Original ArticleBiocompatible Amniotic Sac Implant Maintains a Scar-Free Brain Surface During Recurrent Glioma Surgery
Introduction
Tumor recurrence is an expected outcome after surgery for high-grade gliomas even with maximal and supramaximal resection. To date, there remains no consensus among neurosurgeons as to the optimal management of disease recurrence; however, there is agreement on the role of surgical management as a life-saving measure in patients with impending herniation. Moreover, the effects of tumor debulking and a decreased tumor burden on reducing cerebral edema and improving the patient's quality of life is a goal that most neurosurgeons agree on. Although several studies have alluded to the role of re-resection in improving overall neurologic function and survival, the associated data are not sufficiently robust to support further reoperations for repeated tumor recurrence.1, 2, 3, 4, 5 Regardless, however, this is generally considered a safe and effective approach for addressing tumor recurrence and is the standard of care at many neuro-oncological centers.2 A recent review by Harvey-Jumper et al.1 advocated for additional reoperations on recurrence in patients with a favorable Karnofsky Performance Score, which may improve the overall survival in these patients.1
Reoperating on patients with recurrent high-grade gliomas can be a formidable task owing to heavy scarring and formation of arachnoid adhesions over time, which can make for a very challenging dissection without causing cortical vessel and tissue injury. These connective tissue bridges form between the meningeal layer of the dura and the pia-arachnoid membrane. Dissecting these adhesions can prove frustrating for neurosurgeons because of the risk of cortical vessel and tissue injury, an obscured previous surgical cavity, and prolonged anesthesia time. The formation and the extent of these adhesions is directly related and influenced by numerous factors, including the patient's immune response, brain tissue manipulation, and dural closure from previous surgery.6
Numerous studies have investigated the use of subdural substances as well as different dural closure techniques to help overcome this challenge.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 However, most of those techniques have not proven successful in effectively reducing scar formation in all patients in a consistent fashion.6 Here we describe our experience with a biocompatible amniotic sac implant to prevent and/or minimize postsurgical brain surface adhesions. To our knowledge, this is the first report on the use of amniotic membrane (AM) grafts, in an off-label application, to prevent postoperative brain adhesions between the pia-arachnoid surface and the meningeal dural layer.
Section snippets
Methods
In our procedure, amniotic sac implants are laid on the brain surface after glioma resection. These implants are available in different sizes, and the appropriate size is selected based on the dimensions of the surgical cavity and the presence of surrounding vessels. After irrigating the surgical site with saline solution, the amniotic implant is gently handled with forceps and applied on the brain surface to cover the surgical crater as well as the surrounding vessels, especially in the
Results
In all recurrent glioma surgeries in which a BioD film was previously used along the resection cavity before closure, we found minimal to no adhesions on the pia-arachnoid surface of the brain (Figure 2). In all recurrent exposures after dural opening, we found a loosely attached neo-membrane that could be easily dissected off the brain surface and vessels (Video 1). This layer did not appear in areas where the AM graft did not cover the brain subdurally. The BioD film is especially
Discussion
The first reported use of an AM graft was for skin transplantation in 1910.22 Since then, its application has expanded broadly to include the treatment of leg ulcers and skin burns, as well as the repair of omphaloceles; reconstruction of the oral cavity, bladder, and vagina; and prevention of adhesions in the pelvis and abdomen. It was also used in ophthalmic surgery starting in the 1940s but then was abandoned for decades before being reintroduced in the early 1990s.23, 24, 25, 26, 27, 28, 29
Conclusion
Because high-grade gliomas are known to recur, reoperation for resection of recurrent disease should be considered a viable and practical option, especially in young patients with a good Karnofsky Performance Scale score. To that end, closure of an initial case should account for the possibility of a comeback surgery with the least amount of scarring and adhesions to avoid direct injury to the brain and cortical vessels. Application of the BioD graft, a Food and Drug Administration–approved
Acknowledgment
We thank Nathan Moore for editing the video and the figure.
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2021, Journal of Clinical NeuroscienceCitation Excerpt :AM's favored use is strongly related to its antiangiogenic, anti-inflammatory [13], and anti-fibrotic [14] effects. Also, AM has antimicrobial [15,16] and strong epithelialization [17] proprieties [3,18–21]. Dural substitutes with anti-inflammatory properties might reduce the risk of adherence formation, thus decreasing operative time, blood loss, risk of CSF fistula formation, infections, and other complications [22,23].
Homologous cryopreserved amniotic membrane in the repair of myelomeningocele: preliminary experience
2018, Acta Neurochirurgica
Conflict of interest statement: Ali F. Krisht is a consultant for BioD, LLC. The patent for use of the BioD membrane as a brain surface antiadhesive has been filed and is pending approval. The other authors have no conflicts to report.
Supplementary digital content available online.