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Spiekerman van Weezelenburg MA, Bakens MJAM, Daemen JHT, Aldenhoven L, van Haaren ERM, Janssen A, Vissers YLJ, Beets GL, van Bastelaar J. Prevention of Seroma Formation and Its Sequelae After Axillary Lymph Node Dissection: An Up-to-Date Systematic Review and Guideline for Surgeons. Ann Surg Oncol 2024; 31:1643-1652. [PMID: 38038792 DOI: 10.1245/s10434-023-14631-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify techniques to prevent seroma formation. The aim of this systematic review and network meta-analysis is to use available literature to identify the best intervention for prevention of seroma after standalone ALND. METHODS A literature search was performed for all comparative articles regarding seroma formation in patients undergoing a standalone ALND or ALND with breast-conserving surgery in the last 25 years. Data regarding seroma formation, clinically significant seroma (CSS), surgical site infections (SSI), and hematomas were collected. The network meta-analysis was performed using a random effects model and the level of inconsistency was evaluated using the Bucher method. RESULTS A total of 19 articles with 1962 patients were included. Ten different techniques to prevent seroma formation were described. When combining direct and indirect comparisons, axillary drainage until output is less than 50 ml per 24 h for two consecutive days results in significantly less CSS. The use of energy sealing devices, padding, tissue glue, or patches did not significantly reduce the incidence of CSS. When comparing the different techniques with regard to SSIs, no statistically significant differences were seen. CONCLUSIONS To prevent CSS after ALND, axillary drainage is the most valuable and scientifically proven measure. On the basis of the results of this systematic review with network meta-analysis, removing the drain when output is < 50 ml per 24 h for two consecutive days irrespective of duration seems best. Since drainage policies vary widely, an evidence-based guideline is needed.
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Affiliation(s)
| | - Maikel J A M Bakens
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Jean H T Daemen
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Loeki Aldenhoven
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | | | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | - James van Bastelaar
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
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Buch-Villa E, Castañer-Puga C, Delgado-Garcia S, Fuster-Diana C, Vidal-Herrador B, Ripoll-Orts F, Galeote-Quecedo T, Prat A, Andrés-Matias M, Jimeno-Fraile J, Muñoz-Sorsona E, Vento G, Gumbau-Puchol V, Adrianzen M, López-Flor V, Ortega J. Clinical and cost outcomes of a polyethylene glycol (PEG)-coated patch versus drainage after axillary lymph node dissection in breast cancer: results from a multicentre randomized clinical trial. Br J Surg 2023; 110:1180-1188. [PMID: 37311694 PMCID: PMC10416686 DOI: 10.1093/bjs/znad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/29/2023] [Accepted: 05/01/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND The aim of this study was to compare the clinical outcomes between breast cancer patients who underwent axillary lymph node dissection with postoperative management using a polyethylene glycol-coated patch versus axillary drainage. The direct costs associated with both postoperative management strategies were also evaluated. METHODS This was a multicentre RCT in women with breast cancer who underwent axillary lymph node dissection (ClinicalTrials.gov identifier: NCT04487561). Patients were randomly assigned (1 : 1) to receive either drainage or a polyethylene glycol-coated patch as postoperative management. The primary endpoints were the need for an emergency department visit for any event related to the surgery and the rate of seroma development. RESULTS A total of 227 patients were included , 115 in the patch group (50.7 per cent) and 112 (29.4 per cent ) in the drainage group. The incidence of emergency department visits was significantly greater for patients with drainage versus a polyethylene glycol-coated patch (incidence rate difference 26.1 per cent, 95 per cent c.i. 14.5 to 37.7 per cent; P < 0.001). Conversely, the seroma rate was significantly higher in the polyethylene glycol-coated patch group (incidence rate difference 22.8 per cent, 95 per cent c.i. 6.7 to 38.9 per cent; P < 0.0055). Compared with drainage, using a polyethylene glycol-coated patch resulted in cost savings of €100.41 per patient. An incremental cost-effectiveness ratio analysis found that drainage was associated with an incremental cost-effectiveness ratio of €7594.4 for no need for hospital admission and €491.7 for no need for an emergency department visit. CONCLUSION Compared with patients who received drainage after axillary lymph node dissection, the use of a polyethylene glycol-coated patch resulted in a higher rate of seroma, but a lower number of postoperative outpatient or emergency department visits and thus a reduction in overall costs.
