Introduction

In the realm of hepatic surgeries, controlling intraoperative bleeding is a critical challenge. Despite significant advancements in surgical techniques and perioperative care, managing bleeding effectively remains a paramount concern. Intraoperative bleeding can lead to numerous complications, including the need for additional interventions, extended hospital stays, increased healthcare costs, and, in severe cases, even mortality. Effective hemostatic strategies are essential for optimizing surgical outcomes and patient safety [1].

Oxidized regenerated cellulose gauze (ORCG) has emerged as a vital tool in the management of surgical bleeding. This blog delves into the pivotal role of ORCG in liver surgeries, exploring its applications, benefits, and future directions in the field of hemostatic agents.

Surgical Techniques for Managing Bleeding

Surgeons employ various techniques to manage bleeding during liver surgeries:

Vascular Clamping: Temporarily stopping blood flow to the liver using techniques like the Pringle Maneuver, which clamps the hepatic artery and portal vein, or Total Vascular Occlusion, which stops blood flow by clamping both inflow and outflow vessels.

Dissection Devices for Transection of Liver Parenchyma: Using both classic methods, such as scalpels and the finger-fracture technique, and advanced methods, including the Cavitron Ultrasonic Surgical Aspirator (CUSA), Hydro-Jet, and radiofrequency ablation devices. Each method has its advantages for cutting liver tissue precisely while minimizing bleeding.

Low Central Venous Pressure (CVP): Reducing CVP helps minimize bleeding by decreasing the pressure within blood vessels. This can be achieved through volume contraction, phlebotomy, and the use of vasodilating agents [2].

While these techniques have made significant strides, sometimes they’re not enough. This is where topical hemostatic agents come in.

Role of Topical Hemostatic Agents

Topical hemostatic agents, promising in the battle against postoperative complications, are designed to staunch bleeding and seal the liver resection surface, offering hope for patients and surgeons alike. When standard surgical techniques are not enough to control bleeding, topical hemostatic agents play a critical role by inducing blood clotting, providing an immediate and effective means to stop bleeding. Topical hemostats, including oxidized regenerated cellulose (ORC), gelatin, collagen, thrombin, fibrin sealants, and adhesives, are widely used in hepatic surgery to control bleeding and improve surgical outcomes [3].

Spotlight on Oxidized Regenerated Cellulose Gauze (ORCG)

Oxidized regenerated cellulose gauze (ORCG) is a plant-derived passive hemostat developed over 60 years ago. Initially used as oxidized cellulose (OC) in 1942, ORC was developed by 1960 [4]. ORCG is widely used in medical applications due to its convenience, biocompatibility, and bactericidal properties. When ORCG comes into contact with blood, it forms a brownish or black gelatinous mass that promotes hemostasis by providing a structure for platelet adhesion and aggregation as shown in Fig.1.

Fig.1: Application of Oxidized Regenerated Cellulose Gauze (ORCG) on a porcine liver bleeding model [5]

Commercially Available ORC Products in Gauze Form

ORCG is currently available in many commercial products such as Surgicel Original, Emosist, GELITA-CEL^® STANDARD, CuraCel^® Standard, Surgi-ORC^® Original/Standard and Surgi-ORC^® Knit (Aegis Lifesciences Pvt. Ltd.).

Clinical Overview

In 2020, Zhang et al. conducted a prospective randomized controlled clinical trial involving 78 patients undergoing hepatectomy. The study aimed to compare the effectiveness of oxidized regenerated cellulose gauze (ORCG) and oxidized non-regenerated cellulose gauze (ONRCG). Both groups achieved 100% hemostasis within 10 minutes, although the study did not provide details on the materials’ characteristics such as oxidation degree and porosity, which significantly influence hemostatic performance [6].

Oxidized cellulose (OC) vs Oxidized regenerated cellulose (ORC) – Present Takeaway

Oxidized cellulose is highly efficient for hemostasis, degradable, and effectively prevents bacterial growth. Nevertheless, one major drawback is its cytotoxicity due to the strongly acidic nature during degradation. This can lead to foreign body reactions, increased inflammation, and delayed healing [7, 8]. Despite its long-standing use as a hemostatic agent, oxidized cellulose does not fully meet the clinical practice’s diverse demands. Thus, clinicians often prefer oxidized regenerated cellulose (ORC) over oxidized cellulose (OC) due to better cytotoxicity, bactericidal, and hemostatic profiles.

Frequently Asked Questions about ORCG in Liver Surgeries

Q: How does oxidized regenerated cellulose gauze (ORCG) interact with blood to control bleeding?
A: When ORCG contacts blood, it forms a gelatinous mass that promotes hemostasis by providing a scaffold for platelet adhesion and aggregation, effectively aiding in blood clotting.

Q: In which specific scenarios during liver surgery is ORCG most effectively used?
A: ORCG is particularly effective in controlling diffuse low-pressure bleeding from the liver parenchyma during hepatectomies and other liver resections. It is also used to manage bleeding from small vessels and capillary beds that are difficult to suture or ligate.

Q: How does ORCG enhance the overall outcome of liver surgeries?
A: ORCG enhances surgical outcomes by providing rapid and effective hemostasis, reducing intraoperative blood loss, minimizing the need for blood transfusions, and lowering the risk of postoperative complications such as infections.

Q: What factors should surgeons consider when selecting ORCG for bleeding management in liver surgeries?
A: Surgeons should consider:
– Type and Severity of Bleeding: ORCG specially knit variant is suitable for moderate to severe bleeding but might need to be combined with other techniques for extensive hemorrhage.
– Surgical Site Accessibility: The ability to apply ORCG effectively in the specific surgical site.
– Patient History: Any previous adverse reactions to hemostatic agents or underlying health conditions that might influence the choice of hemostatic strategy.

