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Vanessa T, Sally K, Johanna S, Andreas E, Lukas P, Norbert H. Quality of life in breast reconstruction: a comparison of lightweight and conventional breast implants. Arch Gynecol Obstet 2024:10.1007/s00404-024-07572-5. [PMID: 38874778 DOI: 10.1007/s00404-024-07572-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 05/27/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Due to the declining mortality rates of breast carcinoma and the rising incidence of risk-reducing mastectomies, enhancing the quality of life after breast reconstructions has become an increasingly important goal. The advantages of lightweight breast implants (B-Lite®) may significantly contribute to achieving this objective. This study aims to investigate whether lightweight implants are suitable for patients undergoing breast reconstruction and could improve the quality of life in comparison to conventional implants. METHODS In this study, we retrospectively analyzed 48 patients (38 implants in each group) who underwent implant-based breast reconstruction with either B-Lite® or conventional breast implants between 2019 and 2022 at the University Center for Plastic Surgery in Regensburg. As part of the postoperative follow-up, a clinical examination and a survey using the Breast-Q® questionnaire were conducted to evaluate the postoperative quality of life. RESULTS The implants used were similar in weight and shape. On average, the B-Lite® implants had a higher implant volume and patients in this group had a slightly higher BMI. Patients who received B-Lite® implants showed a significantly better result regarding the sensation of sensitivity in the surgical area and the scar formation also appeared to be more favorable. However, patients with B-Lite® implants perceived their implants as more uncomfortable than those with conventional breast implants. In other terms concerning quality of life, both groups appeared similar. CONCLUSION In summary, there are confounding factors that could influence the outcome of some aspects in this study, which could not be avoided due to the retrospective study design and the temporary suspension of B-Lite implants. Nevertheless, as the first of its kind, this study demonstrated that B-Lite implants could also be suitable for usage in breast reconstructions, thus providing an important foundation for further prospective studies to build upon.
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Affiliation(s)
- Tessmann Vanessa
- Center of Plastic, Hand and Reconstructive Surgery, University Hospital, Regensburg, Germany
| | - Kempa Sally
- Center of Plastic, Hand and Reconstructive Surgery, University Hospital, Regensburg, Germany
| | - Stern Johanna
- Center of Plastic, Hand and Reconstructive Surgery, University Hospital, Regensburg, Germany.
| | - Eigenberger Andreas
- Center of Plastic, Hand and Reconstructive Surgery, University Hospital, Regensburg, Germany
| | - Prantl Lukas
- Center of Plastic, Hand and Reconstructive Surgery, University Hospital, Regensburg, Germany
| | - Heine Norbert
- Center of Plastic, Hand and Reconstructive Surgery, University Hospital, Regensburg, Germany
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Spiekerman van Weezelenburg MA, Daemen JHT, van Kuijk SMJ, van Haaren ERM, Janssen A, Vissers YLJ, Beets GL, van Bastelaar J. Seroma formation after mastectomy: A systematic review and network meta-analysis of different flap fixation techniques. J Surg Oncol 2024; 129:1015-1024. [PMID: 38247263 DOI: 10.1002/jso.27589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024]
Abstract
Flap fixation is the most promising solution to prevent seroma formation after mastectomy. In this systematic review with network meta-analysis (NMA), three different techniques were compared. The NMA included 25 articles, comprising 3423 patients, and revealed that sutures are superior to tissue glue in preventing clinically significant seroma. In addition, running sutures seemed to be superior to interrupted sutures. An RCT comparing these suture techniques seems necessary, given the quality and nature of existing literature.
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Affiliation(s)
| | - Jean H T Daemen
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, 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 Centre, Sittard-Geleen, The Netherlands
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Rodicio Miravalles JL, Méndez CSM, Lopez-Monclus J, Moreno Gijón M, López Quindós P, Amoza Pais S, López López A, García Bear I, Menendez de Llano Ortega R, Díez Pérez de Las Vacas MI, Garcia-Urena MA. Short-term outcomes of a multicentre prospective study using a "visible" polyvinylidene fluoride onlay mesh for the prevention of midline incisional hernia. Langenbecks Arch Surg 2024; 409:136. [PMID: 38652308 DOI: 10.1007/s00423-024-03307-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Prophylactic meshes in high-risk patients prevent incisional hernias, although there are still some concerns about the best layer to place them in, the type of fixation, the mesh material, the significance of the level of contamination, and surgical complications. We aimed to provide answers to these questions and information about how the implanted material behaves based on its visibility under magnetic resonance imaging (MRI). METHOD This is a prospective multicentre observational cohort study. Preliminary results from the first 3 months are presented. We included general surgical patients who had at least two risk factors for developing an incisional hernia. Multivariate logistic regression was used. A polyvinylidene fluoride (PVDF) mesh loaded with iron particles was used in an onlay position. MRIs were performed 6 weeks after treatment. RESULTS Between July 2016 and June 2022, 185 patients were enrolled in the study. Surgery was emergent in 30.3% of cases, contaminated in 10.7% and dirty in 11.8%. A total of 5.6% of cases had postoperative wound infections, with the requirement of stoma being the only significant risk factor (OR = 7.59, p = 0.03). The formation of a seroma at 6 weeks detected by MRI, was associated with body mass index (OR = 1.13, p = 0.02). CONCLUSIONS The prophylactic use of onlay PVDF mesh in midline laparotomies in high-risk patients was safe and effective in the short term, regardless of the type of surgery or the level of contamination. MRI allowed us to detect asymptomatic seromas during the early process of integration. STUDY REGISTRATION This protocol was registered at ClinicalTrials.gov (NCT03105895).
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Affiliation(s)
- José Luis Rodicio Miravalles
- Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Avda de Roma, s/n, Oviedo, Asturias, 33011, Spain.
| | - Carlos San Miguel Méndez
- Division of General Surgery, Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Hospital Universitario del Henares, Madrid, Spain
| | - Javier Lopez-Monclus
- Division of General Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - María Moreno Gijón
- Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Avda de Roma, s/n, Oviedo, Asturias, 33011, Spain
| | - Patricia López Quindós
- Division of General Surgery, Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Hospital Universitario del Henares, Madrid, Spain
| | - Sonia Amoza Pais
- Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Avda de Roma, s/n, Oviedo, Asturias, 33011, Spain
| | - Antonio López López
- Division of General Surgery, Hospital Universitario Nuestra Señora del Prado, Toledo, Spain
| | - Isabel García Bear
- Division of General Surgery, Hospital Universitario San Agustin, Avilés, Spain
| | | | | | - Miguel Angel Garcia-Urena
- Division of General Surgery, Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria, Hospital Universitario del Henares, Madrid, Spain
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Hakseven M, Avşar G, Çetindağ Ö, Deryol R, Benk MS, Sırgancı G, Culcu S, Ünal AE, Bayar S. Prospective Study on Avoiding Seroma Formation by Flap Fixation After Modified Radical Mastectomy. Am Surg 2024; 90:533-540. [PMID: 37183415 DOI: 10.1177/00031348231175497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Seroma development after mastectomy is a common complication. Continued seroma causes increased outpatient visits, repeated aspirations, infection, delayed healing, delayed adjuvant therapy, and increased cost. Various treatments are being attempted to prevent and reduce seroma development. We examined the effects of flap fixation on seroma using absorbable sutures after modified radical mastectomy (MRM). METHODS The prospectively recorded data of patients who underwent surgery for breast cancer were analyzed retrospectively. 72 consecutive patients who underwent MRM were included in the study. Patients who underwent MRM in the same way by the same surgeon were divided into two groups: the group whose wound was closed by fixing the flap to the chest wall with an absorbable suture (group A), and the group whose wound was closed with the classical method (group B). The groups were compared in terms of seroma development, clinicopathological data, and early complications. RESULTS Drain removal time and the total amount of drained fluid in group A patients were significantly lower than drain removal time and the total amount of drained fluid in group B patients (P < .001). Similarly, the amount of aspirated seroma in the control examinations of group A patients was significantly lower than that in group B (P < .05). Group B needed re-aspiration significantly more than group A (P < .05). CONCLUSIONS Flap fixation with suture after MRM is a method that reduces seroma formation and the amount of drained fluid, enables early removal of the drain, prevents delay in starting adjuvant treatment, is more comfortable for the patient and physician, and is also inexpensive.
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Affiliation(s)
- Musluh Hakseven
- Department of Surgical Oncology, School of Medicine, Ankara University, Ankara, Turkey
| | - Gökhan Avşar
- Department of Surgical Oncology, School of Medicine, Ankara University, Ankara, Turkey
| | - Özhan Çetindağ
- Department of Surgical Oncology, School of Medicine, Ankara University, Ankara, Turkey
| | - Rıza Deryol
- Department of Surgical Oncology, School of Medicine, Ankara University, Ankara, Turkey
| | - Mehmet Sah Benk
- Department of Surgical Oncology, School of Medicine, Ankara University, Ankara, Turkey
| | - Gözde Sırgancı
- Department of Measurement and Evaluation, Bozok University Faculty of Education, Yozgat, Turkey
| | - Serdar Culcu
- Department of Surgical Oncology, School of Medicine, Ankara University, Ankara, Turkey
| | - Ali Ekrem Ünal
- Department of Surgical Oncology, School of Medicine, Ankara University, Ankara, Turkey
| | - Sancar Bayar
- Department of Surgical Oncology, School of Medicine, Ankara University, Ankara, Turkey
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Spiekerman van Weezelenburg MA, de Rooij L, Aldenhoven L, van Kuijk SMJ, van Haaren ERM, Janssen A, Vissers YLJ, Beets GL, van Bastelaar J. Drain-free mastectomy and flap fixation: The interim analysis of a randomized controlled noninferiority trial. J Surg Oncol 2024; 129:975-980. [PMID: 38173366 DOI: 10.1002/jso.27577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Flap fixation after mastectomy has proven to be one of the most promising solutions to reduce seroma formation. Drain placement remains standard practice in many clinics, even though this may be redundant after flap fixation. METHODS This is a prospective randomized controlled trial comparing mastectomy and wound closure using flap fixation with or without drain placement. The primary outcome measure was clinically significant seroma (CSS) incidence. The aim of this interim analysis was to assess the assumptions for the sample size calculation and to provide preliminary results. RESULTS Between July 2020 and January 2023, 112 patients were included. CSS incidence was 9.1% in the drain group and 21% in the no-drain group. In total, 10 patients were lost to follow-up. These numbers are similar to the ones used for the sample size calculation. In the drain group, three patients required interventions for wound complications compared to nine in the no-drain group (odds ratio: 3.612 [95% confidence interval: 0.898-14.537]). CONCLUSION The sample size calculation seems to be correct and no protocol amendments are necessary. Current preliminary results show no significant differences in CSS incidence. Complete results should be awaited to draw a well-powered conclusion regarding drain policy after mastectomy.
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Affiliation(s)
| | - Lisa de Rooij
- Department of Surgery, Zuyderland Medical Centre, Sittard, Limburg, the Netherlands
| | - Loeki Aldenhoven
- Department of Surgery, Zuyderland Medical Centre, Sittard, Limburg, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Centre, Sittard, Limburg, the Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Centre, Sittard, Limburg, 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 Centre, Sittard, Limburg, the Netherlands
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Vu L, Jeganathan C, Ponniah K, Ofri A. Trainees as primary operators do not significantly impact perioperative complication rates in breast surgery. Surgeon 2024; 22:121-124. [PMID: 38105134 DOI: 10.1016/j.surge.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND There is a trend for specialist care in breast surgery resulting in fewer primary operative cases for general surgery trainees; and subsequently that trainees performing advanced oncoplastic techniques in breast surgery may negatively impact patient morbidity. We have reviewed the complication rates between Australian general surgery trainees and Breast Consultants. METHODS A retrospective analysis was performed over a 5-year period (January 2016-December 2021). The key endpoints measured were relative complication rates for consultants compared to trainees, subdivided by surgery type. Surgeries were categorised as either benign, primary breast cancer surgery or re-excision. RESULTS A total of 2646 operative cases were performed with the primary operator rate for consultants 58.35 % (n = 1544) and for trainees 41.65 %% (n = 1102). The overall complication rate was 2.83 % (n = 75); the overall rate for the consultants was 2.65 % and 3.08 % for the trainees. The complication rates were not statistically significant (p = 0.59) between the two groups. The mastectomy only complication rate was higher in the consultant group with a result of 7.3 % compared to 2.8 % for the trainees however was not statistically significant (p = 0.18). The most common complication was haematoma formation for both groups. CONCLUSIONS This study has demonstrated that trainees can safely perform advanced oncoplastic techniques without statistically elevated morbidity. In an era where breast surgery caseloads are increasing, but the exposure to breast surgery during training are decreasing, it is necessary to implement a practice where trainees can perform breast operations under supervision at a specialized unit.
