Perioperative and postoperative tranexamic acid reduces the local wound complication rate after surgery for breast cancer

Total Sealing Technique (TST) with a bipolar vessel sealing system reduces lymphorrhea and seroma formation for axillary lymph node dissection in primary breast cancer

Background

The purpose of this study is to evaluate the potential of a novel surgical procedure, the Total Sealing Technique (TST), using the latest bipolar vessel sealing system (BVSS; LigaSure™ Exact Dissector) to reduce lymphatic leakage and seroma formation after electrocautery axillary lymph node dissection (ALND) in breast cancer surgery. Prolonged drainage is a common occurrence after ALND, primarily due to lymphatic leakage. In addition, the presence of seroma often leads to delays in the administration of postoperative adjuvant chemotherapy even after drain removal.

Methods

We conducted a comparative analysis of 36 patients who underwent total mastectomy with ALND using conventional electrocautery technique (CONV) during the first 3 years, and 35 patients who underwent the same procedure using TST during the subsequent 3 years. The following factors were compared to assess the impact of TST: operation time, blood loss, total drainage volume, mean time to drain removal, postoperative hospital stay, mean time to initiation of postoperative chemotherapy, and postoperative complications in each group.

Results

TST significantly reduced drainage volume (360.5 vs. 820.6 mL, p < 0.001), days to drain removal (4.8 vs. 6.8 days, p < 0.001), postoperative hospital stay (5.9 vs. 9.6 days, p < 0.001), the incidence of seroma (28.6 % vs. 65.9 %, p = 0.001), and time to chemotherapy initiation (33.1 vs. 61.4 days, p < 0.001) compared to CONV.

Conclusions

TST in total mastectomy with ALND effectively decreases the incidence of lymphorrhea and seroma formation; thus, it can be recommended for total mastectomy with ALND.

Reducing the incidence of problematic seroma formation and skin necrosis post-lymphadenectomy: Triple action of topical tranexamic acid, negative pressure wound therapy, and prolonged drainage

BACKGROUND

Axillary and inguinal lymph node dissections are commonly associated with complications that often require additional interventions.

METHODS

Patients who underwent axillary or inguinal lymphadenectomy via standard procedures were compared to an intervention cohort of patients who underwent axillary or inguinal lymphadenectomy with the use of topical tranexamic acid (TXA) to the wound cavity, a PICO (Smith&Nephew UK) closed-incision negative pressure dressing, and discharged early with a drain in-situ.

RESULTS

Seventy-six patients in the control group (mean age 65.8 years, mean BMI 28.4 kg/m2) underwent open lymphadenectomy without topical TXA and a simple dressing. Seventy-eight patients were included in the intervention group (mean age 67.1 years, mean BMI 28.5 kg/m2). Patients in the intervention group had an inpatient stay of mean 5.6 days fewer than those in the control group (CI 3.09-5.31; p < .0001), an estimated saving to the healthcare trust of £ 3046.40 (US$3723.61) per patient in "bed days." They had longer drain duration (mean 15 days vs. 8.3 days); however, they had a statistically significant lower risk of seroma formation requiring drainage (6.4% vs. 21%; p = .009), and skin necrosis (0% vs. 6.6%; p = .027). They also had a lower risk of infection (17% vs. 29%), wound dehiscence (15% vs. 25%), and readmission (7.7% vs. 14%), although they were not statistically significant. Patients in the control group were more likely to receive antibiotics as inpatients (51% vs. 7.7%; p < .00001) and on discharge (24% vs. 5%; p < .0011) than those in the intervention group.

CONCLUSIONS

Topical TXA, PICO dressing, and early discharge with a drain following lymphadenectomy results in a reduced rate of complications.

Use of Tranexamic Acid in Gender-Affirming Mastectomy Reduces Rates of Postoperative Hematoma and Seroma

BACKGROUND

The established safety and efficacy of tranexamic acid (TXA) in minimizing perioperative blood loss has led to increased interest within plastic surgery. Prior studies have demonstrated decreased edema and ecchymosis and reduced rates of postoperative collection with administration of TXA; however, its use has not been reported in gender-affirming mastectomy. This represents the first study to evaluate the effects of TXA on postoperative outcomes in patients undergoing gender-affirming mastectomy.

METHODS

A single-center cohort study was performed analyzing all consecutive patients undergoing gender-affirming mastectomy with the senior author (R.B.-L.) between February of 2017 and October of 2022. Beginning in June of 2021, all patients received 1000 mg of TXA intravenously before incision and 1000 mg at the conclusion of the procedure. Patients were stratified according to intraoperative administration of TXA, with demographic characteristics, surgical characteristics, and postoperative outcomes compared between groups.

RESULTS

A total of 851 patients underwent gender-affirming mastectomy. Of these, 646 cases were performed without TXA, and 205 patients received intravenous TXA intraoperatively, as described previously. Patients who received TXA had significantly lower rates of seroma (20.5% versus 33.0%; P < 0.001) and hematoma (0.5% versus 5.7%; P = 0.002). There was no difference in rates of surgical-site infection ( P = 0.74). TXA use was not associated with increased rates of venous thromboembolism ( P = 0.42).

CONCLUSIONS

Intraoperative administration of TXA in patients undergoing gender-affirming mastectomy may safely reduce the risk of postoperative seroma and hematoma without increased risk of thromboembolic events. Additional data collection and prospective studies are warranted to corroborate these findings.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Efficacy of perioperative systemic tranexamic acid along with topical hemocoagulase in decreasing axillary drain output in breast cancer patients undergoing axillary lymph node dissection: A randomized, double-blind, placebo-controlled, superiority trial

BACKGROUND

Excess and prolonged axillary drainage is a frequent nuisance following axillary lymph node dissection (ALND) in breast cancer patients. No consensus exists about the best method to prevent this consistently and reliably. Tranexamic acid (TA) has been found to reduce the amount and duration of drainage, but the reduction is not optimal. We hypothesized that systemic administration of TA along with the topical application of hemocoagulase (H) to the axillary dissection bed may decrease the cumulative axillary drain output and shorten the requirement of drainage after ALND as compared to placebo.

PATIENT AND METHODS

Seventy women undergoing ALND for breast carcinoma were randomized into two groups, the intervention (TA + H) group and the control (C) group. The cumulative drain output (primary objective), duration of drainage, incidence of seroma formation after drain removal, number of seroma aspirations required, volume of seroma aspirated, and incidence of surgical site infection (SSI) were compared.

RESULTS

The mean cumulative output in the TA + H group was significantly lower than the C group (290 ± 200 mL vs. 552 ± 369 mL, p < 0.001). Axillary drains were removed significantly earlier in the TA + H group (6.6 ± 2.2 vs. 11.7 ± 6.0 days, p < 0.001), but the incidence of seroma formation (p = 0.34), number of aspirations required (p = 0.33), volume of seroma aspirated (p = 0.47), and the incidence of SSI (p = 0.07) were similar.

CONCLUSIONS

Perioperative systemic administration of tranexamic acid along with topical application of H to the axillary dissection bed is effective in reducing cumulative axillary drain output after ALND. This strategy may also facilitate earlier removal of suction drains.

