Ultrasonic dissection versus electrocautery in mastectomy for breast cancer - a meta-analysis

Economic evaluation of flap fixation techniques after mastectomy: Results of a double-blind randomized controlled trial (SAM-trial)

BACKGROUND

An economic evaluation was performed alongside an RCT investigating flap fixation in reducing seroma formation after mastectomy. The evaluation focused on the first year following mastectomy and assessed cost-effectiveness from a health care and societal perspective.

METHODS

The economic evaluation was conducted between 2014 and 2018 in four Dutch breast clinics. Patients with an indication for mastectomy or modified radical mastectomy were randomly assigned to: conventional closure (CON), flap fixation with sutures (FFS) or flap fixation with tissue glue (FFG). Health care costs, patient and family costs and costs due to productivity losses were assessed. Outcomes were expressed in incremental cost-effectiveness ratios (ICERs): the incremental cost per quality-adjusted life year (QALY). Bootstrapping techniques, sensitivity and secondary analyses were employed to address uncertainty.

RESULTS

The FFS-group yielded most QALYs (0.810; 95%-CI 0.755-0.856), but also incurred the highest mean costs at twelve months (€10.416; 95%-CI 8.231-12.930). CON was the next best alternative with 0.794 QALYs (95%-CI 0.733-0.841) and mean annual costs of €10.051 (95%-CI 8.255-12.044). FFG incurred fewer QALYs and higher costs, when compared to the CON group. The ICER of FFS compared to CON was €22.813/QALY. Applying a willingness to pay threshold in the Netherlands of €20.000/QALY, the probability that FFS was cost-effective was 42%, compared to 37% and 21% for CON and FFG, respectively.

CONCLUSION

The cost-effectiveness of FFS following mastectomy, versus CON and FFG, is uncertain from a societal perspective. Yet, from a health care and hospital perspective FFS is likely to be the most cost-effective intervention.

Budget impact analysis of HARMONIC FOCUS™+ Shears for mastectomy and breast-conserving surgery with axillary lymph node dissection compared with monopolar electrocautery from an Italian hospital perspective

Background

Mastectomy or breast conserving surgery, both with axillary lymph node dissection, are common treatments for early-stage breast cancer. Monopolar electrocautery is typically used for both procedures, despite evidence of improved clinical outcomes with HARMONIC FOCUS™+. This analysis evaluated the budget impact of adopting HARMONIC FOCUS™+ versus monopolar electrocautery for patients undergoing these procedures from an Italian hospital perspective.

Methods

Total costs for an annual caseload of 100 patients undergoing mastectomy or breast conserving surgery, with axillary lymph node dissection, with either the intervention or comparator were calculated. Italian clinical and cost input data were utilised. The analysis included costs for the device, operating room time, postoperative length of stay, treating seroma and managing postoperative chest wall drainage. Deterministic and probabilistic sensitivity analyses assessed uncertainty of model input values. Two scenario analyses investigated the impact of conservative estimates of postoperative length of stay reduction and daily hospital cost on the simulated cost difference.

Results

HARMONIC FOCUS™+ achieves annual savings of EUR 100,043 compared with monopolar electrocautery, derived from lower costs for operating room time, postoperative length of stay and seroma and postoperative chest wall drainage management, offsetting the incremental device cost increase (EUR 43,268). Cost savings are maintained in scenario analyses and across all variations in parameters in deterministic sensitivity analysis, with postoperative hospital stay costs being key drivers of budget impact. The mean (interquartile range) cost savings with HARMONIC FOCUS™+ versus monopolar electrocautery in probabilistic sensitivity analysis are EUR 101,637 (EUR 64,390–137,093) with a 98% probability of being cost saving.

Conclusions

The intervention demonstrates robust cost savings compared with monopolar electrocautery for mastectomy or breast conserving surgery, with axillary lymph node dissection, in an Italian hospital setting, and improved clinical and resource outcomes. These findings, with other clinical and cost analyses, support HARMONIC FOCUS™+ use in this setting.

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

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

A Prospective Randomised Controlled Study Comparing Ultrasonic Dissector with Electrocautery for Axillary Dissection in Patients of Carcinoma Breast

Background

Axillary dissection is one of the important components of modified radical mastectomy (MRM). The present study was conducted to compare surgical outcomes by using monopolar electrocautery and ultrasonic dissector for axillary dissection in MRM.

