COMPARISON OF AVITENE, TOPICAL THROMBIN, AND GELFOAM AS SOLE HEMOSTATIC AGENT IN TUBOPLASTIES*

Transcription

1 FERTILITY AND STERILITY Copyright" 1980 The American Fertility Society Vol. 33, No.3, March 1980 Printed in U.SA. COMPARISON OF AVITENE, TOPICAL THROMBIN, AND GELFOAM AS SOLE HEMOSTATIC AGENT IN TUBOPLASTIES* JOSEPH S. SANFILIPPO, M.D.t GEORGE H. BARROWS, M.D.:!: MARVIN A. YUSSMAN, M.D. Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, and Department of Pathology, University of Louisville School of Medicine, Louisville, Kentucky Forty-eight virgin guinea pigs were subjected to bilateral sectioning of the uterine horn and cuff type salpingostomy. Avitene, Topical Thrombin, or Gelfoam was used as the sole hemostatic agent in each of three study groups. Bipolar cauterization was used in a control series. These agents were compared with regard to ease of application, degree of adhesion formation, net surface area, and microscopic evaluation of degree of fibrosis and inflammatory reaction. The results revealed no statistically significant differences among the various methods of hemostasis. Data were evaluated by uni- and multivariate analyses. Several trends in the data were noted: the greatest amount of fibrosis was associated with Topical Thrombin and Avitene, and the greatest inflammatory response was associated with Avitene. These agents show no superiority to currently used cautery methods of obtaining hemostasis. Fertil Steril 33:277, 1980 The relationship between hemostasis and improved results in tubal surgery has been alluded to in the literature. l - 3 With the advent of improved techniques of tubal repair, new methods must be explored for providing perfect hemostasis without associated destruction of fallopian tube tissue. It was the purpose of this project to evaluate three hemostatic agents to determine whether anyone agent improved upon currently popular bipolar cautery techniques of controlling small vessel bleeding. Received April 25, 1979; revised September 19, 1979, and November 19, 1979; accepted November 21,1979. *Presented at the Thirty-Fifth Annual Meeting of The American Fertility Society, February 3 to 7, 1979, San Francisco, Calif. t Assistant Professor, Department of Obstetrics and Gynecology. To whom reprint requests should be addressed at Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Louisville School of Medicine, 323 East Chestnut Street, Louisville, Ky :!:Assistant Professor, Department of Pathology. Associate Professor, Department of Obstetrics and Gynecology; Director, Division of Reproductive Endocrinology and Infertility. Uterine horns of guinea pigs were subjected to bilateral sectioning and cuff type "salpingostomy." Three hemostatic agents were evaluated: Avitene (Avicon, Inc., Fort Worth, Tex.), Topical Thrombin (Parke, Davis and Company, Princeton, N. J.), and Gelfoam (The Upjohn Company, Kalamazoo, Mich.). One agent was used as the sole means of providing hemostasis within the group studied. A control series consisted of bipolar cauterization to achieve hemostasis; Each hemostatic agent was applied according to the manufacturer's recommendations as stated in the package insert. A comparison was made with respect to ease of application, degree of adhesion formation, net surface area, and microscopic evaluation of degree offibrosis and inflammatory reaction, and its potential use in tubal surgery. Animals MATERIALS AND METHODS Forty-eight guinea pigs were used. They were divided into four equal groups. Each animal was 311

