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LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 857-858

Exploring the efficacy of topical tranexamic acid in headand-neck cancer surgery


Department of Head-and-Neck Oncosurgery, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

Date of Submission18-Oct-2020
Date of Decision07-Dec-2020
Date of Acceptance09-Dec-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Mandar Sureshchandra Deshpande
Department of Head-and-Neck Oncosurgery, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_329_20

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How to cite this article:
Gupta I, Chaudhari SA, Deshpande MS. Exploring the efficacy of topical tranexamic acid in headand-neck cancer surgery. Cancer Res Stat Treat 2020;3:857-8

How to cite this URL:
Gupta I, Chaudhari SA, Deshpande MS. Exploring the efficacy of topical tranexamic acid in headand-neck cancer surgery. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jan 26];3:857-8. Available from: https://www.crstonline.com/text.asp?2020/3/4/857/304996



We read the article written by Anand et al.[1] on the role of topical tranexamic acid (TXA) and the accompanying editorial by Shah et al.[2] with great interest. We would like to congratulate the authors for a well-conducted clinical trial and a nicely written article. The duration of postoperative stay after head-and-neck surgery is usually decided based on the amount and period of drainage from the neck. TXA is an antifibrinolytic agent, which has both local as well as systemic effects. All previous attempts to study the role of TXA in head-and-neck surgery involved its administration through the intravenous route and have not been successful. Systemic administration of TXA also has concerns of thromboembolic complications.[3] This trial is unique, as the topical application of TXA has been used for the first time in head-and-neck surgery.

It was a single-institution, randomized controlled trial with a sample size of 100 patients (approximately 50 in each arm). All patients undergoing conventional neck dissection as a part of head-and-neck surgery were included. Patients in the intervention arm had 20 ml of TXA (25 mg/ml) sprayed on the surgical wound before drain placement and closure. Patients in the control arm had conventional closure without any TXA application. The drain output over 5 days, the date of drain removal, and the complications were recorded. The authors have concluded that the topical application of TXA significantly reduced the drain output and facilitated early drain removal without any significant increase in complications in comparison to the standard wound closure.[1]

There are very few surgical interventional randomized trials conducted in the area of head-and-neck surgery. This trial had a simple design and was well-executed. There are definite positive and encouraging results from this trial. Moreover, these results are easily applicable in clinical practice. TXA is a cheap, easily, and locally available drug. Its application is simple and does not require specialized equipment, workforce, or training. Topical TXA does not reduce the drain output at the cost of local or systemic complications.[4]

However, this trial had its limitations. The authors themselves have aptly reported some of them. Like in most surgical interventional trials, in this trial, the investigators were not blinded to the intervention, although, drain removal was performed by a different person. This could have influenced the result as the surgical team members can influence the postoperative decisions. This could have been avoided by adopting a placebo-controlled, double-blinded approach. As mentioned by Shah et al., the statistical power of the study could have been set at 95%.[2] This would have increased the sample size and the duration of the study, etc. Moreover, the authors have not given detailed information about the primary tumors and their distribution between the two groups. In addition, there is also a lack of detailed information about the type of node dissection (supraomohyoid, modified radical, or radical neck dissection) and their distribution between the two groups. This is an important parameter, as different subsites and procedures may influence the drainage volumes.[5] The authors have used <20 ml of drain output per day for 2 days as the criterion for drain removal. However, most centers use <50 ml of drain output over 24 h ours as a criterion for drain removal.[6] By this standard, even in the control arm, drain removal would have happened much earlier, thus influencing the results.

To conclude, this is a well-conceived and well-conducted open-label randomized controlled trial showing the beneficial effect of topical TXA after neck dissection. However, we require more such trials before changing the current clinical practice.

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
  [Full text]  
2.
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.  Back to cited text no. 2
  [Full text]  
3.
Kulkarni AP, Chaukar DA, Patil VP, Metgudmath RB, Hawaldar RW, Divatia JV, et al. Does tranexamic acid reduce blood loss during head and neck cancer surgery? Indian J Anaesth 2016;60:19-24.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
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. 4
    
5.
Saito I, Hasegawa T, Natsuki E, Satomi Y, Daisuke A, Akikio T, et al. Postoperative drainage in head and neck surgery for oral cancer. J Oral Maxillofac Surg Med Pathol 2017;29:21721.  Back to cited text no. 5
    
6.
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. 6
    




 

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