Methods

A parallel randomised controlled single blinded study was conducted with a sample size of 70 patients who were randomised into two groups. One group underwent MRM using ultrasonic dissector (Group A) and the other one using electrocautery (Group B). Intra- and post-operative outcomes were compared.

Results

Group A had an average operating time of 30.86 min, which was statistically less than that of Group B. The mean mop count and the daily drain output in Group A were less as compared to Group B and the differences were statistically significant. Drain was removed early in Group A as compared to Group B. However, post-operative pain scores and seroma formation were not statistically significant among the two groups.

Conclusion

Ultrasonic dissector group had significantly lesser intra-operative bleeding, operating time and post-operative drain output when compared to electrocautery group. However, the two groups had no significant difference in post-operative pain scores and seroma formation.

Reducing Seroma Formation and Its Sequelae After Mastectomy by Closure of the Dead Space: A Multi-center, Double-Blind Randomized Controlled Trial (SAM-Trial)

BACKGROUND

Seroma is a common complication after mastectomy, with an incidence of 3% to 85%. Seroma is associated with pain, delayed wound healing, and additional outpatient clinic visits, leading potentially to repeated seroma aspiration or even surgical interventions. This study aimed to assess the effect of flap fixation using sutures or tissue glue in preventing seroma formation and its sequelae.

METHODS

Between June 2014 and July 2018, 339 patients with an indication for mastectomy or modified radical mastectomy were enrolled in this randomized controlled trial in the Netherlands. Patients were randomly allocated to one of the three following arms: conventional wound closure (CON, n = 115), flap fixation using sutures (FFS, n = 111) or flap fixation using tissue glue (FFG, n = 113). The primary outcome was the need for seroma aspiration. The secondary outcomes were additional outpatient department visits, surgical-site infection, shoulder function and mobility, cosmesis, skin-dimpling, and postoperative pain scores.

RESULTS

Flap fixation after mastectomy leads to fewer seroma aspirations than conventional wound closure (CON 17.5% vs FFS 7.3% vs FFG 10.8%; p = 0.057), with a significant difference between flap fixation with sutures and conventional wound closure (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.16-0.89; p = 0.025). Flap fixation has no significant negative effect on surgical-site infections, shoulder function and mobility, cosmesis, skin-dimpling, or postoperative pain.

CONCLUSION

Flap fixation using sutures leads to a significant reduction in aspirations of post-mastectomy seromas. The authors strongly advise surgeons to use sutures for flap fixation in patients undergoing mastectomy. (ClinicalTrials.gov no. NCT03305757).

PREREGISTRATION

The trial was registered after enrollment of the first participant. However, no specific explanation exists for this except that through the years more importance has been given to central trial registration. Our research team can ensure that after enrollment of the first participant, no changes were made to the trial, analysis plan, and/or study design.

Pneumoendoscopic single port approach to breast cancer. How we do it?

Endoscopic procedures have not become the gold standard in breast surgery. In order to improve today's outcomes we have developed a pilot study in the Breast Pathology Unit of Hospital Germans Trias i Pujol. A surgical procedure was performed creating a pneumoendoscopic cavity by using a Single Incision Laparoscopic Surgery (Single port) approach with a follow up of four years. Four patients underwent pneumoendoscopic single-port breast surgery receiving skin-sparing quadrantectomy and axillary surgery requiring lymphadenectomy in all of them. All patients had immediate reconstruction with a Latisimus Dorsi flap. No perioperative complications appeared. Mean operative time was 290 min (range 240-315 min) and mean hospital stay was 3,2 days. Surgical margins of all cases were pathologically negative and all patients were disease free after four years of monitoring. All patients were satisfied with the cosmetic outcome in the immediate postoperative and during the follow up. Although all innovative techniques generate hesitation on their beginnings and are liable to improve, we believe that pneumoendoscopic single-port breast surgery can be suitable for breast cancer, offering better cosmetic outcomes with oncological safety.

Mastectomy Without Drains Reduces Cost with No Detriment to Patient Outcome

Introduction 

Use of drains after mastectomy remains highly variable. This study aimed to establish whether simple mastectomy managed without a drain would cost less than the same procedure managed with a drain and whether there would be any difference in complications.

