Preparation of fibrin glue from single-donor fresh-frozen plasma

Fibrin glue is used widely in Europe as a tissue sealant and hemostatic agent. The European glue is prepared commercially from pooled human blood. It is not available in this country because of the risk of transmission of hepatitis B, acquired immune deficiency syndrome, and other blood-transmitted diseases. We describe a cryoprecipitation technique for preparation of fibrin glue from single-donor fresh-frozen plasma. This technique enables the glue to be made in large quantities with no greater risk of disease transmission than with that from the transfusion of single-unit fresh-frozen plasma. We have found that the glue is a useful tool in surgery. By helping to control difficult bleeding, its use can decrease the need for blood transfusions and shorten operating room time. It also is effective as a means to pretreat highly porous vascular prostheses that currently are used infrequently because of bleeding. These porous grafts offer potential advantages in handling, suturing, and long-term patency. This new technique of fibrin glue preparation may make this useful surgical adjunct as readily available in this country as it is in Europe.     

Hemostatic effectiveness of fibrin glue derived from single-donor fresh frozen plasma

Fibrin glue derived from pooled human blood is an effective sealant for high-porosity vascular grafts and a valuable topical hemostatic agent in heparinized patients. Use of this agent in the United States is prohibited because of potential transmission of hepatitis B, acquired immunodeficiency syndrome, and other serologically transmitted illnesses. We have developed a cryoprecipitation technique that allows preparation of fibrin glue from single-donor fresh frozen plasma. Use of this agent presumably entails no greater risk of disease transmission than intravenous administration of single-unit fresh frozen plasma. This report describes our early clinical experience with this material. Fibrin glue was used as a sealant for porous woven Dacron tubular prostheses and cardiovascular patches in 19 patients. The fibrin glue sealant has also been employed to control bleeding from needle holes and small anastomotic tears in 22 patients. No patient in this series had a bleeding complication from a suture line or graft treated with fibrin glue. This experience indicates that like fibrin glue from pooled blood, fibrin glue from single-donor plasma is effective as a graft sealant and topical hemostatic agent. Preparation of fibrin glue from single-donor plasma is simple and economical, and may provide cardiothoracic surgeons in the United States with a widely available, valuable hemostatic adjunct.     

Minimal suture blepharoplasty: Closure of incisions with autologous fibrin glue

Blepharoplasty incisions can be closed safely with autologous fibrin glue. The fibrinogen, prepared either from a whole-blood or plasmapheresis source, is mixed with commercially available thrombin to form a seal that is both hemostatic and adhesive. The complication rate is low and primarily due to technical factors in the initial cases. 'When compared with standard suture techniques, the incidence of minor problems such as milia formation was much lower. In select cases, the technique of using fibrin glue and a minimal number of sutures may be useful as an alternative method of would closure in blepharoplasty patients.Presented at the annual meeting of the American Society of Aesthetic Plastic Surgery, April 30, 1990, New York, NY, USA     

Frontal sinus repair with free autologous bone grafts and fibrin glue

BACKGROUND: The authors describe a technique for repairing the frontal sinus with autologous bone grafts removed during craniotomy and fibrin glue. METHODS: This technique was used in 12 patients who underwent craniotomy for aneurysms (n = 9), brain tumors (n = 2), and acute epidural hematoma (n = 1). RESULTS: The repair was successful in all cases. There were no instances of postoperative infection or leakage of cerebrospinal fluid. No complications from the repair have occurred over a mean follow-up of 51 months. CONCLUSION: This technique is simpler than others used to seal a frontal sinus.     

Use of autologous fibrin glue in the treatment of splenic trauma: an experimental study.