Comprehensive analysis of risk factors for postoperative wound infection following radical mastectomy in breast cancer patients

Surgical site infections (SSIs) following radical mastectomy in breast cancer patients can significantly affect patient recovery and healthcare resources. Identifying and understanding the risk factors for postoperative wound infections (PWIs) are crucial for improving surgical outcomes. This retrospective study was conducted from June 2020 to June 2023, including 23 breast cancer patients who developed PWIs post-radical mastectomy and a control group of 46 patients without such infections. Comprehensive patient data, including variables such as intraoperative blood loss, hospital stay duration, body mass index (BMI), operation time, anaemia, drainage time, diabetes mellitus, cancer stage, white blood cell (WBC) count, serum albumin levels and preoperative neoadjuvant chemotherapy, were meticulously gathered. Statistical analyses, including univariate and multivariate logistic regression, were performed using SPSS software (Version 27.0). The univariate analysis identified several factors significantly associated with an increased risk of PWIs, including preoperative neoadjuvant chemotherapy, low serum albumin levels, advanced cancer stage, diabetes mellitus and reduced WBC count. Multivariate logistic regression highlighted anaemia, prolonged drainage time, diabetes mellitus, advanced cancer stage, reduced WBC count, hypoalbuminemia and preoperative neoadjuvant chemotherapy as significant contributors to the increased risk of PWIs. Anaemia, extended drainage time, diabetes mellitus, advanced cancer stage, low WBC count, hypoalbuminemia and preoperative neoadjuvant chemotherapy are key risk factors for SSIs post-radical mastectomy. Early identification and proactive management of these factors are imperative to reduce the incidence of postoperative infections and enhance recovery outcomes in breast cancer patients.

Bioglass/ceria nanoparticle hybrids for the treatment of seroma: a comparative long-term study in rats

Background: Seroma formation is a common postoperative complication. Fibrin-based glues are typically employed in an attempt to seal the cavity. Recently, the first nanoparticle (NP)-based treatment approaches have emerged. Nanoparticle dispersions can be used as tissue glues, capitalizing on a phenomenon known as 'nanobridging'. In this process, macromolecules such as proteins physically adsorb onto the NP surface, leading to macroscopic adhesion. Although significant early seroma reduction has been shown, little is known about long-term efficacy of NPs. The aim of this study was to assess the long-term effects of NPs in reducing seroma formation, and to understand their underlying mechanism. Methods: Seroma was surgically induced bilaterally in 20 Lewis rats. On postoperative day (POD) 7, seromas were aspirated on both sides. In 10 rats, one side was treated with NPs, while the contralateral side received only NP carrier solution. In the other 10 rats, one side was treated with fibrin glue, while the other was left untreated. Seroma fluid, blood and tissue samples were obtained at defined time points. Biochemical, histopathological and immunohistochemical assessments were made. Results: NP-treated sides showed no macroscopically visible seroma formation after application on POD 7, in stark contrast to the fibrin-treated sides, where 60% of the rats had seromas on POD 14, and 50% on POD 21. At the endpoint (POD 42), sides treated with nanoparticles (NPs) exhibited significant macroscopic differences compared to other groups, including the absence of a cavity, and increased fibrous adhesions. Histologically, there were more macrophage groupings and collagen type 1 (COL1) deposits in the superficial capsule on NP-treated sides. Conclusion: NPs not only significantly reduced early manifestations of seroma and demonstrated an anti-inflammatory response, but they also led to increased adhesion formation over the long term, suggesting a decreased risk of seroma recurrence. These findings highlight both the adhesive properties of NPs and their potential for clinical therapy.

Safety and Outcomes in Multiplane Facial Rejuvenation with Tranexamic Acid: A Cohort Study

Background

Tranexamic acid (TXA) has demonstrated promising outcomes in plastic surgery. Our aim was to assess the effect of TXA in intraoperative bleeding, operative time, and complications among patients undergoing facial surgical procedures.

Methods

A retrospective cohort study of patients who underwent multiplane facial rhytidectomy from January 2018 to September 2022 at the Clinica Ziegler, Lima, Peru. Patients were divided into two groups according to the use of intravenous plus local infiltration of TXA. We performed the chi square test to assess associations among categorical variables, the Student t test and Mann-Whitney U test for categorical with continuous variables, and Pearson correlation for quantitative variables.

Results

A total of 100 patients were included with 50 patients in each group. The median age was 59.5 years and the majority were women (88%). The median operative time was 288.5 minutes. The TXA group presented less intraoperative bleeding (40 versus 90 mL, P < 0.05) and shorter operative time (237 versus 353 minutes, P < 0.05); no differences in the development of hematoma (2% versus 12%, P = 0.11), less ecchymosis (2% versus 36%, P < 0.05), edema (2% versus 100%, P < 0.05), and time to drain removal (3 versus 6 days, P < 0.05).

Conclusions

TXA improves the short- and long-term outcomes of patients who undergo multiplane facial rhytidectomy. It also decreases intraoperative bleeding by more than half and reduces the operative time by one third. Moreover, patients receiving TXA presented significantly less ecchymosis, edema, and time to drain removal.

Perioperative treatment with tranexamic acid in melanoma (PRIME): protocol for a Danish multicentre randomised controlled trial investigating the prognostic and treatment-related impact of the plasminogen-plasmin pathway

INTRODUCTION

Inflammation is a hallmark of cancer and is involved in tumour growth and dissemination. However, the hallmarks of cancer are also the hallmarks of wound healing, and modulating the wound inflammatory response and immune contexture in relation to cancer surgery may represent effective targets of therapies.Repurposing anti-inflammatory drugs in a cancer setting has gained increasing interest in recent years. Interestingly, the known and thoroughly tested antifibrinolytic drug tranexamic acid reduces the risk of bleeding, but it is also suggested to play important roles in anti-inflammatory pathways, improving wound healing and affecting anti-carcinogenic mechanisms.As a novel approach, we will conduct a randomised controlled trial using perioperative treatment with tranexamic acid, aiming to prevent early relapses by >10% for patients with melanoma.

METHODS AND ANALYSIS

Design: investigator-initiated parallel, two-arm, randomised, blinded, Danish multicentre superiority trial.

PATIENTS

≥T2 b melanoma and eligible for sentinel lymph node biopsy (n=1204).Project drug: tranexamic acid or placebo.

TREATMENT

before surgery (intravenous 15 mg/kg) and daily (peroral 1000 mg x 3) through postoperative day 4.

PRIMARY OUTCOME

relapse within 2 years after surgery.Primary analysis: risk difference between the treatment arms (χ2 test).

SECONDARY OUTCOMES

postoperative complications, adverse events and survival.Inclusion period: summer 2023 to summer 2026.

ETHICS AND DISSEMINATION

The trial will be initiated during the summer of 2023 and is approved by the National Committee on Health Research Ethics, the Danish Medicine Agency, and registered under the Data Protection Act. The study will be conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. Patients included in the study will adhere to normal Danish treatment protocols and standards of care, and we expect only mild and temporary side effects. Positive and negative results will be published in peer-reviewed journals, with authorships adhering to the Vancouver rules.

TRIAL REGISTRATION NUMBER

NCT05899465; ClinicalTrials.gov Identifier.

The Effects of Tranexamic Acid in Breast Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Tranexamic acid (TXA) is used in trauma and surgical settings. Its role in reducing postoperative blood loss in breast surgery remains unclear. The primary objective of this study was to determine the effect of TXA on postoperative blood loss in breast surgery.

METHODS

Searches of the PubMed, Ovid MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases were performed from inception to April 3, 2020. Inclusion criteria were any retrospective reviews, prospective cohort studies, and randomized controlled trials that administered TXA (topical or intravenously) in the context of breast surgery. Quality of studies were evaluated using the risk of bias in randomized trials tool and the risk of bias in nonrandomized studies of interventions tool. Data were pooled, and a meta-analysis was performed.

RESULTS

In total, seven studies were included, representing 1226 patients (TXA, 632 patients; control, 622 patients). TXA was administered as follows: topically (20 mL of 25 mg/mL TXA intraoperatively; n =258 patients), intravenously (1 to 3 g perioperatively; n = 743 patients), or both (1 to 3 g daily up to 5 days postoperatively; n = 253 patients). TXA administration reduced hematoma formation in breast surgery (risk ratio, 0.48; 95% CI, 0.32 to 0.73), with no effect on drain output (mean difference, -84.12 mL; 95% CI, -206.53 to 38.29 mL), seroma formation (risk ratio, 0.92; 95% CI, 0.60 to 1.40), or infection rates (risk ratio, 1.01; 95% CI, 0.46 to 2.21). No adverse effects were reported.

