Electrothermal bipolar vessel sealing system in axillary dissection: A prospective randomized clinical study

Total Sealing Technique (TST) with a bipolar vessel sealing system reduces lymphorrhea and seroma formation for axillary lymph node dissection in primary breast cancer

Background

The purpose of this study is to evaluate the potential of a novel surgical procedure, the Total Sealing Technique (TST), using the latest bipolar vessel sealing system (BVSS; LigaSure™ Exact Dissector) to reduce lymphatic leakage and seroma formation after electrocautery axillary lymph node dissection (ALND) in breast cancer surgery. Prolonged drainage is a common occurrence after ALND, primarily due to lymphatic leakage. In addition, the presence of seroma often leads to delays in the administration of postoperative adjuvant chemotherapy even after drain removal.

Methods

We conducted a comparative analysis of 36 patients who underwent total mastectomy with ALND using conventional electrocautery technique (CONV) during the first 3 years, and 35 patients who underwent the same procedure using TST during the subsequent 3 years. The following factors were compared to assess the impact of TST: operation time, blood loss, total drainage volume, mean time to drain removal, postoperative hospital stay, mean time to initiation of postoperative chemotherapy, and postoperative complications in each group.

Results

TST significantly reduced drainage volume (360.5 vs. 820.6 mL, p < 0.001), days to drain removal (4.8 vs. 6.8 days, p < 0.001), postoperative hospital stay (5.9 vs. 9.6 days, p < 0.001), the incidence of seroma (28.6 % vs. 65.9 %, p = 0.001), and time to chemotherapy initiation (33.1 vs. 61.4 days, p < 0.001) compared to CONV.

Conclusions

TST in total mastectomy with ALND effectively decreases the incidence of lymphorrhea and seroma formation; thus, it can be recommended for total mastectomy with ALND.

Monopolar diathermy versus a vessel-sealing device for reducing postoperative drain output after simple mastectomy: randomized clinical trial

BACKGROUND

Electrosurgical devices are commonly used during mastectomy for simultaneous dissection and haemostasis, and can provide potential benefits regarding vessel and lymphatic ligation. The aim of this prospective RCT was to assess whether using a vessel-sealing device (LigaSure™) improves perioperative outcomes compared with monopolar diathermy when performing simple mastectomy.

METHODS

Patients were recruited prospectively and randomized in a 1 : 1 manner to undergo simple mastectomy using either LigaSure™ or conventional monopolar diathermy at a single centre. The primary outcome was the number of days the drain remained in situ after surgery. Secondary outcomes of interest included operating time and complications.

RESULTS

A total of 86 patients were recruited (42 were randomized to the monopolar diathermy group and 44 were randomized to the LigaSure™ group). There was no significant difference in the mean number of days the drain remained in situ between the monopolar diathermy group and the LigaSure™ group (7.75 days versus 8.23 days; P = 0.613) and there was no significant difference in the mean total drain output between the monopolar diathermy group and the LigaSure™ group (523.50 ml versus 572.80 ml; P = 0.694). In addition, there was no significant difference in the mean operating time between the groups, for simple mastectomy alone (88.25 min for the monopolar diathermy group versus 107.20 min for the LigaSure™ group; P = 0.078) and simple mastectomy with sentinel lymph node biopsy (107.20 min for the monopolar diathermy group versus 114.40 min for the LigaSure™ group; P = 0.440).

CONCLUSION

In this double-blinded single-centre RCT, there was no difference in the total drain output or the number of days the drain remained in situ between the monopolar diathermy group and the LigaSure™ group.

REGISTRATION NUMBER

EudraCT 2018-003191-13 BEAUMONT HOSPITAL REC 18/66.

Efficacy and safety of surgical energy devices for axillary node dissection: a systematic review and network meta-analysis

