Surgery


Evaluating advances in haemostat solutions


Daniel Garrett discusses the progress achieved over 80 years of development in haemostat solutions. He provides an in-depth review of oxidised cellulose and gelatin sponge haemostats.


An absorbable haemostatic agent, commonly referred to as a haemostat, is a material designed to generate haemostasis, which is the process of stopping unwanted bleeding during surgery by creating a blood clot in damaged vessels. The absorbable haemostat can be left in the body after surgery and is then absorbed in the tissues, leaving no trace behind.1 One of the first documented uses of a haemostat was in 1879 by Halsted who suggested he had observed a form of cellulose being used to stop haemorrhage in papillary cysts of the thyroid.2


The first official use of


an absorbable haemostat has been credited to Cushing, a Neurosurgeon who in 1911 suggested that fibrin from whipped blood could be plastered on bleeding surfaces to create haemostasis.3 During the Second World War, the


requirement for surgery and the need to prevent unwanted bleeding significantly increased and therefore research into haemostats progressed rapidly with Frantz (1943) introducing the use of oxidised cellulose as a haemostatic material that could gradually dissolve.4


Shortly after, Correll & Wise (1945)


introduced the gelatin sponge which was originally used as a carrying media for thrombin, aiding the clotting process.4 Eighty years after their introduction to the


surgical world, oxidised cellulose haemostats and gelatin sponge haemostats are still widely used every day in a range of surgical disciplines, with manufacturers of oxidised cellulose including Synthesia’s Okcel and Johnson & Johnson’s Surgicel, and Gelatin Sponge such as Mascia Brunelli’s Cutanplast and Gelfoam by Pfizer.


The oxidised cellulose haemostat When oxidised cellulose was introduced, it was derived from wood pulp containing around 50% cellulose5


and was the first absorbable


haemostat to be made from plant-based products.4


In the 1960s, some suppliers started


changing how they manufactured their oxidised cellulose haemostats by using a chemical regeneration process,5


creating what is now


known as oxidised regenerated cellulose (ORC), an example of which is Surgicel. Other suppliers have continued to manufacture non-regenerated cellulose (ONRC), an example of which is Okcel, suggesting there are benefits over ORC. There have been many studies conducted comparing ORC and ONRC,6,7


looking at various


factors that influence haemostasis, such as absorbency, density and pH levels. One such experiment was conducted by Lahovský (2019)6 where he directly compared the mechanical and


biological performance of ONRC (Okcel) and ORC (Surgicel). The image in Figure 1 shows both the standard


forms of Okcel (H-T) and Surgicel (Original) under 500x magnification. Lahovský’s (2019)6 study demonstrated that ONRC absorbed 50% more saline than ORC, and the images in Figure 1 helped confirm that ONRC has a higher surface area; these results have also been seen in the study by Lewis, et al, (2013),7


with the research


also showing that ONRC provided a significantly superior time to haemostasis than ORC. Oxidised cellulose comes in different sizes and formats to suit the needs of the healthcare professional. There are three formats which multiple suppliers offer, standard (a knitted textile form), heavy-duty (a densely woven knitted form) and cotton wool form (non-woven fibrous). The standard form, such as Okcel H-T, shown


in Figure 1, has the indication to be used for control of capillary, minor venous and minor arteriolar bleeding8


and is the most commonly


used version of oxidised cellulose due to its wide range of applications. Although the most commonly used, the other two formats of oxidised cellulose could provide benefits to improve surgical performance and patient outcomes. Heavy-duty oxidised cellulose has the indication to be used for higher volume bleeding than standard forms of the product.8 This is due to it being three times denser, providing a larger surface area, which results in haemostasis being achieved up to 36% faster than standard versions.9


Along with being used


for preventing unwanted heavier bleeding, the product has been advocated as an option that can be sutured onto delicate tissue, due to its pliable weave design.9


An example of this would


be to bolster the anastomosis of a dacron graft to the aorta, to prevent any movement of the haemostat10


Figure 1 – an example can be seen in Figure 2. Cotton wool, non-woven oxidised cellulose is a


layered haemostat with an even larger surface area, leading to haemostasis being achieved up


December 2024 I www.clinicalservicesjournal.com 37


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