CONCLUSION

The use of TXA in breast surgery is a safe and effective modality with low-level evidence that it reduces hematoma rates without affecting seroma rates, postoperative drain output, or infection rates.

Impact of Topical Epinephrine with Xylocaine on Drainage After Axillary Lymph Node Dissection: A Randomized Controlled Trial

INTRODUCTION

We evaluated the impact of topical epinephrine with xylocaine on drainage after axillary lymph node dissection.

METHODS

Fifty-two women were randomized into two groups, epinephrine with xylocaine drainage (ED) and conventional drainage group (CD). The amount of drainage, duration of drainage catheter, incidence of seroma formation and wound infection were noted.

RESULTS

The mean total drainage volume was less in ED group as compared to CD group (195 ml vs. 353 ml; p = .002). Drainage catheter was removed earlier in ED group as compared to CD group (5.07 + / - 0.99 days vs. 6.65 + / - 1.07 days; p = 0.0001). The incidence of seroma and wound infection was similar in two groups.

CONCLUSION

Topical epinephrine with xylocaine after axillary lymph node dissection results in significantly decreased drainage volume and duration of drainage.

Effect of Clavipectoral Fascia Suturing on Postmastectomy Seroma Formation

<b><br>Introduction:</b> Post-mastectomy seroma formation is a challenging sequela which has a negative impact on patient recovery and quality of life.</br> <b><br>Aim:</b> We aim to publicize our technique of clavipectoral fascia re-closure and to assess its efficacy in reducing the incidence of seroma formation.</br> <b><br>Methods:</b> This is a prospective randomized controlled trial, conducted in South Cancer institute, Assiut University, Egypt. It included 84 breast cancer patients who were randomly divided into two groups: a control group (n = 44) and a fascia suture group (n = 40). The patients were followed up until drain removal and then to 3 months after surgery.</br> <b><br>Results:</b> The fascia suture group showed significantly shorter duration of drain removal with a significant reduction in the total amount of drained fluid and the amount of drained fluid 1 week postoperatively. One patient in the fascia suture group developed Grade 2-3 seroma vs. 7 in the control group (P < 0.05).</br> <b><br>Conclusions:</b> Clavipectoral fascia suture technique is a simple and effective method for reducing seroma formation after mastectomy in breast cancer patients and is advisable in patients at a high risk for seroma formation.</br>.

Are Surgical Drains Needed in DIEP Flap Surgery? The Drain-Free DIEP Flap Concept

BACKGROUND

Studies support an inherent morbidity associated with the use of surgical drains-such as postoperative pain, infection, reduction in mobility, and delay in patient discharge-and they do not prevent seroma or hematoma. The authors' series aims to evaluate the feasibility, benefits, and safety of performing drainless deep inferior epigastric perforator (DIEP) flap surgery and to formulate an algorithm for when this can be used.

METHODS

A retrospective review of DIEP reconstruction outcomes of two surgeons was performed. Over the course of 24 months, consecutive DIEP flap patients were included from the Royal Marsden Hospital in London and Austin Hospital in Melbourne, and drain use, drain output, length of stay (LOS), and complications were analyzed.

RESULTS

A total of 107 DIEP flap reconstructions were performed by two surgeons. Thirty-five patients had abdominal drainless DIEP flaps, and 12 patients had totally drainless DIEP flaps. Mean age was 52 years (range, 34 to 73 years) and mean body mass index was 26.8 kg/m 2 (range, 19.0 to 41.3 kg/m 2 ). Abdominal drainless patients showed a potential trend toward shorter hospital stays as compared with the ones with drains (mean LOS, 3.74 days versus 4.05 days; P = 0.154). Totally drainless patients had an even shorter, statistically significant, mean LOS of 3.10 days, as compared with patients with drains (4.05 days, P = 0.002), with no increase in complications.

CONCLUSIONS

The avoidance of abdominal drains in DIEP flaps reduces hospital stay without increasing complications, and this has become our standard practice for patients with a body mass index of less than 30 kg/m 2 . It is our opinion that the totally drainless DIEP flap procedure is safe in selected patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A Comparative Study Between Mastectomy Flap Quilting Sutures with Axillary Drain Versus Conventional Sutures with Axillary and Pectoral Drain in Reducing Post-Modified Radical Mastectomy Seroma Formation

The aim of this study was to compare quilting suture with axillary drain versus conventional sutures with axillary and pectoral drain on the formation of seroma after modified radical mastectomy with axillary lymph node dissection. The study was undertaken among 90 female patients with breast cancer who were candidates for modified radical mastectomy with axillary clearance. The intervention group (N = 43) with quilting and axillary drain placement and the control group (N = 33) without quilting with axillary and pectoral drain placement. All the patients were followed up for complications pertaining to this procedure. There were no significant differences between the two groups with regard to demographic characteristics, comorbidities, pre-operative chemotherapy, post-operative pathological findings, lymph node involvement or clinical staging. The incidence of seroma formation on follow-up was significantly lower in the intervention group than that in the control group (23% versus 58%; p < 0.05) whereas there was no significant difference with respect to flap necrosis, superficial skin necrosis and wound gaping between the two groups. Furthermore, it took a shorter duration for seroma to resolve in the intervention group (4 days versus 9 days; p < 0.001) with a smaller duration of hospital stay (4 days versus 9 days; p < 0.001). The use of quilting sutures for flap fixation in order to obliterate dead space post-modified radical mastectomy with placement of axillary drain significantly reduced seroma formation along with shorter duration of wound drainage and a smaller hospital stay with only slightly increased operative time. Therefore, we recommend quilting of flap as a routine step after mastectomy.

Povidone Iodine Sclerotherapy for the Treatment of Persistent Seromas after Breast Cancer Surgery

Persistent seroma following breast cancer surgery causes morbidity and delays adjuvant treatment. Sclerotherapy helps in managing recalcitrant seromas. We evaluated efficacy of 10% povidone iodine sclerotherapy treatment for persistent seromas after breast cancer surgery. Persistent drainage of > 100 mL/day 15 days following surgery, and seromas that required aspiration > 100 mL/week 2 weeks after drain removal, was considered for 10% povidone sclerotherapy in a non-randomized observational study. Resolution (drain output < 20 mL/day), treatment days, recurrence, and complications were assessed as measures of efficacy. Descriptive measures of central tendency and dispersion were reported. The relationship of the seroma quantity with risk factors (age, body mass index, levels and number of axillary lymph nodes dissected, neoadjuvant chemotherapy) and efficacy was analysed. We examined the correlation using Pearson and Spearman' signed rank, Student's t, and Mann-Whitney U-tests, to compare the means. Of 14/312 (4.5%) patients with persistent seroma, 13 (92.8%) had complete resolution after sclerotherapy within 6.71 days (range: 6-8). AC (p = 0.04), neoadjuvant chemotherapy (NACT) (p = 0.005), and number of nodes harvested without NACT (p = 0.025) were significantly associated with the quantity of discharge, while age (p = 0.072), body mass index (p = 0.432), type of surgery (breast conservation surgery vs. modified radical mastectomy) (p = 0.28), and total number of axillary lymph nodes (p = 0.679) were not. When used in this unique innovative manner, 10% povidone iodine sclerotherapy was found to be very effective (93%), minimally invasive, and safe in our study, and therefore appears to be an ideal sclerosing agent.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01629-0.

A Propensity-Matched Analysis of Tranexamic Acid and Acute Respiratory Distress Syndrome in Trauma Patients

INTRODUCTION

Tranexamic acid (TXA) protects the vasculature endothelium after hemorrhage, resulting in a decreased capillary leak. These properties may protect patients receiving TXA from acute respiratory distress syndrome (ARDS), however, clinical studies have yet to examine this topic. We hypothesized that trauma patients receiving TXA would have lower incidence of ARDS.

