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Suction Drain Volume following Axillary Lymph Node Dissection for Melanoma-When to Remove Drains? A Retrospective Cohort Study. J Pers Med 2022; 12:jpm12111862. [PMID: 36579583 PMCID: PMC9699104 DOI: 10.3390/jpm12111862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Postoperative complications such as seroma formation and wound-site infection occur following completion axillary lymph node dissection (ALND) for melanoma. We analyzed the impact of time-to-drain removal and drainage volume on seroma formation after ALND. We retrospectively analyzed data from 118 patients after completion ALND for melanoma. Primary endpoints were daily amount of drainage volume, seroma formation and time-to-drain removal. Secondary endpoints included patient-related, disease-specific and perioperative parameters as well as the number of histologically analyzed lymph nodes and surgical complications graded by the Clavien−Dindo classification (CDCL). Statistical analyses were performed using logistic regression models. Drain removal around the 8th postoperative day was statistically associated with a lower risk for the occurrence of seroma formation (p < 0.001). Patients with an increased drainage volume during the early postoperative days were more prone to develop seroma after drain removal. With 49% (CDCL I and II), most complications were managed conservatively, while only 5.9% (CDCL III) required revision surgery (CDCL overall: 55.9%). ALND is a safe procedure with a low rate of severe CDCL III type of complications. To decrease seroma evacuation, our results imply that drains should be removed around the 8th postoperative day to reduce the risk of infection, readmission or prolonged hospitalization.
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Abstract
OBJECTIVES The most common method of performing breast reconstruction after a mastectomy is using tissue expanders. Significant drainage that can lead to seromas and possible infection is a common sequela after mastectomies, and therefore, closed suction drains are routinely placed during the initial surgery (Vardanian et al. Plast Reconstr Surg. 2011;128:403-410). Drains, however, are associated with increased pain and discomfort for the patient and have been attributed to an increased infection rate by some authors (Degnim et al. Ann Surg. 2013;258:240-247; Saratzis et al. Clin Breast Cancer. 2009;9:243-246). We report on our experience using a dual-chamber tissue expander placed in the prepectoral space without acellular dermal matrix or other supportive material, which allows for drainage of periprosthetic fluid and avoids drain placement. PATIENTS AND METHODS A retrospective, single-institution review of patients' records was performed for all patients who underwent prepectoral tissue expander placement between January 2018 and June 2019. Patients who had drains placed or who underwent autologous reconstruction in combination with expander placement were excluded. Thirty-nine patients were selected, with a total of 66 expander placements. Demographics including body mass index, comorbidities, history of smoking or steroid use, perioperative chemotherapy and radiation therapy, and intraoperative details and indications for surgery were retrospectively collected. Outcomes were separated into minor and major complications. Major complications were defined as complications that required surgical intervention. RESULTS There were 51 prepectoral reconstructions with a dual-chamber tissue expander and no further surgical drain and 15 reconstructions using a standard expander with an additional closed suction drain. Overall complications for the no-drain cohort were 13.7% compared with 20% in the drain cohort (P = 0.68). Surgical site infection rate is 7.84% in the no-drain cohort compared with 13.3% in the drain cohort (P = 0.61). Mean numeric postoperative pain score at 6 hours was 3.2 in the no-drain cohort compared with 4.3 in the drain cohort (P = 0.03) and 4.17 compared with 5.6 at 12 hours, respectively (P = 0.04). Mean time to exchange of implant in the no-drain cohort was 152 days versus 126 days in the drain cohort (P = 0.38). Median follow-up times were 157 days for the no-drain cohort and 347 days for the drain cohort. CONCLUSIONS Immediate breast reconstruction using a dual-chamber tissue expander offers a drain-free alternative to the immediate implant-based breast reconstruction. Our infection rate with 7.8% is lower than our own reported rates with subpectoral tissue expander reconstruction using either acellular dermal matrix or poly-4-hydroxybutyrate (17% and 11%). The overall complication rate is similar to historic data associated with breast reconstruction after mastectomy and suggests that dual-chamber expander placement offers a safe alternative possibly decreasing the patient's postoperative pain and discomfort that often is associated with closed suction drains (Saratzis et al. Clin Breast Cancer. 2009;9:243-246).
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de Rooij L, van Kuijk SMJ, van Haaren ERM, Janssen A, Vissers YLJ, Beets GL, van Bastelaar J. A single-center, randomized, non-inferiority study evaluating seroma formation after mastectomy combined with flap fixation with or without suction drainage: protocol for the Seroma reduction and drAin fRee mAstectomy (SARA) trial. BMC Cancer 2020; 20:735. [PMID: 32767988 PMCID: PMC7412663 DOI: 10.1186/s12885-020-07242-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/30/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Seroma formation is a common complication after breast cancer surgery and can lead to delayed wound healing, infection, patient discomfort and repeated visits to the outpatient clinic. Mastectomy combined with flap fixation is becoming standard practice and is currently combined with closed-suction drainage. There is evidence showing that closed-suction drainage may be insufficient in preventing seroma formation. There is reasonable doubt whether there is still place for closed-suction drainage after mastectomy when flap fixation is performed. We hypothesize that mastectomy combined with flap fixation and closed suction drainage does not cause a significant lower incidence of seroma aspirations, when compared to mastectomy and flap fixation alone. Furthermore, we expect that patients without drainage will experience significantly less discomfort and comparable rates of surgical site infections. METHODS This is a randomized controlled trial in female breast cancer patients undergoing mastectomy and flap fixation using sutures with or without sentinel lymph node biopsy (SLNB). Patients will be eligible for inclusion if they are older than 18 years, have an indication for mastectomy with or without sentinel procedure. Exclusion criteria are modified radical mastectomy, direct breast reconstruction, previous history of radiation therapy of the unilateral breast, breast conserving therapy and inability to give informed consent. A total of 250 patients will be randomly allocated to one of two groups: mastectomy combined with flap fixation and closed-suction drainage or mastectomy combined with flap fixation without drainage. Follow-up will be conducted up to six months postoperatively. The primary outcome is the proportion of patients undergoing one or more seroma aspirations. Secondary outcome measures consist of the number of invasive interventions, surgical site infection, quality of life measured using the SF-12 Health Survey, cosmesis, pain and number of additional outpatient department visits. DISCUSSION To our knowledge, no randomized controlled trial has been conducted comparing flap fixation with and without closed-suction drainage with seroma aspiration as the primary outcome. This study could result in finding evidence that supports performing mastectomy without closed-suction drainage. TRIAL REGISTRATION This trial was approved by the medical ethical committee of Zuyderland Medical Center METC-Z on 20 March 2019 (METCZ20190023). The SARA Trial was registered at ClinicalTrials.gov as per July 2019, Identifier: NCT04035590 .
