Fibrin glue in thyroid and parathyroid surgery: is under-flap suction still necessary?
The introduction of fibrin sealants has brought into question the necessity of routinely placing suction drains. We conducted a retrospective study to determine whether fibrin sealants are comparable to traditional drains in terms of length of hospital stay and hematoma prevention. We evaluated 124 patients who had undergone thyroidectomy and 47 patients who had undergone parathyroidectomy. Of these, 22 thyroid surgery patients and 10 parathyroid surgery patients had their incisions closed without a drain after the application of fibrin glue. We found that the use of fibrin glue resulted in a statistically significant decrease in the length of hospital stay following both types of surgery (p = 0.033 and p = 0.022, respectively). Two hematomas in the drain group required immediate surgical evacuation; in both of these patients, the suction was clotted and ineffective. One minor hematoma occurred in the fibrin glue group, and it was opened at the bedside 24 hours after surgery. We conclude that fibrin sealants offer a comparative advantage over under-flap suction in both thyroid and parathyroid surgery. Also, fibrin glue is less expensive, and its use obviates the discomfort felt by patients when a drain is removed.
Although the use of a fibrin sealant was first reported in 1940, (1) fibrin glue has been commercially available in the United States only since 1998. (2) Commercially available fibrin glue is made up of two components: One component contains fibrinogen, aprotinin, and/or factor XIII, and the other is made up of human thrombin dissolved in a calcium chloride solution.
For the past several years, we have been routinely using a fibrin sealant at the conclusion of our thyroidectomies and parathyroidectomies in order to achieve hemostasis, to avoid the need for a drain or pressure dressing, and to shorten the length of hospital stay. In this article, we describe our experience with 171 surgeries.
Patients and methods
We retrospectively obtained data on 233 operations--167 thyroidectomies and 66 parathyroidectomies--that had been performed at our institution between Jan. 1, 2003, and April 30, 2005. During our review, we excluded 62 patients: 43 who had undergone thyroidectomy and 19 who had undergone parathyroidectomy.
Thyroidectomy group. Of the 43 excluded thyroidectomy patients, 22 had extensive concomitant surgery (15 multilevel lateral neck dissections, 4 laryngectomies, 2 median sternotomies, and 1 suprapubic dissection). Eleven others were excluded because of confounding factors (5 had been closed with both fibrin glue and a drain, 3 had been closed with an absorbable hemostatic agent without a drain, 2 had received fibrin glue and an absorbable hemostatic agent prior to closure, and 1 had been hospitalized for 30 days for medical problems not related to his surgery). Another 10 patients were excluded for insufficient data.
The remaining 124 patients--27 males and 97 females, aged 15 to 92 years--were subclassified as to whether they were closed with fibrin glue without a drain or pressure dressing (n = 22) or in the standard fashion with a drain (n = 102) (table 1).
Parathyroidectomy group. We excluded 16 patients who had undergone parathyroidectomy for type 2 and 3 hyperparathyroidism; for most of these patients, the postoperative course was dictated more by the end-stage renal disease than by surgery. Three other cases were excluded--1 because the patient had received fibrin glue and a drain and 2 because of insufficient data.
The remaining 47 patients--11 males and 36 females, aged 14 to 87 years--were also subclassified as to whether they received fibrin glue (n = 10) or a traditional drain (n = 37) (table 1). Nine of the 10 fibrin glue patients had adenomas and 1 had hyperplastic parathyroid glands. Thirty-one of the drain patients had adenomas, and 6 were hyperparathyroid secondary to hyperplastic glands.
We also correlated the type of surgery with the final pathologic diagnosis in both groups.
Surgical technique. At the conclusion of each procedure, hemostasis was achieved meticulously.
In the fibrin glue group, Tissomat (Baxter AG; Vienna, Austria) was used to spray 2 ml of Tisseel VH (Baxter) over the entire surface of the wound. The incision was then closed in the standard manner. No drain was used, and no pressure dressing was applied.
In the traditional drain group, the wound was simply closed over a drain in the standard fashion.
The study protocol was approved by the Institutional Review Board of the Keck School of Medicine of the University of Southern California.
Length of stay. The average length of hospital stay following thyroid surgery was 1 day in the fibrin glue group and 1.45 days in the drain group--a statistically significant difference (p = 0.033) (table 2). For patients who under-went parathyroid surgery, the average length of stay was 1 and 1.49 days, respectively--again, a significant difference (p = 0.022).
