Cyanoacrylate therapy for the treatment of gastric varices: a new method.

OBJECTIVE: Cyanoacrylate (CYA) injection is recommended for bleeding gastric varices (GV) but with significant adverse effects. Transesophageal endoscopic ultrasound-guided therapy of large GV with a combined coil and CYA injection has shown promising results. However, it is expensive and requires technical expertise. In this study, we aimed to compare the safety and efficacy of a new method with UCYA [undiluated CYA (UCYA) followed by lipiodol-diluated CYA (DCYA)] in the management of large bleeding GV. METHODS: Fifteen consecutive patients with bleeding from large GV (>1 cm) were prospectively treated with DCYA and another 15 patients treated with UCYA retrospectively. All patients in the DCYA group underwent thoracic computed tomography scan to identify glue embolism. RESULTS: Baseline characteristics were similar between the two groups. Rates of GV obliteration and rebleeding were 100% vs 93.3% (P = 0.309) and 6.7% vs 33.3% (P = 0.06) in the DCYA and UCYA groups, respectively. One patient in the UCYA group had needle fixation which led to fatal bleeding after forceful needle extraction. In DCYA group none had glue embolism. CONCLUSIONS: Both UCYA and DCYA are effective in treating bleeding from large GV. DCYA has lower rebleeding rates and tends to have fewer adverse events than UCYA injection, although the differences are not statistically significant. Large-sample-sized prospective randomized trials are required.

Clinical outcome and quality of life in 100 consecutive laparoscopic totally extra-peritoneal (TEP) groin hernia repairs using fibrin glue (Tisseel™): a United Kingdom experience.

PURPOSE: The use of fibrin sealant (FS) (Tisseel™) for mesh fixation in patients undergoing laparoscopic groin hernia surgery is a well-recognised technique in Europe, but no study to date has examined effect on quality of life (QoL) on patients undergoing FS mesh fixation. A prospective study was therefore conducted to examine the effects on QoL of patients undergoing laparoscopic groin hernia surgery using FS in the United Kingdom. MATERIALS AND METHODS: Between March 2007 and January 2011, all patients undergoing laparoscopic total extra preperitoneal (TEP) groin hernia repair using FS were included in the study. A validated hernia questionnaire from The Royal College of Surgeons of England supplemented by the EORTC QLQ C-30 to assess the pre- and postoperative QoL, pain scores and health outcome measures was used. All the patient's demographics, duration of surgery, size of hernia, recurrence, morbidity and hospital stay were recorded. RESULTS: Data from 92 patients (87 males and 5 females) with a median age of 46 years (range, 19-82 years) was collected for the study (response rate of 92/121, 73 %). A total of 58 patients (63 %) had a unilateral and 34 patients (37 %) a bilateral hernia repair, of which 6 (7 %) were recurrent inguinal hernia. The mean operating time for a unilateral hernia was 36 min (30-62), and that for a bilateral hernia was 59 min (51-83). There were no conversions to open surgery out of the 92 patients included with the recorded morbidity of 7 %. There were no early recurrences. Eighty-nine patients (98 %) of patients were discharged in the first 24 h after surgery. There was a significant statistical difference recorded in patients visual analogue pain score (VAS 0-10) before and after surgery (P < 0.0001, Mann-Whitney U test). The physical, emotional, social and health components of the questionnaire were statistically significant pre- and postoperatively (P < 0.001 Mann-Whitney U test). CONCLUSION: Groin hernia TEP repair with FS fixation did not have a detrimental effect on QoL and pain scores. In addition, the low early recurrence rate provided good evidence of the mesh fixation properties of FS. FS can therefore be continued to be recommended, as an alternative fixation method in laparoscopic groin hernia surgery.

[Esophageal sinus formation due to cyanoacrylate injection for esophageal variceal ligation-induced ulcer bleeding in a cirrhotic patient].

Intravariceal injection of N-butyl-2-cyanoacrylate is widely used for the hemostasis of bleeding gastric varices, but not routinely for esophageal variceal hemorrhage because of various complications such as pyrexia, bacteremia, deep ulceration, and pulmonary embolization. We report a rare case of esophageal sinus formation after cyanoacrylate obliteration therapy for uncontrolled bleeding from post-endoscopic variceal ligation (EVL) ulcer. A 50-year-old man with alcoholic liver cirrhosis presented with hematemesis. Emergent esophagogastroscopy revealed bleeding from large esophageal varices with ruptured erosion, and bleeding was initially controlled by EVL, but rebleeding from the post-EVL ulcer occurred at 17th day later. Although we tried again EVL and the injections of 5% ethanolamine oleate at paraesophageal varices, bleeding was not controlled. Therefore, we administered 1 mL cyanoacrylate diluted with lipiodol and bleeding was controlled. Three months after the endoscopic therapy, follow-up endoscopy showed medium to large-sized esophageal varices and sinus at lower esophagus. Barium esophagography revealed an outpouching in esophageal wall and endoscopic ultrasonography demonstrated an ostium with sinus. It is noteworthy that esophageal sinus can be developed as a rare late complication of endoscopic cyanoacrylate obliteration therapy.

Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli.

Bleeding gastric varices are increasingly being obliterated with the aid of endoscopic injection of n-butyl-cyanoacrylate (histoacryl) diluted with lipiodol. This glue acts as a tissue adhesive that polymerizes on contact with blood in a gastric varix. Severe glue pulmonary embolism is a rare complication of injection therapy. This case involves a 52-year-old man with fundal gastric varices, who developed multiple pulmonary emboli following glue injection with profound hypoxia requiring hospital admission for 13 days, but with eventual recovery of normal lung function.

