A comparison of 5-day and 8-day drainage following mastectomy and axillary clearance

Bilateral prophylactic mastectomy: should we preserve the pectoral fascia? Protocol of a Dutch double blinded, prospective, randomised controlled pilot study with a within-subject design (PROFAS)

INTRODUCTION

Bilateral prophylactic mastectomy (BPM) in women with a high risk of developing breast cancer has shown to provide the greatest risk reduction. Many surgical guidelines recommend the removal of the pectoral fascia (PF) in mastectomies; however, there is no evidence to support this statement. Reported wound-related complications following mastectomy include seroma, flap necrosis, infection and haematoma. Seroma causes discomfort and may delay the reconstructive procedures. Whether removal or preservation of the PF influences drain volume, seroma formation and other postoperative complications following BPM remains unclear. The aim of this study is to assess the impact of removal versus preservation of the PF on drain policy and seroma after BPM.

METHODS AND ANALYSIS

This is a double blinded, prospective, randomised controlled pilot study with a within-subject design. The inclusion criteria are women >18 years, presenting in the Academic Breast Cancer Centre Rotterdam, who are opting for BPM. Patients with a history or diagnosis of breast cancer are excluded. According to the sample size calculation based on the difference in total drain volume, a number of 21 eligible patients will be included. Randomisation will occur within the patient, which means PF preservation in one breast and PF removal in the contralateral breast. The primary study endpoint is total drainage volume. Secondary study outcomes include time to drain removal, number of needle aspirations, postoperative complications and length of hospital stay.

ETHICS AND DISSEMINATION

The study is approved by the Erasmus Medical Center Review Board (REC 2020-0431). Results will be presented during international conferences and published in a peer-reviewed academic journal.

TRIAL REGISTRATION NUMBER

NCT05391763; clinicaltrials.gov.

Adverse effects of long-term drain placement and the importance of direct aspiration: a retrospective cohort study

BACKGROUND

Long-term placement of prophylactic drains may result in retrograde infections.

AIM

To investigate the association between the timing of drain removal and clinical outcomes.

METHODS

This retrospective, single-centre cohort study evaluated 110 patients who underwent elective gastrointestinal or hepatopancreatobiliary surgery and developed subsequent organ/space surgical site infection (SSI) between 2016 and 2020. The difference between the culture-positive species of prophylactic drains and direct aspiration was evaluated; whether the prophylactic drains functioned effectively at the time of SSI diagnosis; and whether the empirical antibiotics administered before drainage were effective against all the detected bacteria. Finally, clinical outcomes were compared between early (i.e. cases wherein the prophylactic drain had already been removed or replaced at the time of SSI diagnosis) and late (removal after diagnosis) drain removal.

FINDINGS

The prophylactic drains functioned effectively in only 27 (25%) patients at the time of SSI diagnosis. Due to the results of direct aspiration cultures, 43% of patients required antibiotic escalation. The median time to drain removal or first replacement was seven postoperative days. The early removal group included 43 patients (39%). Compared with early removal, late removal resulted in a higher frequency of vancomycin use (7.0% vs 22.4%; P = 0.037).

CONCLUSION

Prolonged prophylactic drain placement is associated with complicated infections requiring vancomycin; therefore, the drains should be removed as soon as possible. Additionally, obtaining the cultures of direct aspiration should be actively considered, as escalation of antimicrobial therapy is often performed based on culture results.

Biological and clinical review of IORT-induced wound fluid in breast cancer patients

Intraoperative radiotherapy (IORT) has become a growing therapy for early-stage breast cancer (BC). Some studies claim that wound fluid (seroma), a common consequence of surgical excision in the tumor cavity, can reflect the effects of IORT on cancer inhibition. However, further research by our team and other researchers, such as analysis of seroma composition, affected cell lines, and primary tissues in two-dimensional (2D) and three-dimensional (3D) culture systems, clarified that seroma could not address the questions about IORT effectiveness in the surgical site. In this review, we mention the factors involved in tumor recurrence, direct or indirect effects of IORT on BC, and all the studies associated with BC seroma to attain more information about the impact of IORT-induced seroma to make a better decision to remove or remain after surgery and IORT. Finally, we suggest that seroma studies cannot decipher the mechanisms underlying the effectiveness of IORT in BC patients. The question of whether IORT-seroma has a beneficial effect can only be answered in a trial with a clinical endpoint, which is not even ongoing.

