EP3648804A1 - A tissue sealant for use in the formation of an anastomosis in the gastrointestinal tract - Google Patents
A tissue sealant for use in the formation of an anastomosis in the gastrointestinal tractInfo
- Publication number
- EP3648804A1 EP3648804A1 EP18746094.4A EP18746094A EP3648804A1 EP 3648804 A1 EP3648804 A1 EP 3648804A1 EP 18746094 A EP18746094 A EP 18746094A EP 3648804 A1 EP3648804 A1 EP 3648804A1
- Authority
- EP
- European Patent Office
- Prior art keywords
- tissue sealant
- fibrin
- sealant according
- tissue
- sealant
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Withdrawn
Links
Classifications
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L24/00—Surgical adhesives or cements; Adhesives for colostomy devices
- A61L24/04—Surgical adhesives or cements; Adhesives for colostomy devices containing macromolecular materials
- A61L24/10—Polypeptides; Proteins
- A61L24/106—Fibrin; Fibrinogen
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L24/00—Surgical adhesives or cements; Adhesives for colostomy devices
- A61L24/001—Use of materials characterised by their function or physical properties
- A61L24/0015—Medicaments; Biocides
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L24/00—Surgical adhesives or cements; Adhesives for colostomy devices
- A61L24/04—Surgical adhesives or cements; Adhesives for colostomy devices containing macromolecular materials
- A61L24/10—Polypeptides; Proteins
- A61L24/108—Specific proteins or polypeptides not covered by groups A61L24/102 - A61L24/106
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L2300/00—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices
- A61L2300/40—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices characterised by a specific therapeutic activity or mode of action
- A61L2300/412—Tissue-regenerating or healing or proliferative agents
- A61L2300/414—Growth factors
Definitions
- the present invention relates to a tissue sealant for use in the formation of an anastomosis in the gastrointestinal tract, a method for treating cancer in the gastrointestinal tract, and the use of fibrin and one or more human or recombinant growth factor (s) for the manufacture of a tissue sealant.
- Gastrointestinal resections are frequently performed due to a diseased segment, either benign or malignant.
- the remaining bowel ends need to be reconnected by an anastomosis and heal to restore bowel function.
- Proper wound healing is an integral part of the patients' recovery and is especially important for those critically ill. Disruption of its course may result in a delayed healing process, dehiscence, infection and death.
- the healing process of acute wounds involves a complex, dynamic, well-orchestrated series of events 1 . Colonic anastomoses tend to heal slower and are usually accompanied by a higher rate of complications in comparison to other segments of the gastrointestinal tract 2-3 .
- Colonic anastomoses are usually created either with staplers or are hand-sewn 4-5 , both techniques were shown to evoke an inflammatory response due to a foreign body reaction at the site of the anastomosis 2 ' 6 ' 7 that further compromises healing and may contribute to post-operative complications 8-9 .
- the most feared complication after colonic resection remains anastomotic leakage with an incidence of up to 25% 10 ⁇ 12 . Leakage is a significant contributor to the overall morbidity and mortality from colon resection. Additional complications following bowel resections include ileus, bleeding and strictures. While strictures are usually a late complication, ileus and bleeding often occur within the first week following the operation 13-16 .
- the colon like most of the gastrointestinal tract consists of four layers: mucosa, submucosa, muscularis intestinal, and serosa.
- the healing process following a surgical resection is initiated by the full-thickness injury to the intestine and involves a series of events including three well-defined phases: hemostasis & inflammation (0-3 days), proliferation (3-14 days), and remodeling & scar maturation (day 15 and onwards) 1 ' 3 .
- the submucosa provides the intestine with sufficient structural integrity and strength to protect against intraluminal pressures 17 ' 18 .
- US2015351730A discloses devices for sealing two bowels stumps together on the external circumference using a sealing cuff to ensure that the bowel stumps remain in position.
- a sealant can be applied on the external part of the intestine between the intestine and the sealing cuff.
- devices that use a medicament in conjunction with staples are known, see e.g. US2017056566A, which discloses an implantable adjunct that can be configured to be applied to tissue by a surgical stapler in conjunction with staples.
- the adjunct can have one or more medicaments releasably retained therein.
- medicaments include an antimicrobial agent, an antifungal agent, an antiviral agent, an antiinflammatory agent, a growth factor, an analgesic, an anticancer agent, an anti-adhesion agent, a tissue matrix degradation inhibitor, a nutrient, an oxygen expelling agent, an amino acid, glutamine, insulin, butyrate, and dextran.
- the present invention relates to a tissue sealant for use in the formation of an anastomosis in the gastrointestinal tract, wherein the tissue sealant comprises 8 mg/ml or more fibrin and one or more human or recombinant growth factor (s) .