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Affiliation(s)
- Linda Vu
- Breast Clinic, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia; University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia.
| | - Chaithanya Jeganathan
- Breast Clinic, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Kallyani Ponniah
- Breast Clinic, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia; University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia
| | - Adam Ofri
- Breast Clinic, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia; Department of Surgery, Mater Hospital, North Sydney, NSW 2060, Australia; Central Clinical School, University of Sydney, Sydney, NSW 2050, Australia; Royal Prince Alfred Hospital Institute of Academic Surgery, Camperdown, NSW 2050, Australia
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Spiekerman van Weezelenburg MA, Bakens MJAM, Daemen JHT, Aldenhoven L, van Haaren ERM, Janssen A, Vissers YLJ, Beets GL, van Bastelaar J. Prevention of Seroma Formation and Its Sequelae After Axillary Lymph Node Dissection: An Up-to-Date Systematic Review and Guideline for Surgeons. Ann Surg Oncol 2024; 31:1643-1652. [PMID: 38038792 DOI: 10.1245/s10434-023-14631-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify techniques to prevent seroma formation. The aim of this systematic review and network meta-analysis is to use available literature to identify the best intervention for prevention of seroma after standalone ALND. METHODS A literature search was performed for all comparative articles regarding seroma formation in patients undergoing a standalone ALND or ALND with breast-conserving surgery in the last 25 years. Data regarding seroma formation, clinically significant seroma (CSS), surgical site infections (SSI), and hematomas were collected. The network meta-analysis was performed using a random effects model and the level of inconsistency was evaluated using the Bucher method. RESULTS A total of 19 articles with 1962 patients were included. Ten different techniques to prevent seroma formation were described. When combining direct and indirect comparisons, axillary drainage until output is less than 50 ml per 24 h for two consecutive days results in significantly less CSS. The use of energy sealing devices, padding, tissue glue, or patches did not significantly reduce the incidence of CSS. When comparing the different techniques with regard to SSIs, no statistically significant differences were seen. CONCLUSIONS To prevent CSS after ALND, axillary drainage is the most valuable and scientifically proven measure. On the basis of the results of this systematic review with network meta-analysis, removing the drain when output is < 50 ml per 24 h for two consecutive days irrespective of duration seems best. Since drainage policies vary widely, an evidence-based guideline is needed.
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Affiliation(s)
| | - Maikel J A M Bakens
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Jean H T Daemen
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Loeki Aldenhoven
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | | | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, 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 Centre, Sittard-Geleen, The Netherlands
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López Gordo S, Ruiz-Edo N, Fernández-Planas MT, Viscaya-Martín S, Serra-Serra C. Seroma control in axillary lymphadenectomy with Glubran 2® without drain. Multicenter, prospective, randomized, clinical trial. GALA-ND study (Glubran, Axillary Lymphadenectomy, Ambulatory, No Drain). Trials 2024; 25:142. [PMID: 38388444 PMCID: PMC10885511 DOI: 10.1186/s13063-023-07840-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 11/30/2023] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Seroma after breast cancer surgery is a frequent entity; therefore, different products have been described in literature with the aim to reduce it. The most studied ones have been the sealants products, being tested with aspirative drains. Symptomatic seroma represents the 19% after axillary lymphadenectomy without drains. The aim of this study is to analyze the effect of a sealant in the seroma control after axillary lymphadenectomy without drains and identify the risk factors related to symptomatic seroma. METHODS This is a prospective, multicenter, international, and randomized clinical trial. Patients undergoing conservative surgery and axillary lymphadenectomy for breast cancer will be randomized to control group (lymphadenectomy without sealant) or interventional group (lymphadenectomy with sealant Glubran 2®). In any of the study groups, drains are placed. Patients who received neoadjuvant treatment are included. Measurements of the study outcomes will take place at baseline; at 7, 14, and 30 days post-surgery; and at 6-12 months. The primary outcome is symptomatic seroma. Secondary outcomes are seroma volume, morbidity, quality of life, and lymphedema. DISCUSSION Several studies compare the use of sealant products in axillary lymphadenectomy but generally with drains. We would like to demonstrate that patients who underwent axillary lymphadenectomy could benefit from an axillary sealant without drains and reduce axillary discomfort while maintaining a good quality of life. Assessing the relationship between axillary volume, symptoms, and related risk factors can be of great help in the control of seroma in patients who received breast cancer surgery. TRIAL REGISTRATION ClinicalTrials.gov, NCT05280353. Registration date 02 August 2022.
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Affiliation(s)
- Sandra López Gordo
- General Surgeon, Breast Cancer Unit of Maresme Health Consortium (Mataró Hospital), Carr. de Cirera, 230, 08304 Mataró, Barcelona, Spain.
- Associated professor at the Autonomous University of Barcelona (UAB), Bellaterra 08193, Barcelona, Spain.
| | - Neus Ruiz-Edo
- General Surgeon, Breast Cancer Unit of Maresme Health Consortium (Mataró Hospital), Carr. de Cirera, 230, 08304 Mataró, Barcelona, Spain
| | - Maria Teresa Fernández-Planas
- General Surgeon, Breast Cancer Unit of Maresme Health Consortium (Mataró Hospital), Carr. de Cirera, 230, 08304 Mataró, Barcelona, Spain
- Radiologist, Breast Cancer Unit of Maresme Health Consortium (Mataró Hospital), Carr. de Cirera, 230, 08304 Mataró, España
| | - Sara Viscaya-Martín
- General Surgeon, Breast Cancer Unit of Maresme Health Consortium (Mataró Hospital), Carr. de Cirera, 230, 08304 Mataró, Barcelona, Spain
| | - Cristina Serra-Serra
- General Surgeon, Breast Cancer Unit of Maresme Health Consortium (Mataró Hospital), Carr. de Cirera, 230, 08304 Mataró, Barcelona, Spain
- Gynecologist, Breast Cancer Unit of Maresme Health Consortium (Mataró Hospital), Carr. de Cirera, 230, 08304 Mataró, España
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Fairhurst K, Roberts K, Fairbrother P, Potter S. Current use of drains and management of seroma following mastectomy and axillary surgery: results of a United Kingdom national practice survey. Breast Cancer Res Treat 2024; 203:187-196. [PMID: 37878150 PMCID: PMC10787912 DOI: 10.1007/s10549-023-07042-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/06/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE Up to 40% of the 56,000 women diagnosed with breast cancer each year in the UK undergo mastectomy. Seroma formation following surgery is common, may delay wound healing, and be uncomfortable or delay the start of adjuvant treatment. Multiple strategies to reduce seroma formation include surgical drains, flap fixation and external compression exist but evidence to support best practice is lacking. We aimed to survey UK breast surgeons to determine current practice to inform the feasibility of undertaking a future trial. METHODS An online survey was developed and circulated to UK breast surgeons via professional and trainee associations and social media to explore current attitudes to drain use and management of post-operative seroma. Simple descriptive statistics were used to summarise the results. RESULTS The majority of surgeons (82/97, 85%) reported using drains either routinely (38, 39%) or in certain circumstances (44, 45%). Other methods for reducing seroma such as flap fixation were less commonly used. Wide variation was reported in the assessment and management of post-operative seromas. Over half (47/91, 52%) of respondents felt there was some uncertainty about drain use after mastectomy and axillary surgery and two-thirds (59/91, 65%) felt that a trial evaluating the use of drains vs no drains after simple breast cancer surgery was needed. CONCLUSIONS There is a need for a large-scale UK-based RCT to determine if, when and in whom drains are necessary following mastectomy and axillary surgery. This work will inform the design and conduct of a future trial.
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Affiliation(s)
- K Fairhurst
- Centre for Surgical Research, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England.
| | - K Roberts
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - P Fairbrother
- Independent Cancer Patient Voice (ICPV), London, England
| | - S Potter
- Centre for Surgical Research, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
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Kim JW, Jeon HH, Lee JY. Latissimus Dorsi Muscle Sling for Reconstruction of Chronic Seroma Pocket in the Axillary Fossa. Am Surg 2023; 89:6267-6269. [PMID: 36271653 DOI: 10.1177/00031348221135775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Managing chronic axillary seroma after breast cancer surgery is troublesome because of the challenges in obliterating the seroma pocket and the possible injury to the axillary neurovascular bundles during the procedure. Using the muscle sling technique, we successfully managed an axillary chronic seroma patient after mastectomy with a latissimus dorsi musculocutaneous (LDMC) flap.A 64-year-old woman with right breast cancer underwent radical mastectomy with axillary lymph node dissection 17 years ago. A mass of chronic seroma was observed in the right axilla 1 year postoperatively and gradually increased in size. The refractory seroma was excised. The LDMC flap was designed to obliterate the pocket, rotated counterclockwise, and fixed to the upper boundary of the pectoralis major in a U-shaped sling. In this way, the direct suture of the flap to the vessels-crossing axillary apex could be avoided, and the flap's lymphatic-rich fat tissue promoted alternative lymphatic drainage that improved lymphedema.
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Affiliation(s)
- Jae Won Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hui Hyung Jeon
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Yong Lee
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Dehariya P, Agarwal N, Yadav SK, Agarwal P, Sharma D. Impact of Topical Epinephrine with Xylocaine on Drainage After Axillary Lymph Node Dissection: A Randomized Controlled Trial. World J Surg 2023; 47:2761-2766. [PMID: 37581639 DOI: 10.1007/s00268-023-07139-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION We evaluated the impact of topical epinephrine with xylocaine on drainage after axillary lymph node dissection. METHODS Fifty-two women were randomized into two groups, epinephrine with xylocaine drainage (ED) and conventional drainage group (CD). The amount of drainage, duration of drainage catheter, incidence of seroma formation and wound infection were noted. RESULTS The mean total drainage volume was less in ED group as compared to CD group (195 ml vs. 353 ml; p = .002). Drainage catheter was removed earlier in ED group as compared to CD group (5.07 + / - 0.99 days vs. 6.65 + / - 1.07 days; p = 0.0001). The incidence of seroma and wound infection was similar in two groups. CONCLUSION Topical epinephrine with xylocaine after axillary lymph node dissection results in significantly decreased drainage volume and duration of drainage.
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Affiliation(s)
- Prerna Dehariya
- Department of Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, 482003, India
| | - Namrata Agarwal
- Department of Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, 482003, India
| | - Sanjay Kumar Yadav
- Department of Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, 482003, India.
| | - Pawan Agarwal
- Department of Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, 482003, India
| | - Dhananjaya Sharma
- Department of Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, 482003, India
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Mohammed M, Hamza H, Omar MI, Hussein M, Tohamy M, Farouk B, Rezk K. Effect of Clavipectoral Fascia Suturing on Postmastectomy Seroma Formation. POLISH JOURNAL OF SURGERY 2023; 96:31-37. [PMID: 38629279 DOI: 10.5604/01.3001.0053.5996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
<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>.
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Affiliation(s)
- Mahmoud Mohammed
- Department of surgical oncology, South Egypt Cancer Institute, Assiut University, Egypt, Clinical fellow, Worcestershire Royal Hospital NHS Trust, UK
| | - Hesham Hamza
- Department of surgical oncology, South Egypt Cancer Institute, Assiut University, Egypt
| | - Mohamed I Omar
- Department of surgical oncology, South Egypt Cancer Institute, Assiut University, Egypt
| | - Mohammed Hussein
- Department of General Surgery, Faculty of Medicine, Assiut University, Egypt
| | - Moaaz Tohamy
- Department of Anesthesia, Intensive Care and Pain Management, South Egypt Cancer Institute, Assiut University, Egypt
| | - Basma Farouk
- Department of Biostatistics and Cancer Epidemiology, South Egypt Cancer Institute, Assiut University, Egypt
| | - Khalid Rezk
- Department of surgical oncology, South Egypt Cancer Institute, Assiut University, Egypt
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Lin YS, Kuan CH, Tsai LW, Wu CH, Huang CH, Yeong EK, Tai HC, Huang CS. The effect of immediate lymphatic reconstruction on the post-operative drain output after axillary lymph node dissection for breast cancer: A retrospective comparative study. Microsurgery 2023; 43:555-562. [PMID: 36762663 DOI: 10.1002/micr.31007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 11/04/2022] [Accepted: 12/30/2022] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Axillary lymph node dissection (ALND) for breast cancer has been considered to be associated with a variety of complications, such as excessive postoperative wound drainage, prolonged drain placement, or seroma formation in the short term, or arm lymphedema in the long run. Immediate lymphedema reconstruction (ILR) has been proposed to reduce the occurrence of arm lymphedema by anastomosing the transected arm lymphatics to nearby branches of the axillary vein immediately after ALND. This study aims to demonstrate that ILR can also reduce the postoperative drainage amount. PATIENTS AND METHODS Between April 2020 and January 2022, a total of 76 breast cancer patients receiving ALND were reviewed. Forty four of them also received ILR immediately after ALND. The assignment of ILR surgery was non-random, based on patients' willingness and plastic surgeons' availability. The lymphatic vessels in the axillary wound were anastomosed with nearby terminal branches of the axillary vein under surgical microscope. Patients' characteristics, including age, body mass index (BMI), neoadjuvant therapy, type of breast surgery, the occurrence of seroma formation, number of removed lymph nodes, number of positive nodes, and the drainage amount from the operative wounds were compared between ILR and non-ILR groups. RESULTS No statistically significant difference was noted between groups in terms of age (56.5 ± 9.8 vs. 60.9 ± 10.7, p = .09), BMI (22.6 ± 3.7 vs. 23.7 ± 3.8, p = .27), type of breast surgery (p = .32), the occurrence of seroma formation (p = 1.0), the likelihood of receiving neoadjuvant therapy (p = .12), number of lymph nodes removed (17.5 ± 7.6 vs. 17.4 ± 8.3, p = .96), or number of positive nodes on final pathology (3.7 ± 5.4 vs. 4.8 ± 8.5, p = .53) except the ILR group had statistically significantly less drainage amount than non-ILR group (39.3 ± 2.6 vs. 48.3 ± 3.7, p = .046). CONCLUSION For breast cancer patients receiving ALND, the immediate lymphatic reconstruction can reduce the postoperative drainage amount from the operative wound.