Hematoma. There were 2 cases of post-thyroidectomy hematoma in the traditional drain group; both required immediate evacuation and neck exploration in the operating room. In the fibrin glue group, 1 case of minor post-thyroidectomy hematoma occurred; this patient had a nonexpanding hematoma, and a Penrose drain was placed at the bedside on postoperative day 1. No hematomas occurred in the parathyroidectomy group.
There has been a strong trend during the past 20 years to significantly decrease the length of hospital stay for patients with virtually all medical conditions. This trend has had a significant impact on both the medical and surgical care of otolaryngology patients.
We all recognize that under-flap suction has greatly enhanced surgery since it was introduced in the 1940s. But perhaps the time has now come to reevaluate this technique. In our study, 2 hematomas required immediate reexploration despite the use of a closed suction drain. The occurrence of hematomas despite drainage has been discussed in the literature. (3-5) In all likelihood, the most important step in preventing a hematoma is meticulous hemostasis rather than drainage. (3,6,7)
What happens to the serosanguineous discharge that is typically removed by suction drainage? Matthews and Briant compared postoperative drainage in patients who did and did not receive Tisseel. (8) They found that patients who received Tisseel had significantly less drain output and a significantly shorter duration of drain placement. At our institution, patients who received fibrin glue following parotidectomy also had significantly less drainage than did patients who received an absorbable hemostatic agent and no coagulant (unpublished data). We suspect that the sealant's tissue-adhesive properties reduce the amount of dead space and subsequent wound drainage. In our review of the literature, we did not find any article that defined an acceptable amount of discharge prior to drain removal. We were surprised to find that 15% of patients in our thyroidectomy group discharged more than 50 ml of output during the 24 hours preceding drain removal. One patient even discharged more than 140 ml during the preceding day, but that drain was removed without consequence. Even though some drains were removed under what many surgeons would consider high-output conditions, both fibrin glue groups still had a significantly shorter length of stay.
For all these reasons, we believe that under-flap suction may no longer be necessary during thyroid surgery. Also, we are beginning to perform our uncomplicated thyroidectomies and parathyroidectomies on an outpatient basis.
(1.) Depondt J, Koka VN, Nasser T, et al. Use of fibrin glue in parotidectomy closure. Laryngoscope 1996;106:784-7.
(2.) Rockville, Md.: U.S. Food and Drug Administration. Available at: http://www.fda.gov. Accessed July 5, 2006.
(3.) Wihlborg O, Bergljung L, Martensson H. To drain or not to drain in thyroid surgery. A controlled clinical study. Arch Surg 1988;123: 40-1.
(4.) Bergamaschi R, Becouarn G, Ronceray J, Arnaud JP. Morbidity of thyroid surgery. Am J Surg 1998;176:71-5.
(5.) Tabaqchali MA, Hanson JM, Proud G. Drains for thyroidectomy/ parathyroidectomy: Fact or fiction? Ann R Coll Surg Engl 1999;81: 302-5.
(6.) Kristoffersson A, Sandzen B, Jarhult J. Drainage in uncomplicated thyroid and parathyroid surgery. Br J Surg 1986;73:121-2.
(7.) Lachachi F, Descottes B, Durand-Fontanier S, et al. The value of fibrin sealant in thyroid surgery without drainage. Int Surg 2000; 85:344-6.
(8.) Matthews TW, Briant TD. The use of fibrin tissue glue in thyroid surgery: Resource utilization implications. J Otolaryngol 1991;20: 276-8.
Manish Patel, MD; Rohit Garg, MD; Dale H. Rice, MD
From the Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles.
Reprint requests: Dale H. Rice, MD, Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1200 N. State St., Room 4136, Los Angeles, CA 90033. Phone: (323) 226-7315; fax: (323) 226-2780; e-mail: firstname.lastname@example.org
Table 1. Demographic data of patients in the thyroid and parathyroid surgery groups Thyroid surgery Parathyroid surgery Fibrin Drain Fibrin Drain Total glue glue Age range 29 to 68 15 to 92 16 to 79 14 to 87 (mean, yr) (46) (50) (61) (63) Male (n) 4 23 4 7 38 Female (n) 18 79 6 30 133 Total (n) 22 102 10 37 171 Table 2. Length of hospital stay in the thyroid and parathyroid surgery groups Thyroid Parathyroid surgery surgery Fibrin Drain Fibrin Drain Total glue glue 1 day 21 75 10 29 135 2 days 0 16 0 4 20 3 days 1 7 0 3 11 4+ days 0 4 0 1 5 Total 22 102 10 37 171
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|Author:||Rice, Dale H.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Aug 1, 2006|
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