Intestinal surgery is commonly performed in small animal veterinary patients, most often for removal of ingested foreign material.1–3 One of the most devastating postoperative complications of intestinal surgery is leakage at the surgical site, which can result in development of septic peritonitis or generalized sepsis and an increase in the risk of death.4,5 Rates of leakage after intestinal resection and anastomosis in dogs and cats have been reported to range from 11% to 14%.6,7 Factors that increase the risk of anastomotic leakage include the presence of inflammation or infection in the peritoneal cavity, decreased blood flow to the surgical site, hypoproteinemia, poor surgical technique, resection and anastomosis involving portions of the large intestine, and perioperative administration of glucocorticoids (eg, prednisone or prednisolone) or antineoplastic treatments.7,8 Anastomotic leakage requires repeated surgery, which can be associated with increased hospitalization time and increased cost for the animal's owner.
Given the potentially deadly consequences of intestinal leakage, the use of surgical sealants, also referred to as tissue sealants, to strengthen the anastomotic site and reduce the risk of leakage has been investigated extensively in human and laboratory animal medicine.9 The ideal sealant is easy to use, biocompatible, inexpensive, and effective for holding 2 tissue surfaces together in a moist environment. It should also be biodegradable, and its use should be associated with minimal to no adverse effects.9 Potential adverse effects of surgical sealants include inflammation, foreign body reaction, toxicosis (often from breakdown products), delayed healing, and tissue distortion. An example of tissue distortion might be stricture formation secondary to sealant use on an organ that has a lumen.9
Tissue sealants can be categorized as synthetic, biomimetic, and biological types.9 Synthetic sealants include the cyanoacrylate glues, among others. Owing to inflammatory reactions and toxic effects, synthetic sealants are generally not suitable for internal surgical use. Biomimetic sealants have been developed to mimic the properties of natural sealants that are effective in wet environments, such as those produced by marine species or gecko species. Biological sealants include fibrin, collagen, albumin, gelatin, and polysaccharide-based products.9,10 They are biocompatible and are frequently used in people for purposes of general hemostasis in surgical applications, during plastic surgery procedures, and for sealing and preventing pulmonary air leaks, lymphatic fluid leaks, and CSF leaks.9–15
Protein-based biological sealants are compounds that solidify when applied and are attractive options for sealing air and fluid leaks because of their ability to bond even in moist environments.9,16–18 In human medicine, a BA-10G sealanta has been approved for use in aortic surgery in the United States.10,19,20 This sealant has also been shown to increase the ex vivo bursting strength of gastrojejunal anastomoses in fresh porcine tissues.21 Recently, a similar BA-DG sealantb,c became available for veterinary use.22 Results of a study23 indicated that ex vivo leakage pressures of enterotomies in fresh caprine tissues were significantly higher with than those achieved without the use of this sealant. The use of the sealant in dogs or cats has not been reported, to our knowledge.
The purpose of the study reported here was to evaluate the effect of a BA-DG sealant on leakage pressures of intestinal anastomoses in jejunal tissue collected from fresh canine cadavers and to evaluate changes in circumference and cross-sectional area of the anastomotic site after application of the sealant. We hypothesized that the leakage pressures would be significantly higher for sutured intestinal anastomoses with sealant application, compared with those values in a control group of sutured anastomoses with no sealant application. We also hypothesized that the application of the sealant would not significantly alter the outer circumference or the cross-sectional area of the intestine at the site of anastomosis.
No third-party funding or support was received in connection with this study or the writing or publication of the manuscript. The authors declare that there were no conflicts of interest.
The authors acknowledge the use of the facilities of the Purdue University Pre-Clinical Research Laboratory, a core facility of the NIH-funded Indiana Clinical & Translational Science Institute. The authors thank Ted Vlahos, Shery Park, Christa Cain, and Robyn McCain for technical assistance.
Bovine albumin crosslinked with 10% glutaraldehyde
Bovine albumin–derivatized glutaraldehyde biopolymer
BioGlue surgical sealant, Cryolife Inc, Kennesaw, Ga.
Kem Schankereli, Avalon Medical, Stillwater, Minn: Personal communication, 2018.
PoliPhase, Avalon Medical, Stillwater, Minn.
PDS II (polydioxanone) suture, Ethicon, Somerville, NJ.
0.9% sodium chloride irrigation USP, Braun, Aschaffenburg, Germany.
Lactated Ringer injection USP, Hospira, Lake Forest, Ill.
Fountain pen India ink, Higgins, Leeds, Mass.
Truwave, Model PX260, 3cm2/60inches, Edwards Life-sciences, Irvine, Calif.
Abbot Plum XL Micro Macro Infusion Pump, Abbot Laboratories, North Chicago, Ill.
STATA SE, version 14.2, StataCorp, College Station, Tex.
6. Duell JR, Thieman Mankin KM, Rochat MC, et al. Frequency of dehiscence in hand-sutured and staples anastomoses in dogs. Vet Surg 2016;45:100–103.
7. Ralphs SC, Jessen CR, Lipowitz AJ. Risk factors for leakage following intestinal anastomoses in dogs and cats: 115 cases (1991–2000). J Am Vet Med Assoc 2003;223:73–77.
8. Snowdon KA, Smeak DD, Chiang S. Risk factors for dehiscence of stapled functional end-to-end intestinal anastomoses in dogs: 53 cases (2001–2012). Vet Surg 2016;45:91–99.