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Affiliation(s)
- Ying-Sheng Lin
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chen-Hsiang Kuan
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Li-Wei Tsai
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- Department of Surgical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Chien-Hui Wu
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chieh-Huei Huang
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Eng-Kean Yeong
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Hao-Chih Tai
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chiun-Sheng Huang
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
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14
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Buch-Villa E, Castañer-Puga C, Delgado-Garcia S, Fuster-Diana C, Vidal-Herrador B, Ripoll-Orts F, Galeote-Quecedo T, Prat A, Andrés-Matias M, Jimeno-Fraile J, Muñoz-Sorsona E, Vento G, Gumbau-Puchol V, Adrianzen M, López-Flor V, Ortega J. Clinical and cost outcomes of a polyethylene glycol (PEG)-coated patch versus drainage after axillary lymph node dissection in breast cancer: results from a multicentre randomized clinical trial. Br J Surg 2023; 110:1180-1188. [PMID: 37311694 PMCID: PMC10416686 DOI: 10.1093/bjs/znad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/29/2023] [Accepted: 05/01/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND The aim of this study was to compare the clinical outcomes between breast cancer patients who underwent axillary lymph node dissection with postoperative management using a polyethylene glycol-coated patch versus axillary drainage. The direct costs associated with both postoperative management strategies were also evaluated. METHODS This was a multicentre RCT in women with breast cancer who underwent axillary lymph node dissection (ClinicalTrials.gov identifier: NCT04487561). Patients were randomly assigned (1 : 1) to receive either drainage or a polyethylene glycol-coated patch as postoperative management. The primary endpoints were the need for an emergency department visit for any event related to the surgery and the rate of seroma development. RESULTS A total of 227 patients were included , 115 in the patch group (50.7 per cent) and 112 (29.4 per cent ) in the drainage group. The incidence of emergency department visits was significantly greater for patients with drainage versus a polyethylene glycol-coated patch (incidence rate difference 26.1 per cent, 95 per cent c.i. 14.5 to 37.7 per cent; P < 0.001). Conversely, the seroma rate was significantly higher in the polyethylene glycol-coated patch group (incidence rate difference 22.8 per cent, 95 per cent c.i. 6.7 to 38.9 per cent; P < 0.0055). Compared with drainage, using a polyethylene glycol-coated patch resulted in cost savings of €100.41 per patient. An incremental cost-effectiveness ratio analysis found that drainage was associated with an incremental cost-effectiveness ratio of €7594.4 for no need for hospital admission and €491.7 for no need for an emergency department visit. CONCLUSION Compared with patients who received drainage after axillary lymph node dissection, the use of a polyethylene glycol-coated patch resulted in a higher rate of seroma, but a lower number of postoperative outpatient or emergency department visits and thus a reduction in overall costs.
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Affiliation(s)
- Elvira Buch-Villa
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | | | | | - Carlos Fuster-Diana
- Department of Surgery, Valencian Institute of Oncology (IVO), Valencia, Spain
| | - Beatriz Vidal-Herrador
- Department of Surgery, University Clinical Hospital of Santiago de Compostela, A Coruña, Spain
| | | | | | - Antonio Prat
- Department of Surgery, General Hospital of Requena, Valencia, Spain
| | | | - Jaime Jimeno-Fraile
- Department of Surgery, University Clinical Hospital of Marques de Valdecilla, Santander, Spain
| | - Ernesto Muñoz-Sorsona
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Giovani Vento
- Department of Surgery, Valencian Institute of Oncology (IVO), Valencia, Spain
| | | | - Marcos Adrianzen
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Vicente López-Flor
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Joaquín Ortega
- Department of Surgery, University Clinical Hospital of Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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15
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Zeelst LJV, Ten Wolde B, Plate JDJ, Volders JH, van Eekeren RRJP, Doeksen A, Hoven-Gondrie ML, Olieman AFT, van Riet YEA, van der Velden APS, Vijfhuize S, Witjes HHG, de Wilt JHW, Strobbe LJA. The QUILT study: quilting sutures in patients undergoing breast cancer surgery: a stepped wedge cluster randomized trial study. BMC Cancer 2023; 23:667. [PMID: 37460983 DOI: 10.1186/s12885-023-11154-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/04/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Seroma is the most common complication following breast cancer surgery, with reported incidence up to 90%. Seroma causes patient discomfort, is associated with surgical site infections (SSI), often requires treatment and increases healthcare consumption. The quilting suture technique, in which the skin flaps are sutured to the pectoralis muscle, leads to a significant reduction of seroma with a decrease in the number of aspirations and surgical site infections. However, implementation is lagging due to unknown side effects, increase in operation time and cost effectiveness. Main objective of this study is to assess the impact of large scale implementation of the quilting suture technique in patients undergoing mastectomy and/or axillary lymph node dissection (ALND). METHODS The QUILT study is a stepped wedge design study performed among nine teaching hospitals in the Netherlands. The study consists of nine steps, with each step one hospital will implement the quilting suture technique. Allocation of the order of implementation will be randomization-based. Primary outcome is 'textbook outcome', i.e.no wound complications, no re-admission, re-operation or unscheduled visit to the outpatient clinic and no increased use of postoperative analgesics. A total of 113 patients is required based on a sample size calculation. Secondary outcomes are shoulder function, cosmetic outcome, satisfaction with thoracic wall and health care consumption. Follow-up lasts for 6 months. DISCUSSION This will be one of the first multicentre prospective studies in which quilting without postoperative wound drain is compared with conventional wound closure. We hypothesize that quilting is a simple technique to increase textbook outcome, enhance patient comfort and reduce health care consumption.
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Affiliation(s)
- L J van Zeelst
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands.
| | - B Ten Wolde
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - J D J Plate
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - J H Volders
- Department of Surgical Oncology, Diakonessenhuis, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands
| | - R R J P van Eekeren
- Department of Surgical Oncology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - A Doeksen
- Department of Surgical Oncology, St. Antonius Hospital, Soestwetering 1, 3543 AZ, Nieuwegein, Netherlands
| | - M L Hoven-Gondrie
- Deparment of Surgical Oncology, Hospital Gelderse Vallei, Willy Brandtlaan 10, 6716 RP, Ede, Netherlands
| | - A F T Olieman
- Department of Surgical Oncology, Martini Hospital, Van Swietenplein 1, 9728 NT, Groningen, Netherlands
| | - Y E A van Riet
- Department of Surgical Oncology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, Netherlands
| | - A P Schouten van der Velden
- Department of Surgical Oncology, St. Jansdal Hospital, Wethouder Jansenlaan 90, 3844 DG, Harderwijk, Netherlands
| | - S Vijfhuize
- Deparment of Surgical Oncology, Bravis Hospital, Boerhaavelaan 25, 4708 AE, Roosendaal, Netherlands
| | - H H G Witjes
- Department of Surgical Oncology, Onze Lieve Vrouwe Gasthuis, Jan Tooropstraat 164, 1061 AE, Amsterdam, Netherlands
| | - J H W de Wilt
- Radboudumc Department of Surgical Oncology, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, Netherlands
| | - L J A Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
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16
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Köpke MB, Wild CM, Schneider M, Pochert N, Schneider F, Sagasser J, Kühn T, Untch M, Hinske C, Reiger M, Traidl-Hoffmann C, Dannecker C, Jeschke U, Ditsch N. Elderly and Patients with Large Breast Volume Have an Increased Risk of Seroma Formation after Mastectomy-Results of the SerMa Pilot Study. Cancers (Basel) 2023; 15:3606. [PMID: 37509269 PMCID: PMC10377181 DOI: 10.3390/cancers15143606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
The collective of the SerMa pilot study included 100 cases of primary breast cancer or Carcinoma in situ who had undergone a mastectomy procedure with or without reconstruction of the breast using an implant or expander at Augsburg University Hospital between 12/2019 and 12/2022. The study aimed to investigate possible causes of seroma formation; reported here are the clinicopathological correlations between seroma formation and tumor biology and surgical procedures. Seroma occurred significantly more often in patients with older age (median patient age in cases with seroma was 73 years vs. 52 years without seroma; p < 0.001). In addition, patients with larger mastectomy specimen were significantly more likely to develop seroma (median ablation weight in cases with seroma 580 g vs. 330 g without seroma; p < 0.001). Other significant parameters for seroma formation were BMI (p = 0.005), grading (p = 0.015) and tumor size (p = 0.036). In addition, with insertion of implant or expander, a seroma occurred significantly less frequently (p < 0.001). In a binary logistic regression, age in particular was confirmed as a significant risk factor. In contrast, tumor biological characteristics, number of lymph nodes removed or affected showed no significant effect on seroma formation. The present study shows the need for patient education about the development of seroma in particular in older patients and patients with large breast volumes within the preoperative surgical clarification. These clinicopathological data support the previously published results hypothesizing that seroma formation is related to autoimmune/inflammatory processes and will be tested on a larger collective in the planned international multicenter SerMa study.
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Affiliation(s)
- Melitta Beatrice Köpke
- Department of Gynecology and Obstetrics, University Hospital Augsburg, 86156 Augsburg, Germany
| | - Carl Mathis Wild
- Department of Gynecology and Obstetrics, University Hospital Augsburg, 86156 Augsburg, Germany
- Institute for Digital Medicine, University Augsburg, 86153 Neusäß, Germany
| | - Mariella Schneider
- Department of Gynecology and Obstetrics, University Hospital Augsburg, 86156 Augsburg, Germany
| | - Nicole Pochert
- Department of Gynecology and Obstetrics, University Hospital Augsburg, 86156 Augsburg, Germany
- Department for Environmental Medicine, Medical Faculty, University Augsburg, 86156 Augsburg, Germany
| | - Felicitas Schneider
- Department of Gynecology and Obstetrics, University Hospital Augsburg, 86156 Augsburg, Germany
| | - Jacqueline Sagasser
- Department of Gynecology and Obstetrics, University Hospital Augsburg, 86156 Augsburg, Germany
| | - Thorsten Kühn
- Clinic for Gynaecology and Obstetrics, Filderklinik, Filderstadt-Bonlanden, 70794 Filderstadt, Germany
- Department of Gynecology and Obstetrics, University Hospital Ulm, 89070 Ulm, Germany
| | - Michael Untch
- Helios Clinic Berlin-Buch, Obstetrics and Gynaecology, 13125 Berlin, Germany
| | - Christian Hinske
- Institute for Digital Medicine, University Augsburg, 86153 Neusäß, Germany
| | - Matthias Reiger
- Department for Environmental Medicine, Medical Faculty, University Augsburg, 86156 Augsburg, Germany
| | - Claudia Traidl-Hoffmann
- Department for Environmental Medicine, Medical Faculty, University Augsburg, 86156 Augsburg, Germany
| | - Christian Dannecker
- Department of Gynecology and Obstetrics, University Hospital Augsburg, 86156 Augsburg, Germany
| | - Udo Jeschke
- Department of Gynecology and Obstetrics, University Hospital Augsburg, 86156 Augsburg, Germany
| | - Nina Ditsch
- Department of Gynecology and Obstetrics, University Hospital Augsburg, 86156 Augsburg, Germany
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17
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Pintault C, Pondaven A, Lebechec A, Jugan AL, Coudriou C, Berti MDE, Ouldamer L. Implementation of Enhanced Recovery After Surgery Pathway for Patients Undergoing Mastectomy. J Gynecol Obstet Hum Reprod 2023; 52:102600. [PMID: 37150481 DOI: 10.1016/j.jogoh.2023.102600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND - Mastectomy is still a common treatment for breast cancer. The introduction of the Enhanced Recovery After Surgery pathway (ERAS) having proven its benefits for major surgeries has not yet been validated for mastectomy without reconstruction. Our study was conducted to investigate the effects of implementing an ERAS pathway for mastectomies, including the length of hospital stay, postoperative complications and patient satisfaction. METHOD -The study population included all patients who underwent mastectomy without immediate breast reconstruction in the gynecological surgery department of the Tours University Hospital during the year 2020. We compared patients who underwent an ERAS protocol with those who were managed in a standard manner. RESULTS - Of the 92 patients managed for mastectomy, 32 were managed in the ERAS group. The two groups were comparable. We found fewer postoperative complications with this protocol in multivariate analysis. We also obtained a 37% response rate to the satisfaction questionnaires. We did not find any significant difference between the 2 groups. CONCLUSION - There is a trend towards a decrease in the length of hospitalization associated with a decrease in postoperative complications thanks to the implementation of a ERAS protocol for the management of mastectomies. Future studies should focus on both objective clinical outcomes and patient-reported experiences to provide a comprehensive understanding of the effectiveness of ERAS protocols in mastectomy patients.
