Fibrin glue instillation under skin flaps to prevent seroma-related morbidity following breast and axillary surgery

Infection-Resistant Polypropylene Hernia Mesh: Vision & Innovations

The surgical repair of hernias, a prevalent condition affecting millions worldwide, has traditionally relied on polypropylene (PP) mesh due to its favorable mechanical properties and biocompatibility. However, postoperative infections remain a significant complication, underscoring the need for the development of infection-resistant hernia meshes. This study provides a comprehensive analysis of current advancements and innovative strategies aimed at enhancing the infection resistance of PP mesh. It presents an overview of various research efforts focused on the integration of antimicrobial agents, surface modifications, and the development of bioactive coatings to prevent bacterial colonization and biofilm formation. Additionally, the synergistic effects of novel material designs and the role of nanotechnology in optimizing the anti-infective properties of PP mesh are explored. Recent clinical outcomes and in vitro studies are critically examined, highlighting challenges and potential future directions in the development of next-generation hernia meshes. Emphasis is placed on the importance of interdisciplinary approaches in advancing surgical materials with the ultimate goal of improving patient outcomes in hernia repair.

The effectiveness of fibrin sealants in head and neck surgery: a systematic review and meta-analysis

BACKGROUND

Fibrin sealants are increasingly used in head and neck surgery to aid hemostasis, but individual studies lack conclusive evidence. This systematic review investigates their effectiveness compared to placebo or usual care in head and neck surgery.

METHODS

Studies comparing fibrin sealant to placebo or usual care in patients 18 years or older who have undergone soft tissue surgery of the head and neck with drain placement were included. Primary outcomes include wound complications and time to surgical drain removal postoperatively. Secondary outcomes include length of hospital stay, drain volume output, surgical management of hematoma, blood transfusion rates, and adverse reactions. Electronic databases were searched on October 2023 for randomized controlled and quasi-experimental studies. Studies underwent independent screening, review, and appraisal by two reviewers using JBI appraisal tools. Certainty was assessed with GRADE, and meta-analysis was conducted using JBI SUMARI, presenting effect sizes as relative risk ratios or mean differences with 95% confidence intervals.

RESULTS

Fourteen studies were included examining 904 patients. The fibrin sealant group exhibited reduced postoperative wound complications (hematoma, seroma, wound dehiscence, wound infection) (RR = 0.64, 95% CI = 0.45-0.92), shorter drain removal times (MD =  - 0.49 days, 95% CI =  - 0.68 to - 0.29), decreased drain output (MD =  - 16.52 mL, 95% CI =  - 18.56 to - 14.52), and shorter hospital stay (MD =  - 0.84 days, 95% CI =  - 1.11 to - 0.57) compared to controls. There was no statistically significant difference on the rate of intervention for postoperative hematoma and the rate of adverse reactions.

DISCUSSION

Evidence demonstrates with low certainty that fibrin sealant use is associated with a modest reduction in the rate of wound complications, drain duration, and length of stay, and a small reduction in drain volume output. Methodological weaknesses and clinical heterogeneity limit these findings. Further research should focus on enhancing methodological quality and exploring the cost-effectiveness of fibrin sealant use in surgery.

SYSTEMATIC REVIEW REGISTRATION

CRD42023412820.

FUNDING

Nil.

Prospective Study on Avoiding Seroma Formation by Flap Fixation After Modified Radical Mastectomy

INTRODUCTION

Seroma development after mastectomy is a common complication. Continued seroma causes increased outpatient visits, repeated aspirations, infection, delayed healing, delayed adjuvant therapy, and increased cost. Various treatments are being attempted to prevent and reduce seroma development. We examined the effects of flap fixation on seroma using absorbable sutures after modified radical mastectomy (MRM).

METHODS

The prospectively recorded data of patients who underwent surgery for breast cancer were analyzed retrospectively. 72 consecutive patients who underwent MRM were included in the study. Patients who underwent MRM in the same way by the same surgeon were divided into two groups: the group whose wound was closed by fixing the flap to the chest wall with an absorbable suture (group A), and the group whose wound was closed with the classical method (group B). The groups were compared in terms of seroma development, clinicopathological data, and early complications.