Methods 

Prospective data were collected on all patients undergoing simple mastectomy ± sentinel lymph node biopsy over sixteen months. Surgeons decided intra-operatively whether to place a drain. Data included operative details, mastectomy weight, length of stay and postoperative complications. Costing data were identified by combining hospital finance costs for admission and follow-up appointments along with the cost of consumables.

Results 

One hundred and thirty mastectomies were performed on 119 patients. There was a significant difference in mastectomy weight between drain group patients (n=80, median: 730g) and no drain group patients (n=50, median: 424g) (p=<0.001). The mean cost for drain group patients was £639.77 whilst for the no drain group was £365.46, indicating a potential unit saving of £21944.93 over sixteen months. Length of stay was shorter in the no drain group (range: 1-2 days) than the drain group (range: 1-4 days). The presence or absence of drains did not influence complication rates, with no change in seroma interventions (p=0.803).

Conclusions 

Managing simple mastectomy patients without a drain resulted in no increase in complications or subsequent interventions for seroma. Significant cost savings to both the hospital and to the patient can be achieved by omitting drain use. Routine use of drains in patients undergoing simple mastectomy ± SNB may be unnecessary and costly.

The use of ultrasonic scalpel lowers the risk of post-mastectomy seroma formation in obese women

Introduction: Seroma formation (SF) is the most common postoperative complication after mastectomy and axillary surgery. The aim of this study was to assess its incidence and risk factors following a modified radical mastectomy in breast cancer patients.

Materials and methods: 271 patients who underwent a modified radical mastectomy (250 with traditional electrocautery and 21 with an ultrasonic scalpel) were studied. The SF rate was calculated and its association with patient-related factors, surgical features and postoperative variables was assessed and statistically analyzed with P<0.05 as a significance threshold.

Results: SF was observed in 18% of patients. Patient's age, operating time and number of removed axillary lymph nodes did not significantly differ between SF and non-SF patients. Patients BMI, total drainage amount, number of days with drain were higher and postoperative hospital stay was significantly longer in SF patients (P<0.001 each). The dissection instrument was also an important risk factor: SF developed in 20% of patients operated with electrocautery and in none with an ultrasonic scalpel (P<0.05). The association between surgical instrument and the number of removed lymph nodes, patient's age and BMI was not significant. Dissection with an ultrasonic scalpel resulted in a statistically significant lower total drainage amount. However, it was also related to a significantly longer operating time (P<0.001 each).

Conclusions: Risk of SF after a modified radical mastectomy is significantly higher in patients with obesity. Despite longer operating time, using an ultrasonic scalpel is a valuable option in those cases because it lowers the total drainage amount and seems to be an important protective factor against SF.

Advanced hemostasis in axillary lymph node dissection for locally advanced breast cancer: new technology devices compared in the prevention of seroma formation

Background

Breast cancer is the most frequent neoplasm in women. Axillary lymph nodes dissection represents the treatment of choice in locally advanced breast cancer for prognostic and curative purposes. Seroma formation, an abnormal collection of fluid in the dead space of the axilla, is described in Literature with a wide range of incidence (3–85%). It is a source of significant morbidity and discomfort. The aim of the study is to compare the different haemostasis devices used in breast surgery, investigating the eventual superiority of an instrument among the others in terms of intraoperative and postoperative outcome, especially of seroma formation.

Methods

Clinical cases of female patients undergone axillary lymph nodes dissection for local advanced breast cancer between January 2013 and July 2017 at the Surgery Unit of University of Campania “Luigi Vanvitelli” were retrospectively reviewed. Patients were divided into four groups, according to device utilized during surgery: Electrocautery, Harmonic Scalpel, LigaSure and Thunderbeat. All patients underwent II level axillary lymph nodes dissection associated to radical mastectomy or quadrantectomy.

Results

One hundred consecutives patients were enrolled in the study. Intra-operative blood loss resulted statistically significant different (P < 0,01) between the Electrocautery group (94,7 ml) and the Thunderbeat group (57,2 ml), while the Harmonic Scalpel group and the Ligasure group, despite presented a lower amount of blood loss, did not differ significantly. Drainage volume resulted significantly lower (P = 0,002) in the comparison between the Electrocautery group and the Thunderbeat group; the Ligasure group and Harmonic Scapel group showed no difference between them and Electrocautery group. About the seroma formation, the Electrocautery group resulted affected by the highest seroma formation rate (64%). Seroma incidence in Harmonic Scalpel group was 24%, in Ligasure group was 44%, while Thunderbeat group showed the lowest presentation of seroma with 16%.