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Affiliation(s)
- Lisa de Rooij
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130, MB, Sittard, the Netherlands.
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Els R M van Haaren
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130, MB, Sittard, the Netherlands
| | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130, MB, Sittard, the Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130, MB, Sittard, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | - James van Bastelaar
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130, MB, Sittard, the Netherlands
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The use of surgical site drains in breast reconstruction: A systematic review. J Plast Reconstr Aesthet Surg 2019; 73:651-662. [PMID: 31926896 DOI: 10.1016/j.bjps.2019.11.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 10/22/2019] [Accepted: 11/22/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Use of drains has been advocated in order to prevent seroma and hematoma; however, specific recommendations vary widely. The goal is to perform a systematic analysis of published literature on the use of drains for breast reconstruction. METHODS The literature search was performed according to the PRISMA guidelines. The search included the Cochrane Library, Embase, and Pubmed databases using the terms "breast reconstruction" and "breast flap" combined with "drain", "seroma," and "seroma prevention". The references were appraised in two rounds, by two independent reviewers; studies were included/excluded based on relevance of title and subsequently by the content of their abstracts/manuscripts. Outcomes regarding seroma, infection rate, length of stay (LOS), drainage, reconstruction type and complications were analyzed. RESULTS Of 2252 studies identified via search, 64 were relevant and 21 met inclusion criteria. Most of the study designs were case series or retrospective cohort studies (Level of Evidence III or IV), with the exception of one prospective randomized-controlled trial. Seroma rate was given in 18 studies, infection rate in 11, and criteria for drain removal in 19. Reoperation rate was available in 7 and LOS in 18 studies. The majority of studies (13) agreed to remove the drain when the output was less than 30 ml/24 h. Drain output was reported in 11, and 20 reported drain type used. CONCLUSION There is sparse literature available with which to make evidence-based guidelines. A standardized guideline for reporting drain use is crucial to providing a better understanding of complications in breast reconstruction related to surgical drains.
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Jackson PC, MacInnes EG, Nicholson JK, Brayshaw I, Relton S, Achuthan R. Mastectomy Without Drains Reduces Cost with No Detriment to Patient Outcome. Cureus 2019; 11:e5160. [PMID: 31528512 PMCID: PMC6743667 DOI: 10.7759/cureus.5160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Use of drains after mastectomy remains highly variable. This study aimed to establish whether simple mastectomy managed without a drain would cost less than the same procedure managed with a drain and whether there would be any difference in complications. Methods Prospective data were collected on all patients undergoing simple mastectomy ± sentinel lymph node biopsy over sixteen months. Surgeons decided intra-operatively whether to place a drain. Data included operative details, mastectomy weight, length of stay and postoperative complications. Costing data were identified by combining hospital finance costs for admission and follow-up appointments along with the cost of consumables. Results One hundred and thirty mastectomies were performed on 119 patients. There was a significant difference in mastectomy weight between drain group patients (n=80, median: 730g) and no drain group patients (n=50, median: 424g) (p=<0.001). The mean cost for drain group patients was £639.77 whilst for the no drain group was £365.46, indicating a potential unit saving of £21944.93 over sixteen months. Length of stay was shorter in the no drain group (range: 1-2 days) than the drain group (range: 1-4 days). The presence or absence of drains did not influence complication rates, with no change in seroma interventions (p=0.803). Conclusions Managing simple mastectomy patients without a drain resulted in no increase in complications or subsequent interventions for seroma. Significant cost savings to both the hospital and to the patient can be achieved by omitting drain use. Routine use of drains in patients undergoing simple mastectomy ± SNB may be unnecessary and costly.
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Affiliation(s)
| | | | | | - Ian Brayshaw
- Breast Surgery, Leeds Teaching Hospitals Trust, Leeds, GBR
| | - Samuel Relton
- Miscellaneous, Leeds Institute of Health Sciences, The University of Leeds, Leeds, GBR
| | - Raj Achuthan
- Breast Surgery, Leeds Teaching Hospitals Trust, Leeds, GBR
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Pouwer A, Hinten F, van der Velden J, Smolders R, Slangen B, Zijlmans H, IntHout J, van der Zee A, Boll D, Gaarenstroom K, Arts H, de Hullu J. Volume-controlled versus short drainage after inguinofemoral lymphadenectomy in vulvar cancer patients: A Dutch nationwide prospective study. Gynecol Oncol 2017; 146:580-587. [DOI: 10.1016/j.ygyno.2017.06.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/26/2017] [Accepted: 06/27/2017] [Indexed: 11/25/2022]
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Koplin G, Mall JW, Raue W, Böhm S, Hoeller U, Haase O. Quantity-guided drain management reduces seroma formation and wound infections after radical lymph node dissection: results of a comparative observational study of 374 melanoma patients. Acta Chir Belg 2017; 117:238-244. [PMID: 28274179 DOI: 10.1080/00015458.2017.1296703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Lymphatic fistulas are common complications after lymph node dissections in melanoma patients. We investigated whether drain management could improve the patient's outcome. METHODS Patients who underwent axillary or inguinal lymph node dissection (RALND or RILND) for malignant melanoma were recorded in a prospective database. Two different methods of drain management were compared. Either the drain was removed no later than the eighth postoperative day (period I, 2003-2007) or it was left in place until fluid flow was below 50 ml in 24 h for two consecutive days (period II, 2008-2011). The main outcome criterion was the incidence of seroma punctures after drain removal. RESULTS 374 patients were analysed. The incidence of seroma punctures significantly decreased in period II. The number of patients with elevated lymphatic secretions rose by 41.3% (RALND) and 38.1% (RILND). With the exception of lymphatic fistulas, we observed significantly more local complications with need for treatment in period I (n = 104, 52%) than in period II (n = 31, 18%). In period II, the hospital stays after both procedures were significantly reduced. CONCLUSIONS We conclude that quantity-guided drain management leads to a prolonged interval of drainage but is associated with a lower incidence of seroma formation and shorter hospital stay.