There is little doubt that preserving the spleen will contribute to a much more favourable outcome in patients undergoing splenic surgery, as a result of avoiding the well known risks of splenectomy. Among many operative methods described for splenic salvage, application of autologous fibrin glue (AFG) is particularly promising because of its unique characteristics. The use of AFG has been evaluated and its efficacy and tissue compatibility assessed in the treatment of splenic trauma in 15 partially splenectomized New Zealand White rabbits. The application of the AFG to the resected splenic surface achieved complete haemostasis in all animals. The animals were divided into four groups and were killed at varying intervals ranging from 24 h to 10 weeks. During re-exploration there was no evidence of recurrent bleeding and histopathological examination revealed progressive absorption of the AFG with a minimal inflammatory response. It is concluded that AFG is an effective haemostatic agent with good systemic and local compatibility and can be used in splenic salvage, which thereby avoids the use of non-autologous products with their risks of disease transmission.     

Autologous fibrin glue from intraoperatively collected platelet-rich plasma.

A simple and inexpensive means of creating autologous fibrin glue is described that avoids the potential disadvantages of conventionally obtained material. This improvement may allow more widespread use of fibrin glue for operative bleeding.     

The use of autologous fibrin glue for closing sinus membrane perforations during sinus lifts.

Sinus lift procedures depend greatly on fragile structures and anatomical variations. These procedures may cause sinus membrane perforations, which can lead to graft infection and early failure. The aim of this study was to assess the efficacy of autologous fibrin glue in the management of large perforations of the maxillary sinus membrane occurring during sinus lifts. After elevating the sinus membrane in the bilateral maxillary sinuses of 6 adult female mongrel dogs, a laceration (about 2.0 cm in length) was made in the membrane and either repaired with autologous fibrin glue or covered with a bioabsorbable collagen membrane as a control. Wounded areas were biopsied 2 weeks after the operation. Wounds repaired with autologous fibrin glue showed newly formed continuous epithelium across the previous perforation site. However, extensive fibrosis, inflammatory infiltration, and absent epithelium were observed in wounds treated with the collagen membrane control. Our results support the clinical use of autologous fibrin glue for repairing sinus membrane perforations.     

Sutures or fibrin glue for divided rat nerves: Schwann cell and muscle metabolism

Peripheral nerve anastomoses using either epiperineurial sutures or a fibrinogen adhesive technique have been compared in the rat sciatic nerve model. Evaluation of results was made using radiolabelling of the metabolically active acid-soluble phosphate fractions of both nerve and muscle. In none of the situations tested--traumatic degeneration and regeneration in the sciatic nerve proximal segment, Wallerian degeneration and regeneration in its distal segment, atrophy and regeneration of the fast gastrocnemius muscle, and atrophy and regeneration of the slow soleus muscle--was one repair method significantly superior to the other. A significant degree of cross-reinnervation was shown to take place after anastomosis, altering the characteristics of the regenerating muscles. Both repair methods were equally inferior to the spontaneous repair occurring after a simple nerve crush.     

Nerve anastomosis with glue: comparative histologic study of fibrin and cyanoacrylate glue

The authors report the results of a comparative experimental nerve study, using a biologic tissue glue (fibrin) and a synthetic glue (2-cyanoacrylate) in a rat model. A tension-free repair is necessary with the use of fibrin glue, or gapping may occur, thus limiting the use of the agent in promoting re-neurotization. In addition, the human origin of fibrin and thrombin allow for the possibility of viral transmission. The aim of the study was to verify if the synthetic glue is a viable alternative, or whether it causes cellular and tissue lesions. Their main finding was that the cyanoacrylate causes a foreign-body inflammatory reaction and retractile fibrosis, often reducing the nerve diameter up to two-thirds. Cyanoacrylate glue is thus not recommended for peripheral nerve repair.     