Conclusions

In patients affected by breast cancer requiring axillary lymphnodes dissection, the use of advanced hemostasis devices is highly desirable. Among the non-traditional tools, Thunderbeat resulted to be superior in terms of reduction of intra-operative blood loss and post-operative drainage output, moreover associated to a substantial reduction of postoperative seroma incidence.

Comparison of Energy-Based Tissue Dissection Techniques in Abdominoplasty: A Randomized, Open-Label Study Including Economic Aspects

BACKGROUND

Abdominoplasty is one of the most common procedures in plastic surgery, and energy-based tissue dissection techniques have become the gold standard. Despite its frequency, abdominoplasty is still associated with high complication rates.

OBJECTIVES

The authors compared clinical and economic data of 4 methods of energy-based tissue dissection in a randomized, open-label study.

METHODS

A total of 57 patients were preoperatively randomized into 4 groups: electrocautery, Ultracision Harmonic Scalpel, argon plasma coagulation, and PEAK-Plasmablade. Demographic and operational data as well as information on the postoperative course and complications were collected. For economic analysis, quotes were obtained from the device companies or official suppliers.

RESULTS

Duration of surgery, drainage quantity, and wound healing complications did not differ significantly between groups. The Ultracision method caused significantly greater blood loss compared with all other techniques (P < 0.01). PEAK and Ultracision devices entailed greater surgical costs compared with APC and electrocautery.

CONCLUSIONS

All methods evaluated can be applied safely and effectively in abdominoplasty procedures. However, these data demonstrate a significantly higher blood loss for the Ultracision Harmonic Scalpel. Considering the clinical data, the higher costs of PEAK and Ultracision methods appear unjustified.

LEVEL OF EVIDENCE: 2

Axillary dissection for breast cancer using electrocautery versus ultrasonic dissectors: A prospective randomized study

BACKGROUND

The major morbidities of modified radical mastectomy both short- and long-term are sequelae of axillary dissection. Flap complications, prolonged seroma, need for axillary drainage, wound infection, lymphedema, shoulder stiffness, and paresthesia are major causes for morbidity after axillary dissection. Different techniques have been implemented to tackle these problems. Few of these include reducing the axillary dead space, using various forms of energy devices.

AIMS

We have prospectively compared two energy sources, namely, ultrasonic dissector (UD) against the electrocautery dissection in axillary dissection for breast cancer with respect to outcomes.

MATERIALS AND METHODS

One hundred female patients with breast cancer undergoing modified radical mastectomy were randomized to either of the two arms - axillary dissection using UD and axillary dissection using electrocautery. The parameters taken into consideration were operating time, operative blood loss, amount and duration of axillary drainage, flap complications, nodal yield, and postoperative pain scoring.

RESULTS

There were no significant differences overall between the two groups with respect to oncological safety and functional outcomes.

Comparing the Harmonic Scalpel with Electrocautery in Reducing Postoperative Flap Necrosis and Seroma Formation after Modified Radical Mastectomy in Carcinoma Breast Patients: A Double-Blind Prospective Randomized Control Trail

Introduction

Only a few studies compare the efficacy of the harmonic scalpel and electrocautery in performing mastectomies, and these have mainly compared their intraoperative parameters. But the main concern with electrocautery is the incidence of flap necrosis and seroma formation. Therefore, this study was done to determine if the harmonic scalpel has any advantages over electrocautery in reducing postoperative flap necrosis and seroma formation in patients undergoing a modified radical mastectomy (MRM).

Methodology

This randomized control trial was carried out over a one-year period in a tertiary care centre in South India. The study patients were randomized into an electrocautery group and a harmonic scalpel group. In the first group, mastectomy including flap and axillary dissection was done using electrocautery. In the second group, a harmonic scalpel was used for dissection. This study compared the efficacy of the harmonic scalpel with electrocautery in terms of postoperative seroma formation and flap necrosis. Various other perioperative parameters like the number of drain days, total drainage volume (in mL), operating time (in minutes), intraoperative blood loss (in mL), and postoperative wound site pain were also studied. During each postoperative visit, the presence of seroma was assessed clinically, and the number of aspirations required for the seroma was also analysed.

