surgical techniques.     

Fibrin glue achieves hemostasis in patients with coagulation disorders

Fibrin glue (FG), made with highly concentrated human fibrinogen and clotting factors, was used to achieve parenchymal organ hemostasis in patients with disordered coagulation secondary to massive transfusion, chronic disease, and disseminated intravascular coagulation; it was effective in controlling liver hemorrhage in seven patients and in the performance of a splenorrhaphy in one other patient. The coagulation profile was grossly abnormal in all patients, and the mean +/- SD intraoperative blood loss was 5.1 +/- 4.2 L; patients received 14 +/- 10 U of blood perioperatively. The amount of FG required to achieve hemostasis varied directly with the extent of injury and intraoperative blood loss (r = .84), and all patients with a blood loss greater than 4 L required at least 25 mL of FG to stop bleeding. Two patients died postoperatively secondary to cardiac arrest and adult respiratory distress syndrome. Because FG does not depend on adequate platelet or clotting factor levels to be effective, it is especially useful in patients with parenchymal organ hemorrhage and disordered coagulation.     

Use of fibrin glue in hepatic trauma

We evaluated the efficacy and safety of fibrin glue (FG) made with highly concentrated human fibrinogen and clotting factors in achieving hemostasis of superficial and deep hepatic injuries. Experimentally produced hepatic injuries were produced in 12 adult mongrel dogs and hemostatically sealed with FG. Half of the dogs each received two penetrating hepatic injuries consisting of a large laceration and a deep stab wound through the liver; the remaining dogs underwent resection of a large segment of the left lobe of the liver. Hemostasis was achieved by applying FG into and over the bleeding wounds; hepatic arterial occlusion was not used. Complete hemostasis was achieved in all animals before skin closure. One dog from each group was re-explored and the liver specimens harvested for gross and microscopic examination at postoperative intervals of 12 hours, 24 hours, and 2, 3, 6, and 8 weeks. There were no cases of intra-abdominal infection, abscess formation, or bile fistulae. Histologic examination demonstrated a thickened capsule containing fibrous connective tissue and neovascular proliferation; there were no signs of local or systemic toxicity. One dog died on postoperative day 1 from rebleeding from the hepatic injury; all other dogs survived without complications. We conclude that FG provides effective hemostasis of superficial and deep hepatic injuries, and has good systemic and local compatibility. Its use in surgery for hepatic trauma may lead to less intraoperative blood loss and transfusion requirements, as well as a reduced need for major hepatic resection to control hemorrhage.     

The management of civilian ureteral gunshot wounds: a review of 8 patients

Ureteral injury is a rare consequence of abdominal gunshot wounds. We recently treated 8 patients with ureteral injuries. Failure to diagnose ureteral injury at presentation led to postoperative complications, necessitating additional operative procedures in 4 patients. However, in all 8 patients renal salvage was achieved.     

The use of indwelling ureteral stents in managing ureteral injuries due to external violence

Eighteen consecutive cases of ureteral injury due to external violence occurring over a 6-year period were reviewed. The diagnosis of ureteral injury was made either preoperatively on an intravenous urogram, or intraoperatively using indigo carmine. No patient had an isolated ureteral injury. Four patients with ureteral contusions were managed expectantly and needed no further therapy. Eleven patients with ureteral lacerations underwent spatulated, interrupted anastomoses of absorbable suture and placement of Silastic double-J ureteral catheters and had prompt resolution of urinary drainage and normal urograms post stent removal. Two initially nonstented patients with lacerations required delayed ureteral stent placement for massive retroperitoneal urine leakage while one patient did well with simple ureteroureterostomy without stenting. The only important complication from the use of ureteral stents was limited to a single patient, who failed to return for followup and developed a staghorn calculus on the stent. The use of Silastic double-J ureteral catheters resulted in little morbidity and allowed: relatively maintenance-free care; an extra measure of safety in multiply injured patients; and early hospital discharge.     

