Influence of fibrin glue on seroma formation after breast surgery

Hemostatic Agents Do Not Significantly Affect Seroma Formation in Abdominal Body Contouring

BACKGROUND

Objective: Seroma formation is plaguing complication in abdominal body contouring surgery (ABCS) that has been loosely associated with the use of intraoperative hemostatic agents. The aim of this study was to investigate the association between hemostatic agent usage and seroma development following ABCS.

METHODS

A retrospective review of patients undergoing ABCS between 2010 and 2020 was completed. Cases who received hemostatic agents were matched to controls (1:2) based on potential confounders including age, BMI, and ASA score. Demographic data, operative details, and postoperative complications including development of seroma, hematoma, venous thromboembolism, wound dehiscence, and delayed wound healing were collected.

RESULTS

Seven hundred and seven patients were included in the study. Sixty-five patients (9.2%) received at least one hemostatic agent. The most used agents were topical thrombin (n = 33, 50.1%), dry matrices including oxidized cellulose, microporous polysaccharides, and absorbable gelatin matrices (n = 15, 23.1%) followed by combination fibrin sealant/thrombin preparations (n = 9, 14.0%). No significant differences with respect to demographic data or medical comorbidities between the cases and controls were identified. Bivariate analysis demonstrated no significant differences in the rate of development of seroma (OR: 0.83, 95% confidence interval [CI] = 0.23-1.99, p = 0.781), hematoma (OR: 3.72, 95% confidence interval [CI] = 0.95-14.65, p = 0.060), venous thromboembolism (OR: 0.40, 95% confidence interval [CI] = 0.44-3.81, p = 0.433).

CONCLUSION

Hemostatic agent use, regardless of type, does not significantly affect the risk of seroma, hematoma, and venous thromboembolism development, nor does it influence the rates of delayed wound healing or wound dehiscence.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction

BACKGROUND

Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction.

METHODS

A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered.

RESULTS

Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps.

CONCLUSIONS

Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.

The Use of Fibrin-based Tissue Adhesives for Breast in Reconstructive and Plastic Surgery

Background:

Breast plastic surgery is a rapidly evolving field of medicine. The modern view of surgical trends reflects the desire to minimize complications and introduce advanced technologies. These always will be priorities for surgeons. Reconstructive surgery, a branch of plastic surgery focusing on restoration of lost functional and aesthetic component, seeks to enhance psychological rehabilitation and improves the quality of life, as well as aesthetic recovery.

Objective:

This review addresses the action of fibrin agents and their effect on the quality of surgical hemostasis.

Discussion and Conclusion:

The fundamental goals for the surgeon are to perform a minimally traumatic intervention and to prevent any form of complication. Achieving complete hemostasis is an intraoperative necessity. Timely prevention of bleeding and hemorrhagic phenomena can affect not only the outcome of the operation, but also the incidence of postoperative complications. Topics include the integrity of microvascular anastomoses, tissue adhesion, and the incidence of seromas and hematomas associated with fibrin glue usage. The literature on fibrin adhesives with respect to prevention of postoperative complications, and the effectiveness with active drainage also are analyzed.

Effect of topical microporous polysaccharide hemospheres on the duration and amount of fluid drainage following mastectomy: a prospective randomized clinical trial

Background

Seroma formation is the most common complication after mastectomy and places patients at risk of associated morbidities. Microporous polysaccharide hemospheres (MPH) consists of hydrophilic, plant based, polysaccharide particles and is currently used as an absorbable hemostatic agent. An animal model evaluating MPH and seroma formation after mastectomy with axillary lymph node dissection showed a significant decrease in seroma volume. Study aim was to evaluate topical MPH on the risk of post-mastectomy seroma formation as measured by total drain output and total drain days.

Methods

Prospective randomized single-blinded clinical trial of patients undergoing mastectomy for the treatment of breast cancer. MPH was applied to the surgical site in the study group and no application in the control group.

Results

Fifty patients were enrolled; eight were excluded due to missing data. Forty-two patients were evaluated, control (n = 21) vs. MPH (n = 21). No difference was identified between the two groups regarding demographics, tumor stage, total drain days, total drain output, number of clinic visits, or complication rates. On a subset analysis, body mass index (BMI) greater than 30 was identified as an independent risk factor for high drain output. Post hoc analyses of MPH controlling for BMI also revealed no statistical difference.

Conclusions

Unlike the data presented in an animal model, no difference was demonstrated in the duration and quantity of serosanguinous drainage related to the use of MPH in patients undergoing mastectomy for the treatment of breast cancer. BMI greater than 30 was identified as an independent risk factor for high drain output and this risk was not affected by MPH use. NCT03647930, retrospectively registered 08/2018.

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 fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms

BACKGROUND

Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use.

OBJECTIVES

To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults.

DATA SOURCES

Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms.

REVIEW METHODS

This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis.

RESULTS

We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I² = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I² = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays.

