Download - 10.1007_s10151-003-0014-8--
I. Kanellos () • I. Mantzoros • I. Goulimaris • E. Zacharakis
A. Zavitsanakis • D. Betsis
Fourth Department of Surgery
Aristotle University of Thessaloniki, Greece
E-mail: [email protected]
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