METHODS

This was a retrospective review of adult (18+ y) patients who presented to a large Level I trauma center with an injury severity score ≥ 16 from admit years 2012-2020. Propensity matching was employed to examine how TXA administration is associated with ARDS.

RESULTS

There were a total of 2751 patients meeting study criteria, with 162 (5.9%) received TXA. Of the 162 patients that received TXA, only 12 (7.4%) received pre-hospital TXA, while 4 (2.5%) received TXA both pre-hospital and in hospital. Of the 63 patients developing ARDS, 62 (98.4%) did not receive TXA. After propensity matching, 304 patients remained, with 152 in each cohort. The incidence of ARDS (P = 0.08), pneumonia (P = 0.68), any pulmonary complication (P = 0.33), and mortality (P = 0.37) were not different in patients receiving TXA on propensity matching.

CONCLUSIONS

TXA did not protect trauma patients from pulmonary complications; however, nearly all patients developing ARDS did not receive TXA. Larger studies should examine this relationship to improve understanding of therapies that may prevent ARDS.

The role of tranexamic acid in reducing post-operative bleeding and seroma formation in breast surgery: A meta-analysis

INTRODUCTION

Tranexamic acid (TXA) reduces blood loss and blood transfusion requirements in surgery. Seroma and haematoma formation occur as complications of breast surgery. We aimed to perform a meta-analysis evaluating TXA in reducing post-operative haematoma and seroma formation for breast surgery.

METHODS

A systematic review was performed in accordance with PRISMA guidelines. Results were expressed as dichotomous variables pooled as odds ratios (OR) with corresponding 95% confidence intervals (CIs) using the Mantel-Haenszel method.

RESULTS

Seven studies including 1446 patients were included. There were 1830 breast surgery procedures performed with TXA administered in 797 cases (43.6%). There was a significant reduction in haematoma rates in the TXA group (TXA: 3.184% (22/691) vs Control: 6.787% (64/943), OR: 0.41, 95% CI: 0.20-0.86, P = 0.020). Based on surgical procedure, haematoma rates were similar for TXA and control groups in cancer surgery (P = 0.230). Haematoma rates reduced following TXA use in cosmetic procedures (TXA: 3.807% (15/394) vs. Control: 9.091% (34/374), OR: 0.41, 95% CI: 0.22-0.75, P = 0.004). Haematoma rates were also reduced in procedures where axillary lymph node dissection (ALND) was not performed; in the TXA group, 3.379% (22/651) developed a haematoma versus 6.623% (60/906) in the control group (OR: 0.45, 95% CI 0.27-0.77, P = 0.003). TXA administration did not impact seroma formation or infection rates.

CONCLUSION

Perioperative administration of TXA may impact the incidence of haematoma in breast surgery, particularly in cosmetic procedures and procedures without ALND. Well-designed randomised studies are required to determine its true efficacy. TXA has no effect on seroma formation or infection in breast surgery.

Topical Tranexamic Acid (TXA) Decreases Time to Drain Removal, Wound Healing Complications, and Postoperative Blood Loss in Autologous Breast Reconstruction: A Retrospective Study

Introduction: Drain placement is commonplace after many plastic surgery procedures to evacuate excess blood and fluid. Tranexamic acid (TXA) is an antifibrinolytic that has been shown to decrease bleeding and fluid production at surgical sites and can be administered orally, intravenously, and topically. The purpose of this study is to evaluate the effect of topical TXA on drain removal in abdominally based autologous breast reconstruction (ABABR). Methods: A retrospective chart review was performed on patients who underwent ABABR from August 2018 to November 2019. In 1 cohort, a 2.5% TXA solution was topically applied to the abdominal wall prior to closure. Drains were removed when output was less than 30 mL/day for 2 consecutive days. The primary outcome was days to drain removal. Secondary outcomes include daily inpatient drain output, postoperative hemoglobin levels, blood transfusions, and complications within 30 days postoperatively. Results: Eighty-three patients were included, with 47 in the control group and 36 in the TXA group. Drains were removed significantly earlier in patients who received TXA (16 days vs 23 days, P = .02). Additionally, significantly fewer patients required postoperative blood transfusions in the TXA group (2 vs 14, P = .005). Abdominal complications were fewer in the TXA group with significantly less wound healing complications (22% vs 49%, P = .01). There was no difference in flap loss or systemic thromboembolic events. Conclusion: Topical TXA use in ABABR results in earlier abdominal drain removal, less blood transfusions, and lower abdominal wound complications without an increased risk of flap loss or adverse patient outcomes.

Importance of Nutrition in the development of Seroma after Breast Surgery

Amaç: Meme cerrahisi sonrası seroma gelişiminde nütrisyonun önemini araştırmak. Seroma mastektomi sonrası görülen en sık komplikasyon olup, görülme sıklığı %10- 50 arasında değişmektedir. Seroma cilt nekrozu, enfeksiyon, yara iyileşmesini gecikmesi ve bunun sonucu olarak ek tedavilerin gecikmesine neden olabileceği için ciddiye alınması gereken bir komplikasyondur. Metod: Bu deneysel çalışmada 10’arlı gruplara ayrılan toplan 40 rat kullanıldı. Preoperatif 7 gün boyunca 1.gruba (kontrol) normal rat gıdası, 2. gruba kontrol grubunun %70’i kadar normal rat gıdası (malnütrisyon), 3. ve 4. gruba proteinden zengin diyet (Glutamin-Arjinin-Metil Bütirat) (10gr protein /kg/gün) verildi ve gruplara 7. gün tek taraflı (sağ) pektoral majör kas eksizyonu ve aksiler diseksiyon uygulandı. Postoperatif 10 gün boyunca 1. gruba normal rat gıdası, 2. gruba kontrol grubunun %70’ i kadar normal rat gıdası, 3. gruba normal rat gıdası ve 4. gruba proteinden zengin diyet verildi. Postoperatif 10. günde ratlardan seroma örneği alınarak sakrifiye edildi. Bulgular: Kontrol grubunun seroma miktarı 1,5 ml (1ml-2,5ml), malnütrüsyon grubunun seroma miktarı 1,5ml (1ml-2,75ml), preoperatif proteinden zengin diyetle beslenen 3.grubun seroma miktarı 1ml (0,5ml-1ml), preoperatif ve postoperatif proteinden zengin diyetle beslenen 4.grubun seroma miktarı 0,75ml (0,5ml-1ml) olarak bulundu. Seroma miktarları ortanca olarak verildi. Bu değerlere göre proteinden zengin diyetle beslenen grupların seroma miktarları anlamlı olarak düşük bulundu. (p=0,001 ) Sonuç: Çalışmamızda elde edilen veriler doğrultusunda deneysel mastektomi ve aksiller diseksiyon (AD) modelinde preoperatif ve postoperatif dönemde proteinden yüksek diyetle beslenmenin seroma oluşumunu azalttığı görülmüştür. Benzer şekilde klinik çalışmaların planlanması gerektiği kanaatindeyiz.

The role of tranexamic acid in breast and body contouring surgery: a review of the literature

Background: Postoperative seroma and haematoma are two of the most common complications follow-ing large surface area surgeries. A review of the literature was performed to evaluate evidence for the use of tranexamic acid in reducing postoperative seroma and haematoma formation in breast surgery and body contouring surgery. Methods A literature search was performed using MEDLINE, the Cochrane Database of Systematic Review, the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Ef-fect (DARE) and PubMed in English from 1 Jan 1990–30 Mar 2020. The search terms ‘TXA’, ‘breast reduction’, ‘mammaplasty’, ‘breast implants’, ‘breast implantation’, ‘breast reconstruction’, ‘mastectomy’, ‘tissue ex-pansion’, ‘body contouring’, ‘breast’ and ‘abdominoplasty’ were used alone and in combination. Results: A total of six articles were found including three randomised controlled trials, two cohort studies and one retrospective study. Two ongoing trials were found on The Cochrane Central Register of Con-trolled Trials (CENTRAL). No systematic reviews were found. Conclusion: Literature surrounding the use of TXA in breast and body contouring surgery is sparse com-pared to what is available in other surgical sub-specialties. The literature available shows promising results with the use of TXA in controlling haematoma, drain output and seroma formation in breast surgery and body contouring surgery with minimal morbidity in these patient groups.