- the invention relates to that gastrointestinal tract stump ends are formed by resecting a segment of the gastrointestinal tract, the tissue sealant is applied to one or both gastrointestinal stump end(s), and the gastrointestinal stump ends are connected to form the anastomosis in the gastrointestinal tract.
- the present invention suggests applying the tissue sealant to one or both gastrointestinal stump end(s) to assist in the connection of the gastrointestinal stump ends when the anastomosis is formed.
- the present invention applies a concentration of fibrin in the tissue sealant, which is significantly higher than the concentration in plasma. It is currently believed that the higher concentration of fibrin provides a sustained release matrix for accommodating growth factors and/or platelets. As the healing progresses, the fibrin matrix will be degraded by the digestion of naturally occurring enzymes like plasmin, thereby liberating platelets and activating the growth factors to the anastomosis area.
- the sustained release ensures that growth factors are provided to the anastomosis area during an extended time period of the healing process.
- the platelet-rich plasma (PRP) used in the prior art as the sealant releases the platelets and the derived growth factors relatively fast. It has been estimated that the platelets deliver about 90% of their pay load of platelet derived growth factors within 60 min. Swift M J, et al shows that the 80% release threshold of the platelet derived growth factors bFGF and TGF- ⁇ was passed after 2 hours.
- the presence of a higher fibrin concentration in the activated product also results in a highly viscous and sticky sealant, that remains on the stump ends after application without draining off. This effect is notably pronounced when the polymerisation of the sealant occurs simultaneous with the application to the stump end(s) .
- the viscous and sticky sealant provides for an effective initial attachment of the stump ends.
- tissue sealant may further be applied around the anastomosis in a distance above and below the anastomotic line, such as 0.5 cm to 5 cm, suitably 1 to 3 cm above and/or below the anastomotic line.
- the resected segment of the gastrointestinal tract is diseased or expected to be diseased.
- diseases include the presence of benign or malignant cancer cells.
- gastrointestinal resection is performed to treat colorectal cancer.
- Other diseases which may be treated by resecting a segment of the gastrointestinal tract include inflammatory conditions of the gastrointestinal tract, such as inflammatory bowel disease, colorectal polyps, colonic diverticular disease, Crohn's disease and ulcerative colitis.
- Crohn's disease may affect the small intestine and large intestine, the mouth, esophagus, stomach and the anus, whereas ulcerative colitis primarily affects the colon and the rectum.
- the resected segment of the gastrointestinal tract includes traumatized tissue, e.g. caused by blunt or penetrating trauma. Specific examples include accidents, combat injuries, or criminal acts.
- the resected segment is healthy, and the segment is removed due to an obesity surgery, such as bariatric surgery. Bariatric surgery may be performed by resecting and rerouting the small intestine to the small stomach pouch, i.e. gastric bypass surgery. Other types of bariatric surgery include biliopancreatic diversion, such as a duodenal switch in which the part of the stomach along the greater curve is resected.
- the present invention is applied in the treatment of intussusception.
- Intussusception is a medical condition in which a part of the intestine folds into the section next to it. It typically involves the small intestine and less commonly the large intestine.
- Specific examples of intussusception include entering of the ileum into the cecum, or the prolapsing of ileum or jejunum into itself.
- the resected segment includes the intussusception.
- tissue sealants also called tissue glues or surgical tissue adhesives
- tissue glues or surgical tissue adhesives
- tissue sealants are commercially available and include fibrin sealants, cyanoacrylate sealants, gelatin-based sealants, polyurethan-based sealants, PEG-based sealants, polyester- baser based sealants, polyvinylalcohol-based sealants, oxidized regenerated methylcellulose sealants, glutaraldehyde-based adhesives, and human fibrinogen and thrombin fleece.
- the tissue sealant is a fibrin sealant, i.e. a tissue sealant comprising fibrin.
- a Fibrin sealant has the advantage of participating in the hemostasis.
- the fibrin sealant is generally derived from mammal blood to form bovine fibrin, human fibrin, equine fibrin, porcine fibrin, etc. Human fibrin is preferably used to increase the biocompatibility .
- the fibrin sealant is derived from the patient's own blood, i.e. the fibrin is autologous. The risk of mammal-borne contaminants is eliminated, which will protect the patient and the surgeon against e.g. viral diseases not yet identified. Furthermore, the use of autologous fibrin further increases the biocompatibility and reduces the risk of viral infections.
- the tissue sealant contains one or more human or recombinant growth factor (s) .
- the growth factors are capable of stimulating cell growth, proliferation, healing and cellular differentiation of the gastrointestinal stump ends, thereby promoting the healing process.
