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

Postoperative lymphatic leakage following laparoscopic totally extraperitoneal inguinal hernia repair: the first case report and review of the literature

PURPOSE

Postoperative lymphatic leakage (PLL) is a rare and poorly understood complication following laparoscopic inguinal hernia repair (LIHR). While seroma is a well-documented postoperative finding, the potential for lymphatic leakage and subsequent lymphatic fistula is frequently overlooked and often misclassified. This report presents a unique case of postoperative lymphocele following Totally Extraperitoneal (TEP) inguinal hernia repair and discusses diagnostic considerations, management strategies, and implications for surgical practice.

METHODS

We report the case of a 56-year-old male who developed a large, symptomatic inguinal lymphocele after undergoing TEP LIHR. Diagnosis was confirmed via magnetic resonance imaging (MRI) and analysis of the drained fluid. Management involved surgical drainage followed by low-dose radiotherapy. A narrative literature review was also performed to identify existing evidence on PLL following LIHR.

RESULTS

The patient developed a significant septated fluid collection (115 × 60 × 50 mm) compressing the bladder, consistent with a lymphocele. Drain output peaked at 350 mL/day. Fractionated low-dose radiotherapy (0.5 Gy × 10 sessions) led to a marked reduction in lymphatic output to <10 mL/day, permitting safe drain removal. At two-month follow-up, the patient remained asymptomatic. A narrative literature search revealed no previously reported cases of PLL following LIHR.

CONCLUSION

To our knowledge, this is the first reported case of lymphocele and lymphatic fistula formation following TEP LIHR. This case highlights the need to recognize lymphatic leakage as a distinct complication. Low-dose radiotherapy appears to be an effective, minimally invasive treatment. Standardized terminology and further research are essential to improve diagnosis and management.

Oncologic surgical complications: Imaging approach and characteristics

Cancer is a disease that has multisystemic facets in its diagnosis and management. The treatment of choice with curative intent in many sites is surgery for early disease, commonly combined with neoadjuvant or adjuvant treatment. Oncologic surgery can have both locoregional and systemic complications, occasionally accentuated by multimodality treatment. While complications are of concern in any surgical setting, they may have specific intricate implications in the care of a cancer patient. Diagnostic imaging provides a non-invasive means of detecting complications and communicating the findings to the rest of the team for decision-making. Clinical clues, site-specific considerations and visual characteristics can aid the radiologist in arriving at a diagnosis of a locoregional oncologic surgical complication. Knowledge of systemic or distant complications, their clinical and imaging characteristics is a must-know following oncologic surgery. This article as an educational narrative review addresses imaging approach and characteristics of oncologic surgical complications, by pairing clinical considerations and imaging aspects.

Cyanoacrylate glue in breast surgery: the GLUBREAST Trial

Introduction

In 2018, the National Cancer Institute of Naples has launched the GLUBREAST Trial to verify the efficacy of cyanoacrylate sealing glue to prevent or reduce seroma after axillary dissection in breast surgery. The glue is a synthetic sealant (N-Butyl-2-CyanoAcrylate+Metacryloxisulfolane) biocompatible, CE approved for internal human uses and surgical procedures. The assumed mechanism of action in breast surgery is that the glue would create a seal coating in the operative field to occlude lymphatic leaks and limit seroma formation.

Materials and methods

The trial included 180 patients scheduled for breast-conserving surgery or for radical modified mastectomy without reconstruction. Out of 180 patients, 91 were randomized to receive suction drain and sealant glue after axillary dissection (Experimental Arm), whereas 89 patients (Control Arm) received suction drain without glue.

Statistics

A multivariable mixed effect model on presence of liquid drained and volume drained was calculated. Stratified models by visits were performed.

Results

The trial ended in June 2022. Older age was associated with a higher volume of seroma drained per day (β 0.30; 95% CI: 0.00-0.60). A 5-U increase in body mass index was associated with higher daily drained seroma volume in patients who underwent breast-conserving surgery (β 5.0; 95% CI: 0.62-9.4), but not in patients who underwent mastectomy (β 2.5; 95% CI: -3.6-8.6). We did not find statistically significant differences in presence of liquid drained and volume drained among the study groups. An advantage for the Experimental Arm was observed from third and fourth to fifth outpatient visits without reaching a statistical significance (p=0.069 and p=0.072, respectively); so far, 5% of patients in the Experimental Group had clinical benefit from the glue.

Conclusions

The vast majority of data in the literature come from case series, and surgeons need a higher level of evidence to drive surgical decision-making and choose proper devices to increase patient quality of life. The GLUBREAST randomized trial tested the efficacy of cyanoacrylate sealing glue to prevent postoperative seroma in breast surgery. Although only a small number of patients benefited from sealant application, we regret to say this trial has some limitation, i.e., the prolonged presence of suction drain. Further research is warranted to better clarify the benefit of cyanoacrylate glue in breast surgery.