LIMITATIONS

It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available.

CONCLUSIONS

The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020710.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Use of Low-Thrombin Fibrin Sealant Glue After Axillary Lymphadenectomy for Breast Cancer to Reduce Hospital Length and Seroma

BACKGROUND

Axillary lymphadenectomy for primary breast cancer produces a non-negligible rate of postoperative lymphorrhea, prolonged hospital stays, and multiple seroma punctures. We evaluated the impact of low-thrombin fibrin sealant glue on surgical wounds in patients undergoing axillary lymph node dissection for breast cancer.

METHODS

We conducted an observational study of 149 patients who underwent axillary lymphadenectomy for primary breast cancer between January 2014 and December 2015. Data were obtained from 2 successive prospective studies. The hospital stay length and morbidity (seromas, punctures) were compared between 2 groups: patients who had padding sutures and low-thrombin fibrin sealant glue without drainage (n = 49) and patients with drainage alone (n = 100). Hospital costs were assessed from the hospital perspective.

RESULTS

The mean hospital stay length was shorter in the fibrin sealant group (2.6 vs. 4.7 days; P < .001). Seroma magnitude and punctures were similar in patients treated with fibrin sealant compared with patients with drainage alone. The rate of needle aspiration for seroma was similar irrespective of whether or not a drain or fibrin sealant was used (30.6% vs. 33.0%, P = .77).

CONCLUSION

Low-thrombin fibrin sealant glue does not significantly reduce the amount of fluid produced in the axilla after breast surgery; however, its systematic use may help reduce hospital stays and costs.

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.

Bioinspired Nanoparticulate Medical Glues for Minimally Invasive Tissue Repair

Delivery of tissue glues through small-bore needles or trocars is critical for sealing holes, affixing medical devices, or attaching tissues together during minimally invasive surgeries. Inspired by the granule-packaged glue delivery system of sandcastle worms, a nanoparticulate formulation of a viscous hydrophobic light-activated adhesive based on poly(glycerol sebacate)-acrylate is developed. Negatively charged alginate is used to stabilize the nanoparticulate surface to significantly reduce its viscosity and to maximize injectability through small-bore needles. The nanoparticulate glues can be concentrated to ≈30 w/v% dispersions in water that remain localized following injection. With the trigger of a positively charged polymer (e.g., protamine), the nanoparticulate glues can quickly assemble into a viscous glue that exhibits rheological, mechanical, and adhesive properties resembling the native poly(glycerol sebacate)-acrylate based glues. This platform should be useful to enable the delivery of viscous glues to augment or replace sutures and staples during minimally invasive procedures.

Wound drainage after plastic and reconstructive surgery of the breast

BACKGROUND

Wound drains are often used after plastic and reconstructive surgery of the breast, in order to reduce potential complications. It is unclear whether there is any evidence to support this practice and we therefore undertook a systematic review of the best evidence available.

OBJECTIVES

To compare the safety and efficacy of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast.

SEARCH METHODS

For the first update of this review we searched the Cochrane Wounds Group Specialised Register (searched 4 March 2015); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid MEDLINE (2012 to March 3 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations March 3 2015); Ovid EMBASE (2012 to March 3 2015); and EBSCO CINAHL (2012 to March 4 2015). There were no restrictions on the basis of date or language of publication.

SELECTION CRITERIA

Three review authors undertook independent screening of the search results. All randomised trials (RCTs) that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g. infection, other wound complications, pain, and length of hospital stay). Risk of bias was assessed independently by two review authors. We calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals. Analysis was on an intention-to-treat basis.

MAIN RESULTS

Three randomised trials were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. No new trials were identified for this first update. In total there were 306 women in the three trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Apart from a significantly shorter duration of hospital stay for those participants who did not have drains (MD 0.77; 95% CI 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes.

AUTHORS' CONCLUSIONS

The limited evidence available shows no significant benefit of using post-operative wound drains in reduction mammoplasty, though hospital stay may be shorter when drains are not used. No data are available for breast augmentation or breast reconstruction, and this requires investigation.

Techniques in the prevention and management of seromas after breast surgery

Seromas are the most frequent complications following breast surgery, resulting in significant discomfort and morbidity with possible delays in commencing adjuvant therapies. Varied clinical practices exist in the techniques employed to prevent and manage seromata. This article assesses published literature on the techniques employed in prevention of seroma formation following breast surgery, evaluating the different methodologies used. Although prevention is the best strategy, seromata remain problematic and we consider their management. The principle findings were that prevention is key to the management of seromata. Methods employed to prevent seromata include suction drainage, shoulder immobilization, quilting sutures, fibrin sealants and innovative measures of managing the axilla, among others. The evidence demonstrated that a combination of quilting and drains significantly reduces the incidence and volumes of seromata. These effects are sustained by minimizing use of electrocautery, alongside increasing frequencies of axillary sentinel lymph node biopsies and node sampling. The efficacy data on fibrin sealants is inconclusive and consequently should not be routinely used alone or accompanied by quilting sutures. Clinically significant seromas deemed 'symptomatic' by patients and complicating infected seromas should be aspirated. There are limited data on the recommended treatment of established seromas with a paucity of high-quality studies and further research involving randomized trials are indicated.

