A gelatin matrix-thrombin tissue sealant (FloSeal) application in the management of groin breakdown after inguinal lymphadenectomy for vulvar cancer

Final results of the PräVAC trial: prevention of wound complications following inguinal lymph node dissection in patients with penile cancer using epidermal vacuum-assisted wound closure

PURPOSE

Inguinal lymphadenectomy in penile cancer is associated with a high rate of wound complications. The aim of this trial was to prospectively analyze the effect of an epidermal vacuum wound dressing on lymphorrhea, complications and reintervention in patients with inguinal lymphadenectomy for penile cancer.

PATIENTS AND METHODS

Prospective, multicenter, randomized, investigator-initiated study in two German university hospitals (2013-2017). Thirty-one patients with penile cancer and indication for bilateral inguinal lymph node dissection were included and randomized to conventional wound care on one side (CONV) versus epidermal vacuum wound dressing (VAC) on the other side.

RESULTS

A smaller cumulative drainage fluid volume until day 14 (CDF) compared to contralateral side was observed in 15 patients (CONV) vs. 16 patients (VAC), with a median CDF 230 ml (CONV) vs. 415 ml (VAC) and a median maximum daily fluid volume (MDFV) of 80 ml (CONV) vs. 110 ml (VAC). Median time of indwelling drainage: 7 days (CONV) vs. 8 days (VAC). All grade surgery-related complications were seen in 74% patients (CONV) vs. 74% patients (VAC); grade 3 complications in 3 patients (CONV) vs. 6 patients (VAC). Prolonged hospital stay occurred in 32% patients (CONV) vs. 48% patients (VAC); median hospital stay was 11.5 days. Reintervention due to complications occurred in 45% patients (CONV) vs. 42% patients (VAC).

CONCLUSIONS

In this prospective, randomized trial we could not observe a significant difference between epidermal vacuum treatment and conventional wound care.

Use of a gelatin-thrombin hemostatic matrix in obstetrics and gynecological surgery

Gelatin-thrombin matrix (GTM) is a hemostatic sealant consisting of bovine-derived gelatin matrix and human-derived thrombin, combining both mechanical and active mechanisms to achieve hemostasis. It was approved by the Food and Drug Administration in 1999. GTM has been used by several surgical specialties; however, it is a possibly an under-used tool in obstetrics and gynecology. A limited number of studies have been performed on its use during laparoscopic endometrioma excision and myomectomy. It may prove useful in endometrioma excision in reproductive aged women because it is likely to harm ovarian reserve less than electrocautery; however, this conclusion needs to be validated. The only study on GTM use in myomectomy included 50 women randomized into GTM and control groups, and showed decreased blood loss and shorter hospital stays in the GTM group. In gynecologic oncology, it was successfully used to reduce lymphocele cases in a cohort study. GTM has been used successfully in obstetrics in a handful of cases of uncontrolled bleeding from caesarean scar, placental site, ectopic pregnancy, rectovaginal hematoma, and venous plexus over the vaginal vault after emergency postpartum hysterectomy. Risk of viral transmission is a major concern about GTM, yet there are no reports on disease transmission with GTM use to date. Rare but serious adverse effects and complications have been reported such as fatal or near-fatal thromboembolism and small bowel obstruction. Although GTM is mostly a safe product, it is still not free of complications and risks. In conclusion, although routine use of GTM cannot be recommended due to concerns about its safety, cost, and availability, it may prove useful when conventional hemostatic methods such as suturing and electrocauterization fail or are not appropriate.

How to locate and treat lymph leaks using patent blue V dye and Floseal

Lymph leaks after vascular groin dissections can be a challenging postoperative complication for both patient and surgeon. A multidisciplinary team at a district general hospital in the United Kingdom consisting of breast, plastic, and vascular surgeons performed intraoperative lymphatic mapping using patent blue V dye to locate the exact location of a groin lymph leak before sealing the leak with direct vision ligation and Floseal Hemostatic Matrix (Baxter Healthcare Corp., Hayward, CA).