Fibrin glue from stored human plasma. An inexpensive and efficient method for local blood bank preparation

European surgeons have used fibrin glue extensively during thoracic, cardiovascular, and general surgical operations. Until now, however, it has been available only as a commercial preparation made from pooled human plasma, and it has not been approved by the U.S. Food and Drug Administration for use in the United States because of a high associated risk of hepatitis and acquired immune deficiency syndrome. Methods of obtaining fibrinogen, an essential component of fibrin glue, from cryoprecipitate or fresh frozen plasma have been published recently. However, the cryoprecipitate method results in relatively low concentrations of fibrinogen, which can reduce glue effectiveness. The fresh frozen plasma method is more expensive and does not meet the standards of the American Association of Blood Banks for the "closed" system required for safe handling and management of blood component products. Both the cryoprecipitate and the fresh frozen plasma methods result in waste of unstable clotting factors. These factors are necessary to replace human plasma clotting deficiencies but are not necessary for the production of fibrin glue. The authors have developed an efficient, high-concentration blood bank method for producing and maintaining a local supply of a safer and less expensive but equally effective material derived from stored human plasma. This material is produced using approved blood bank techniques for a "closed" system in blood component production, thus reducing the risks of contamination and infection, and its fibrinogen concentration is higher than that of standard cryoprecipitate. The cost of 1 unit of this fibrin glue is comparable to that for 1 unit of cryoprecipitate and less than that for 1 unit of fresh frozen plasma.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sellar floor reconstruction after transsphenoidal surgery using fibrin glue without grafting or implants: technical note

BACKGROUND: Different techniques have already been described for reconstructing the sellar floor after transsphenoidal (TS) procedures. This paper reports on the use of fibrin glue alone without grafting or the use of implants in the reconstruction of the sellar floor after TS. METHODS: Five hundred sixty-seven patients who submitted to TS for pituitary and sellar region tumors were studied. No intraoperative cerebrospinal fluid (CSF) leak occurred in 503 patients (group 1); in the remaining 64 patients (group 2), intraoperative CSF leak was noted. In group 1 patients, closure of the sellar floor consisted of packing the surgical bed with hemostatic material only. When CSF leak was noted, the surgical bed was covered with a layer of hemostatic material and the intrasellar space was filled up with fibrin glue. An additional layer of hemostatic material was added at the topography of the preexisting sellar floor, and a second amount of fibrin glue was applied over it. At the end of surgery, a continuous lumbar CSF drainage system was installed in group 2 patients and kept for 5 days. Prophylactic antibiotics were administered during this period. RESULTS: We did not observe delayed CSF leak, meningitis, or visual loss in group 1 patients. In group 2, 2 patients presented with complications: 1 patient got meningitis but no overt CSF leak, and the other disclosed a delayed postoperative leak treated by reoperation. DISCUSSION: Our results showed that closure of the sellar floor with hemostatic material and fibrin glue without grafting or the use of implants is a safe and efficient method to prevent postoperative complications after TS. Generally speaking, there is no need for grafting or the use of implants at the end of TS.     

Circumcision in hemophilia: the use of fibrin glue for local hemostasis.

Circumcision can be fatal in hemophilia patients unless they are treated with the missing coagulation factor. We describe 10 severe hemophilia patients in whom circumcision was performed with local fibrin glue instead of infusion of factor concentrate. Of the 10 patients 3 had postoperative bleeding and only 2 of them required infusion of factor VIII concentrate. Fibrin glue is a useful treatment modality for circumcision in patients with bleeding diathesis, and it is safer and cheaper than the infusion of factor concentrate.     

Mediastinal fibrin glue: hemostatic effect and tissue response in calves

There is continued controversy regarding the effectiveness and potential adverse effects of fibrin glue. Thus, we chose to evaluate it in a model of experimental calf aortic valve replacement that has been previously well established. Concentrated fibrinogen and topical thrombin were sprayed to form a thin layer of fibrin glue over the mediastinal tissues of 20 consecutive calves undergoing aortic valve replacement. Chest tube outputs of these animals were compared with those of the preceding 20 consecutive calves undergoing aortic valve replacement without fibrin glue. All procedures were performed by the same surgeon, and no other technical changes were made between the two series. Total postoperative chest tube output (mean +/- standard error) was 553 +/- 50 mL for the calves treated with fibrin glue and 1,155 +/- 103 mL for the control calves (p less than 0.001). On histological examination of mediastinal tissues from 5 treated calves killed 6 weeks after operation, there was no evidence of inflammation, fibrosis, or residual fibrin. To our knowledge, this is the first controlled laboratory study to show that fibrin glue spray is an effective hemostatic agent and that it produces no long-term tissue reaction.     

