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Table of Contents
EDITORIAL
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 572-573

Utility of topical tranexamic acid in head-and-neck cancer surgery: A myth or reality?


Department of Surgical Oncology, Division of Head and Neck Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission04-Aug-2020
Date of Decision05-Aug-2020
Date of Acceptance05-Aug-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Shivakumar Thiagarajan
Department of Surgical Oncology, Division of Head and Neck Oncology, Tata Memorial Centre, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_266_20

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How to cite this article:
Shah S, Thiagarajan S. Utility of topical tranexamic acid in head-and-neck cancer surgery: A myth or reality?. Cancer Res Stat Treat 2020;3:572-3

How to cite this URL:
Shah S, Thiagarajan S. Utility of topical tranexamic acid in head-and-neck cancer surgery: A myth or reality?. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Oct 22];3:572-3. Available from: https://www.crstonline.com/text.asp?2020/3/3/572/295510



We read with interest the article by Anand et al.[1] on the role of topical application of tranexamic acid (TXA) following neck dissection in patients with head-and-neck cancer in reducing the drain output, time to drain removal, and postoperative complications. We would like to congratulate the authors for their effort. Their study is focused on some of the important postoperative concerns following neck dissection, which are neck drain output, time to drain removal, and the duration of hospital stay. The purpose of the drains is to obliterate the dead space and drain the blood or other fluids from the operated site. This prevents fluid accumulation at the site of the wound, thereby reducing seroma and hematoma formation, which in turn can improve skin apposition and wound healing.[2] However, leaving a drain in situ for a prolonged period can cause discomfort and predispose the patient to infection, which may prolong the hospital stay and have financial implications for the patients and the healthcare system at large.[3],[4] Thus, it is imperative to strike a fine balance between the time to drain removal and limiting the morbidities. One of the ways investigators have tried to address this issue is with the use of drugs such as TXA administered intravenously to minimize the blood loss, reduce the requirement for blood transfusions, reduce the drain output, and the time to drain removal along with minimizing the occurrence of other complications such as surgical site infections, seroma, and hematoma.[5],[6] The primary concern with the use of TXA is the lack of clarity pertaining to its optimal route of administration, dosage, and potential complications, such as thromboembolic events and mortality. There is strong evidence that TXA reduces blood transfusion requirements following surgery, but its effect on thromboembolic events and mortality remains uncertain,[5],[6],[7] which may be the reason for its limited use. Similarly, the evidence on the effect of the topical application of TXA is lacking, especially in patients who have undergone head-and-neck surgery. Moreover, as alluded to by the authors, the optimal dose for its topical application is still questionable. Different studies have used different doses of TXA for topical application (10–100 mg/ml).[1]

The authors have conducted this open-label randomized trial consisting of two arms to study the effect of the topical application of TXA solution on the difference in the drain output, the time to drain removal, and the associated complications, if any, between the two arms. One hundred patients with a confirmed diagnosis of head-and-neck cancer were included in this study. In the intervention arms (n = 51), after achieving hemostasis, 20 ml of TXA solution (25 mg/ml) was sprayed on the operated region of the neck. Thereafter, standard skin closure was done with a suction drain in place. In the standard arm (n = 48), standard skin closure alone was done without the application of the TXA solution with a suction drain in place. The authors have concluded that the application of the TXA solution significantly reduced the drain output and facilitated early drain removal without an increase in complications in comparison to standard skin closure. We believe that providing the risk ratios with the 95% confidence intervals along with the P values could have added more value to the results.

The authors have pointed out some limitations of their study. However, we would like to share some of our observations. First, it is not clear as to which subsites of the head-and-neck region or histologies were included in the study. This is important information as the different subsites in the head and neck have different drain outputs and can thus influence the time to drain removal.[8] Even though the authors have stated that the two arms were well balanced, we observed that there was some relevant mismatch that could have influenced the results in favor of the intervention arm. For instance, the number of patients requiring bilateral neck dissection was slightly more in the standard arm (n = 13) in comparison to the intervention arm (n = 7). Furthermore, the type of neck dissection done was not mentioned, which could also have influenced the drain output and removal. The drain output is more for radical neck dissection followed by modified radical neck dissection and then selective neck dissection.[8] Yet another observation is that though there were more patients who required reconstruction in the intervention arm, the type of reconstruction was not mentioned. This again could have influenced the drain output. Patients with a pedicled flap may have more drain output than those with a local flap.[9] Second, the drain volume of 20 ml was considered as the threshold for drain removal. This led to delayed drain removals on postoperative day 6. This volume is rather arbitrary as the literature suggests that a drain volume of 50 ml can be considered safe for drain removal and thus early discharge.[7] Harris et al. also concluded that waiting for the drain volume to reduce to 25 ml took about an average of 1.3 days more, thus prolonging the hospital stay further.[7] They had neck drains removed on an average at postoperative day 3. Certain other critical information regarding postoperative complications such as parotid fistula and chyle leak are missing. These factors lead to a persistent increase in the drain output and a subsequent delay in drain removals and hospital discharge.[10],[11] Anand et al.[1] have performed an interesting study, as no other study has explored the effects of the topical application of TXA on the operative field for the head-and-neck cancers. However, this approach has been shown to be quite effective in rhinology for epistaxis control and sinus surgeries, but the dosage is 500 mg in 5 ml normal saline, which is quite high in comparison to the dosage used in the current study.[12]

