Hemostatic Agents in Hepatobiliary and Pancreas Surgery: A Review of the Literature and Critical Evaluation of a Novel Carrier-Bound Fibrin Sealant (TachoSil)
Background. Despite progress in surgical techniques applied during hepatobiliary and pancreas (HPB) surgery, bleeding and bile leak remain significant contributors to postoperative mortality and morbidity. Topical hemostatics have been developed and utilized across surgical specialties, but data regarding effectiveness remains inconsistent and sparse in HPB surgery. Methods. A comprehensive search for studies and reviews on hemostatics in HPB surgery was performed via an October 2011 query of Medline, EMBASE, and Cochrane Library. In-depth evaluation of a novel carrier-bound fibrin sealant (TachoSil) was also performed. Results. The literature review illustrates multiple attempts have been made at developing different topical hemostatics and sealants to aid in surgical procedures. In HPB surgery, efforts have been directed at decreasing bleeding, biliary leakage, and pancreatic fistula. Conflicting scientific evidence exists regarding the effectiveness of these agents. Critical evaluation of the literature demonstrates TachoSil is a valuable tool in achieving hemostasis, and possibly biliostasis and pancreatic fistula prevention. Conclusion. While progress has been made in topical hemostatics for HPB surgery, an ideal agent has not yet been identified. TachoSil is promising, but larger randomized, controlled clinical trials are required to more fully evaluate its efficacy in reducing bleeding, biliary leakage, and pancreatic fistulas in HPB surgery. 1. Introduction Improvements in hepatobiliary and pancreas (HPB) surgery over the past 2 decades have resulted in low surgical mortality (<1 to 5%) and morbidity rates (4 to 20%) in high-volume centers [1–3]. However, bleeding (specifically diffuse oozing from the raw resection surface) and bile leakage continue to be problematic in these operations, both intraoperatively, as well as, in the postoperative period. While there are thousands of publications available in various surgical fields regarding the use of hemostats, glues, and sealants; a very small number have focused on HPB surgery [4–6]. Differing requirements and needs for each surgical specialty should lead one to apply caution before inferring equal appropriateness and efficacy of hemostatic (and bilostatic) agents across specialties [7]. A very thorough update and comparison of FDA-approved topical hemostats (capable of clotting blood), sealants (provide a sealing barrier in the presence or absence of blood), and adhesives (bond tissues together) in the “surgical toolbox” was recently performed by Spotnitz and Burks [8, 9]. These authors have
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