A Prospective Analysis of the Effects of a Powder-Type Hemostatic Agent on the Short-Term Outcomes after Liver Resection.

Background and Objectives: Postoperative bleeding is a significant cause of morbidity and mortality following liver resection. Therefore, it is crucial to minimize bleeding during liver resection and effectively manage it when it occurs. Arista® AH (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) is a microporous polysaccharide hemosphere (MPH), a new plant-derived polysaccharide powder hemostat that can be applied to the entire surgical field. This study prospectively assessed the effectiveness of Arista for bleeding control when applied intraoperatively to the liver resection surface. Materials and Methods: Data were collected at Seoul National University Bundang Hospital for patients who underwent liver resection owing to malignant hepatocellular carcinoma or benign liver diseases. We compared the outcomes between 45 patients managed with Arista® AH (data were prospectively collected between September 2022 and May 2023) and 156 patients managed without the use of Arista® AH (data were retrospectively collected between January 2021 and December 2021). Results: There were no significant differences in patient characteristics between the two groups. The estimated blood loss (EBL) was significantly lower in the Arista® AH group compared with the control group (495.56 ± 672.7 mL vs. 691.9 ± 777.5 mL, p = 0.049). The mean postoperative hospital stay was significantly shorter in the Arista® AH group (5.93 ± 1.88 days vs. 6.94 ± 4.17 days, p = 0.024). The time to Jackson-Pratt drain removal was also significantly shorter in the Arista® AH group (4.64 ± 1.31 days vs. 5.30 ± 2.87 days, p = 0.030). The patient subgroup was divided into four categories based on the type of resection and the presence or absence of cirrhosis. Within the subgroup of major resections in non-cirrhotic patients, the Arista® AH group demonstrated significantly better outcomes compared to the control group, showed lower EBL, reduced need for blood transfusions, decreased volume of drain fluid collected within 48 h, earlier removal of drains, and shorter hospital stays. In contrast, for the other subgroups such as minor resection (both non-cirrhotic and cirrhotic) and major resection with cirrhosis, the differences between the Arista® AH and control groups in various parameters like EBL, blood transfusion rates, drain fluid volume, time to drain removal, and duration of hospital stay were not statistically significant. Conclusions: Arista® AH significantly improved intraoperative blood management and postoperative recovery in patients undergoing liver resection, particularly in non-cirrhotic patients who underwent major resection.

Chitosan-Based Biomaterials for Hemostatic Applications: A Review of Recent Advances.

Hemorrhage is a detrimental event present in traumatic injury, surgery, and disorders of bleeding that can become life-threatening if not properly managed. Moreover, uncontrolled bleeding can complicate surgical interventions, altering the outcome of surgical procedures. Therefore, to reduce the risk of complications and decrease the risk of morbidity and mortality associated with hemorrhage, it is necessary to use an effective hemostatic agent that ensures the immediate control of bleeding. In recent years, there have been increasingly rapid advances in developing a novel generation of biomaterials with hemostatic properties. Nowadays, a wide array of topical hemostatic agents is available, including chitosan-based biomaterials that have shown outstanding properties such as antibacterial, antifungal, hemostatic, and analgesic activity in addition to their biocompatibility, biodegradability, and wound-healing effects. This review provides an analysis of chitosan-based hemostatic biomaterials and discusses the progress made in their performance, mechanism of action, efficacy, cost, and safety in recent years.

Effect of hyperthermic chemotherapy on topical hemostatic agents.

