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The Use of Cyanoacrylate in Surgical Anastomosis: an Alternative to Microsurgery

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The Use of Cyanoacrylate in Surgical Anastomosis: an Alternative to Microsurgery [Downloaded free from http://www.jstcr.org on Tuesday, June 29, 2010, IP: 41.185.132.78] SUrGiCAL opiNioN The Use of Cyanoacrylate in Surgical Anastomosis: An Alternative to Microsurgery G. M. Bot, K. G. Bot1, J. O. Ogunranti2, J. A. Onah2, A. Z. Sule, I. Hassan3, E. D. Dung Department of Surgery, Jos University Teaching Hospital, ABSTRACT 1Faculty of Medical Science, University of Jos, 2Department of Anatomy, University of Jos, 3Department of Surgery, To present anastomosis with cyanoacrylate as a cheap, Aminu Kano University Teaching Hospital, Plateau State, simple, fast, and available technique for anastomosis in Nigeria urological, vascular, gynecological, and general surgical procedures. This method may in the future be a good alternative to microsurgery, particularly in centers where INTRODUCTION facilities are unavailable and the financial implication is unbearable for the patient. Cyanoacrylate is an adhesive or glue that is available in different chemical forms ranging from he use of cyanoacrylate is not widespread despite ethylcyanoacrylate (superglue) to Isobutylcyanoacrylate a number of published studies on the subject.[1] and octylcyanoacrylate (dermerbond), which is in TCyanoacrylate is an adhesive that was first clinical use. Anastomosis with cyanoacrylate requires discovered by Dr. Harry Coover and Fred Joyner in the the application of stay sutures, a luminal stent and the [2] subsequent application of the adhesive. The adhesives with Kodak laboratory. Cyanoacrylates were first synthesized lower molecular weights produce a rigid and patent region by Airdis in 1949, while Coover et al. described their of anastomosis, while the higher molecular compounds adhesive property and suggested their possible use as produce a consistency close to the normal tissue. This surgical adhesives in the 1960s.[3,4] There are different technique presents a surgical method that is socially, culturally, and ethically acceptable, which is affordable to a types ranging from ethylcyanoarylate (super glue) to larger majority of patients in our subregion. Cyanoacrylate isobutylcyanoacrylate and octylcyanoacrylate (dermabond, anastomosis may in the future present a fast, convenient, which is approved by the food and drug agency of the simple, and affordable option in the treatment of patients United State of America). The physical properties of the requiring anastomosis. In our subregion where the socio- glue differ based on the molecular weight of the chemical. cultural, psychological, and economic burden of failed anastomosis is high, associated with the low per capital Even as the low molecular weight ones are more rigid and income, this may be a novel option for the management fairly more toxic, the higher molecular weight substances of urogynecological, vascular, neurosurgical, and general are stronger, more pliable, and less toxic.[3,4] surgical procedures requiring either microscopic or macroscopic anastomosis. An anastomosis is a surgical connection between two structures. It usually means a connection that is created Key words: Alternative, anastomosis, cyanoacrylate, between tubular structures, such as blood vessels or loops microsurgery, limited, resource, subregion of the intestine. The word anastomosis is derived from DOI: 10.4103/2006-8808.63727 two Greek words, which literarily means without a mouth, that is, when a tubular viscus (bowel) or vessel is joined after resection or bypass without exteriorization with a preference for the one-layered closure where the mucosa stoma, or having been tied off.[1] Anastomoses in the bowel was not incorporated. Connell later described the single were not undertaken successfully until the nineteenth layer of interrupted sutures incorporating all layers of century. Prior to that period the experience was limited to the bowel. This was further modified to the through- exteriorization or simple closure of the laceration. In 1826, and-through continuous single layer with a ‘loop-on-the- Lembert described the seromuscular suture technique, mucosa’ suture, which is otherwise called the Connell stitch. which became the main stay in bowel anastomosis. Senn Kocher developed the two-layer closure, inner continuous, recommended the two-layer closure, while Halsted showed and outer interrupted stitches. Currently the single layer extramucosal anastomosis by Metheson of Aberdeen is Address for correspondence: Dr. Gyang Markus Bot, advocated because it produces the least necrosis, narrowing Department of Surgery, Jos University Teaching Hospital, of lumen, and adequate tensile strength.