Repurposing Tranexamic Acid as an Anticancer Agent

Tranexamic Acid (TA) is a clinically used antifibrinolytic agent that acts as a Lys mimetic to block binding of Plasminogen with Plasminogen activators, preventing conversion of Plasminogen to its proteolytically activated form, Plasmin. Previous studies suggested that TA may exhibit anticancer activity by blockade of extracellular Plasmin formation. Plasmin-mediated cleavage of the CDCP1 protein may increase its oncogenic functions through several downstream pathways. Results presented herein demonstrate that TA blocks Plasmin-mediated excision of the extracellular domain of the oncoprotein CDCP1. In vitro studies indicate that TA reduces the viability of a broad array of human and murine cancer cell lines, and breast tumor growth studies demonstrate that TA reduces cancer growth in vivo. Based on the ability of TA to mimic Lys and Arg, we hypothesized that TA may perturb multiple processes that involve Lys/Arg-rich protein sequences, and that TA may alter intracellular signaling pathways in addition to blocking extracellular Plasmin production. Indeed, TA-mediated suppression of tumor cell viability is associated with multiple biochemical actions, including inhibition of protein synthesis, reduced activating phosphorylation of STAT3 and S6K1, decreased expression of the MYC oncoprotein, and suppression of Lys acetylation. Further, TA inhibited uptake of Lys and Arg by cancer cells. These findings suggest that TA or TA analogs may serve as lead compounds and inspire the production of new classes of anticancer agents that function by mimicking Lys and Arg.

Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer

Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.

Local Infiltration of Tranexamic Acid (TXA) in Liposuction: A Single-Surgeon Outcomes Analysis and Considerations for Minimizing Postoperative Donor Site Ecchymosis

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there have been limited data on the utilization of TXA to mitigate liposuction donor site ecchymosis.

OBJECTIVES

The authors sought to investigate whether infiltration of TXA into liposuction donor sites safely reduces postoperative ecchymosis.

METHODS

A single-surgeon retrospective cohort study was performed to analyze patients undergoing autologous fat transfer for breast reconstruction between 2016 and 2019. Following lipoaspiration, patients in the intervention group received 75 mL of TXA (3 g in NaCl 0.9%) infiltrated into the liposuction donor sites, whereas the historical controls did not. Patient demographics, degree of ecchymosis, surgical complications, and thromboembolic events were examined. A blinded assessment of postoperative photographs of the donor sites was performed.

RESULTS

Overall, 120 autologous fat grafting procedures were reviewed. Sixty patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar among the groups. No difference existed between groups regarding donor site locations, tumescent volume, lipoaspirate volume, or time to postoperative photograph. Ten blinded evaluators completed the assessment. The median bruising score of patients who received TXA was significantly lower than that of patients who did not (1.6/10 vs 2.3/10, P = 0.01). Postoperative complications were similar among the groups. Adverse effects of TXA were not observed.

CONCLUSIONS

Patients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis than patients who did not. Further prospective randomized studies are warranted.

LEVEL OF EVIDENCE: 4

Oncoplastic breast surgery: A guide to good practice

Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.

Mixed Metal Oxide Nanoparticle Formulations for the Treatment of Seroma

Seroma formation is a well-recognized postoperative complication for many plastic and general surgical procedures. Although various tissue adhesives and substances have been used in an effort to treat seroma formation, no therapies have been established clinically. Recently, the nano-bridging phenomenon has been introduced as a promising approach to achieve tissue adhesion and strong closure of deep skin wounds in rats. The present study seeks to assess the potential of nano-bridging beyond skin wounds in a rat model of seroma. Seromas were induced in 20 Lewis rats through bilateral axillary lymphadenectomy, excision of the latissimus dorsi and cutaneous maximus muscles, and disruption of dermal lymphatics. On postoperative day (POD) 7, the seroma was aspirated on both sides. A bioactive nanoparticle (NP) suspension based on zinc-doped strontium-substituted bioglass/ceria nanoparticles (NP group) or fibrin glue (fibrin group) was injected into the right seroma cavity, while the left side was left untreated. On POD 14, the NP group showed complete remission (no seromas at all), while the fibrin group recorded a reduction of only 63% in the seroma fluid volume. The NPs exerted local anti-inflammatory and neo-angiogenic effects, without any detectable systemic changes. Moreover, the ceria levels recorded in the organs did not surpass the background level, indicating that the nanoparticles stayed at the site of application. This study is a promising first example demonstrating the ability of inorganic nanoparticle formulations to reduce seroma formation in a rat model, without any detectable systemic adverse effects. These results emphasize the potential of nanotechnological solutions in the therapeutic management of seroma in the clinical setting.

A Systematic Review of Tranexamic Acid in Plastic Surgery: What's New?

BACKGROUND

Blood loss associated with surgical interventions can lead to several complications. Therefore, minimizing perioperative bleeding is critical to improve overall survival. Several interventions have been found to successfully reduce surgical bleeding, including the antifibrinolytic agent. After aprotinin was withdrawn from the market in 2008, TXA remained the most commonly used medication. The safety and efficacy of TXA has been well studied in other specialties. TXA has been rarely used in plastic surgery, except in craniofacial procedures. Since the last review, the number of articles examining the use of TXA has doubled; so the aim of this systematic review is to update the readers on the current knowledge and clinical recommendations regarding the efficacy of TXA in plastic surgical procedures.

METHODS

A systematic literature search was conducted in Medline, SciELO, Cochrane, and Google Scholar to evaluate all articles that discussed the use of TXA in plastic surgery in the fields of aesthetic surgery, burn care, and reconstructive microsurgery.

RESULTS

A total of 233 publications were identified using the search criteria defined above. After examination of titles and abstracts, and exclusion of duplicates, a total of 23 articles were selected for analysis.

CONCLUSIONS

The literature shows a clear benefit of using TXA to decrease blood loss regardless of the administration route, with no risk of thrombosis events. Also, TXA elicits a potent anti-inflammatory response with a decrease in postoperative edema and ecchymosis, which improves recovery time. Further investigations are needed to standardize the optimal administration route and dosage of TXA.

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.

Flap Fixation as a Technique for Reducing Seroma Formation in Patients Undergoing Modified Radical Mastectomy: an Institutional Experience

Formation of seroma most frequently occurs after mastectomy and axillary surgery. This study is intended at creating data on whether flap fixation has any role in reducing the seroma formation in patients undergoing the modified radical mastectomy. A prospective comparative study was conducted among 61 patients scheduled for modified radical mastectomy from 1st of January 2017 to 31st of December 2017. Patients were divided into two groups. In the flap fixation group (N = 30), the skin flaps were sutured to the pectoral muscle with Vicryl 3-0 sutures, and in the control group (N = 31), the wound was closed in the conventional methods at the edges. Closed suction drain was used in both groups. Flap fixation group showed a significantly lower frequency of seroma formation compared with the control group. In the flap fixation group, the drain was removed earlier compared with the control group. Mean value of the total amount of fluid drained for the study group was significantly lower than that of control. Flap fixation is a surgical technique which appears to reduce the total volume of fluid drained, the development of seroma, and the need for seroma aspirations.

