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PubMed2005

Feasibility study for robotic radical prostatectomy cautery-free neurovascular bundle preservation.

INTRODUCTION: Efforts continue to develop techniques that maintain the neurovascular bundles and minimize trauma for robotic laparoscopic radical prostatectomy. We evaluated the feasibility of preserving the nerve bundles without cautery or surgical clips. TECHNICAL CONSIDERATIONS: The seminal vesicles were dissected using scissors and bipolar cautery. After the rectum was mobilized, the vascular pedicles (VPs) were delineated. Laparoscopic bulldog clamps (30 mm) were placed at least 1 cm from the prostate. Using scissors, the VPs were divided right at the prostate. The neurovascular bundle was gently dissected off the prostatic capsule. After mobilizing the bundle, FloSeal was applied along its entire length. The FloSeal was then covered with a dry 1 x 4-cm sheet of Gelfoam. Once the prostate was removed, the bulldog clamps were sequentially withdrawn. The VPs were observed, and, if pulsatile bleeding was encountered, a 3-0 figure-of-eight suture was precisely placed for hemostasis. When hemostasis was complete, the anastomosis was performed. RESULTS: In 17 men, temporary vascular occlusion was applied to 27 VPs and FloSeal and Gelfoam was applied each time. In 4 cases (15%), hemostasis was inadequate because of continued arterial bleeding that was easily controlled with a superficial figure-of-eight ligature of 3.0 absorbable suture. The average estimated blood loss was 91 mL (range 75 to 150). CONCLUSIONS: Cautery-free, clip-free, nerve-sparing robotic laparoscopic radical prostatectomy is feasible using a combination of temporary occlusion of the thick posterior prostatic pedicles with bulldog clamps followed by application of FloSeal. The effect on potency needs further follow-up.

Adult↗

PubMed2005

Vascular complications after percutaneous nephrolithotomy: are there any predictive factors?

OBJECTIVES: To evaluate the severe hemorrhagic complications of percutaneous nephrolithotomy (PNL) and their management and to analyze the predictive factors. METHODS: We retrospectively analyzed the data of 1854 patients who had undergone PNL for removal of renal calculi at our institute between 1993 and 2003. All patients were resuscitated with intravenous fluids and blood transfusions. Patients in whom bleeding did not respond to conservative means underwent angiography and subsequent embolization. Multivariate analyses were done to determine the various factors responsible for the occurrence of these lesions. RESULTS: Of the 1854 patients, 27 (1.4%), with a mean age of 38.6 years (range 19 to 63) required angiography and/or embolization for bleeding control. The mean time to the onset of hemorrhage was 8 days (range 2 to 18). Renal arteriography revealed pseudoaneurysm in 13, arteriovenous fistula in 6, a combination of both in 4, lumbar artery injury in 1, and no lesion in 3 patients. In 22 patients, successful embolization of the offending vessel was achieved and in 2 the hematuria recurred. These 2 patients underwent repeat angiography and embolization of the lesion. Metallic coils were used in 13, Gelfoam in 5, and coils and Gelfoam in 8 patients. On multivariate analysis, only stone size was the significant factor predicting for the occurrence of these vascular complications. CONCLUSIONS: Severe hematuria is a rare complication of PNL that can be successfully managed with angioembolization. Our results indicated that stone size significantly predicted for the occurrence of lesions in patients undergoing PNL for symptomatic stone disease.

Adult↗

PubMed1992

Nonoperative management of visceral aneurysms and pseudoaneurysms.