RESULTS

Drain removal time and the total amount of drained fluid in group A patients were significantly lower than drain removal time and the total amount of drained fluid in group B patients (P < .001). Similarly, the amount of aspirated seroma in the control examinations of group A patients was significantly lower than that in group B (P < .05). Group B needed re-aspiration significantly more than group A (P < .05).

CONCLUSIONS

Flap fixation with suture after MRM is a method that reduces seroma formation and the amount of drained fluid, enables early removal of the drain, prevents delay in starting adjuvant treatment, is more comfortable for the patient and physician, and is also inexpensive.

Association between surgical hernia repair techniques and the incidence of seroma: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Ventral hernia repair (VHR) includes the surgical reconstruction of the abdominal wall (AW) using different surgical techniques. Although such procedures are usually devoid of complications, the formation of seroma may frequently occur. We performed a systematic review to assess the evidence from randomized controlled trials (RCTs) comparing VHR techniques and their impact on seroma formation.

METHODS

We included RCTs having seroma formation as primary endpoint. We included patients of both sexes (age > 18). For data synthesis we applied a random-effects model and calculated risk ratios (RR) with 95% confidence intervals (CI) using the Mantel-Haenszel method. Risk of bias (ROB) and publication bias were evaluated following Cochrane recommendations.

RESULTS

After database search and article screening, 21 records were included in this review. Ten RCTs compared onlay vs. sublay mesh placement techniques. Pooled analysis showed a significantly higher risk ratio for seroma in the onlay cohort (RR = 2.61, 95% CI 1.86-3.66, I² = 0, GRADE quality of evidence, moderate). Five RCTs compared laparoscopic intraperitoneal onlay mesh repair vs. open mesh placement. Pooled analysis showed that seroma formation did not differ significantly between groups (RR = 1.91, 95% CI 0.69-5.28, I² = 66%, GRADE quality of evidence, poor). High ROB was found in all studies and significant publication bias was detected in both meta-analyses.

CONCLUSION

Compared to sublay ventral hernia repair, the onlay procedure is associated with a significantly higher risk of seroma. No significant differences were observed when laparoscopic VHR was compared with the open surgical procedure. Due to the diversity of surgical techniques reported in included RCTs, it is currently not possible to draw conclusive clinical recommendations. Future studies should be standardized to provide detailed data allowing thorough evaluation of the impact of the evidence on clinical practice.

Fibrin Sealants and Axillary Lymphatic Morbidity: A Systematic Review and Meta-Analysis of 23 Clinical Randomized Trials

Simple Summary

Axillary dissection is a highly mobile procedure with severe lymphatic consequences. The off-label application of fibrin sealants in the axilla, with the sole aim to eliminate dead space and to provoke sealing of the disrupted lymphatic vessels at the end of axillary dissection, is an experimental procedure to reduce lymphatic morbidity. The aim of our systematic review and meta-analysis is to investigate the effects of fibrin sealants on lymphatic morbidity after axillary dissection. Our results show that this experimental procedure is able to decrease the total axillary drainage output, the number of days before the axillary drainage is removed, and the length of hospital stay. However, no effects on the occurrence rate of axillary lymphocele or on the surgical site complications rate were demonstrated

Abstract

Background: use of fibrin sealants following pelvic, paraaortic, and inguinal lymphadenectomy may reduce lymphatic morbidity. The aim of this meta-analysis is to evaluate if this finding applies to the axillary lymphadenectomy. Methods: randomized trials evaluating the efficacy of fibrin sealants in reducing axillary lymphatic complications were included. Lymphocele, drainage output, surgical-site complications, and hospital stay were considered as outcomes. Results: twenty-three randomized studies, including patients undergoing axillary lymphadenectomy for breast cancer, melanoma, and Hodgkin’s disease, were included. Fibrin sealants did not affect axillary lymphocele incidence nor the surgical site complications. Drainage output, days with drainage, and hospital stay were reduced when fibrin sealants were applied (p < 0.0001, p < 0.005, p = 0.008). Conclusion: fibrin sealants after axillary dissection reduce the total axillary drainage output, the duration of drainage, and the hospital stay. No effects on the incidence of postoperative lymphocele and surgical site complications rate are found.

Fascia Suture Technique Is a Simple Approach to Reduce Postmastectomy Seroma Formation

Purpose

Seroma formation is a common complication in breast cancer patients undergoing mastectomy, and it negatively affects patient recovery after surgery. The present study aimed to evaluate a simple method using fascia suture technique to fix the flap and reduce the incidence of seroma.