- the growth factors may emanate from a biological or synthetic origin.
- the human growth factors are derived from platelets.
- the tissue sealant is enriched with platelets, also called thrombocytes.
- platelets also called thrombocytes.
- the function of platelets is to help stop the bleeding by clumping and clotting blood vessel injuries.
- the platelets present in the tissue sealant will increase the healing activity at the intestine stump ends.
- the patient's own circulating platelets may also be attracted to the anastomosis site and assist the platelets of the tissue sealant in the hemostasis of the anastomosis.
- the human growth factors at least partly emanate from the platelets of the tissue sealant.
- the platelets may be derived from a human blood source.
- the platelets of the tissue sealant are derived from the patient's own blood. It is generally believed that fewer complications are experienced with autologous platelets due to the absent or reduced risk of immunological reactions.
- the concentration of platelets in the tissue sealant is at least twice the concentration of platelets in the patient's own blood. The increased amount of platelets in the fibrin matrix provides sufficient growth factors during the sustained release period.
- the concentration of platelets in the tissue sealant is at least three times the concentration of platelets in the patient's own blood.
- the concentration of the platelets in the tissue sealant is no more than 10 times the concentration of platelets in the patient's own blood, such as no more than 7 times.
- the concentration of platelets in the tissue sealant is about 3 to about 9 times, such as about 5 to 7 times, the concentration of platelets in the patient's own blood.
- At least a portion of the fibrin is fibrin I monomer maintained at a pH lower than pH 5.
- the advantage is that the fibrin I polymer is soluble under mild acid conditions and thus easily can be applied to the stump ends.
- at least 90% of the fibrin in the tissue sealant is fibrin I.
- the amount of fibrin is at least 8 mg/mL.
- a higher concentration of fibrin I may be selected, such as a concentration above 10 mg/mL, such as above 12 mg/mL, such as above 14 mg/mL such as above 16 mg/mL.
- the concentration of fibrin I does not exceed 50 mg/mL to reduce the risk of the sealant from becoming too viscous.
- the concentration of the fibrin I does not exceed 30 mg/mL.
- the concentration of fibrin I in the tissue sealant is 15 to 25 mg/mL.
- the tissue sealant may comprise an anti-fibrinolytic agent, such as tranexamic acid to reduce the risk of blood loss during surgery and to reduce the decomposition of fibrin.
- an anti-fibrinolytic agent such as tranexamic acid to reduce the risk of blood loss during surgery and to reduce the decomposition of fibrin.
- the amount of tranexamic acid when present is at least 0.05 mg/mL, such as at least a 0.1 mg/mL.
- the optional addition of anti-fibrinolytic agent such as tranexamic acid may be used to adjust the delivery time for the tissue factors. The time period of highest importance for obtaining a successful healing process is from day 0 to day 7.
- the amount of tranexamic acid may be adjusted so that a steady release of growth factors optionally derived from platelets is obtained during the first 7 days after surgery.
- the amount of tranexamic acid in the tissue sealant of the invention is adjusted so that the recommended i.v. dose of lOmg/kg 3-4 daily is not exceeded.
- the concentration is not above 500 mg/ml in the sealant of the invention to prevent too slow degradation of the fibrin.
- a suitable concentration of anti-fibrinolytic agent is 1.5 mg/mL to 100 mg/mL .
- the high concentration of fibrin in the tissue sealant according to the invention result in effective connection between the 2 stump ends as illustrated by the increased burst pressure obtained in the experiments reported in the appending examples. Furthermore, a high elasticity of the anastomosis in the early stages is obtained for the tissue sealant according to the invention, which will reduce the risk of leakage when partly degraded food objects are passing the gastrointestinal tract.
- the tissue sealant is Vivostat® PRF® (platelet rich fibrin) sealant.
- Vivostat® PRF® platelet rich fibrin
- citrate is transferred to the Vivostat® PRF®- Preparation Unit, and 120 mL of blood is collected from the patient into the Preparation Unit.
- the pH 4 syringe is placed in the Preparation Unit, which is then loaded into the Vivostat® Processor Unit.
- the blood is warmed to 36°C and it is separated in the upper reservoir chamber of the Preparation Unit by centrifugation .
- Plasma containing the platelet fraction
- batroxobin that has been released from the cartridge contained in the Preparation Unit
- the fibrin I polymerizes and is isolated on the walls of the chamber by repeated centrifugation .
- Excess fibrinogen and platelet depleted serum are then withdrawn back into the upper reservoir (waste) chamber of the Preparation Unit, leaving concentrated fibrin I and platelets in the reaction chamber.
