The impact of topical tranexamic acid on drain duration and seroma volume in axillary lymph node dissection for breast cancer: A randomized controlled trial

Abstract

We read with great interest in the October issue of World Journal of Surgery the article by Pachimatla et al. assessing the effects of topical tranexamic acid (TA), a widely used antifibrinolytic agent, on breast cancer patients undergoing axillary lymph node dissection (ALND).1 The authors conducted a randomized study in a total of 150 patients evaluating the impact of a single intraoperative dose of diluted TA, alone or in addition to 5 daily postoperative TA doses, on the duration of drain, volume of seroma and rate of complications after ALND, in comparison to placebo. As a result, single or multiple doses of topical TA had no significant effect on duration of the postoperative drain, total drain volume, or the rate of complications. In another recent placebo-controlled trial involving 1,245 participants, the impact of perioperative TA was assessed in patients undergoing liver resection for a cancer-related indication, mainly colorectal cancer metastases.2 The study showed that bolus infusion of TA did not reduce the incidence of bleeding or the need for blood transfusions within 7 days after surgery, and its use had increased postoperative complications. These findings highlight the necessity for careful consideration before adopting TA in cancer surgery, and compel us to consider other options to minimize seroma formation and blood loss.As it is widely known, excessive bleeding during surgery can disrupt lymphatic and vascular integrity, leading to increased fluid accumulation and subsequent seroma formation in the postoperative period. Desmopressin (dDAVP) is a vasopressin peptide analog used as a hemostatic and blood-saving agent in the management of bleeding disorders and in complex surgeries characterized by large blood loss.3 dDAVP enhances platelet aggregation at the site of vascular injury and activates the arginine vasopressin type 2 membrane receptor (AVPR2) present in endothelium, causing the release of von Willebrand factor, tissue-type plasminogen activator and coagulation factor VIII. Interestingly, dDAVP has also been studied for its ability to inhibit growth, angiogenesis and metastatic spread of malignant cells expressing AVPR2, including breast and colorectal cancer cells.In a phase II dose-escalation trial in patients undergoing breast cancer surgery (NCT01606072), dDAVP, given immediately before and 24 hours after surgical resection, reduced intraoperative bleeding and caused a significant postoperative drop in circulating tumor cells.4 Additionally, In a phase I/II trial in patients with bleeding colorectal cancer (NCT01623206), dDAVP administration was also associated with hemostatic control and reduction of tumor vascular perfusion.5 By acting on both vascular and tumor AVPR2, perioperative use of dDAVP may potentially result in multiple therapeutic benefits, reducing intraoperative bleeding and also impairing the survival and growth of residual malignant cells. However, its use should be carefully weighed against the risk of adverse effects, particularly hyponatremia and hypotension.3,4,5dDAVP presents potential advantages as a surgical adjuvant, especially in the context of oncological surgeries where TA has shown limited efficacy. Future research is encouraged to further explore dDAVP effects on bleeding, postoperative complications and long-term outcomes in cancer patients, such as those undergoing ALND for breast cancer.