I. Kanellos () • I. Mantzoros • I. Goulimaris • E. Zacharakis

A. Zavitsanakis • D. Betsis

Fourth Department of Surgery

Aristotle University of Thessaloniki, Greece

E-mail: ik@hol.gr

treated) than in group A. Conclusion Fibrin glue application

around a sutured anastomosis provides a safer anastomosis

which is stronger than the sutured one.

Key words Colonic anastomosis • Fibrin glue • Healing

Introduction

Anastomotic dehiscence, which results in an increase in the

mortality and morbidity rates in colorectal surgery, is one of 

the most serious complications [1]. It has been shown that

fibrin sealant contributes to wound healing by improving

angiogenesis, fribroblast proliferation and collagen produc-

tion [2]. This study was aimed at examining whether the

addition of fibrin glue to a sutured colonic anastomosis

improves its healing or not.

Materials and methods

Thirty-six Wistar rats weighing 250–350 g were randomized in two

groups (A and B) of 18 rats each. All animals had unrestricted

access to water and food preoperatively. Operations were per-

formed under intraperitoneal thiopental anesthesia (40 mg/kg body

weight). Through a 3-cm midline incision, a segment of 1 cm of the

transverse colon was resected, 10 cm from the ileocecal valve. An

end-to-end anastomosis was performed in the rats of group A with

the use of a single layer of 8 interrupted 6–0 polypropylene sutures.

The same procedure was followed for the rats of group B, but in

these animals fibrin glue (Tissucol; Immuno, Vienna, Austria) was

applied around the anastomoses. Animals were given a standard

diet, which included tap water ad libitum postoperatively.

Rats were sacrificed on the eighth postoperative day. During post-

mortem examination, the anastomoses were examined macroscopical-

ly. Integrity of the anastomosis, existence of perianastomotic abscess

or peritonitis and adhesion formation were recorded. Evaluation was

performed according to the scale of Van der Hamm et al. [3].

I. Kanellos • I. Mantzoros • I. Goulimaris • E. Zacharakis • A. Zavitsanakis • D. Betsis

Effects of the use of fibrin glue around the colonic anastomosis of the rat

Received: 1 August 2002 / Accepted: 15 November 2002

O R I G I N A L A R T I C L E

Abstract Background This study was aimed at examining

whether the addition of fibrin glue to a sutured colonic anas-

tomosis improves its healing or not. Methods We studied

the effect of adding fibrin glue on a sutured colonic anasto-

mosis. Thirty-six Wistar rats were randomized into two

groups of 18 rats each. A sutured anastomosis was per-

formed in all rats. Fibrin glue was applied around the anas-

tomosis of the rats of group B. Rats were sacrificed on the

eighth postoperative day. Results The rate of anastomotic

leakage was found not to be significantly different between

the two groups. The mean bursting pressure of the colonic

anastomoses was significantly higher in group B (fibrin-

Tech Coloproctol (2003) 7:82–84

DOI 10.1007/s10151-003-0014-8 © Springer-Verlag 2003

 

I. Kanellos et al.: Fibrin glue on colonic anastomoses 83

The anastomosis and a 2.5-cm segment of colon on either side

were removed and cleared of stools. The proximal end was ligated

using a 3/0 silk suture and a catheter was secured into the distal end.

This was fixed to the bursting pressure apparatus as has been

described elsewhere [4]. Through this catheter normal saline was

infused at a constant rate of 1 ml/min. The bursting pressure was

defined as the pressure at which leakage of saline or gross rupture

was noted.

The anastomotic site was resected and placed in 4% formalde-

hyde. After staining with hematoxylin and eosin, anastomoses were

graded histologically in a blind fashion, with the use of the Ehrlich

and Hunt numerical scale [4].

Continuous variables were summarised with the use of means

with 95% confidence intervals and medians with interquartile

ranges (IQRs). The statistical methods employed were Fisher’s

exact test for comparison of proportions. Differences between

groups with respect to bursting pressures were tested using Mann-

Whitney test. Analyses were conducted in SPSS 10 (SPSS,

Chicago, USA). All reported  p values are two-tailed. The level for

statistical significance was set at  p<0.05.

Results

One animal from group A (5.6%) was found, in postmortem

examination, to have anastomotic dehiscence, while no ani-

mals in group B had anastomotic leakage. Most rats in both

groups had moderate adhesions. There was no significant

difference between the two groups regarding the frequency

of either anastomotic dehiscence or adhesion. Anastomotic

bursting pressures were significantly higher in group B (fib-

rin glue) than in control group A (Table 1). The wound heal-

ing process, as assessed by inflammatory cell infiltration,

blood vessel neodevelopment, collagen deposition and

fibroblast activity did not differ significantly between the

two groups ( p=0.704,  p=0.845,  p=1.000 and  p=1.000,

respectively; data not shown).