- This platelet-rich fibrin concentrate is then mixed with 3.5 mL of pH 4 sodium acetate buffer to dissolve the fibrin I molecules.
- the resulting acidified platelet-rich fibrin I solution is transferred into the bottom of the Preparation Unit. Any residual pH 4 buffer is dumped into a separate bottom in the Preparation Unit and the acidified platelet- rich fibrin I solution is then withdrawn into the empty pH 4 buffer syringe.
- the concentrated fibrin I monomer solution is stable for up to 8 hours at room temperature or for several days at -20°C.
- the fibrin I monomer can be transferred to the desired applicator device for use in the present invention.
- the concentrated fibrin I monomer solution is co-applied to the stump end(s) with an alkaline buffer (carbonate/- bicarbonate buffer, pH 10) to activate the fibrin I.
- an alkaline buffer carbonate/- bicarbonate buffer, pH 10.
- described herein is also a method for applying fibrin I to one or both stump ends formed by resecting a segment of the gastrointestinal tract, comprising the step of spraying the tissue sealant of the invention comprising 8 mg/ml or more fibrin I to the stump end(s) and simultaneously spraying an alkaline buffer to activate the fibrin I.
- the ratio between the concentrated fibrin I monomer solution and the alkaline buffer is usually in the range of 4-10:1.
- the co-spraying of the fibrin I solution and the alkaline buffer result in an almost instant polymerization of the fibrin I monomer to the polymer.
- the almost instant polymerization provides the possibility of fast surgical intervention, which will reduce the time the patient is fully anesthetized.
- both the carefully mixed fibrin syringe and the syringe containing pH 10 carbonate/bicarbonate buffer are loaded into the Applicator Unit.
- the plungers of the syringes move upwards at a set rate to deliver the two solutions through a multi-lumen tube until the system is primed (i.e., both lumens are completely full from syringe to tip of the Spraypen Applicator) .
- air pressurized by the pump in the Application Unit, passes through a third lumen and exits together with the two solutions at the application tip where a fine spray is formed.
- Fibrin I in the now alkalized Vivostat® PRF® polymerizes, and after Vivostat® PRF® is applied, fibrinopeptide B (FPB) is released and react with endogenous thrombin to form fibrin II, which is crosslinked and polymerized by the activity of endogenous FXIIIa.
- FBP fibrinopeptide B
- a connecting device is used in addition to the tissue sealant to secure the physical integrity of the anastomosis.
- the connecting device may be a suture hand-sewed by the surgeon to connect the stump end(s) .
- a number of specialized staplers commercially available may be used to obtain the reconnection .
- Examples of useful stapling devices include ChexTM LC 60 linear stapler, ChexTM circular stapler obtainable from Frankenman Ltd; Echelon FlexTM GST System; DST SeriesTM EEATM staplers available from Medtronic; and Circular stapler Circulo 3R and Pro - H View available from Sferamed.
- the connecting device is wholly or partly covered with fibrin to increase the biocompatibility and reduce the risk of infection.
- a connecting device such as a staple
- the staples may be covered by the same fibrin sealant as used in the formation of the anastomosis.
- the fibrin is autologous, which will reduce the risk of rejection.
- the tissue sealant may be co-administered with a desired substance selected among drugs, structural reinforcing substances, cells, or a mixture thereof.
- the desired substance for coadministration is an antibiotic agent, an antifibrinolytic agent, a chemotherapeutic agent, or a pain relief medicament.
- An antibiotic agent is generally used as a preventive treatment in case of a leak of content from the anastomosis.
- An anti- fibrinolytic agent may be used to inhibit the fibrinolysis.
- a chemotherapeutic agent may be used in the treatment of cancer, such as colorectal cancer as a supplement to the removal of a segment of the gastrointestinal tract.
- a pain relief medicament may be used to increase the patient well-being or recovery.
- the co-administered cells are stem cells, such as bone marrow or embryonic stem cells, or cells derived from adipose tissue.
- the co-administered cells may be useful in the formation of tissue at or around the anastomosis.
- the stem cells are selected as allogenic or autologous stem cells for delivery to a patient also treated with chemotherapy or radiation.
- the co-administrated desired substance is embedded in the fibrin II structure for sustained release.
- Anti-fibrinolytic agents may be added to the tissue sealant to prevent degradation of fibrin.
- a proteolytic enzyme such as plasmin or trypsin, may be added to the tissue sealant to speed up the degradation process .
- the present invention also relates to a method for treating cancer in the gastrointestinal tract, comprising the steps of: a) resecting a segment of the gastrointestinal tract, thereby producing a proximal gastrointestinal stump end and a distal gastrointestinal stump end,
- the present invention also relates to the use of fibrin for the manufacture of a tissue sealant as disclosed above, for treatment or prevention of cancer in the gastro-intestinal tract .