Various surgical energy devices are used for axillary lymph-node dissection. However, those that reduce seroma during axillary lymph-node dissection are unknown. We aimed to determine the best surgical energy device for reducing seroma by performing a network meta-analysis to synthesize the current evidence on the effectiveness of surgical energy devices for axillary node dissection for breast cancer patients. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform Search Portal. Two reviewers independently selected randomized controlled trials (RCTs) comparing electrosurgical bipolar vessel sealing (EBVS), ultrasonic coagulation shears (UCS), and conventional techniques for axillary node dissection. Primary outcomes were seroma, drained fluid volume (mL), and drainage duration (days). We analyzed random-effects and Bayesian network meta-analyses. We evaluated the confidence of each outcome using the CINeMA tool. We registered with PROSPERO (CRD42022335434). We included 34 RCTs with 2916 participants. Compared to the conventional techniques, UCS likely reduces seroma (risk ratio [RR], 0.61; 95% credible interval [CrI], 0.49-0.73), the drained fluid volume (mean difference [MD], - 313 mL; 95% CrI - 496 to - 130), and drainage duration (MD - 1.79 days; 95% CrI - 2.91 to - 0.66). EBVS might have little effect on seroma, the drained fluid volume, and drainage duration compared to conventional techniques. UCS likely reduce seroma (RR 0.44; 95% CrI 0.28-0.69) compared to EBVS. Confidence levels were low to moderate. In conclusion, UCS are likely the best surgical energy device for seroma reduction during axillary node dissection for breast cancer patients.

High-energy devices in different surgical settings: lessons learnt from a full health technology assessment report developed by SICE (Società Italiana di Chirurgia Endoscopica)

BACKGROUND

The present paper aims at evaluating the potential benefits of high-energy devices (HEDs) in the Italian surgical practice, defining the comparative efficacy and safety profiles, as well as the potential economic and organizational advantages for hospitals and patients, with respect to standard monopolar or bipolar devices.

METHODS

A Health Technology Assessment was conducted in 2021 assuming the hospital perspective, comparing HEDs and standard monopolar/bipolar devices, within eleven surgical settings: appendectomy, hepatic resections, colorectal resections, cholecystectomy, splenectomy, hemorrhoidectomy, thyroidectomy, esophago-gastrectomy, breast surgery, adrenalectomy, and pancreatectomy. The nine EUnetHTA Core Model dimensions were deployed considering a multi-methods approach. Both qualitative and quantitative methods were used: (1) a systematic literature review for the definition of the comparative efficacy and safety data; (2) administration of qualitative questionnaires, completed by 23 healthcare professionals (according to 7-item Likert scale, ranging from - 3 to + 3); and (3) health-economics tools, useful for the economic evaluation of the clinical pathway and budget impact analysis, and for the definition of the organizational and accessibility advantages, in terms of time or procedures' savings.

RESULTS

The literature declared a decrease in operating time and length of stay in using HEDs in most surgical settings. While HEDs would lead to a marginal investment for the conduction of 178,619 surgeries on annual basis, their routinely implementation would generate significant organizational savings. A decrease equal to - 5.25/-9.02% of operating room time and to - 5.03/-30.73% of length of stay emerged. An advantage in accessibility to surgery could be hypothesized in a 9% of increase, due to the gaining in operatory slots. Professionals' perceptions crystallized and confirmed literature evidence, declaring a better safety and effectiveness profile. An improvement in both patients and caregivers' quality-of-life emerged.

CONCLUSIONS

The results have demonstrated the strategic relevance related to HEDs introduction, their economic sustainability, and feasibility, as well as the potentialities in process improvement.

Use of LigaSure vessel sealing system versus conventional axillary dissection in breast cancer patients: a retrospective comparative study

BACKGROUND

In locally advanced breast cancer, axillary lymph node dissection remains a pivotal component of surgical therapy. Apart from this, it has been mostly replaced by sentinel node biopsy. Complications after axillary dissection include wound infection, neuropathy, lymphedema and-most frequently-seroma. In this retrospective multi-centre study, we compared the use of LigaSure^TM with monopolar electrocautery regarding perioperative outcome.

METHODS

A retrospective data analysis from female breast cancer patients who underwent axillary dissection at two breast centres in Austria that are using two different surgical techniques was performed for this study. We compared the rate of complications and re-operations, length of hospital stay, time to drain removal, total drain fluid, seroma formation after drain removal, number of seroma aspirations and total seroma fluid.

RESULTS

Seventy one female patients with a median age of 63 (30-83) were included in this study. In 35 patients LigaSure^TM and in 36 monopolar cautery was used for axillary dissection. There was no significant difference regarding intraoperative complications and rate of re-operations between the two groups (2.9 vs. 5.6%; p = 1 and 2.9 vs. 13.9%; p = 0.199). The time to drain removal and the length of hospital stay was similar in both groups. A significant difference in the occurence of postoperative wound infection could also not be shown. However, we found a significantly smaller total drain fluid in the LigaSure^TM-group compared to the cautery-group (364.6 ml vs. 643.4 ml; p = 0.004). Seroma formation after drain removal was more frequent in the LigaSure^TM-group (68.6 vs. 41.7%; p = 0.032) with a higher number of outpatient seroma aspirations (2.0 vs. 0.9; p = 0.005).