Methods

A single-center, prospective, randomized controlled trial was carried out among 160 patients who had undergone mastectomy from May 2018 to September 2019. All patients were randomly divided into the fascia suture group (n = 80) or control group (n = 80) and were followed up for at least 3 months for the assessment of immediate and late complications after surgery.

Results

No significant differences were observed between the 2 groups with regard to the basic characteristics. Duration of surgery in the fascia suture group was longer by about 6 minutes compared with that in the control group (114.93 ± 13.67 minutes vs. 108.81 ± 15.20 minutes, p = 0.008). The fascia suture group had a shorter duration of drain placement (10.99 ± 3.26 days vs. 13.85 ± 5.37 days, p < 0.001), a smaller volume of the total drainage (460.95 ± 242.92 mL vs. 574.83 ± 285.23 mL, p = 0.007), and the first 3-day drainage (224.96 ± 101.01 mL vs. 272.3 ± 115.47 mL, p = 0.006), compared with the control group. The incidence of seroma formation (G2 or G3) was significantly lower in the fascia suture group compared with the control group (28.8% vs. 12.5%, p = 0.033). Besides, there was no statistical difference between the 2 groups in the assessment of other complications, including postoperative pain, hematoma, surgical site infections, flap necrosis, and skin dimpling (all p > 0.050).

Conclusion

The fascia suture technique is a simple and effective method for reducing seroma formation and should be used to prevent seroma formation after mastectomy.

Trial Registration

Chinese Clinical Trials Registry Identifier: ChiCTR1800015913.

Determining the effectiveness of fibrin sealants in reducing complications in patients undergoing lateral neck dissection (DEFeND): study protocol for a randomised external pilot trial

Background

Complications after major surgery are a significant cause of morbidity and mortality. Neck dissection is one of the most commonly performed major operations in Head and Neck Surgical Oncology. Significant surgical complications occur in approximately 10-20% of all patients, increasing to 40% in patients who have had previous treatment to the area or have multiple co-morbidities and/or polypharmacy.Current evidence suggests that fibrin sealants (FS) may have potential clinical advantages in Head and Neck Surgery through the reduction of complications, volume of wound drainage and retention time of the drains. However, a paucity of high-quality trial-based evidence means that a surgical trial to determine the effectiveness of FS in reducing the rate and severity of complications in patients undergoing lateral neck dissection is warranted. The DEFeND randomised external pilot trial will address critical questions on how well key components of the proposed study design work together as well as the feasibility of a future phase III trial.

Methods

The study design that is being piloted is that of a two-arm, parallel group, superiority trial with block randomisation in a 1:1 allocation ratio. The interventional arm will constitute the application of FS (Artiss, Baxter Healthcare Ltd.) to the surgical wound following completion of a neck dissection procedure, in addition to standard of care (SOC). The control arm will constitute SOC alone. Eligible patients will include patients who require a lateral neck dissection with a minimum of three cervical nodal levels. Patients who require bilateral neck procedures or undergoing immediate reconstruction with free or regional flaps will be excluded. The outcomes being assessed will be recruitment rate, screened to randomisation rate, fidelity of blinding process using blinding indices, number of missing or incomplete data entries, number of protocol deviations and number of losses to follow-up. Suitability of the outcome measures proposed for the future phase III trial will also be assessed.

Discussion

The anticipated challenges for this study will be recruitment, complexity of the intervention and adherence to the protocol. The outcomes will inform the design, feasibility and conduct of a future phase III surgical trial.

Trial registration

First participant randomised: November 06, 2018; UKCRN Portfolio ID: 37896; ISRCTN99181100.

Fibrin-thrombin sealant does not reduce lymphocele formation in patients with inguinofemoral lymphadenectomy for vulvar cancer

Purpose: Inguinofemoral lymphadenectomy (IFLD) is associated with very high morbidity. Fibrin sealant patches are used in various surgical procedures to prevent hematomas and lymphoceles. Here, we report a single-institution experience of fibrin sealants after IFLD in vulvar cancer and give an overview of the current literature.