Laparoscopic ureterocalicostomy: development of a technique simplified by application of Nitinol clips and a wet monopolar electrosurgery device

PURPOSE: We developed a technique for laparoscopic ureterocalicostomy with the use of intracorporeal suturing and subsequently simplified the technique by application of experimental Nitinol clips. MATERIALS AND METHODS: We performed laparoscopic ureterocalicostomy on 16 domestic swine divided into four groups of four animals each. The kidney was exposed laparoscopically, and the renal artery was atraumatically clamped. The lower pole of the kidney was amputated to expose a lower-pole calix, and hemostasis of the cut renal surface was obtained with a wet monopolar electrosurgical device (Floating Ball device [FB]; TissueLink, Dover, NH). Anastomosis of the ureter to the lower-pole calix was performed over a guidewire using 3-0 Vicryl suture in group 1 and Nitinol clips in group 3. A double-J ureteral stent was then deployed retrograde under fluoroscopic guidance. In addition, we evaluated the use of fibrin glue as a sealant over the sutured or clipped anastomotic site (groups 2 and 4, respectively). Ureteral stents were removed after 3 weeks, and the animals were evaluated and sacrificed after an additional 3 weeks. RESULTS: Laparoscopic ureterocalicostomy was completed in all 16 animals. In each case, excellent renal parenchymal hemostasis was obtained with the FB device, with a mean hemostasis time of 4.1 minutes. The mean anastomotic time with standard suture reconstruction was 37.1 +/- 5.4 minutes, while the anastomotic time with the Nitinol clips was 29.0 +/- 8.0 minutes (P = 0.0339). Retrograde pyelograms in groups 1 and 3 (no fibrin glue) showed a patent anastomosis with no hydronephrosis in three of the four animals in each group. One animal in group 1 and one animal in group 3 developed large urinomas secondary to anastomotic failure. The animals that received fibrin glue over the anastomotic site (groups 2 and 4) all showed narrowed anastomoses with severe hydronephrosis. CONCLUSIONS: With available instrumentation, laparoscopic ureterocalicostomy is technically feasible. Nitinol clip technology significantly reduces collecting-system reconstruction time. Application of fibrin glue as a urinary tract sealant resulted in an unexpected adverse outcome.     

Ureteral and renal pelvic injuries from external trauma: diagnosis and management

To define the optimal methods of diagnosis and repair of ureteral and renal pelvic injuries, we reviewed the records of 18 patients with 19 collecting system injuries (16 penetrating, three blunt). Hematuria was absent in five of 16 patients. Intravenous urography was diagnostic of ureteral injury in three and normal or nondiagnostic in eight. Retrograde pyelography was performed in only one patient and was diagnostic of bilateral ureteral injury. Treatment consisted of primary repair (minimal or no debridement and closure) in 11 injuries, ureteroureterostomy (debridement and reanastomosis) in six, ureteroneocystostomy in one, and transureteroureterostomy in one. Ureteral stents were placed in 12 injuries, nephrostomy catheter in one, and both in two. Four patients had no form of diversion. Followup was available for 14 patients; serum creatinine values were normal in each. Results of imaging studies in 13 were normal in 11; one showed mild caliectasis and one a resolving urinoma. Both intravenous urography and initial urinalysis may be unreliable indicators of ureteral and renal pelvic injury, and high suspicion mandates exploration. Usually the urinary tract can be satisfactorily reconstructed. Satisfactory urinary diversion can be achieved in most cases with an internal ureteral stent.     

Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale

PURPOSE: Ureteral injuries are uncommon and challenging. In this study we report our institutional experience with ureteral injuries. We evaluated the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for ureteral injuries as a predictor of outcomes for complexity of repair, morbidity, mortality and associated injuries. MATERIALS AND METHODS: We performed a retrospective, 120-month study (January 1992 to December 2002) at an urban, level I trauma center. RESULTS: In the 57 patients mean hospital Admission blood pressure +/- SD was 115 +/- 25 mm Hg, mean Revised Trauma Score was 7.38 +/- 0.84 and mean Injury Severity Score was 15 +/- 1.15. The mechanism of injury was penetrating in 55 cases (96.5%), including gunshot wound in 52 (54.5%) and stab wound in 2 (5.5%), and in blunt 2 of motor vehicle accidents (3.5%). The anatomical location was the left side in 33 cases (58%), right side in 23 (40%) and bilateral in 1 (2%). The distribution of injuries was proximal in 15 cases (26%), mid in 21 (37%) and distal in 21 (37%). Associated injuries were present in 56 patients (98%). An intraoperative diagnosis was made in 44 cases (77%). Of the patients 50 (88%) required complex repairs or an adjunct procedure, including a double pigtail stent in 33 (58%), ureteroureterostomy in 20 (35%), ureteroneocystostomy with a psoas hitch in 10 (18%), external diversion in 9 (16%), suprapubic cystostomy in 8 (14%), nephrostomy in 2 (3.5%), nephrectomy in 2 (3.5%) and ligation in 2 (3.5%). Injury grade was I to V in 5 (8%), 8 (13%), 13 (22.8%), 18 (31.6%) and 13 (22.8%) cases, respectively. Overall 51 patients (89%) survived. No deaths were related to ureteral injury. Renal salvage was achieved in 49 of the 51 surviving patients (96%). CONCLUSIONS: Ureteral injuries are uncommon. The complexity of repair and number of associated injuries increase with AAST-OIS injury grade. Mortality increases with AAST-OIS injury grade but it is not related to the ureteral injury. Excellent results can be achieved with complex techniques of primary repair, leading to renal salvage.     

Fibrin glue sealing of polytetrafluoroethylene vascular graft anastomoses: comparison with oxidized cellulose

To evaluate potential clinical applications of nonautologous fibrin glue (FG) as a hemostatic agent in vascular surgery, we compared its efficacy to oxidized regenerated cellulose (OC) in hemostatically sealing polytetrafluoroethylene (PTFE) vascular graft anastomoses. PTFE grafts (4 mm wide and 4 to 6 cm in length) were placed to each femoral artery in a heparinized canine model, in end-to-end fashion in half of the dogs and in end-to-side fashion in the remaining dogs. Each set of graft-arterial anastomoses was then sealed with either FG or OC, determined randomly, followed by simultaneous measurement of blood loss through the graft anastomoses and needle holes. There was significantly less bleeding from anastomoses sealed with FG compared with those sealed with OC, regardless of whether the anastomoses sealed with FG compared with those sealed with OC, regardless of whether the anastomosis was constructed in end-to-end (p less than 0.03) or end-to-side (p less than 0.004) fashion; overall, the operative blood loss for grafts sealed with FG was 14 +/- 6 (mean +/- standard error of the mean) vs 99 +/- 27 ml/min for those sealed with OC (p less than 0.001). In the early postoperative period, significant groin hematomas occurred more frequently in grafts sealed with OC compared with those sealed with FG. Microscopic examination of graft-arterial specimens harvested at postoperative intervals ranging from 1 day to 3 months revealed no significant inflammatory reaction with either hemostatic agent; after 2 to 3 weeks, paired specimens appeared histologically similar despite previous treatment with either FG or OC.(ABSTRACT TRUNCATED AT 250 WORDS)     

Changing times and the treatment of liver injury

We hypothesized that the frequency, diagnosis and treatment of liver injury have changed dramatically in the past 30 years. Patients with liver injuries treated in an urban level I trauma center were analyzed for three separate time periods, namely, 1969-1970, 1981-1982, and 1997-1998. The injuries were categorized by etiology; Abbreviated Injury Score severity, and type of treatment, including observation (Ob), laparotomy without treatment of liver injury (OR No Rx), suture repair (Sut), tractotomy with intraperipheral hemostasis (Tr), dearterialization (HAL), and resection (Re) (See Table, below). There were 249 patients in 1969-1970, 70, 79 in 1981-1982, and 116 in 1997-1998. Stab wounds and gunshot wounds decreased from 235 patients in 1969-1970 to 61 patients in 1997-1998. Blunt injuries increased from 14 patients in 1969-1970 to 55 patients in 1997-1998. Major injuries (Abbreviated Injury Score 4-5) fell from 104 to 25 to 20 during the decade. Laparotomy was done in all patients in 1969-1970 and 1981-1982, whereas most blunt injuries were observed in 1997-1998; only 9 of 65 blunt injuries in 1997-1998 required hemostasis. [table in text] We conclude the following: 1) Central urban depopulation reduces experience with liver trauma, 2) abdominal CT increases the diagnosis of liver injury, and 3) observation of stable patients with blunt liver injury is now the standard.     

