Intraoperative hemostasis keeps complications to a minimum

Bordeaux, France - Although still considered rare, hemorrhagic complications remain the most common of the complications that can occur following dermatologic surgery, according to results of a study.

Performing a meticulous hemostasis intraoperatively is key in helping to keep complications at a minimum.

“Various complications including infectious, hemorrhagic and anesthesia-associated complications can all occur in the perioperative period and of these, hemorrhagic-associated complications appear to be the most common,” says Patrick Guillot, M.D., department of dermatology, Hospital C.H.U. of Bordeaux, and medical surgical center, Arès-France. “Nevertheless, the frequency of all of these complications is very low, underscoring the safety of the dermatologic surgery procedures performed.”

Complications study

Dr. Guillot and colleagues recently conducted a study to evaluate the frequency of the surgical complications seen during and after dermatologic surgery (Amici JM, Rogues AM, Lasheras A, et al. Br J Dermatol. 2005;153(5):967-971). In the prospective multicenter study, data was collected over a three-month period on 3,788 consecutive dermatologic surgery cases performed by 84 dermatologists across France. Ages of study participants ranged from 13 to 99 years (mean 51.5 years).

The cutaneous surgeries included in the evaluation were all of the excisions of malignant and benign tumors located on the face and neck (54 percent), trunk (28 percent) and limbs (18 percent), and excluded surgeries of sebaceous cysts and pyodermas. Procedures ranged from small excisions with simple suture closure to larger excisions with skin flap or skin graft closure techniques.

Patient demographics included 770 smokers (20 percent), 232 taking antiplatelet agents (6 percent), 105 taking anticoagulants (3 percent), 61 with immunosuppressants (2 percent), 108 with diabetes (3 percent), and 29 who received antibiotics before the surgical procedure due to previous infection not related to the procedure (1 percent). Ninety-six percent of surgeries were performed under local anesthesia, and all were performed on an outpatient basis.

Of the 3,788 surgical cases reviewed, the researchers found that only 236 complications (6 percent), mostly minor, had occurred in 213 of the dermatologic surgical procedures performed. Of the complications that occurred, bleeding was the most common (3 percent), including 38 percent during surgery, 32 percent immediately after surgery, and 33 percent postsurgical hematoma. Data showed that the hemorrhagic complications were much more frequent in male patients, when anticoagulant, antiplatelet or immunosuppressed agents were used, and in cases of prolonged procedures, skin flaps or full skin grafts.

Blood tests

In the past, it was common practice to simply stop anticoagulant therapy prior to surgical procedures; however, Dr. Guillot says the current conventional wisdom is to closely check international normalized ratio (INR) or prothrombin time (PT) levels in the blood in order to help avoid any potential hemorrhagic complications. According to Dr. Guillot, these blood tests should be performed two to three days before the surgical procedure to closely monitor the patient’s clotting status. Anticoagulant treatment can then be reduced appropriately until a satisfactory INR or PT level is reached, allowing for the surgical procedure to proceed, while maintaining the necessary benefits of the anticoagulant for the patient’s comorbidities.

“Performing a meticulous intraoperative hemostasis with fine and precise electrocoagulation is essential in helping to prevent potential hemorrhagic complications. In addition, an appropriate management of a patient’s anticoagulant therapy - if they are concomitantly taking these medications - is equally important in minimizing hemorrhagic events throughout the perioperative period,” Dr. Guillot says.

The second most frequent complication seen was vasovagal syncope in 51 patients (1 percent), the most frequent of the anesthesia-associated complications, and had an onset before surgery in 6 percent, during surgery in 45 percent and after surgery in 37 percent of patients, with 12 percent of unknown onset. According to Dr. Guillot, the anesthetic complications were always benign and without any allergic reaction, and were likely related to the level of anxiety associated with the surgical procedures.

Infectious complications occurred in 79 patients (2 percent) and here, the vast majority (92 percent) of infections that occurred were graded as superficial and were confined to the surgical site, while four cases (5 percent) were classified as abscess. Only 1 percent (22 cases) of all of the surgeries performed required antibiotic therapy or revision surgery.

International consensus

In the past, Dr. Guillot says, an international consensus was still lacking regarding recommendations for patients who are at risk for endocarditis or those with prosthetic devices. But now, a consensus recently put forth by the European Society of Cardiology advocates in most cases the absence of necessity of a prevention of the endocarditis by a preliminary antibiotic treatment. Therefore, Dr. Guillot says the decision to administer antibiotic prophylaxis must be carefully weighed from case to case.

“In dermatologic surgery procedures, prophylaxis is not needed because the overall incidence of infection is low. For this reason, we do not readily practice antibiotic prophylaxis in our dermatologic surgery patients. This is in following with the recommendation of the Société Française d’Anesthésie Réanimation (SFAR). Even in those patients who may be at high risk of infection such as in immunosuppressed patients, we do not choose a prophylaxis,” he says.

Other study data showed that there was no statistical significant correlation with the characteristics of the dermatologic surgeons in respect to their training and amount of surgical experience, and no link was established between the complications seen and the surgical conditions.

“In respect to our very large study cohort in this trial, we found that the incidence of the complications seen were very low, which first and foremost supports the safety of dermatologic surgical procedures currently performed in France,” Dr. Guillot says. “Moreover, we believe that the positive results seen are in part a reflection of the quality and care associated with the dermatologic surgery procedures performed.”

Disclosures: Dr. Guillot reports no relevant financial interests.