Roy L. Tawes

Autologous fibrin glue: The last step in operative hemostasis

BACKGROUND Fibrin glue may be the perfect hemostatic agent for operative use as it seals in minutes, has no tissue toxicity, reabsorbs, and promotes local tissue growth and repair. Use in the United States has been limited because of lack of Food and Drug Administration approval of the commercial homologous products, lack of a concentrated source of fibrinogen, and because of the potential for viral transmission, particularly hepatitis, with pooled homologous plasma and cryoprecipitate-based methods. Autologous fibrin glue (AFG) obviates these problems. METHODS During the past year, we obtained AFG through the same routine predonation procedure as with red blood cells before major elective surgery. Intraoperatively, we made AFG from the platelet-rich plasma derived from the Plasma-Saver. Our experience has been with 36 patients undergoing aortic, thoracoabdominal, and thoracic surgery, as well as patch graft angioplasty cases. RESULTS Fibrin glue formation mimics the final stage in the coagulation cascade. The AFG from predonation acts more like an epoxy glue, while the AFG made during surgery is less viscous and acts more like a sealant because of the lesser concentration of fibrinogen in platelet-rich plasma. In emergencies, however, the intraoperative method is obviously the only choice available, and it is a useful adjunct to hemostasis at the end of the procedure. The technique will be described. CONCLUSION This relatively new approach to hemostasis should gain popularity because it is easy and fairly inexpensive to produce, and because the patients own blood is used.

Is the "salvaged-cell syndrome" myth or reality?

BACKGROUND Intraoperative autotransfusion (IAT) has been implicated in anecdotal cases and experimental models to precipitate, aggravate, or exacerbate a coagulopathy. This study assesses this hypothesis. METHODS A retrospective database review of over 36,000 multispecialty cases of IAT during an 18-year experience was conducted with special reference to the occurrence of coagulopathy (disseminated intravascular coagulation [DIC]) in association with adult respiratory syndrome (ARDS). RESULTS The incidence of coagulopathy was low (0.05%). A total of 18 cases of DIC/ARDS were identified: 10 associated with ruptured aneurysms, 6 following massive trauma, and 2 after complex redo cardiac surgery. All 18 patients suffered shock and profound hypothermia. The mean transfusion requirement was 28 units. The mortality was 100%. CONCLUSION Although some degree of bleeding and clotting disorders are not uncommon in major cases, in our experience coagulopathy occurs infrequently and is a result of a complex interaction of shock, hypothermia, and multiple transfusions. It is our contention that these factors trigger the DIC, not the autotransfusor, and that the ARDS results from reperfusion injury following a profound ischemic event, associated in many cases with multiorgan failure.

The cell-saver and autologous transfusion: An underutilized resource in vascular surgery

The vascular surgeons best resource for blood transfusion is the patients own blood. It is readily available for recycling, already precisely typed and crossmatched, and without the risk of transfusion-related diseases such as hepatitis and AIDS. The relative ease, safety, and cost-effectiveness of autologous blood transfusions, intraoperative autotransfusions, and postoperative autotransfusions has been shown in our hospital experience with 320 cases and in the literature. We predict that autologous donor blood and autotransfusion will soon be widely accepted and utilized as the best and safest method of blood replacement.

Prognosis of renal cell carcinoma with vena caval and renal vein involvement: an update

In tumor surgery, vascular invasion usually portends a grave prognosis; however, in patients with renal cell carcinoma, aggressive management can achieve survival rates approaching those of contained hypernephroma. This retrospective review of 65 patients treated from 1975 to 1986 has revealed a 28 percent incidence of renal vein and vena caval involvement (each seen alone or in combination per patient), which was significantly higher than previously reported rates (6 to 8 percent). We attribute this to our evaluation of all patients preoperatively with arteriography and subsequent radiography of the vena cava in those suspected of having tumor thrombus in the renal vein, or vena cava, or both. We think arteriographic studies are more sensitive and reliable for assessment of vascular invasion than computerized tomography. There was a 100 percent follow-up of those patients with vascular invasion (mean, more than 5 years). The low survival rate in patients with nodal metastases (8 percent) has been noted previously, but the 87.5 percent survival rate in those patients with venous invasion without nodal involvement was considerably higher than what has been reported previously. We conclude that proper preoperative evaluation to diagnose vascular invasion will allow a carefully planned combined urologic and vascular surgical approach with removal of renal vein or vena caval tumor, while avoiding tumor thromboemboli during resection.