During the period from 1975 to 1991, 41 patients with 60 visceral artery aneurysms were treated at the Affiliated Hospitals of Emory University. The total included 13 patients in whom 16 aneurysms were treated primarily by transarterial embolization. There were seven hepatic artery aneurysms, three splenic artery aneurysms, three gastroduodenal artery aneurysms, two left gastric artery aneurysms, and one right gastroepiploic artery aneurysm. Average age of these patients was 50 years; there were eight males and five females. Seven patients presented with gastrointestinal bleeding, and two patients presented with abdominal pain. In four patients, the aneurysm was an incidental finding. Etiology of the true or false aneurysms consisted of pancreatitis in two patients, trauma in three patients, connective tissue disease in one, and was unknown in the remainder. Embolization was performed in seven cases with Gianturco coils and Gelfoam, with coils alone in four, with Gelfoam alone in four, and with detachable balloons in one instance. Complete occlusion was achieved initially in 13 cases. Recanalization occurred in two patients over a mean follow-up period of 8.6 months, requiring re-embolization in one patient, whereas the other patient was managed expectantly. In three cases, embolization was unsuccessful: two cases required surgical correction, and one case was managed expectantly. Only one complication was related to the embolization procedure, which was a common hepatic arterial dissection that proceeded to the formation of a false aneurysm. Embolization as the primary treatment modality for visceral artery aneurysms should be considered in patients with the following diagnoses: pseudoaneurysms associated with pancreatitis, intrahepatic aneurysms, most splenic artery aneurysms, and gastric, gastroduodenal, and gastroepiploic aneurysms. The procedure has a low risk and may obviate a difficult surgical procedure, but it does not preclude surgical intervention should the need arise.

Adolescent↗

PubMed1985

Hemorrhagic pancreatitis: a complication of transcatheter embolization treated successfully by total pancreatectomy.

Since pancreatitis can be produced experimentally in dogs by embolization of microspheres into the pancreatic arterial circulation, there has been speculation that intentional or inadvertent embolization of the pancreas in human subjects could also produce pancreatitis. Although such therapeutic embolization has increased, no pathologically documented case of this complication has been recorded. We have reported the first such case occurring in a patient with a large, highly vascular, nonfunctioning islet cell carcinoma of the tail of the pancreas preoperatively embolized with Gianturco coils and Gelfoam particles suspended in sodium tetradecylsulfate solution to facilitate distal pancreatectomy. The resultant hemorrhagic pancreatitis and duodenal necrosis required a total pancreatectomy. We conclude that, by itself, occlusion of the origin of the splenic and gastroduodenal arteries with coils would have been effective and without complication; however, the addition of Gelfoam particles in a sclerosing solution reduced the microscopic pancreatic circulation to a critical point and resulted in hemorrhagic pancreatitis.

Adenoma, Islet Cell↗

PubMed2000

The effect of epidermal growth factor on the fetal rabbit mandibular condyle and isolated condylar fibroblasts.

The load-bearing surface of the mandibular condyle presents a unique arrangement of tissues consisting of an avascular layer composed largely of collagen bundles. Fibroblasts are interspersed amongst these bundles and are generally agreed to produce the collagen. The mechanisms controlling development of these tissues have not been determined. This study was conducted to explore the role of epidermal growth factor (EGF), which appears to be important in the development of many oral tissue types as well as in the growth and differentiation of the mandibular condyle. Superficial cells of the fibrous zone of the condyle were isolated from fetal rabbit condyles and [(3)H]thymidine incorporation into DNA measured. The application of EGF produced a significant increase in radiolabel incorporation after 2 days compared to 4 days in the controls, suggesting that EGF induced cells to enter S-phase more rapidly. Fetal condyles were also cultured on gelfoam surgical sponges for up to 21 days. Autoradiography of cultured condyles showed that cells of all three zones may potentially replicate, as indicated by incorporation of [(3)H]thymidine. All three regions displayed greater increases in cell numbers in samples exposed to EGF than in control samples. The measurement of zone thickness in condyles cultured on gelfoam sponges with or without EGF showed that this peptide was able to re-establish thickness, bringing it in line with the relation observed when the condyles were isolated initially, particularly of the intermediate zone over a period of 21 days. As very little autoradiographic labelling occurred at this time-point in any of the zones, the increase in thickness must primarily be due to matrix production. It is concluded that EGF is one factor potentially regulating both replication and differentiation in mandibular condyle and its associated cells.

Analysis of Variance↗

PubMed2003

Delayed transplantation of fibroblasts genetically modified to secrete BDNF and NT-3 into a spinal cord injury site is associated with limited recovery of function.

