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Early subcutaneous wash-out in acute extravasations

2004; Elsevier BV; Volume: 15; Issue: 7 Linguagem: Inglês

10.1093/annonc/mdh271

1569-8041

Riccardo E. Giunta,

Vascular Tumors and Angiosarcomas

Schrijvers [1.Schrijvers D.L. Extravasation: a dreaded complication of chemotherapy.Ann Oncol. 2003; 14: iii26-iii30Abstract Full Text PDF PubMed Scopus (118) Google Scholar] has published a review article on extravasation injuries and their treatment. The paper gives guidelines of prevention, and conservative and late operative treatment. However, the early treatment option of subcutaneous wash-out [2.Gault D.T. Extravasation injuries.Br J Plast Surg. 1993; 46: 91-96Abstract Full Text PDF PubMed Scopus (183) Google Scholar, 3.Giunta R. Akpaloo J. Kovacs L. Biemer E. Technik der subkutanen Spülung bei hochtoxischen Paravasaten.Handchir Mikrochir Plast Chir. 2002; 34: 399-402Crossref PubMed Scopus (12) Google Scholar] is neither mentioned nor referenced.Despite this the technique is very successful in our experience, possibly due to an early reduction in concentration of the highly toxic chemotherapeutic, and especially when it is performed within 6 h of extravasation injury [3.Giunta R. Akpaloo J. Kovacs L. Biemer E. Technik der subkutanen Spülung bei hochtoxischen Paravasaten.Handchir Mikrochir Plast Chir. 2002; 34: 399-402Crossref PubMed Scopus (12) Google Scholar]. Under regional anesthesia we position two to three incisions, thereby providing sufficient access to the affected subcutaneous tissue (Figure 1). With an infiltration canula, which is commonly used in liposuction, isotonic NaCl solution is infiltrated and may be flushed out through the other incisions. In a second step the infiltrated fluid is removed by careful suction with a small liposuction canula. This procedure is repeated until 300–500 ml of wash-out solution has been used. Eight patients with full extravasation injury of vinca alkaloids or anthracyclines have been treated with this technique, out of a larger series with other, less toxic extravasation injuries. All patients healed without soft tissue defect and in none of the patients was a secondary surgical procedure necessary. No patient experienced any loss in the range of motion of the joints in the hand.Schrijvers [1.Schrijvers D.L. Extravasation: a dreaded complication of chemotherapy.Ann Oncol. 2003; 14: iii26-iii30Abstract Full Text PDF PubMed Scopus (118) Google Scholar] presents a typical case of conservatively treated extravasation of highly toxic doxorubicin, where the opportunity for early subcutaneous wash-out was missed and skin necrosis developed, with exposure of the muscles and ligaments. Despite all precautions, the tissue toxicity of the drug possibly led to lacerations of the fragile vascular wall, with all the consequences of extravasations. However, a surgical treatment was considered only 24 h after injury, which in our experience is too late for subcutaneous wash-out. Follow-up showed that 6 weeks after treatment a skin graft was enough to cover the defect, which is surprising from a surgical point of view: when ligaments or tendons are exposed a flap is usually needed. However, nothing was reported concerning the result in terms of hand function, which is often highly deficient and multiple operations may be needed for restorage. Reduced hand function and severely prolonged hospitalization may be disastrous, especially for a tumor patient. At the end of the case report the author mentions that the patient sued the department for medical fault. This highlights a further aspect of early subcutaneous wash-out, which may diminish legal consequences. On the other hand, additional medico-legal problems may arise when this treatment is not considered by the treating oncologist or surgeon.In conclusion, early subcutaneous wash-out in acute extravasation injuries is a safe and simple procedure. We consider the technique a further option in the armament of extravasation treatment that helps to reduce the severe sequelae of highly toxic drug extravasation for the patient and that deserves more attention. Every review or monograph on extravasation injury should at least mention and discuss the technique to provide complete information to readers. Schrijvers [1.Schrijvers D.L. Extravasation: a dreaded complication of chemotherapy.Ann Oncol. 2003; 14: iii26-iii30Abstract Full Text PDF PubMed Scopus (118) Google Scholar] has published a review article on extravasation injuries and their treatment. The paper gives guidelines of prevention, and conservative and late operative treatment. However, the early treatment option of subcutaneous wash-out [2.Gault D.T. Extravasation injuries.Br J Plast Surg. 1993; 46: 91-96Abstract Full Text PDF PubMed Scopus (183) Google Scholar, 3.Giunta R. Akpaloo J. Kovacs L. Biemer E. Technik der subkutanen Spülung bei hochtoxischen Paravasaten.Handchir Mikrochir Plast Chir. 2002; 34: 399-402Crossref PubMed Scopus (12) Google Scholar] is neither mentioned nor referenced. Despite this the technique is very successful in our experience, possibly due to an early reduction in concentration of the highly toxic chemotherapeutic, and especially when it is performed within 6 h of extravasation injury [3.Giunta R. Akpaloo J. Kovacs L. Biemer E. Technik der subkutanen Spülung bei hochtoxischen Paravasaten.Handchir Mikrochir Plast Chir. 2002; 34: 399-402Crossref PubMed Scopus (12) Google Scholar]. Under regional anesthesia we position two to three incisions, thereby providing sufficient access to the affected subcutaneous tissue (Figure 1). With an infiltration canula, which is commonly used in liposuction, isotonic NaCl solution is infiltrated and may be flushed out through the other incisions. In a second step the infiltrated fluid is removed by careful suction with a small liposuction canula. This procedure is repeated until 300–500 ml of wash-out solution has been used. Eight patients with full extravasation injury of vinca alkaloids or anthracyclines have been treated with this technique, out of a larger series with other, less toxic extravasation injuries. All patients healed without soft tissue defect and in none of the patients was a secondary surgical procedure necessary. No patient experienced any loss in the range of motion of the joints in the hand. Schrijvers [1.Schrijvers D.L. Extravasation: a dreaded complication of chemotherapy.Ann Oncol. 2003; 14: iii26-iii30Abstract Full Text PDF PubMed Scopus (118) Google Scholar] presents a typical case of conservatively treated extravasation of highly toxic doxorubicin, where the opportunity for early subcutaneous wash-out was missed and skin necrosis developed, with exposure of the muscles and ligaments. Despite all precautions, the tissue toxicity of the drug possibly led to lacerations of the fragile vascular wall, with all the consequences of extravasations. However, a surgical treatment was considered only 24 h after injury, which in our experience is too late for subcutaneous wash-out. Follow-up showed that 6 weeks after treatment a skin graft was enough to cover the defect, which is surprising from a surgical point of view: when ligaments or tendons are exposed a flap is usually needed. However, nothing was reported concerning the result in terms of hand function, which is often highly deficient and multiple operations may be needed for restorage. Reduced hand function and severely prolonged hospitalization may be disastrous, especially for a tumor patient. At the end of the case report the author mentions that the patient sued the department for medical fault. This highlights a further aspect of early subcutaneous wash-out, which may diminish legal consequences. On the other hand, additional medico-legal problems may arise when this treatment is not considered by the treating oncologist or surgeon. In conclusion, early subcutaneous wash-out in acute extravasation injuries is a safe and simple procedure. We consider the technique a further option in the armament of extravasation treatment that helps to reduce the severe sequelae of highly toxic drug extravasation for the patient and that deserves more attention. Every review or monograph on extravasation injury should at least mention and discuss the technique to provide complete information to readers.