High-intensity ultrasound treatment of blunt abdominal solid organ injury: an animal model

BACKGROUND: High-intensity focused ultrasound (HIFU) is effective in producing hemostasis in injuries from organ lacerations and punctures in animals but has not been evaluated in impact injuries. METHOD: High-energy blows were applied to 11 heparinized and anesthetized pigs, resulting in solid organ injury. HIFU was applied to injuries via laparotomy. The animals were closed, administered saline, observed under general anesthesia for 3.6 +/- 0.4 hours, reopened, and inspected, and abdominal free fluid was aspirated. RESULTS: Organ hemostasis was achieved (mean +/- SD) with 15 +/- 6 minutes of HIFU treatment and 54 +/- 3 minutes of operating time, and 18.8 +/- 13.1 mL/kg of blood was recovered from the abdomen. One animal died from an untreated occult injury to a large vein. HIFU-treated sites were hemostatic at relaparotomy, with 8.6 +/- 6.2 mL/kg abdominal serosanguinous fluid recovered. CONCLUSION: HIFU is effective in producing hemostasis by direct treatment of injured parenchyma in blunt trauma.     

Splenic salvage using biologic glue

Fibrin sealant (FS) is a biologic adhesive containing highly concentrated human fibrinogen that is effective in the face-to-face sealing of tissues, and in establishing hemostasis. We evaluated FS in 32 experimentally produced splenic injuries in six adult mongrel dogs. Complete hemostasis was achieved in all animals prior to closure. The dogs were reexplored postoperatively at intervals varying from four hours to six weeks (mean +/- SD, 21 +/- 20 days). When the dogs were killed, there was no gross evidence of splenic disruption or recurrent bleeding; all of the spleens had developed well-healed capsules. Histologic examination demonstrated a regenerated fibrous capsule extending over the superficial injuries as well as into the deep injuries, without significant inflammatory response. We conclude the following: that FS provides adequate hemostatic control of superficial and deep splenic injuries, FS has good systemic and local compatibility, it can be applied to bleeding parenchymal wounds, it reduces the need for parenchymal sutures that may be traumatic, and it promotes splenic wound healing.     

Renal reconstruction after injury

During an 11-year period 1,363 patients presented to our institution with renal trauma. Renal exploration was performed in 127 patients (133 renal units). Most patients had multiple organ injuries, as indicated by a mean blood loss of 4,160 ml. and a mean injury severity score of 25.8. Absolute indications for exploration were bleeding and pulsatile perirenal hematoma and relative indications included urinary extravasation, nonviable renal tissue and incomplete staging. Renal surgery was required in 2.4% of the blunt injuries, 45% of the stab wounds and 76% of the gunshot wounds. Salvage was successful in 88.7% of the kidneys explored and total nephrectomy was required in 11.3%. The success rate was based on early vascular control and reconstructive techniques of "renorrhaphy," partial nephrectomy, vascular repair and coverage with omental pedicle flaps. Complications occurred in 9.9% of the cases but none resulted in renal loss. When indicated, renal exploration after trauma is safe and in a high percentage of cases reconstruction will be successful.     