9. Duarte AP, Coelho JF, Bordado JC, et al. Surgical sealants: systematic review of the main types and development forecast. Prog Polym Sci 2012;37:1031–1050.
11. Spotnitz WD, Dalton MS, Baker JW, et al. Reduction of perioperative hemorrhage by anterior mediastinal spray application of fibrin glue during cardiac operation. Ann Thorac Surg 1987;44:529–531.
12. Saltz R, Zamora S. Tissue sealants and applications in plastic and reconstructive surgery. Aesthetic Plast Surg 1998;22:439–443.
13. Samuels LE, Shaw PM, Blaum LC. Percutaneous technique for management of persistent airspace with prolonged air leak using fibrin glue. Chest 1996;109:1653–1655.
14. Sawamura Y, Asoaka K, Terasaka S, et al. Evaluation of application techniques of fibrin sealant to prevent cerebrospinal fluid leakage: a new device for the application of aerosolized fibrin glue. Neurosurgery 1999;44:332–337.
15. Gregor RT. Management of chyle fistulization in association with neck dissection. Otolaryngol Head Neck Surg 2000;122:434–439.
17. Liu Y, Kopelman D, Wu L-Q, et al. Biomimetic sealant based on gelatin and microbial transglutaminase: an initial in vivo investigation. J Biomed Mater Res B Appl Biomater 2009;91:5–16.
19. Küçükaksu DS, Akgul AC, Caoli K, et al. Beneficial effect of BioGlue surgical sealant in repair of iatrogenic aortic dissection. Tex Heart Inst J 2000;27:307–308.
21. Nandakumar G, Richards BG, Trencheva K, et al. Surgical sealant increases burst pressure and seals leaks in stapled gastrojejunostomy. Surg Obes Relat Dis 2010;6:498–501.
23. Jones CT, Chen CY, Campbell BG, et al. Assessment of leakage pressure following enterotomy closure reinforced by tissue sealant in a caprine cadaver model. N Z Vet J 2017;65:248–251.
24. Fossum TW, Dewey CW, Horn CV, et al. Surgery of the digestive system. Small animal surgery. 4th ed. St Louis: Elsevier, 2013;506–507.
25. Hansen LA, Monnet EL. Evaluation of serosal patch supplementation of surgical anastomoses in intestinal segments from canine cadavers. Am J Vet Res 2013;74:1138–1141.
26. Vakalopoulos KA, Wu Z, Kroese LF, et al. Sutureless closure of colonic defects with tissue adhesives: an in vivo study in the rat. Am J Surg 2017;213:151–158.
27. Vakalopoulos KA, Bosmans JWAM, van Barneveld KWY, et al. Impact of tissue adhesives on the prevention of anastomotic leakage of colonic anastomoses: an in vivo study. Int J Colorectal Dis 2017;32:961–965.
28. Vakalopoulos KA, Daams F, Wu Z, et al. Tissue adhesives in gastrointestinal anastomosis: a systematic review. J Surg Res 2013;180:290–300.
29. Vakalopoulos KA, Wu Z, Kroese LF, et al. Mechanical strength and rheological properties of tissue adhesives with regard to colorectal anastomosis: an ex vivo study. Ann Surg 2015;261:323–331.
30. Vakalopoulos KA, Wu Z, Kroese LF, et al. Clinical, mechanical, and immunohistopathological effects of tissue adhesives on the colon: an in vivo study. J Biomed Mater Res B Appl Biomater 2017;105:846–854.
32. Chiba T, Sarr MG, Kendrick ML, et al. Limitations of implantable, miniature ultrasonic transducers to measure wall movement in the canine jejunum. J Surg Res 2004;116:219–226.
33. Hansen LA, Smeak DD. In vitro comparison of leakage pressure and leakage location for various staple line offset configurations in functional end-to-end stapled small intestinal anastomoses of canine tissues. Am J Vet Res 2015;76:644–648.
34. Curran KM, Fransson BA, Gay JM. A comparison of in situ and in vitro techniques for bursting pressure testing of canine jejunum. Am J Vet Res 2010;71:370–373.
35. Knecht CD, Allen AR, Williams DJ, et al. Suture patterns. In: Peterson D, ed. Fundamental techniques in veterinary surgery. 3rd ed. Philadelphia: WB Saunders, 1987;57–59.
36. Wu Z, Vakalopoulos KA, Boersema GSA, et al. The prevention of colorectal anastomotic leakage with tissue adhesives in a contaminated environment is associated with the presence of anti-inflammatory macrophages. Int J Colorectal Dis 2014;29:1507–1516.
37. Wu Z, Boersema GSA, Kroese LF, et al. Reducing colorectal anastomotic leakage with tissue adhesive in experimental inflammatory bowel disease. Inflamm Bowel Dis 2015;21:1038–1046.
38. Ozmen MM, Ozalp N, Zulfikaroglu B, et al. Histoacryl blue versus sutured left colonic anastomoses: experimental study. ANZ J Surg 2004;74:1107–1110.
40. Despoudi K, Mantzoros I, Ioannidis O, et al. Effects of albumin/glutaraldehyde glue on healing of colonic anastomosis in rats. World J Gastroenterol 2017;23:5680–5691.