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

Seroma or lymphocele remains the most common complication after mastectomy and lymphadenectomy for breast cancer. Many different techniques are available to prevent this complication: wound drainage, reduction of the dead space by flap fixation, use of various types of energy, external compression dressings, shoulder immobilization or physical activity, as well as numerous drugs and glues. We searched MEDLINE, clinicaltrials.gov, Cochrane Library, and Web of Science databases for publications addressing the issue of prevention of lymphocele or seroma after mastectomy and axillary lymphadenectomy. Quality was assessed using Hawker's quality assessment tool. Incidence of seroma or lymphocele were collected. Fifteen randomized controlled trials including a total of 1766 patients undergoing radical mastectomy and axillary lymphadenectomy for breast cancer were retrieved. The incidence of lymphocele or seroma in the study population was 24.2% (411/1698): 25.2% (232/920) in the test groups and 23.0% (179/778) in the control groups. Neither modification of surgical technique (RR 0.86; 95% CI [0.72, 1.03]) nor application of a medical treatment (RR 0.96; 95% CI [0.72, 1.29]) was effective in preventing lymphocele. On the contrary, decreasing the drainage time increased the risk of lymphocele (RR 1.88; 95% CI [1.43, 2.48). There was no publication bias but the studies were of medium to low quality. To conclude, despite the heterogeneity of study designs, drainage appears to be the most effective technique, although the overall quality of the data is low.

An Optimal Timing for Removing a Drain After Breast Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

In clinical practice, drains had been routinely used for reducing seroma formation after breast surgery. However, an optimal timing to remove drains does not identify yet.

METHODS

This study aimed to compare the clinical outcome, such as seroma formation, surgical site infection (SSI), and a length of hospital stay between early removal and late removal. A systematic review was performed using PubMed, MEDLINE, and the Cochrane Library. Breast cancer patients who received surgery using drains were eligible. Those parameters were compared between early vs late removal.

RESULTS

Eleven studies included in this meta-analysis. Seroma formation in the early removal group was significantly higher than the one in the late removal group (RR = 1.58: 95%CI [1.25-2.01], P = 0.0001), meanwhile no significant difference was found among the groups for SSI (RR = 0.82: 95%CI [0.51-1.31], P= 0.40). A length of hospital stay in the early removal group was also significantly shorter than late removal (RR -3.31: 95%CI [-5.13-1.49], P = 0.0004).

CONCLUSIONS

Seroma formation was significantly higher in patients who had early drain removal. Conversely, SSI incidence was low, and early removal did not increase SSI incidence. In conclusion, early drain removal has no proved clinical benefit in these settings besides reduction of hospital stays.

Conventional suture with prolonged timing of drainage is as good as quilting suture in preventing seroma formation at pectoral area after mastectomy

Background

The aim of this study was to compare conventional suture with prolonged timing of drainage with quilting suture on the formation of seroma at pectoral area after mastectomy (ME) with sentinel lymph node biopsy (SLN) or axillary lymph node dissection (ALND) for breast cancer.

Methods

Three hundred and eighty-eight consecutive breast cancer patients were retrospectively analyzed and categorized into three groups. Patients in group 1 were with quilting suture, group 2 with conventional suture and 13–15 days drainage in situ, and group 3 with conventional suture and 20–22 days drainage. The primary outcome was the incidence of grades 2 and 3 seroma at anterior pectoral area within 1 month postoperatively. Cox regression was used for analysis.

Results

The incidence of grades 2 and 3 seroma was comparable among groups (9.5% vs. 7.9% vs. 5.3%, p = 0.437), as well as late grades 2 and 3 seroma among groups (4.3% vs. 2.9% vs. 1.5%, p = 0.412). Old age, high body mass index, and hypertension were independent risk factors for grades 2 and 3 seroma.