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Affiliation(s)
- Gerold Koplin
- Department of Surgery, Charité ? University Medicine Berlin, Campus Mitte/Campus Virchow-Klinikum, Berlin, Germany
| | - Julian W. Mall
- Department of General, Visceral, Vascular and Bariatric Surgery, KRH-Klinikum Nordstadt, Klinikum Region Hannover GmbH, Hannover, Germany
| | - Wieland Raue
- Department of Surgery, Charité ? University Medicine Berlin, Campus Mitte/Campus Virchow-Klinikum, Berlin, Germany
| | - Stefanie Böhm
- Department of Surgery, Charité ? University Medicine Berlin, Campus Mitte/Campus Virchow-Klinikum, Berlin, Germany
| | - Ulrike Hoeller
- Department of Radiation Oncology, Charité – Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Oliver Haase
- Department of Surgery, Charité ? University Medicine Berlin, Campus Mitte/Campus Virchow-Klinikum, Berlin, Germany
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Stoyanov GS, Tsocheva D, Marinova K, Dobrev E, Nenkov R. Drainage after Modified Radical Mastectomy - A Methodological Mini-Review. Cureus 2017; 9:e1454. [PMID: 28929038 PMCID: PMC5590707 DOI: 10.7759/cureus.1454] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Breast cancer is a socially relevant group of malignant conditions of the mammary gland, affecting both males and females. Most commonly the surgical approach of choice is a modified radical mastectomy (MRM), due to it allowing for both the removal of the main tumor mass and adjacent glandular tissue, which are suspected of infiltration and multifocality of the process, and a sentinel axillary lymph node removal. Most common post-surgical complications following MRM are the formation of a hematoma, the infection of the surgical wound and the formation of a seroma. These post-surgical complications can, at least in part, be attributed to the drainage of the surgical wound. However, the lack of modern and official guidelines provides an ample scope for innovation, but also leads to a need for a randomized comparison of the results. We compared different approaches to wound drainage after MRM, reviewed based on the armamentarium, number of drains, location, type of drainage system, timing of drain removal and no drainage alternatives. Currently, based on the general results, scientific and comparative discussions, seemingly the most affordable methodology with the best patient outcome, with regards to hospital stay and post-operative complications, is the placement of one medial to lateral (pectoro-axillary) drain with low negative pressure. Ideally, the drain should be removed on the second or third postoperative day or when the amount of drained fluid in the last 24 hours reaches below 50 milliliters.
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Affiliation(s)
- George S Stoyanov
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Dragostina Tsocheva
- Department of Surgery, Division of Thoracic Surgery, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Katerina Marinova
- Department of Surgery, Division of Thoracic Surgery, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Emil Dobrev
- Department of Surgery, Division of Thoracic Surgery, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
| | - Rumen Nenkov
- Department of Surgery, Division of Thoracic Surgery, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Varna, Bulgaria
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Freitas-Junior R, Ribeiro LFJ, Moreira MAR, Queiroz GS, Esperidião MD, Silva MAC, Pereira RJ, Zampronha RAC, Rahal RMS, Soares LR, dos Santos DL, Thomazini MV, de Faria CFS, Paulinelli RR. Complete axillary dissection without drainage for the surgical treatment of breast cancer: a randomized clinical trial. Clinics (Sao Paulo) 2017; 72:426-431. [PMID: 28793003 PMCID: PMC5525160 DOI: 10.6061/clinics/2017(07)07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/16/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE: This randomized clinical trial evaluated the possibility of not draining the axilla following axillary dissection. METHODS: The study included 240 breast cancer patients who underwent axillary dissection as part of conservative treatment. The patients were divided into two groups depending on whether or not they were subjected to axillary drainage. ClinicalTrials.gov: NCT01267552. RESULTS: The median volume of fluid aspirated was significantly lower in the axillary drainage group (0.00 ml; 0.00 - 270.00) compared to the no drain group (522.50 ml; 130.00 - 1148.75). The median number of aspirations performed during conservative breast cancer treatment was significantly lower in the drainage group (0.5; 0.0 - 4.0) compared to the no drain group (5.0; 3.0 - 7.0). The total volume of serous fluid produced (the volume of fluid obtained from drainage added to the volume of aspirated fluid) was similar in the two groups. Regarding complications, two cases (2.4%) of wound dehiscence occurred in the drainage group compared to 13 cases (13.5%) in the group in which drainage was not performed, with this difference being statistically significant. Rates of infection, necrosis and hematoma were similar in both groups. CONCLUSION: Safety rates were similar in both study groups; hence, axillary dissection can feasibly be performed without drainage. However, more needle aspirations could be required, and there could be more cases of wound dehiscence in patients who do not undergo auxiliary drainage.
