Intraoperative topical tetracycline sclerotherapy following mastectomy: a prospective, randomized trial

Effect of Clavipectoral Fascia Suturing on Postmastectomy Seroma Formation

<b><br>Introduction:</b> Post-mastectomy seroma formation is a challenging sequela which has a negative impact on patient recovery and quality of life.</br> <b><br>Aim:</b> We aim to publicize our technique of clavipectoral fascia re-closure and to assess its efficacy in reducing the incidence of seroma formation.</br> <b><br>Methods:</b> This is a prospective randomized controlled trial, conducted in South Cancer institute, Assiut University, Egypt. It included 84 breast cancer patients who were randomly divided into two groups: a control group (n = 44) and a fascia suture group (n = 40). The patients were followed up until drain removal and then to 3 months after surgery.</br> <b><br>Results:</b> The fascia suture group showed significantly shorter duration of drain removal with a significant reduction in the total amount of drained fluid and the amount of drained fluid 1 week postoperatively. One patient in the fascia suture group developed Grade 2-3 seroma vs. 7 in the control group (P < 0.05).</br> <b><br>Conclusions:</b> Clavipectoral fascia suture technique is a simple and effective method for reducing seroma formation after mastectomy in breast cancer patients and is advisable in patients at a high risk for seroma formation.</br>.

Seroma After Breast Reconstruction With Tissue Expanders: Outcomes and Management

BACKGROUND

Seroma is a relatively common complication after breast reconstruction with tissue expanders. The main risk in the presence of seroma is development of periprosthetic infection, which can lead to implant loss. Our goals were to identify risk factors for seroma, and to describe our protocol for managing fluid accumulation.

PATIENTS AND METHODS

An IRB approved breast reconstruction database was reviewed to identify patients who underwent tissue expander reconstruction. Patient characteristics, details of surgery, outcomes and treatment were recorded.

RESULTS

Two hundred nineteen tissue expander reconstructions were performed in 138 patients. Twenty-eight reconstructions developed seroma (12.8%), and 75 were identified to have prolonged drains (34.2%). Seroma was more common in patients with lymph node surgery ( P = 0.043), delayed reconstruction ( P = 0.049), and prepectoral reconstruction ( P = 0.002). Seroma and/or prolonged drains were more commonly noted in patients with higher body mass index ( P = 0.044) and larger breast size ( P = 0.001). Aspiration was the most common intervention (85.7%), which was performed in the clinic utilizing the expander port site. There was no difference in infection or explantation rate between seroma and no-seroma patients ( P = 0.546 and 0.167), whereas patients with any fluid concern (seroma and/or prolonged drains) were more prone to developing infection and undergoing explantation ( P = 0.041 and P < 0.005).

CONCLUSION

We recommend that prolonged drain placement longer than 3 weeks should be avoided, and patients should be screened for fluid accumulation after drain removal. Serial aspiration via expander port site and continuation of expansion provide a safe and effective method to manage seromas to avoid infection and expander loss.

Management of Postoperative Seroma: Recommendations Based on a 12-Year Retrospective Study

Introduction: Seroma formation is a serious postoperative complication. Since the management algorithms available in the literature are scarce, we aimed to analyze our experience with postoperative seroma in order to identify indicators for revisional surgery and propose recommendations for management. Methods: This retrospective study included all patients with postoperative seroma treated in a tertiary university hospital from 2008 to 2020. Patients’ demographics, medical history, and seroma treatment details were recorded and analyzed. Results: Overall, 156 patients were included: 41% were initially treated through needle aspiration, with 61% eventually undergoing surgical treatment for postoperative seroma. Comorbidities, such as heart failure and coronary heart disease, were significantly associated with an increased need for revisional surgery (p < 0.05). Both a duration of >40 days of repeated needle aspirations and drain re-insertions were significantly correlated with an increased risk for revisional surgery (p < 0.05). Conclusion: Patients requiring seroma aspiration should be counseled on surgical treatment sooner rather than later, as prolonged aspiration time (over 40 days) greatly increases the risk of surgical revision. Moreover, the reinsertion of a drain should only be used as a temporizing measure, at most, and patients requiring a drain to control the size of the seroma should promptly be scheduled for a surgical revision.

Prevention of lymphocele or seroma after mastectomy and axillary lymphadenectomy for breast cancer: systematic review and meta-analysis

Seroma or lymphocele remains the most common complication after mastectomy and lymphadenectomy for breast cancer. Many different techniques are available to prevent this complication: wound drainage, reduction of the dead space by flap fixation, use of various types of energy, external compression dressings, shoulder immobilization or physical activity, as well as numerous drugs and glues. We searched MEDLINE, clinicaltrials.gov, Cochrane Library, and Web of Science databases for publications addressing the issue of prevention of lymphocele or seroma after mastectomy and axillary lymphadenectomy. Quality was assessed using Hawker's quality assessment tool. Incidence of seroma or lymphocele were collected. Fifteen randomized controlled trials including a total of 1766 patients undergoing radical mastectomy and axillary lymphadenectomy for breast cancer were retrieved. The incidence of lymphocele or seroma in the study population was 24.2% (411/1698): 25.2% (232/920) in the test groups and 23.0% (179/778) in the control groups. Neither modification of surgical technique (RR 0.86; 95% CI [0.72, 1.03]) nor application of a medical treatment (RR 0.96; 95% CI [0.72, 1.29]) was effective in preventing lymphocele. On the contrary, decreasing the drainage time increased the risk of lymphocele (RR 1.88; 95% CI [1.43, 2.48). There was no publication bias but the studies were of medium to low quality. To conclude, despite the heterogeneity of study designs, drainage appears to be the most effective technique, although the overall quality of the data is low.

Importance of Nutrition in the development of Seroma after Breast Surgery

Amaç: Meme cerrahisi sonrası seroma gelişiminde nütrisyonun önemini araştırmak. Seroma mastektomi sonrası görülen en sık komplikasyon olup, görülme sıklığı %10- 50 arasında değişmektedir. Seroma cilt nekrozu, enfeksiyon, yara iyileşmesini gecikmesi ve bunun sonucu olarak ek tedavilerin gecikmesine neden olabileceği için ciddiye alınması gereken bir komplikasyondur. Metod: Bu deneysel çalışmada 10’arlı gruplara ayrılan toplan 40 rat kullanıldı. Preoperatif 7 gün boyunca 1.gruba (kontrol) normal rat gıdası, 2. gruba kontrol grubunun %70’i kadar normal rat gıdası (malnütrisyon), 3. ve 4. gruba proteinden zengin diyet (Glutamin-Arjinin-Metil Bütirat) (10gr protein /kg/gün) verildi ve gruplara 7. gün tek taraflı (sağ) pektoral majör kas eksizyonu ve aksiler diseksiyon uygulandı. Postoperatif 10 gün boyunca 1. gruba normal rat gıdası, 2. gruba kontrol grubunun %70’ i kadar normal rat gıdası, 3. gruba normal rat gıdası ve 4. gruba proteinden zengin diyet verildi. Postoperatif 10. günde ratlardan seroma örneği alınarak sakrifiye edildi. Bulgular: Kontrol grubunun seroma miktarı 1,5 ml (1ml-2,5ml), malnütrüsyon grubunun seroma miktarı 1,5ml (1ml-2,75ml), preoperatif proteinden zengin diyetle beslenen 3.grubun seroma miktarı 1ml (0,5ml-1ml), preoperatif ve postoperatif proteinden zengin diyetle beslenen 4.grubun seroma miktarı 0,75ml (0,5ml-1ml) olarak bulundu. Seroma miktarları ortanca olarak verildi. Bu değerlere göre proteinden zengin diyetle beslenen grupların seroma miktarları anlamlı olarak düşük bulundu. (p=0,001 ) Sonuç: Çalışmamızda elde edilen veriler doğrultusunda deneysel mastektomi ve aksiller diseksiyon (AD) modelinde preoperatif ve postoperatif dönemde proteinden yüksek diyetle beslenmenin seroma oluşumunu azalttığı görülmüştür. Benzer şekilde klinik çalışmaların planlanması gerektiği kanaatindeyiz.

Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer

Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.

Effects of Different Applications on Postoperative Seroma Formation and Wound Healing Following Mastectomy and Axillary Dissection in Rats

The most frequent postoperative complication after breast surgery is seroma formation. Seroma occurs due to lymphatic and vascular fluid leakage into the dead space created by surgical dissection. The objective of the research was to evaluate the effects of local fibrin glue, tetracycline, talc applications, and flap fixation technique on reducing seroma formation after mastectomy and axillary dissection. In addition, we aimed to determine the level of efficacy for these applications, as well as to identify the most appropriate method to be used in operations with high risk of seroma formation. Materials and Methods. This experimental study was conducted using a total of 60 female Wistar albino rats. They were allocated into six groups and each comprised ten rats. Unilateral mastectomy and axillary dissection were performed on all the rats. Local applications of fibrin glue, tetracycline, talc, and alcoholic iodine were performed in four separate groups. Flap fixation technique was applied in one group and those rats that did not receive any intervention constituted the control group. On the 10th postoperative day, seroma was aspirated under anesthesia, and the amount of seroma fluid was recorded. Seroma fluid was analyzed for interleukin 1-β, vascular endothelial growth factor, and C-reactive protein levels. Tissue samples were obtained from the skin overlaying the dissection area, the axilla, and the thoracic wall. Wound healing was evaluated with histopathological examination. Results. Seroma volume was lower and the wound healing scores were the highest in the flap fixation group and the tetracycline group as compared to the control group. However, the alcoholic iodine group and the talc group had a greater amount of seroma (p < 0.05). There was no difference between the fibrin glue group and the control group. Conclusions. In our mastectomy model, local application of alcoholic iodine and talc substances caused more wound site problems and postoperative seroma formation. While fibrin glue did not cause wound site problems, it did increase seroma formation. These three substances were determined to be inefficacious in postoperative seroma formation. Local tetracycline application and flap fixation technique were found to reduce postoperative seroma and benefit wound healing.

Retrospective Evaluation of the Effectiveness of a Synthetic Glue and a Fibrin-Based Sealant for the Prevention of Seroma Following Axillary Dissection in Breast Cancer Patients

Introduction: Seroma formation represents one of the most frequent postoperative complications of axillary dissection in breast cancer (BC) patients. We aimed to retrospectively explore the effectiveness of the intraoperative use of a synthetic cyanoacrylate glue (specifically Glubran®2) vs. the intraoperative use of a fibrin sealant (specifically Tisseel) in reducing seroma formation compared to the use of nonsealant in BC patients who underwent breast surgery and axillary dissection. Materials and Methods: We conducted a retrospective, monocentric observational study on BC patients who underwent axillary dissection associated with breast surgery. The axillary dissection was completed with the application of a closed suction drain and was preceded by the application of either Glubran®2 glue or Tisseel sealant or nonsealant. We analyzed the quantity of serum drained in the first 3 postoperative days, length of hospitalization, days of permanence of axillary drain, seroma development, and presence of postoperative infection signs. Results: Forty-one BC patients were considered. Based on the device used during the surgical treatment, the patients were divided into three groups: group A (17 patients), to whom suction axillary drain was applied; group B (7 patients), to whom Tisseel and axillary suction drain were applied; and group C (17 patients), to whom Glubran®2 and axillary suction drain were applied. Among the three groups, we did not find significant differences in terms of amount of serum drained in the first 3 postoperative days, length of hospitalization, and incidence of seroma. Group C maintained the axillary drain in a significantly lower number of days compared to the other two groups (p = 0.02); it also had a lower incidence of postoperative infections (6%) compared to group A (23%) and group B (57%) (p = 0.02). Conclusions: We did not find any evidence that the use of surgical glues may reduce the formation of seroma following axillary dissection in BC patients. Nevertheless, the use of cyanoacrylate glue in association with closed suction axillary drain seems to contribute to the reduction in days of axillary drain permanence and of postoperative infections, which are known factors delaying the schedule of any adjuvant oncological therapies.

Effects of Fibrin Sealant on Seroma Reduction for Patients with Breast Cancer Undergoing Axillary Dissection: Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Seroma formation is common in patients with breast cancer after axillary dissection. Fibrin sealant, containing fibrinogen and thrombin, has been developed to improve wound healing. We conducted a systematic review and meta-analysis to evaluate the efficacy of fibrin sealants in reducing seroma among patients with breast cancer undergoing axillary dissection.

METHODS

We searched the PubMed, EMBASE, and Cochrane Library databases for randomized controlled trials (RCTs) published up to April 2020. Pooled estimates of the outcomes were computed using a random-effects model. The primary outcomes were incidence and volume of seroma, while the secondary outcomes were volume and duration of drainage, incidence of infection, and length of hospital stay.

RESULTS

We reviewed 23 RCTs that included 1640 patients. Compared with the control group, the fibrin sealant group had no significant differences in the incidence of seroma, length of hospital stay, or incidence of surgical site infection. Significant intergroup differences were discovered in lower volume of seroma (weighted mean difference [WMD] - 71.88, 95% confidence interval [CI] - 135.58 to - 8.19), volume of drainage (WMD - 73.24, 95% CI - 107.32 to - 39.15), and duration of drainage (WMD - 0.84, 95% CI - 1.50 to - 0.19).

CONCLUSIONS

Fibrin sealants provide limited benefits in reducing the volume of seroma and the volume and duration of drainage. Therefore, after shared decision making, surgeons may apply fibrin sealants to patients with breast cancer undergoing axillary dissection.

Prospective comparison of indwelling cannulas drain and needle aspiration for symptomatic seroma after mastectomy in breast cancer patients

Aims

Postoperative seroma is the most frequent sequelae after mastectomy and axillary surgery with no optimal regimens for seroma resolution recommended in routine clinical. Indwelling cannulas with needle and catheter have been widely used in long-term medication therapies, but evidence of indwelling cannulas in seroma management after mastectomy is lacking. The purpose of this study is to evaluate the feasibility of indwelling cannulas in seroma management after mastectomy.