Q: How does the application technique of ORCG influence its effectiveness?
A: The effectiveness of ORCG depends on proper application. It should be applied directly to the bleeding site with sufficient pressure to ensure good contact. Excess material should be avoided to prevent excessive foreign body reactions.

Innovations and Future Trends

The field of hemostatic agents, including oxidized regenerated cellulose gauze (ORCG), is evolving with several promising advancements:

1. Enhanced Biocompatibility: Research is focusing on optimizing the chemical structure of ORCG to further reduce tissue irritation and enhance the healing process [9].
2. Improved Bactericidal Properties: Future developments aim to incorporate antimicrobial compounds to boost ORCG’s bactericidal properties, thereby reducing the risk of postoperative infections [10].
3. Nanotechnology Integration: Utilizing nanotechnology could significantly improve the performance of ORCG by enhancing its surface area and reactivity, leading to faster and more effective hemostasis [11].
4. Customizable Degradation Rates: Researchers are developing ORCG with tailored degradation rates to match specific tissue healing needs, optimizing both hemostatic effects and tissue integration [12].

Emerging Technologies

Slezak et al. (2021) conducted a comparative efficacy evaluation of recombinant topical thrombin (RECOTHROM^®) with a gelatin sponge carrier versus topical oxidized regenerated cellulose (TABOTAMP^® / SURGICEL^®) in a porcine liver bleeding model. The study highlighted the potential of new hemostatic agents to improve bleeding control in surgical settings [5].

Future Improvements

Rodić-Grabovac et al. (2020) discussed the future applications and developments in oxidized cellulose, emphasizing the potential for new formulations and delivery methods to enhance hemostatic performance and reduce complications [4].

Conclusion

While surgical techniques for managing bleeding during hepatic resections have significantly advanced, the integration of topical hemostatic agents like oxidized regenerated cellulose gauze offers a crucial adjunct to achieve optimal outcomes. These agents enhance the hemostatic process and contribute to improved overall patient care, addressing some of the inherent challenges in liver surgery.

References
1. Bodur MS, Tomas K, Topaloğlu S, Oğuz Ş, Küçükaslan H, Dohman D, Karabulut E, Calik A. Effects of intraoperative blood loss during liver resection on patients’ outcome: a singlecenter experience. Turkish Journal of Medical Sciences. 2021;51(3):1388-95.

2. Alkozai EM, Lisman T, Porte RJ. Bleeding in liver surgery: prevention and treatment. Clinics in liver disease. 2009 Feb 1;13(1):145-54.

3. Genyk Y, Kato T, Pomposelli JJ, Wright Jr KJ, Sher LS, Tetens V, Chapman WC. Fibrin sealant patch (TachoSil) vs oxidized regenerated cellulose patch (Surgicel Original) for the secondary treatment of local bleeding in patients undergoing hepatic resection: a randomized controlled trial. Journal of the American College of Surgeons. 2016 Mar 1;222(3):261-8.

4. Rodić-Grabovac B, SailovićP, Lipić N. Medical and pharmaceutical application of oxidized cellulose. Journal of Chemists, Technologists and Environmentalists. 2020;1(1):1-11.

5. Slezak P, Keibl C, Labahn D, Schmidbauer A, Genyk Y, Gulle H. A comparative efficacy evaluation of recombinant topical thrombin (RECOTHROM^®) with a gelatin sponge carrier versus topical oxidized regenerated cellulose (TABOTAMP^® / SURGICEL^®) in a porcine liver bleeding model. Journal of Investigative Surgery. 2021 Jul 22;34(8):862-8.

6. Zhang C, Fu D, Wang F, Zhong X, Yang L, Wu G, Li B, Zhang J. A randomized controlled trial to compare the efficacy of regenerated and non-regenerated oxidized cellulose gauze for the secondary treatment of local bleeding in patients undergoing hepatic resection. Annals of surgical treatment and research. 2021 Apr;100(4):193.

7. Sezer UA, Sahin İ, Aru B, Olmez H, Demirel GY, Sezer S. Cytotoxicity, bactericidal and hemostatic evaluation of oxidized cellulose microparticles: Structure and oxidation degree approach. Carbohydrate polymers. 2019 Sep 1;219:87-94.

8. Wagenhäuser MU, Mulorz J, Ibing W, Simon F, Spin JM, Schelzig H, Oberhuber A. Oxidized (non)-regenerated cellulose affects fundamental cellular processes of wound healing. Scientific Reports. 2016 Aug 25;6(1):32238.

9. Cheng F, Wu Y, Li H, Yan T, Wei X, Wu G, He J, Huang Y. Biodegradable N, O-carboxymethyl chitosan/oxidized regenerated cellulose composite gauze as a barrier for preventing postoperative adhesion. Carbohydrate polymers. 2019 Mar 1;207:180-90.

10. Cheng F, He J, Yan T, Liu C, Wei X, Li J, Huang Y. Antibacterial and hemostatic composite gauze of N, O-carboxymethyl chitosan/oxidized regenerated cellulose. RSC advances. 2016;6(97):94429-36.

11. Cheng F, Liu C, Li H, Wei X, Yan T, Wang Y, Song Y, He J, Huang Y. Carbon nanotube-modified oxidized regenerated cellulose gauzes for hemostatic applications. Carbohydrate polymers. 2018 Mar 1;183:246-53.

12. Bazghaleh AA, Dogolsar MA. Preparation of degradable oxidized regenerated cellulose gauze by zinc modification on HNO 3/Cu oxidized viscose fibers. fibers and polymers. 2019 Jun;20:1125-35.