Intravenous Tranexamic Acid in Implant-Based Breast Reconstruction Safely Reduces Hematoma without Thromboembolic Events

BACKGROUND

Antifibrinolytic medications, such as tranexamic acid, have recently garnered increased attention. Despite its ability to mitigate intraoperative blood loss and need for blood transfusion, there remains a paucity of research in breast reconstruction. The authors investigate whether intravenous tranexamic acid safely reduces the risk of hematoma following implant-based breast reconstruction.

METHODS

A single-center retrospective cohort study was performed to analyze all consecutive patients undergoing immediate two-stage implant-based breast reconstruction following mastectomy between 2015 and 2016. The incidence of postoperative hematomas and thromboembolic events among all patients was reviewed. The patients in the intervention group received 1000 mg of intravenous tranexamic acid before mastectomy incision and 1000 mg at the conclusion of the procedure. Fisher's exact test and the Mann-Whitney-Wilcoxon test were used. Multivariate logistic regression models were performed to study the impact of intravenous tranexamic acid after adjusting for possible confounders.

RESULTS

A total of 868 consecutive breast reconstructions (499 women) were reviewed. Overall, 116 patients (217 breasts) received intravenous tranexamic acid, whereas 383 patients (651 breasts) did not. Patient characteristics and comorbidities were similar between the two the groups. Patients who received tranexamic acid were less likely to develop hematomas [n = 1 (0.46 percent)] than patients who did not [n = 19 (2.9 percent)] after controlling for age, hypertension, and type of reconstruction (prepectoral and subpectoral) (p = 0.018). Adverse effects of intravenous tranexamic acid, including thromboembolic phenomena were not observed. Multivariate analysis demonstrated that age and hypertension independently increase risk for hematoma.

CONCLUSIONS

Intravenous tranexamic acid safely reduces risk of hematoma in implant-based breast reconstruction. Further prospective randomized studies are warranted to further corroborate these findings.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Topical moistening of mastectomy wounds with diluted tranexamic acid to reduce bleeding: randomized clinical trial

BACKGROUND

Topical administration of tranexamic acid (TXA) may be an alternative to intravenous administration to reduce bleeding with a lower risk of systemic adverse events. The aim of this study was to investigate whether moistening a surgical wound with TXA before closure, leaving a thin film of drug only, would reduce postoperative bleeding.

METHODS

This was a two-centre, stratified, parallel-group, placebo-controlled, double-blind RCT. Patients undergoing mastectomy with or without axillary lymph node clearance were randomized 1 : 1 to moistening of wound surface before closure with either 25 mg/ml TXA or 0·9 per cent sodium chloride (placebo). The primary endpoint was postoperative bleeding as measured by drain production in the first 24 h. Secondary endpoints were early haematoma, total drain production, postoperative complications and late aspirations of seroma within 3 months.

RESULTS

Between 1 January 2016 and 31 August 2018, 208 patients were randomized. Two patients were converted to a different surgical procedure at surgery, and four did not receive the intervention owing to technical error. Thus, 202 patients were included in the study (101 in the TXA and 101 in the placebo group). TXA reduced mean drain production at 24 h (110 versus 144 ml; mean difference 34 (95 per cent c.i. 8 to 60) ml, P = 0·011). One patient in the TXA group had early haematoma compared with seven in the placebo group (odds ratio (OR) 0·13 (95 per cent c.i. 0·02 to 1·07); P = 0·057). There was no significant difference in postoperative complications between TXA and placebo (13 versus 10; OR 1·11 (0·45 to 2·73), P = 0·824) or need for late seroma aspirations (79 versus 67 per cent; OR 1·83 (0·91 to 3·68), P = 0·089).

CONCLUSION

Moistening the wound with TXA 25 mg/ml before closure reduces postoperative bleeding within the first 24 h in patients undergoing mastectomy. Registration number: NCT02627560 (https://clinicaltrials.gov).

Role of early povidone iodine instillation in post-renal transplant lymphorrhea: A prospective randomized study

OBJECTIVE

The aim of the present study was to prospectively evaluate the role of early povidone iodine instillation in the management of post-renal transplant lymphorrhea.

MATERIAL AND METHODS

Live-related renal transplant recipients operated between January 2002 and December 2015 were included in the study. Significant lymphorrhea was defined as >50 mL lymph from drain beyond postoperative day 5. Such patients were randomized into two groups by simple randomization using a computer-generated random list: group A (received 0.5% povidone iodine instillation) and group B (no instillation). Absolute risk reduction and numbers needed to treat were calculated to estimate the effect of povidone iodine instillation for the treatment of lymphorrhea and decrease in the incidence of lymphocoele.

RESULTS

A total of 1766 patients underwent renal transplant during this period. One hundred seventeen patients with lymphorrhea through the drain underwent randomization into group A (n=61) and group B (n=56). In group A, 58 patients had successful resolution within 2 weeks, whereas in group B, 34 patients had successful resolution within 2 weeks. Overall, 9 (14.75%) patients in group A and 29 (51.78%) patients in group B had lymphatic collections (both symptomatic and asymptomatic). Symptomatic lymphocoele was present in 1 patient in group A and 7 patients in group B on follow-up. Absolute risk reduction was 10.8%, and for every symptomatic lymphocoele prevented, 10 patients needed povidone iodine instillation.

CONCLUSION

Povidone iodine instillation after 5 days of transplantation aids in the early resolution of post-renal transplantation lymphorrhea, as well as reduces the incidence of future lymphocoele.

Advanced hemostasis in axillary lymph node dissection for locally advanced breast cancer: new technology devices compared in the prevention of seroma formation

Background

Breast cancer is the most frequent neoplasm in women. Axillary lymph nodes dissection represents the treatment of choice in locally advanced breast cancer for prognostic and curative purposes. Seroma formation, an abnormal collection of fluid in the dead space of the axilla, is described in Literature with a wide range of incidence (3–85%). It is a source of significant morbidity and discomfort. The aim of the study is to compare the different haemostasis devices used in breast surgery, investigating the eventual superiority of an instrument among the others in terms of intraoperative and postoperative outcome, especially of seroma formation.

Methods

Clinical cases of female patients undergone axillary lymph nodes dissection for local advanced breast cancer between January 2013 and July 2017 at the Surgery Unit of University of Campania “Luigi Vanvitelli” were retrospectively reviewed. Patients were divided into four groups, according to device utilized during surgery: Electrocautery, Harmonic Scalpel, LigaSure and Thunderbeat. All patients underwent II level axillary lymph nodes dissection associated to radical mastectomy or quadrantectomy.

Results

One hundred consecutives patients were enrolled in the study. Intra-operative blood loss resulted statistically significant different (P < 0,01) between the Electrocautery group (94,7 ml) and the Thunderbeat group (57,2 ml), while the Harmonic Scalpel group and the Ligasure group, despite presented a lower amount of blood loss, did not differ significantly. Drainage volume resulted significantly lower (P = 0,002) in the comparison between the Electrocautery group and the Thunderbeat group; the Ligasure group and Harmonic Scapel group showed no difference between them and Electrocautery group. About the seroma formation, the Electrocautery group resulted affected by the highest seroma formation rate (64%). Seroma incidence in Harmonic Scalpel group was 24%, in Ligasure group was 44%, while Thunderbeat group showed the lowest presentation of seroma with 16%.

Conclusions

In patients affected by breast cancer requiring axillary lymphnodes dissection, the use of advanced hemostasis devices is highly desirable. Among the non-traditional tools, Thunderbeat resulted to be superior in terms of reduction of intra-operative blood loss and post-operative drainage output, moreover associated to a substantial reduction of postoperative seroma incidence.

Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials.

STUDY DESIGN AND METHODS

A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis.

RESULTS

A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not.

CONCLUSION

Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.

Examination of the Effects of Celecoxib on Postmastectomy Seroma and Wound Healing

Objectives:

To examine the effect of celecoxib on wound healing and development of seroma after mastectomy.