Delivery of neurotrophic factors in acute models of spinal cord injury in adult rats can rescue axotomized neurons, promote axonal growth, and partially restore function. The extent to which repair and recovery of function can be achieved after chronic injury has received less attention. In the companion paper we show that transplanting fibroblasts genetically modified to produce neurotrophic factors into chronic (6-week) hemisection injuries results in sprouting, partial neuroprotection, but only limited regeneration. Here we describe functional consequences of this treatment using a series of behavioral tests. Adult rats received a complete unilateral C3/C4 hemisection and recovery from the injury was assessed over 5 weeks. At 6 weeks postoperative, the experimental group received grafts of a combination of fibroblasts modified to secrete BDNF or NT-3. The operated control groups received grafts of either gelfoam or gelfoam with fibroblasts expressing GFP into the lesion site. Behavioral recovery in the three groups was assessed over the next 10 weeks. Severe deficits with no recovery in any of the groups were observed in several tests (BBB, limb preference, narrow beam, horizontal rope test) that measure primarily motor function. Recovery was observed in the grid test, a measure of sensorimotor function, and the von Frey test, a measure of response to mechanical stimulation, but there were no differences between the operated control or experimental groups. Both groups also showed recovery from heat-induced hyperalgesia, with the experimental group exhibiting greater recovery than the operated control groups. In this test, delivery of neurotrophic factors from transplanted fibroblasts does not worsen responses to nociceptive stimuli and in fact appears to reduce hypersensitivity. Our data also demonstrate that additional damage to the spinal cord upon placement of a graft further compromises behavioral recovery for locomotor and postural function. Additional therapeutic interventions will be necessary to provide greater levels of recovery after chronic injuries.

Animals↗

PubMed1977

Therapeutic renal infarction.

Pre-nephrectomy therapeutic renal infarction by injecting gelfoam into the renal artery was done in 10 patients with hypernephroma. This technique facilitates nephrectomy and decreases blood loss. A post-infarction syndrome characterized by flank pain, fever and nausea occurred in most patients. In addition, a dialysis patient underwent bilateral renal infarction with improvement of blood pressure control. Distal embolization of gelfoam occurred in this patient, resulting in significant gangrene of 1 foot.

Adenocarcinoma↗

PubMed1999

Preoperative embolization of meningiomas with pial supply: successful treatment of two cases.

BACKGROUND: The efficacy of preoperative embolization for hypervascular meningiomas fed by the pial branches of the internal carotid artery was evaluated. METHODS: Two cases of hypervascular meningiomas fed by the cortical branches of the internal carotid arteries are presented. In the first patient, the left anterior frontal internal artery was embolized with gelatin sponge (Gelfoam) as a preoperative treatment using a microcatheter. The tumor was totally resected with 1,000 ml of blood loss. In the second patient, the right sulcal artery was embolized with Gelfoam. The patient subsequently underwent surgical resection with 100 mL of blood loss. RESULTS: No neurological deficit appeared after the embolization or the surgery in either case. CONCLUSION: Preoperative embolization of hypervascular meningiomas, mainly fed by the cortical branches of the internal carotid arteries, may be possible and effective.

Carotid Artery, Internal↗

PubMed1998

The effects of central administration of neurotrophins or transplants of fetal tectal tissue on retinal ganglion cell survival following removal of the superior colliculus in neonatal rats.

In neonatal rats, intraocular injections of brain-derived neurotrophic factor (BDNF) or neurotrophin 4/5 (NT-4/5) enhance the survival of retinal ganglion cells (RGCs) following superior colliculus (SC) ablation [Q. Cui, A.R. Harvey, At least two mechanisms are involved in the death of retinal ganglion cells following target ablation in neonatal rats, J. Neurosci., 15, 1995, pp. 8143-8155.]. The aim of the present study was to determine if: (i) fetal tectal tissue grafted into the lesion site, or (ii) neurotrophins applied centrally to the injured SC, also decreased lesion-induced RGC death. Nuclei of tectally projecting RGCs were identified by injecting diamidino yellow (DY) into the left SC of 2-day-old (P2) Wistar rats. Injected SCs were lesioned at P4. In some animals, embryonic (E16) tectal tissue was then implanted into the lesion cavity; host rats were perfused 24 h or 20 days later. In short-term (24-h) studies, the number of DY-labelled pyknotic profiles was compared to the number of normal DY-labelled RGCs in retinal wholemounts (right eyes). The proportion of dying RGCs in animals with grafts (10.7%, n = 17) was not significantly different from lesion-only rats (13.2%, n = 26). Nonetheless, the long-term (20-day) study showed that, in most rats, fetal tectal tissue survived in the lesion cavity and in some cases, the grafts received host retinal input. In another group, different doses of BDNF or NT-4/5 were applied to the SC after P4 tectal lesions. Rats were perfused 24 h later and the number of pyknotic vs. normal DY-labelled RGCs was determined. Initial trials in which SC lesions were filled with gelfoam soaked in BDNF or NT-4/5 were unsuccessful; however, RGC death was reduced (p < 0.05, Dunnett's test) in rats that received gelfoam implants as well as focal neurotrophin injections into SC rostral to the lesion. The lowest pyknotic rate in individual animals from the BDNF and NT-4/5 groups was 2.41% and 2.01%, respectively. Overall, the proportion of dying RGCs was 7.0% (n = 8) for BDNF and 7.4% (n = 17) for NT-4/5 treated rats. Normal RGC densities were also significantly higher in these animals. NT-4/5 topically applied to the posterior surface of the eye did not reduce RGC death. The data show that the viability of injured neonatal RGCs is increased by specific retrograde neurotrophin-mediated survival signals which can be activated from the SC.