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Affiliation(s)
- C Pintault
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, 10 boulevard Tonnelé, BP 3223, 37032 Tours cedex, France
| | - A Pondaven
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, 10 boulevard Tonnelé, BP 3223, 37032 Tours cedex, France
| | - A Lebechec
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France
| | - A L Jugan
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France
| | - C Coudriou
- Department of Anesthesiology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France
| | - M DE Berti
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, 10 boulevard Tonnelé, BP 3223, 37032 Tours cedex, France
| | - L Ouldamer
- Department of Gynaecology, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, 10 boulevard Tonnelé, BP 3223, 37032 Tours cedex, France; INSERM unit 1069, Tours, France.
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18
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Borg G, Dihge L, Johansson K. Risk factors for seroma formation after axillary lymph node dissection with special focus on the impact of early shoulder exercise. Acta Oncol 2023:1-7. [PMID: 37129993 DOI: 10.1080/0284186x.2023.2203831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Shoulder and arm dysfunction such as reduced range of motion (ROM) and seroma formation, are common complications following axillary lymph node dissection (ALND). There are conflicting results on the effect of early postoperative exercise on the risk of seroma. This study aims to present incidence of symptomatic seroma formation in a large, population-based cohort, and assesses whether early shoulder mobilization, and other common patient and treatment-related factors are predictors of seroma. METHODS This observational cohort study at the Surgical clinic at Lund University Hospital in Sweden, included 217 consecutive patients who underwent ALND due to breast cancer, cutaneous malignant melanoma (CMM), or carcinoma of unknown primary. A shoulder exercise program was introduced on the first postoperative day and data were collected at routine follow-up 4-6 weeks postsurgery. Main outcome was the strength of the associations between postsurgery exercise and seroma incidence based on logistic regression analyses, supported by data on seroma volume and number of aspirations. RESULTS Two hundred patients completed the study. The overall seroma incidence was 67.5% and the odds of seroma were lower for patients practicing ROM exercise two times/day versus 0-1 time/day (OR 0.42, 95% CI 0.18-0.96, p = .038). ROM exercise greater than two times/day did not increase the volume, neither did the arm cycling exercise. ALND combined with mastectomy and CMM surgery were associated with larger seroma volumes (1116 ± 1068ml, p = .006) and (1318 ± 920 ml, p < .001), respectively, compared to the breast conserving surgery (537 ± 478ml) while neoadjuvant chemotherapy showed no influence. The effect of age, patients ≥60 years compared to younger, or BMI ≥ 30.0 were weaker (p = .08). CONCLUSIONS Extensive surgical treatments for breast cancer and malignant melanoma produces more seroma, and higher age and obesity may also influence the risk. ROM exercises twice daily predict a lower incidence of seroma following ALND, and more frequent shoulder exercise do not increase the volumes.
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Affiliation(s)
- Gunilla Borg
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Looket Dihge
- Department of Clinical Sciences, Division of Surgery, Lund University, Lund, Sweden
- Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Karin Johansson
- Department of Health Sciences, Lund University, Lund, Sweden
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19
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El Hajj H, Ferraioli D, Meus P, Beurrier F, Tredan O, Ray-Coquard I, Chopin N. Splenectomy in epithelial ovarian cancer surgery. Int J Gynecol Cancer 2023:ijgc-2022-003928. [PMID: 36948526 DOI: 10.1136/ijgc-2022-003928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVE Splenectomy is performed in 4-32% of cytoreductive surgeries for ovarian cancer. The objective of our study was to assess splenectomy and evaluate its impact on overall and disease-free survival. METHODS We conducted a retrospective single-center study between January 2000 and December 2016. Patients who underwent a cytoreduction for epithelial ovarian cancer, regardless of stage and surgical approach, were eligible for the study. Patients deemed not operable were excluded from the study. Patients were stratified into two groups, splenectomy or no splenectomy. A univariate analysis followed by a multivariate analysis was conducted to evaluate the postoperative complications after splenectomy and the overall and disease-free survival. RESULTS This cohort included 464 patients. Disease stages, peritoneal carcinomatosis scores, and the rate of radical surgery (Pomel classification) were significantly higher in the splenectomy group, p=0.04, p<0.0001, and p<0.001, respectively. However, no significant difference was found in the rate of complete cytoreduction between the two groups (p=0.26) after multivariate analysis. In univariate analysis, splenectomy was significantly associated with extensive surgical procedures. In multivariate analysis, the two more prevalent complications in the splenectomy group were the risk of abdominopelvic lymphocele (overall response (OR) =4.2; p=0.01) and blood transfusion (OR=2.4; p=0.008). The average length of hospital stay was significantly longer in the splenectomy group, 17.4 vs 14.6 days (p<0.0001). The delay in adjuvant chemotherapy was longer in the splenectomy group (p=0.001). There was no significant difference in overall and disease-free survival (p=0.09) and (p=0.79), respectively. CONCLUSION Splenectomy may be considered an acceptable and safe procedure; however, with no impact on overall or disease-free survival. In addition, it is associated with longer hospital stay and longer time to chemotherapy.
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Affiliation(s)
- Houssein El Hajj
- Gynecologic Oncology, Centre Leon Berard, Lyon, Rhône-Alpes, France
| | | | - Pierre Meus
- Gynecologic Oncology, Centre Leon Berard, Lyon, Rhône-Alpes, France
| | | | - Olivier Tredan
- Medical Oncology Department, Centre Leon Berard, Lyon, Rhône-Alpes, France
| | - Isabelle Ray-Coquard
- Medical Oncology Department, Centre Leon Berard, Lyon, Rhône-Alpes, France
- Hesper lab, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Nicolas Chopin
- Gynecologic Oncology, Centre Leon Berard, Lyon, Rhône-Alpes, France
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20
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Smith CB, Baker JA, Yoon SC, Lowell DA, Grimm L. Ethanol Sclerotherapy for Postoperative Seroma of the Breast and Axilla. JOURNAL OF BREAST IMAGING 2023; 5:167-173. [PMID: 38416938 DOI: 10.1093/jbi/wbad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Evaluate the effectiveness of alcohol sclerotherapy in postoperative breast and axillary seromas. METHODS This was an IRB-approved retrospective review of consecutive patients from 2017 to 2021. The procedure involves aspiration of seroma fluid, injection of ethanol for 15 to 30 minutes, and then aspiration of the injected ethanol. Following review of the medical record, patient and procedure data were recorded. Success was defined as no recurrence of seroma. Statistical analysis was performed using a chi-square or t-test, as appropriate. RESULTS Twenty seromas were treated in 19 patients (mean age, 63 years; range, 49-79) following mastectomy (9/20, 45%), lumpectomy (25%, 5/20), axillary nodal dissection (5/20, 25%), or chest wall surgery (1/20, 5%). The mean seroma volume was 146 ± 165 mL. There was a mean of 1.4 prior aspiration attempts (range, 0-3). Mean injected ethanol volume was 39 mL (range, 8-60 mL) for a mean of 26 ± 5 minutes. Seromas recurred in 85% (17/20) of cases, and repeat aspiration was performed in 35% (6/17). The mean recurrence time was 34 ± 29 days. The recurrent seromas were 31% smaller (mean, 80 ± 48 mL). Only a smaller pre-ablation seroma was associated with successful ablation (P < 0.01), as the mean pre-ablation volume was 36 ± 24 mL for successful ablations and 119 ± 56 mL for unsuccessful ablations. There were no post-procedural complications. CONCLUSION Single-treatment ethanol sclerotherapy is typically unsuccessful in ablating breast and axillary seromas. Only a smaller pre-ablation seroma size was associated with successful ablation.
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Affiliation(s)
- Camron B Smith
- University of Kansas Medical Center, Department of Radiology, Kansas City, KS, USA
| | - Jay A Baker
- Duke University Hospital, Department of Radiology, Durham, NC, USA
| | - Sora C Yoon
- Duke University Hospital, Department of Radiology, Durham, NC, USA
| | - Dorothy A Lowell
- Duke University Hospital, Department of Radiology, Durham, NC, USA
| | - Lars Grimm
- Duke University Hospital, Department of Radiology, Durham, NC, USA
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21
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Roman MM, Delrue P, Karler C, Del Marmol V, Bourgeois P. Indo-cyanine green administration to identify loss of lymph after axillary lymph node dissection. Front Oncol 2023; 13:1045495. [PMID: 36994214 PMCID: PMC10040774 DOI: 10.3389/fonc.2023.1045495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 02/16/2023] [Indexed: 03/16/2023] Open
Abstract
BackgroundNear infrared fluorescence imaging with Indocyanine Green (ICG) is now used for the imaging of lymph nodes and lymphatic vessels. In this work, we investigated the impact of its pre-operative and peri-operative administration on our ability to detect axillary lymphatic loss after breast cancer surgery.MethodsOne subcutaneous injection of ICG was administered in the ipsilateral hand of 109 women who were scheduled to have either a mastectomy with total axillary lymph node dissection (CALND) or a lumpectomy with selective lymphadenectomy (SLN) the day before (n = 53) or the same day of surgery (n = 56). The lymph leakages were assessed by means of the application of a compress in the operated armpit and by the presence or absence of fluorescence on it, as well as in the post-operative axillary drains.ResultsThe compress was fluorescent in 28% of SLN patients and 71% of CALND patients. The liquids in the axillary drains were also fluorescent in 71% of patients with CALND. No statistical significance was observed between the ICG injection groups. The association between compressive fluorescent and the presence of fluorescence in the axillary drains is significant in the pre-operative subgroup and in the whole group.ConclusionOur research demonstrates that lymphatic leaks aid in the development of seromas and calls into question the effectiveness of the ligatures and/or cauterizations used during surgery. A prospective, multicentric, randomized trial should be conducted to verify the efficacy of this approach.
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Affiliation(s)
- Mirela Mariana Roman
- Department of Mammo-Pelvic Surgery, Institute Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
- *Correspondence: Mirela Mariana Roman,
| | - Pauline Delrue
- Department of Mammo-Pelvic Surgery, Institute Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Clarence Karler
- Department of Anesthesia-Algologia Hospital Moliere, Université Libre de Bruxells, Brussels, Belgium
| | - Véronique Del Marmol
- Service of Dermatology, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Bourgeois
- Service of Dermatology, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Services of Nuclear Medicine, Institut Jules Bordet and Hôpitaux Iris Sud- Iris Ziekenhuizen Zuid (HIS-IZZ) Hospitals, Université Libre de Bruxelles, Brussels, Belgium
- Multi-disciplinary Clinic of Lymphology, Institute Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
- Service of Vascular Surgery, Institut Jules Bordet and Hôpitaux Iris Sud- Iris Ziekenhuizen Zuid (HIS-IZZ) Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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22
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van Zeelst LJ, van der Waal DC, Keemers-Gels ME, van den Wildenberg FJH, Schlooz-Vries MS, Wijers CHW, de Wilt JHW, Strobbe LJA. Effect of different quilting techniques on seroma formation after breast surgery: retrospective study. BJS Open 2023; 7:zrac171. [PMID: 36932651 PMCID: PMC10023826 DOI: 10.1093/bjsopen/zrac171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/29/2022] [Accepted: 12/08/2022] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Quilting, a technique in which skin flaps are sutured to the underlying muscle, reduces seroma after mastectomy and/or axillary lymph node dissection. The aim of this study was to assess the effect of different quilting techniques on the formation of clinically significant seroma. METHODS This was a retrospective study including patients undergoing mastectomy and/or axillary lymph node dissection. Four breast surgeons applied the quilting technique based on their own discretion. Technique 1 was performed using Stratafix in 5-7 rows placed at 2-3 cm distance. Technique 2 was performed using Vicryl 2-0 in 4-8 rows placed at 1.5-2 cm distance. Technique 3 was performed using Vicryl 0/1 in 3 rows placed at 3-4 cm distance. Technique 4 was performed using Vicryl 0 in 4-5 rows placed at 1.5 cm distance. The primary outcome was clinically significant seroma. RESULTS A total of 445 patients were included. Clinically significant seroma incidence was 4.1 per cent (six of 147) for technique 1, which was significantly lower than that for the other techniques (25.0 per cent (29 of 116), 29.4 per cent (32 of 109), and 33 per cent (24 of 73) for techniques 2, 3, and 4 (P < 0.001) respectively). The duration of surgery was not significantly longer for technique 1 compared with the other three techniques. The length of hospital stay, number of additional visits to the outpatient clinic, and reoperations did not differ significantly between the four techniques. CONCLUSION Quilting using Stratafix and placing 5-7 rows with 2-3 cm distance between the stitches associates with low clinically significant seroma incidence without adverse effects.