Genius,Creativity, and Leadership

Research in reduced suture fibrin glue (FG) and sutureless FG anastomosis has been lagging behind FG utilization in other surgical fields. A review of the literature for vascular, esophageal, tracheal, gastrointestinal, common bile duct, ureteral, vas deferens, and Fallopian tube FG anastomosis indicates that reduced suture FG and sutureless FG procedures may be performed with less training, reduced operating time, leakage, ischemia, inflammation, and necrosis compared to sutured techniques. Reduced suture FG vasular anastomosis augments early anastomotic strength. Suture number for esophageal, tracheal, and tracheobronchial anastomoses can be reduced with FG. Bursting strength in pig small intestine and rat colon was lower at 4 days postoperatively, but returned to sutured strength at 7 days. Mortality was unaffected, and 18-month follow-up in sutureless FG intestinal anastomosis in pigs showed no stenosis. Preliminary ureteral studies have demonstrated successful sutureless FG and reduced suture FG laparoscopic techniques in pigs. Reduced suture FG and sutureless FG vas deferens anastomosis may reduce sperm granuloma rates, with increased patency and pregnancy rates. Patency and pregnancy rates have been similar for tubal FG, reduced suture FG, autologous fibrin glue (AFG), and sutured anastomosis. Any risk of viral transmission or immune response is eliminated by AFG. While there are few studies in many areas of FG hollow vessel anastomosis, the current literature illustrates many of the advantages of FG over other anastomotic techniques and should provide impetus for continued research in this promising field of surgery.     

Sutureless and reduced suture anastomosis of hollow vessels with fibrin glue: a review.

Research in reduced suture fibrin glue (FG) and sutureless FG anastomosis has been lagging behind FG utilization in other surgical fields. A review of the literature for vascular, esophageal, tracheal, gastrointestinal, common bile duct, ureteral, vas deferens, and Fallopian tube FG anastomosis indicates that reduced suture FG and sutureless FG procedures may be performed with less training, reduced operating time, leakage, ischemia, inflammation, and necrosis compared to sutured techniques. Reduced suture FG vascular anastomosis augments early anastomotic strength. Suture number for esophageal, tracheal, and tracheobronchial anastomoses can be reduced with FG. Bursting strength in pig small intestine and rat colon was lower at 4 days postoperatively, but returned to sutured strength at 7 days. Mortality was unaffected, and 18-month follow-up in sutureless FG intestinal anastomosis in pigs showed no stenosis. Preliminary ureteral studies have demonstrated successful sutureless FG and reduced suture FG laparoscopic techniques in pigs. Reduced suture FG and sutureless FG vas deferens anastomosis may reduce sperm granuloma rates, with increased patency and pregnancy rates. Patency and pregnancy rates have been similar for tubal FG, reduced suture FG, autologous fibrin glue (AFG), and sutured anastomosis. Any risk of viral transmission or immune response is eliminated by AFG. While there are few studies in many areas of FG hollow vessel anastomosis, the current literature illustrates many of the advantages of FG over other anastomotic techniques and should provide impetus for continued research in this promising field of surgery.     

医原性输尿管膀胱损伤诊治分析

目的 探讨医原性输尿管膀胱损伤发生原因及防治方法.方法 医原性输尿管膀胱损伤患者47例,男7例,女40例.其中妇产科手术损伤38例、泌尿外科5例、普外科4例. 结果 术中发现输尿管损伤16例,其中断裂14例,输尿管壁部分撕裂伤2例;行输尿管断端吻合术13例,肾盂输尿管吻合术1例,1例输尿管镜手术引起输尿管穿孔者予终止手术并留置双J管,1例被迫切除肾脏;术后3～7 d发现输尿管损伤7例,其中输尿管下段被结扎4例.输尿管阴道瘘3例,均于术后2周内行输尿管下段膀胱再植术.术中发现膀胱损伤19例,膀胱壁不规则撕裂长约1～3 cm;行膀胱修补术17例,由腔镜和TVT手术引起膀胱穿孔2例予留置导尿1周;术后1周～1个月发现膀胱阴道瘘5例,均于3个月后行瘘管切除修补术.术后47例随访5个月～11年,平均47个月,患者均治愈,无并发症. 结论 医原性损伤重在预防,术中及时发现、正确处理可避免二次手术;术后出现尿瘘者选择合理治疗方案可提高治愈率.     