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.

Quilting prevents seroma formation following breast cancer surgery: closing the dead space by quilting prevents seroma following axillary lymph node dissection and mastectomy

BACKGROUND

Seroma is a frequent problem after mastectomy (ME) and axillary lymph node dissection (ALND). Seroma is associated with pain, discomfort, impaired mobilisation and repeated aspirations, often resulting in a surgical site infection (SSI). It has already been demonstrated that minimizing dead space through fixation of the skin flaps to the underlying muscles (quilting) lowers the incidence of seroma. The aim of this study was to evaluate the effect of quilting on the incidence of seroma, and SSI.

METHODS

Two consecutive groups with a total of 176 patients following ME and/or ALND were retrospectively compared. Endpoints were the incidence of seroma, and number and volume of aspirations and SSIs. Analysed risk factors were age, ME, lymph node dissection, neoadjuvant therapy, body mass index (BMI) and hypertension.

RESULTS

The quilted group (n = 89) scored significantly better on all endpoints compared with the conventional group (n = 87). The incidence of seroma decreased from 80.5 % to 22.5 % (p < 0.01), the mean number of aspirations from 4.86 to 2.40 (p = 0.015), the volume of aspirations from 1660 ml to 611 ml (p = 0.05) and the SSIs from 31.0 % to 11.2 % (p < 0.01). Increasing age and lymph node dissection were found to be risk factors for seroma; quilting was a protective factor.

CONCLUSION

Quilting is an effective method for preventing seroma and its complications.

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

BACKGROUND

Fibrin glue (FG) combines fibrinogen and thrombin, under the presence of factor XIII and calcium chloride, and produces a 'fibrin clot' as would occur through the natural clotting cascade. FG is thought to close over any small vessels including lymphatics that are too small for conventional surgical closure, thereby reducing seroma formation, seroma incidence and related comorbidities.

OBJECTIVES

To assess the evidence on the effectiveness of FG in people undergoing breast and axillary surgery and to establish whether FG is an efficient modality to prevent postoperative seroma and seroma-related outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register (9 December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2012), MEDLINE (9 December 2011), EMBASE (9 December 2011), LILACS (22 October 2012), SCI-E (22 October 2012), the World Health Organization's International Clinical Trial Registry (9 December 2011) and ClinicalTrials.gov (22 October 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of FG in terms of reducing the postoperative seroma incidence and related comorbidities in people undergoing breast and axillary surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. The pooled analysis of the extracted data was achieved by the statistical analysis on Review Manager software. The quality of studies was assessed using The Cochrane Collaboration's 'Risk of bias' tool.

MAIN RESULTS

The search of four standard electronic databases yielded 119 potentially relevant studies but only 18 RCTs involving 1252 people were found suitable for statistical analysis. There was significant heterogeneity among trials and the majority of trials were of poor quality. The use of FG under skin flaps following breast and axillary surgery failed to reduce the incidence of postoperative seroma (risk ratio (RR) 1.02; 95% Confidence Interval (CI) 0.90 to 1.16, P value = 0.73), mean volume of seroma (standardised mean difference (SMD) -0.25; 95% CI -0.92 to 0.42, P value = 0.46), wound infection (RR 1.05; 95% CI 0.63 to 1.77, P value = 0.84), postoperative complications (RR 1.13; 95% CI 0.63 to 2.04, P value = 0.68) and length of hospital stay (SMD -0.2; 95% CI -0.78 to 0.39, P value = 0.51). FG reduced the total volume of drained seroma (SMD -0.75, 95% CI -1.24 to -0.26, P value = 0.003) and duration of persistent seromas requiring frequent aspirations (SMD -0.59; CI 95% -0.95 to -0.23, P value = 0.001).

AUTHORS' CONCLUSIONS

FG did not influence the incidence of postoperative seroma, the mean volume of seroma, wound infections, complications and the length of hospital stays in people undergoing breast cancer surgery. Due to significant methodological and clinical diversity among the included studies this conclusion may be considered weak and biased. Therefore, a major multicentre and high-quality RCT is required to validate these findings.

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

BACKGROUND

Fibrin glue (FG) combines fibrinogen and thrombin, under the presence of factor XIII and calcium chloride, and produces a 'fibrin clot' as would occur through the natural clotting cascade. FG is thought to close over any small vessels including lymphatics that are too small for conventional surgical closure, thereby reducing seroma formation, seroma incidence and related comorbidities.