Methods

Patients who underwent modified radical mastectomy (MRM) and developed symptomatic seroma after removal of the drains between August 2017 and December 2018, were randomized into two groups either indwelling cannulas drain of seroma (Group A) or needle aspiration of seroma (Group B). We prospectively compared the number of visits for seroma, the time from removal of the drain to the final seroma resolution and the cost between the methods.

Results

A total of 860 patients underwent MRM between August 2017 and December 2018, among which 86 patients who developed symptomatic seroma after removal of the drains, were randomized into two groups either Group A or Group B. The number of visits for seroma in Group A was 2.35 ± 0.69 times, which was less than those in Group B (4.86 ± 1.06 times). Similarly, the time of drain removal to final seroma resolution in Group A was 4.65 ± 0.78 days, which was shorter than 7.09 ± 1.54 in Group B. In Group A, the total mean cost per patient (25.81 ± 7.71 RMB) was less than the total mean cost per patient (49.30 ± 9.85 RMB) in Group B. Cost savings were noted with using indwelling cannulas in seroma management.

Conclusion

It is feasible to drain indwelling cannulas drain for postmastectomy seroma, with less visits for patients, rapid seroma resolution and less cost. Indwelling cannulas can be an efficient, cost effective solution to treat symptomatic seroma after breast surgery.

Identifying the superior antibiotic prophylaxis strategy for breast surgery: A network meta-analysis

BACKGROUND

The clinical roles of different antibiotic prophylaxis strategies for breast surgery remains large unknowns. The aim of this study is to evaluate different antibiotic prophylaxis strategies based on a network meta-analysis.

METHODS

We initially retrieved literature from globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating the antibiotic prophylaxis strategies for breast surgery. Relative postoperative infection rates were quantitatively pooled and estimated based on the Bayesian theorem. Values of surface under the cumulative ranking curve (SUCRA) probabilities were calculated and ranked. Additional pairwise meta-analyses were performed to validate differences between the respective strategies at the statistical level for further explanations.

RESULTS

After a detailed review, a total of 14 RCTs containing 6 different strategies were included for the network meta-analysis. The results indicated that the application of antibiotics administered during pre- plus post- plus intraoperative periods possessed the highest possibility of having the best clinical effects (SUCRA, 0.40), followed by intraoperative administration alone (SUCRA, 0.35) and pre- plus intraoperative administrations (SUCRA, 0.20). Moreover, an additional pairwise meta-analysis determined that pre- and intraoperative-related strategies significantly reduced postoperative infections at a statistical level.

CONCLUSION

Based on the current evidence, we concluded that application of antibiotics administered during pre- plus post- plus intraoperative periods seemed to reveal superior benefits. However, the essential roles of pure intraoperative and postoperative application were still need to be further validated.

Effect of topical microporous polysaccharide hemospheres on the duration and amount of fluid drainage following mastectomy: a prospective randomized clinical trial

Background

Seroma formation is the most common complication after mastectomy and places patients at risk of associated morbidities. Microporous polysaccharide hemospheres (MPH) consists of hydrophilic, plant based, polysaccharide particles and is currently used as an absorbable hemostatic agent. An animal model evaluating MPH and seroma formation after mastectomy with axillary lymph node dissection showed a significant decrease in seroma volume. Study aim was to evaluate topical MPH on the risk of post-mastectomy seroma formation as measured by total drain output and total drain days.

Methods

Prospective randomized single-blinded clinical trial of patients undergoing mastectomy for the treatment of breast cancer. MPH was applied to the surgical site in the study group and no application in the control group.

Results

Fifty patients were enrolled; eight were excluded due to missing data. Forty-two patients were evaluated, control (n = 21) vs. MPH (n = 21). No difference was identified between the two groups regarding demographics, tumor stage, total drain days, total drain output, number of clinic visits, or complication rates. On a subset analysis, body mass index (BMI) greater than 30 was identified as an independent risk factor for high drain output. Post hoc analyses of MPH controlling for BMI also revealed no statistical difference.

Conclusions

Unlike the data presented in an animal model, no difference was demonstrated in the duration and quantity of serosanguinous drainage related to the use of MPH in patients undergoing mastectomy for the treatment of breast cancer. BMI greater than 30 was identified as an independent risk factor for high drain output and this risk was not affected by MPH use. NCT03647930, retrospectively registered 08/2018.

Examination of the Effects of Celecoxib on Postmastectomy Seroma and Wound Healing

Objectives:

To examine the effect of celecoxib on wound healing and development of seroma after mastectomy.

Seroma is an accumulation of serous fluid in dead space emerging after breast cancer surgery. The pathophysiology of seroma has not been clearly elucidated. Development of seroma leads to prolongation of hospital stay, increase in costs, ischemia of the flaps, infections due to fluid accumulation, and delayed adjuvant treatment.

Seroma is still a current problem, and the most common treatment method for this problem is drainage and repeated aspirations for 5–7 days after surgery.

Methods:

The effect of celecoxib whose anti-inflammatory, antiangiogenic, and antioxidant effectiveness has been demonstrated in a mastectomy model applied on female Wistar rats has been investigated in the present study. A total of 20 rats including 10 rats in the control and 10 in the celecoxib group were studied.

Intraperitoneal 0.25 cc/250 g (20 mg/kg/day) celecoxib was administered to the celecoxib group for 5 days after mastectomy, and the same volume of physiological saline solution was given to the control group for 5 days. Rats were followed up for 10 days after surgery. During this process, vitality of the rats, movements of the extremities, wound healing conditions, wound infections, flap necrosis, and occurrence of seroma were recorded. At the end of this period, seromas were aspirated, tissue samples were retrieved, and the rats were sacrificed. Fibrin, hemorrhage, edema, vascularization, congestion, polymorphonuclear leukocytes, and increase in fibrotic tissue fibroblasts, lymphocytes, and macrophages were evaluated in tissue samples.

In seroma fluids, interleukin-1 beta (IL-1β), an acute phase reactant, and vascular endothelial growth factor, a vital parameter of vascular proliferation and angiogenesis, were examined.

Results:

At the end of the experiments, the seroma volume decreased significantly in the celecoxib group (p=0.804; 0.001), the IL-1β level decreased significantly as detected in the biochemical examination (p=0.014), and in the histopathological examination, an increase in congestion in the celecoxib group was determined.

Conclusion:

In conclusion, celecoxib markedly decreased interleukin and the volume of seroma after mastectomy; suppressed the level of an acute phase reactant, IL-1β; and demonstrated this effect through its anti-inflammatory activity. We believe that the effects of celecoxib should be investigated using different dose applications and larger number of subjects.

Management of chronic abdominal wall seroma with Doxycycline sclerotherapy using a Negative Pressure Wound Therapy System KCI-V.A.C.Ulta™-A case report

INTRODUCTION

Seroma is a common and challenging post-operative complication that surgeons are often faced with after performing procedures in which tissue dead spaces have been created. The management strategies consist of non-operative management, percutaneous drainage, or surgical drainage. Our case report discusses the use of Doxycycline sclerotherapy in the successful resolution of a chronic abdominal wall seroma.