Breast Cancer Patient Flap Management After Mastectomy: A Best Practice Implementation Project

BACKGROUND

Breast cancer is a prevalent malignancy in women, with mastectomy as the main surgery. Common postmastectomy complications are seroma (15%-81%), infections (2.9%-3.8%), and flap necrosis (10%-18%), severely impacting quality of life and costs. However, there's a lack of standardized flap care protocols and limited staff knowledge.

OBJECTIVES

This study aims to apply best evidence for flap management post-mastectomy to standardize practices, reduce complications, and enhance patient's quality of life.

METHODS

This project followed JBI PACES and GRiP principles, implementing evidence-based practices in a Chinese tertiary hospital between January and May 2023. It entailed evidence identification, integration into clinical context, protocol development, baseline audits, barrier/enabler analysis. The study compared pre- and post-evidence implementation rates of flap complications, healthcare staff's knowledge/skill scores on mastectomy flap management, and audit indicator adherence by both staff and patients.

RESULTS

After evidence application, flap ischemia/necrosis rates dropped from 8.57% to 5.56% (P < .001), wound infection rates after surgery reduced from 5.71% to 2.78% (P < .001), and seroma rates decreased from 17.14% to 2.78% (P < .001). Healthcare staff's knowledge and skill scores for flap management following mastectomy increased from 50.67 ±18.32 preimplementation to 98.33 ± 4.01 (t = -13.90, P < .001). Audit criterion compliance rates increased from 8.57% to 94.29% to between 91.67% and 100%, with statistically significant differences in all 15 criteria (P < .001).

CONCLUSIONS

Evidence-based management of flaps after mastectomy improves healthcare staff's knowledge and skills, enhances nursing quality, effectively reduces flap complications in patients, and boosts their quality of life.

Animal models for preventing seroma after surgery: a systematic review and meta-analysis

Novel interventions for seroma prevention are urgently needed in clinical practice. Animal models are pivotal tools for testing these interventions; however, a significant translational gap persists between clinical and animal model outcomes. This systematic review aims to assess the methodological characteristics and quality of animal models utilized for seroma prevention. A meta-analysis was performed to estimate the expected seroma incidence rate for control groups and determine the effect size of typical interventions. We systematically retrieved all studies describing animal models in which seroma formation was induced. Methodological characteristics, risks of bias, and study quality were assessed. Seroma volume and -incidence data were used for the meta-analysis. In total, 55 studies were included, with 42 eligible for meta-analysis. Rats (69%) were the most frequently used species, with mastectomy (50%) being the predominant surgical procedure in these models. Despite significant risks of bias across all studies, an improving trend in reporting quality per decade was observed. The meta-analysis revealed an average seroma incidence of 90% in typical control groups. The average intervention halved the seroma incidence (RR = 0.49; CI 0.35, 0.70) and significantly reduced seroma volume (SMD = -3.31; CI -4.21, -2.41), although notable heterogeneity was present. In conclusion, animal models for seroma prevention exhibit methodological flaws and multiple risks of bias. Implementing sufficiently powered positive and negative control groups could improve the internal validity of these models. More research is needed for further development of animal seroma models.

The Effects of Systemic Tranexamic Acid Administration on Drainage Volume, Duration of Drain Placement, and Length of Hospital Stay in Skin- and Nipple-Sparing Mastectomies with Immediate Expander-Based Breast Reconstruction

Background: Skin- (SSM) and nipple-sparing (NSM) mastectomies are frequently performed surgeries with a considerable risk for post-operative hematoma or seroma. Tranexamic acid (TXA) is a potent antifibrinolytic drug commonly used in many surgical fields but rather novel in plastic and, specifically, breast surgery. This study investigates the influence of TXA in patients undergoing SSM or NSM with expander-based reconstruction (EbR) on post-operative outcomes. Methodology: A retrospective study was conducted on 132 patients undergoing uni- or bilateral SSM or NSM with EbR between May 2015 and March 2022. Patients receiving systemic TXA treatment for 48 h following a standardized protocol were compared to those who received no treatment. Multivariable linear regression was performed to identify influencing factors and quantify their effect on drainage volume, duration of drain placement, length of hospital stay, post-operative bleeding, and seroma formation. Results: The 132 patients underwent a total of 155 mastectomies (72 in the TXA group, 83 in the control group). TXA significantly reduced drainage volume (-22.3 mL, p = 0.011). Duration of drain placement and length of hospital stay were significantly shorter in the TXA group (p < 0.001 and p = 0.001). No significant side effects were reported. Conclusion: TXA is a safe drug if administered respecting the well-defined contraindications. Systemic TXA administration significantly reduces drainage volume in patients undergoing SSM or NSM and should encourage surgeons to reconsider using drains in post-operative protocols. Duration of drain placement and length of hospital stay were significantly reduced in the TXA group but other factors like resection weight might have a more substantial impact.