PURPOSE: There is no clear consensus as to which topical hemostatic agent is best used during cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy. The aim of this study was to evaluate the effect of hyperthermic chemotherapy on the biomechanical properties of organic topical hemostatic agents and histologically fibrin formation rates. METHODS: Four topical hemostatic agents (Spongostan™, Surgicel®, Fibrillar™, Arista®) were evaluated. All agents were mixed with 3 ml blood in sterile tubes separately to form clot formation. The resulting clot formations were incubated with 36 °C and 42 °C with saline or cisplatin for 1 h. Strength and flexibility of hemostatic samples were evaluated under weight of 0 g, 50 g, 100 g, 200 g and 300 g. All samples were stained with hemotoxylin-eosin and compared histologically for fibrin clot formation under light microscope. RESULTS: There were no statistically significant differences according to strength and flexibility of topical hemostatic agents on hyperthermic chemotherapy. Histopathologically, the highest fibrin formation was observed in Surgicel®, followed by Fibrillar™. The least fibrin formation was detected in Arista®. CONCLUSIONS: This study demonstrated that exposure to hyperthermic chemotherapy did not significantly affect the biomechanical properties of organic topical hemostatic agents and the fibrin clot formation.

Severe haematoperitoneum caused by ovarian bleeding after transvaginal oocyte retrieval: a retrospective analysis and systematic literature review.

A case series of haematoperitoneum caused by ovarian bleeding after transvaginal oocyte retrieval (TVOR) is presented and all published cases summarized. In a retrospective case series, four patients with ovarian bleeding after TVOR were included. In addition, a pooled analysis of all published cases (n = 32) who underwent surgical intervention for severe haematoperitoneum caused by ovarian bleeding after TVOR was carried out. Main outcome measures were incidence, risk factors, course and intraoperative findings. In the pooled analysis, the incidence was 0.08%. The first sign of haematoperitoneum was evident in 33.3% within the first postoperative hour, and, cumulatively, in 93.3% within 24 h. The median time between TVOR and surgical intervention was 10 h. In four patients, the ovary could not be preserved, which was associated with a longer time interval between TVOR and the onset of symptoms (median 18 h versus 2.5 h; P = 0.004) as well as between TVOR and surgical intervention (median 21.5 h versus 8.5 h; 0.004). In conclusion, severe haematoperitoneum occurs in 0.08% after TVOR. Late-onset bleeding is common. A longer time interval between TVOR and surgical intervention might put a patient at risk of ovariectomy.

Topical hemostatic agents in spinal surgery.

Spinal surgery can be associated with significant intraoperative blood loss which may lead to various complications. As the number of patients undergoing spinal surgery increases over time, accurate and effective hemostasis becomes critically important. Despite various surgical hemostatic techniques, conventional interventions such as compression, suture, ligation, and heat-generating cautery, are not suitable for osseous and epidural venous plexus bleeding during spinal procedures. Therefore, a variety of hemostatic agents have been developed to promote hemostasis. As they differ in terms of mechanism, form, application and potential adverse reactions, it is important to understand the natural features of existing agents. Here we comprehensively review currently available topical hemostatic agents from different sources and summarize their mechanisms of action, applications, and current or potential utilization in spinal surgery. We found hemostatic agents from different sources exert hemostatic actions through different mechanisms. In addition, topical hemostatic agents play various roles in spinal surgery including as hemostatic agent, dura mater repair, drug-carrier, skin closure, and fibrosis prevention. Compressive neurological complications are the most common complications of these hemostatic agents. Therefore, optimal use in spinal environments should match their features, indications, and efficacy with clinical conditions.

Expert panel recommendations for topical hemostatic agent use in varied bleeding sites and situations during neuro-spine surgeries.

Intraoperative bleeding poses a substantial challenge, particularly in neuro-spine surgeries leading to complications such as hematomas, infections, and hemodynamic instability. Despite their proven efficacy, use of topical hemostatic agents (THAs) lacks comprehensive published literature and guidelines particularly in the Indian setting. The present study provides the first-ever Indian expert panel recommendations for effective adjunct THA use in different intraoperative bleeding sites and situations in neuro-spine surgeries. A comprehensive approach, encompassing a literature review, followed by experience sharing in a meeting using a survey helped integrate expert opinions in the form of practical algorithms to guide THA selection. Our survey results revealed a strong inclination towards specific THAs, flowable gelatin + thrombin being choice of THA for difficult to access and problematic bleeding situations during tumor removal/resection, transsphenoidal hypophysectomy and skull-based procedures. Both oxidized regenerated cellulose (ORC)/Fibrillar and flowable gelatin + thrombin were recommended for continuous oozing. ORC/Fibrillar was preferred for arteriovenous and cavernous malformations. This expert-panel guidance on THA use aims to optimize hemostat use practices and improve surgical outcomes in neuro-spine surgery.