OBJECTIVES

To assess the evidence on the effectiveness of FG in people undergoing breast and axillary surgery and to establish whether FG is an efficient modality to prevent postoperative seroma and seroma-related outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register (9 December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2012), MEDLINE (9 December 2011), EMBASE (9 December 2011), LILACS (22 October 2012), SCI-E (22 October 2012), the World Health Organization's International Clinical Trial Registry (9 December 2011) and ClinicalTrials.gov (22 October 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of FG in terms of reducing the postoperative seroma incidence and related comorbidities in people undergoing breast and axillary surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. The pooled analysis of the extracted data was achieved by the statistical analysis on Review Manager software. The quality of studies was assessed using The Cochrane Collaboration's 'Risk of bias' tool.

MAIN RESULTS

The search of four standard electronic databases yielded 119 potentially relevant studies but only 18 RCTs involving 1252 people were found suitable for statistical analysis. There was significant heterogeneity among trials and the majority of trials were of poor quality. The use of FG under skin flaps following breast and axillary surgery failed to reduce the incidence of postoperative seroma (risk ratio (RR) 1.02; 95% Confidence Interval (CI) 0.90 to 1.16, P value = 0.73), mean volume of seroma (standardised mean difference (SMD) -0.25; 95% CI -0.92 to 0.42, P value = 0.46), wound infection (RR 1.05; 95% CI 0.63 to 1.77, P value = 0.84), postoperative complications (RR 1.13; 95% CI 0.63 to 2.04, P value = 0.68) and length of hospital stay (SMD -0.2; 95% CI -0.78 to 0.39, P value = 0.51). FG reduced the total volume of drained seroma (SMD -0.75, 95% CI -1.24 to -0.26, P value = 0.003) and duration of persistent seromas requiring frequent aspirations (SMD -0.59; CI 95% -0.95 to -0.23, P value = 0.001).

AUTHORS' CONCLUSIONS

FG did not influence the incidence of postoperative seroma, the mean volume of seroma, wound infections, complications and the length of hospital stays in people undergoing breast cancer surgery. Due to significant methodological and clinical diversity among the included studies this conclusion may be considered weak and biased. Therefore, a major multicentre and high-quality RCT is required to validate these findings.

Seroma suppression using TissuGlu® in a high-risk patient post-mastectomy: a case report

Introduction

Post-mastectomy seromas are a common problem in modern oncological surgery. Occurrence rates of up to 59% have been reported in the literature. High-risk patients, that is, those who have received previous surgeries, radiation or chemotherapy, present a particular challenge. Several surgical techniques, including progressive tension suture application, have shown promise. Noninvasive measures such as fibrin-based adhesives have thus far not been able to prevent seroma occurrence effectively. A recent study using a lysine-derived urethane adhesive named TissuGlu®, however, showed promising results in patients after abdominoplasty.

Case presentation

We used TissuGlu® to treat a high-risk 64-year-old female patient with a history of breast cancer and severe post-mastectomy seroma. The postsurgical period showed successful seroma suppression, without any adverse effects or complications.

Conclusions

This type of adhesive should be evaluated as an alternative, less-invasive option for preventing seroma in patients after a mastectomy.

Wound drainage after plastic and reconstructive surgery of the breast

BACKGROUND

Wound drains are often used after plastic and reconstructive surgery of the breast, in order to reduce potential complications. It is unclear whether there is any evidence to support this practice and we therefore undertook a systematic review of the best evidence available.

OBJECTIVES

To compare the safety and efficacy of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 3 August 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); Ovid MEDLINE (1950 to July Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 2, 2011); Ovid EMBASE (1980 to 2012 Week 30); and EBSCO CINAHL (1982 to 2 August 2012). There were no restrictions on the basis of date or language of publication.

SELECTION CRITERIA

Two review authors undertook independent screening of the search results. All randomised trials that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g. infection, other wound complications, pain, and length of hospital stay). Risk of bias was assessed independently by two review authors. We calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals. Analysis was on an intention-to-treat basis.

MAIN RESULTS

Three randomised trials were identified and included in the review out of 109 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. In total there were 306 women in the three trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Apart from a significantly shorter duration of hospital stay for those participants who did not have drains (MD 0.77; 95% CI 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes.

AUTHORS' CONCLUSIONS

The limited evidence available shows no significant benefit of using post-operative wound drains in reduction mammoplasty, though hospital stay may be shorter when drains are not used. No data are available for breast augmentation or breast reconstruction, and this requires investigation.

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.

Randomized, prospective study of TissuGlu® surgical adhesive in the management of wound drainage following abdominoplasty

BACKGROUND

Wound drainage and seroma formation following abdominoplasty remain significant concerns to both surgeons and patients due to the resulting increased need for patient follow-up and delays in returning to normal function. While a number of approaches are used to reduce wound drainage and seroma formation, there is still no definitive solution. A promising strategy to reduce these complications is the development of an effective method for closing dead space between tissue layers in order to achieve improved patient outcomes.