2 312 SANFILIPPO ET AL. March 1980 separately housed and had free access to dry food and water before and after surgery. Several complications occurred during the study: anesthesia death, visceral laceration, wound dehiscence, and bowel obstruction eliminated several animals. For completion of the study 38 guinea pigs qualified and were grouped as follows: Avitene, 10; Topical Thrombin, 10; Gelfoam, 9; and bipolar cautery, 9. All procedures were carried out by the authors. Description of Hemostatic Agents Avitene. Avitene is an absorbable topical hemostatic agent composed of purified bovine corium collagen. In this experiment only that amount of Avitene necessary for hemostasis was utilized. Care was taken to avoid spillage on nonbleeding surfaces. Topical Thrombin. Topical Thrombin is a protein substance produced through a conversion reaction in which prothrombin is activated by tissue thromboplastin. It is supplied as a freeze-dried preparation requiring reconstitution with sterile distilled water or normal saline solution. Its FIG. 1. Diagram of salpingostomy and application of hemostatic agent. FIG. 2. Normal appearance of guinea pig uterine horn <original magnification x 60). mechanism of action includes direct clotting of blood fibrinogen. The primary indication for Topical Thrombin is in the control of oozing from capillaries and small venules. In this study all solutions were prepared fresh. Each incised surface ofuterine horn received 500 units of Topical Thrombin. Gelfoam. Gelfoam is a purified gelatin. It too provides hemostasis for capillary oozing. A 2 x 1 cm strip of Gelfoam moistened with normal saline solution was affixed to the mesosalpinx with 3-0 chromic suture. The lumen of each incised horn was completely covered with Gelfoam. Bipolar Cautery. Bipolar cauterization was employed for hemostasis in the fourth series and served as a control. A Codman (Codman & Shurtlett, Inc., Randolph, Mass.) bipolar cauterization unit at a setting of 10 with coagulation forceps was used. In an operating theater each animal was weighed and anesthetized with Ketamine Plus (Ketamine, Promazine, and aminopentamide, Bristol Laboratories, Syracuse, N. Y.), 35 mglkg, and Rompum (xylazine, Bayvet Laboratories, Shawnee, Kan.), 5 mglkg. When satisfactory anesthesia was achieved, the abdomen was shaved and prepared with Betadine. Using aseptic technique, a midline incision was made. The uterine horn was gently grasped and brought into the field. It was cross-sectioned 2.5 cm from the bifurcation. The proximal portion was then incised longitudinally for 0.5 cm, and a cuff salpingostomy, modified from the technique of Holden and Sovak, 4 was performed used 3-0 chromic sutures (Fig. n Hemostasis was secured by application of one hemostatic agent or by bipolar cauterization. To the distal segment of the uterine horn only a hemostatic agent or bipolar cautery was applied to secure hemostasis. Upon completion of this procedure,

3 Vol. 33, No.3 COMPARISON OF HEMOSTATIC AGENTS IN TUBOPLASTY FIG. 3. Maximal fibrosis (4+) in uterine horn (original magnification x 220). any visible blood clots in the peritoneal cavity were removed with forceps. No peritoneal lavage was performed. Ease of application of the hemostatic agent was subjectively evaluated according to preparation required prior to application, difficulty in handling, and observed displacement after application (prior to closure of the abdomen). The incision was closed in three layers using 3-0 chromic catgut (Ethicon, Inc.) for peritoneum and rectus muscle and 2-0 Vicryl (polyglactin) (Ethicon, Inc., Somerville, N. J.) for approximation of abdominal muscles. Each guinea pig received 150,000 units of Bicillin, (penicillin G benzathine suspension, Wyeth Laboratories, Chicago, Ill.) as routine prophylaxis in the animal care facilities. The animals were then numbered and replaced in individual cages. Ninety days were allowed for maximal healing. A repeat laparotomy was performed and the degree of adhesion formation was evaluated. The cervix, uterine horns, tubes, and ovaries were removed en bloc and fixed in formalin for histologic evaluation. Microscopic evaluation was performed on the distal uterine horn at the site of application of the hemostatic agent. Microscopic changes evaluated included degree of fibrosis and inflammation (Fig. 2). To determine the degree of fibrosis the entire slide was evaluated. The area of maximal fibrosis was graded according to the following system scaled between 0 and 4; 0, no fibrosis; 1 +, fibrosis present but minimal; 2+, fibrosis present and significant; 3+, moderate fibrosis; and 4+, extensive and heavy fibrosis (Fig. 3). The entire slide was evaluated with respect to chronic inflammation, and the area of maximal inflammation was graded from 0 to 4 + : 0, none; 1 +, scattered lymphocytes; 2 +, light 313 and diffuse; 3 +, moderate; and 4 +, heavy infiltration of inflammatory cells (Fig. 4). Adhesion formation was noted at the time of repeat laparotomy, and was graded from 0 to 4 + : 0, none; 1 +, few and filmy; 2 +, few and thick; 3 +, dense and filmy; and 4+ dense and thick. Each uterine horn was evaluated for net surface area via a computer-assisted approach. 5 This represented an effort to provide an objective comparison of agents. Changes in net surface area represented uterine horn distention, which is accompanied by stretching and thinning of the wall as seen in Figure 5. If this process is unaccompanied by a change in wall composition, the net cross-sectional area should remain the same. An example of this is seen in Figure 6. Each uterine horn had nearly identical net wall cross-sectional areas, although one horn was markedly distended. The net surface area of the uterine horns was objectively quanti~ tated using a computer-assisted morphometric approach. A calibrated photograph of each crosssectional tube was projected onto a digitizing platen. The net surface area was c~librated be- FIG. 4. Heavy infiltration of inflammatory cells (4+ ) (original magnification x 220).