Phase 1 prospective evaluation of the oncological adequacy of robotic assisted video-endoscopic inguinal lymphadenectomy in patients with penile carcinoma

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Several lymph node staging strategies have been proposed as a response to the high morbidity seen after standard inguinal lymphadenectomy for penile cancer. A video-endoscopic (laparoscopic and robotic) approach has been proposed as a less morbid procedure in several retrospective studies. To date, none has evaluated the oncological adequacy with regard to whether all relevant nodes have been removed. To the authors' knowledge this is the first prospective study of a robotic or laparoscopic inguinal lymphadenectomy that evaluates the oncological adequacy of this approach for penile cancer. The study shows that robotic inguinal lymphadenectomy allowed adequate staging of disease in the inguinal region by removing all relevant lymph nodes as assessed by an independent evaluating urological oncologist.

OBJECTIVE

To prospectively determine the oncological adequacy of robotic assisted video-endoscopic inguinal lymphadenectomy (RAVEIL).

PATIENTS AND METHODS

Patients with T1-3N0 penile cancer were enrolled into a prospective phase I trial at a tertiary care institution from March 2010 to January 2012. All patients underwent an initial RAVEIL approach. Verification of adequacy of dissection was performed by an independent surgeon via a separate open incision at the conclusion of the RAVEIL procedure. Out of 10 patients, if more than two superficial inguinal fields with ≥2 nodes or more than four with ≥1 node remained within the superficial dissection field, the study would not proceed to phase II.

RESULTS

Of 10 enrolled patients two had inguinal metastases and all positive nodes were detected by RAVEIL. The remaining eight patients had no metastases, with a mean of nine (range 5-21) left and nine (range 6-17) right nodes removed. One inguinal field RAVEIL was converted to an open dissection. The verifying surgeon confirmed that 18 of 19 inguinal fields (94.7% in nine patients) had an adequate dissection. Two benign nodes were found just beneath Scarpa's fascia above the inguinal dissection field. Limitations of the study include an inability to determine decisively what specific wound complications were related to RAVEIL because of the protocol-specified creation of a small inguinal incision for verification of adequate dissection.

CONCLUSION

RAVEIL allowed adequate staging of disease in the inguinal region among patients with penile cancer at risk for inguinal metastases.

The use of novel hemostatic sealant (Tisseel) in laparoscopic myomectomy: a case-control study

BACKGROUND

This is the first case-control study on the use of a fibrin sealant (Tisseel) on uterine suture during laparoscopic myomectomy (LM), with the primary endpoint to evaluate the intraoperative bleeding and postoperative blood loss. In addition, we evaluated the time required to achieve hemostasis using Tisseel and how much it can influence operative time.

METHODS

From December 2009 to January 2011, consecutive patients older than 18 years with symptomatic isolate intramural myoma with maximal diameter B6 cm and ≥ 4 cm and with a sonographically diagnosed free myometrium margin ≥ 0.5 cm were included in the study. We selected from our institute's database a group of consecutive patients with homogeneous features of the study group, who underwent laparoscopic myomectomy without Tisseel application.

RESULTS

Fifteen women with symptomatic myoma were enrolled in the study (group A). Regarding the control group (group B), we selected a homogenous group of 15 patients with the same preoperative characteristics of the study group. Mean operative time was 47.7 min and 62.1 min, for groups A and B respectively (p < 0.05). Mean time required to achieve complete haemostasis was 195.5 s in group A and 361.8 in control group B (p < 0.0001). Mean estimated blood loss was 111.3 mL and 230 mL in groups A and B, respectively (p < 0.05). Mean hemoglobin decrease was 1.36 g/dL and 2.04 g/dL in groups A and B, respectively (p < 0.05).

