Research review
Tissue adhesives in gastrointestinal anastomosis: a systematic review

https://doi.org/10.1016/j.jss.2012.12.043Get rights and content

Abstract

Background

Anastomotic leakage in gastrointestinal (GI) surgery remains a major problem. Although numerous studies have been undertaken on the role of tissue adhesives as GI anastomotic sealants, no clear overview has been presented. This systematic review aims to provide a clear overview of recent experimental and clinical research on the sealing of different levels of GI anastomosis with tissue adhesives.

Methods

We searched MEDLINE and Embase databases for clinical and experimental articles published after 2000. We included articles only if these addressed a tissue adhesive applied around a GI anastomosis to prevent anastomotic leakage or decrease leakage-related complications. We categorized results according to level of anastomosis, category of tissue adhesive, and level of evidence.

Results

We included 48 studies: three on esophageal anastomosis, 13 on gastric anastomosis, four on pancreatic anastomosis, eight on small intestinal anastomosis, and 20 on colorectal anastomosis; 15 of the studies were on humans.

Conclusions

Research on ileal and gastric/bariatric anastomosis reveals promising results for fibrin glue sealing for specific clinical indications. Sealing of pancreatico-enteric anastomosis does not seem to be useful for high-risk patients; however, research in this field is limited. Ileal anastomotic sealing was promising in every included study, and calls for clinical evaluation. For colorectal anastomoses, sealing with fibrin glue sealing seems to have more positive results than with cyanoacrylate. Further research should concentrate on the clinical evaluation of promising experimental results as well as on new types of tissue adhesives. This research field would benefit from a systematic experimental approach with comparable methodology.

Introduction

Each year, millions of gastrointestinal (GI) anastomoses are created worldwide. Anastomotic leakage (AL) after the creation of a GI anastomosis remains an important complication in GI surgery. Despite years of research, the incidence of AL remains high, especially after esophageal and colorectal anastomosis [1], [2], [3]. Anastomotic leakage is known to have a multifactorial etiology, mostly based on ischemia of the bowel endings and/or technical failure. Many risk factors are known, and can be categorized into patient-related risk factors (i.e., comorbidity, body mass index, drug use) and operative factors (i.e., surgeon’s experience, after-hours surgery, anastomotic location and operating time) [2], [4].

Tissue adhesives have gained popularity in various fields of surgical practice, especially in skin closure. There are various types of tissue adhesives, each with their own adhesive mechanisms and uses [5]. Basically, a tissue adhesive forms bonds with its substrate, ensuring sufficient adhesion. These bonds can either be chemical, of which covalent bonds are the strongest, or physical, including hydrogen bonds or van der Waals forces [6]. Furthermore, the total strength of the glue bond depends on the balance between interaction within the tissue adhesive (cohesion) and between the tissue adhesive–substrate interface (adhesion). Tissue adhesives can either be glues, intended to independently connect various structures (i.e., wound edges), or sealants, used to cover and protect an anastomosis.

Except for external use, tissue adhesives can also be used intracorporeally. Various tissue adhesives are being used in cardiovascular surgery, plastic surgery, and, increasingly, surgery of the GI tract [7], [8]. Tissue adhesives are promising tools for wound closure. They distribute forces throughout the wound more evenly and noninvasively than sutures and staples, are strong and flexible, and do not interfere with the wound-healing process. Also, the technique of tissue adhesive application to the wound is easy and standardizable, resulting in less variation in technique between surgeons.

By using tissue adhesives as sealants of GI anastomosis, enhancing standard anastomotic techniques, AL might be prevented or reduced and its clinical symptoms ameliorated. Numerous research projects have been undertaken to assess the applicability of available tissue adhesives in GI surgery; however, no recent literature provides the surgical community with an up-to-date overview of the progress in this field.

This systematic review includes recent information on tissue adhesives with regard to all types of anastomotic configurations in the GI tract and provides a means to discover similarities and make comparisons among different levels of anastomoses. An overview is provided on all available clinical and experimental research concentrating on the use of tissue adhesives around the GI anastomosis, either as suture reinforcement or in sutureless closure, presented by level of anastomosis and category of tissue adhesive used.

We hypothesized that the use of tissue adhesives around a GI anastomosis is a viable concept in the prevention of anastomotic leakage and that sufficient evidence, especially clinically, has arisen in past years to justify the implementation of several types of tissue adhesives for routine use.

Section snippets

Search strategy

We performed this systematic review according to the PRISMA guidelines [9]. We performed a literature search including all relevant articles from January 1, 2000, until May 12, 2011. The search was performed using the Embase and MEDLINE databases. We included only English articles and excluded review articles and meta-analyses. For the study selection process, see Figure.

Study selection

We included articles only if they addressed a tissue adhesive applied around a GI anastomosis to prevent AL or to decrease

Results

Table 1 provides an overview of all types of tissue adhesives, as mentioned in the included articles. Results are summarized below according to the level of GI anastomosis, and are grouped by type of research (experimental or clinical) and by tissue adhesive category; tissue adhesive categories are mentioned only if they were used in at least one included study.

Discussion

Anastomotic leakage remains an important complication in GI surgery. It is a significant cause of morbidity and mortality, necessitating redo operations and increasing length of hospital stay [56], [57]. Anastomotic leakage occurs at every level of GI surgery. In this review, we address recent tissue adhesive research for all levels of GI anastomosis.

Acknowledgments

The authors thank W. Bramer and G. de Jonge for kind assistance throughout the formation of this review.

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