METHODS

We conducted a multicenter, prospective, randomized trial assessing the use of a lysine-derived urethane adhesive (TissuGlu®, Cohera Medical) in patients undergoing abdominoplasty. Twenty patients were randomized to a treatment group and a control group, with the adhesive applied to the abdominal wall prior to closure of the abdominoplasty flap in the treatment group. Control patients underwent an identical procedure but without application of TissuGlu. Outcome measures included time to drain removal, total wound drainage prior to drain removal, and surgical complications.

RESULTS

The use of TissuGlu was associated with a trend toward decreased time to drain removal compared to the control group (2.9±1.4 vs. 3.7±1.5 days; P=0.13). Mean total drain volume also tended to be lower in the treatment versus the control group (208.7±138.2 vs. 303.5±240.8 ml; P=0.14). There were no differences in adverse events or complication rates between the two study groups.

CONCLUSION

The application of TissuGlu in abdominoplasty is safe and may decrease wound drainage and the length of time required for postsurgical drains in abdominoplasty patients.

Does the use of fibrin glue prevent seroma formation after axillary lymphadenectomy for breast cancer? A prospective randomized trial in 159 patients

BACKGROUND

Seroma formation frequently occurs in patients who have undergone axillary lymphadenectomy. The aim of the study was to evaluate the effect of fibrin glue in the prevention of seroma formation after axillary lymphadenectomy.

MATERIALS AND METHODS

Hundred fifty-nine breast cancer patients about to undergo quadrantectomy or mastectomy plus axillary lymphadenectomy were enrolled in the study and randomized into two groups. Fibrin glue spray applied to the axillary fossa plus placement of closed suction drainage were used in 80 patients (group A); placement of closed suction drainage was only used in 79 patients (group B).

RESULTS

Group A patients showed a slight advantage with regard to the mean duration of axillary drainage placement (4.5 +/- 1.3 days in group A vs. 5.1 +/- 1.6 days in group B) and number of seroma aspirations (6.3 +/- 1.1 in group A vs. 6.7 +/- 1.2 in group B). No statistically significant differences were observed between the two groups of patients regarding the mean volume of total axillary drainage and of total seroma volume.

CONCLUSIONS

The use of fibrin glue does not prevent seroma formation and does not reduce seroma magnitude and duration. The costs of the product involved do not justify its routine use in patients undergoing axillary dissection.

A prospective randomized trial of the efficacy of marginal quilting sutures and fibrin sealant in reducing the incidence of seromas in the extended latissimus dorsi donor site

BACKGROUND

The extended latissimus dorsi is a workhorse flap and plays an important role in breast reconstruction. Unfortunately, seromas at the flap donor site are a frustrating problem complicating many procedures. The purpose of this study was to evaluate the efficacy of a combination of fibrin sealant (Quixil; Johnson & Johnson, Langhorne, Pa.) and limited quilting sutures at reducing seroma formation.

METHODS

This was a prospective, double-blinded, clinical trial under a single surgeon. Twenty-six patients were enrolled in the study, and all were followed up for a period of 6 months. The patients were randomized to receive either quilting sutures only (group 1) or a combination of Quixil sealant and marginal quilting sutures (group 2).

RESULTS

The incidence of seroma was 23.1 percent in group 1 and 7.7 percent in group 2 (odds ratio, 0.28; relative risk, 0.33). The mean total volume aspirated was significantly higher in group 1 (196.7 ml compared with 30 ml, p = 0.01). The average number of aspirations was 2.7 in group 1 compared with one in group 2. There was a significant reduction in inpatient stay for group 2 by 2 days (p = 0.01). Operative time was shortened by an average of 25 minutes.

CONCLUSIONS

The combination of fibrin sealant and marginal quilting sutures significantly reduces total drainage, hospital stay, and seroma formation. In the authors' opinion, the benefits of seroma prevention outweigh the extra costs associated with this product. The potential, albeit small, risk of virus transmission and allergic reaction, however, needs to be taken into consideration, as with any blood transfusion product.

Sealants after axillary lymph node dissection for breast cancer: good intentions but bad results

BACKGROUND

This study was conducted to evaluate the effect of 2 surgical sealants on postsurgical drainage and lymphocele formation after axillary surgery for breast cancer.

METHODS

This was a prospective, randomized study. Seventy-seven consecutive patients with breast cancer were included and randomized into a control group (18F vacuum drain) and 2 study groups (18F vacuum drain plus COSEAL or BioGlue).

RESULTS

The 3 groups were matched. Neither postsurgical drainage nor time to drain removal was affected by the use of either of the 2 sealants. Although no statistically significant difference in lymphocele formation and wound infection was noted, complications caused by intense foreign-body reaction that led to surgical intervention occurred in both study groups.

COMMENTS

The use of surgical sealants is not recommended after axillary lymph node dissection for breast cancer. Complications of their use may lead to reoperation.