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Affiliation(s)
- Lotte J van Zeelst
- Canisius Wilhelmina Hospital, Department of Surgical Oncology, Nijmegen, The Netherlands
| | - Dagmar C van der Waal
- Canisius Wilhelmina Hospital, Department of Surgical Oncology, Nijmegen, The Netherlands
| | - Mariël E Keemers-Gels
- Canisius Wilhelmina Hospital, Department of Surgical Oncology, Nijmegen, The Netherlands
| | | | - Margrethe S Schlooz-Vries
- Canisius Wilhelmina Hospital, Department of Surgical Oncology, Nijmegen, The Netherlands
- Radboudumc, Department of Surgical Oncology, Nijmegen, The Netherlands
| | - Charlotte H W Wijers
- Canisius Wilhelmina Hospital, Canisius Wilhelmina Hospital Academy, Nijmegen, The Netherlands
| | | | - Luc J A Strobbe
- Canisius Wilhelmina Hospital, Department of Surgical Oncology, Nijmegen, The Netherlands
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Lymphaticovenular Anastomosis for Lymphorrhea after Expander-based Breast Reconstruction: A Case Report. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4835. [PMID: 36875920 PMCID: PMC9984159 DOI: 10.1097/gox.0000000000004835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/12/2023] [Indexed: 03/06/2023]
Abstract
Refractory axillary lymphorrhea is a postoperative complication of breast cancer with no established standard treatment. Recently, lymphaticovenular anastomosis (LVA) was used to treat not only lymphedema but also lymphorrhea and lymphocele in the inguinal and pelvic regions. However, only a few reports have been published on the treatment of axillary lymphatic leakage with LVA. This report presents a case of successful treatment of refractory axillary lymphorrhea after breast cancer surgery with LVA. A 68-year-old woman underwent nipple-sparing mastectomy for right breast cancer, axillary lymph node dissection, and immediate subpectoral tissue expander placement. Postoperatively, the patient developed refractory lymphorrhea and subsequent seroma around the tissue expander, and underwent postmastectomy radiation therapy and frequent percutaneous aspiration of the seroma. However, lymphatic leakage persisted, and surgical treatment was planned. Preoperative lymphoscintigraphy showed lymphatic outflow from the right axilla to the space around the tissue expander. There was no dermal backflow in the upper extremities. To reduce lymphatic flow into the axilla, LVA was performed at two sites in the right upper arm. The lymphatic vessels used for anastomosis were 0.35 mm and 0.50 mm in diameter, and each was anastomosed to the vein in an end-to-end fashion. The axillary lymphatic leakage stopped shortly after the operation, and there were no postoperative complications. LVA may be a safe and simple option for the treatment of axillary lymphorrhea.
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Foulon A, Mancaux A, Theret P, Naepels P, Mychaluk J, Merviel P, Abboud P, Fauvet R. Efficacy and aesthetic outcomes for quilting sutures in the prevention of seroma after mastectomy. Sci Rep 2023; 13:1898. [PMID: 36732364 PMCID: PMC9894844 DOI: 10.1038/s41598-023-29154-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
Worldwide, mastectomy for breast cancer is one of the most frequently performed surgical procedures. As one of the main complications of mastectomy, seroma is associated with pain, infections and a prolonged hospital stay. We performed a prospective multicenter randomized trial to assess the efficacy and esthetic outcomes associated with quilting the skin flap. Eighty-seven patients were included. The proportion of patients with seroma on postoperative day 15 was significantly lower in the quilting group (12 out of 39 (30.8%)) than in a control group with conventional wound closure (21 out of 40 (52.5%); P = 0.05). The mean breast seroma volume was significantly lower in the quilting group (130.2 mL) than in the control group (236.8 mL; P = 0.02). There were no differences in the esthetic outcomes. The pain level on day 1 was similar in the quilting and control groups (mean visual analog scale score: 2.5 vs. 2.1, respectively; P = 0.3). Quilting the skin flap was associated with a lower prevalence of seroma and a lower seroma volume, and did not worsen the esthetic outcomes or pain levels. This technique is technically straightforward and should be offered to all patients scheduled for mastectomy.
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Affiliation(s)
- Arthur Foulon
- Service de Gynécologie Obstétrique, CHU Amiens Picardie, 1 Rond-Point Bd du Pr Christian Cabrol, 80000, Amiens, France.
| | - Albine Mancaux
- Service de Gynécologie Obstétrique, CHU Amiens Picardie, 1 Rond-Point Bd du Pr Christian Cabrol, 80000, Amiens, France
| | - Pierrick Theret
- Service de Gynécologie Obstétrique, CHU Amiens Picardie, 1 Rond-Point Bd du Pr Christian Cabrol, 80000, Amiens, France
| | - Philippe Naepels
- Service de Gynécologie Obstétrique, CHU Amiens Picardie, 1 Rond-Point Bd du Pr Christian Cabrol, 80000, Amiens, France
| | - Johanna Mychaluk
- Service de Gynécologie, CH Compiègne, 8 Avenue Henri Adnot, 60200, Compiègne, France
| | - Philippe Merviel
- Service de Gynécologie, CHU Brest, 2 Avenue Foch, 29200, Brest, France.,Université Occidentale de Bretagne, UFR de Médecine, 3 Rue Des Archives, 29238, Brest, France
| | - Pascal Abboud
- Service de Gynécologie, CH Soissons, 46 aAvenue du Général de Gaulle, 02200, Soissons, France
| | - Raffaele Fauvet
- Service de Gynécologie, CHU Caen Normandie, 1 Bd de La Côte de Nacre, 14000, Caen, France.,Université Caen Normandie, UFR de Médecine, Espl. de La Paix, 14000, Caen, France
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Teotia SS, Kadakia Y, Amaya J, Liu Y, Haddock NT. Evaluating the Efficacy of Povidone-Iodine Solution Infection Prophylaxis in Immediate Tissue Expander-Based Breast Reconstruction: A Controlled Retrospective Analysis. Plast Surg (Oakv) 2023; 31:29-35. [PMID: 36755822 PMCID: PMC9900035 DOI: 10.1177/22925503211024762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/25/2021] [Indexed: 11/16/2022] Open
Abstract
Background: There is currently no consensus among plastic surgeons regarding the optimal infection prophylaxis for immediate tissue expander placement following mastectomy. The goal of this study was to determine whether irrigation with 1 L of standard triple antibiotic solution (TAS) can achieve similar infection rates compared to a regimen of 180 mL of TAS with povidone-iodine solution (Betadine) painted on the field immediately prior to the placement of the expander. Methods: The 2 regimens were compared via retrospective propensity matching of all patients of the 2 senior authors who underwent bilateral tissue expander placement immediately following mastectomy with one of 3 mastectomy surgeons from January 2013 to December 2019 (n = 281). Groups were controlled for mastectomy surgeon, mastectomy type, mastectomy weight, age, race, body mass index, diabetes, hypertension, smoking, smoking status, prepectoral/subpectoral placement, use of acellular dermal matrix, operating room time, and duration of postoperative antibiotics. Results: Compared to the Betadine cohort (n = 65), the non-Betadine cohort (n = 65) experienced a similar rate of infections (13.8% vs 12.3%, P = 1.00), including major injections requiring intravenous antibiotic treatment (10.8% vs 9.2%, P = 1.00), after propensity matching. Infections in the non-Betadine cohort did not grow different bacteria on culture, require different antibiotic coverage, or result in prolonged duration of average antibiotic therapy (12.0 days vs 19.3 days, P = .19). Rates of subsequent expander washout and exchange (P = 1.00) and overall complications that required return to the operating room (P = .826) were similar between groups. Conclusion: The addition of Betadine solution to TAS added no benefit to infection prophylaxis or reduction of surgical complications in immediate tissue expander placement procedures.
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Affiliation(s)
- Sumeet S. Teotia
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
| | - Yash Kadakia
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
| | - Joshua Amaya
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
| | - Yulun Liu
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
| | - Nicholas T. Haddock
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
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Mason IT, Rose HJ, Williamson SF, Jowsey AT, Gorman SJ, Chittock HD, Wong CC, Dheda AJ, Turner SB, Park YE, Kollmetz T, Sonis JM, Kamm JL, May BC. Evaluation of Tissue Apposition and Seroma Prevention in an Ovine Model of Surgical Dead Space Using a Novel Air-Purged Vacuum Closure System. EPLASTY 2022; 22:e46. [PMID: 36408121 PMCID: PMC9643872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Postoperative complications associated with seroma formation resulting from surgical dead space continue to present a challenge in modern surgery. There is an unmet need for new technologies that address surgical dead space as well as prevent seroma formation and associated downstream postoperative complications. METHODS The novel implantable tissue apposition and drainage system ENIVO was developed and tested in a bilateral ovine external abdominal oblique (EAO) resection model of surgical dead space. The ENIVO system is a portable powered pump and wound interface featuring air-purged vacuum closure (APVC) that delivers a sustained level of vacuum pressure (80 and 100 mmHg) to the treatment site with an intermittent burst of sterile filtered air through the implanted wound interface. Seroma area, seroma volume, and drain migration were assessed at postoperative days 7 and 14, and all animals were euthanized at day 28 with gross assessment of treatment efficacy including the presence of residual seroma and tissue apposition. RESULTS The bilateral model created relatively uniform defects of ~120 cm2 following excision of ~30 to 50 g of EAO muscle. Median seroma area of ENIVO-treated defects was statistically smaller than standard of care (SoC)-treated defects at days 7 and 14. Median seroma volume at 14 days was significantly reduced in ENIVO-treated defects relative to SoC-treated defects [1.3 (IQR 0.0-79.5) mL and 188.5 (IQR 27.6-342.9) mL, respectively]. At postoperative day 28, 40% (n = 4/10) of SoC defects showed a residual seroma, whereas in contrast, none of the ENIVO-treated defects showed signs of a residual seroma. Median tissue apposition scoring was higher in the ENIVO treatment group [3 (IQR 3-3)] compared with the SoC group [3 (IQR 0-3)]. CONCLUSIONS The ENIVO system represents a new approach to dead space management and seroma prevention and was shown to outperform a SoC surgical drain in a challenging large defect model of surgical dead space management and seroma prevention.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - J Lacy Kamm
- Vet Associates Equine, Auckland, New Zealand
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Thalji SZ, Cortina CS, Guo MS, Kong AL. Postoperative Complications from Breast and Axillary Surgery. Surg Clin North Am 2022; 103:121-139. [DOI: 10.1016/j.suc.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Papanikolaou A, Minger E, Pais MA, Constantinescu M, Olariu R, Grobbelaar A, Lese I. Management of Postoperative Seroma: Recommendations Based on a 12-Year Retrospective Study. J Clin Med 2022; 11:jcm11175062. [PMID: 36078992 PMCID: PMC9457167 DOI: 10.3390/jcm11175062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/15/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Athanasios Papanikolaou
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
| | - Eliane Minger
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
| | - Michael-Alexander Pais
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
- Correspondence:
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
| | - Adriaan Grobbelaar
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
| | - Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
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Fabro EAN, Teodózio CGC, Costa RM, Macedo FO, Cardoso ACDDLM, Jacob RBE, Thuler LCS, Bergmann A. Clinical Experience with Compression Taping to Treat Seroma After Breast Cancer Surgery: A Medical Device Clinical Study. Adv Skin Wound Care 2022; 35:1-6. [PMID: 35723961 DOI: 10.1097/01.asw.0000831068.34587.3d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the safety of compressive taping in patients with seroma secondary to breast cancer surgery. METHODS This study was a nonrandomized clinical study of medical devices applied to women indicated for seroma aspiration puncture after breast cancer surgery in a public reference hospital in Brazil. The intervention consisted of applying compressive taping over the seroma fluctuation area and maintained for 5 days. Evaluated outcomes comprised dermal changes caused by taping, subjective symptoms reported during the intervention period, and percent change in the punctured volume before and after the intervention. RESULTS A total of 35 women (mean age, 56.7 ± 12.2 years) were included. Most presented with an advanced disease stage (≥IIB; 62.9%). Although a 28.6% incidence of dermal changes caused by taping was observed, an average reduction in the aspirated volume of -28.2 mL was identified (95% confidence interval, -48.3 to -8.0; P = .008). Treatment adherence was high (91.4%), and most patients reported satisfaction with the treatment (85.7%). CONCLUSIONS The use of compressive taping on seroma areas can be considered safe, is well accepted by patients, and might be used as a noninvasive treatment option for seroma developing after breast cancer surgery.