Seroma is an accumulation of serous fluid in dead space emerging after breast cancer surgery. The pathophysiology of seroma has not been clearly elucidated. Development of seroma leads to prolongation of hospital stay, increase in costs, ischemia of the flaps, infections due to fluid accumulation, and delayed adjuvant treatment.

Seroma is still a current problem, and the most common treatment method for this problem is drainage and repeated aspirations for 5–7 days after surgery.

Methods:

The effect of celecoxib whose anti-inflammatory, antiangiogenic, and antioxidant effectiveness has been demonstrated in a mastectomy model applied on female Wistar rats has been investigated in the present study. A total of 20 rats including 10 rats in the control and 10 in the celecoxib group were studied.

Intraperitoneal 0.25 cc/250 g (20 mg/kg/day) celecoxib was administered to the celecoxib group for 5 days after mastectomy, and the same volume of physiological saline solution was given to the control group for 5 days. Rats were followed up for 10 days after surgery. During this process, vitality of the rats, movements of the extremities, wound healing conditions, wound infections, flap necrosis, and occurrence of seroma were recorded. At the end of this period, seromas were aspirated, tissue samples were retrieved, and the rats were sacrificed. Fibrin, hemorrhage, edema, vascularization, congestion, polymorphonuclear leukocytes, and increase in fibrotic tissue fibroblasts, lymphocytes, and macrophages were evaluated in tissue samples.

In seroma fluids, interleukin-1 beta (IL-1β), an acute phase reactant, and vascular endothelial growth factor, a vital parameter of vascular proliferation and angiogenesis, were examined.

Results:

At the end of the experiments, the seroma volume decreased significantly in the celecoxib group (p=0.804; 0.001), the IL-1β level decreased significantly as detected in the biochemical examination (p=0.014), and in the histopathological examination, an increase in congestion in the celecoxib group was determined.

Conclusion:

In conclusion, celecoxib markedly decreased interleukin and the volume of seroma after mastectomy; suppressed the level of an acute phase reactant, IL-1β; and demonstrated this effect through its anti-inflammatory activity. We believe that the effects of celecoxib should be investigated using different dose applications and larger number of subjects.

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 Efficacy and Safety of Tranexamic Acid in Cranio-Maxillofacial and Plastic Surgery

The antifibrinolytic drug tranexamic acid (TXA) is effective in reducing blood loss and transfusion requirements in other fields of elective surgery and its use is emerging in a number of plastic surgical subspecialties. This systematic review and meta-analysis evaluates the current evidence for the efficacy and safety of TXA in craniomaxillofacial, head and neck, breast, aesthetic, burns, and reconstructive microsurgery. We searched PubMed, EMBASE, Medline, The Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials for randomized controlled trials of TXA in plastic surgery. Studies were analyzed using standard methodology. A total of 7965 records were screened, of which 14 met the inclusion criteria. Seven were suitable for meta-analysis. In craniofacial surgery, TXA was associated with a mean reduction in blood loss of 18.2 mL/kg (P = 0.00001) and a mean reduction in blood transfusion of 8.7 mL/kg (P = 0.0001). In orthognathic surgery, TXA was associated with a mean reduction in blood loss of 156 mL (P = 0.001). Tranexamic acid may also have a role in reducing drainage output volumes in oncological breast excision and lymph node dissection of the neck. Level-1 evidence for efficacy in aesthetic surgery, burns, and reconstructive microsurgery is lacking. Although no reported complications were attributable to TXA, there remain no phase IV trials published. Level-1 evidence supports the use of TXA in craniofacial and orthognathic surgery. There exists an unmet need for studies in areas, including burns, aesthetic surgery, and reconstructive microsurgery. Phase IV trials in areas of proven efficacy are also required.

Prospective randomized controlled study to assess the value of a hemostatic and sealing agent for preventing seroma after axillary lymphadenectomy

BACKGROUND AND OBJECTIVES

Postoperative seroma after axillary lymphadenectomy leads to an increased use of resources and an impaired quality of life of patients. This randomized clinical trial was designed to assess the value of a hemostatic and sealing agent for decreasing seroma occurrence after axillary lymphadenectomy.

METHODS

A prospective, randomized, blind study was conducted on 91 axillary lymphadenectomies distributed into a control group (n = 47) and a test group in which a collagen sponge coated with human coagulation factors was used (n = 44). Primary end-points were number of days before removal of axillary drainage, axillary drainage output, and occurrence of seroma, wound infection, haematoma, or wound dehiscence, within 8 weeks of surgery. Bivariate and multivariate analyses on seroma occurrence were performed.

RESULTS

Seroma occurred in 29 patients (31.86%). A significant direct relationship (P = 0.002) was only noted between use of the hemostatic and sealing agent and nonoccurrence of seroma. In the multivariate study, the only variable found to be significantly related to seroma occurrence was use of the above agent (P = 0.046; odds ratio: 3.365 [95%CI: 1.024-11.060]).

CONCLUSIONS

Use of a collagen sponge coated with human coagulation factors following axillary lymphadenectomy was associated to a lower incidence of postoperative seroma. J. Surg. Oncol. 2016;114:423-427. © 2016 Wiley Periodicals, Inc.

Tranexamic acid in life-threatening military injury and the associated risk of infective complications

BACKGROUND

Tranexamic acid (TXA) has been shown to reduce mortality from severe haemorrhage. Although recent data suggest that TXA has anti-inflammatory properties, few analyses have investigated the impact of TXA on infectious complications in injured patients. The aim was to examine the association between TXA administration and infection risk among injured military personnel.

METHODS

Patients who received TXA were matched by Injury Severity Score with patients who did not receive TXA. Conditional logistic regression was used to examine risk factors associated with infections within 30 days. A Cox proportional analysis evaluated risk factors in a time-to-first-infection model.

RESULTS

A total of 335 TXA recipients were matched with 626 patients who did not receive TXA. A greater proportion of TXA recipients had an infection compared with the comparator group (P < 0·001). Univariable analysis estimated an unadjusted odds ratio (OR) of 2·47 (95 per cent c.i. 1·81 to 3·36) for the association between TXA and infection risk; however, TXA administration was not significant in multivariable analysis (OR 1·27, 0·85 to 1·91). Blast injuries, intensive care unit (ICU) admission, and receipt of 10 units or more of blood within 24 h after injury were independently associated with infection risk. The Cox proportional model confirmed the association with ICU admission and blood transfusion. Traumatic amputations were also significantly associated with a reduced time to first infection.

CONCLUSION

In life-threatening military injuries matched for injury severity, TXA recipients did not have a higher risk of having infections nor was the time to develop infections shorter than in non-recipients. Extent of blood loss, blast injuries, extremity amputations and ICU stay were associated with infection.

The impact of tissue glue in wound healing of head and neck patients undergoing neck dissection

We investigated the impact of fibrin glue on postoperative drainage amount and duration in head and neck cancer patients who underwent neck dissection. This study was a prospective randomized controlled trial. Patients who were scheduled to undergo neck dissection due to head and neck cancer were eligible for this study. After receiving a detailed explanation, all patients signed an informed consent form before enrollment. Patients were then randomly assigned to the study group (fibrin glue) or control group. In the study group, 2 ml of fibrin glue (Tissucol(®); Duploject, Baxter AG) was applied on the surface of the surgical wound before closure. Basic demographic data along with tumor-related features, operation-related variables, postoperative drainage amount/duration, postoperative pain, and analgesic usage were collected and analyzed. A total of 15 patients were included in the final analyses, with eight patients in the study group and seven patients in the control group. No significant differences were found between the two groups in age, gender, primary site, clinical N stage, neck dissection levels, perioperative bleeding, postoperative drainage amount/duration, hospitalization duration, and postoperative pain status. The application of 2 ml fibrin glue by the method described herein did not reduce the postoperative drainage amount/duration nor the postoperative pain status in patients who underwent neck dissection.