PRESENTATION OF CASE

We present the case of a 50 year old patient with extensive history of multiple abdominal surgeries, including appendectomy, multiple hernia repairs with recurrent mesh replacement as a result of infection followed by post-operative formation of seroma after each repair. Recently, patient underwent panniculecotomy complicated by seroma that was successfully resolved with the use of doxycycline sclerotherapy.

DISCUSSION

Sclerotherapy has been used previously in the surgical field such as thoracic surgery, as a successful use of sclerosants in chronic pleural effusions has been documented. Sclerosants range from talc, tetracycline antibiotics, ethanol, polidocanol, erythromycin, OK-432, fibrin glue, and povidone-iodine, and are largely safe and easily applicable. Doxycycline in particular can be a simple and effective method for resolution of chronic seroma. This case demonstrates the successful use of doxycycline in the resolution of a chronic abdominal wall seroma.

CONCLUSION

Chronic and recurrent seroma after surgery can be difficult to deal with. Using sclerosants such as Doxycycline would be an effective solution to treat this chronic issue and to prevent its recurrence especially if it is used with a Negative Pressure Wound Therapy System.

The Effect of Fibrin Sealant Combined with Fibrinolysis Inhibitor on Reducing the Amount of Lymphatic Leakage after Axillary Evacuation in Breast Cancer

Background and Aims:

One third of women undergoing mastectomy with axillary evacuation for primary breast cancer suffer from postoperative seromas leading to unnecessary costs and complications such as infections and new operations. Different methods to prevent seroma formation have been tried without permanent success. The aim of this prospective randomised study was to examine the effect of fibrin sealant with fibrinolysis inhibitor firstly on the reduction of the amount of lymphatic leakage after axillary evacuation and secondly on the reduction of days with drains and postoperative seroma punctures.

Methods:

40 patients with primary breast cancer were prospectively randomised to the treatment group (n = 19) getting fibrin clue combined with fibrinolysis inhibitor (aprotinin) sprayed into the axillary fossa and to the control group (n = 21).

Results:

There were no differences in the incidence of postoperative seromas between the groups. However, the seromas were easier to treat if fibrin clue was used. Total quantity (mean ± SD) of lymphorrhea and total number of aspirations (mean ± SD) were almost twice as high in the patients of the control group compared to those having fibrin sealant. In the treatment group seromas resolved after one or occasionally after two aspirations in 71 % of patients, while in the control group 90 % of patients needed three or more aspirations.

Conclusion:

Potentially, fibrin sealant combined with fibrinolysis inhibitor might be used for the treatment of post-axillary evacuation lymphorrhea and seroma.

Prospective randomized controlled study to assess the value of a hemostatic and sealing agent for preventing seroma after axillary lymphadenectomy

BACKGROUND AND OBJECTIVES

Postoperative seroma after axillary lymphadenectomy leads to an increased use of resources and an impaired quality of life of patients. This randomized clinical trial was designed to assess the value of a hemostatic and sealing agent for decreasing seroma occurrence after axillary lymphadenectomy.

METHODS

A prospective, randomized, blind study was conducted on 91 axillary lymphadenectomies distributed into a control group (n = 47) and a test group in which a collagen sponge coated with human coagulation factors was used (n = 44). Primary end-points were number of days before removal of axillary drainage, axillary drainage output, and occurrence of seroma, wound infection, haematoma, or wound dehiscence, within 8 weeks of surgery. Bivariate and multivariate analyses on seroma occurrence were performed.

RESULTS

Seroma occurred in 29 patients (31.86%). A significant direct relationship (P = 0.002) was only noted between use of the hemostatic and sealing agent and nonoccurrence of seroma. In the multivariate study, the only variable found to be significantly related to seroma occurrence was use of the above agent (P = 0.046; odds ratio: 3.365 [95%CI: 1.024-11.060]).

CONCLUSIONS

Use of a collagen sponge coated with human coagulation factors following axillary lymphadenectomy was associated to a lower incidence of postoperative seroma. J. Surg. Oncol. 2016;114:423-427. © 2016 Wiley Periodicals, Inc.

Dead space closure with quilting suture versus conventional closure with drainage for the prevention of seroma after mastectomy for breast cancer (QUISERMAS): protocol for a multicentre randomised controlled trial

INTRODUCTION

Postoperative wound seroma is common after mastectomy. This complication is associated with significant impact on patient outcomes and healthcare costs. The optimal closure approach for seroma prevention remains unknown but some evidence suggests that quilting suture of the dead space could lower the incidence of seroma. The aim of this trial is to compare seroma formation using quilting suture versus conventional closure with drainage in patients undergoing mastectomy.

METHODS AND ANALYSIS

This is a multicentre, superiority, randomised controlled trial in women undergoing mastectomy with or without axillary involvement. Exclusion criteria include indication of bilateral mastectomy or immediate reconstruction and any physical or psychiatric condition that could impair patient's ability to cooperate with postoperative data collection or that do not allow an informed consent. 320 participants will be randomised in a 1:1 ratio to receive either quilting suture or conventional wound closure with drain. The primary outcome is seroma requiring either aspiration or surgical intervention within 21 days following mastectomy. Secondary outcomes include seroma regardless of whether or not it requires an intervention, surgical site infection, pain score, cosmetic result, patient's quality of life, costs and cost-effectiveness. The primary analysis will be an intention-to treat analysis performed with a χ(2) test (or Fisher's exact test).

ETHICS AND DISSEMINATION

Written informed consent will be obtained from all participants. This study was approved by Tours Research ethics committee (CPP TOURS-Region Centre-Ouest 1, 2014-R20, 16 December 2014). Study findings will be published in peer-reviewed journals and presented at relevant national and international breast cancer conferences.

TRIAL REGISTRATION NUMBER

NCT02263651.

Antimicrobial Formulation and Delivery in the Prevention of Surgical Site Infection

BACKGROUND

A number of adjunct antimicrobial measures have been studied in an attempt to reduce surgical site infection (SSI) rates. In addition to parenteral antibiotic prophylaxis, these measures include oral antibiotics in bowel preparation for colorectal surgery, antiseptic/antimicrobial irrigation, antimicrobial sutures, local antibiotics, skin incision antibacterial sealants, and antimicrobial dressings. It is the purpose of this review to study the evidence behind each of these measures and to evaluate relevant data for recommendations in each area.

METHODS

A systematic review of the literature through PubMed was performed.

RESULTS

Need for adequate dosing and re-dosing of intravenous peri-operative antibiotics, duration of antibiotic usage past wound closure, and the use of antibiotic bowel preparation in colorectal surgery are well defined in the published literature. However, data on local antimicrobial measures remain controversial.

