Abstract
Introduction
Surgicel (oxidized cellulose) is used for intra-operative haemostasis and adhesion prevention. Previously local tissue reactions to oxidized cellulose have been reported at many surgical sites, but not in the head and neck.
Presentation of case
A 56 year old lady presented 30 days following total thyroidectomy with wound swelling and erythema. Multiple sinuses were noted within the wound, through which oxidized cellulose partially extruded. Following removal of the un-absorbed material the symptoms resolved over 3 days.
Discussion
The absence of any systemic symptoms confirm that this was most likely a type four hypersensitivity reaction. The removal of the unabsorbed material was a further unique part of this case.
Conclusion
We present the first head and neck reaction to oxidized cellulose. This report serves to remind head and neck surgeons of the potential for local tissue reactions to this material.
Keywords: Thyroidectomy, Foreign-body reaction, Oxidized cellulose
1. Introduction
Surgicel (oxidized cellulose) made by Ethicon Inc. of Johnson & Johnson Medical Limited is a bio-absorbable fabric used widely for intraoperative haemostasis and adhesion prevention in surgery.1 The senior author routinely uses Surgicel for haemostasis during thyroidectomy, especially in the region of the cricothryoid joint/recurrent laryngeal nerve. This report describes a case of a local tissue reaction to Surgicel mimicking a postoperative abscess, following thyroidectomy that resolved following removal of the Surgicel.
2. Case report
A 56-year-old lady had a total thyroidectomy for a multinodular goitre (confirmed on histological examination, weight 83 g). Thyroid function tests pre-operatively were in normal range and she had a history of Hodgkin's lymphoma that was in remission. She had received 6 cycles of chemotherapy, which she completed 9 months prior to her operation. She did not receive any radiotherapy. Total thyroidectomy was performed via a four-centimeter incision, which was closed with skin adhesive (Dermabond, Ethicon Inc. of Johnson & Johnson Medical Limited) and strap muscles were closed with monocryl (Ethicon Inc. of Johnson & Johnson Medical Limited). A postage stamp sized piece of Surgicel (1.5 cm × 1 cm) was placed around the recurrent laryngeal nerve bilaterally for haemostasis and prophylactic co-amoxiclav was given at induction with no further subsequent doses. She was discharged on the first post-operative day and reviewed 10 days following with a clean wound. Thirty days following thyroidectomy she presented to accident and emergency complaining of a three-day history of neck swelling, erythema and discharge from the surgical site (see Fig. 1). She had no pyrexia or tachycardia and there was no airway compromise. Surgicel was seen protruding from multiple sinuses and the wound was visibly erythematous and swollen. The Surgicel was subsequently removed as an intact sheet, showing no evidence of absorption and she was discharged without any subsequent treatment. Her symptoms then resolved over the next 2–3 days.
Fig. 1.
Wound on presentation with multiple sinuses and Surgicel protruding through.
3. Discussion
Surgicel facilitates in the production of an artificial clot the mechanism of which described varies throughout the literature.2,3 Surgicel may be removed or left in situ depending on the clinical need. If left in situ degradation is expected to commence within 24–48 h and will be surrounded by inflammatory granulation tissue at day 7; complete degradation will usually occur between 4 and 8 weeks.4,5
Surgicel has been reported as mimicking pseudocancer; abscess formation and granuloma.2–12 The majority can be described by cell mediated type 4 delayed hypersensitivity and peritoneal histiocytic reactions.10,11 The bulk of these cases presented with pain or on routine follow up imaging between 6 and 52 weeks.2–12 The reported case is the first reported complication to Surgicel in the head and neck surgical field. We believe that this was a type four hypersensitivity reaction based on the timing of the event and the absence of any systemic symptoms. A case of a more acute reaction was described by Arnold and Sodickson 4 days following open cholecystectomy that was managed conservatively.7
A further unique part of this case is removal of unchanged material followed by full resolution of symptoms. Ibrahim et al. reported a whitish thick cheesy material with the appearance of pus with pieces of non-absorbed Surgicel one year following surgery.9 The cultures on this material turned out to be sterile with no organisms seen or grown. More detailed histological reports have shown a histiocytic reaction with intracytoplasmic material with densities of histiocytes decreasing with time.10,11,13
This is the first adverse event caused by Surgicel noted by the senior author in a personal series of 748 thyroidectomies, in which he had used Surgicel for haemostasis in the region of the recurrent laryngeal nerve. This is the first reported case of a local tissue reaction to Surgicel in head and neck surgery. At other operative sites no mortalities have been reported and conservative management has shown to be effective even in cases with worrying symptoms.7 For this reason it is important to document in notes when oxidized cellulose is used despite typical radiological appearances being reported.7 Other guidelines include using it sparingly, as many cases have been attributed to use in excess.9
In conclusion we present the first case of oxidized cellulose reaction in neck surgery, the removal and resolution confirming it as the cause. We continue to use Surgicel in small quantities despite this reaction, as its benefits far outweigh its potential consequences. It remains important for surgeons and radiologists to be aware of its possible complications despite its rare incidence.
Conflict of interest
All authors have no conflict of interest.
Funding
None.
Ethical approval
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Authors’ contributions
Jonathan Royds: wrote the article, researched previous cases and analysis; Stephen Kieran: researched previous cases and analysis and reviewed article; and Prof Conrad Timon: involved in operation and follow up, data collection and reviewed article.
References
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