4 314 SANFILIPPO ET AL. March 1980 A2 -AI = TUBE WALL AREA for X,Y coordinates = enclosed area A: A = I (X,-Xu-n)(Y,+YU-u) i-i 2 FIG. 5. Schematic representation of change in the net surface area of a uterine horn. FIG. 6. Identical net surface areas of two uterine horns. tween outer and inner surfaces. Any increase in net surface area was ascribed to muscle replacement by fibrosis within the walls of the uterine horn. RESULTS Ease of Application of Hemostatic Agent. Topical Thrombin and bipolar cauterization were easiest to apply. However, reconstitution of the lyophilized Topical Thrombin with normal saline solution prior to application was necessary. Avitene became difficult to work with after the initial application because of adhesion of the powdered material to the applying forceps. Gelfoam required securing to the mesosalpinx and was the most cumbersome. Subsequent data were evaluated by one-way and multivariate analyses (Tables 1 to 3). Microscopic Evaluation. Microscopic changes included evaluation of degree of fibrosis and inflammation. The greatest amount of fibrosis was noted in the Topical Thrombin and Avitene series. However, there was no statistically significant difference among the groups compared. Chronic inflammation was primarily confined to a degree of 2 + or less. Analysis of data revealed a trend to less inflammation in the Gelfoam series. The Avitene Volume of uterine horn (ml) Fibrosis (0-4) Inflammation (0-4) Net surface area (sq mm) Adhesion formation (0-4) avalues are means ± standard deviation. TABLE 1. Results with the Hemostatic Agents" Avitene (10 animals) 1.70 ± ± ± ± ± 1.51 and Topical Thrombin series had virtually identical degrees ofinflammation. The bipolar series had slightly less inflammation. No statistically significant difference was noted among groups. Adhesion Formation. Adhesions graded 3 + or greater were noted primarily in the A vitene series. No statistically significant difference among groups was noted, but a trend of minimal adhesions with the Gelfoam and Topical Thrombin series was seen. The net surface area was found to be maximal in the Gelfoam series, but no statistically significant results were noted. Means and standard deviations for uterine horn volume, fibrosis, inflammation, net surface area, and adhesion formation are noted in Table 1. Oneway analysis of variance revealed no statistically significant difference among anyone series at the P> 0.05 or P > 0.01 levels (Table 2). There was good interclass correlation of data. In an effort to evaluate multiple factors, multivariate analysis was examined (Table 3). There was no significant difference among the three hemostatic agents as compared with the control (F value = 2.16,criticalF. = 2.74attheP> 0.05 level and 4.17 at the P > 0.01 level). Several trends were noted and reflect less inflammation and adhesion formation in the Gelfoam series. Topical Thrombin 110 animals) 3.81 ± ± ± ± ± 1.25 Gelfoam 19 animals) 3.59 ± ± ± ± ± 0.79 Bipolar cautery (9 animals) 2.37 ± ± ± ± ± 1.13