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Affiliation(s)
- Elvira Buch-Villa
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | | | | | - Carlos Fuster-Diana
- Department of Surgery, Valencian Institute of Oncology (IVO), Valencia, Spain
| | - Beatriz Vidal-Herrador
- Department of Surgery, University Clinical Hospital of Santiago de Compostela, A Coruña, Spain
| | | | | | - Antonio Prat
- Department of Surgery, General Hospital of Requena, Valencia, Spain
| | | | - Jaime Jimeno-Fraile
- Department of Surgery, University Clinical Hospital of Marques de Valdecilla, Santander, Spain
| | - Ernesto Muñoz-Sorsona
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Giovani Vento
- Department of Surgery, Valencian Institute of Oncology (IVO), Valencia, Spain
| | | | - Marcos Adrianzen
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Vicente López-Flor
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Joaquín Ortega
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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Gasparri ML, Kuehn T, Ruscito I, Zuber V, Di Micco R, Galiano I, Navarro Quinones SC, Santurro L, Di Vittorio F, Meani F, Bassi V, Ditsch N, Mueller MD, Bellati F, Caserta D, Papadia A, Gentilini OD. Fibrin Sealants and Axillary Lymphatic Morbidity: A Systematic Review and Meta-Analysis of 23 Clinical Randomized Trials. Cancers (Basel) 2021; 13:cancers13092056. [PMID: 33923153 PMCID: PMC8123055 DOI: 10.3390/cancers13092056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/11/2021] [Accepted: 04/21/2021] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Axillary dissection is a highly mobile procedure with severe lymphatic consequences. The off-label application of fibrin sealants in the axilla, with the sole aim to eliminate dead space and to provoke sealing of the disrupted lymphatic vessels at the end of axillary dissection, is an experimental procedure to reduce lymphatic morbidity. The aim of our systematic review and meta-analysis is to investigate the effects of fibrin sealants on lymphatic morbidity after axillary dissection. Our results show that this experimental procedure is able to decrease the total axillary drainage output, the number of days before the axillary drainage is removed, and the length of hospital stay. However, no effects on the occurrence rate of axillary lymphocele or on the surgical site complications rate were demonstrated Abstract Background: use of fibrin sealants following pelvic, paraaortic, and inguinal lymphadenectomy may reduce lymphatic morbidity. The aim of this meta-analysis is to evaluate if this finding applies to the axillary lymphadenectomy. Methods: randomized trials evaluating the efficacy of fibrin sealants in reducing axillary lymphatic complications were included. Lymphocele, drainage output, surgical-site complications, and hospital stay were considered as outcomes. Results: twenty-three randomized studies, including patients undergoing axillary lymphadenectomy for breast cancer, melanoma, and Hodgkin’s disease, were included. Fibrin sealants did not affect axillary lymphocele incidence nor the surgical site complications. Drainage output, days with drainage, and hospital stay were reduced when fibrin sealants were applied (p < 0.0001, p < 0.005, p = 0.008). Conclusion: fibrin sealants after axillary dissection reduce the total axillary drainage output, the duration of drainage, and the hospital stay. No effects on the incidence of postoperative lymphocele and surgical site complications rate are found.
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Affiliation(s)
- Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, via Tesserete 46, 6900 Lugano, Switzerland; (M.L.G.); (F.M.); (V.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), via Giuseppe Buffi 13, 6900 Lugano, Switzerland
| | - Thorsten Kuehn
- Interdisciplinary Breast Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, 73730 Neckar, Germany;
| | - Ilary Ruscito
- Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, via di Grottarossa 1035, 00189 Rome, Italy; (I.R.); (F.B.); (D.C.)
| | - Veronica Zuber
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
| | - Rosa Di Micco
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80138 Naples, Italy
| | - Ilaria Galiano
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
| | | | - Letizia Santurro
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
| | - Francesca Di Vittorio
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
| | - Francesco Meani
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, via Tesserete 46, 6900 Lugano, Switzerland; (M.L.G.); (F.M.); (V.B.)
