Clinical Surgery-International
Invited commentary on effectiveness of fibrin glue
in conjunction with collagen patches to reduce seroma
formation after axillary lymphadenectomy for breast cancer
John T. Vetto, M.D.*
Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR 97239, USA
Ruggiero et al
1
have taken on a clinically practical and
persistently challenging topic: the reduction of axillary
drainage after nodal dissection for breast cancer. Prolonged
drainage and/or seromas are not only troublesome to pa-
tients and their providers, but they can significantly impact
treatment by delaying adjuvant therapy, increasing the risk
of infection, and, in extreme cases, produce nutritional and
immunologic deficits, possibly necessitating reoperation.
This study differs from most American studies by several
aspects. First, some patients underwent quandrantectomies or
mastectomies (with additional drains that likely communicated
with the axillary dissection cavity) and stayed in the hospital up
to 3 to 4 days after surgery (even after breast conservation,
likely resulting in earlier arm immobilization than for other
patients typically discharged earlier). Second, the authors rou-
tinely removed the drains early, as opposed to keeping them in
until drainage decreased below a fixed threshold. Third, the
end points were somewhat subjective (seroma size on ul-
trasound and the number of aspirations required). The re-
sults are further clouded by the fact that the lymphadenec-
tomies were performed with electric scalpels, which may
have lowered the incidence of postoperative lymph drainage
in both groups.
Despite the small and nonjustified sample size, the au-
thors found a significant decrease in the volume of drainage
and the magnitude and duration of seromas. Although the
mean number of aspirations performed was lower in the
intervention group, the difference was not significant when
one looks at the ranges. Importantly, it is not clear that the
groups are similar in terms of nodal disease burden; drain-
age typically increases with macroscopic nodal involve-
ment, and the distribution of involved nodal volume be-
tween the 2 groups is not presented. Most importantly,
although the results may be statistically significant, the
question remains whether the results are clinically signifi-
cant. Specifically, the intervention did not lower the inci-
dence of axillary dissection wound problems, and the ques-
tion remains whether the average reduction in time to heal
of 4 days justifies the expense and potential risk of the
intervention.
Despite these concerns, the results are encouraging; as out-
lined in the authors’ excellent discussion on this topic, studies
to date have not shown a consistent benefit to placing more
drains, immobilizing the arm, or using single agents, such as
fibrin glue, alone. Indeed, a recent randomized study has found
no impact of either surgical technique or drain type on the
volume of axillary drainage.
2
If the authors are correct that the
dual intervention of fibrin glue and collagen patch is effective
in reducing axillary drainage, it would be pleasing to see this
confirmed in a larger trial using an outpatient surgery setting
and a more objective end point, such as time to drain removal
using a fixed volume cut-off point.
References
1. Ruggiero R, Procaccini E, Piazza P, et al. Effectiveness of fibrin glue in
conjunction with collagen patches to reduce seroma formation after axillary
lymphadenectomy for breast cancer. Am J Surg 2008;196:170 – 4.
2. Nadkarni MS, Rangole AK, Sharma RK, et al. Influence of surgical
technique on axillary seroma formation: a randomized study. ANZ
J Surg 2007 May;77(5):385–9.
* Corresponding author. Tel.: ϩ1-503-494-5501; fax: ϩ1-503-494-
7572.
E-mail address: vettoj@ohsu.edu
Manuscript received December 10, 2007; revised manuscript Decem-
ber 11, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2007.12.048
The American Journal of Surgery (2008) 196, 175