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Affiliation(s)
- Ruffo Freitas-Junior
- Gynecology and Breast Unit, Hospital Araújo Jorge, Goiás Anticancer Association, Goiânia, GO, BR
- Breast Program, Department of Gynecology and Obstetrics, School of Medicine, Federal University of Goiás, Goiânia, GO, BR
- *Corresponding author. E-mail:
| | | | | | - Geraldo Silva Queiroz
- Gynecology and Breast Unit, Hospital Araújo Jorge, Goiás Anticancer Association, Goiânia, GO, BR
| | | | | | - Rubens José Pereira
- Gynecology and Breast Unit, Hospital Araújo Jorge, Goiás Anticancer Association, Goiânia, GO, BR
| | | | - Rosemar Macedo Sousa Rahal
- Breast Program, Department of Gynecology and Obstetrics, School of Medicine, Federal University of Goiás, Goiânia, GO, BR
| | - Leonardo Ribeiro Soares
- Gynecology and Breast Unit, Hospital Araújo Jorge, Goiás Anticancer Association, Goiânia, GO, BR
| | | | - Maria Virginia Thomazini
- Breast Program, Department of Gynecology and Obstetrics, School of Medicine, Federal University of Goiás, Goiânia, GO, BR
| | | | - Régis Resende Paulinelli
- Gynecology and Breast Unit, Hospital Araújo Jorge, Goiás Anticancer Association, Goiânia, GO, BR
- Breast Program, Department of Gynecology and Obstetrics, School of Medicine, Federal University of Goiás, Goiânia, GO, BR
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Thomson DR, Trevatt AEJ, Furniss D. When should axillary drains be removed? A meta-analysis of time-limited versus volume controlled strategies for timing of drain removal following axillary lymphadenectomy. J Plast Reconstr Aesthet Surg 2016; 69:1614-1620. [PMID: 27777176 DOI: 10.1016/j.bjps.2016.09.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/20/2016] [Accepted: 09/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite numerous studies over the past few decades, the optimum strategy for deciding when to remove drains following axillary lymphadenectomy remains unknown. This meta-analysis aims to compare time-limited and volume-controlled strategies for drain removal. METHODS A total of 584 titles were identified following a systematic literature search of EMBASE, MEDLINE, Cinahl and the Cochrane library; 6 titles met our eligibility criteria. Data were extracted and independently verified by two authors. Time-limited drain removal was defined as drain removal at <5 days; volume-controlled strategies ranged from <20 ml/24 h to <50 ml/24 h. RESULTS In all the studies, the time-limited approach resulted in earlier drain removal. Development of a seroma is 2.54 times more likely with early drain removal (Mantel-Haenszel Fixed Odds Ratio (OR) 2.54, p < 0.00001). However, there is no difference in infection rates between early and late drain removal (OR = 1.07, p = 0.76). CONCLUSIONS This meta-analysis demonstrates that a strategy of early drain removal following axillary lymphadenectomy is safe, with no difference in infection rates; however, the incidence of seroma is significantly higher, which may necessitate more demanding outpatient care. There is a need for further well-designed clinical trials to address the clinical equipoise in this common area of surgical practice.
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Affiliation(s)
- David R Thomson
- Department of Plastic and Reconstructive Surgery, St George's Hospital, London, UK.
| | | | - Dominic Furniss
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
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Piñero-Madrona A, Castellanos-Escrig G, Abrisqueta-Carrión J, Canteras-Jordana M. Prospective randomized controlled study to assess the value of a hemostatic and sealing agent for preventing seroma after axillary lymphadenectomy. J Surg Oncol 2016; 114:423-7. [PMID: 27338717 DOI: 10.1002/jso.24344] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/14/2016] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Antonio Piñero-Madrona
- Department of General Surgery, "Virgen de la Arrixaca" University Hospital, Murcia, Spain
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Ouldamer L, Bonastre J, Brunet-Houdard S, Body G, Giraudeau B, Caille A. 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. BMJ Open 2016; 6:e009903. [PMID: 27044574 PMCID: PMC4823448 DOI: 10.1136/bmjopen-2015-009903] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Lobna Ouldamer
- Department of Gynecology, CHRU de Tours, Tours, France
- INSERM unit 1069, Tours, France
| | - Julia Bonastre
- Gustave Roussy, Service de Biostatistique et d'Epidemiologie, Villejuif, France
- CESP, Centre for Research in Epidemiology and Population Health, Villejuif, France
| | - Solène Brunet-Houdard
- Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
- CHRU de Tours, Unité d'Evaluation Médico-Economique, Tours, France
| | - Gilles Body
- Department of Gynecology, CHRU de Tours, Tours, France
- Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
| | - Bruno Giraudeau
- Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
- CHRU de Tours, Tours, France
| | - Agnès Caille
- Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
- CHRU de Tours, Tours, France
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Turner EJH, Benson JR, Winters ZE. Techniques in the prevention and management of seromas after breast surgery. Future Oncol 2015; 10:1049-63. [PMID: 24941989 DOI: 10.2217/fon.13.257] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Seromas are the most frequent complications following breast surgery, resulting in significant discomfort and morbidity with possible delays in commencing adjuvant therapies. Varied clinical practices exist in the techniques employed to prevent and manage seromata. This article assesses published literature on the techniques employed in prevention of seroma formation following breast surgery, evaluating the different methodologies used. Although prevention is the best strategy, seromata remain problematic and we consider their management. The principle findings were that prevention is key to the management of seromata. Methods employed to prevent seromata include suction drainage, shoulder immobilization, quilting sutures, fibrin sealants and innovative measures of managing the axilla, among others. The evidence demonstrated that a combination of quilting and drains significantly reduces the incidence and volumes of seromata. These effects are sustained by minimizing use of electrocautery, alongside increasing frequencies of axillary sentinel lymph node biopsies and node sampling. The efficacy data on fibrin sealants is inconclusive and consequently should not be routinely used alone or accompanied by quilting sutures. Clinically significant seromas deemed 'symptomatic' by patients and complicating infected seromas should be aspirated. There are limited data on the recommended treatment of established seromas with a paucity of high-quality studies and further research involving randomized trials are indicated.