CONCLUSION

LigaSure^TM and monopolar cautery provide equivalent techniques in axillary lymph node dissection with comparable postoperative outcomes.

Comparison of surgical morbidities between LigaSure™ and conventional techniques in inguinal or ilioinguinal lymph node dissection for skin cancer: A single center retrospective study

Skin cancer patients with clinical nodal disease or whose positive sentinel nodes had great tumor burden remain candidates for regional lymph node dissections. Among these patients, inguinal or ilioinguinal lymph node dissection is frequently required in clinical practice, which is associated with significant postoperative morbidity-including lymphatic leakage. The aim of this retrospective study was to evaluate the efficacy of LigaSure™, an electrothermal bipolar vessel sealing system, in reducing lymphatic leakage in inguinal or ilioinguinal lymph node dissection. In total, 58 patients who received inguinal or ilioinguinal lymph node dissection (conventional group, 48; LigaSure™ group, 10) and shared similar characteristics were included in this study. Lymphatic leakage after drain removal was significantly lower in the LigaSure™ group than that in the conventional group (present ratio, 0% vs. 37%; p = 0.02). The daily lymphatic drainage volume also tended to be lower in the LigaSure™ than that in the conventional group, with significant differences on postoperative day 1 (p = 0.02). Other perioperative outcomes including the operating time, intraoperative blood loss, time to drain removal, duration of hospital stay, flap necrosis, and wound infection showed no significant differences between the two groups. The use of the LigaSure™ in inguinal or ilioinguinal lymph node dissection for the treatment of skin cancer could reduce the incidence of postoperative lymphatic leakage after drain removal.

A Prospective Randomized Study to Compare Postoperative Drainage After Mastectomy Using Electrosurgical Bipolar Systems and Conventional Electro-Cautery

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, LigaSure^TM (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.

Incidence of and risk factors for surgical site infection following canine limb amputation

OBJECTIVE

To determine the incidence of and risk factors for surgical site infection (SSI) following canine thoracic and pelvic limb amputations.

STUDY DESIGN

Retrospective, multicenter study.

ANIMALS

Dogs (n = 248).

METHODS

Medical records were reviewed for preoperative, intraoperative, and postoperative variables including indication for amputation, amputation type, method of muscle transection, duration of surgery and anesthesia, and wound classification. Follow up was ≥30 days or until SSI development. Logistic regression and Fisher's exact tests were used to compare SSI incidence to variables of interest.

RESULTS

The incidence of SSI was 12.5% for all procedures and 10.9% for clean procedures. Factors increasing odds of SSI were muscle transection with a bipolar vessel sealing device (P = .023 for all procedures, P = .025 for clean procedures), procedure classified as other than clean (P = .003), and indication for amputation of bacterial infection (P = .041) or traumatic injury (P = .003) compared to neoplasia.

CONCLUSION

Use of bipolar vessel sealing devices for muscle transection increased the odds of developing an SSI whereas use of electrosurgery and/or sharp transection did not. Dogs with surgical sites that were other than clean, or with bacterial infection and/or traumatic injury were also at increased odds of SSI.

CLINICAL SIGNIFICANCE

Use of electrosurgery or sharp transection for muscle transection should be considered rather than use of bipolar vessel sealing devices to decrease odds of SSI in dogs undergoing limb amputation. Further studies across a variety of procedures are needed to validate these findings given the increasing popularity of these devices in veterinary medicine.

Ligasure™ Impact and Ligasure™ Small Jaw in Body Contouring after Massive Weight Loss: A New Perspective

BACKGROUND

The most effective dissection technique for elevating flaps in body contouring is still controversial, particularly in high-risk massive weight loss (MWL) patients. LigaSure (Medtronic, Dublin, Ireland) is an energy device commonly used among different surgical specialties to reduce morbidity and improve outcomes. The aim of this study is to investigate the effectiveness of LigaSure Impact and LigaSure Small Jaw in body contouring after MWL compared with conventional technique.

MATERIAL AND METHODS

Patients who underwent abdominoplasty, mastopexy, brachioplasty and thigh lift after MWL at a single center from 1 December 2018 to 1 March 2020 were retrospectively reviewed. In each procedure patients were divided into two groups according to the dissection technique: LigaSure group and monopolar electrosurgery group. Patients characteristics, perioperative details and postoperative complications were evaluated.