Inhalable tranexamic acid for haemoptysis treatment

PURPOSE

An inhalable dry powder formulation of tranexamic acid (TA) was developed and tested in a novel high-dose Orbital® multi-breath inhaler. The formulation was specifically intended for the treatment of pulmonary haemorrhage and wound healing associated with haemoptysis.

METHODS

Inhalable TA particles were prepared by spray drying and the powder characterised using laser diffraction, electron microscopy, thermal analysis, moisture sorption and X-ray powder diffraction. The aerosol performance was evaluated using cascade impaction and inline laser diffraction and interaction with epithelia cells and wound healing capacity investigated using Calu-3 air interface model.

RESULTS

The spray dried TA particles were crystalline and spherical with a D0.5 of 3.35 μm. The powders were stable and had limited moisture sorption (0.307%w/w at 90%RH). The Orbital device delivered ca. 38 mg powder per 'inhalation' at 60 l · min(-1) across four sequential shots with an overall fine particle fraction (⩽ 6.4 μm) of 59.3 ± 3.5% based on the emitted mass of ca. 150 mg. The TA particles were well tolerated by Calu-3 bronchial epithelia cells across a wide range of doses (from 1 nM to 10nM) and no increase in inflammatory mediators was observed after deposition of the particles (a decrease in IL-1β, IL-8 and INFγ was observed). Time lapse microscopy of a damaged confluent epithelia indicated that wound closure was significantly greater in TA treated cells compared to control.

CONCLUSION

A stable, high performance aerosol of TA has been developed in a multi-breath DPI device that can be used for the treatment of pulmonary lesions and haemoptysis.

Single-dose tranexamic acid in advanced ovarian cancer surgery reduces blood loss and transfusions: double-blind placebo-controlled randomized multicenter study

OBJECTIVE

To determine whether single-dose tranexamic acid given intravenously immediately before surgery for presumed advanced ovarian cancer reduces perioperative blood loss and blood transfusions.

DESIGN

A randomized double-blind, placebo-controlled multicenter study.

SETTING

Two university hospitals and two central hospitals in the southeast health region of Sweden.

POPULATION

One hundred women with presumed advanced ovarian cancer scheduled for radical debulking surgery between March 2008 and May 2012 who complied with inclusion/exclusion criteria were randomized; 50 were allocated to receive tranexamic acid and 50 to receive placebo. Analysis was performed according to intention-to-treat principles.

METHODS

The volume of tranexamic acid (15 mg/kg body weight, 100 mg/mL tranexamic acid) or the same volume of placebo (0.9% NaCl) was added to a 100-mL saline solution plastic bag. The study medication was given immediately before the start of surgery. Data were analyzed by means of non-parametric statistics and multivariate models adjusted for confounding factors.

MAIN OUTCOME MEASURES

Blood loss and red blood cell transfusions.

RESULTS

The total blood loss volume and transfusion rate were significantly lower in the tranexamic acid group compared with the placebo group. Median total blood loss was 520 and 730 mL, respectively (p = 0.03). Fifteen (30%) and 22 (44%), respectively received transfusions (odds ratio 0.44; upper 95% CI 0.97; p = 0.02).

CONCLUSION

A single dose of tranexamic acid given immediately before surgery reduces blood loss and transfusion rates significantly in advanced ovarian cancer surgery. Tranexamic acid may be recommended as standard prophylactic treatment in advanced ovarian cancer surgery.

Systematic review, meta-analysis and meta-regression of the effect of tranexamic acid on surgical blood loss

Background

Tranexamic acid (TXA) reduces blood transfusion in surgery but the extent of the reduction in blood loss and how it relates to the dose of TXA is unclear.

Methods

A systematic review of randomized trials was performed. Data were extracted on blood loss from trials comparing intravenous TXA with no TXA or placebo in surgical patients. A Bayesian linear regression was used to describe the relationship between the reduction in blood loss with TXA and the extent of bleeding as measured by the mean blood loss in the control group. A meta-analysis of the log-transformed data was conducted to quantify the effect of TXA on blood loss, stratified by type of surgery, timing of TXA administration and trial quality. Meta-regression was used to explore the effect of TXA dosage.

Results

Data from 104 trials were examined. Although the absolute reduction in blood loss with TXA increased as surgical bleeding increased, the percentage reduction was similar. TXA reduced blood loss by 34 per cent (pooled ratio 0·66, 95 per cent confidence interval 0·65 to 0·67; P &lt; 0·001). The percentage reduction in blood loss with TXA differed by type of surgery, timing of TXA administration and trial quality, but the differences were small. The effect of TXA on blood loss did not vary over the range of doses assessed (5·5–300 mg/kg).

Conclusion

TXA reduces blood loss in surgical patients by about one-third. A total dose of 1 g appears to be sufficient for most adults. There is no evidence to support the use of high doses.

Seroma formation after breast cancer surgery: what we have learned in the last two decades

Formation of a seroma most frequently occurs after mastectomy and axillary surgery. Prolonged drainage is troublesome as it increases the risk for infection and can significantly delay adjuvant therapy. Seroma has been defined as serous fluid collection under the skin flaps or in the axillary dead space following mastectomy and/or axillary dissection. Because the true etiology of a seroma is unknown, a multifactorial-causation hypothesis has been accepted. Surgical factors include technique, extent of dissection and the surgical devices used for dissection. Obliteration of dead space with various flap fixation techniques, use of sclerosants, fibrin glue and sealants, octreotide, and pressure garments have been attempted with conflicting results and none have been consistent. Early movement of the shoulder during the postoperative period may increase the formation of seroma, although delayed physiotherapy decreases the formation of seroma. A detailed analysis of the use of drains showed that use of single or multiple drains, early or late removal, and drains with or without suction are not significantly different for the incidence of seroma. Although there is evidence for reduced seroma formation after early drain removal, very early removal within 24 hours seems to increase formation of seroma. No patient or tumor factors seem to affect seroma formation except body mass index and body weight. Consensus is lacking among studies/trials with different groups producing conflicting evidence. Besides a few established factors such as body mass index, the use of electrocautery for dissection, early drain removal, low vacuum drains, obliteration of dead space, and delayed shoulder physiotherapy, most of the hypothesized causes have not been demonstrated consistently. Thus, seroma remains a threat to both the patient and surgeon. Recurrent transcutaneous aspiration remains the only successful management.

Risk factors for surgical site infection in breast surgery

AIMS AND OBJECTIVES

To study risks of surgical site infection in breast surgery. The objectives were to measure the association of postoperative infection with patient- and procedure-related factors.

BACKGROUND

The infection rate in breast surgery is expected to be low but it varies a lot. The variation is recommended to be assessed by measuring procedure-related factors.

DESIGN

A retrospective chart review of 982 breast surgery patients was completed.

METHODS

The data on patient demographics, procedure types, patient and surgery-related factors were collected. A multivariate logistic regression model for all breast operations (n=982), lumpectomies (n=700) and mastectomies (n=282) was performed.

RESULTS

The infection rate was 6.7%. In a multivariate logistic regression model for all operations, a contaminated or dirty wound, high American Society of Anesthesiologists score, high body mass index, use of surgical drains and re-operation predicted increased infection risk. In lumpectomies high body mass index and use of surgical drains predicted increased risk. In mastectomies, the significant predictor was re-operation.

CONCLUSIONS

The surgical site infection rate was high. In addition to the two classical risks (high wound class and anaesthesia risk), high body mass index, re-operation and use of surgical drain increased the infection risk among all patients.

RELEVANCE TO CLINICAL PRACTICE

In breast surgery careful assessment, documentation and adherence to aseptic practices are important with all patients. Patients with heavy weight need special attention. The need for antimicrobial prophylaxis in re-operations and the need of surgical drains in lumpectomies are important to consider carefully.