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Affiliation(s)
- E Jane H Turner
- Department of Surgery, Croydon University Hospital, 530 London Road, Thornton Heath, Surrey, CR7 7YE, UK
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Ebner F, deGregorio N, Vorwerk E, Janni W, Wöckel A, Varga D. Should a drain be placed in early breast cancer surgery? Breast Care (Basel) 2014; 9:116-22. [PMID: 24944555 DOI: 10.1159/000360928] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The current surgical debate has led to a reduction in the extent of surgery performed and thereby to a reduced occurrence of surgical trauma and, over the recent years, reduced seroma formation. This reduction in surgical procedures calls the need for a drain into question. METHOD Using Google Scholar and the National Library of Medicine (PubMed), a literature review was performed on systematic reviews and meta-analyses regarding breast cancer surgery ± axillary dissection. Additionally, randomized trials for the time period after the last systematic review were included and evaluated according to the Jadad score. RESULTS The search returned 5 systematic reviews, in which a total of 1,075 patients were included (537 cases and 538 controls). Since the last review, no prospective randomized trial meeting the inclusion criteria has been published. The current reviews conclude that insertion of a drain is associated with a longer hospital stay and reduced seroma formation. The data regarding wound infection and drain insertion is inconclusive. The omission of a drain is associated with early discharge, reduced postsurgical pain, and early mobilization, but also with an increase in outpatient seroma aspirations. CONCLUSION The omission of a drain is possible in early breast cancer surgery (wide local excision and sentinel node biopsy) with adequate surgical techniques and instruments.
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Yue B, Nizzero D, Zhang C, van Zyl N, Ting J. Accuracy of surgical wound drainage measurements: an analysis and comparison. ANZ J Surg 2014; 85:327-9. [PMID: 24891212 DOI: 10.1111/ans.12657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Surgical drain tube readings can influence the clinical management of the post-operative patient. The accuracy of these readings has not been documented in the current literature and this experimental study aims to address this paucity. METHODS Aliquots (10, 25, 40 and 90 mL) of black tea solution prepared to mimic haemoserous fluid were injected into UnoVac, RedoVac and Jackson-Pratt drain tubes. Nursing and medical staff from a tertiary hospital were asked to estimate drain volumes by direct observation; analysis of variance was performed on the results and significance level was set at 0.05. RESULTS Doctors and nurses are equally accurate in estimating drain tube volumes. Jackson-Pratt systems were found to be the most accurate for intermediate volumes of 25 and 40 mL. For extreme of volumes (both high and low), all drainage systems were inaccurate. CONCLUSION This study suggests that for intermediate volumes (25 and 40 mL), Jackson-Pratt is the drainage system of choice. The accuracy of volume measurement is diminished at the extremes of drain volumes; emptying of drainage systems is recommended to avoid overfilling of drainage systems.
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Affiliation(s)
- Brian Yue
- Plastic and Reconstructive Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Thomson DR, Sadideen H, Furniss D. Wound drainage after axillary dissection for carcinoma of the breast. Cochrane Database Syst Rev 2013; 2013:CD006823. [PMID: 24158902 PMCID: PMC8606254 DOI: 10.1002/14651858.cd006823.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Axillary dissection is commonly performed for breast carcinoma. It is uncertain whether insertion of a drain reduces complication rates. OBJECTIVES To assess the effects of wound drainage after axillary dissection for breast carcinoma on the incidence of postoperative seroma formation. Secondary outcome measures include the incidence of infection and length of hospital stay. SEARCH METHODS We searched the Cochrane Wound and Breast Cancer Group's Specialised Registers (22 February 2013), MEDLINE (1950 to 22 February 2013), EMBASE (1966 to 22 February 2013), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (22 February 2013) for all prospectively registered and ongoing trials (22 February 2013). Reference lists of included studies were handsearched by two independent review authors to look for additional eligible trials. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing wound drainage versus no wound drainage in individuals after axillary dissection for the treatment of breast carcinoma were included. All disease stages were considered. Breast-conserving surgery and mastectomy were considered. Patients undergoing sentinel node biopsy without axillary dissection were not included. No limits were applied to language or study location. Two review authors independently determined the eligibility of each study. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data for each included study using a predesigned data extraction proforma and assessed risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. Discrepancies were resolved by consensus discussion with a third review author. Dichotomous variables were analysed using a Mantel-Haenszel model to produce odds ratios (ORs). Continuous variables were analysed using an inverse variance model to produce a mean difference (MD). MAIN RESULTS Seven RCTs including 960 participants were identified. The quality of trials was generally low, with several studies at risk of selection bias, and no studies used blinding during treatment or outcome assessment. There was a high level of statistical variation between the studies, which therefore reduces the reliability of the evidence. The OR for seroma formation was 0.46 (95% confidence interval (CI) 0.23 to 0.91, P = 0.03) in favour of a reduced incidence of seroma in participants with drains inserted. There was no significant difference in infection rates between drainage and no drainage groups (OR = 0.70; 95% CI 0.44 to 1.12, P = 0.14). The mean difference in length of hospital stay, reported in four trials consisting of 600 participants, was 1.47 days greater in the drained population (95% CI 0.67 to 2.28, P = 0.0003). A mean difference of 0.79 fewer postoperative seroma aspirations was found in the drained population (95% CI 1.23 to 0.35 fewer, P = 0.0004) in two trials including 212 participants. No significant difference in volume of seroma aspirations was reported (MD -19.44, 95% CI -59.45 to 20.57, P = 0.34) in three trials including 519 participants. No significant difference in the incidence of lymphoedema was noted (OR 2.31 favouring no drainage, 95% CI 0.47 to 11.37, P = 0.30), with only six instances reported in three trials of 360 participants, nor was any significant difference in the incidence of haematoma observed (OR 1.68, 95% CI 0.33 to 8.51, P = 0.53), with only five instances reported in two trials of 314 participants. AUTHORS' CONCLUSIONS There is limited quality evidence that insertion of a drain following axillary lymphadenectomy reduced the odds of developing a seroma and reduced the number of post-operative seroma aspirations. These benefits should be balanced against an increased length of hospital stay in the drained population.