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Affiliation(s)
- Erica Alves Nogueira Fabro
- At the National Cancer Institute, Rio de Janeiro, Brazil, Erica Alves Nogueira Fabro, MSc, PT, is Physical Therapist Manager, Physiotherapy Service, Cancer Hospital III; Clarice Gomes Chagas Teodózio, MSc, PT, is a PhD student, Oncology PhD Student Program; Rejane Medeiros Costa, PhD, PT, and Flávia Oliveira Macedo, MSc, PT, are Physical Therapists, Physiotherapy Service, Cancer Hospital III; Aline Cecilia Drumond Dutra Luz Machado Cardoso, BSc, and Raquel Barroso Evaldt Jacob, BSc, are nurses, Nursing Service, Cancer Hospital III; and Luiz Claudio Santos Thuler, MD, PhD, and Anke Bergmann, PhD, PT, are Researchers, Clinical Epidemiology Program. Acknowledgment: The authors thank Fisiovital (Indaiatuba, Sao Paolo, Brazil) for donating the Vitaltape bandage necessary for this research. The authors have disclosed no other financial relationships related to this article. Submitted May 19, 2021; accepted in revised form August 18, 2021
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Park HS, Lee J, Kim JY, Park JM, Kwon Y. A Prospective Randomized Study to Compare Postoperative Drainage After Mastectomy Using Electrosurgical Bipolar Systems and Conventional Electro-Cautery. J Breast Cancer 2022; 25:307-317. [PMID: 35914746 PMCID: PMC9411027 DOI: 10.4048/jbc.2022.25.e29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/06/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Advanced energy devices, including electrosurgical bipolar systems or ultrasonic shears, are widely used in various surgeries. An electrosurgical bipolar device allows surgeons to grasp and dissect tissues, as well as simultaneously ligate and cut vessels and lymphatics during surgery. This study aimed to evaluate the effects of advanced bipolar energy devices on the reduction in seroma formation during mastectomy, axillary staging, and/or reconstruction. METHODS This prospective randomized clinical trial with a 1:1 ratio compared the use of an electrosurgical bipolar device, LigaSureTM (LGS), against conventional cut-and-ligate techniques in mastectomy with axillary procedures for patients with breast cancer. A total of 82 patients with breast cancer who underwent definitive surgery were enrolled in this study. The primary endpoint was the total drainage volume after surgery. RESULTS The clinicopathological characteristics of the two groups were not significantly different. The total postoperative drainage volume was significantly lower in the LGS group than in the control group (756.26 mL vs. 1,167.74 mL, p = 0.009). The actual postoperative drainage volume and duration also decreased significantly in the LGS group compared with those in the control group (all p < 0.05). The rate of postoperative complications was lower in the LGS group than in the control group (9.8% vs. 27.5%, p = 0.05). CONCLUSION Electrosurgical bipolar devices showed better performance in terms of decreasing postoperative drainage during mastectomy and axillary staging and/or reconstruction.
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Affiliation(s)
- Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.
| | - Jeea Lee
- Department of Surgery, Uijeongbu Eulji, Medical Center, Eulji University, Uijeongbu, Korea
| | - Jee Ye Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Mi Park
- Department of Biostatistics and Computing, Graduate School, Yonsei University, Seoul, Korea
| | - Yonghan Kwon
- Department of Biostatistics and Computing, Graduate School, Yonsei University, Seoul, Korea
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Rehabilitation for women undergoing breast cancer surgery: a systematic review and meta-analysis of the effectiveness of early, unrestricted exercise programs on upper limb function. Clin Breast Cancer 2022; 22:650-665. [DOI: 10.1016/j.clbc.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/17/2022] [Indexed: 11/17/2022]
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Zhang M, Liu Y, Yang H, Jin F, Zheng A. Breast adenoid cystic carcinoma: a report of seven cases and literature review. BMC Surg 2022; 22:113. [PMID: 35331206 PMCID: PMC8953026 DOI: 10.1186/s12893-022-01560-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/15/2022] [Indexed: 11/24/2022] Open
Abstract
Background Primary adenoid cystic carcinoma (ACC) of breast is rarely seen clinically. It is a special subtype of triple-negative breast cancer characterized by low expression of Ki-67, low malignant potential, slow progression and favorable prognosis. To date, treatment for this disease is controversial and no consensus is reached. We analyzed clinical manifestations and pathological characteristics of seven primary breast ACC cases and reported in combination with literature review to promote understanding, diagnosis and treatment of this disease. Case presentation We collected seven breast ACC cases pathologically diagnosed and treated in Department of breast surgery of the First Affiliated Hospital of China Medical University from January 2015 to December 2018. We organized and summarized the clinical, imaging, pathological and prognostic information and performed statistical analysis. The median age was 60 years (ranging from 54 to 64 years). Tumors of all patients were detected by immunohistochemistry. Molecular types were mostly triple negative (4/7), and Ki-67 expression was low (5/7). Lymph node metastases were absent in all patients received axillary lymph node surgery. Median follow-up time was 39 months (ranging from 25 to 68 months). There was no occurrence of relapse, distant metastasis or death. Conclusion Breast ACC is accompanied with favorable diagnosis, which is different from typical triple-negative breast cancer. Accurate diagnosis of ACC is particularly important.
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Affiliation(s)
- Meilin Zhang
- Department of Breast Surgery, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.,Department of Burn Plastic Surgery, Chaoyang Central Hospital, Chaoyang, Liaoning, China
| | - Yanbiao Liu
- Department of Breast Surgery, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Hongguang Yang
- Department of Burn Plastic Surgery, Chaoyang Central Hospital, Chaoyang, Liaoning, China
| | - Feng Jin
- Department of Breast Surgery, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.
| | - Ang Zheng
- Department of Breast Surgery, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.
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Morarasu S, Clancy C, Ghetu N, Musina AM, Velenciuc N, Iacob S, Frunza T, Roata CE, Lunca S, Dimofte GM. Impact of Quilting Sutures on Surgical Outcomes After Mastectomy: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2022; 29:3785-3797. [PMID: 35103890 DOI: 10.1245/s10434-022-11350-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/05/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Seroma after mastectomy and/or axillary lymph node dissection (ALND) is among the most common issue surgeons have to face in the early postoperative management of breast cancer. Using quilting sutures (QS) to aid in tissue approximation and decrease dead space is proposed as a simple technique to reduce seroma rate. We aimed to perform a systematic review, and analyse, in a meta-analytical model, the role of QS in improving wound outcomes and decrease volume, duration of drainage, and length of stay in hospital. METHODS The study was registered with PROSPERO. A systematic search of the PubMed, EMBASE, and SCOPUS databases was performed for all comparative studies examining surgical outcomes in patients who underwent QS versus conventional closure (CC) after mastectomy ± ALND. RESULTS Twenty-one studies with a total of 3473 patients (1736 in the study group and 1737 in the control group) were included based on the selection criteria. The study group showed significantly lower rates of seroma (p < 0.00001), total volume of drainage (p < 0.0001), days to drain removal (p < 0.00001), and length of stay (p < 0.00001) compared with the control group, while wound complication rates (surgical site infection, flap necrosis, hematoma, skin dimpling) were comparable between the two groups. CONCLUSIONS QS are a reliable intraoperative technique that decrease seroma formation, volume of postoperative drainage, duration of drainage and length of hospital stay, and should be considered in mastectomies with or without ALND.
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Affiliation(s)
- Stefan Morarasu
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
| | - Cillian Clancy
- Department of Surgery, Saint Vincent's University Hospital, Dublin 4, Ireland.
| | - Nicolae Ghetu
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
| | - Ana Maria Musina
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
| | - Natalia Velenciuc
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
| | - Stefan Iacob
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
| | - Tudor Frunza
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
| | - Cristian Ene Roata
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
| | - Sorinel Lunca
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
| | - Gabriel-Mihail Dimofte
- 2nd Department of Surgical Oncology, Regional Institute of Oncology (IRO), Iasi, Romania
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Lee TH, Langbart M, Lehane C. Reconstruction after salvage axillary dissection for squamous cell carcinoma. ANZ J Surg 2022; 92:3049-3050. [PMID: 35076155 DOI: 10.1111/ans.17507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/21/2021] [Accepted: 01/09/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Tae H Lee
- Department of Surgery, Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia.,Faculty of Medicine, University of New South Wales Prince of Wales Clinical School, Randwick, New South Wales, Australia
| | - Marc Langbart
- Department of Surgery, Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
| | - Christopher Lehane
- Department of Surgery, Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
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Tansawet A, Nakchuai P, Techapongsatorn S, Sukhvibul P, Lolak S. Prediction of seroma after total mastectomy using an artificial neural network algorithm. Breast Dis 2022; 41:21-26. [PMID: 34250921 DOI: 10.3233/bd-201051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Seroma is a common complication after mastectomy. To the best of our knowledge, no prediction models have been developed for this. Henceforth, medical records of total mastectomy patients were retrospectively reviewed. Data consisting of 120 subjects were divided into a training-validation data set (96 subjects) and a testing data set (24 subjects). Data was learned by using a 9-layer artificial neural network (ANN), and the model was validated using 10-fold cross-validation. The model performance was assessed by a confusion matrix in the validating data set. The receiver operating characteristic curve was constructed, and the area under the curve (AUC) was also calculated. Pathology type, presence of hypertension, presence of diabetes, receiving of neoadjuvant chemotherapy, body mass index, and axillary lymph node (LN) management (i.e., sentinel LN biopsy and axillary LN dissection) were selected as predictive factors in a model developed from the neural network algorithm. The model yielded an AUC of 0.760, which corresponded with a level of acceptable discrimination. Sensitivity, specificity, accuracy, and positive and negative predictive values were 100%, 52.9%, 66.7%, 46.7%, and 100%, respectively. Our model, which was developed from the ANN algorithm can predict seroma after total mastectomy with high sensitivity. Nevertheless, external validation is still needed to confirm the performance of this model.
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Affiliation(s)
- Amarit Tansawet
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Panupong Nakchuai
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Suphakarn Techapongsatorn
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pakkapol Sukhvibul
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Sermkiat Lolak
- Section of Data Science for Healthcare, Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Prajapati S, Ramasamy S, Vats M, Neogi S, Kantamaneni K, Tudu SK. Effect of Octreotide on Lymphorrhea in Patients After Modified Radical Mastectomy for Carcinoma Breast: A Randomized Controlled Trial. Cureus 2021; 13:e19225. [PMID: 34877203 PMCID: PMC8642125 DOI: 10.7759/cureus.19225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Lymphorrhea or seroma formation after modified radical mastectomy (MRM) is a serious and disabling complication of axillary lymphadenectomy. Octreotide is a hormone with general anti-secretory effects. The potential role of octreotide in the treatment of lymphorrhea after axillary lymph node dissection in patients undergoing MRM is being investigated in this study. The purpose of this research is to study the effect of octreotide on the magnitude and duration of lymphorrhea in patients after MRM for carcinoma breast. Methods This clinical trial was registered in the Clinical Trials Registry India (CTRI/2017/11/010653). It was conducted in the Department of General Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi from September 2015 to March 2017. This study is a parallel randomized controlled trial with a 1:1 allocation ratio. Thirty patients were enrolled and allocated equally into two groups. The intervention group received standard medical care plus injection octreotide 100 micrograms eight hourly intravenously post-operatively for five days and the control group received only standard medical care. The primary outcomes were lymphorrhea volume from 24 hours post-surgery till five days post-operatively and the number of days till the suction drain was removed. Secondary outcomes were surgical site infection, the incidence of seroma formation, complications of octreotide, duration of hospital stay, and the number of lymph nodes isolated. All the patients were followed up twice a week for the first six weeks after discharge followed by three monthly visits. Results A total of 30 patients were included in the study. The mean age was 46.2 years. The mean operative time in the control group was 137.87 ± 23.28 minutes and in the octreotide group was 128.13 ± 12.29 (p = 0.163). The volume of lymphorrhea in the control group was 354.67 ± 346.28 ml and in the octreotide group was 194.00 ± 240.62 ml (p = 0.081). Seroma occurred in 9% of patients in the control group and 2 % of patients in the octreotide group (p = 0.010). The duration of lymphorrhea was 4.93 ± 2.49 days in the control group and 3.13 ± 1.36 days in the octreotide group (p = 0.029). The duration of stay was 7.07 ± 2.40 days in the control group and 5.13 ± 1.06 days in the octreotide and was found to be statistically significant (p = 0.010). No obvious adverse reactions related to injection octreotide, namely, nausea, vomiting, abdominal discomfort, hypotension, bradycardia, and dysglycemia, were seen in any of our patients. Conclusion The duration of lymphorrhea, incidence of seroma formation, and duration of hospital stay were lesser in the octreotide group, and the difference was statistically significant. The wound infection rates were similar in both groups. Thus injection octreotide can be used safely and effectively.
