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Getting to hemostasis: general and thoracic surgical challenges.

In general and thoracic surgery, as in all surgical specialties, achieving hemostasis remains a key goal and is best achieved by superior surgical technique. However, there are multiple situations in which difficult-to-control bleeding, from lesions that cannot be sutured or cauterized, is encountered. These include synthetic graft anastomoses to both large- and small-caliber vessels; minimally invasive procedures, including laparoscopic, robotic, endoscopic, and single-port-access approaches; elderly patients, with more fragile tissues; and surgical coagulopathy caused by the newest, difficult-to-reverse, anticoagulation regimens. These challenges are best met by general and thoracic surgeons who operate with a complete toolbox that includes surgical hemostats, sealants, and adhesives.1–4 The achievement of rapid hemostasis is accompanied by many benefits, which confer such immediate consequences as improved vision and hemodynamic stability and such delayed benefits as avoidance of the potentially negative effects of blood transfusions.5,6 
 
Multiple agents are available to cause blood to coagulate, to seal tissues, and to glue portions of the body together.1–3 All are potentially useful for achieving hemostasis. These agents can be divided into groups, categories, and classes that clarify their potential benefits (Table I).2–4 Each of the 3 groups—hemostats, sealants, and adhesives—has a different specific function. Hemostats clot blood, sealants create barriers to prevent leakage from tissues, and adhesives glue tissues together. Although each of the 3 groups' functions is different, agents from all of these groups can be used to stop or prevent bleeding and are recognized as having hemostatic effects. The most recent United States Food and Drug Administration (FDA)-approved additions to each of the 3 groups are illustrated. Pooled plasma fibrin sealant on an equine collagen patch (Fig. 1) has been approved as a hemostat in cardiac surgical procedures.3 Polyethylene glycol (PEG) polymer with human serum albumin (Fig. 2) has been approved as a pneumostatic sealant during pulmonary resection.3 Human pooled plasma fibrin sealant liquid (Fig. 3) has been approved as an adhesive for burn-related skin graft attachment as well as facial flap attachment during rhytidectomy.7 Knowledge of the safety, efficacy, usability, and cost of all hemostats, sealants, and adhesives can improve the quality of their use.1–3 Awareness of these 4 factors can help to reduce the risks associated with these materials and their metabolites, resulting in potentially life-saving outcomes; to improve the effectiveness of their application by understanding preparation requirements and available applicators; and to reduce costs by knowing the differences in expenses associated with the use of these agents. 
 
 
 
Fig. 1 TachoSil® fibrin sealant patch hemostat (Baxter Healthcare Corporation; Westlake Village, Calif). 
 
 
 
 
 
Fig. 2 Progel® lung sealant, made of polyethylene glycol and human serum albumin (Neomend, Inc.; Irvine, Calif). 
 
 
 
 
 
Fig. 3 Artiss fibrin sealant in liquid form, used as skin graft and facial flap adhesive (Baxter Healthcare Corporation; Westlake Village, Calif). 
 
 
 
 
 
Table I. Reference System for Organizing Available Hemostats, Sealants, and Adhesives 
 
 
 
Although some of the established older agents were approved without the requirement for clinical trials, most of the newer hemostats, sealants, and adhesives have been approved by the FDA on the basis of multicenter, prospective, randomized trials. For some agents, such as fibrin sealant, the results of up to 20 such trials are available in the published literature.4 However, as of this time, a lack of cost–benefit data continues to complicate the use of all of these materials. This lack of data might be an obstacle to further increasing appropriate use in the present cost-conscious healthcare environment3 and remains an area for future study. 
 
In general surgery, these tools can be used in multiple procedures, which include reoperation, liver and spleen trauma, burn-wound debridement, soft-tissue dissection of the breast or groin, gastrointestinal anastomoses, organ transplantation, and vascular bleeding. In thoracic surgery, these materials can be useful during video-assisted thoracic surgery (VATS), lung volume reduction procedures, reoperation, transplantation, and bronchoscopy, including the treatment of broncho-pleural fistula. Both the general and thoracic surgical specialties have been at the forefront of minimally invasive approaches. In response, the manufacturers of hemostats, sealants, and adhesives have also designed delivery devices appropriate for these procedures.3,4 
 
The use of hemostats, sealants, and adhesives is not often taught in our training programs. Yet evidence exists to show that knowledge of and experience with their use can improve effectiveness and reduce the learning curves that can be associated with some complex procedures.4 The same meticulous attention to detail that surgeons exercise daily during operative procedures needs to be extended to the proper understanding and application of these materials as well. 
 
In summary, increased knowledge of these materials—and experience with their use—will improve the practice of general and thoracic surgery. Future research and development should result in additional new agents, as well as in evidence to support both the advantages and the cost benefits of hemostats, sealants, and adhesives.