CONCLUSIONS

The use of Tisseel during LM may represent a valid alternative solution for obtaining hemostasis, reducing intra- and postoperative bleeding. Furthermore, it may help the surgeon to obtain a rapid healing of the injured surfaces, probably reducing the use of electrocoagulationand traumatisms.

Prospective assessment of postoperative complications and associated costs following inguinal lymph node dissection (ILND) in melanoma patients

BACKGROUND

We prospectively assessed the incidence, risk factors, and costs associated with wound complications and lymphedema in melanoma patients undergoing inguinal lymph node dissection (ILND).

MATERIALS AND METHODS

A total of 53 melanoma patients were accrued to 2 trials (June 2005 to July 2008) that included prospective evaluations of postoperative complications; 30-day wound complications included infection, seroma, and/or dehiscence. There were 20 patients who underwent limb volume measurement and completed a 19-item lymphedema symptom assessment questionnaire preoperatively and 3 months postoperatively. A multivariate analysis was performed to evaluate potential risk factors for complications. A microcosting analysis was also performed to evaluate the direct costs associated with wound complications.

RESULTS

The 30-day wound complications were noted in 77.4% of patients. A BMI ≥ 30 (n = 28) increased the risk for wound complications (odds ratio [OR] = 11.4, 95% confidence interval [95%CI] 1.6-78.5, P = .01), while advanced nodal disease approached significance (OR = 9.0, 95%CI: 0.79-103.1, P = .08). Other risk factors, including diabetes, smoking, and the addition of a deep pelvic (iliac/obturator) dissection to ILND, were not significant. Of 20 patients, 9 (45%) developed limb volume change (LVC) ≥5% at 3 months, with associated mean symptom scores of 6.1 versus 4.6 for those without LVC. Costs for patients with wound complications were significantly higher than for those without wound complications.

CONCLUSIONS

Postoperative wound complications and early onset lymphedema occur frequently following ILND for melanoma. Obesity is an adverse risk factor for 30-day wound complications that can significantly increase postoperative costs, as is likely the case for advanced disease. Risk reduction practices and novel treatment approaches are needed to reduce postoperative morbidity.

Eosinophil-rich inflammatory response to FloSeal hemostatic matrix presenting as postoperative pelvic pain

FloSeal hemostatic matrix has been reported to be effective for the control of intraoperative bleeding in various surgeries. We report 3 patients who experienced a possible allergic response to FloSeal with the formation of excessive granulation tissue and fibrosis that were associated with early postoperative pelvic pain that led to additional surgical intervention.

Hemostatic properties of a venomic protein in rodent dermal injuries

Hemostatic properties of a factor Xa-like protease (Q8009) from the Australian snake Pseudonaja textilis textilis were determined. In tail-tip transection and dermal incision (hind limb) models, reagents were applied with collagen matrix. Blood was collected on filter paper chads for 12 one-minute intervals or until hemostasis. Determination of blood loss was performed using the hematin content and reported as blood loss per minute and total blood lost. Results from the studies demonstrated that the addition of the protease Q8009 and collagen matrix significantly reduced the volume of blood loss and shortened the time-to-hemostasis. In the dermal incision model, Q8009 (100, 250 and 1000 microg/ml) plus collagen matrix significantly reduced (p<0.001) the volume of blood lost relative to Thrombin and shortened the time-to-hemostasis to 2.0 min compared to 4.77 min with Thrombin. In the tail-tip transection model when Q8009 was mixed with a collagen matrix there was no significant reduction in blood loss, when compared to Thrombin plus collagen matrix. However, when injured tail-tips were held in Q8009 (1000 microg/ml) solution, there was a significant reduction (p<0.001) in blood loss (5.88 microl) versus that of Thrombin at 58.0 mul, and time-to-hemostasis was reduced from 11 min with Thrombin to 3 min when the Q8009 solution was used. In these studies, topical application of the venomic protease Q8009 significantly reduced total blood loss with a shorter time-to-hemostasis relative to Thrombin.