Sclerotherapy for the Management of Seromas

A Systematic Review

Aditya Sood, MD, MBA; Vasanth S. Kotamarti, MD; Paul J. Therattil, MD; Edward S. Lee, MD

Disclosures

ePlasty. 2017;17(e25) 

In This Article

Abstract and Introduction

Abstract

Objective: Despite improved recognition of risk factors, plastic surgeons commonly encounter seromas postoperatively and must decide upon management. Current recommendations for minimally invasive, chemical management originate from the literature on management of pneumothorax and pleural effusions. A handful of published reports have suggested the efficacy of sclerotherapy in seroma management. The aim of this study was to assess the literature on the use of sclerosants to treat subcutaneous fluid collections.

Methods: A systematic review of the literature was performed on the PubMed, MEDLINE, and Cochrane databases for primary research articles on sclerotherapy for seroma treatment between January 1975 and January 2017. Exclusion criteria were surgical treatment, sclerotherapy for seroma prevention, hematoma, or absence of detailed documentation. Data related to seroma location, sclerosant, and resolutions were extracted.

Results: The literature search yielded 7 relevant articles of level IV evidence and 12 case reports, with a total of 84 patients treated with sclerotherapy for persistent seromas. Slerosant included talc, tetracycline antibiotics, ethanol, polidocanol, erythromycin, OK-432, fibrin glue, and povidone-iodine. All agents achieved high rates of success. Repeat aspirations and instillations were easily performed when required. Complications, while uncommon, included pain, tightness or discomfort of the treated area, and infection.

Conclusion: Sclerotherapy appears to be effective and safe for recurrent seromas. While a variety of sclerosing agents may be applied successfully, talc and tetracyclines remain popular choices. Because of the small scale and retrospective nature of the published literature, larger, randomized, comparative studies are necessary to assess and optimize this treatment approach.

Introduction

Seromas are common complications faced by plastic surgeons.[1–3] These fluid collections often cause aesthetic deformity or compression of neighboring structures. In certain circumstances, they may become super infected and present as abscesses.[1,3,4] Additional procedures including percutaneous aspiration, drain replacement, and even returns to the operating room may be required for resolution.[1,3]

Collections of serous fluid develop through a multifactorial process. Inflammation as well as transected blood vessels and lymphatic channels contribute to accumulation of plasma, lymph, and inflammatory exudate in a surgically or traumatically created space.[1,3,5,6] Shear forces may create or maintain the dead space, preventing apposition and adhesion of the tissue surfaces. Morel-Lavallée lesions are unique examples of subcutaneous fluid collections, specifically formed after blunt trauma, that exert shear forces separating the subcutaneous tissue from the underlying fascia.[5,7] While seromas contain a largely acellular fluid, Morel-Lavallée lesions are filled with serosanguinous fluid and cellular debris.[7] Allowed to persist, these postsurgical or posttraumatic fluid collections will form pseudocysts as the cavity becomes lined by fibrous tissue lacking a proper epithelium.[6]

Efforts to prevent seromas have identified several independent risk factors including elevated body mass index (BMI), large dead space, electrocautery, and time-controlled drain removal.[1,3] Minimizing these risks through reducing dead space, maintaining lymphatic integrity, and treating high-risk patients conservatively are tenets of preventing seroma formation.[1] Unfortunately, seromas may form nonetheless. While most serous collections resolve with conservative management, some require repeat drainage or additional therapies ranging from excision of the cavity lining to injection of a sclerosant.[5]

Sclerotherapy involves filling the seroma cavity with an irritating substance, which induces a fibrotic response to seal the dead space. Recommendations are derived from the thoracic surgery literature addressing pleural effusions.[1,3] Commonly used substances for malignant pleural effusions include doxycycline, bleomycin, ethanol, and talc.[1] Few published reports document the use of sclerosants to treat subcutaneous seromas. Those that exist suggest that this treatment is effective and well tolerated. However, a comprehensive, comparative analysis of the different possible options is lacking.

Several sclerosants stimulate fibrous union of the tissue surfaces by inducing inflammation. Ethanol, for example, is a common pleurodesis agent and causes sclerosis through protein coagulation and hyperosmolar cell destruction, which ultimately lead to tissue necrosis. The resulting inflammatory reaction causes fibrosis and closure of the pseudocyst.[8] Polidocanol, an approved sclerosant for varicose veins, promotes vascular sclerosis by provoking endothelial inflammation leading to necrosis or apoptosis and ultimately thrombosis of the treated vessel.[6] In a rabbit pleurodesis model, both erythromycin and tetracycline produced robust inflammatory responses and fibrosis.[9] Hypotheses for the sclerosing action of doxycycline include the destruction of mesothelial cells lining the pseudocyst as well as the inhibition of fibrinolysis and the induction of fibroblast growth factors.[10]

Sclerosants that stimulate tissue adhesion without an inflammatory response have been reported as well. Fibrin glue contains fibrinogen, factor XIII, thrombin, and calcium to stimulate the final stage of the clotting cascade. The fibrin that is produced directly adheres tissue surfaces together without stimulating inflammation.[5] Talc (hydrated magnesium silicate) is one of the most commonly used agents in the treatment of subcutaneous fluid collections but acts through a poorly defined mechanism.[3] When used in pleurodesis, talc stimulates a fibrotic reaction involving polymporphonucleocytes as well as the cytokines interleukin-8 and basic fibroblast growth factor.[11,12] However, in a porcine model of axillary lymph node dissection, prophylactic talc administration produced no histologic signs of active inflammation or acute inflammatory process.[4] It has been hypothesized that in subcutaneous tissues, talc may not induce inflammation. Instead, it may increase friction between tissue surfaces and therefore reduce the effects of shear forces.[3,4]

A unique agent, OK-432, is a lyophilized mixture of a low-virulence (Su) strain of Streptococcus pyogenes incubated with benzylpenicillin potassium. While it performs an immunomodulatory role in the treatment of tumors, the agent may treat seromas without producing a significant inflammatory response.[13] Instead, through stimulation of cytokine release, it may increase endothelial permeability and accelerate lymph flow.[13] In lymphangiomas, OK-432 stimulates increases in cytokines related to granulation tissue formation and fibrotic changes.[14]

Recognizing that sclerotherapy may be an effective option for seroma treatment, we aimed to assess the published literature on subcutaneous seroma sclerotherapy and evaluate whether any substances are more effective or contribute less to patient morbidity.

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