RESULTS

Fourty-five patients underwent abdominoplasty, twenty-six mastopexy, twenty brachioplasty and sixteen medial thigh lift. Using LigaSure, operative time was longer in abdominoplasty and thigh lift, but shorter in mastopexy and brachioplasty. Although not statistically significant, the amount of blood and serum recorded from drains in the first 36 hours was reduced in LigaSure groups. Additional analgesic intake was reduced with LigaSure as well as postoperative subjective pain. In all body contouring procedures statistically significant difference was found in days of hospital stay favoring LigaSure groups. Complications occurred most frequently in control groups compared to LigaSure groups.

CONCLUSION

LigaSure Impact and LigaSure Small Jaw may be beneficial in improving outcomes because they might reduce fluids drainage, analgesics intake, hospital stay and postoperative complications.

Reduced morbidity by using LigaSure compared to conventional inguinofemoral lymphadenectomy in vulvar cancer patients: A randomized controlled trial

BACKGROUND

Inguinofemoral lymphadenectomy (IFL) is part of the surgical treatment of different malignancies of the genital tract and/or the lower limb including vulvar carcinoma, penile carcinoma and melanoma. IFL is associated with morbidity in up to 85% of the patients. The aims of this MAMBO-IC study (Morbidity And Measurement of the Body) are to study the feasibility of using LigaSure for IFL and to assess the differences in the incidence of short-term complications using LigaSure versus conventional IFL randomized within each individual patient.

METHODS

In this multicenter randomized controlled trial (RCT), women diagnosed with squamous cell carcinoma of the vulva with an indication for bilateral IFL were included. It was randomly assigned for which groin the LigaSure was used; the other groin was treated with conventional IFL (sharp/diathermia). We estimated the incidence of ≥1 complication(s) per groin using logistic regression and compared this between the two surgical methods, adjusting for possible confounders.

RESULTS

We included 40 groins of 20 patients. The estimated incidence of ≥1 complication(s) was 29% after LigaSure versus 70% after conventional IFL (risk difference 41% (95% CI 19-62), p < 0.001). Patients' reported restriction of daily living activities and maximum pain score were equal for both treatment methods. There were no differences in the surgeon reported workload scores.

CONCLUSIONS

This RCT shows that LigaSure for IFL is feasible and associated with significantly less short-term surgical complications compared to conventional IFL. Further studies with a larger sample size are needed to validate our findings. ISRCTN15057626.

Seroma in breast surgery: all the surgeons fault?

BACKGROUND

Despite a trend for less radical surgical approaches in breast cancer due to better understanding of tumour biology and new treatment options such as neoadjuvant chemotherapy (NAC) and intra-operative radiotherapy (IORT), seroma production remains one of the main surgical side effects that can result in prolonged recovery, delay of radiotherapy and patient discomfort. The aim of this study is to provide an update on risk factors for seroma production after breast cancer surgery considering the latest treatment options.

METHODS

A retrospective analysis of seroma production in primary breast cancer patients treated between 01.01.2010 and 31.12.2014 at the Breast Cancer Centre, University Hospital Ulm, was performed. Patients with previous breast/axillary surgery or more than one intervention were excluded. Seroma formation was measured using wound drains placed in breast and axilla.

RESULTS

In total, 581 patients met the inclusion criteria. Median age at diagnosis was 60 years, and median BMI 25.6 kg/m². 60 (10.3%) patients had a mastectomy, 175 (30.1%) patients received IORT, and 72 (12.4%) patients received NAC. Median amount of seroma production was 82.5 ml (range 0-3012.5 ml). Multivariate analysis revealed that most of the observed variation in seroma production was due to type of surgery (mastectomy vs. breast conserving), length of surgery and number of removed lymph nodes. Both NAC and IORT explained a significant but very small amount of the observed variation in seroma production.

CONCLUSION

The most important factors for seroma production are extent and duration of breast surgery.

Impact of a Surgical Sealing Patch on Lymphatic Drainage After Axillary Dissection for Breast Cancer: The SAKK 23/13 Multicenter Randomized Phase III Trial

BACKGROUND

Several studies and a meta-analysis showed that fibrin sealant patches reduced lymphatic drainage after various lymphadenectomy procedures. Our goal was to investigate the impact of these patches on drainage after axillary dissection for breast cancer.