Administration, Topical↗

PubMed1999

Rescue of axotomized rubrospinal neurons by brain-derived neurotrophic factor (BDNF) in the developing opossum, Didelphis virginiana.

Many rubrospinal neurons die in developing opossums when their axon is cut at thoracic levels of the spinal cord and in the present study we asked whether they can be rescued by brain-derived neurotrophic factor (BDNF). Bilateral injections of Fast Blue (FB) were made into the rostral lumbar cord to prelabel rubrospinal neurons and 5 days later the rubrospinal tract was cut unilaterally by hemisecting the thoracic cord. Immediately after hemisection, BDNF-soaked gelfoam was placed into the lesion cavity. Since pilot data indicated that one application of BDNF was not sufficient to produce a rescue effect, a second application was made 7 days later. Seven days after the second application the pups were killed by an overdose of anesthetic so that the red nucleus contralateral and ipsilateral to the lesion site could be examined for labeled neurons. The rubrospinal tract is almost entirely crossed, so the red nucleus contralateral to the lesion contained many axotomized neurons, whereas the red nucleus ipsilateral to it did not. Age-matched controls were subjected to the same procedures, but the gelfoam applied to the lesion site in the experimental animals was soaked only in the vehicle used to deliver BDNF. In all cases, labeled neurons were fewer in number in the red nucleus contralateral to the lesion than ipsilateral to it. It was of particular interest, however, that labeled neurons contralateral to the lesion were more numerous in the animals treated with BDNF than in the controls. We conclude that BDNF rescues at least some rubrospinal neurons from axotomy-induced cell death in developing opossums suggesting that loss of access to BDNF, and perhaps other neurotrophins, contributes to failure of rubrospinal neurons to survive axotomy.

Amidines↗

PubMed1997

A comparison of the biocompatibility of three absorbable hemostatic agents in the rat middle ear.

Absorbable gelatin sponge (Gelfoam) has been used for many years in middle ear surgery. Although the sponge is generally well tolerated, fibrosis occasionally forms in the mesotympanum; some studies indicated that the absorbable gelatin sponge may be responsible. Many of these studies lack statistical analysis. We prospectively studied three absorbable hemostatic agents in the middle ear of adult male Sprague-Dawley rats to determine which promotes fibrosis to the greatest degree: absorbable gelatin sponge (Gelfoam), absorbable gelatin sheet (Gelfilm), or absorbable collagen sheet (Instat). The materials were implanted in the middle ear through a post-auricular approach and the temporal bones were serially harvested at different time intervals so we could examine histologic changes. The nonimplanted ear served as surgical control. Examination of the specimens at 6, 8, and 10 weeks by light microscopy revealed that although absorbable gelatin film and collagen-absorbable hemostat are well tolerated in this animal model, absorbable gelatin sponge promoted the presence of fibrosis to a significantly greater degree, (p = 0.0344). We conclude that absorbable gelatin sponge promotes fibrosis more frequently than do collagen-absorbable hemostat and absorbable gelatin film in this animal model.

Absorption↗

PubMed1996

Effect of decalcified freeze-dried bone allograft on the healing of jaw defects after cyst enucleation.