Results

A total of 240 patients were randomized into two groups of 120 patients each. Baseline parameters were comparable across both groups. There were significant differences in the duration of surgery [151.38 mins vs. 112.33 mins; p = 0.001] and intraoperative blood loss [276.25 mL vs.200.13 mL; p = 0.001]. On Postoperative Day (POD) 1, the difference in the mean pain scores [6 vs. 4; p = 0.001] was statistically significant. In addition, the differences in the mean total drainage volume [937.5 mL vs. 470 mL; p = 0.002] and the incidence of seroma during the first follow-up [34.2% vs. 21.7 %; p = 0.030] were statistically significant. The difference in the incidence of flap necrosis on POD 4 [7.5% vs. 4.2%; p = 0.2706] was not statistically significant. None of the patients developed flap necrosis after four days.

Conclusion

The harmonic scalpel reduces the total drainage volume of seromas, the number of drain days, intraoperative blood loss, duration of surgery, postoperative pain (especially on POD 1 and 5), and incidence of flap necrosis.

Performance of Harmonic devices in surgical oncology: an umbrella review of the evidence

Background

We performed an umbrella review of systematic reviews summarizing the evidence on the Harmonic scalpel (HS) compared with conventional techniques in surgical oncology (including lymph node dissection).

Methods

We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from inception to end of March of 2017 for meta-analyses or systematic reviews of randomized trials comparing HS to conventional techniques in surgical oncology. We assessed the quality of included systematic reviews with AMSTAR (A MeaSurement Tool to Assess systematic Reviews) and assessed the certainty in evidence for each pooled outcome using GRADE (Grading of Recommendations Assessment, Development, and Evaluation).

Results

We identified ten systematic reviews on breast cancer (n = 3), gastric cancers (n = 3), oral, head, and neck cancers (n = 1), and colon cancers (n = 3). Most reviews received a higher rating using AMSTAR. For operative time, systematic reviews reported a reduction of 25 to 29 min for HS compared with conventional methods across oncology types, with the exception of breast cancer where little differences were observed (very low to moderate quality of evidence (GRADE)). For blood loss and drainage volume, the majority of reviews reported statistically significant reductions with HS, and reductions ranged from 42 to 141 mL, and from 42 to 292 mL, respectively (very low to moderate quality of evidence). Hospitalization days were reported to decrease with use of HS by 0.2 to 3.2 days; however, reductions were only statistically significant for half of the included reviews (low to moderate quality of evidence). Regarding perioperative complications, two of six reviews reported a significantly reduced risk with HS use (breast cancer surgery) (moderate to high quality evidence)).

Conclusion

Across surgical oncology types, the majority of included systematic reviews showed a statistically significant or numerical improvement in surgical outcomes with use of the HS compared with conventional methods. Well-designed randomized studies with large sample sizes will help to provide more precise estimates and reduce the risk of heterogeneity.

Electronic supplementary material

The online version of this article (10.1186/s12957-017-1298-x) contains supplementary material, which is available to authorized users.

Impact of the Ultrasonic scalpel on the amount of drained lymph after axillary or inguinal lymphadenectomy

BACKGROUND

Seroma formation and lymphoedema are frequently encountered complications after radical lymph node dissection (RLND). Attempts to reduce the lymphatic morbidity include the use of Ultrasonic Scalpel. The aim of the present analysis was to assess the impact of the ultrasonic scalpel on the amount of drained lymph after lymph node dissection.

METHODS

Patients listed for a RLND or completion lymph node dissection (CLND) were enrolled in a prospective randomized trial to compare the impact of two surgical dissection techniques (USS versus control) on the amount of drained lymph. The lymph drained in 24 h was collected. Our primary endpoint was to compare the daily amount of drained lymph between the two groups. Secondary endpoints were the comparison of drained lymph with the BMI of the patients, the gender and the surgical site (axilla, groin).

RESULTS

Eighty patients were randomly assigned to the USS group or the Control (C) group. No difference was measured in the total amount of lymph drained (USS: 2908 ± 2453 ml vs. C: 3898 ± 5791 ml; p-value = 0.382). The result was also similar after adjusting for gender, age, and BMI. A significant higher amount of lymph was measured after inguinal dissection with USS compared to axillary (p < 0.001).

CONCLUSION

The study suggests that the use of Harmonic scalpel did not influence the amount of lymph drained after RLND and not support the theory that USS induces oversealing of lymphatics.