METHODS

In a phase III superiority trial, we randomized patients undergoing breast-conserving surgery at 14 Swiss sites to receive versus not receive three large TachoSil^® patches in the dissected axilla. Axillary drains were inserted in all patients. Patients and investigators assessing outcomes were blinded to group assignment. The primary endpoint was total volume of drainage.

RESULTS

Between March 2015 and December 2016, 142 patients were randomized (72 with TachoSil^® and 70 without). Mean total volume of drainage in the control group was 703 ml [95% confidence interval (CI) 512-895 ml]. Application of TachoSil^® did not significantly reduce the total volume of axillary drainage [mean difference (MD) -110 ml, 95% CI -316 to 94, p = 0.30]. A total of eight secondary endpoints related to drainage, morbidity, and quality of life were not improved by use of TachoSil^®. The mean total cost per patient did not differ significantly between the groups [34,253 Swiss Francs (95% CI 32,625-35,880) with TachoSil^® and 33,365 Swiss Francs (95% CI 31,771-34,961) without, p = 0.584]. In the TachoSil^® group, length of stay was longer (MD 1 day, 95% CI 0.3-1.7, p = 0.009), and improvement of pain was faster, although the latter difference was not significant [2 days (95% CI 1-4) vs. 5.5 days (95% CI 2-11); p = 0.2].

CONCLUSIONS

TachoSil^® reduced drainage after axillary dissection for breast cancer neither significantly nor relevantly.

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.

Flap fixation reduces seroma in patients undergoing mastectomy: a significant implication for clinical practice

BACKGROUND

Seroma formation is a common complication following mastectomy for invasive breast cancer. Mastectomy flap fixation is achieved by reducing dead space volume using interrupted subcutaneous sutures.

METHODS

All patients undergoing mastectomy due to invasive breast cancer or ductal carcinoma in situ (DCIS) were eligible for inclusion. From May 2012 to March 2013, all patients undergoing mastectomy in two hospitals were treated using flap fixation. The skin flaps were sutured on to the pectoral muscle using polyfilament absorbable sutures. The data was retrospectively analysed and compared to a historical control group that was not treated using flap fixation (May 2011 to March 2012).

RESULTS

One hundred and eighty patients were included: 92 in the flap fixation group (FF) and 88 in the historical control group (HC). A total of 33/92 (35.9%) patients developed seroma in the group that underwent flap fixation; 52/88 (59.1%) patients developed seroma in the HC group (p = 0.002). Seroma aspiration was performed in 14/92 (15.2%) patients in the FF group as opposed to 38/88 (43.2%) patients in the HC group (p < 0.001).

CONCLUSIONS

Flap fixation is an effective surgical technique in reducing dead space and therefore seroma formation and seroma aspirations in patients undergoing mastectomy for invasive breast cancer or DCIS.

Effect of Lavage with Gentamicin vs. Clindamycin vs. Physiologic Saline on Drainage Discharge of the Axillary Surgical Bed after Lymph Node Dissection

BACKGROUND

To date, without placement of a drain, seroma formation cannot be avoided after axillary lymph node dissection (ALND). The purpose of this study was to evaluate the effect on drainage volume of pre-closure axillary lavage with physiologic saline, gentamicin solution, or clindamycin solution.

METHODS

A randomized study was performed between January 2013 and October 2014. Inclusion criteria were a diagnosis of breast neoplasm and plans to undergo an elective ALND because of axillary metastases. The patients were randomized into three groups: Two lavages with 500 mL of physiologic saline (Group 1), lavage with 500 mL of saline followed by lavage with 500 mL of a 240-mg gentamicin solution (Group 2), and lavage with 500 mL of saline followed by lavage with 500 mL of a 600-mg clindamycin solution (Group 3).

RESULTS

A total of 51 patients were included. The mean number of days with a drain in place was 7.1±3 in Group 1, 4.1±1.2 in Group 2, and 6.4±2.1 in Group 3 (p<0.001). Total drainage volume before tube removal was 435.3±220.1 mL in Group 1, 155.2±82.4 mL in Group 2, and 352.3±212.9 mL in Group 3 (p=0.03). In a pairwise analysis, irrigation with gentamicin solution achieved a lower drainage volume and a reduction in the number of days of drainage maintenance compared with the other two groups.

CONCLUSION

The post-operative output of the axillary drain is substantially lower in patients undergoing lavage of the surgical bed with a gentamicin solution than in patients undergoing lavage with physiologic saline or clindamycin solution.