Discussion

Fibrin glue is a water-resistant cover and can thus consti-

tute a physical barrier around the anastomosis. Hjortrup et

al. [5] used sutures externally and fibrin glue internally,

and this is resulted in a low incidence of anastomotic

dehiscence in the rectum of dogs. Similar results were

obtained by the experimental study conducted by

Hapukiro et al. [6]. In our study the application of fibrin

glue around sutured anastomoses diminished the dehis-

cence rate from 5.6% to 0%, although this difference is not

significant. Thus, the use of fibrin glue seems to seal and

strengthen the anastomosis.

Van der Hamm et al. [7] found that the bursting pressure

of the combined anastomosis was significantly higher com-

pared to the sutured one. On the other hand, Hjortrup et al.

[8] performed a sutured anastomosis of the small intestine of 

pigs and used fibrin glue in order to seal it. They found no

significant difference as far as the bursting pressure was con-

cerned. On the contrary, in our study we found that the appli-

cation of fibrin glue resulted in a significant increase of the

bursting pressure of the anastomoses. It is possible that fib-

rin glue seals the anastomotic sites and covers slight or sub-

clinical ruptures.

A previous study has suggested that fibrin adhesive may

decrease intra-abdominal adhesion formation [9]. On the

other hand, Van der Hamm et al. [7] reported a significant

increase of adhesion formation around the colonic anasto-

mosis, due to the application of fibrin glue during their

experiment. In our study there was no significant difference

of adhesion formation between the two groups.

In conclusion, the application of fibrin glue around a

sutured anastomosis provides a safer anastomosis that is

stronger than the sutured one. The latter was demonstrated

by the significantly higher mean bursting pressure that was

measured in our experiment.

AcknowledgementsWe thank Ms. Vicky Kanellou for revising and

proofreading this paper.

References

1. Reidl S, Wiebelt H, Bergmann U, Hermanek P Jr (1995)

Postoperative Komplikationen und Letalitaet in der

Chirurgischen Therapie des colon carcinoms. Chirurg

66:697–706

2. Phol J, Bruhn HD, Christophers E (1979) Thrombin and fib-

rin induced growth of fibroblasts: role of wound repair and

thrombus organization. Klin Wochenschr 57:273–277

Table 1 Bursting pressures of sutured colonic anastomoses in rats, according to whether or not fibrin glue was applied

Bursting pressure, mmHg Mann-Whitney

 p value

Group Mean 95% CI Median IQR

A (n=17) 151.60 134.45–168.75 152.0 120.0–180.0 <0.001

B (n=18) 244.13 206.39–281.86 240.0 196.5–265.5

CI , confidence interval;  IQR, interquartile range

 

84 I. Kanellos et al.: Fibrin glue on colonic anastomoses

3. Van der Hamm AC, Kort WJ, Weijma MI, Van der Ingh HF,

Jeekel J (1991) Effect of fibrin sealant on the healing of 

colonic anastomosis in the rat. Br J Surg 78:49–53

4. Kanellos I, Kazantzidou D, Evagelou I, Galovatsea K,

Zaraboukas T, Dadoukis I (1998) Healing of colonic anasto-

moses after immediate and delayed administration of 5-fluo-

rouracil plus folinic acid. Eur Surg Res 30:312–316

5. Hjortrup A, Norrdkild P, Christensen T, Sjøntoft E, Kjaergaard

J (1989) Rectal anastomosis with aplication of luminal fibrin

adhesive in the rectum of dogs. Dis Colon Rectum

32:422–425

6. Hapukiro KA, Hulkko A, Alavaikko MJ, Laitinen ST (1988)

Sutureless colon anastomosis with fibrin glue in the rat. Dis

Colon Rectum 31:601–604

7. Van der Hamm AC, Kort WJ, Weijma M, van der Ingh

HFGM, Jeekel H (1992) Effect of antibiotics in fibrin sealant

on healing colonic anastomoses in the rat. Br J Surg

79:525–528

8. Hjortrup A, Nordkild P, Kiaergaard J, Sjontoft E, Olesen HP

(1986) Fibrin adhesive versus sutured anastomosis: a compar-

ative intraindividual study in the small intestine of pigs. Br J

Surg 73:760–761

9. De Virgillio C, Dubrow T, Sheppard BB (1990) Fibrin glue

inhibits adhesion formation. Arch Surg 125:1378–1382