| | - Valerio Bassi
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, via Tesserete 46, 6900 Lugano, Switzerland; (M.L.G.); (F.M.); (V.B.)
| | - Nina Ditsch
- Department of Gynecology and Obstetrics, University Hospital of Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany;
| | - Michael D. Mueller
- Department of Obstetrics and Gynecology, University Hospital of Bern, Friedbühlstrasse 19, 3010 Bern, Switzerland;
| | - Filippo Bellati
- Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, via di Grottarossa 1035, 00189 Rome, Italy; (I.R.); (F.B.); (D.C.)
| | - Donatella Caserta
- Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, via di Grottarossa 1035, 00189 Rome, Italy; (I.R.); (F.B.); (D.C.)
| | - Andrea Papadia
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, via Tesserete 46, 6900 Lugano, Switzerland; (M.L.G.); (F.M.); (V.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), via Giuseppe Buffi 13, 6900 Lugano, Switzerland
- Correspondence:
| | - Oreste D. Gentilini
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
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Al-Masri M, Alawneh F, Daoud F, Ebous A, Hamdan B, Al-Najjar H, Al-Masri R, Abu Farah M. Effectiveness of Cyanoacrylate in Reducing Seroma Formation in Breast Cancer Patients Post-Axillary Dissection: A Randomized Controlled Trial. Front Oncol 2021; 10:580861. [PMID: 33569343 PMCID: PMC7868378 DOI: 10.3389/fonc.2020.580861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/27/2020] [Indexed: 11/25/2022] Open
Abstract
Background/Purpose Seroma is a common complication after axillary dissection in women with node-positive breast cancer. We aim to determine the effect of Cyanoacrylate on reducing seroma formation in patients undergoing axillary dissection. This a randomized clinical trial. Methods This is a single-center, randomized, single-blinded, and two-arm parallel study. Women with node-positive breast cancer eligible for axillary dissection were enrolled. Patients with a Body Mass Index (BMI) greater than 35 kg/m2, those who underwent immediate breast reconstruction, and/or received neoadjuvant chemotherapy were excluded. Patients were randomized in a 1:1 ratio, and were stratified according to their age, BMI, tumor size, and operation type. The primary endpoint was the total seroma volume (the total drained volume and the total aspirated volume after drain removal). Data presented as mean and range when applicable. Results 111 patients were randomized (Cyanoacrylate 57; control 54). 105 patients were analyzed. Sixty-nine patients underwent breast conserving surgery, and 36 underwent modified radical mastectomy. There was no difference in the total seroma volume between the Cyanoacrylate vs. control arms (1,304 (60–4,950) vs. 1,446 (100–5,223) ml, p=0.458). Wound infection, flap necrosis, number of manual aspirates, and hematoma formation were not statistically different between the two groups. Time to drain removal was shorter in the Cyanoacrylate arm (11.04(3–23) vs. 13.84(3–37) days, p=0.015). The use of Cyanoacrylate was not cost effective ($586.93 (550–748) vs. $29.63 (0–198), p<0.001). Higher seroma volume was correlated with modified radical mastectomy, older age, and BMI more than 30 kg/m2. Conclusion Cyanoacrylate did not reduce seroma formation and its use was not cost effective. Clinical Trial Registration clinicaltrials.gov, identifier NCT02141373.