Although there are many studies (across different specialties) that have shown the benefits of administering TXA intravenously,[4],[5] there is hardly any evidence of similar benefits with topical application of TA. However, the effect of the use of TXA on thromboembolic events and mortality remains uncertain for both routes of administration. Although logically their incidences should be lower with topical application, this aspect needs to be studied further. Furthermore, there are no studies comparing the two methods of administering TXA to obtain the desired outcomes as mentioned in the above discussion. Therefore, we agree with the authors that their study will not change the clinical practice but may help design future studies in this direction. In the future, studies on a larger cohort of patients can look at issues such as the ideal dosage (especially for topical application) and the serious side effects, such as thromboembolic events and mortality, associated with the different routes of TXA administration. Moreover, it is also necessary to determine the impact of administering these drugs on the financial aspects (health economics), in terms of the duration of hospital stay and associated out-of-pocket expenditure, among others. To conclude, the role of TXA, especially its topical application, is still debatable in head-and-neck cancer surgery until results from a well-designed study come out in the future answering the above lacunae.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Anand S, Singh V, Sahu PK. Evaluating the role of topical tranexamic acid in cancers of the head and neck: A single-center randomized controlled trial. Cancer Res Stat Treat 2020:3:461-6  Back to cited text no. 1
    
2.
Erişen L, Yircali G, Mescigoglu A, Basut O, Coşkun H. Quantitative analysis of the drainage after neck dissection. Otolaryngol Head Neck Surg 2000;123:603-6.  Back to cited text no. 2
    
3.
Panda NK, Sood M, Kaushal D, Bakshi J, Verma RK. How long to keep the surgical drains- looking for evidence. J Assoc Res Otolaryngol 2015;2:92-6.  Back to cited text no. 3
    
4.
Reiffel AJ, Barie PS, Spector JA. A multi-disciplinary review of the potential association between closed-suction drains and surgical site infection. Surg Infect (Larchmt) 2013;14:244-69.  Back to cited text no. 4
    
5.
Fuzi J, Budiono GR, Meller C, Jacobson I. Tranexamic acid in otorhinolaryngology – A contemporary review. World J Otorhinolaryngol Head Neck Surg 2020, published online only aheads of print. [doi.org/10.1016/j.wjorl. 2020.05.010].  Back to cited text no. 5
    
6.
Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: Systematic review and cumulative meta-analysis. Br Med J 2012;344:e3054.  Back to cited text no. 6
    
7.
Harris T, Doolarkhan Z, Fagan JJ. Timing of removal of neck drains following head and neck surgery. Ear Nose Throat J 2011;90:186-9.  Back to cited text no. 7
    
8.
Urquhart AC, Berg RL. Neck dissections: Predicting postoperative drainage. Laryngoscope 2002;112:1294-8.  Back to cited text no. 8
    
9.
Saito I, Hasegawa T, Iwata E, Yonezawa N, Arimoto S, Takeda D, et al. Postoperative drainage in head and neck surgery for oral cancer. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology, 2017;29:217–21.  Back to cited text no. 9
    
10.
Thiagarajan S, Sawhney S, Jain S, Chakraborthy A, Menon N, Gupta A, et al. Factors predisposing to the Unplanned Hospital Readmission (UHR) in patients undergoing surgery for Oral Cavity Squamous Cell Carcinoma (OSCC): Experience from a tertiary cancer centre. Indian J Surg Oncol 2020;Published online only ahead of print. [doi.org/10.1007/s13193-020-01135-1].  Back to cited text no. 10
    
11.
Girkar F, Thiagarajan S, Malik A, Sawhney S, Deshmukh A, Chaukar D, et al. Factors predisposing to the development of orocutaneous fistula following surgery for oral cancer: Experience from a tertiary cancer center. Head Neck 2019;41:4121-7.  Back to cited text no. 11
    
12.
Athanasiadis T, Beule AG, Wormald PJ. Effects of topical antifibrinolytics in endoscopic sinus surgery: A pilot randomized controlled trial. Am J Rhinol 2007;21:737-42.  Back to cited text no. 12
    




 

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