5 Vol. 33, No.3 COMPARISON OF HEMOSTATIC AGENTS IN TUBOPLASTY 315 TABLE 2. One-Way Analysis of Variance Source of variance Degrees of freedom Sum of squares Mean of squares Fvalue Critical F Volume of uterine horn Equality of cell means Error Fibrosis Equality of cell means Error Adhesion formation Equality of cell means Error Inflammation Equality of cell means Error Net surface area Equality of cell means Error P < 0.05 = P < 0.01 = P < 0.05 = P < 0.01 = DISCUSSION In an effort to improve the outcome of tubal surgery, various efforts to control hemostasis and prevent pelvic adhesions 6-9 have been evaluated. Pelvic adhesions have been primarily ascribed to three pathologic processes, viz., pelvic inflammation, endometriosis, and surgical trauma.lo The sequence associated with surgical trauma is peritoneal denudation, increase in small venule permeability, release of histamine from mast cells, and accumulation of protein-rich fluid. The exudate that remains becomes transformed into collagen which organizes into adhesions. 11 Methods designed to minimize the initial pelvic insult, promote dissolution of the fibrinous exudate, and therefore decrease adhesion formation have been sought. It was the purpose of this project to evaluate three hemostatic agents (Avitene, Topical Thrombin, and Gelfoam) in an effort to determine whether anyone agent improved upon currently popular bipolar and unipolar cautery techniques of controlling small vessel bleeding during tubal surgery. Assessment was made with respect to ease of application, microscopic evaluation for fibrosis and inflammatory changes, net surface area changes, and adhesion formation. One-way and multivariate analyses revealed no statistically significant difference among the hemostatic agents as compared with the bipolar cautery con- Volume of uterine horn Fibrosis Inflammation Net surface area Adhesion formation Volume trol series. Although several trends were noted with use of the various agents (viz., fibrosis wa.'s more prominent in the Topical Thrombin and Avitene series; inflammation was least in the Gelfoam series; there was extensive adhesion formation in the A vitene series; and net surface change was maximal in the Gelfoam series). It is concluded from this study that no agent tested was superior to bipolar cauterization, which was equally as effective in controlling small vessel bleeding. Acknowledgments. The authors wish to thank Avicon, Inc., Parke, Davis and Company, The Upjohn Company, and Ethicon, Inc., for their assistance during this project. The authors are also indebted to Dr. Peter Sharp, Animal Care Facilities, University of Louisville, for his assistance. REFERENCES 1. Swolin K: Electromicrosurgery and salpingostomy: long term results. Am J Obstet Gynecol 121:418, Gordji M: Pelvic adhesions and sterility. Acta Eur Fertil 6:279, Gomel V: Reconstructive surgery of the oviduct. J Reprod Med 18:181, Holden F, Sovak F: Reconstruction of the oviducts: an improved technique with report of cases. Am J Obstet Gynecol 24:684, Barrows G, Joyce M, Schrodt G, Greenberg R, Tamburro C: Computer-assisted morphologic quantitation of collagen in human liver biopsies. Lab Invest 40:3, Sg TABLE 3. Estimates of Correlation Fibrosis Inflammation Net surface area 0.15 Adhesion formation

6 316 SANFILIPPO ET AL. March Horne H, Clyman M, Debronner C, Griggs G, Kistner R, Kosasa T, Stevenson C, Taymor M: The prevention of postoperative pelvic adhesions following conservative operative treatment for human infertility. Int J Fertil 18:109, Seitz H, Schenker J, Epstein S, Garcia C: Postoperative intraperitoneal adhesions: a double-blind assessment of their prevention in the monkey. Fertil Steri124:935, Nisell H, Larsson B: Role of blood and fibrinogen in development of intraperitoneal adhesions in rats. Fertil Steril 30:470, Diamond E: Lysis of postoperative pelvic adhesions in infertility. Fertil Steril 31:287, Kistner R, Patton G: Atlas of Infertility Surgery. Boston, Little, Brown and Co, 1975, p Replogle R, Johnson.R, Gross R: Prevention of post operative intestinal adhesions with combined promethazine and dexamethasone therapy: experimental and clinical studies. Ann Surg 163:580, 1966