TRIAL REGISTRATION

Clinical Trial NCT02476357 . Registered 20 of February 2015.

Comparison of dissection with harmonic scalpel and conventional bipolar electrocautery in deep inferior epigastric perforator flap surgery: A consecutive cohort study

Reduced tissue damage is a theoretical advantage of using an ultrasonic harmonic scalpel. We hypothesized that the harmonic scalpel would outperform electrocautery in deep inferior epigastric perforator flap surgery, possibly resulting in a shorter operative time and reduced postoperative drainage and pain. Between January and August 2015, 24 consecutive patients were assigned to immediate deep inferior epigastric perforator flap elevation (12 for bipolar electrocautery and 12 for harmonic scalpel). The main outcome variables were total operative time, flap elevation time (starting from the fascia incision), and drainage volume. We compared the number of perforators isolated and the Moon and Taylor classification of the pedicle. Data were tested for normality using the Kolmogorov-Smirnov test before analysis. Continuous variables were compared by Wilcoxon rank-sum test. Data were analyzed using the statistical software SAS, version 9.3 (SAS Institute, Cary, NC, USA). Both groups were comparable with respect to clinical characteristics (mean age, body mass index, and flap weights). There was a statistically significant difference in the operative time between dissection with the harmonic scalpel and electrocautery (305.2 vs. 380.3 min, respectively, p = 0.002). The flap elevation time was reduced, particularly when using the harmonic scalpel where its usage seems crucial for dissecting deep inferior epigastric perforators (59.8 vs. 145.9 min, respectively, p < 0.0001). No statistical difference was observed in the drainage volume and length of hospital stay between the groups. We conclude that the harmonic scalpel may be more reliable and efficient as an alternative to electrocautery.

A randomized controlled study comparing a vessel sealing system with the conventional technique in axillary lymph node dissection for primary breast cancer

Objective

This study aimed to compare the efficacy and safety of the newest bipolar vessel sealing system (BVSS; LigaSure™ Small Jaw) to that of conventional technique in axillary dissection.

Methods

Sixty-one patients with breast cancer were randomized to a conventional dissection surgical technique (CONV group; n = 30) by scalpel and monopolar cautery or that using a vessel sealing system (BVSS group; n = 31).

Results

There was a significant difference between both groups in the mean number of days until drain removal (6.4 ± 2.9 vs. 8.2 ± 3.8 days; P value = 0.033), and the mean total volume of drainage fluid (365.3 ± 242.2 vs. 625.1 ± 446.6 mL; P value = 0.009). The incidence of seroma was similar in both groups (43.3 vs. 37.9 %; P value = 0.673). There was no statistically significant difference in axillary dissection operating time (66 vs. 70 min; P value = 0.371), or the mean volume of blood loss (18.2 ± 31.1 vs. 20.6 ± 26.3 mL; P value = 0.663).

Conclusions

Our results suggest that BVSS is a more effective device when compared to the conventional techniques in axillary dissection.

Harmonic Scalpel versus Electrocautery Dissection in Modified Radical Mastectomy for Breast Cancer: A Meta-Analysis

BACKGROUND

Despite the common use of conventional electrocautery in modified radical mastectomy for breast cancer, the harmonic scalpel is recently emerging as a dominant surgical instrument for dissection and haemostasis, which is thought to reduce the morbidity, such as seroma and blood loss. But the results of published trials are inconsistent. So we made the meta-analysis to assess the intraoperative and postoperative endpoints among women undergoing modified radical mastectomy with harmonic scalpel or electrocautery.

METHODS

A comprehensive literature search of case-control studies from PubMed, MEDLINE, EMBASE and Cochrane Library databases involving modified radical mastectomy with harmonic scalpel or electrocautery was performed. We carried out a meta-analysis of primary endpoints including postoperative drainage, seroma development, intraoperative blood loss and secondly endpoints including operative time and wound complications. We used odds ratios (ORs) with 95% confidence intervals (CIs) to evaluate the effect size for categorical outcomes and standardised mean differences (SMDs) for continuous outcomes.