Obtaining rapid and effective hemostasis: Part I. Update and review of topical hemostatic agents.

Effective and rapid hemostasis is critical to optimize surgical outcomes. An advantageous adjunct in accelerating the clotting process during dermatologic surgery is the use of topical hemostatic agents, which allow dermatologic surgeons to quickly clear the surgical field while avoiding the adverse effects of systemic medications. The growing rate of patients with pacemakers and defibrillators limits the possibility of electrosurgery. It is not unusual for patients to be taking ≥1 anticoagulant medication(s). For these reasons, the use of topical hemostatic agents is likely to gain more recognition in the literature. The term topical hemostatic agents encompasses an array of pharmacotherapies, sealants, adhesives, absorbable agents, biologics, and combination products. The optimal use of topical hemostatic agents demands that dermatologic surgeons be familiar with each of these options, because the type of product used must be selected based on surgical location, wound size, and the extent of bleeding. With few randomized controlled trials in existence reviewing the efficacy of these medications, the subject of topical styptic agents has largely gone unstudied. Part I of this continuing medical education article reviews the available topical hemostatic agents and the ideal clinical settings for their use.

Methods of Hemostasis in Cranial Neurosurgery: An Anatomy-Based Stepwise Review.

BACKGROUND: Hemostasis is crucial in preventing hemorrhage during cranial neurosurgical procedures and maintaining visualization of the surgical field. There is significant variation in the availability of hemostatic methods across different settings and hemostatic techniques are being continuously developed over the decades of practicing neurosurgery. The aim of this article is to provide an outline of the potential methods to achieve hemostasis based on the sequential operative anatomy of a cranial operation. METHODS: A systematic review was conducted following the PRISMA guidelines. The PubMed database was searched from inception of the database to July 18, 2023. A total of 64 studies were identified fulfilling predefined inclusion criteria, and the risk of bias was assessed using the Joanna Briggs Institute checklists. RESULTS: Seventy-one hemostatic agents, techniques, tools, and devices were identified, which were then categorized according to the operative phase for which they are indicated. Nine operative anatomic targets were addressed in the sequence in which they are involved during a cranial procedure. For each anatomic target, the following number of hemostatic techniques/agents were identified: 11 for scalp, 3 for periosteum, 10 for skull bone, 11 for dura mater, 9 for venous sinuses, 5 for arteries, 6 for veins, 12 for brain parenchyma, and 4 for cerebral ventricles. CONCLUSIONS: Depending on the phase of the surgery and the anatomic structure involved, the selection of the appropriate hemostatic method is determined by the source of bleeding. Surgeon awareness of all the potential techniques that can be applied to achieve hemostasis is paramount, especially when faced with operative nuances and difficult-to-control bleeding during cranial neurosurgical procedures.

US Evaluation of Topical Hemostatic Agents in Post-Thyroidectomy.