Fibrin glue reduces the duration of lymphatic drainage after lumpectomy and level II or III axillary lymph node dissection for breast cancer: a prospective randomized trial

This randomized prospective study investigated the effect of fibrin glue use on drainage duration and overall drain output after lumpectomy and axillary dissection in breast cancer patients. A total of 100 patients undergoing breast lumpectomy and axillary dissection were randomized to a fibrin glue group (N=50; glue sprayed onto the axillary dissection site) or a control group (N=50). Outcome measures were drainage duration, overall drain output, and incidence of seroma. Overall, the fibrin glue and control groups were similar in terms of drainage duration, overall drain output, and incidence of seroma. However, subgroup analysis showed that fibrin glue use resulted in a shorter drainage duration (3.5 vs. 4.7 days; p=0.0006) and overall drain output (196 vs. 278 mL; p=0.0255) in patients undergoing level II or III axillary dissection. Fibrin glue use reduced drainage duration and overall drain output in breast cancer patients undergoing a lumpectomy and level II or III axillary dissection.

Erythromycin sclerotherapy in the management of seroma

Post-operative seroma can present the clinician and patient with a chronic and difficult problem. The authors present their experience of managing refractory seroma with the antibiotic erythromycin, administered for its properties as a sclerosant. The technique was found, in a series of patients, to be effective, simple and without serious complications.

Triamcinolone reduces seroma re-accumulation in the extended latissimus dorsi donor site

BACKGROUND

The incidence of donor site seroma after autologous latissimus dorsi (ALD) breast reconstruction is in the order of 70%. In the majority of cases the seroma recurs following an initial aspiration. We designed a double-blind randomised controlled trial to test the hypothesis that an intracavity injection of the anti-inflammatory corticosteroid triamcinolone would inhibit seroma re-accumulation.

METHODS

We recruited 52 ALD breast reconstructions in 49 patients, of whom 41 involved immediate reconstruction and 11 delayed reconstruction. Patients exhibiting seromas at their first postoperative visit were randomised to receive either intracavity triamcinolone 80 mg (Group A, n=29) or saline (Group B, n=23), following seroma aspiration. We recorded the incidence of wound complications, total time (days) and number/volume of subsequent aspirations to dryness.

RESULTS

Triamcinolone significantly reduced the need for any further aspiration (A=16/29, B=22/23), total number of aspirations (A: median=1, interquartile range=0-1; B: median=4, interquartile range=2-5; P<0.0001), total volume aspirated (A: median=30 ml, interquartile range=0-80; B: median=325 ml, interquartile range=199-550; P<0.0001), and total time to dryness (A: median=12 days, interquartile range 7-17; B: median=37 days, interquartile range 20-49; P<0.0001). The incidence of adjuvant chemotherapy (A=16/29, B=9/23) and radiotherapy (A=16/29, B=10/23) was similar, and there was no effect upon donor site complications (Group A=4/29, Group B=2/23, P=0.725). The mean follow-up time for patients in the steroid group was 264 days compared to 254 days for those in the placebo group. Steroid injections were well tolerated, and there were no infective complications.

CONCLUSION

Following initial aspiration, intracavity injection of triamcinolone significantly reduced seroma re-accumulation after ALD breast reconstruction.

Does LigaSure reduce fluid drainage in axillary dissection? A randomized prospective clinical trial

Background:

Axillary lymph node dissection (ALND) is an integral part of breast cancer treatment. It is required in about 40–50% of patients. The placement of a drain in the axilla after an operation is current surgical practice. Short surgical stay programmes increase operating efficiency and reduce medical care costs, without compromising quality of care. LigaSure^™ is a new haemostatic device that uses bipolar energy to seal vessels. The aim of this study is to determine whether axillary dissection with LigaSure^™ reduces the time of wound drainage, the duration of surgical intervention and the volume of drainage after treatment.

Patients and methods:

This study is a prospective randomized controlled trial. A total of 100 women with breast cancer who needed axillary dissection were randomized into the LigaSure^™ or conventional axillary dissection group. Levels I to III lymph node dissection was performed. A closed suction drain was always placed in the axilla and removed after 6–8 days or when fluid amount was <60 cc in the previous 24 hours.

Results:

There were no significant differences between the two groups when considering the duration of surgical procedure: average duration was 70.7 ± 24.66 minutes for LigaSure^™ patients, while in the conventional dissection group the mean was 70.6 ± 22.47 minutes (p=0.98). Total amount of drained fluid was 624.49 cc in the LigaSure^™ axillary dissection group and 792.96 in the conventional ALND group; this difference did not achieve statistical significance (p=0.09); the duration of draining was also similar, with no statistical difference (p=0.15).

Conclusions:

The present study did not show clear advantages in LigaSure^™ use for ALND, although it represents a good haemostatic device, especially in abdominal surgery.