- the study was designed to test the ability of the tissue sealant Vivostat® PRF® to reinforce colonic anastomosis in a pig colon, the effect on the healing process, and the complications, including leakage and bleeding post-surgery.
- the objective was to evaluate the impact of the Vivostat® PRF® sealant on left side colonic anastomotic healing by postoperative complication rate and wound healing course.
- the 10-day and 30-day group exhibited a weight gain of 5 kg (range, 4-5.5 kg) and 14 kg (range, 12.5-16kg), respectively. These changes in weight are typical for pigs following abdominal surgery at these time points .
- the average bodyweight of the animals at sacrifice for the 4- day group was 43.3 kg (range, 43.0-44.0 kg), for the 10-day group 52.8 kg (range, 51.5-54.0 kg) and for the 30-day group 62.3 kg (range, 62.0-62.5 kg) .
- the mean duration of the sacrifice was 33.5 minutes (range, 10-57 minutes) .
- All anastomoses were created at 20 cm from the anal verge.
- the proximal stump closure was created using a manual purse- string device and the distal stump closure was created using the ChexTM LC 60 linear stapler (Frankenman Ltd.) .
- the circular anastomosis was created using the ChexTM CS 28 mm circular stapler (Frankenman Ltd.) .
- the sealant was found easy to use by the veterinary doctor applying the material and the sealant was visible on the anastomosis during application which assisted in proper placement of the sealant.
- the time to complete the anastomosis was 8.6 minutes (range, 4.5-13.6 minutes) . This was defined as the time from creation of two bowel stumps to the time of retraction of the circular stapler. It took an average of 2.2 minutes (range, 1.4-2.9 minutes) to complete the application of sealant between the two bowel stumps, and an average of 1.8 minutes (range, 1.3-
- a swab test for bacteriology testing was taken from all animals upon opening of the abdominal cavity and was negative in all cases.
- a second swab test for bacteriology testing was taken following the creation of the anastomosis and this was positive for E. coli growth in 3 out of the 16 animals. In one animal, there was sparse population (animal number 2, no sealant in the acute group) in the other two animals there was substantial growth (animals 7 and 8 in the 4-day group, both with sealant) .
- the final swab test for bacteriology testing was done upon entering the abdomen at sacrifice for all animals except the acute group and was negative in all cases. The swabs from the 4-day group at sacrifice were delayed in refrigeration and were tested for bacteriology after a few days.
- Abdominal wall adhesions the 30-day group had no adhesions on the abdominal wall.
- the 10-day group and 4-day group had filmy/ mild adhesions on the abdominal wall most often of small bowel on the suture line area in all specimens. This is a typical finding of abdominal surgery in pigs.
- the acute group underwent bowel preparation before surgery and sacrifice.
- the survival group's animals underwent bowel preparation before surgery but not before sacrifice.
- the anastomosis was harvested 5 cm above and below the anastomotic line and the proximal side was marked with a suture.
- the anastomotic burst pressure was measured ex-vivo on the day of sacrifice in one sealant animal in each group.
- an additional anastomosis was created and the burst pressure was measured ex-vivo for this additional anastomosis.
- Burst pressure measurement method a tube connected to an inflation device was inserted through the distal end of the anastomosis and a zip tie was placed over it. An additional tube connected to a hand-operated mercury sphygmomanometer was inserted through the proximal end and a zip tie was placed over it. The anastomosis with the connected tubing was placed in a temperature controlled bath of 37°C. The actual temperature at the time of the burst testing was measured and was indeed found to be 37°C on average (range 36.8-37.3°C) .
- the pressure required to burst the anastomoses with sealant of the acute, 4 day, 10 day and 30 day anastomoses was 100 mmHg, 100 mmHg, 210 mmHg and 160 mmHg respectively.
- the average burst pressure for the additional acute anastomosis of the non-sealant animals was 37.5 mmHg (range, 20-60 mmHg) . All anastomoses burst as bubbles from the stapler line apart for one animal (animal number 13, 30-day group), which burst from the native tissue.
- the burst pressures for sealant and non-sealant animals are shown below in table 1.
- Sealant 100 100 210 160 141 mmHg
- the data for the burst pressure indicates that the pigs treated with the tissue sealant according to the invention obtains a superior adhesion and sealing compared to the non- sealant group throughout the entire period.
- FIG. 1 Chart of acute burst pressure results for sealant and non sealant animals compared to normal intraluminal bowe pressure is shown in Fig. 1.