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.

Standardization of morbidity assessment in breast cancer surgery using the Clavien Dindo Classification

INTRODUCTION

There are no published data on standardized scoring systems for morbidity after breast cancer surgery. Aim of the study was to establish the Clavien Dindo Classification (CDC) as assessment tool and to identify risk factors for morbidity after breast surgery investigating new techniques including oncoplastic surgery and neoadjuvant chemotherapy.

PATIENTS AND METHODS

Between 2008 and 2010, data were retrospectively evaluated from 485 women with breast cancer who underwent surgery at a university hospital. The CDC was used to assess the severity of postoperative complications. Multivariable analyses were adjusted by body-mass index, smoking, diabetes mellitus and tumour size.

RESULTS

Overall complications (CDC 1-4) were reported in 28.7%. Second surgery related to major complications (CDC 3-4) was mandatory in 4.7%. Axillary dissection was an independent predictor for CDC 1-4 in all patients (P = 0.008, OR of 1.81, 95%CI 1.17-2.82). We found no independent predictor for CDC 3-4. Oncoplastic surgery increased the rate of wound infections (P = 0.010, OR: 2.94, 95%CI 1.30-6.67) and necroses (P < 0.001, OR: 8.38, 95%CI 3.28-21.4). Axillary dissection elevated wound infection (P = 0.040, OR: 2.07, 95%CI 1.03-4.14) and seroma rates (P < 0.001, OR: 2.46, 95%CI 1.51-4.01). Neoadjuvant chemotherapy had no impact on morbidity.

CONCLUSION

The CDC is a valid assessment tool for future clinical trials and may be useful for hospital quality control. While axillary dissection and oncoplastic surgery raised morbidity, no single factor predicted for morbidity related second surgery.

New operative strategy for refractory microcystic lymphangioma

The optimal management of microcystic lymphatic malformations (LMs) in children has not been established. We describe how we used the Ligasure™ Vessel Sealing System (LVSS) to achieve partial resection of refractory microcystic LMs in a 1-year-old boy. The child was admitted in respiratory distress caused by infection and swelling of cervical LMs. The LMs had been diagnosed prenatally, but had not decreased in size despite three treatments with OK-432 sclerotherapy. We performed direct dissection of the microcystic LMs using the LVSS with minimal intraoperative blood loss or lymphatic leakage. The LMs were resected as completely as possible without damage to the jugular vein or major nerves. His postoperative course was uneventful. Histological examination revealed complete sealing of the lymphovascular channels with obliterated lumens. Resection using the LVSS is effective and easy to perform for partial resection of microcystic LMs. We recommend the combination of initial OK-432 injection therapy and subsequent partial resection using the LVSS for refractory microcystic LMs.

Effect of gentamicin lavage of the axillary surgical bed after lymph node dissection on drainage discharge volume

The purpose of this study was to evaluate the effect of axillary lavage with a gentamicin solution before wound closure on drainage volume.

PATIENTS AND METHODS

A prospective, randomized study was performed. Inclusion criteria were a diagnosis of breast neoplasms and plans to undergo an elective axillary lymph node dissection due to axillary metastasis. The patients were randomized into 2 groups: patients undergoing 2 lavages with 500 ml normal saline (Group 1) and patients first undergoing lavage with 500 ml normal saline followed by a second lavage with a 500 ml of a gentamicin (240 mg) solution (Group 2). Microbiological samples were obtained before any lavage, after each lavage and at the time of drain removal.

RESULTS

40 patients were included. Mean number of days maintaining the drain in place was 7.7 ± 3.2 days in Group 1 and 4.3 ± 1.4 days in Group 2 (p = 0.001). Total drainage volume before removal was 465 ± 250.9 ml in Group 1 and 169 ± 102.2 ml in Group 2 (p = 0.003). After a second lavage with normal saline in Group 1 and after a lavage with gentamicin solution in Group 2, microbiological culture was positive in 10 patients (50%) in Group 1 and 1 case (5%) in Group 2 (p = 0.016). Positive cultures were associated with higher drainage volumes.

CONCLUSION

The postoperative drainage volume of the axillary drain is significantly lower in the patients undergoing a lavage of the surgical bed with a gentamicin solution than in the control group undergoing a lavage with normal saline. A significant reduction in the contamination is only obtained after a lavage with gentamicin solution.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01700504.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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