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Affiliation(s)
- David R Thomson
- Oxford University Clinical Academic Graduate School, University of Oxford, John Radcliffe Hospital, Medical Sciences Division, Level 3, John Radcliffe Hospital., Oxford, Oxfordshire, UK, OX3 9DU
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Docimo G, Limongelli P, Conzo G, Gili S, Bosco A, Rizzuto A, Amoroso V, Marsico S, Leone N, Esposito A, Vitiello C, Fei L, Parmeggiani D, Docimo L. Axillary lymphadenectomy for breast cancer in elderly patients and fibrin glue. BMC Surg 2013; 13 Suppl 2:S8. [PMID: 24266959 PMCID: PMC3851152 DOI: 10.1186/1471-2482-13-s2-s8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
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.
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Intérêt d’un combipatch de thrombine et de fibrinogène dans la prévention des lymphocèles après curage axillaire. ACTA ACUST UNITED AC 2013; 41:583-7. [DOI: 10.1016/j.gyobfe.2013.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 05/27/2013] [Indexed: 11/20/2022]
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Yang Y, Gao E, Liu X, Ye Z, Chen Y, Li Q, Qu J, Dai X, Wang O, Pan Y, Zhang X. Effectiveness of OK-432 (Sapylin) to reduce seroma formation after axillary lymphadenectomy for breast cancer. Ann Surg Oncol 2012; 20:1500-4. [PMID: 23104710 DOI: 10.1245/s10434-012-2728-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Yinlong Yang
- Department of Surgical Oncology, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang, People's Republic of China
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Efficacy of fibrin glue on seroma formation after breast surgery. Int J Breast Cancer 2012; 2012:643132. [PMID: 23008776 PMCID: PMC3447350 DOI: 10.1155/2012/643132] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 07/16/2012] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Kathryn T Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Hinten F, van den Einden LCG, Hendriks JCM, van der Zee AGJ, Bulten J, Massuger LFAG, van de Nieuwenhof HP, de Hullu JA. Risk factors for short- and long-term complications after groin surgery in vulvar cancer. Br J Cancer 2011; 105:1279-87. [PMID: 21970884 PMCID: PMC3241565 DOI: 10.1038/bjc.2011.407] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: The cornerstone of treatment in early-stage squamous cell carcinoma (SCC) of the vulva is surgery, predominantly consisting of wide local excision with elective uni- or bi-lateral inguinofemoral lymphadenectomy. This strategy is associated with a good prognosis, but also with impressive treatment-related morbidity. The aim of this study was to determine risk factors for the short-term (wound breakdown, infection and lymphocele) and long-term (lymphoedema and cellulitis/erysipelas) complications after groin surgery as part of the treatment of vulvar SCC. Methods: Between January 1988 and June 2009, 164 consecutive patients underwent an inguinofemoral lymphadenectomy as part of their surgical treatment for vulvar SCC at the Department of Gynaecologic Oncology at the Radboud University Nijmegen Medical Centre. The clinical and histopathological data were retrospectively analysed. Results: Multivariate analysis showed that older age, diabetes, ‘en bloc’ surgery and higher drain production on the last day of drain in situ gave a higher risk of developing short-term complications. Younger age and lymphocele gave higher risk of developing long-term complications. Higher number of lymph nodes dissected seems to protect against developing any long-term complications. Conclusion: Our analysis shows that patient characteristics, extension of surgery and postoperative management influence short- and/or long-term complications after inguinofemoral lymphadenectomy in vulvar SCC patients. Further research of postoperative management is necessary to analyse possibilities to decrease the complication rate of inguinofemoral lymphadenectomy; although the sentinel lymph node procedure appears to be a promising technique, in ∼50% of the patients an inguinofemoral lymphadenectomy is still indicated.
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Affiliation(s)
- F Hinten
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, HB Nijmegen, The Netherlands.
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van Bemmel A, van de Velde C, Schmitz R, Liefers G. Prevention of seroma formation after axillary dissection in breast cancer: A systematic review. Eur J Surg Oncol 2011; 37:829-35. [DOI: 10.1016/j.ejso.2011.04.012] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 04/03/2011] [Accepted: 04/25/2011] [Indexed: 10/17/2022] Open
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Ostapoff KT, Euhus D, Xie XJ, Rao M, Moldrem A, Rao R. Axillary lymph node dissection for breast cancer utilizing Harmonic Focus®. World J Surg Oncol 2011; 9:90. [PMID: 21843361 PMCID: PMC3170616 DOI: 10.1186/1477-7819-9-90] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 08/15/2011] [Indexed: 12/28/2022] Open
Abstract
Background For patients with axillary lymph node metastases from breast cancer, performance of a complete axillary lymph node dissection (ALND) is the standard approach. Due to the rich lymphatic network in the axilla, it is necessary to carefully dissect and identify all lymphatic channels. Traditionally, these lymphatics are sealed with titanium clips or individually sutured. Recently, the Harmonic Focus®, a hand-held ultrasonic dissector, allows lymphatics to be sealed without the utilization of clips or ties. We hypothesize that ALND performed with the Harmonic Focus® will decrease operative time and reduce post-operative complications. Methods Retrospective review identified all patients who underwent ALND at a teaching hospital between January of 2005 and December of 2009. Patient demographics, presenting pathology, treatment course, operative time, days to drain removal, and surgical complications were recorded. Comparisons were made to a selected control group of patients who underwent similar surgical procedures along with an ALND performed utilizing hemostatic clips and electrocautery. A total of 41 patients were included in this study. Results Operative time was not improved with the use of ultrasonic dissection, however, there was a decrease in the total number of days that closed suction drainage was required, although this was not statistically significant. Complication rates were similar between the two groups. Conclusion In this case-matched retrospective review, there were fewer required days of closed suction drainage when ALND was performed with ultrasonic dissection versus clips and electrocautery.