- the histological findings in the study were typical and as expected for colorectal anastomosis in a pig model. There was no significant difference in the histological parameters between sealant and non-sealant animals. The animals in which sealant was used showed no tissue damage or abnormal reaction as a result of the sealant.
- the acute group samples presented with acute hemorrhage with no other findings. There were remnants of sealant material on the serosal surface of the samples, which fell off during trimming and histological processing.
- the 4-day group samples presented with necrosis of the area of anastomosis and marked granulocyte infiltration (acute inflammation) with early macrophage infiltration and early fibroblast proliferation.
- bacteria were observed in the sealant and there were aggregations of neutrophils infiltrating it.
- the sealant was still present, and there was evidence of minimal focal proliferation of fibroblasts in the area with focal neutrophilic infiltration, typical findings of anastomosis at this time point.
- the findings in all samples were very similar with evidence of early organization of the anastomotic area by fibrous tissue attempts of regeneration of the epithelium and decreased inflammation. Serosal fibrosis and adhesions were observed in some of the samples. Sealant was not observed in the 10-day group samples. In the 30-day group samples, regeneration was almost complete; the findings were typical of this time point.
- the thickness of the anastomotic line was measured in millimeters. It is an approximate measurement taken at the level of the submucosa. A thinner anastomotic line indicates maturation of the scar.
- the anastomotic line was not measured for the anastomoses that underwent burst pressure, as this mechanical stretching does not allow for an accurate measurement of the natural anastomotic line.
- the average anastomotic line width was 2.2 mm, 2.8 mm and 1.1 mm for all animals, sealant animals and non-sealant animals, respectively.
- the maturation of the fibrous tissue indicates organization of the granulation tissue (4: no maturation of fibrous tissue; 3: minimal maturation 2: some maturation; 1: distinct maturation 0: mature connective tissue almost normal) . Fibrosis was not present in the acute samples and a few reactive fibroblasts were present in the 4-day samples.
- Foreign body reaction is the end-stage response of the inflammatory and wound healing responses. It is characterized by the presence of micro-granulomas , macrophages or giant cells surrounding food material of debris. Granulomas may form with increased/persistent inflammation or in cases of leakage or perforation, surrounding food material in the wall of the intestine or on the serosa and peripheral fat. Foreign body reaction around the staples is not scored as such. After complete healing of the anastomotic line the staples were mostly encapsulated or extruded in the lumen of the intestine and were no longer observed on histological sections.
- the average foreign body reaction was scored 0.44, 0.39, 0.58 for all animals, sealant animals and non-sealant animals, respectively .
- Inflammation is the infiltration by granulocytes, (neutrophils and eosinophils) and/or by mononuclear cells (lymphocytes, plasma cells, histiocytes) to the anastomotic area.
- Granulocytes increase in the acute phase as part of the healing process and are expected to decrease in the subacute and chronic samples.
- Mononuclear cells increase in the subacute samples, but should be in very small numbers in the chronic samples.
- the average inflammation score based on both mononuclear cells and granulocytes was scored 1.2, 1.3, 1.0 for all animals, sealant animals and non-sealant animals, respectively.
- Epithelization is attempts of mucosa adjacent to the anastomotic line to cover the defect on the mucosal surface due to the creation of the anastomosis (the scale for epithelization was 0 to 4 from 0: Continuous epithelium with muscular regeneration to 4: ulcerated surface, no epithelialization) .
- the average epithelization was scored 2.7, 2.9, 2.3 for all animals, sealant animals and non-sealant animals respectively .
- the histological samples of two animals exhibited signs of micro-leak (animal number 5 and 7 from the 4-day group) . Both animals did not show any clinical signs of leakage (elevated temperature, reduced appetite, reduction in weight) and for both animals no intraabdominal and consonic abscess was found nor did they show any signs of sepsis. For animal number 5 there was no indication other than the histology for a leakage event. The animal wellbeing as well as gross pathology did not result in any suspicion for a leakage event. This anastomosis (animal number 5) underwent burst testing and the burst occurred on the anastomotic line which did not seem to be different from the other samples.
- the mucin content levels are shown in table 6, where a higher mucin percentage is considered a positive parameter for healing.
- the mucin content of the colonic crypt base was calculated using digital images of the PAS/Alcein blue- stained slides, where the bottom half of crypts within 2 mm of the anastomotic line with a clear long axis were chosen as the processing region of interest (ROI) .
- the Image-Pro Plus was filtered with median of 3 x 3 two passes and segmented for mucin.
- the mucin content was semi-quantitatively assessed within 2 mm of the anastomosis in measurable crypts so as to calculate a percentage by dividing the mucin stain by the total tissue area.