三聚氰胺致婴幼儿急性肾功能衰竭临床特征及治疗(附2例报告并文献复习)

目的 探讨三聚氰胺致婴幼儿泌尿系结石急性肾衰的临床特点及其治疗.方法 报告本院收治128例问题奶粉泌尿系结石患儿中2例三聚氰胺致泌尿系结石急性肾功能衰竭患儿的临床资料并复习有关文献.本例以无尿、食欲减退、恶心、呕吐等症状就诊,其中1例行Cr引导微通道经皮肾造瘘(MPCN)治疗.1例经利尿、水化、碱化尿液治疗.结果 1例行CT引导微通道经皮肾造瘘治疗后恢复,无腹腔脏器的损伤,无血管的损伤.1例经利尿、水化、碱化尿液治疗后肾功能恢复.结论 CT能对拟行 mini-PCN术的病例作出准确判断,特别是婴幼儿,术中CT引导可提高穿刺成功率,并有效的避免血管及脏器的损伤,微创出血少,术后可正确评估手术疗效,CT引导mini-PCN术治疗婴幼儿急性肾功能衰竭(梗阻型)安全可行.     

三聚氰胺致婴幼儿急性肾功能衰竭临床特征及治疗(附2例报告并文献复习)

目的 探讨三聚氰胺致婴幼儿泌尿系结石急性肾衰的临床特点及其治疗.方法 报告本院收治128例问题奶粉泌尿系结石患儿中2例三聚氰胺致泌尿系结石急性肾功能衰竭患儿的临床资料并复习有关文献.本例以无尿、食欲减退、恶心、呕吐等症状就诊,其中1例行Cr引导微通道经皮肾造瘘(MPCN)治疗.1例经利尿、水化、碱化尿液治疗.结果 1例行CT引导微通道经皮肾造瘘治疗后恢复,无腹腔脏器的损伤,无血管的损伤.1例经利尿、水化、碱化尿液治疗后肾功能恢复.结论 CT能对拟行 mini-PCN术的病例作出准确判断,特别是婴幼儿,术中CT引导可提高穿刺成功率,并有效的避免血管及脏器的损伤,微创出血少,术后可正确评估手术疗效,CT引导mini-PCN术治疗婴幼儿急性肾功能衰竭(梗阻型)安全可行.     

复杂性肾结石开放手术的并发症及其对策

目的总结开放手术治疗复杂性肾结石的并发症与防治经验。方法对行开放手术治疗的156例复杂性肾结石患者的手术并发症进行分析。结果156例中,结石一次取净144例,残留结石12例。术中出血7例,术后继发出血4例,尿路感染8例,漏尿5例,尿瘘1例,肾盂肾盏颈狭窄闭锁2例,肾功能恶化2例。85例术后随诊3~6个月,彩超探查肾局部缺血萎缩3例,出现肾血管性高血压1例。结论根据具体情况选用不同的取石路径与方法,术中细致操作,妥善止血,输尿管内置双J管,必要时以T型管或Foley导尿管作肾造瘘以通畅引流,以及围手术期积极控制尿路感染等,可以降低手术并发症的发生率。     

Fibrin glue protection of primary anastomosis in the obstructed left colon. An experimental study on the rat

A left-sided colon obstruction was produced with a polypropylene sling in 65 rats. Colon resection and primary anastomosis were performed three days later. The animals were then randomly allocated to the FG (fibrin glue) group receiving sealing of the anastomosis with 0.4 ml of fibrin glue (Beriplast R), or to the NG (non-glue) group. The anastomoses were assessed 30 min, two days and four days later. Adhesion formation was similar in both groups. The number of macroscopic or radiological leakages did not differ either. At 30 min the mean bursting pressure was 74.6 +/- 8.6 (SD) mmHg in the FG group and 58.3 +/- 21.6 mmHg in NG (non-glue) group (p less than 0.05, Mann-Whitney test). Later on the strength of the anastomoses was equal in both groups. We conclude that the initial sealing of weak points in the anastomoses was beneficial but the inherent strength per se could not be enhanced.