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Affiliation(s)
- Katherine T Ostapoff
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9155, USA.
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Phillips BT, Wang ED, Mirrer J, Lanier ST, Khan SU, Dagum AB, Bui DT. Current Practice Among Plastic Surgeons of Antibiotic Prophylaxis and Closed-Suction Drains in Breast Reconstruction. Ann Plast Surg 2011; 66:460-5. [DOI: 10.1097/sap.0b013e31820c0593] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Arsalani-Zadeh R, ElFadl D, Yassin N, MacFie J. Evidence-based review of enhancing postoperative recovery after breast surgery. Br J Surg 2011; 98:181-96. [PMID: 21104705 DOI: 10.1002/bjs.7331] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The introduction of enhanced recovery after surgery (ERAS) protocols has revolutionized preoperative and postoperative care. To date, however, the principles of enhanced recovery have not been applied specifically to patients undergoing breast surgery. METHODS Based on the core features of ERAS, individual aspects of postoperative care in breast surgery were defined. A comprehensive search of MEDLINE, PubMed, Embase and the Cochrane Library database was performed from 1980 to 2010 to determine the best evidence for perioperative care in oncological breast surgery. A graded recommendation based on the best level of evidence was then proposed for each feature of ERAS. RESULTS Twelve core features of enhanced recovery after breast surgery were identified. Use of the thoracic block, from both analgesic and anaesthetic viewpoints, is well supported by evidence and should be encouraged. Trials specific to breast surgery regarding aspects such as perioperative fasting, preanaesthetic medication, prevention of hypothermia and postdischarge support are scarce, and evidence was extrapolated from non-breast trials. Trials on postoperative analgesia and prevention of postoperative nausea and vomiting in breast surgery are generally of small numbers. In addition, there is heterogeneity between studies. CONCLUSION This review suggests that the principles of enhanced recovery can be adopted in breast surgery. A 12-point protocol is proposed for prospective evaluation.
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Affiliation(s)
- R Arsalani-Zadeh
- Postgraduate Medical Institute, University of Hull, Hull HU6 7RX, UK
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Whether drainage should be used after surgery for breast cancer? A systematic review of randomized controlled trials. Med Oncol 2010; 28 Suppl 1:S22-30. [DOI: 10.1007/s12032-010-9673-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 08/24/2010] [Indexed: 11/26/2022]
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Saratzis A, Soumian S, Willetts R, Rastall S, Stonelake PS. Use of multiple drains after mastectomy is associated with more patient discomfort and longer postoperative stay. Clin Breast Cancer 2010; 9:243-6. [PMID: 19933080 DOI: 10.3816/cbc.2009.n.041] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Seromas constitute a common complication following surgery for breast cancer, and closed drainage is used routinely to reduce its incidence. The aim of this study was to evaluate the influence of number of drains on patient discomfort, seroma formation, and hospital stay during the immediate postoperative period after mastectomy for breast cancer. PATIENTS AND METHODS Based on a retrospective review of our clinical database, 110 consecutive patients from January 2004 through January 2006 who had undergone a mastectomy and axillary clearance for breast cancer were sent a simple postal questionnaire for collection of data. RESULTS A total of 70 patients responded (all women; mean age, 69.4 +/- 11.4 years). Twenty-seven patients (38.57%) had 3 drains implanted unilaterally, 24 (34.28%) had 2, and 19 (27.14%) had 1 drain. They were divided into 2 groups: the first group with 1 drain (19 patients) and the other with 2 or 3 drains (51 patients). Median postoperative hospital stay was 2 days (range, 1-8 days); patients with 1 drain had a significantly shorter postoperative hospital stay (median, 2 days [range, 1-4 days] vs. 2 days [range, 1-8 days]; Mann-Whitney U test, P = .02). A total of 15 patients (21.43%) complained of a seroma. There was no difference in seroma rates between groups. Patients who had a single drain implanted had a significantly lower rate of discomfort (median, 2 [range, 1-5] vs. 3 [range, 1-7]; Mann-Whitney U test; P = .04). CONCLUSION The number of drains used after a mastectomy for breast cancer did not significantly affect the rate or amount of seromas in this study, but the use of a single drain after mastectomy was significantly associated with less discomfort and shorter postoperative hospital stay.
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Abstract
Drains have been used in surgery for several years to remove body fluids thereby preventing the accumulation of serous fluid and improving wound healing. Drains may be classified as closed or open systems, and active or passive depending on their intended function. Closed vacuum drains apply negative suction in a sealed environment, producing apposition of tissues and thus promoting healing. Correct assessment of clinical indications might reduce unnecessary usage. This article will introduce the principles and practice of various types of drains and highlight the importance of understanding how surgical drains promote quality patient care.
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Affiliation(s)
- Rajaraman Durai
- Department of Surgery, University Hospital Lewisham, Lewisham High Street, London, SE13 6LH.
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Kim EY, Ko EY, Han BK, Shin JH, Hahn SY, Kang SS, Cho EY, Kim MJ, Chun SY. Sonography of axillary masses: what should be considered other than the lymph nodes? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:923-939. [PMID: 19546334 DOI: 10.7863/jum.2009.28.7.923] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE The purpose of this study was to review the sonographic findings of various axillary masses other than lymph nodes in correlation with other imaging and pathologic findings. METHODS From a sonographic database, we collected interesting cases of axillary masses with pathologic or other imaging corroboration from the last 10 years. RESULTS Images of various soft tissue masses were reviewed. They included masses associated with accessory breasts (fibroadenomas, hamartomas, fat necrosis, and cancer arising from axillary breasts), other soft tissue masses (lipomas, schwannomas, hemangiomas, fibromatosis, epidermoid cysts, and malignant fibrous histiocytomas), and complications presenting as masses after axillary lymph node dissection (seromas, hematomas, suture granulomas, pseudoaneurysms, and lymphangiectasia). CONCLUSIONS Awareness of the characteristic sonographic findings of various disease entities that cause axillary masses will help in the correct diagnosis of axillary masses.
