Assessment of the efficacy of Ankaferd blood stopper on the prevention of postoperative pericardial adhesions.

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 3, May/June 2014 Assessment of the efficacy of Ankaferd blood stopper on the prevention of postoperative pericardial adhesions Yunus Nazli, Necmettin Colak, Mehmet Fatih Alpay, Hacer Haltas, Omer Nuri Aksoy, Ismail Olgun Akkaya, Omer Cakir Abstract Objectives: Ankaferd has been used as a bloodstopping agent and it may also have an anti-inflammatory effect. We investigated the efficacy of Ankaferd in preventing postoperative pericardial adhesions in an experimental rabbit model. Methods: Sixteen New Zealand white rabbits were used and categorised into two groups: an Ankaferd and a control group. The Ankaferd group of rabbits was treated with a sponge impregnated with Ankaferd solution, which was applied over the abraded epicardium. A sponge impregnated with 0.9% isotonic NaCl solution was applied to the control group using the same protocol. Scores for adhesion and visibility of coronary vessels were graded by macroscopic examination, and pericardial tissues were analysed microscopically in terms of inflammation and fibrosis. Results: In the Ankaferd group, the adhesion scores were significantly higher than in the control group (p = 0.007). When the groups were compared according to the prevalence of fibrosis and degree of inflammation, the Ankaferd group was found to be statistically significantly different from the control group in terms of prevalence of fibrosis (p = 0.028). Conclusion: Topical application of Ankaferd to prevent postoperative pericardial adhesions increased adhesion and fibrosis scores. Keywords: cardiac operation, Ankaferd, pericardial adhesion Submitted 6/2/14, accepted 20/2/14 Cardiovasc JAfr 2014; 25: 100-105 www.cvja.co.za DOI: 10.5830/CVJA-2014-011 Postoperative pericardial adhesion formation occurs frequently after cardiac surgery and is an important cause of morbidity and mortality at the time of re-operation. As the number of patients undergoing cardiac surgery continues to increase, the number of potential candidates for re-operation is increasing exponentially. Department of Cardiovascular Surgery, University of Turgut Ozal, Ankara, Turkey Yunus Nazli, MD, yunusnazli@gmail.com Necmettin Colak, MD Mehmet Fatih Alpay, MD Omer Nuri Aksoy, MD Ismail Olgun Akkaya, MD Omer Cakir, MD Department of Pathology, University of Turgut Ozal, Ankara, Turkey Hacer Haltas, MD Despite ongoing improvements during cardiac re-operation surgery, the presence of pericardial adhesions not only adds to the surgery time but also increases the risk of life-threatening injuries to the heart, great vessels or previously placed coronary bypass conduits by obscuring the true anatomy. 1 Various methods and materials have been investigated to prevent or reduce the severity of postoperative adhesions in the retrosternal spaces and mediastinal structures. Fibrinolytic agents, histamine antagonists, anti-coagulants, anti-inflammatory drugs (corticosteroids, non-steroidal drugs), antibiotics, several natural physical barriers (heterologous pericardium, omentum, peritoneum, amnion, fibrin, gelatin, collagen and hyaluronic acid) and synthetic physical barriers (rubber, silicon-based materials, cellulose, polytetrafluoroethylene, polyvinyl alcohol and polyester derivatives) have been tried with variable success for such purposes. 2 6 Unfortunately, despite continuous advances and research, to date there is no ideal method to prevent or reduce postoperative pericardial adhesion formation. Ankaferd blood stopper® (ABS) (Ankaferd Ilac Kozmetik AS, Istanbul, Turkey) is a folkloric medicinal plant extract. Ankaferd has been used as a blood-stopping agent against various types of bleeding. It has been approved by the Ministry of Health in Turkey for the management of bleeds due to external injury and dental surgery. It has also been used as a topical agent for the prevention of postoperative intra-abdominal fibrosis in experimental studies, and variable results have been obtained. 7 8 To the best of our knowledge, there is no report on the effect of Ankaferd in preventing postoperative pericardial adhesions to date. The present experimental study was designed to investigate the effect of intrapericardially administered Ankaferd on reducing postoperative pericardial adhesion formation in the rabbit model. Methods The study protocol was approved by the Ethics Committee for Animal Research, Ankara Education and Research Hospital, Ankara, Turkey. Sixteen New Zealand white rabbits weighing 2.5 to 3.0 kg were anesthetised with 35 mg/kg ketamine hydrocloride and 5 mg/kg xylazine administered intramuscularly. 9 10 After disappearance of the pedal reflex in the hind limbs, the rabbits were placed in the supine position on a heated operating table and their temperature was maintained at 39°C by monitoring their rectal temperature. 11 12 The pedal reflex was checked every five minutes throughout the surgical procedure. A venous line was established in the ear and a saline solution was