Effect of Cyanoacrylate on Closure of Gastric Perforation: A Comparative Study in a Rat Model

This article was downloaded by: [Trinity College Dublin] On: 8 November 2009 Access details: Access Details: [subscription number 785045690] Publisher Informa Healthcare Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Minimally Invasive Therapy and Allied Technologies Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713683124 Effect of cyanoacrylate on closure of gastric perforation: A comparative study in a rat model Omer Faik Ersoy a; Namik Ozkan a; Alper Celik a; Huseyin Ayhan Kayaoglu a; Ebru Cakir b a Department of General Surgery, Gaziosmanpasa University Faculty of Medicine, Tokat, Turkey b Department of Pathology, Ataturk Chest Diseases Research and Training Hospital, Ankara, Turkey Online Publication Date: 01 January 2009 To cite this Article Ersoy, Omer Faik, Ozkan, Namik, Celik, Alper, Kayaoglu, Huseyin Ayhan and Cakir, Ebru(2009)'Effect of cyanoacrylate on closure of gastric perforation: A comparative study in a rat model',Minimally Invasive Therapy and Allied Technologies,18:4,225 — 231 To link to this Article: DOI: 10.1080/13645700903062387 URL: http://dx.doi.org/10.1080/13645700903062387 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article may be used for research, teaching and private study purposes. 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The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. Minimally Invasive Therapy. 2009; 18:4; 225–231 ORIGINAL ARTICLE Effect of cyanoacrylate on closure of gastric perforation: A comparative study in a rat model Omer Faik Ersoy1, Namik Ozkan1, Alper Celik1, Huseyin Ayhan Kayaoglu1, Ebru Cakir2 1Department Downloaded By: [Trinity College Dublin] At: 19:13 8 November 2009 of General Surgery, Gaziosmanpasa University Faculty of Medicine, Tokat, Turkey 2Department of Pathology, Ataturk Chest Diseases Research and Training Hospital, Ankara, Turkey Abstract The aim of the study was to compare suture, clip and clip combined with topical N-butyl cyanoacrylate in an experimental model of gastric perforation. Sixty Wistar-Albino rats were divided into three groups. Midline laparotomy was performed and a 4 mm puncture was done on the anterior surface of the stomach. Closure was performed by sutures in the first group, clip in the second group, and clip with topical cyanoacrylate in the third group. Ten rats underwent a re-laparotomy on the 3rd and 7th days, respectively. Intraabdominal adhesions, burst pressures, procedural time, total operation time and histological evaluation were analyzed. In the early phase, clip with topical cyanoacrylate treatment significantly improved burst pressures (p=0.001). In the late phase, burst pressure levels were slightly higher in the third group. Procedural period and total operation times were significantly higher in the suture-treated group and lower in the clip group. Clip with topical cyanoacrylate treatment improved histological healing indices, with significant difference in granulation, chronic inflammation and collagenisation scores, but at the expense of a significantly increased adhesion formation (P=0.001). Our study shows that gastric perforations can be effectively treated by the combination of clip and cyanoacrylate with shorter time and acceptable sideeffects in selected cases. Key words: Gastric perforation, closure, suture, cyanoacrylate, clip Introduction Gastric perforation results from a number of diseases (e.g. peptic ulcer) and iatrogenic causes such as instrumental injury. There have been various attempts to cure gastric perforations. Before the advent of minimally invasive surgical techniques, conventional treatment was laparotomy. However, improvements in laparoscopic techniques and biomaterials have made it possible to treat gastrointestinal (GI) perforations laparoscopically (1–6). Surgical glues have been extensively used for the treatment of a variety of medical conditions including variceal bleeding, embolization, and urinary, biliary, lymphatic and anastomotic fistulas (7–14). Also glues like fibrin, gelatin and cyanoacrylates (CA) have been used to treat GI fistulas and perforations (15–18). Desired properties of surgical glues include adequate adhesive strength, gradual degradation without foreignbody response, biocompatibility and appropriate polymerization. Some of the most commonly used adhesives in clinical practice are fibrin glues, gelatin and acrylate derivatives. Fibrin glues function by forming a stable fibrin matrix. They are completely biodegradable and are free of toxicity (19). Gelatin glues have a greater strength than fibrin glues, but have cytotoxicity due to the release of formaldehyde during degradation (20). CA have the advantages of applicability to numerous tissues and high polymerization rate (21). Its usage for skin closure is well documented (22–23). Also, they are stronger than fibrin glue (24–26). These advantageous effects played the main role in choosing CA in our study. The question to which extent biological glues can be used to treat GI Correspondence: Omer Faik Ersoy, Gaziosmanpasa