Briefly occlusive coronary anastomosis with tissue adhesive.

OBJECTIVE: We assessed the feasibility of a facilitated, briefly occlusive, sutureless coronary anastomosis technique in which side-to-side preglued (octylcyanoacrylate adhesive) bounded walls were opened by a conventional arteriotomy. METHODS: In low-flow (prothrombotic milieu,

Peristomal allergic contact dermatitis due to Gantrez in Stomahesive paste.

We report a case of severe peristomal dermatitis that was refractory to conventional treatments. Patch testing revealed positive allergies to myroxylon perulase (balsam of Peru), propylene glycol, Stomahesive paste, and Gantrez. This is the second reported case of patch-test-positive peristomal allergy to Gantrez.

Symptomatic pulmonary complications from liquid acrylate embolization of brain arteriovenous malformations.

PURPOSE: To describe symptomatic pulmonary emboli from brain arteriovenous malformation embolization with liquid acrylates and to analyze the reasons for these complications and describe preventive techniques. METHODS: The clinical records of 182 patients embolized with acrylate glue since 1978 for treatment of brain AVMs were searched for evidence of symptomatic pulmonary complications. Originally iso-butyl-2-cyanoacrylate and more recently n-butyl-2-cyanoacrylate were used in all patients. Arteriovenous malformation morphology, amounts and techniques of glue injection, and clinical and radiologic investigations in the symptomatic patients were recorded. RESULTS: Three patients had pulmonary symptoms within 48 hours of glue injection. One patient with a left frontal arteriovenous malformation had embolization with an isobutyl-2-cyanoacrylate/pantopaque/acetic acid mixture; severe pleuritic chest pain developed 2 days later. One patient with a left temporal and one with a left cerebellar arteriovenous malformation had embolization with n-butyl-2-cyanoacrylate/lipiodol mixtures; a cough, pleuritic chest pain, and bloody sputum developed in both within 24 hours. Two patients experienced a significant drop in PO2. No flow-arrest techniques were used for any of the injections in these three patients. All patients demonstrated significant changes on chest x-ray and CT chest examinations. All were treated conservatively and recovered spontaneously. CONCLUSIONS: Symptomatic pulmonary complications can occur after acrylate glue injection, particularly when delivery systems without flow arrest are used in high-flow vascular brain lesions. Techniques using acetic acid to delay polymerization time and "sandwich" techniques in which glue is pushed with dextrose are also more susceptible to this complication.

The postoperative use of wound adhesives. Gum mastic versus benzoin, USP.

Our results, combined with the work of previous authors, show that gum mastic not only offers superior adhesive qualities compared with benzoin, USP but also has a lower incidence of postoperative contact dermatitis and subsequent skin discoloration. In light of the widespread use of surgical adhesives, this study is important in documenting the low incidence of complications and the advantages of gum mastic compared with benzoin, USP.

Allergic contact dermatitis from Stomadhesive paste.

A woman developed dermatitis from Stomadhesive paste used to secure her colostomy appliance. Patch testing revealed that she was allergic to Gantrez (N-butylmonoester of polymethyl vinyl ether maleic acid in an ethanol solution), a water soluble copolymer with stabilizing properties used in the production of Stomadhesive.

Evaluation of fibrin sealing for cardiovascular surgery.

Hemorrhage remains a problem in patients undergoing cardiovascular surgery. To evaluate fibrin sealant, a completely biodegradable hemostatic agent, three series of experiments were performed in mongrel dogs. In series I, 18 dogs had a 7 cm interposition of knitted Dacron (water porosity 1500 ml/min/cm2) in the descending aorta. In group A, all prostheses were treated with fibrin sealant and in group B by blood preclotting. Measurements of blood loss demonstrated 1.29 +/- 0.26 ml/min in group A as compared with 30.16 +/- 2.85 ml/min in group B (p less than .001). In series II, six dogs of each group were compared for thrombogenicity and platelet survival by using indium-111-labeled autologous platelets. According to Goldman et al., the thrombogenicity index was calculated. The mean thrombogenicity index for group A was 0.23 +/- 0.02 in contrast to 0.33 +/- 0.05 for group B (p greater than .05). Mean platelet survival was 5.59 +/- 0.23 days in group A in contrast to 5.34 +/- 0.05 days in group B (p greater than .05). In series III, the gluing potential was investigated by creating four types of injuries: four dogs had an aortic stab wound 3 to 5 mm, six dogs received a 10 to 15 mm stab wound to the left ventricle, seven dogs had a 3 cm laceration of the left atrial appendage, and four dogs had bilateral division of their carotid arteries. Wounds of the aorta and left atrial appendage were treated by partial clamping and the sole use of fibrin sealant, the carotid arteries were repaired by four simple sutures and fibrin sealant, and the left ventricular stab wounds were treated by the combined use of heterologous collagen and fibrin sealant without suture.(ABSTRACT TRUNCATED AT 250 WORDS)

Cutaneous reactions to surgical preparations and dressings.

A prospective study of 100 surgical patients was undertaken to identify causes of contact dermatitis. Patch testing with the North American Contact Dermatitis Standard Series and additional agents used in the surgical preparation and dressing was performed in 11 patients with post-operative dermatitis or a history of tape allergy. 12 patients were diagnosed as having irritant (mechanical) contact dermatitis. One patient had allergic contact dermatitis to benzoin postoperatively; another patient with a history of an adhesive tape reaction had a positive patch test to thiuram mix, rubber accelerators formerly present in adhesive tapes. Our findings indicate that irritant contact dermatitis is a common problem in the surgical patient. Allergic contact dermatitis is less common, occurring in 2 of the 100 patients.