Patients and methods: We retrospectively analyzed outcome data on vulvar cancer patients who underwent bilateral IFLD between November 2014 and June 2016 at the University Hospital Basel. A fibrin sealant patch (Tachosil^®) was placed in one groin only. Postsurgical fluid collection and complications were compared between both groins; time courses of lymphocele formation were analyzed using a linear mixed-effects regression model.

Results: Postsurgical outcome of 11 consecutive patients with bilateral IFLD for vulvar cancer was assessed for a median follow-up of 32 days (range 12–77). Significantly larger lymphoceles were detected over time in the groin with the fibrin sealant patch (median 20 mL vs 5 mL without patch, p=0.002), and more punctures for symptomatic lymphocele were required on this side. The infection rate did not differ between sides.

Conclusion: Fibrin sealant patches should not routinely be used for prevention of lymphoceles after IFLD for vulvar cancer. They do not seem to reduce lymph collection, the need for puncture or the infection risk after lymphadenectomy in our experience and according to a general literature review.

The Use of TissuGlu® Surgical Adhesive for Mastectomy With or Without Lymphonodectomy

BACKGROUND/AIM

Using drains after breast surgery is a preventive, but invasive measure to reduce seroma formation. A polyurethane-based tissue adhesive (TissuGlu®) might facilitate drainage-free wound healing after mastectomy in a non-invasive manner.

PATIENTS AND METHODS

Retrospectively, data from 84 patients (42 receiving TissuGlu®, 42 receiving a drainage) who underwent mastectomy, were collected (90 days postoperative follow-up). Study endpoints were defined as the number of fluid-related postoperative clinical interventions, cumulative volume of postoperative wound fluid, duration of hospitalization and postoperative complications.

RESULTS

In the entirety of postoperative interventions, no significant difference could be demonstrated (p=0.298). The drainage arm showed significantly less seroma aspirations (p=0.024) and complications (p=0.012). A significantly reduced length of hospitalization (p<0.001) and less cumulative wound secretion volume (p<0.001) appeared in the TissuGlu® group.

CONCLUSION

The polyurethane-based tissue adhesive is a less invasive alternative to drain use in mastectomy.

The Use of TissuGlu® Surgical Adhesive for Mastectomy With or Without Lymphonodectomy

BACKGROUND/AIM

Using drains after breast surgery is a preventive, but invasive measure to reduce seroma formation. A polyurethane-based tissue adhesive (TissuGlu®) might facilitate drainage-free wound healing after mastectomy in a non-invasive manner.

PATIENTS AND METHODS

Retrospectively, data from 84 patients (42 receiving TissuGlu®, 42 receiving a drainage) who underwent mastectomy, were collected (90 days postoperative follow-up). Study endpoints were defined as the number of fluid-related postoperative clinical interventions, cumulative volume of postoperative wound fluid, duration of hospitalization and postoperative complications.

RESULTS

In the entirety of postoperative interventions, no significant difference could be demonstrated (p=0.298). The drainage arm showed significantly less seroma aspirations (p=0.024) and complications (p=0.012). A significantly reduced length of hospitalization (p<0.001) and less cumulative wound secretion volume (p<0.001) appeared in the TissuGlu® group.

CONCLUSION

The polyurethane-based tissue adhesive is a less invasive alternative to drain use in mastectomy.

Complete axillary dissection without drainage for the surgical treatment of breast cancer: a randomized clinical trial

OBJECTIVE:

This randomized clinical trial evaluated the possibility of not draining the axilla following axillary dissection.

METHODS:

The study included 240 breast cancer patients who underwent axillary dissection as part of conservative treatment. The patients were divided into two groups depending on whether or not they were subjected to axillary drainage. ClinicalTrials.gov: NCT01267552.

RESULTS:

The median volume of fluid aspirated was significantly lower in the axillary drainage group (0.00 ml; 0.00 - 270.00) compared to the no drain group (522.50 ml; 130.00 - 1148.75). The median number of aspirations performed during conservative breast cancer treatment was significantly lower in the drainage group (0.5; 0.0 - 4.0) compared to the no drain group (5.0; 3.0 - 7.0). The total volume of serous fluid produced (the volume of fluid obtained from drainage added to the volume of aspirated fluid) was similar in the two groups. Regarding complications, two cases (2.4%) of wound dehiscence occurred in the drainage group compared to 13 cases (13.5%) in the group in which drainage was not performed, with this difference being statistically significant. Rates of infection, necrosis and hematoma were similar in both groups.