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Affiliation(s)
- Eun Young Kim
- Department of Radiology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
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Volume-controlled vs no/short-term drainage after axillary lymph node dissection in breast cancer surgery: A meta-analysis. Breast 2009; 18:109-14. [DOI: 10.1016/j.breast.2009.02.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 12/24/2008] [Accepted: 02/12/2009] [Indexed: 11/18/2022] Open
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Effectiveness of fibrin glue in conjunction with collagen patches to reduce seroma formation after axillary lymphadenectomy for breast cancer. Am J Surg 2008; 196:170-4. [PMID: 18639659 DOI: 10.1016/j.amjsurg.2007.09.042] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 09/07/2007] [Accepted: 09/07/2007] [Indexed: 11/21/2022]
Abstract
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.
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Unalp HR, Onal MA. Analysis of Risk Factors Affecting the Development of Seromas Following Breast Cancer Surgeries: Seromas Following Breast Cancer Surgeries. Breast J 2007; 13:588-92. [DOI: 10.1111/j.1524-4741.2007.00509.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McCarthy CM, Disa JJ, Pusic AL, Mehrara BJ, Cordeiro PG. The Effect of Closed-Suction Drains on the Incidence of Local Wound Complications following Tissue Expander/Implant Reconstruction: A Cohort Study. Plast Reconstr Surg 2007; 119:2018-2022. [PMID: 17519694 DOI: 10.1097/01.prs.0000260586.55628.29] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this investigation was to evaluate the effect of drains on complications, including infection, seroma, and hematoma formation, in patients undergoing exchange of a temporary expander for a permanent breast implant. METHODS A review of all tissue expander/implant breast reconstructions performed at a single center from 1997 to 2004 was undertaken. Two patient cohorts were identified: patients who underwent exchange of their expander to a permanent implant with the use of closed-suction drains and patients who underwent the exchange procedure without the use of drains. The incidence of infection, seroma, and hematoma formation was determined for each cohort. Chi-square and two-sample t tests were performed for categorical and continuous variables, respectively. RESULTS A total of 2446 exchange procedures in 1863 patients were performed. In 1495 reconstructions (1165 patients), drains were placed after the exchange procedure; in 951 reconstructions (698 patients), no drains were used. There was no difference in the overall rate of complications following the exchange procedure with or without the use of drains (p = 0.886). Specifically, there was no difference in the incidence of infection necessitating implant removal in the presence of drains compared with that in the absence of drains (p = 0.585). Similarly, there was no significant difference in the rate of hematoma/seroma formation with or without the use of drains (p = 0.742). CONCLUSION The use of periprosthetic, closed-suction drains after exchange of a temporary expander for a permanent breast implant does not affect the incidence of perioperative complications, including infection, seroma, and hematoma formation.
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Tjalma WAA. Suction drain-induced haemorrhage after nerve- and vessel-sparing axillary lymph node dissection for breast cancer. Breast 2006; 15:443-5. [PMID: 16171995 DOI: 10.1016/j.breast.2005.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Revised: 04/30/2005] [Accepted: 07/04/2005] [Indexed: 11/24/2022] Open
Abstract
Suction drainage following axillary lymph node dissection for breast cancer is generally accepted as a routine measure for reducing seroma formation. When performing more nerve- and vessel-sparing axillary lymph node dissection, nerves and vessels can be ruptured by the suction of the drainage system. In the literature no reports could be found describing this type of complication. When using a suction system, we recommend a low-pressure system and that the fully perforated drain should not reach or touch neighbouring vessels or nerves in the axilla when installed.
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Affiliation(s)
- W A A Tjalma
- Department of Gynecology and Gynecologic Oncology, University Hospital Antwerp, Wilrijkstraat 10 2650 Edegem, Belgium.
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Kuroi K, Shimozuma K, Taguchi T, Imai H, Yamashiro H, Ohsumi S, Saito S. Evidence-Based Risk Factors for Seroma Formation in Breast Surgery. Jpn J Clin Oncol 2006; 36:197-206. [PMID: 16684859 DOI: 10.1093/jjco/hyl019] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Seroma is a common problem in breast surgery. The aim of this systematic review was to identify risk factors for seroma formation. METHODS Articles published in English were obtained from searches of Medline and additional references were found in the bibliographies of these articles. Risk factors were graded according to the quality and strength of evidence and to the direction of association. RESULTS One meta-analysis, 51 randomized controlled trials, 7 prospective studies and 7 retrospective studies were identified. There was no risk factor supported by strong evidence, but there was moderate evidence to support a risk for seroma formation in individuals with heavier body weight, extended radical mastectomy as compared with simple mastectomy, and greater drainage volume in the initial 3 days. On the other hand, the following factors did not have a significant influence on seroma formation: duration of drainage; hormone receptor status; immobilization of the shoulder; intensity of negative suction pressure; lymph node status or lymph node positivity; number of drains; number of removed lymph nodes; previous biopsy; removal of drains on the fifth postoperative day versus when daily drainage volume fell to minimal; stage; type of drainage (closed suction versus static drainage); and use of fibrinolysis inhibitor. In contrast, sentinel lymph node biopsy reduced seroma formation. Evidence was weak, or unproven, for other factors that were commonly cited in the literature. CONCLUSIONS Although a number of factors have been correlated with seroma formation, strong evidence is still scarce. However, there is evidence showing that sentinel lymph node biopsy reduces seroma formation.
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Affiliation(s)
- Katsumasa Kuroi
- Division of Surgery and Breast Oncology, Nyuwakai Oikawa Hospital, 2-21-16 Hirao, Chuo-ku, Fukuoka 810-0014, Japan.
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