Inhibition of intra-abdominal adhesions: a comparison of hemaseel APR and cryoprecipitate fibrin glue.

Our previous studies demonstrated fibrin glue (FG) prepared from cryoprecipitate (cryo) inhibits intra-abdominal adhesions in rats. A new FG, Hemaseel APR, is Food and Drug Administration (FDA) approved for hemostasis during cardiac surgery and splenic trauma. This study was undertaken to determine if Hemaseel FG prevents intra-abdominal adhesions, and to compare it to cryo FG. Forty-five rats underwent laparotomy. Bilateral peritoneal-muscular defects were created. Polypropylene mesh was sewn into each defect with a running silk suture. The bowel was abraded with gauze. The rats were then randomized to mesh covered with Hemaseel FG, cryo FG, or control. On postoperative day 7, the severity of adhesions were graded by percentage of mesh covered by adhesion (0-100%) and degree of adhesion (0-3). The mean percentage of mesh covered by adhesion was 9% for Hemaseel FG, 43% for cryo FG (p = .005), and 65% for the controls (p < .0001). The mean density adhesion score was 0.5 for Hemaseel FG, 1.2 for cryo FG (p = .04), and 2.1 for the controls (p < .0001). In the Hemaseel FG group, 77% of patches had no adhesions, compared with 37% in the cryo FG group (p = .004) and 13% in the controls (p < .0001). Thus, Hemaseel FG significantly decreases intra-abdominal adhesions, and is more effective than cryo FG.     

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.     

Lymph leak from a femoral cutdown site in a neonate: repair with fibrin glue

A persistent lymphatic fluid leak from a femoral cutdown site in a neonate was successfully treated by a single application of fibrin glue. This technique resulted in rapid wound healing and is yet another use for this biologic adhesive.     

Preoperative autologous blood donation in primary total knee arthroplasty: critical review of current indications

Preoperative autologous blood donation (PABD) is a well established transfusion practice in elective orthopaedic surgery, involving immunologic and infective advantages but also involving exposure to not negligible risks, and costs as well. The aim of this study was to assess the real need for blood transfusions in primary total knee arthroplasty (TKA). Between January 2000 and July 2005, 214 patients underwent primary unilateral TKA. Altogether, 416 autologous blood units were collected, however only 47 (11.3%) were transfused. Thirty-eight patients (17.8%) received autologous blood, while 4 of them (10.5%) also received allogeneic blood. Based on the results of this study, PABD should be recommended in well selected patients undergoing TKA: older female patients with a low basal haemoglobin level.     

Microvascular anastomosis with minimal suture and fibrin glue: Experimental and clinical study

A comparative study was undertaken to evaluate a new microvascular anastomosis technique utilizing only four sutures placed 90 degrees apart and sealed with fibrin glue, in contrast to the conventional method of eight sutures as a control. The two methods were compared in regard to patency rates, time needed for vascular anastomosis, and microscopic evaluation. Postoperative patency rates were 100% and 85% with the fibrin glue technique compared with 100% and 90% with the conventional technique immediately postoperative and 2 weeks postoperative, respectively. Less time was consumed with the fibrin glue technique, which took 16 minutes, compared with the conventional technique, which took 21 minutes. Microscopically, re-endothelization was complete, with a smooth and less injured inner lining and also with less inflammatory response in the fibrin glue technique compared with the conventional technique. We applied this new technique to clinical cases of 17 digit replantations and one free flap. All cases survived completely except for one toe replantation case, which was severely crushed at the time of injury. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:306–311, 1998