PURPOSE: This study radiographically evaluated the changes that occur in jaw defects after enucleation of cysts and either grafting with demineralized freeze-dried bone allograft (DFDBA) or packing with absorbable gelatine sponge (Gelfoam). PATIENTS AND METHODS: Thirty-two patients (14 males, 18 females) with cystic lesions of the jaws were divided into two groups. Group A underwent enucleation and bone grafting with DFDBA. Group B underwent enucleation and packing with Gelfoam. Both groups were evaluated radiographically before surgery, immediately postoperatively, and 6, 12, 24, and 36 months postoperatively. The density of the area was measured with a digital densitometer. RESULTS: The density in group A was significantly (P < .05 to .01) greater than in group B at 6 and 12 months postoperatively. The difference at 24 months was not significant. Group A reached density levels at 6 months that were reached by group B at 12 months. CONCLUSION: The findings demonstrate that decalcified freeze-dried bone allograft enhances bone healing in jaw defects after cyst removal.

Adolescent↗

PubMed1999

Formulation and in vivo evaluation of ocular insert containing phenylephrine and tropicamide.

A Gelfoam based ocular device containing 1.7 mg of phenylephrine and 0.6 mg of tropicamide was formulated and evaluated for pupillary dilation in rabbits. The manufacturing procedure is fairly simple and the required excipients are inexpensive. The in vivo results show that the mydriatic response produced by the proposed device is larger and longer lasting than that produced by eyedrops with an equivalent amount of phenylephrine and tropicamide. The results reported in this study, along with those of previous studies, imply that Gelfoam(R) is a versatile drug carrier for either local or systemic drug delivery via the ophthalmic route.

Animals↗

PubMed1988

Effect of a topical drug combination on the early healing of extraction sockets in the vervet monkey.

An animal trial was undertaken in 9 vervet monkeys to test the effect of a medicament combination on extraction socket healing. All 4 third molar teeth were extracted and 2 of the sockets in each animal were packed with Gelfoam sponge impregnated with a medicament containing a local anaesthetic, antiseptic, 2 potent antifibrinolytic agents and metronidazole. The remaining 2 sockets acted as controls: one of the sockets was packed with Gelfoam sponge alone and the other allowed to heal spontaneously with no implant. The healing of these sockets was evaluated histometrically in 4-, 6- and 8-day specimens, and from the results it was concluded that sockets containing the medicament compound showed enhanced early socket healing.

Administration, Topical↗

PubMed1999

Experimental evaluation of cellulose acetate NF and ethylene-vinyl alcohol copolymer for selective arterial embolization.

PURPOSE: Studies were conducted in rabbits to evaluate two new liquid polymeric compounds developed for selective arterial embolization. MATERIALS AND METHODS: The compounds consisted of cellulose acetate NF (Embolyx C) or ethylene-vinyl alcohol copolymer (Embolyx E) dissolved in anhydrous dimethyl sulfoxide (DMSO) containing 30% tantalum powder. Acute renal embolization was performed to determine an optimal method of administration and level of embolization. Kidneys were embolized with and without flow around the catheter. DMSO was also injected in the same manner. Tissue sections were examined radiographically and microscopically. Tumor embolization was performed to evaluate the efficacy of the polymers and compare their embolic effects with polyvinyl alcohol (PVA) particles and gelatin sponge (Gelfoam) powder. An embolic agent, saline, or DMSO was injected into the deep femoral artery feeding an intramuscular VX2 carcinoma. Animals were followed up for 3 weeks. RESULTS: Viscosity and administration technique affected polymer distribution and depth of penetration. Embolization with the test polymers was quicker and more easily achieved than with PVA or Gelfoam, and no recanalization occurred. Both polymers were as effective as PVA particles for tumor ablation, but DMSO caused some vascular damage. CONCLUSION: Although use of DMSO has some drawbacks, the results of this study warrant further investigation of the Embolyx polymers for tumor embolization.

Angiography↗

PubMed1997

Effect of Brij-78 on systemic delivery of insulin from an ocular device.