CONCLUSIONS

Proper dosing and re-dosing of prophylactic intravenous antibiotics should become standard practice. Continuation of intravenous antibiotic prophylaxis beyond wound closure is unnecessary in clean cases and remains controversial in clean-contaminated and complex cases. Oral antibiotic bowel preparation is an important adjunct to intravenous antibiotic prophylaxis in colorectal surgery. The use of topical antimicrobial and antiseptic agents such as antibacterial irrigations, local antimicrobial application, antimicrobial-coated sutures, antibacterial wound sealants, and antimicrobial impregnated dressings in the prevention of SSI is questionable.

Efficacy of axillary exclusion on seroma formation after modified radical mastectomy

Background

Breast cancer represented 35.1 % of total female cancer cases in Egypt. Seroma is one of the most serious and common complications of mastectomy and axillary dissection with incidence between 15 and 81 %. Seroma formation delays wound healing and increases susceptibility to infection, skin flap necrosis, and persistent pain as well as prolonging convalescence. Therefore, several techniques have been investigated to minimize seroma formation with no consistent success. Axillary exclusion is a technique aimed to obliterate dead space after axillary clearance and minimize collection.

Methods

Sixty-four patients were prepared for modified radical mastectomy. Of those, the study group contains 32 patients and the control group contains 32 patients. Study group had axillary exclusion while the other had the conventional procedure; total drain outputs were recorded daily for all patients prior to drain removal. The drains were removed when the daily drainage was less than 30 ml.

Results

This study contains 64 patients, the study group contains 32 patients, and the control group contains 32 patients. Age, BMI (mean control = 31.7 and study = 30.2), and tumor size were of no significant differences to be more concise on the effect of axillary exclusion. The mean of day of drain removal in the control group was 17.8 day (15–19) with a mean of total drain output of 4525.6 ml (4430–3660 ml) while the mean in the study group of day of drain removal was 11.3 (10–13) with a mean of total drain output of 1476.2 ml (620–2200 ml), p < 0.00.

Conclusions

Axillary exclusion technique is a valuable procedure that significantly decreases seroma postmastectomy and axillary dissection.

[Quilting suture after mastectomy in prevention of postoperative seroma: a prospective observational study]

OBJECTIVES

The occurrence of a postoperative seroma is the main complication of mastectomy. In 2011, Ouldamer et al. adapted a quilting technique used in reconstructive surgery in mastectomy closure. The aim of this study is to evaluate the impact of quilting in the prevention of postoperative seroma.

PATIENTS AND METHODS

This is an observational prospective study to the Centre Hospital-University of Tours. Hundred and forty-four patients who underwent a mastectomy between January 1st, 2011 and October 1st, 2012 were included. Patients were divided into 2 groups, one with a classic wound closure with drainage and the second with quilting suture of skin flaps to the underlying musculature after mastectomy without drainage.

RESULTS

Quilting suture significantly reduces the postoperative seroma appearance (OR=0.15; CI95% [0.06-0.39]; P<0.001). Operative time is increased by 20minutes in the quilted group (P<0.001). Postoperative pain is not changed by quilting. The duration of hospitalization is significantly shorter (5.09±1.46 days versus 6.49±2.77 days; P<0.001). Quality of the healing and appearance of the scar, rated by patients, are identical in both groups.

CONCLUSION

Quilting is an effective method not only for prevention of seroma, but also for reducing of hospitalization duration, without increasing of postoperative pain and complications.

A simple, safe technique for thorough seroma evacuation in the outpatient setting

Summary:

Seroma formation, a common postoperative complication in reconstructive cases, can lead to capsular contracture and increased office visits and expenses. The authors present a safe, novel technique for ensuring the thorough removal of serous fluid in the outpatient setting. By relying on access with an angiocatheter, potential injury to permanent implants is minimized. The use of low continuous wall suction obviates the need of manual suction via multiple syringes and offers a rapid and thorough evacuation of all types of seromas.

Potential risk factors for the development of seroma following mastectomy with axillary dissection

Seroma is a common complication following breast cancer surgery and the controllable predictive factors remain unknown. Patients who underwent mastectomy with axillary dissection between 2008 and 2011 in our hospital were retrospectively investigated. The demographics, clinical characteristics and therapeutic factors of each patient were recorded. The association of seroma incidence with each variable was evaluated by univariate logistic regression analysis. All the variables were considered independent predictors of seroma incidence. The probability of developing seroma following surgery was evaluated by multivariate logistic regression analysis. A total of 102 patients, with a mean age of 54.86±13.02 years (range, 30-89 years), were included in this study and the incidence of seroma was found to be 22.55%. The operative time (P=0.0066, coefficient = 0.0261, OR=1.03) and the use of patient-controlled intravenous analgesia (PCA) (P=0.0002, coefficient = -1.8089, OR=0.03, ref = no) was significantly associated with the incidence of seroma postoperatively. In conclusion, the prediction of the development of seroma following mastectomy with axillary dissection is challenging. However, a longer operative time and the non-use of PCA may represent potential risk factors for this complication.

Effect of β-glucan on drain fluid and amount of drainage following modified radical mastectomy

INTRODUCTION

To reduce the seroma formation following mastectomy and axillary dissection, many different techniques and drugs have been investigated. The aim of this study is to evaluate the effects of oral β-glucan on drain fluid and efficacy of daily drainage and drain removal day in mastectomy patients.

METHODS

One hundred and thirty breast cancer patients of Ankara Oncology Training and Research Hospital were divided into 2 groups by consecutive randomization (n = 65 each). β-glucan 10 mg capsules were administered to Group 1 twice a day for 10 days. Group 2 took placebos in the same manner. Age, menarche age, menopause, parity, history of oral contraceptives, comorbidities, postoperative daily drainage volumes and drain removal days were recorded and compared. Seroma samples during the first and second day of drainage were taken for analysis of Interleukin-6 (IL-6) and Tumor Necrosis Factor (TNF-α).

RESULTS

There was no difference between groups in terms of age, menarche age, menopause period, parity, oral contraceptive use and comorbidities. Group 1 showed significantly lower daily drainage volumes between days 2 and 8. Mean drain removal day was 7.16 ± 1.72 in Group 1 and 8.59 ± 2.27 in Group 2. The difference was significant (p < 0.001). TNF-α and IL-6 levels on days 1 and 2 in Group 1 were significantly lower (p < 0.001). In addition, β-glucan significantly shortened the number of days required for the drain removal in patients who have comorbidities (p = 0.018). The earliest removal was in patients without comorbidity and who received β-glucan (p = 0.002).

CONCLUSION

β-glucan decreased drain discharges after mastectomy. The drains were removed earlier in β-glucan administered patients.

Axillary lymphadenectomy for breast cancer in elderly patients and fibrin glue

BACKGROUND

Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results.

METHODS

Thirty patients over 60 years underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 15 patients; the other 15 patients were treated with harmonic scalpel.

RESULTS

Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group.

CONCLUSIONS

Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.

Fibrin glue instillation under skin flaps to prevent seroma-related morbidity following breast and axillary surgery

BACKGROUND

Fibrin glue (FG) combines fibrinogen and thrombin, under the presence of factor XIII and calcium chloride, and produces a 'fibrin clot' as would occur through the natural clotting cascade. FG is thought to close over any small vessels including lymphatics that are too small for conventional surgical closure, thereby reducing seroma formation, seroma incidence and related comorbidities.