RESULTS

A total of 11 studies with 702 patients were included for this meta-analysis. There was significant difference in total postoperative drainage (SMD: -0.74 [95%CI: -1.31, -0.16]; P< 0.01), seroma development[OR: 0.49 (0.34, 0.70); P < 0.01], intraoperative blood loss(SMD: -1.14 [95%CI: -1.81,-0.47]; P < 0.01) and wound complications [OR: 0.38 (0.24, 0.59); P < 0.01] between harmonic scalpel dissection and standard electrocautery in modified radical mastectomy for breast cancer. No difference was found as for operative time between harmonic scalpel dissection and standard electrocautery (SMD: 0.04 [95%CI: -0.41, 0.50]; P = 0.85).

CONCLUSION

Compared to standard electrocautery, harmonic scalpel dissection presents significant advantages in decreasing postoperative drainage, seroma development, intraoperative blood loss and wound complications in modified radical mastectomy for breast cancer, without increasing operative time. Harmonic scalpel can be recommended as a preferential surgical instrument in modified radical mastectomy.

Should a drain be placed in early breast cancer surgery?

BACKGROUND

The current surgical debate has led to a reduction in the extent of surgery performed and thereby to a reduced occurrence of surgical trauma and, over the recent years, reduced seroma formation. This reduction in surgical procedures calls the need for a drain into question.

METHOD

Using Google Scholar and the National Library of Medicine (PubMed), a literature review was performed on systematic reviews and meta-analyses regarding breast cancer surgery ± axillary dissection. Additionally, randomized trials for the time period after the last systematic review were included and evaluated according to the Jadad score.

RESULTS

The search returned 5 systematic reviews, in which a total of 1,075 patients were included (537 cases and 538 controls). Since the last review, no prospective randomized trial meeting the inclusion criteria has been published. The current reviews conclude that insertion of a drain is associated with a longer hospital stay and reduced seroma formation. The data regarding wound infection and drain insertion is inconclusive. The omission of a drain is associated with early discharge, reduced postsurgical pain, and early mobilization, but also with an increase in outpatient seroma aspirations.

CONCLUSION

The omission of a drain is possible in early breast cancer surgery (wide local excision and sentinel node biopsy) with adequate surgical techniques and instruments.

Ultrasonic dissection system technology in breast cancer: a case-control study in a large cohort of patients requiring axillary dissection

In the sentinel node era, axillary dissection (ALND) for breast cancer (BC) is required much less frequently than in the past. However, complications, such as prolonged drainage output and seroma formation, are still observed. Harmonic dissection devices (HDDs) are widely used in laparoscopic and minimally invasive surgery to reduce collateral damage during tissue dissection, but its usefulness in breast surgery is unclear. The aim of this study was to evaluate the efficacy of HDDs compared to that of conventional dissection in performing ALND. One hundred thirty-nine women (median age 61 years, range 34-71 years) with confirmed pT1-2 primary infiltrating ductal BC undergoing curative surgery were enrolled in the study. The population was prospectively randomized between two age- and stage-matched arms: group A (cases)-68 (48.9 %) patients (HDD technique), versus group B (controls)-71 (51.1 %) patients (conventional technique). In group B, skin flaps were obtained using a scalpel, scissors, and electrocautery which was never used for ALND. In group A, for each operation time, the HDDs were used exclusively. The mean operative time, intraoperative blood loss, and drainage output were (A vs. B) 95 ± 22 versus 109 ± 25 min, 56 ± 12 versus 86 ± 15 mL, and 412 ± 83 versus 456 ± 69 mL, respectively (p < 0.01). Twenty-nine (20.9 %) patients developed an axillary seroma: 9 (13.2 %) and 20 (28.2 %) for groups A and B, respectively (p = 0.030). Our study confirms that in patients with BC requiring ALND the use of HDDs is more time efficient than conventional surgery, and reduces intraoperative bleeding, the amount of drainage, and the risk of seroma formation. These results may lead to several short- and long-term advantages. Thus, a careful evaluation of the cost-benefits of nontraditional tools, such as HDDs, should be performed in all patients undergoing modified radical or partial mastectomy and ALND for BC.

New technologies in breast cancer surgery

Since breast-conserving surgery has become the gold standard for early breast cancer, the development of less radical or less burdensome technologies has been pressed for in order to preserve the patient from unnecessary harm through the operative procedure. Different technical approaches are under evaluation, and some of them are already being used in the clinical setting. The aim of this article is to present a perspective on future breast cancer surgery by shedding light on the current innovative and new techniques.