Unıversity Faculty of Medicine, Department of General Surgery, 60100 Tokat/Turkey, E-mail: dromerfersoy@yahoo.com ISSN 1364-5706 print/ISSN 1365-2931 online © 2009 Informa UK Ltd DOI: 10.1080/13645700903062387 226 O.F. Ersoy et al. perforations remains to be proven. There is no study comparing the safety of suturing with clip and bioadhesives. This paper contains a unique idea of combining CA and clip to facilitate simple closure of a perforated stomach, which may also be used for clinical instances such as iatrogenic injuries. Our idea may lead to a new concept of a simple approach to tissue approximation. Material and methods Downloaded By: [Trinity College Dublin] At: 19:13 8 November 2009 Experimental protocol This study was approved by the institutional ethical committee. Sixty Wistar-albino rats, weighing 250–350 g were randomly allocated to three groups (n=20, per group). All operative processes and follow-up were performed at Gaziosmanpasa University Animal Studies Research Center. Two to three rats of the same sex were housed in separate wire cages with free access to food and water under standard laboratory conditions (room temperature 23°C, 12 h light-dark cycles). Rats were fasted 12 h before surgery, but had free access to water. On the operative day rats were weighed before surgery, anesthesia was conducted by intraperitoneal injection of ketamin hydrochloride (75 mg/kg) and xylazin (10 mg/kg). Under anesthesia, a midline laparotomy (1.5 cm) was made and a standard 4 mm gastric perforation was performed on the ventral side at a fixed point on the anterior aspect of the gastric corpus, at the midline between each curvatures. In the first group (S group) closure of the gastric perforation was performed by a single suture using 4/0 coated braided lactomer (Autosuture, Norwalk, CT, USA), in the second group (C group) by a single 4  mm clip (Versatack, Autosuture, Tyco Healthcare, Norwalk, CT, USA), and in the third group (CCA group) by a clip together with cyanoacrylate (Glubran®, General Enterprise Marketing, Viareggio, Italy). A clip was applied on the perforation in a perpendicular manner. Two drops (40 μl) of CA were applied. The stomach was returned to the abdomen and the incision was closed. Liquid resuscitation was achieved by subcutaneous application of sterile saline solution (5 ml/100 g body weight) in the back site at the end of the operation. All animals were deprived of food, but had free access to water for 12 h after the operative process. After 12 h, rats were fed ad libitum. Randomly selected ten rats in each group were anesthetized, and sacrificed by decapitation on postoperative day (POD) 3, and the remaining ten rats in each group were sacrificed on POD 7. We measured all procedure periods, and total operation period by chronometer. Procedure period was defined as the time from gastric incision to the end of gastric closure. Total operation time was defined as the time from the beginning of the skin incision to the completion of the last skin suture. Adhesion score Immediate relaparotomy was performed after sacrifice; presence and severity of adhesions were scored as suggested by Knightly as follows; 0: No adhesions; 1: Filmy adhesions; 2: Definite localized adhesions; 3: Dense multiple visceral adhesions; 4: Dense adhesions extending to abdominal wall (27). Burst pressure (BP) After the evaluation of intraabdominal adhesions, all rats underwent total gastrectomy. The esophagus was transected 1-1,5 cm from gastric cardia and double suture ligated. The pyloric end was attached to a polyurethane tube and securely tied in order to prevent air leakage. The other end of the tube was connected to an air infusion pump and a mercury manometer by a Y type connector. Gastrectomy material was further submerged into a water-filled container and air was pumped at a regular rate of 2 ml/min. The pressure at which the pressure suddenly decreased or bubbles were seen was accepted as BP. Maximum pressure available with this manometer was 300 mmHg. For this reason, pressures exceeding this level were recorded as 300 mmHg. Histopathological assessment After the measurement of burst pressures, suture materials or clip were gently removed from the perforation area, and gastrectomy materials were separately kept in formalin-filled containers. All histological analysis was done by the same blinded pathologist. Pathological assessment was done by the following scale: Presence or absence of superficial exudates, fibroblastic proliferation, presence and severity of granulation tissue, acute and chronic inflammation and collagen deposition. By this scale, the status of wound healing was evaluated in a quantitative manner for evaluation of early and late term healing. Granulation tissue, acute and chronic inflammation and collagen deposition were quantitatively evaluated [0: absent; 1: mild; 2: moderate, 3: severe]. Statistical analysis Categorical variables were analyzed using Chi-square test. Numerical variables were assessed by One  Cyanoacrylate on perforation 227 Table I. Demonstration of burst pressure and histological healing indices. (* = p