Coagulopathy associated with peritoneovenous shunting

Le Veen shunts successfully alleviated ascites in 19 of 24 patients (79 percent). Clinical clotting typical of disseminated intravenous coagulation occurred in nine of these patients (37 percent) and was fatal in seven (78 percent). Laboratory findings suggesting disseminated intravenous clotting were present in five other patients (21 percent) but were not associated with troublesome bleeding. Coagulopathy was reversed in 7 of 14 patients (50 percent), if the shunt was ligated and supportive measures were taken early in the postoperative course. Failure to recognize or take immediate action resulted in progressive disseminated intravenous clotting associated with a mortality of 50 percent (7 of 14 patients).

Thyroid carcinoma during youth

Abstract In the treatment of thyroid carcinoma in 60 patients under 21 years, local recurrence developed in 3 of 17 patients who had thyroid lobectomy, but there was no recurrence in 25 patients treated by subtotal thyroidectomy or in 28 patients who had total thyroidectomy. The frequency of recurrent nerve injury was the same in all types of thyroidectomy, but permanent hypoparathyroidism occurred only after total thyroidectomy. Modified neck dissection was an effective as radical neck dissection in the control of cervical lymph node metastases.

Value of postoperative heparin therapy in peripheral arterial thromboembolism

The experience with 359 patients with arterial thromboembolism from 1963 to 1982 has been reported. Combined operative and anticoagulant therapy appears the most beneficial form of treatment. Treatment with heparin after catheter embolectomy was associated with a decrease in mortality (7.6 percent), number of amputations (5 percent), and recurrent emboli (6 percent). Serious wound complications occurred less frequently than anticipated (8 percent). We advocate prompt arteriography and revascularization procedures to ensure long-term limb function after initial embolectomy for salvage, if the result is less than optimal or expected. Postoperative heparin seems to buy time in marginal cases, enabling secondary operations to ensure a satisfactory outcome in most patients.

Endoscopic Technique for Subfascial Perforating Vein Interruption

Surgical treatment of incompetent perforating veins of the lower leg performed openly carries considerable morbidity associated with wound healing. Newer minimally invasive techniques offer an effective treatment alternative that avoids the lengthy incisions of the classical subfascial ligation techniques. The authors report a simple and quick two-port endoscopic method for clipping incompetent perforating veins of the lower leg using commonly available endoscopic instrumentation. The technique is unique in its use of a balloon dissector to rapidly establish the subfascial working space.

The Plasma Collection System: A New Concept in Autotransfusion

We have used the Haemonetics Cell-Saver autotransfusion technique in over 6,500 cases since 1979, salvaging more than 11,000 units of packed red blood cells. Major utilization has been in cardiac, vascular, and orthopedic cases. Coagulopathy associated with hypothermia, shock, multiple transfusions, and the autotransfusion technique, which removes clotting factors and platelets, often necessitated use of fresh-frozen plasma and platelet packs postoperatively to control bleeding and clotting problems. However, this defeats the prevention of disease transmission, transfusion reaction, and autoimmunization. Haemonetics has recently developed a plasma collection system which salvages up to 1,000 cc of platelet-rich plasma. Early experience suggests this technique will not only decrease the incidence of postoperative bleeding but further decrease the use of homologous (bank) blood and components. A step-by-step guide to the plasma collection system is discussed. The plasma collection system augments the present autotransfusion technique that conserves red blood cells, thus making complete autologous blood transfusion a reality.

Endoscopic Perforator Vein Surgery: Creation of a Subfascial Space

The endoscopic treatment of incompetent perforator veins has opened a whole new era in peripheral venous surgery. This concept was introduced in 1985 by Hauer who first described the endoscopic technique for the division of perforating veins.1 The importance of incompetent perforator veins in chronic venous insufficiency is clear as 1%–2% of the general population have or have had venous ulceration with an associated disease process that is marked by chronicity and recurrence when treated with conservative medical therapy.2 Past conventional surgical therapy has been efficacious in the majority of cases, but complicated by a high morbidity rate.2 This has led to a general trend toward conservative management despite the dismal course of the disease with standard compression therapy. Endoscopic modes of treatment are increasingly being applied in all fields of surgical treatment due to their decreased invasiveness and markedly reduced patient morbidity.