- the mean mucin percentage for matrix-treated cases was greater than the control anastomoses (54.5% vs. 42.3%) with higher mucin content in the earlier phase of the anastomosis for the non-sealant treated animals and a more constant mucin content for the sealant-treated group.
- on day 0 there was a consistent starting epithelial line thickness with 53% mucin content in both groups.
- the epithelial thickness had increased slightly in the sealant-treated cases with mucin maintenance (excluding one animal #11 for possible contamination as suggested by the presence of increased epithelization and variable amounts of Collagen III) .
- mucin production remained high in the sealant-treated cases with by 30 days an overall thicker epithelial layer in matrix-treated cases and similar mucin reduction in both groups.
- a qualitative collagen maturity analysis was made with polarized light using the Picrosirius red (PSR) stain, detecting the relative amount of collagen III (immature collagen) as thin fibres with green birefringence.
- Picrosirius Red staining at day 0 showed no immature collagen III (thin fibers with green birefringence) in any of the sites examined.
- day 4 there was only a minimal amount of collagen III in all the sites examined with no difference noted between sealant-treated and control groups.
- sealant- treated sites showed variable amounts of collagen III with less immature collagen deposition in those anastomoses with sealant.
- day 30 there was a predominance of collagen fibers evident as orange birefringence with only rare small bundles of immature collagen evident in both matrix-treated and control anastomosis.
- M2 macrophages CD163/CD68+ and cMAF+
- non-M2 macrophages CD163/CD68+, cMAF-
- a morphometric approach was used to semi-quantitatively assess differences in the degree of inflammatory cell infiltrate, where the pathologist was blinded to the treatment and times of tissue harvest.
- the type and number of inflammatory cells were assessed on 5-7 H&E- stained, randomly selected high power fields (x 4000) and captured with a Q imaging camera (Olympus BH-2 microscope) . Images were assessed with an image analyzer (MetaMorph imaging system, Universal Imaging Corporation, West Chester PA) .
- M2 macrophages which are involved in tissue repair and which are predominantly associated with an immunomodulatory Th2-type cytokine production profile
- Table 8 shows the M2 and non-M2 densities in the matrix-treated and control groups at days 4, 10 and 30 along with the total macrophage density .
- Non-M2 macrophage density was lower than the M2 density when the sealant was used although there was no appreciable difference between the two groups by 30 days.
- total macrophage density was highest in the mucosa and muscularis in the control animals with no appreciable differences in M2 macrophage infiltration.
- Day 10 the mucosa and the muscularis of control animals showed a marked reduction in the total macrophage density with higher levels of M2 macrophages in the mucosa and the muscularis of matrix-treated compared with control cases. This would suggest a different dynamic of pro-inflammatory macrophage infiltration with Sealant treatment.
Landscapes
- Health & Medical Sciences (AREA)
- Surgery (AREA)
- Epidemiology (AREA)
- Life Sciences & Earth Sciences (AREA)
- Animal Behavior & Ethology (AREA)
- General Health & Medical Sciences (AREA)
- Public Health (AREA)
- Veterinary Medicine (AREA)
- Chemical & Material Sciences (AREA)
- Engineering & Computer Science (AREA)
- Materials Engineering (AREA)
- Materials For Medical Uses (AREA)
Abstract
Description
Claims
Applications Claiming Priority (2)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
DKPA201770554 | 2017-07-07 | ||
PCT/DK2018/050174 WO2019007469A1 (en) | 2017-07-07 | 2018-06-29 | A tissue sealant for use in the formation of an anastomosis in the gastrointestinal tract |
Publications (1)
Publication Number | Publication Date |
---|---|
EP3648804A1 true EP3648804A1 (en) | 2020-05-13 |
Family
ID=63035829
Family Applications (1)
Application Number | Title | Priority Date | Filing Date |
---|---|---|---|
EP18746094.4A Withdrawn EP3648804A1 (en) | 2017-07-07 | 2018-06-29 | A tissue sealant for use in the formation of an anastomosis in the gastrointestinal tract |
Country Status (2)
Country | Link |
---|---|
EP (1) | EP3648804A1 (en) |
WO (1) | WO2019007469A1 (en) |
Families Citing this family (3)
Publication number | Priority date | Publication date | Assignee | Title |
---|---|---|---|---|
US20210252040A1 (en) * | 2018-04-23 | 2021-08-19 | The University Of Chicago | Materials and methods of using an inhibitor of plasminogen activation to treat anastomotic leak |