OBJECTIVES

To assess the evidence on the effectiveness of FG in people undergoing breast and axillary surgery and to establish whether FG is an efficient modality to prevent postoperative seroma and seroma-related outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register (9 December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2012), MEDLINE (9 December 2011), EMBASE (9 December 2011), LILACS (22 October 2012), SCI-E (22 October 2012), the World Health Organization's International Clinical Trial Registry (9 December 2011) and ClinicalTrials.gov (22 October 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of FG in terms of reducing the postoperative seroma incidence and related comorbidities in people undergoing breast and axillary surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. The pooled analysis of the extracted data was achieved by the statistical analysis on Review Manager software. The quality of studies was assessed using The Cochrane Collaboration's 'Risk of bias' tool.

MAIN RESULTS

The search of four standard electronic databases yielded 119 potentially relevant studies but only 18 RCTs involving 1252 people were found suitable for statistical analysis. There was significant heterogeneity among trials and the majority of trials were of poor quality. The use of FG under skin flaps following breast and axillary surgery failed to reduce the incidence of postoperative seroma (risk ratio (RR) 1.02; 95% Confidence Interval (CI) 0.90 to 1.16, P value = 0.73), mean volume of seroma (standardised mean difference (SMD) -0.25; 95% CI -0.92 to 0.42, P value = 0.46), wound infection (RR 1.05; 95% CI 0.63 to 1.77, P value = 0.84), postoperative complications (RR 1.13; 95% CI 0.63 to 2.04, P value = 0.68) and length of hospital stay (SMD -0.2; 95% CI -0.78 to 0.39, P value = 0.51). FG reduced the total volume of drained seroma (SMD -0.75, 95% CI -1.24 to -0.26, P value = 0.003) and duration of persistent seromas requiring frequent aspirations (SMD -0.59; CI 95% -0.95 to -0.23, P value = 0.001).

AUTHORS' CONCLUSIONS

FG did not influence the incidence of postoperative seroma, the mean volume of seroma, wound infections, complications and the length of hospital stays in people undergoing breast cancer surgery. Due to significant methodological and clinical diversity among the included studies this conclusion may be considered weak and biased. Therefore, a major multicentre and high-quality RCT is required to validate these findings.

Fibrin glue instillation under skin flaps to prevent seroma-related morbidity following breast and axillary surgery

BACKGROUND

Fibrin glue (FG) combines fibrinogen and thrombin, under the presence of factor XIII and calcium chloride, and produces a 'fibrin clot' as would occur through the natural clotting cascade. FG is thought to close over any small vessels including lymphatics that are too small for conventional surgical closure, thereby reducing seroma formation, seroma incidence and related comorbidities.

OBJECTIVES

To assess the evidence on the effectiveness of FG in people undergoing breast and axillary surgery and to establish whether FG is an efficient modality to prevent postoperative seroma and seroma-related outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register (9 December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2012), MEDLINE (9 December 2011), EMBASE (9 December 2011), LILACS (22 October 2012), SCI-E (22 October 2012), the World Health Organization's International Clinical Trial Registry (9 December 2011) and ClinicalTrials.gov (22 October 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of FG in terms of reducing the postoperative seroma incidence and related comorbidities in people undergoing breast and axillary surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. The pooled analysis of the extracted data was achieved by the statistical analysis on Review Manager software. The quality of studies was assessed using The Cochrane Collaboration's 'Risk of bias' tool.

MAIN RESULTS

The search of four standard electronic databases yielded 119 potentially relevant studies but only 18 RCTs involving 1252 people were found suitable for statistical analysis. There was significant heterogeneity among trials and the majority of trials were of poor quality. The use of FG under skin flaps following breast and axillary surgery failed to reduce the incidence of postoperative seroma (risk ratio (RR) 1.02; 95% Confidence Interval (CI) 0.90 to 1.16, P value = 0.73), mean volume of seroma (standardised mean difference (SMD) -0.25; 95% CI -0.92 to 0.42, P value = 0.46), wound infection (RR 1.05; 95% CI 0.63 to 1.77, P value = 0.84), postoperative complications (RR 1.13; 95% CI 0.63 to 2.04, P value = 0.68) and length of hospital stay (SMD -0.2; 95% CI -0.78 to 0.39, P value = 0.51). FG reduced the total volume of drained seroma (SMD -0.75, 95% CI -1.24 to -0.26, P value = 0.003) and duration of persistent seromas requiring frequent aspirations (SMD -0.59; CI 95% -0.95 to -0.23, P value = 0.001).

AUTHORS' CONCLUSIONS

FG did not influence the incidence of postoperative seroma, the mean volume of seroma, wound infections, complications and the length of hospital stays in people undergoing breast cancer surgery. Due to significant methodological and clinical diversity among the included studies this conclusion may be considered weak and biased. Therefore, a major multicentre and high-quality RCT is required to validate these findings.

Seroma formation after breast cancer surgery: what we have learned in the last two decades

Formation of a seroma most frequently occurs after mastectomy and axillary surgery. Prolonged drainage is troublesome as it increases the risk for infection and can significantly delay adjuvant therapy. Seroma has been defined as serous fluid collection under the skin flaps or in the axillary dead space following mastectomy and/or axillary dissection. Because the true etiology of a seroma is unknown, a multifactorial-causation hypothesis has been accepted. Surgical factors include technique, extent of dissection and the surgical devices used for dissection. Obliteration of dead space with various flap fixation techniques, use of sclerosants, fibrin glue and sealants, octreotide, and pressure garments have been attempted with conflicting results and none have been consistent. Early movement of the shoulder during the postoperative period may increase the formation of seroma, although delayed physiotherapy decreases the formation of seroma. A detailed analysis of the use of drains showed that use of single or multiple drains, early or late removal, and drains with or without suction are not significantly different for the incidence of seroma. Although there is evidence for reduced seroma formation after early drain removal, very early removal within 24 hours seems to increase formation of seroma. No patient or tumor factors seem to affect seroma formation except body mass index and body weight. Consensus is lacking among studies/trials with different groups producing conflicting evidence. Besides a few established factors such as body mass index, the use of electrocautery for dissection, early drain removal, low vacuum drains, obliteration of dead space, and delayed shoulder physiotherapy, most of the hypothesized causes have not been demonstrated consistently. Thus, seroma remains a threat to both the patient and surgeon. Recurrent transcutaneous aspiration remains the only successful management.

Collagen sealant patch to reduce lymphatic drainage after lymph node dissection

Background

Seroma formation is a frequent complication following radical lymph node dissection (RLND) in patients with metastatic melanoma. Several strategies have been used to prevent fluid accumulation and thereby reduce the duration of postoperative drainage, including fibrin sealants.

Methods

This was a prospective, single-center study in which consecutive patients undergoing surgical treatment of stage III metastatic melanoma by axillary or ilio-inguinal RLND were randomized to receive standard treatment plus fibrinogen/thrombin-coated collagen sealant patch (CSP) or standard treatment alone. The primary endpoint of the study was postoperative duration of drainage.