BACKGROUND: the aim of this study was to describe the ultrasound appearance of topical hemostatics after thyroidectomy. METHODS: we enrolled 84 patients who were undergoing thyroid surgery and were treated with two types of topical hemostats, 49 with an absorbable hemostat of oxidized regenerated cellulose (Oxitamp®) and 35 with a fibrin glue-based hemostat (Tisseel®). All patients were examined using B-mode ultrasound. RESULTS: In 39 patients of the first group (approximately 80%), a hemostatic residue was detected and in some cases confused with a native gland residue, or with cancer recurrence in oncological patients. No residue was detected in patients in the second group. The main ultrasound characteristics of the tampon were analyzed and arranged according to predefined patterns, and suggestions to recognize it and avoid wrong diagnoses were provided. A part of the group of patients with tampon residue was re-evaluated after 6-12 months, ensuring that the swab remained for months after the maximum resorption time declared by the manufacturer. CONCLUSIONS: with equal hemostatic effectiveness, the fibrin glue pad is more favorable in the ultrasound follow-up because it creates reduced surgical outcomes. It is also important to know and recognize the ultrasound characteristics of oxidized cellulose-based hemostats in order to reduce the number of diagnostic errors and inappropriate diagnostic investigations.

Damage Control for Vascular Trauma from the Prehospital to the Operating Room Setting.

Early management of vascular injury, starting at the field, is imperative for survival no less than any operative maneuver. Contemporary prehospital management of vascular trauma, including appropriate fluid and volume infusion, tourniquets, and hemostatic agents, has reversed the historically known limb hemorrhage as a leading cause of death. In this context, damage control (DC) surgery has evolved to DC resuscitation (DCR) as an overarching concept that draws together preoperative and operative interventions aiming at rapidly reducing bleeding from vascular disruption, optimizing oxygenation, and clinical outcomes. This review addresses contemporary DCR techniques from the prehospital to the surgical setting, focusing on civilian vascular injuries.

Topical Hemostatic Agents: What the Oral and Maxillofacial Surgeon Needs to Know.

Hemostasis is a key step in safe and predictable surgery. Knowledge of normal blood clotting mechanisms and abnormal diathesis is necessary to anticipate potential problems during and after surgery. As an adjunct to bleeding control, topical hemostatic agents have long been used in all surgical disciplines. This article provides a brief review of hemostasis and a topical summary of different classes of topical hemostatic agents useful to oral and maxillofacial surgery, including indications and potential complications/side effects. This rapidly evolving field promises to yield future agents with increased efficacy, cost efficiency, and decreased complications.

Hemostasis and Hepatic Surgery.

Operative blood loss is a major source of morbidity and even mortality for patients undergoing hepatic resection. This review discusses strategies to minimize blood loss and the utilization of allogeneic blood transfusion pertaining to oncologic hepatic surgery.

Achieving hemostasis in dermatology-Part II: Topical hemostatic agents.

Bleeding is a common occurrence during any dermatologic surgery that disrupts blood vessels. The complications of excess bleeding can include delayed wound healing, hematoma formation, infection, dehiscence, and necrosis. In part one of this review, we discussed the pre-operative, intra-operative, and post-operative management of patients undergoing dermatologic surgery. In Part two, we discuss traditional and new topical hemostatic agents used to achieve hemostasis in dermatological procedures and surgery. We will evaluate the caustic and non-caustic hemostatic agents as well as hemostatic dressings. The mechanisms of action, side effect profile, and advantages and disadvantages of the topical hemostatic agents are provided. Sources for this article were found searching the English literature in PubMed for the time period 1940 to March 2012. A thorough bibliography search was also performed and key references examined.

Patient blood management: use of topical hemostatic and sealant agents.

Patient blood management is the scientific use of safe, effective medical and surgical techniques designed to conserve blood, prevent anemia, decrease bleeding, and optimize coagulation in an effort to improve patient outcomes. Perioperative and primary care nurses play a vital role in promoting and making the best use of patient blood management and can play a key role in implementing effective strategies that decrease or eliminate patient exposure to allogeneic blood. The fast and effective minimization of intraoperative bleeding is integral in an effective blood management program. Topical hemostatic and sealant agents can be used to improve blood conservation, reduce overall procedure time, and contribute to faster patient recovery based on specific clinical situations. The proper selection of hemostatic agents can greatly influence the patient's clinical outcomes.