David A. Reiersen MD, Timothy S. Lian MD FACS *LSU

The Effect of Fibrin Glue on Wound Healing with
Unilateral Neck Dissections
David A. Reiersen MD*, Timothy S. Lian MD FACS*
*LSU-Health Shreveport -- Department of Otolaryngology/Head & Neck Surgery
Abstract
Results
Methods
Educational Objective: At the conclusion of this presentation, the participants should be
able to discuss the use of fibrin glue in head and neck surgery and discuss an evidence
based cost-benefit analysis of its use in unilateral neck dissections.
Objectives: To demonstrate decreased post-operative drain output for patients who had
intraoperative application of fibrin glue (FG) for unilateral neck dissections.
The study was designed as a retrospective chart review. Records were reviewed for 75
patients at a single institution with a focus of unilateral neck dissection; bilateral neck
dissections and laryngectomies were excluded from the study due to increased variability of
the post-operative course. A total of 33 patients met the inclusion criteria, of these patients,
15 had application of fibrin glue and 18 did not (NFG=15, Nnon-FG=18). The fibrin glue was
applied to the wound bed just prior to closure. T-test was used to compare mean drain
output. Power analysis for 3 days post-op showed that an N of 30 would be necessary for
80% power at p-value of 0.05.
Study Design: Retrospective chart review.
Methods: Records were reviewed for 75 patients from a single institution with a focus of
unilateral neck dissection. Bilateral neck dissections and laryngectomies were excluded
from the study due to increased variability of the post-operative course. A total of 33
patients met the inclusion criteria, of these patients, 15 had application of fibrin glue and 18
did not (FG=15, non-FG=18). T-test was used to compare mean drain output.
The mean drain output observed for the first 24 hours was 110.1±36.8 mL versus
63.2±66.7 mL for the FG and non-FG groups respectively with a p-value of 0.0166.
However, the total drain output was not significantly different based on use of fibrin glue;
106.4±78.7 mL (FG) versus 104±79.1 mL (non-FG) with a mean difference 1.6 mL
(p=0.953). There was no difference in rate of complications or length of hospital stay.
The patients were discharged home from hospital after removal of last drain per protocol.
Average hospital stay for the FG group was 3 days. 13% were discharged on postoperative-day (POD) 2, 47% were discharged on post-operative-day (POD) 3, 20% were
discharged on post-operative-day (POD) 4, 20% were discharged on post-operative-day
(POD) 5. Similarly, the average hospital stay for the non-FG group was 3 days. 11% were
discharged on post-operative-day (POD) 2, 42% were discharged on post-operative-day
(POD) 3, 47% were discharged on post-operative-day (POD) 4.
There were no post-operative complications experienced by the 33 patients who underwent
a unilateral neck dissection. There was modest variability in diagnosis. The FG group
consisted of 60% oral cancer, 13% oropharyngeal cancer, 13% melanoma, 7%
hypopharyngeal cancer, and 7% thyroid cancer. In addition, the unilateral neck dissections
which had application of fibrin glue had a single positive node in 40% of the cases and
multiple positive nodes in 20% of the cases. The non-FG group consisted of 32%
oropharyngeal cancer, 21% oral cancer, 21% nodal disease with an unknown primary, 11%
parotid cancer, 5% paraganglioma, 5% melanoma, and 5% thyroid cancer. Of these
unilateral neck dissections with no use of fibrin glue there was a single positive node in
16% of the cases and multiple positive nodes in 42% of the cases.
Results: Mean drain output within first 24 hours was 110.1±36.8mL versus 63.2±66.7mL
for the FG and non-FG groups with a p-value of 0.0166. The total drain output was not
statistically significant based on use of fibrin glue, 106.4±78.7ml (FG) versus 104±79.1mL
(non-FG), mean difference 1.6mL (p=0.953). Prior radiation was noted to be associated
with decreased drain output; pre-radiated group (XRT) with 45.3±20.9mL compared to
non-radiated group (non-XRT) with 100.5±61.1mL (p=0.0006) in first 24 hours. The total
output for radiation was significant with 63.4±32.8ml (XRT) versus 116.4±82.6mL (nonXRT), mean difference 53.0mL (p=0.0141).
Interestingly, a history of prior radiation was noted to be associated with decreased drain
output. The pre-radiated group (XRT) had a mean of 45.3±20.9 mL compared to nonradiated group (non-XRT) which had a mean of 100.5±61.1 mL (p=0.0006) in first 24
hours. Similar findings were seen for total output. The total output for the XRT group had a
mean of 63.4±32.8 mL (XRT) compared to a mean of 116.4±82.6 mL for the non-XRT
group; resulting in a difference of 53.0 mL (p=0.0141).
Conclusions: Confirmed less drain output with fibrin glue within the first 24 hours, but no
difference in total drain output. The use of fibrin glue did not decrease risk of complications
or result in shorter hospital stay.
Background
Fibrin glue/gel/sealant/adhesive is a two component biological material, sometimes referred
to a biological system or biological reaction. The two agents mimic the final stage of the
coagulation cascade (where thrombin in the presence of calcium, activates the conversion
of the fibrinogen monomer into a fibrin polymer). The components: (1) a protein solution of
human fibrinogen and a synthetic fibrinolysis inhibitor (Aprotonin, which prevents fibrin clot
degradation) and (2) a solution of human thrombin with calcium chloride. The product is
adhesive and full adsorption is expected to occur over the days to weeks following
application depending on protyolytic activity of the recipient site.
Mean Drain Output by Group
Clinical uses of nonautologous fibrin/fibrinogen has been discussed and tried in the
literature for over a century. In recent years, technology including improvements in
concentration/purification of human fibrinogen has allowed for the development of the
current products. Since then, there have been multiple studies demonstrating the use of
Fibrin Glue for various clinical applications across surgical specialties. This study aims to
evaluate a single institution’s use of the fibrin glue in neck dissections.
Unilateral neck dissections were evaluated specifically during this study because the
placement of a closed suction drain at the time of surgery provided an objective means for
evaluation of wound healing. The hypothesis was that there would be demonstrable
benefits from use of fibrin glue during unilateral neck dissections due to the hemostatic and
adhesive properties. A secondary objective was to evaluate for evidence of unwanted
increase in inflammation, foreign body reaction, tissue necrosis, or fibrosis. Fibrin Glue was
expected to improve wound healing in a way that could be demonstrated by a decrease in
drain output from closed suction Jackson Pratt drains. This observation is of particular use
because drain output is associated with length of hospital stay and overall cost of medical
care. Increased drain output may also be an early sign of complication such as chyle leak
or pharynocutaneous fistula.
Discussion
The study confirmed less drain output in early post-operative course with fibrin glue but
showed no significance difference in total drain output. There was no difference in
complications or length of hospital stay. From this study, there appears to be a lack of
additional benefit or harm with use of the fibrin glue prior to wound closure for unilateral
neck dissections.
The authors of this study can neither recommend for or against the use of fibrin glue
application to the wound bed prior to closure in unilateral neck dissections. There may be
additional studies in the future that may find additional applications of fibrin glue but at this
time there is no demonstrable benefit from the use of fibrin glue in unilateral neck
dissections.
Histograms
With Fibrin Glue
References
POD 0
POD 1
POD 2
POD 0
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POD 3
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20
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63
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61
60
63
30
34
27
18
31
9
Unilateral Radiated Necks with Fibrin Glue
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69
41
35
20
130
Unilateral Radiated Necks without Fibrin Glue
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53
42
10
0
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112
64
25
9
0
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