Results

A total of 70 patients underwent axillary (n = 47) or ilio-inguinal (n = 23) RLND and received CSP plus standard treatment (n = 37) or standard treatment alone (n = 33). Mean duration of drainage was significantly reduced in the CSP group compared with standard treatment (ITT analysis: 20.1 ± 5.1 versus 23.3 ± 5.1 days; p = 0.010). The percentage of patients drainage-free on day 21 was significantly higher in the CSP group compared with the standard treatment group (86% versus 67%; p = 0.049).

Conclusions

Use of the tissue sealant resulted in a significant reduction in duration of drainage. Further studies are warranted to confirm these results in different and selected types of lymphadenectomy.

Effectiveness of OK-432 (Sapylin) to reduce seroma formation after axillary lymphadenectomy for breast cancer

BACKGROUND

The occurrence of seroma formation after axillary lymphadenectomy for breast cancer cannot be ignored. Various approaches have been used in an effort to reduce it, but these results are still controversial. We aimed to describe a new method of application of OK-432 (Sapylin, heat-treated Su strain of Streptococcus) to reduce seroma formation after axillary lymphadenectomy for breast cancer and to verify the safety and efficacy of it as a beneficial supplement for conventional surgery.

METHODS

A prospective, randomized analysis of consecutive quadrantectomy or mastectomy plus axillary lymphadenectomy using or not using OK-432 was designed. From July 2010 to November 2011, a total of 111 patients were enrolled in this prospective, randomized study and completed the follow-up. OK-432 applied to the axillary fossa plus placement of closed suction drainage was used in 54 patients (the experimental group); placement of closed suction drainage was used in 57 patients (the control group).

RESULTS

There were no statistical significance between the two groups in terms of age, body mass index, treatment received, tumor size, number of removed lymph nodes, and lymph node status. Postoperative drainage magnitude and duration were significantly reduced in the experimental group (P = 0.008 and 0.003, respectively). One week after hospital discharge, fewer patients developed a palpable seroma in the experimental group: 10 in the experimental group versus 28 in the control group (P = 0.001). Fewer seromas needed aspiration (mean 1 [range 0-3] in the experimental group vs. mean 4 [range 1-5] in the control group; P < 0.001). There were no significant differences in terms of the incidence of complications associated with axillary lymphadenectomy (P = 0.941).

CONCLUSIONS

OK-432 is a feasible and safe option for axillary lymphadenectomy for breast cancer. The use of it does not always prevent seroma formation, but it can reduce drainage magnitude and duration, as well as decrease the incidence of seroma after the removal of drainage. It may be increasingly conducted in day surgery clinics.

Efficacy of fibrin glue on seroma formation after breast surgery

Background and Objectives. This study was designed to determine the effectiveness of fibrin glue plus conventional drain placement versus conventional drain placement in the prevention of seromas after breast procedures. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies, with controversial results. Design and Setting. A prospective, randomized, controlled study of subjects who were randomized into control and experimental groups was conducted. Methods. Collected data included age, surgeon, medical and surgical history, comorbidities, procedure performed, number of axillary nodes, number of positive axillary nodes collected, final pathologic diagnosis, cancer stage, hospital stay, postoperative day of drain removal, complications, incidence of seroma formation, interval to seroma resolution, and number of postoperative visits. Results. Analysis of 60 patients showed similarly matched groups. Seroma formation rate was 24.1% in the control group and 16.1% in the fibrin glue group. The rate of wound complications was similar. Conclusions. Although use of fibrin sealant resulted in a nonsignificant decrease in seroma formation rate compared with that of drain placement, the higher cost and cumbersome technique tend to indicate that there is no advantage to using fibrin glue over drain placement with the technique described.

Axillary lymphadenectomy for breast cancer. A randomized controlled trial comparing a bipolar vessel sealing system to the conventional technique

AIM

To compare safety and efficacy of a bipolar vessel sealing system (BVSS) to the conventional technique in axillary node dissection.

METHODS

116 women with breast cancer were randomized to conventional node dissection surgical technique (control; n = 58) by scalpel and monopolar cautery or using an electrothermal BVSS (study group; n = 58).

RESULTS

The median (range) total volume of fluid collected by drain and aspirations was 305 (30-1420) mL in the study group and 335 (80-1070) mL in the control group (p = 0.325). The median (range) total volume of lymph collected by percutaneous aspirations was 207.5 (40-1050) mL in the study group and 505 (270-705) mL in the control group (p = 0.010). The incidence of seroma was similar in both groups (p = 0.845). The axillary drain was removed earlier in the study group than in controls (p = 0.046).

CONCLUSION

The use of a BVSS offers marginal advantages when compared to the conventional technique.

Seroma formation after mastectomy: pathogenesis and prevention

Post mastectomy seroma remains an unresolved quandary as the risk factors for its formation have still not been identified. Seromas of the axillary space following breast surgery can lead to significant morbidity and delay in the initiation of adjuvant therapy. Various techniques and their modifications have been practiced and published in English literature, but there seems to be no consensus. In this article, all aspects of seroma formation from pathogenesis to prevention including drug therapies have been discussed.

Does the use of fibrin glue prevent seroma formation after axillary lymphadenectomy for breast cancer? A prospective randomized trial in 159 patients

BACKGROUND

Seroma formation frequently occurs in patients who have undergone axillary lymphadenectomy. The aim of the study was to evaluate the effect of fibrin glue in the prevention of seroma formation after axillary lymphadenectomy.

MATERIALS AND METHODS

Hundred fifty-nine breast cancer patients about to undergo quadrantectomy or mastectomy plus axillary lymphadenectomy were enrolled in the study and randomized into two groups. Fibrin glue spray applied to the axillary fossa plus placement of closed suction drainage were used in 80 patients (group A); placement of closed suction drainage was only used in 79 patients (group B).

RESULTS

Group A patients showed a slight advantage with regard to the mean duration of axillary drainage placement (4.5 +/- 1.3 days in group A vs. 5.1 +/- 1.6 days in group B) and number of seroma aspirations (6.3 +/- 1.1 in group A vs. 6.7 +/- 1.2 in group B). No statistically significant differences were observed between the two groups of patients regarding the mean volume of total axillary drainage and of total seroma volume.

CONCLUSIONS

The use of fibrin glue does not prevent seroma formation and does not reduce seroma magnitude and duration. The costs of the product involved do not justify its routine use in patients undergoing axillary dissection.

Erythromycin sclerotherapy in the management of seroma

Post-operative seroma can present the clinician and patient with a chronic and difficult problem. The authors present their experience of managing refractory seroma with the antibiotic erythromycin, administered for its properties as a sclerosant. The technique was found, in a series of patients, to be effective, simple and without serious complications.

Effectiveness of fibrin glue in conjunction with collagen patches to reduce seroma formation after axillary lymphadenectomy for breast cancer

BACKGROUND

Axillary lymphadenectomy remains an integral part of breast cancer treatment, yet seroma formation occurs in 15% to 85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies, with controversial results.

