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

A higher incidence of postoperative seroma (fluid collection under skin) in people undergoing breast and axillary (under-arm) surgery for breast cancer is responsible for longer hospital stays, frequent repeat aspiration procedures, increased cost of breast disease, delays in the provision of adjunctive treatments and consequently potentially reduced overall all-cause survival. Fibrin glue (FG) instillation under skin flaps after surgery produces a 'fibrin clot', sealing leaky lymph vessels, which leads to reduced seroma formation and related comorbidities.

We systematically analysed the published trials comparing the usefulness of FG as a small-vessel sealing agent. Eighteen randomised controlled trials on 1252 people were retrieved following bibliographic searches on standard medical databases. There were significant clinical and methodological differences among the included trials. The use of FG following breast and axillary surgery did not reduce the incidence of postoperative seroma, mean volume of seroma, wound infections, postoperative complications and the length of hospital stays. FG reduced the total volume of drained seroma and the duration of persistent seroma requiring frequent aspirations.

This review showed no overall benefit of using FG. Although this conclusion is based on the combined analysis of 18 trials, the majority of these were of poor quality due to flaws in trial methods. Therefore, this conclusion should be taken cautiously and a major, multicentre, high-quality randomised controlled trial on people undergoing breast and axillary surgery for breast cancer is required to corroborate this conclusion.

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.

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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 strategy: 

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).

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