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Affiliation(s)
- Mahmoud Al-Masri
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Fade Alawneh
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Faiez Daoud
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Ali Ebous
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Basem Hamdan
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Hani Al-Najjar
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Rama Al-Masri
- School of Medicine, University of Jordan, Amman, Jordan
| | - Marwan Abu Farah
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
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Chang YT, Shih SL, Loh EW, Tam KW. Effects of Fibrin Sealant on Seroma Reduction for Patients with Breast Cancer Undergoing Axillary Dissection: Meta-Analysis of Randomized Controlled Trials. Ann Surg Oncol 2020; 27:5286-5295. [PMID: 32564232 DOI: 10.1245/s10434-020-08747-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Seroma formation is common in patients with breast cancer after axillary dissection. Fibrin sealant, containing fibrinogen and thrombin, has been developed to improve wound healing. We conducted a systematic review and meta-analysis to evaluate the efficacy of fibrin sealants in reducing seroma among patients with breast cancer undergoing axillary dissection. METHODS We searched the PubMed, EMBASE, and Cochrane Library databases for randomized controlled trials (RCTs) published up to April 2020. Pooled estimates of the outcomes were computed using a random-effects model. The primary outcomes were incidence and volume of seroma, while the secondary outcomes were volume and duration of drainage, incidence of infection, and length of hospital stay. RESULTS We reviewed 23 RCTs that included 1640 patients. Compared with the control group, the fibrin sealant group had no significant differences in the incidence of seroma, length of hospital stay, or incidence of surgical site infection. Significant intergroup differences were discovered in lower volume of seroma (weighted mean difference [WMD] - 71.88, 95% confidence interval [CI] - 135.58 to - 8.19), volume of drainage (WMD - 73.24, 95% CI - 107.32 to - 39.15), and duration of drainage (WMD - 0.84, 95% CI - 1.50 to - 0.19). CONCLUSIONS Fibrin sealants provide limited benefits in reducing the volume of seroma and the volume and duration of drainage. Therefore, after shared decision making, surgeons may apply fibrin sealants to patients with breast cancer undergoing axillary dissection.
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Affiliation(s)
- Ya-Ting Chang
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shen-Liang Shih
- Cancer Center, Yuan's General Hospital, Kaohsiung, Taiwan.,Department of Health Business Administration, Meiho University, Pingtung, Taiwan
| | - El-Wui Loh
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan. .,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
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Covarelli P, Barberini F, Cannavicci D, Cirocchi R, Rulli A, Boselli C, De Giorgi V. Reduction of postoperative lymphorrhoea in patients undergoing radical lymphadenectomy for stage III melanoma: prospective study using collagen-fibrin patches. MINERVA CHIR 2019; 75:111-116. [PMID: 31820617 DOI: 10.23736/s0026-4733.19.08114-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Radical lymph nodes dissection (RLND) is the standard procedure for regional control of disease in patients with metastatic melanoma (stage III). Because of its aggressiveness, lymphorrhoea is a constant problem in postoperative. METHODS In this prospective nonrandomized study with a retrospective analysis of data, patients undergoing surgical treatment of axillary or iliac-inguinal RLND received standard treatment plus a collagen-fibrin sealant patch (TachoSil) (N.=50) or standard treatment alone (N.=50). The first endpoint was the comparison between the treated population and the control group, in terms of persistence of drainage and average daily volume of lymphorrhoea. The second aim was to relate patients' BMI, volume of lymphorrhoea and time of drainage in the two groups. RESULTS In the comparison between the two groups receiving or not the treatment with collagen-fibrin patch, we found an average difference both in the volume of daily lymphorrhoea (42.91±6.61 cc) and in the persistence of drainage (9.292±1.644 days) with P value <0.0001. Besides, the collagen-fibrin patch was actually effective in reducing lymphorrhoea and time of drainage, regardless of patients' BMI. CONCLUSIONS The results of this study confirm and support the starting thesis: TachoSil is an effective tissue sealant able to reduce lymphorrhoea and drainage removal times following a radical lymphadenectomy, independently from the BMI.
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Affiliation(s)
- Piero Covarelli
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy -
| | - Francesco Barberini
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Daniele Cannavicci
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Roberto Cirocchi
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Antonio Rulli
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Carlo Boselli
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Prodromidou A, Iavazzo C, Fotiou A, Psomiadou V, Drakou M, Vorgias G, Kalinoglou N. The application of fibrin sealant for the prevention of lymphocele after lymphadenectomy in patients with gynecological malignancies: A systematic review and meta-analysis of randomized controlled trials. Gynecol Oncol 2019; 153:201-208. [DOI: 10.1016/j.ygyno.2019.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/03/2019] [Accepted: 01/08/2019] [Indexed: 12/14/2022]
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Weber WP. ASO Author Reflections: Abandoning the Drains by Eliminating the Radical Procedures Necessitating the Drains. Ann Surg Oncol 2018; 25:671-672. [PMID: 30374930 DOI: 10.1245/s10434-018-6965-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Walter Paul Weber
- Breast Center, University Hospital Basel, University of Basel, Basel, Switzerland. .,SAKK, Bern, Switzerland.
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