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Affiliation(s)
- Sahaj Prajapati
- Pediatric Surgery, Lady Hardinge Medical College, New Delhi, IND
| | | | - Manu Vats
- Surgery, Maulana Azad Medical College, New Delhi, IND
| | | | - Ketan Kantamaneni
- Surgery, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Gannavaram, IND
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van Zeelst LJ, Ten Wolde B, van Eekeren RRJP, Volders JH, de Wilt JHW, Strobbe LJA. Quilting following mastectomy reduces seroma, associated complications and health care consumption without impairing patient comfort. J Surg Oncol 2021; 125:369-376. [PMID: 34786726 PMCID: PMC9298805 DOI: 10.1002/jso.26739] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/05/2021] [Accepted: 10/25/2021] [Indexed: 11/11/2022]
Abstract
Background An important complication following mastectomy is seroma formation. Quilting, in which skin flaps are sutured to the underlying muscle, is reported to reduce seroma incidence, but might induce pain and impair shoulder function. Main objective is to compare quilting with conventional wound closure, regarding seroma incidence, health care consumption, and patient discomfort. Methods In a combined prospective and retrospective study, 254 patients undergoing mastectomy and/or axillary lymph node dissection (ALND) were included. Patients received quilting sutures or conventional closure. Primary outcome was clinical significant seroma (CSS). In prospectively included patients shoulder function and analgesic use was observed. Results CSS incidence was 12.9% in the quilted versus 62.3% in the nonquilted cohort (p < 0.001). Surgical site infections were reported significantly less in the quilted cohort. Duration of hospital stay was shorter and outpatient clinic visits were less in the quilted cohort. Surgical procedure required 10 additional minutes for quilting. No significant differences were observed in postoperative shoulder function and analgesic use. Conclusion Quilting following mastectomy reduces CSS incidence. Quilting requires 10 additional minutes during surgery. It facilitates day treatment and results in less additional outpatient clinic visits culminating in reduced health care consumption. Shoulder function and pain are not affected by quilting.
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Affiliation(s)
- Lotte J van Zeelst
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Britt Ten Wolde
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - José H Volders
- Department of Surgical Oncology, Gelre Hospital, Apeldoorn, The Netherlands
| | | | - Luc J A Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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Effect of quilting on seroma formation in mastectomies: A meta-analysis. Surg Oncol 2021; 39:101665. [PMID: 34563996 DOI: 10.1016/j.suronc.2021.101665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/15/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Seroma is the most common complication following mastectomy and can require several days of drainage and lead to delayed wound healing, longer hospital stays, and an increased financial and emotional burden. Seroma formation is not well understood and but there is good evidence that closing the dead space via quilting can help reduce seroma formation. This study assessed randomized controlled trials and reviewed current literature to elucidate if there is a strong association between quilting sutures and seroma formation. METHODS A systematic search of 5 databases using search terms similar to "seroma", "quilting", "flap fixation", "random", and "mastectomy". Data was extracted and Medcalc software used to perform a meta-analysis of the primary outcome: incidence of seroma formation, as well as secondary outcomes: volume and duration of drainage. RESULTS Eleven randomized controlled trials with 2009 patients were included. Quilting with sutures greatly reduced the incidence of seroma formation compared with conventional closure (p < 0.001, RR 0.367 [95% CI 0.25, 0.539]; I2 = 63.56%) as well as duration of drainage (p = 0.015, SMD -1.657, SE 0.680 [95% CI -2.991, -0.324]; 8 studies, n = 1578; I2 = 98.98%). Quilting did not significantly affect volume of drainage. CONCLUSIONS Quilting was found to be associated with lower seroma rates. Future studies should investigate the use of quilting in combination with other preventative techniques to search for a synergistic method that will further improve patient care.
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Shima H, Kutomi G, Sato K, Kuga Y, Wada A, Satomi F, Uno S, Nisikawa N, Kameshima H, Ohmura T, Mizuguchi T, Takemasa I. An Optimal Timing for Removing a Drain After Breast Surgery: A Systematic Review and Meta-Analysis. J Surg Res 2021; 267:267-273. [PMID: 34171562 DOI: 10.1016/j.jss.2021.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/24/2021] [Accepted: 05/07/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND In clinical practice, drains had been routinely used for reducing seroma formation after breast surgery. However, an optimal timing to remove drains does not identify yet. METHODS This study aimed to compare the clinical outcome, such as seroma formation, surgical site infection (SSI), and a length of hospital stay between early removal and late removal. A systematic review was performed using PubMed, MEDLINE, and the Cochrane Library. Breast cancer patients who received surgery using drains were eligible. Those parameters were compared between early vs late removal. RESULTS Eleven studies included in this meta-analysis. Seroma formation in the early removal group was significantly higher than the one in the late removal group (RR = 1.58: 95%CI [1.25-2.01], P = 0.0001), meanwhile no significant difference was found among the groups for SSI (RR = 0.82: 95%CI [0.51-1.31], P= 0.40). A length of hospital stay in the early removal group was also significantly shorter than late removal (RR -3.31: 95%CI [-5.13-1.49], P = 0.0004). CONCLUSIONS Seroma formation was significantly higher in patients who had early drain removal. Conversely, SSI incidence was low, and early removal did not increase SSI incidence. In conclusion, early drain removal has no proved clinical benefit in these settings besides reduction of hospital stays.
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Affiliation(s)
- Hiroaki Shima
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan.
| | - Goro Kutomi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Kiminori Sato
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Yoko Kuga
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Asaka Wada
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Fukino Satomi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan; Sapporo Kitaguchi Clinic, Sapporo, Hokkaido, Japan
| | - Satoko Uno
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan; Muroran City General Hospital, Muroran city, Hokkaido
| | - Noriko Nisikawa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan; Sapporo Kitaguchi Clinic, Sapporo, Hokkaido, Japan
| | | | - Tosei Ohmura
- Department of Surgery, Higashi Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Toru Mizuguchi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan; Department of Nursing, Surgical Science and Technology, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Hokkaido, Japan
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Conventional suture with prolonged timing of drainage is as good as quilting suture in preventing seroma formation at pectoral area after mastectomy. World J Surg Oncol 2021; 19:148. [PMID: 33980267 PMCID: PMC8117557 DOI: 10.1186/s12957-021-02257-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/30/2021] [Indexed: 11/17/2022] Open
Abstract
Background The aim of this study was to compare conventional suture with prolonged timing of drainage with quilting suture on the formation of seroma at pectoral area after mastectomy (ME) with sentinel lymph node biopsy (SLN) or axillary lymph node dissection (ALND) for breast cancer. Methods Three hundred and eighty-eight consecutive breast cancer patients were retrospectively analyzed and categorized into three groups. Patients in group 1 were with quilting suture, group 2 with conventional suture and 13–15 days drainage in situ, and group 3 with conventional suture and 20–22 days drainage. The primary outcome was the incidence of grades 2 and 3 seroma at anterior pectoral area within 1 month postoperatively. Cox regression was used for analysis. Results The incidence of grades 2 and 3 seroma was comparable among groups (9.5% vs. 7.9% vs. 5.3%, p = 0.437), as well as late grades 2 and 3 seroma among groups (4.3% vs. 2.9% vs. 1.5%, p = 0.412). Old age, high body mass index, and hypertension were independent risk factors for grades 2 and 3 seroma. Conclusions Prolonged timing of drainage to 13–15 days in conventional suture was long enough to decrease the incidence of grades 2 and 3 seroma as lower as that in quilting suture group at pectoral area within 1 month after mastectomy.
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Gasparri ML, Kuehn T, Ruscito I, Zuber V, Di Micco R, Galiano I, Navarro Quinones SC, Santurro L, Di Vittorio F, Meani F, Bassi V, Ditsch N, Mueller MD, Bellati F, Caserta D, Papadia A, Gentilini OD. Fibrin Sealants and Axillary Lymphatic Morbidity: A Systematic Review and Meta-Analysis of 23 Clinical Randomized Trials. Cancers (Basel) 2021; 13:cancers13092056. [PMID: 33923153 PMCID: PMC8123055 DOI: 10.3390/cancers13092056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/11/2021] [Accepted: 04/21/2021] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Axillary dissection is a highly mobile procedure with severe lymphatic consequences. The off-label application of fibrin sealants in the axilla, with the sole aim to eliminate dead space and to provoke sealing of the disrupted lymphatic vessels at the end of axillary dissection, is an experimental procedure to reduce lymphatic morbidity. The aim of our systematic review and meta-analysis is to investigate the effects of fibrin sealants on lymphatic morbidity after axillary dissection. Our results show that this experimental procedure is able to decrease the total axillary drainage output, the number of days before the axillary drainage is removed, and the length of hospital stay. However, no effects on the occurrence rate of axillary lymphocele or on the surgical site complications rate were demonstrated Abstract Background: use of fibrin sealants following pelvic, paraaortic, and inguinal lymphadenectomy may reduce lymphatic morbidity. The aim of this meta-analysis is to evaluate if this finding applies to the axillary lymphadenectomy. Methods: randomized trials evaluating the efficacy of fibrin sealants in reducing axillary lymphatic complications were included. Lymphocele, drainage output, surgical-site complications, and hospital stay were considered as outcomes. Results: twenty-three randomized studies, including patients undergoing axillary lymphadenectomy for breast cancer, melanoma, and Hodgkin’s disease, were included. Fibrin sealants did not affect axillary lymphocele incidence nor the surgical site complications. Drainage output, days with drainage, and hospital stay were reduced when fibrin sealants were applied (p < 0.0001, p < 0.005, p = 0.008). Conclusion: fibrin sealants after axillary dissection reduce the total axillary drainage output, the duration of drainage, and the hospital stay. No effects on the incidence of postoperative lymphocele and surgical site complications rate are found.
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Affiliation(s)
- Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, via Tesserete 46, 6900 Lugano, Switzerland; (M.L.G.); (F.M.); (V.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), via Giuseppe Buffi 13, 6900 Lugano, Switzerland
| | - Thorsten Kuehn
- Interdisciplinary Breast Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, 73730 Neckar, Germany;
| | - Ilary Ruscito
- Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, via di Grottarossa 1035, 00189 Rome, Italy; (I.R.); (F.B.); (D.C.)
| | - Veronica Zuber
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
| | - Rosa Di Micco
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80138 Naples, Italy
| | - Ilaria Galiano
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
| | | | - Letizia Santurro
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
| | - Francesca Di Vittorio
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
| | - Francesco Meani
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, via Tesserete 46, 6900 Lugano, Switzerland; (M.L.G.); (F.M.); (V.B.)
| | - Valerio Bassi
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, via Tesserete 46, 6900 Lugano, Switzerland; (M.L.G.); (F.M.); (V.B.)
| | - Nina Ditsch
- Department of Gynecology and Obstetrics, University Hospital of Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany;
| | - Michael D. Mueller
- Department of Obstetrics and Gynecology, University Hospital of Bern, Friedbühlstrasse 19, 3010 Bern, Switzerland;
| | - Filippo Bellati
- Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, via di Grottarossa 1035, 00189 Rome, Italy; (I.R.); (F.B.); (D.C.)
| | - Donatella Caserta
- Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant’Andrea University Hospital, Sapienza University of Rome, via di Grottarossa 1035, 00189 Rome, Italy; (I.R.); (F.B.); (D.C.)
| | - Andrea Papadia
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, via Tesserete 46, 6900 Lugano, Switzerland; (M.L.G.); (F.M.); (V.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), via Giuseppe Buffi 13, 6900 Lugano, Switzerland
- Correspondence:
| | - Oreste D. Gentilini
- Breast Surgery Unit, Department of Surgery, San Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy; (V.Z.); (R.D.M.); (I.G.); (L.S.); (F.D.V.); (O.D.G.)
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Flap fixation in preventing seroma formation after mastectomy: an updated meta-analysis. Updates Surg 2021; 73:1307-1314. [PMID: 33886107 PMCID: PMC8397649 DOI: 10.1007/s13304-021-01049-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/02/2021] [Indexed: 11/09/2022]
Abstract
Seroma formation following mastectomy is one of the most experienced complications, with a very variable incidence ranging from 3 to 90%. In recent years, many publications have been realized to define an effective technique to prevent its formation and several approaches have been proposed. Given the potential of flap fixation in reducing seroma formation, we performed a meta-analysis of the literature to investigate the role of this approach as definitive gold standard in mastectomy surgery. Inclusion criteria regarded all studies reporting on breast cancer patients undergoing mastectomy with or without axillary lymph node dissection; studies that compared mastectomy with flap fixation to mastectomy without flap fixation were selected. Papers were eligible for inclusion if outcome was described in terms of seroma formation. As secondary outcome, also surgical site infection (SSI) was evaluated. The included studies were 12, involving 1887 female patients: 221/986 (22.41%) patients experienced seroma formation after flap fixation and 393/901 (43.61%) patients had this complication not receiving flap fixation, with a significant statistical difference between the two groups (OR = 0.267, p = 0.001, 95% CI 0.153, 0.464). About, SSI 59/686 (8.6%) in flap fixation group and 67/686 (9.7%) in patients without flap fixation, with no statistical differences between groups (OR = 0.59, p = 0.056, 95% CI 0.344, 1.013). The heterogeneity between included studies does not allow us to reach definitive conclusions but only to suggest the strong evaluation of this approach after mastectomy in seroma preventing and SSI reduction.