METHODS

Fifty patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray and a collagen patch were applied to the axillary fossa in 25 patients; the other 25 patients were treated conventionally.

RESULTS

Suction drainage was removed between postoperative days 3 and 4. Seroma magnitude and duration were significantly reduced (P = .004 and .02, respectively) and there were fewer evacuative punctures in patients receiving fibrin glue and collagen patches compared with the conventional treatment group.

CONCLUSIONS

Use of fibrin glue with collagen patches does not always prevent seroma formation, but it does reduce seroma magnitude and duration, as well as necessary evacuative punctures.

Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies

BACKGROUND

The most common complications following body contouring surgery for massive weight loss include delayed wound healing and seroma. The authors investigated risk factors for seroma in this patient population and describe treatment strategies.

METHODS

A retrospective review of 222 patients who underwent body contouring surgery for massive weight loss from March of 1997 to December of 2005 was performed. Risk factors assessed included age, sex, medical conditions, tobacco use, body mass index, weight of skin excised, and surgery performed.

RESULTS

Within this group, there were 187 women and 35 men, with a mean age of 42 years. Weight loss was achieved by open (n = 167) or laparoscopic (n = 35) gastric bypass surgery, or diet (n = 20). Average body mass index at contouring was 33, ranging from 20 to 69. Surgical areas addressed alone or in combination included the abdomen (n = 205), thigh (n = 71), arm (n = 69), back (n = 59), and chest (n = 57). Average weight of skin excised at surgery was 9.6 lb, ranging up to 49 lb. Seroma occurred in 31 patients, placing the risk at 14 percent in this series. Seroma risk in abdominal panniculectomy was 12 percent; in circumferential belt lipectomy, the risk was 18 percent; and in thigh lift, the risk was 4 percent. On multivariate statistical analysis, the major risk factor for seroma formation was weight of skin excised, with seroma risk increasing 9 percent for each additional pound of skin excised.

CONCLUSIONS

The most important risk factor for seroma is weight of skin excised at the time of surgery. Treatment strategies include aspiration, drain placement, sclerosis, and surgery.

Abdominal wall pseudocyst following abdominoplasty after postmastectomy radiation therapy

Abdominoplasty is a common surgical procedure that is performed either alone or in conjunction with other intra abdominal procedures. Seroma is a known occurrence after abdominoplasty and various techniques have been described to reduce the quantity and duration of seroma formation. We report a case of pseudocyst following abdominoplasty after post mastectomy radiation. Breast reconstruction with abdominal flaps after abdominoplasty, and the effect of radiation in immediate and delayed flap reconstruction have been described but we could not find any literature on abdominoplasty following radiotherapy. The pathogenesis of seroma formation and, as in our case, the effect of radiation, which is the likely cause of pseudocyst, is discussed.

Comparison of Sutured versus Non-Sutured Subcutaneous Fat Tissue in Abdominal Surgery

PURPOSE

The aim of this prospective randomized study was to investigate the necessity of suturing subcutaneous fat tissue in elective abdominal surgery.

METHODS

415 patients undergoing elective abdominal surgery were admitted to the trial. The patients were divided into two basic groups according to wound contamination: clean operations (n = 201) and clean-contaminated operation (n = 214). Subcutaneous suturing of the subcutaneous fat tissue was performed in half of the patients in each group, determined using the envelope method ('Suture Yes' or 'Suture No'). Wounds were checked on postoperative days 3, 7, 14, and 30. Infectious and non-infectious wound complications were charted in the records. Data were statistically analyzed. The percentages of complications in groups with and without subcutaneous suturing were statistically compared using Yates' corrected chi(2) two-tailed test.

RESULTS

There were no statistically significant group differences in infectious and non-infectious wound complications.

CONCLUSION

These results suggest that omission of subcutaneous fat tissue suturing does not increase the occurrence of infectious or non-infectious wound complications.

Concepts of seroma formation and prevention in breast cancer surgery

BACKGROUND

Seroma formation is the commonest early sequel to breast cancer surgery especially when axillary dissection is undertaken. It is associated with significant morbidity and financial burden. The main pathophysiology of seroma is still poorly understood and remains controversial. The optimal ways to reduce the incidence of seroma formation are unknown. The aim of this paper is to review the concepts of pathophysiology of seroma formation following mastectomy and breast-conserving surgery for cancer. The various techniques in practice to reduce its incidence and treatment are outlined.

METHOD

MEDLINE search of published work on the subject with respect to its pathophysiology, prevention and treatment was carried out. Manual retrieval of relevant articles in the reference lists of the original papers from the MEDLINE was then carried out.

RESULT

The pathophysiology and mechanism of seroma formation in breast cancer surgery remains controversial and not fully understood. Methods of prevention and treatment of seroma remain varied and inconclusive.

CONCLUSION

Evidence suggests an increase in the incidence of seroma because of thermal trauma from electrocautery dissection, but this is indispensable for surgical haemostasis. Obliteration of dead space by various flap apposition techniques has been shown to be advantageous in reducing incidence and volume of seroma. Low-pressure suction drainage reduces seroma volume and duration of drainage leading to earlier drain removal. Preventive measures have to be tailored according to individual patient and operative factors.

INFLUENCE OF SURGICAL TECHNIQUE ON AXILLARY SEROMA FORMATION: A RANDOMIZED STUDY

The aim of this study was to evaluate the influence of surgical technique in the form of electrocautery and suction drains on seroma formation following surgery for breast cancer. A prospective randomized study was carried out. One hundred and sixty patients with breast cancer who underwent surgery were allocated to four arms using a 2 x 2 factorial design. This method enabled us to evaluate the independent effect of two different causative factors on the incidence of postoperative seroma formation using a single dataset with limited numbers. The main outcome measure was postoperative seroma formation defined as a postoperative axillary collection requiring more than one aspiration after removal of the drain. The incidence of seroma in our institution is 90%. Incidence of postoperative seroma was 88.3% if electrocautery was used, which reduced to 82.2% if surgery was carried out using scissors for dissection and ligatures for haemostasis (P = 0.358). There was no influence on the incidence of seroma formation whether suction drain (84.6%) or corrugated drains (86.1%) were used (P = 0.822). The use of electrocautery in axillary dissection does not adversely affect postoperative seroma formation after surgery for breast cancer. The use of different drainage techniques has no bearing on the postoperative seroma formation. The surgical technique has no influence on the rate of seroma formation after surgery for breast cancer.

Complications in Breast Surgery

Most breast operations are categorized as low-morbidity procedures, but a variety of complications can occur in association with diagnostic and multidisciplinary management procedures. Some of these complications are related to the breast itself, and others are associated with axillary staging procedures. This article first addresses some general, nonspecific complications (wound infections, seroma formation, hematoma). It then discusses complications that are specific to particular breast-related procedures: lumpectomy (including both diagnostic open biopsy and breast-conservation therapy for cancer), mastectomy; axillary lymph node dissection, lymphatic mapping/sentinel lymph node biopsy, and reconstruction.