Abdominal Wall Reconstruction following Severe Loss of Domain: The R Adams Cowley Shock Trauma Center Algorithm

BACKGROUND

Large, complex, posttraumatic and recurrent abdominal hernias present a reconstructive challenge. Multiple techniques have been described to restore the integrity of the abdominal wall, although the indications and applications can be difficult to navigate. The authors propose an algorithm that facilitates the assessment and treatment of secondary large ventral defects.

METHODS

The algorithm described involves a systematic approach to abdominal wall reconstruction and was applied to 23 consecutive patients at the R Adams Cowley Shock Trauma Center. Data collected from the chart review included age, body mass index, mechanism of injury, placement of skin graft and use of resorbable mesh before definitive reconstruction, size of defect, number of tissue expanders placed, length of follow-up, and complications.

RESULTS

There were six female patients and 17 male patients, with an average age of 36 years. The average follow-up was 7 months. Seventeen patients had posttraumatic laparotomies, five patients had aggressive abdominal wall debridement following necrotizing fasciitis, and one patient developed a large abdominal wall hernia following complications from gastric bypass surgery. All patients underwent delayed abdominal wall reconstruction, with an average time to initial reconstruction of 19.5 months. Sixteen patients had no postoperative complications. Seven patients had complications, including one with an enterocutaneous fistula, one with a partial small bowel obstruction, two with seromas, one with a superficial wound infection, and two with recurrent abdominal wall laxity.

CONCLUSIONS

The reconstructive ladder for large, complex abdominal hernias is poorly defined. The proposed algorithm provides a systematic staged approach that incorporates available techniques used for delayed reconstruction of the abdominal wall.

Progressive Tension Sutures in the Prevention of Postabdominoplasty Seroma: A Prospective, Randomized, Double-Blind Clinical Trial

BACKGROUND

The purpose of this study was to evaluate the seroma reduction capabilities of progressive tension sutures and compare them with the conventional use of drains.

METHODS

Sixty female patients were randomized into four groups: group 1 (control, no drains, and no progressive tension sutures), group 2 (progressive tension sutures alone), group 3 (drains alone), and group 4 (progressive tension sutures and drains). All patients underwent a classic abdominoplasty and drains were left for 7 days in the corresponding groups. Clinical and ultrasound assessments were performed 2 weeks after the operation by blinded evaluators. Punctures, volumes, nonseroma complications, and aesthetic outcome were also measured.

RESULTS

Surgical time was 50 minutes longer in groups 2 and 4. Drain outputs were higher in group 3 than in group 4. The clinical and ultrasound seroma frequency was 35 percent and 90 percent respectively, without significant differences among the groups. The control group was interrupted at 10 patients because of considerably larger seromas and an increased amount of punctures needed for treatment. No differences were found in the other groups. There were no differences with respect to complication rates and aesthetic outcome after follow-up.

CONCLUSIONS

Progressive tension sutures increase surgical time, reduce drain outputs, and have the same clinical and ultrasound seroma frequency as the use of drains alone. The combination of both methods simultaneously does not add any advantages. However, complications and interventions increase if at least one of them is not used. The mechanism of action of progressive tension sutures could be the compartmentalization of the fluid collection under the flap facilitating absorption.

Concepts of seroma formation and prevention in breast cancer surgery

BACKGROUND

Seroma formation is the commonest early sequel to breast cancer surgery especially when axillary dissection is undertaken. It is associated with significant morbidity and financial burden. The main pathophysiology of seroma is still poorly understood and remains controversial. The optimal ways to reduce the incidence of seroma formation are unknown. The aim of this paper is to review the concepts of pathophysiology of seroma formation following mastectomy and breast-conserving surgery for cancer. The various techniques in practice to reduce its incidence and treatment are outlined.

METHOD

MEDLINE search of published work on the subject with respect to its pathophysiology, prevention and treatment was carried out. Manual retrieval of relevant articles in the reference lists of the original papers from the MEDLINE was then carried out.

RESULT

The pathophysiology and mechanism of seroma formation in breast cancer surgery remains controversial and not fully understood. Methods of prevention and treatment of seroma remain varied and inconclusive.

CONCLUSION

Evidence suggests an increase in the incidence of seroma because of thermal trauma from electrocautery dissection, but this is indispensable for surgical haemostasis. Obliteration of dead space by various flap apposition techniques has been shown to be advantageous in reducing incidence and volume of seroma. Low-pressure suction drainage reduces seroma volume and duration of drainage leading to earlier drain removal. Preventive measures have to be tailored according to individual patient and operative factors.

The Use of Hemostatic Agents and Sealants in Urology

PURPOSE

While hemostatic agents and sealants have long been used in the fields of surgery and urology, confusion persists about their indications for use and the optimal agent choice. We comprehensively defined and evaluated the scientific basis for hemostatic agent and sealant use in urology, and provide a conceptual framework for future research and discussion.