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Karaköse O, Pülat H, Çağlar Özçelik K, Zihni İ, Kürşat Bozkurt K, Şenol S, Nihan Cankara F, Erol Eroğlu H. Effects of Different Applications on Postoperative Seroma Formation and Wound Healing Following Mastectomy and Axillary Dissection in Rats. GALICIAN MEDICAL JOURNAL 2021. [DOI: 10.21802/gmj.2021.1.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
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.
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Al-Masri M, Alawneh F, Daoud F, Ebous A, Hamdan B, Al-Najjar H, Al-Masri R, Abu Farah M. Effectiveness of Cyanoacrylate in Reducing Seroma Formation in Breast Cancer Patients Post-Axillary Dissection: A Randomized Controlled Trial. Front Oncol 2021; 10:580861. [PMID: 33569343 PMCID: PMC7868378 DOI: 10.3389/fonc.2020.580861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/27/2020] [Indexed: 11/25/2022] Open
Abstract
Background/Purpose Seroma is a common complication after axillary dissection in women with node-positive breast cancer. We aim to determine the effect of Cyanoacrylate on reducing seroma formation in patients undergoing axillary dissection. This a randomized clinical trial. Methods This is a single-center, randomized, single-blinded, and two-arm parallel study. Women with node-positive breast cancer eligible for axillary dissection were enrolled. Patients with a Body Mass Index (BMI) greater than 35 kg/m2, those who underwent immediate breast reconstruction, and/or received neoadjuvant chemotherapy were excluded. Patients were randomized in a 1:1 ratio, and were stratified according to their age, BMI, tumor size, and operation type. The primary endpoint was the total seroma volume (the total drained volume and the total aspirated volume after drain removal). Data presented as mean and range when applicable. Results 111 patients were randomized (Cyanoacrylate 57; control 54). 105 patients were analyzed. Sixty-nine patients underwent breast conserving surgery, and 36 underwent modified radical mastectomy. There was no difference in the total seroma volume between the Cyanoacrylate vs. control arms (1,304 (60–4,950) vs. 1,446 (100–5,223) ml, p=0.458). Wound infection, flap necrosis, number of manual aspirates, and hematoma formation were not statistically different between the two groups. Time to drain removal was shorter in the Cyanoacrylate arm (11.04(3–23) vs. 13.84(3–37) days, p=0.015). The use of Cyanoacrylate was not cost effective ($586.93 (550–748) vs. $29.63 (0–198), p<0.001). Higher seroma volume was correlated with modified radical mastectomy, older age, and BMI more than 30 kg/m2. Conclusion Cyanoacrylate did not reduce seroma formation and its use was not cost effective. Clinical Trial Registration clinicaltrials.gov, identifier NCT02141373.
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Affiliation(s)
- Mahmoud Al-Masri
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Fade Alawneh
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Faiez Daoud
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Ali Ebous
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Basem Hamdan
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Hani Al-Najjar
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Rama Al-Masri
- School of Medicine, University of Jordan, Amman, Jordan
| | - Marwan Abu Farah
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
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Robinson AV, Ali F, Dewar DJ, Peach AHS. Managing infected seroma post-lymphadenectomy; A retrospective cohort study and cost analysis in melanoma patients. J Plast Reconstr Aesthet Surg 2021; 74:2251-2257. [PMID: 33582049 DOI: 10.1016/j.bjps.2020.12.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/23/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Seromas are a common and unavoidable complication following lymphadenectomy, and often become clinically significant with superseded infection requiring re-admission for prompt intervention. However, there is no consensus as to whether a formal surgical incision and drainage (I&D), ultrasound (US)-guided aspiration or intravenous (IV) antibiotics alone is the most efficacious method of managing an infected seroma, the investigation of which formed the rationale for this study. SUBJECTS AND METHODS This retrospective cohort study included a consecutive series of patients readmitted for infected seroma following a lymphadenectomy for melanoma at Leeds Teaching Hospitals Trust (LTHT) from 2006 to 2017. Details on management, length of hospital stay, length of follow-up and number of clinical appointments required were examined. FINDINGS Seventy-one cases of infected seroma were identified from the cohort of 1691 lymphadenectomies. Initially, 21 patients (29.5%) were managed by IV antibiotics alone (failure rate of 52.4%); 18 (25.4%) with US-guided aspiration (failure rate 27.8%) and 32 (45.1%) with surgical I&D, which was 100% effective. Ultimately, 62.5% of the cohort required surgical management. Patients who underwent surgical I&D were discharged significantly faster following the procedure (3 versus 5 days for US-guided aspiration, p = 0.002) and spent fewer days in hospital overall (p = 0.022). The overall average cost was comparable across the three treatment groups. CONCLUSIONS Surgical management seemed preferential to conservative approaches in terms of efficacy and was not significantly more expensive overall; but carries anaesthetic risk. There may be a clinically significant difference in outcome depending on management; however, more evidence is required to investigate this.
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Affiliation(s)
- A V Robinson
- School of Medicine, University of Leeds, Leeds, United Kingdom.
| | - F Ali
- School of Medicine, University of Leeds, Leeds, United Kingdom
| | - D J Dewar
- Department of Plastic, Reconstructive and Aesthetic Surgery, Leeds General Infirmary, Leeds, United Kingdom
| | - A H S Peach
- Department of Plastic, Reconstructive and Aesthetic Surgery, Leeds General Infirmary, Leeds, United Kingdom
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Lin W, Yang Y, Zhong W, Lin Q, Rao N, Liang G, Ling Y, Liu Z, Luo Q, Tian Z, Gong C. The Effect of Low and High Vacuum Drainage on the Postoperative Drainage of Breast Cancer: Insights from a Prospective, Non-Inferiority, Randomized Clinical Trial. Cancer Manag Res 2020; 12:12487-12496. [PMID: 33299355 PMCID: PMC7721110 DOI: 10.2147/cmar.s283031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 11/02/2020] [Indexed: 12/24/2022] Open
Abstract
Background Vacuum drains have been extensively applied to prevent seroma formation after breast surgery. However, the usage of negative suction drainage is mainly determined by surgeon’s experience and preferences. The aim of this study is to prospectively compare the drain effect after breast surgery between the low and high vacuum drains. Methods This prospectively randomized trial (from January 2018 to June 2019) involved 188 patients who were subjected to modified radical mastectomy (group A, n=128) or immediate breast reconstruction with implants (group B, n=60). In each group, patients were randomized to receive high vacuum drain (pressure=–98 kPa) or low vacuum drain (pressure=–12 kPa) after surgery. Days of drain permanence, which means the duration of drainage, was the primary endpoint. Results According to the comparison of days of drain permanence, the effect of a low vacuum drain is not inferior to a high vacuum drain in group A (pectoral drain, P<0.001; axillary drain, P<0.001) or group B (submuscular drain, P=0.002). The complications frequently occurred on patients with high vacuum drain (11.7%), such as seroma formation. The expense of low vacuum drain was significantly lower than high vacuum drain in both groups (P<0.01). Conclusion The drain effect of the low vacuum drain is not inferior to a high vacuum drain in both group A and group B. The low vacuum drain was effective, relatively cheap, and did not increase the incidence of complications; it is therefore more recommended after breast surgery.
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Affiliation(s)
- Wanyi Lin
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Yaping Yang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Wenjing Zhong
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Qun Lin
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Nanyan Rao
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Oncoplastic and Reconstruction Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Gehao Liang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Yun Ling
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Zihao Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Qing Luo
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Zhenluan Tian
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China
| | - Chang Gong
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Department of Breast Surgery, Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, People's Republic of China.,Bioland Laboratory, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Guangzhou, 510005, People's Republic of China
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Cong Y, Cao J, Qiao G, Zhang S, Liu X, Fang X, Zou H, Zhu S. Fascia Suture Technique Is a Simple Approach to Reduce Postmastectomy Seroma Formation. J Breast Cancer 2020; 23:533-541. [PMID: 33154828 PMCID: PMC7604369 DOI: 10.4048/jbc.2020.23.e51] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 08/29/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Seroma formation is a common complication in breast cancer patients undergoing mastectomy, and it negatively affects patient recovery after surgery. The present study aimed to evaluate a simple method using fascia suture technique to fix the flap and reduce the incidence of seroma. Methods A single-center, prospective, randomized controlled trial was carried out among 160 patients who had undergone mastectomy from May 2018 to September 2019. All patients were randomly divided into the fascia suture group (n = 80) or control group (n = 80) and were followed up for at least 3 months for the assessment of immediate and late complications after surgery. Results No significant differences were observed between the 2 groups with regard to the basic characteristics. Duration of surgery in the fascia suture group was longer by about 6 minutes compared with that in the control group (114.93 ± 13.67 minutes vs. 108.81 ± 15.20 minutes, p = 0.008). The fascia suture group had a shorter duration of drain placement (10.99 ± 3.26 days vs. 13.85 ± 5.37 days, p < 0.001), a smaller volume of the total drainage (460.95 ± 242.92 mL vs. 574.83 ± 285.23 mL, p = 0.007), and the first 3-day drainage (224.96 ± 101.01 mL vs. 272.3 ± 115.47 mL, p = 0.006), compared with the control group. The incidence of seroma formation (G2 or G3) was significantly lower in the fascia suture group compared with the control group (28.8% vs. 12.5%, p = 0.033). Besides, there was no statistical difference between the 2 groups in the assessment of other complications, including postoperative pain, hematoma, surgical site infections, flap necrosis, and skin dimpling (all p > 0.050). Conclusion The fascia suture technique is a simple and effective method for reducing seroma formation and should be used to prevent seroma formation after mastectomy. Trial Registration Chinese Clinical Trials Registry Identifier: ChiCTR1800015913.
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Affiliation(s)
- Yizi Cong
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Jianqiao Cao
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Guangdong Qiao
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Song Zhang
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xinjie Liu
- Surgery Department of West Area, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xiaoming Fang
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Haidong Zou
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Shiguang Zhu
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
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De Rooij L, Bosmans JWAM, van Kuijk SMJ, Vissers YLJ, Beets GL, van Bastelaar J. A systematic review of seroma formation following drain-free mastectomy. Eur J Surg Oncol 2020; 47:757-763. [PMID: 33051116 DOI: 10.1016/j.ejso.2020.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/14/2020] [Accepted: 10/09/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Seroma is a common complication after mastectomy. The aim of this review is to elucidate whether closed suction drainage can safely be omitted in patients undergoing mastectomy when assessing seroma formation and its complications. The second aim is to assess the influence of flap fixation on seroma related complications, as there is existing evidence showing that combining mastectomy with flap fixation may make the use of drainage systems obsolete. SEARCH & SELECTION A review of the literature was performed and articles that compared mastectomy with drainage and mastectomy without drainage were selected. Due to the small number of eligible studies, no selection based on whether flap fixation was performed was possible. If outcome was described in terms of seroma formation or seroma related complications, papers were eligible for inclusion. Studies older than 20 years, animal studies, studies not written in English and studies with male patients were excluded. RESULTS A total of eight articles were eligible for inclusion. Four prospective studies and four retrospective studies were included. In four studies, flap fixation was performed. Frequency of seroma formation as well as seroma that required intervention was reported. The included studies demonstrated that omitting closed suction drainage does not lead to a higher incidence of seroma formation in patients undergoing mastectomy. CONCLUSION Despite substantial heterogeneity, there is evidence that drainage can safely be omitted without exacerbating seroma formation and its complications. A well-powered, randomized controlled trial evaluating the effect of drainage omission on seroma formation, with or without flap fixation, is needed.
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Affiliation(s)
- L De Rooij
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands.
| | - J W A M Bosmans
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Y L J Vissers
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - G L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands; GROW School for Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | - J van Bastelaar
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
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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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Lymphaticovenous anastomosis: Treatment of a persistent breast seroma. ANN CHIR PLAST ESTH 2020; 65:332-337. [PMID: 32636046 DOI: 10.1016/j.anplas.2019.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 06/24/2019] [Indexed: 11/20/2022]
Abstract
Lymphaticovenous anastomoses are mainly used in secondary limbs lymphedema. They also can be used to treat iatrogenic seroma. This technique was used to treat a patient with a painful breast seroma that appeared after a mastectomy with axillary dissection, resistant to multiple ponctions and persistent 8 months after. Pre operative both lymphoscintigraphy and lympho-MRI have been performed and we identified lymphatic ducts responsible for the seroma. The one involved in the seroma was also the preferential drainage network of the arm. Innoperative, we performed an indocyanine green angiography to map those lymphatic ducts. A total capsulectomy of the breast seroma has been performed. An incision was made in front of lymphatics selected for lymphaticovenous anastomoses on the anterior axilla face. We performed two microscopic lymphaticovenous anastomoses. The patient was followed up at one, three, six months and one year post operative. No recurrence occurred during the follow-up. At six month the arm perimeter reduced of two centimeters. Lymphoscintigraphy and lympho-MRI were performed at six month showing a disappearance of the drainage asymmetry and collateralities of the upper limb; and no measurable volume in projection of the right breast area. Lymphaticovenous anastomoses may be an effective therapeutic solution for resistant seroma after node dissection. Lymphoscintigraphy and lympho IRM are very useful in those cases.
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