CONCLUSION:

Safety rates were similar in both study groups; hence, axillary dissection can feasibly be performed without drainage. However, more needle aspirations could be required, and there could be more cases of wound dehiscence in patients who do not undergo auxiliary drainage.

Impact of the Ultrasonic scalpel on the amount of drained lymph after axillary or inguinal lymphadenectomy

BACKGROUND

Seroma formation and lymphoedema are frequently encountered complications after radical lymph node dissection (RLND). Attempts to reduce the lymphatic morbidity include the use of Ultrasonic Scalpel. The aim of the present analysis was to assess the impact of the ultrasonic scalpel on the amount of drained lymph after lymph node dissection.

METHODS

Patients listed for a RLND or completion lymph node dissection (CLND) were enrolled in a prospective randomized trial to compare the impact of two surgical dissection techniques (USS versus control) on the amount of drained lymph. The lymph drained in 24 h was collected. Our primary endpoint was to compare the daily amount of drained lymph between the two groups. Secondary endpoints were the comparison of drained lymph with the BMI of the patients, the gender and the surgical site (axilla, groin).

RESULTS

Eighty patients were randomly assigned to the USS group or the Control (C) group. No difference was measured in the total amount of lymph drained (USS: 2908 ± 2453 ml vs. C: 3898 ± 5791 ml; p-value = 0.382). The result was also similar after adjusting for gender, age, and BMI. A significant higher amount of lymph was measured after inguinal dissection with USS compared to axillary (p < 0.001).

CONCLUSION

The study suggests that the use of Harmonic scalpel did not influence the amount of lymph drained after RLND and not support the theory that USS induces oversealing of lymphatics.

TRIAL REGISTRATION

Clinical Trial NCT02476357 . Registered 20 of February 2015.

Effect of Tissue Adhesives on Seroma Incidence After Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Tissue adhesives (TAs) are widely utilized in abdominoplasty to reduce postoperative seroma. However, current literature regarding TAs in abdominoplasty is limited to small studies and the findings of single institutions.

OBJECTIVES

The authors reviewed the current literature regarding the effects of TAs on seroma formation and other endpoints following abdominoplasty, and summarized the types of TAs and application techniques that have been described to date.

METHODS

A systematic review of the Medline, Embase, Web of Science, and Cochrane databases was conducted to identify randomized controlled trials (RCTs) in which the numbers of patients who experienced seroma after abdominoplasty were indicated. The Cochrane Collaboration's tool for assessing risk of bias was applied.

RESULTS

Seven studies were included in a descriptive review, 5 of which were RCTs. Data from the 5 RCTs were pooled for a meta-analysis. Patients who received TAs following abdominoplasty had a similar incidence of seroma compared with patients who did not receive TAs. However, the total drainage volume was significantly lower for patients who received TAs.

CONCLUSIONS

There is a paucity of high-quality evidence to support the delivery of TAs to prevent seroma formation after abdominoplasty. Well-designed RCTs are needed to assess with confidence the overall effects of TAs in abdominoplasty.

LEVEL OF EVIDENCE

2 Therapeutic.

No-drain mastectomy - Preventing seroma using TissuGlu(®): A small case series

Introduction

Post-mastectomy seroma, with an occurrence of up to 59%, is a major complication in modern oncological surgery. While drain placement is a common tool in dealing with this complication, some patients may either be incapable or unwilling to accept this course of action, requiring an alternative option for seroma prevention. A recent study using a lysine-derived urethane adhesive named TissuGlu^® has shown promising results in mastectomy patients.

Case presentation

We used TissuGlu^® in three patients who could not have a post-operative drain after mastectomy due to a variety of reasons. Standard mastectomy protocols were followed. Two no-drain mastectomy patients did not show any post-operative seroma formation (cases 1 and 2), while a third patient had to be aspirated twice at two (180 ml) and four weeks (60 ml) post-surgery. No complications such as hematoma, wound dehiscence or adverse reactions to the adhesive were observed. Patient satisfaction with the no-drain situation was high as post-surgical discomfort was minimal.

Conclusion

Although one patient developed small amounts of seroma, TissuGlu^® may present an additional option in the high risk, no-drain post-mastectomy scenario.