MATERIALS AND METHODS

A MEDLINE search of all available literature concerning hemostatic agents in urology was performed, including topical hemostats, anti-fibrinolytics, fibrin sealants and matrix hemostats. Select references were also chosen from the broader surgical literature. Animal studies, case reports, retrospective and prospective studies, and opinion articles were reviewed.

RESULTS

Hemostatic agents include a wide range of components. Recent literature has focused on fibrin sealants and matrix agents. Two main indications exist for hemostatic agents, including 1) hemostasis and 2) sealant. The best evidence for efficacy and safety exists for hemostasis, especially for nephrectomy and trauma. Newer data highlight urinary tract reconstruction, fistula and percutaneous tract closure, suture line strengthening and infertility as potential uses. Novel drug delivery and tissue engineering are areas with large clinical potential.

CONCLUSIONS

Hemostatic agent use is promising and yet unproven for most conditions currently treated in urology. Hemostasis continues to be the main indication, which is well established. Few trials have examined comparative efficacy among hemostatic agents and further prospective studies are needed to justify additional indications as well as determine the optimal mode of use. Minimally invasive surgery will further drive the use of hemostatic agents and sealants. Cost-effective, evidence based hemostatic agent use will continue to challenge all urologists.

Systematic review and meta-analysis of the use of fibrin sealant to prevent seroma formation after breast cancer surgery

Background

The use of fibrin sealant has been proposed as a means of preventing seroma formation following breast cancer surgery. Conflicting trial results require the efficacy of fibrin sealant to be reviewed critically.

Methods

A systematic review of randomized controlled trials was conducted to examine the efficacy of fibrin sealants in reducing postoperative drainage and seroma formation after breast cancer surgery. Studies were identified by computer searches of Medline, Embase, the Cochrane Central Register of Controlled Trials and manufacturer websites (to June 2005), and bibliographic searches of published articles. Trials were eligible for inclusion if they reported data on postoperative drainage and the number of patients who developed a seroma.

Results

Eleven trials met the criteria for inclusion. Generally, the trials were small and of poor methodological quality. Fibrin sealant did not reduce the rate of postoperative seroma (relative risk 1·14, 95 per cent confidence interval (c.i.) 0·88 to 1·46), the volume of drainage (weighted mean difference − 117·7, 95 per cent c.i. − 259·2 to 23·8 ml), or the length of hospital stay (weighted mean difference − 0·38, 95 per cent c.i. − 1·58 to 0·83 days).

Conclusions

The current evidence does not support the use of fibrin sealant in breast cancer surgery to reduce postoperative drainage or seroma formation.

Early removal of postmastectomy drains is not beneficial: results from a halted randomized controlled trial

BACKGROUND

Closed-suction drainage to reduce seromas is standard after mastectomy. This study evaluates the safety of early drain removal.

METHODS

Women undergoing mastectomy were randomized to early removal on postoperative day 2 or standard removal (< 30 mL drainage in 24 hours or postoperative day 14). Primary endpoints were time to drain removal and physician visits. Secondary endpoints were number of seroma aspirations, drain reinsertions, and infections.

RESULTS

Twenty-seven patients were recruited before an interim analysis was performed to address safety concerns. Three patients withdrew before trial completion, leaving 14 patients in the standard group and 10 in the early group. Patients in the standard group had significantly fewer seroma aspirations, fewer drain reinsertions, and fewer physician visits. The trial was halted because of the higher rate of events in the early group.

CONCLUSION

Surgical drains cannot be safely removed on postoperative day 2 after mastectomy. Early removal significantly increases the occurrence of seromas requiring treatment.

Evidence-Based Risk Factors for Seroma Formation in Breast Surgery

BACKGROUND

Seroma is a common problem in breast surgery. The aim of this systematic review was to identify risk factors for seroma formation.

METHODS

Articles published in English were obtained from searches of Medline and additional references were found in the bibliographies of these articles. Risk factors were graded according to the quality and strength of evidence and to the direction of association.

RESULTS

One meta-analysis, 51 randomized controlled trials, 7 prospective studies and 7 retrospective studies were identified. There was no risk factor supported by strong evidence, but there was moderate evidence to support a risk for seroma formation in individuals with heavier body weight, extended radical mastectomy as compared with simple mastectomy, and greater drainage volume in the initial 3 days. On the other hand, the following factors did not have a significant influence on seroma formation: duration of drainage; hormone receptor status; immobilization of the shoulder; intensity of negative suction pressure; lymph node status or lymph node positivity; number of drains; number of removed lymph nodes; previous biopsy; removal of drains on the fifth postoperative day versus when daily drainage volume fell to minimal; stage; type of drainage (closed suction versus static drainage); and use of fibrinolysis inhibitor. In contrast, sentinel lymph node biopsy reduced seroma formation. Evidence was weak, or unproven, for other factors that were commonly cited in the literature.

CONCLUSIONS

Although a number of factors have been correlated with seroma formation, strong evidence is still scarce. However, there is evidence showing that sentinel lymph node biopsy reduces seroma formation.