[1] In vascular PMB 2076 Jos, Plateau State, Nigeria. E-mail: gyangbot@ anastomosis, which was pioneered by Carrel, an everting yahoo.co.uk anastomosis was advocated, with triangular stay sutures, 44 Journal of Surgical Technique and Case Report | Jan-Jun 2010 | Vol-2 | Issue-1 [Downloaded free from http://www.jstcr.org on Tuesday, June 29, 2010, IP: 41.185.132.78] Bot, et al.:Surgical anastomosis with cyanoacrylate to ease the application of the continuous monofilament deformation of spermatogenesis, and partial deformation sutures.[1] of the sertoli and leydig cell.[11] Currently, several suture substitutes have been used such as Another study in mongrel hounds shows that cyanoacrylate staples and adhesive glues. The basic principles of bowel, appears to be unsuitable for use in forming the large- vascular, and urogynecological anastomosis must be taken diameter vesicourethral anastomosis required in radical into consideration. In bowel surgery, locally, at the site prostatectomy.[8] In vascular surgery, cyanoacrylate of anastomosis, there must be a good supply of blood, might be a good alternative to sutures (in anastomosis inverting sutures applied, accurate tissue apposition, and of arterovenous shunts and bypass procedures in avoidance of tissue damage, while systemic considerations microsurgery).[12-14] In gastrointestinal surgery, while include prophylactic antibiotics, adequate oxygenation, it appears to be useful in esophageal anastomosis and correction of shock, and good nutritional rehabilitation. In gastroenterostomy, the usefulness in colonic anastomosis vascular surgery, the considerations include, proximal and is still questioned.[15-18] Cyanoacrylate may therefore distal vascular control, minimal tissue handling, proline- be relevant as a sealant and also for reinforcement of like sutures are used, knotts are secured, the sutures are sutures in the colon. Cardiothoracic surgeons have used passed from inside out to fix any arteromatous plaque, and cyanoacrylate to reinforce bronchial anastomosis after anticoagulants are used.[1] pulmonary resection. Surprisingly, its untoward effect of increased inflammatory reaction is observed to accelerate The use of cyanoacrylate for anastomosis of vessels, the Wallerian degeneration, and it may therefore have a more urogenital tract, and bowel have been reported in different beneficial effect compared to sutures for reconstruction experimental models ranging from rat to rabbits, and dogs of peripheral nerves.[19] and monkeys, with varying outcomes.[5-8] Cyanoacrylate may in the future be used in humans for Stricture and ureterocutaneous fistula for the urologist, anastomosis of vessels, intestines and the urethra. enterocutenous fistula for the general surgeon, failed arterovenous fistula for the vascular surgeon, mediastinitis The surgical techniques involved in the use of cyanoacrylate from esophageal leak for the cardiothoracic surgeon, for surgical anastomosis can be divided into two. The and tubal infertility for the gynecologist, are conditions first involves the use of cyanoacrylate as the main agent that pose significant management difficulty. However, of anastomosis. While in the second it serves as a sealant cyanoacrylate anastomosis may provide a way to overcome and for reinforcement of an anastomosis. In the first these obstacles in the future. technique where cyanoacrylate is the main agent of anastomosis, ethical clearance is obtained and the subject DISCUSSION anesthetized. The region to be anastomosed is exposed. If a resection has been done the two ends are approximated The surgical use of cyanoacrylate for surgical apposition and apposed with four to six stay sutures and the glue is of wound edges, hemostasis, and embolization has then carefully applied, to ensure that there is no spillage been documented in humans.[4,9,10] However; the use of into the lumen. A period of 45 - 90 seconds is allowed cyanoacrylate in surgical anastomosis, to the best of our for polymerization. There is the lid technique, which knowledge, has not been reported in humans and if it is used in microvascular anastomosis. In this method a has been, then there are very few cases. This technique in combination of sutures and cyanoacrylate is used. At the experimental animals, however, is well established. distal end of the vessel two parallel incisions are made at 180 degrees. Two sutures are placed from the proximal The surgical use of cyanoacrylate in experimental animals end to the exit at the most distal part of the longitudinal is well known. Experimentally, it is used in urology, vascular incision. The adhesive is then applied to the proximal surgery, gynecology, and gastrointestinal surgery. In urology vessel and the full-thickness vascular ‘lid’, and the flap is a study by Merimsky and Baratz on 10 dogs showed that closed over it on the anterior and posterior surfaces.[20] In ureteroureteral anastomosis resulted in good anastomosis the second technique it serves
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