EP3756698A3 (en) * | 2019-06-28 | 2021-01-06 | Vivostat A/S | A tissue sealant for use in anterior cruciate ligament (acl) reconstruction |
US20230248643A1 (en) * | 2022-02-09 | 2023-08-10 | Aktivax, Inc. | Concentrated injectable tranexamic acid compositions and methods of use thereof |
Family Cites Families (1)
Publication number | Priority date | Publication date | Assignee | Title |
---|---|---|---|---|
IL230151A0 (en) * | 2013-12-24 | 2014-09-30 | Omrix Biopharmaceuticals Ltd | One component fibrin glue comprising a polymerization inhibitor |
-
2018
- 2018-06-29 WO PCT/DK2018/050174 patent/WO2019007469A1/en active Search and Examination
- 2018-06-29 EP EP18746094.4A patent/EP3648804A1/en not_active Withdrawn
Also Published As
Publication number | Publication date |
---|---|
WO2019007469A1 (en) | 2019-01-10 |
Similar Documents
Publication | Publication Date | Title |
---|---|---|
JP6552115B2 (en) | Adhesive medical products and methods for treating gastrointestinal tract lesions | |
JP6200997B2 (en) | Tissue occlusive agent | |
JP5204646B2 (en) | Compositions and methods for promoting hemostasis and other physiological activities | |
Yol et al. | Effects of platelet rich plasma on colonic anastomosis | |
Kotzampassi et al. | Tissue sealants in endoscopic applications for anastomotic leakage during a 25-year period | |
EP3648804A1 (en) | A tissue sealant for use in the formation of an anastomosis in the gastrointestinal tract | |
US9302026B2 (en) | Method for improved fibrin sealing | |
Fotiadis et al. | The use of isobutylcyanoacrylate as a tissue adhesive in abdominal surgery | |
Ozel et al. | Does a fibrin-collagen patch support early anastomotic healing in the colon? An experimental study | |
JP2020130536A (en) | Liquid polymeric compound composition and medical material | |
Kayaoglu et al. | Effect of n‐Butyl‐2‐Cyanoacrylate on High‐Risk Colonic Anastomoses | |
Tokgöz et al. | Postoperative adhesions after application of topical hemostatic agents: outcomes in a rat partial nephrectomy model | |
RU2256452C1 (en) | Method for treating mallory-weiss syndrome | |
Güngör et al. | Cyanoacrylate application on colonic anastomosis: is it safe or not? | |
Yaman et al. | The effect of a special amino acid mixture on healing of left colonic anastomosis: an experimental study | |
EP3957338A1 (en) | Liquid medical material | |
US20230081604A1 (en) | Treatment of anastomoses | |
JP2022035398A (en) | Liquid medical material | |
Karakaya et al. | The effects of stem cells and platelet-rich fibrin on colonic anastomosis: An experimental study | |
JP2022035989A (en) | Liquid medical material | |
JP2021115286A (en) | Liquid medical material | |
JP2021115288A (en) | Liquid composition and liquid medical material | |
JP2021115287A (en) | Liquid medical material | |
Stanojević et al. | The effects of topical fibrin glue and epidermal growth factor (EFG) on the colon anastomosis healing process-a comparative experimental study | |
DAĞLIOĞLU et al. | Comparison of platelet rich plasma versus fibrin glue on colonic anastomoses in rats (1) |
Legal Events
Date | Code | Title | Description |
---|---|---|---|
STAA | Information on the status of an ep patent application or granted ep patent |
Free format text: STATUS: UNKNOWN |
|
STAA | Information on the status of an ep patent application or granted ep patent |
Free format text: STATUS: THE INTERNATIONAL PUBLICATION HAS BEEN MADE |
|
PUAI | Public reference made under article 153(3) epc to a published international application that has entered the european phase |
Free format text: ORIGINAL CODE: 0009012 |
|
STAA | Information on the status of an ep patent application or granted ep patent |
Free format text: STATUS: REQUEST FOR EXAMINATION WAS MADE |
|
17P | Request for examination filed |
Effective date: 20200207 |
|
AK | Designated contracting states |
Kind code of ref document: A1 Designated state(s): AL AT BE BG CH CY CZ DE DK EE ES FI FR GB GR HR HU IE IS IT LI LT LU LV MC MK MT NL NO PL PT RO RS SE SI SK SM TR |
|
AX | Request for extension of the european patent |
Extension state: BA ME |
|
DAV | Request for validation of the european patent (deleted) | ||
DAX | Request for extension of the european patent (deleted) | ||
STAA | Information on the status of an ep patent application or granted ep patent |
Free format text: STATUS: EXAMINATION IS IN PROGRESS |
|
17Q | First examination report despatched |
Effective date: 20210301 |
|
STAA | Information on the status of an ep patent application or granted ep patent |
Free format text: STATUS: THE APPLICATION IS DEEMED TO BE WITHDRAWN |
|
18D | Application deemed to be withdrawn |
Effective date: 20211112 |