The use of superficial circumflex iliac perforator (SCIP) pedicle vein for lymphovenous anastomosis to treat inguinal lymphatic fistula: A case report

The management of lymphatic fistulas following surgical procedures, in particular after inguinal lymphadenectomy, represents a significant clinical challenge. The current case report shows the novel use of the superficial circumflex iliac perforator (SCIP) pedicle vein for lymphovenous anastomosis (LVA) to treat a chronic inguinal lymphatic fistula in a 58-year-old male patient. This patient had developed a persistent lymphorrhea and wound dehiscence after a right inguinal lymph node biopsy performed for oncological reasons 1.5 months before. Pre-operative assessment with indocyanine green (ICG) lymphography confirmed a substantial lymphatic contribution to the wound discharge, thus guiding the surgical strategy. During the procedure, a pedicled tissue segment containing the SCIV was dissected and utilized to fill the wound's dead space and facilitate LVA with the leaking lymphatic vessel. Notably, a coupler device was employed for the anastomosis due to the large caliber of the lymphatic vessel involved, a technique not commonly reported in lymphatic surgeries. The result of the procedure was successful, with intra-operative ICG imaging confirming the patency of the anastomosis. After surgery the wound healed without complications. This case illustrates the potential of SCIV employment in lymphatic fistula repair in the inguinal region. While further research is needed to validate these findings, this report provides an unconventional approach to a relatively common problem in clinical practice.

Comparison of the effect of ultrasounic-harmonic scalpel and electrocautery in the treatment of axillary lymph nodes during radical surgery for breast cancer

OBJECTIVE

To compare the efficacy of ultrasounic-harmonic scalpel and electrocautery in the treatment of axillary lymph nodes during radical surgery for breast cancer.

METHODS

A prospective study was conducted in the Department of Breast Surgery, Zhongda Hospital Affiliated to Southeast University. A total of 128 patients with pathologically confirmed breast cancer who were treated by the same surgeon from July 2023 to November 2023 were included in the analysis. All breast operations were performed using electrocautery, and surgical instruments for axillary lymph nodes were divided into ultrasounic-harmonic scalpel group and electrocautery group using a random number table. According to the extent of lymph node surgery, it was divided into four groups: sentinel lymph node biopsy, lymph node at station I, lymph node at station I and II, and lymph node dissection at station I, II and III. Under the premise of controlling variables such as BMI, age and neoadjuvant chemotherapy, the effects of ultrasounic-harmonic scalpel and electrocautery in axillary surgery were compared.

RESULTS

Compared with the electrosurgical group, there were no significant differences in lymph node operation time, intraoperative blood loss, postoperative axillary drainage volume, axillary drainage tube indwelling time, postoperative pain score on the day after surgery, and the incidence of postoperative complications (p>0.05).

CONCLUSION

There is no significant difference between ultrasounic-harmonic scalpel and electrocautery in axillary lymph node treatment for breast cancer patients, which can provide a basis for the selection of surgical energy instruments.

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.

Effect of Clavipectoral Fascia Suturing on Postmastectomy Seroma Formation

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

The Efficacy and Safety of Somatostatin Analog after Axillary Node Dissection in Breast Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Somatostatin analogs are expected to reduce lymphatic leakage. However, whether they can be used after axillary lymphadenectomy is unclear. This study aimed to assess the efficacy and safety of somatostatin analogs in axillary lymphadenectomy for breast cancer patients.

METHODS

We performed a random-effects meta-analysis by searching electronic databases for randomized trials and trial registries until June 2022. The primary outcomes were the volume of drained fluid, the duration of drainage, and seroma incidence. Bias was assessed using the Cochrane Collaboration's tool and the Grading of Recommendations, Assessment, Development, and Evaluations approach.

RESULTS

Six trials (738 participants) and one protocol without results were included. Somatostatin analogs may reduce the volume of drained fluid (mean difference = -22.07 mL, 95% confidence interval [CI] = -42.09 to -2.05; I2 = 56%) while resulting in a slight-to-no difference in the duration of drainage (mean difference = -0.48 days, 95% CI = -1.43 to 0.46; I2 = 87%) and seroma incidence (risk ratio = 0.91, 95% CI = 0.61-1.34; I2 = 55%). The certainty of the evidence was low.

CONCLUSIONS

There was limited evidence supporting somatostatin analogs for lymphorrhea after axillary lymphadenectomy. Multicenter randomized controlled trials are needed to confirm the efficacy and safety of somatostatin analogs after axillary lymphadenectomy.

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.