An ocular insert is developed for the controlled systemic delivery of insulin. Commercially available Gelfoam absorbable gelatin sponge, USP, is used in the fabrication of the ocular insert in the form of a matrix system. Two eyedrop formulations and 13 eye device formulations were evaluated. The efficacy of insulin ocular delivery was quantitated by monitoring the changes in its pharmacological response (i.e., blood glucose lowering). The in vivo results from devices containing 0.5 or 1.0 mg of insulin with 20 micrograms of polyoxyethylene-20-stearyl ether (Brij-78) give a substantial improvement in insulin activity and a significant prolongation in its duration compared with the eyedrops. In addition, the mean blood glucose concentration returns to nearly normal levels within 60 min after the removal of the device. Overall, the application of the Gelfoam device makes it feasible to obtain a prolonged systemic delivery of insulin within the desired therapeutic levels without the risk of hypoglycemia.

Animals↗

PubMed2000

Experimental study of the influence of endoleak size on pressure in the aneurysm sac and the consequences of thrombosis.

BACKGROUND: This was an experimental study of endovascular aortic surgery, looking at the relationship between the size of an endoleak, pressure in the aneurysm sac and the effect of thrombosis produced by coagulation. METHODS: In three pigs, 16 saccular aneurysms were connected to the aorta by various side branches with different diameters and lengths ('endoleaks'). Mean and pulse pressures were measured in the systemic circulation as well as in the aneurysm sac during the experiment. Duplex ultrasonography was used to determine whether the endoleak and the aneurysm were patent or thrombosed. Thrombosis was influenced by systemic tranexamic acid, fibrinogen in the aneurysm sac, Gelfoam in both endoleak and aneurysm sac, and by Histoacryl glue in the endoleak. RESULTS: With an open endoleak, the mean pressure in the aneurysm and the aorta was identical. Mean aneurysm pressure was lower with a thrombosed endoleak and was related to the diameter of the endoleak. Pulse pressure was recorded in the aneurysm sac when there was an open endoleak and a non-thrombosed aneurysm, and was related to the diameter of the open endoleak. Thrombosed endoleaks never produced pulse pressure in the aneurysm. If Histoacryl and Gelfoam induced thrombosis of the endoleak, the decrease in mean aneurysm pressure was identical to that resulting from the spontaneous thrombosis of endoleaks. CONCLUSION: An open endoleak results in systemic arterial pressure in the aneurysm sac. Pulse pressure is detected if the aneurysm is patent, but absent if there is complete or partial thrombosis of the aneurysm. Endoleak thrombosis, either spontaneous or by embolization, is accompanied by a decrease in mean pressure and the absence of pulse pressure in the aneurysm sac. The extent to which these experimental findings are comparable to the clinical situation represents a field of further research.

Aortic Dissection↗

PubMed1999

Effective hepatic artery chemoembolization for advanced hepatocellular carcinoma with extensive tumour thrombus through the hepatic vein.

BACKGROUND AND AIMS: Advanced hepatocellular carcinoma (HCC) with extensive tumour growth through the hepatic vein still has an extremely poor prognosis, even after cancer chemotherapy and/or transarterial embolization. Although aggressive surgical treatments using extracorporeal circulation and liver transplantation have been performed by some authors, the reported results were still unsatisfactory. In this study, we report the favourable result of hepatic artery chemoembolization and subsequent surgical resection in three patients with advanced HCC with extensive tumour thrombus through the hepatic vein. METHODS AND RESULTS: Three irresectable patients with HCC with extensive tumour thrombus through the hepatic vein underwent hepatic artery chemoembolization with aclarubicin, mitomycin C, lipiodol and/or Gelfoam. After the reduction of tumour extent with hepatic artery chemoembolization, two of the three patients underwent surgical resection. These two patients are still alive at 59 and 21 postoperative months, respectively. In the other case, the extent of the tumour and functional reserve of the liver prevented us from performing surgical resection, but the patient is doing well 62 months after the initial treatment. CONCLUSIONS: Hepatic artery chemoembolization with aclarubicin, mitomycin C, lipiodol and/or Gelfoam might be an effective treatment for irresectable advanced HCC with extensive tumour thrombus into the inferior vena cava or the right atrium through the hepatic vein. Radical surgical resection might be applicable for selected patients without high surgical risk after reducing tumour extent by hepatic artery chemoembolization.

Aclarubicin↗