Conclusions

Prolonged timing of drainage to 13–15 days in conventional suture was long enough to decrease the incidence of grades 2 and 3 seroma as lower as that in quilting suture group at pectoral area within 1 month after mastectomy.

A systematic review of seroma formation following drain-free mastectomy

BACKGROUND

Seroma is a common complication after mastectomy. The aim of this review is to elucidate whether closed suction drainage can safely be omitted in patients undergoing mastectomy when assessing seroma formation and its complications. The second aim is to assess the influence of flap fixation on seroma related complications, as there is existing evidence showing that combining mastectomy with flap fixation may make the use of drainage systems obsolete.

SEARCH & SELECTION

A review of the literature was performed and articles that compared mastectomy with drainage and mastectomy without drainage were selected. Due to the small number of eligible studies, no selection based on whether flap fixation was performed was possible. If outcome was described in terms of seroma formation or seroma related complications, papers were eligible for inclusion. Studies older than 20 years, animal studies, studies not written in English and studies with male patients were excluded.

RESULTS

A total of eight articles were eligible for inclusion. Four prospective studies and four retrospective studies were included. In four studies, flap fixation was performed. Frequency of seroma formation as well as seroma that required intervention was reported. The included studies demonstrated that omitting closed suction drainage does not lead to a higher incidence of seroma formation in patients undergoing mastectomy.

CONCLUSION

Despite substantial heterogeneity, there is evidence that drainage can safely be omitted without exacerbating seroma formation and its complications. A well-powered, randomized controlled trial evaluating the effect of drainage omission on seroma formation, with or without flap fixation, is needed.

A single-center, randomized, non-inferiority study evaluating seroma formation after mastectomy combined with flap fixation with or without suction drainage: protocol for the Seroma reduction and drAin fRee mAstectomy (SARA) trial

BACKGROUND

Seroma formation is a common complication after breast cancer surgery and can lead to delayed wound healing, infection, patient discomfort and repeated visits to the outpatient clinic. Mastectomy combined with flap fixation is becoming standard practice and is currently combined with closed-suction drainage. There is evidence showing that closed-suction drainage may be insufficient in preventing seroma formation. There is reasonable doubt whether there is still place for closed-suction drainage after mastectomy when flap fixation is performed. We hypothesize that mastectomy combined with flap fixation and closed suction drainage does not cause a significant lower incidence of seroma aspirations, when compared to mastectomy and flap fixation alone. Furthermore, we expect that patients without drainage will experience significantly less discomfort and comparable rates of surgical site infections.

METHODS

This is a randomized controlled trial in female breast cancer patients undergoing mastectomy and flap fixation using sutures with or without sentinel lymph node biopsy (SLNB). Patients will be eligible for inclusion if they are older than 18 years, have an indication for mastectomy with or without sentinel procedure. Exclusion criteria are modified radical mastectomy, direct breast reconstruction, previous history of radiation therapy of the unilateral breast, breast conserving therapy and inability to give informed consent. A total of 250 patients will be randomly allocated to one of two groups: mastectomy combined with flap fixation and closed-suction drainage or mastectomy combined with flap fixation without drainage. Follow-up will be conducted up to six months postoperatively. The primary outcome is the proportion of patients undergoing one or more seroma aspirations. Secondary outcome measures consist of the number of invasive interventions, surgical site infection, quality of life measured using the SF-12 Health Survey, cosmesis, pain and number of additional outpatient department visits.

DISCUSSION

To our knowledge, no randomized controlled trial has been conducted comparing flap fixation with and without closed-suction drainage with seroma aspiration as the primary outcome. This study could result in finding evidence that supports performing mastectomy without closed-suction drainage.

TRIAL REGISTRATION

This trial was approved by the medical ethical committee of Zuyderland Medical Center METC-Z on 20 March 2019 (METCZ20190023). The SARA Trial was registered at ClinicalTrials.gov as per July 2019, Identifier: NCT04035590 .

Infecciones del sitio operatorio posterior a mastectomía radical modificada, análisis epidemiológico en una clínica oncológica

Introducción. La tasa de incidencia de infecciones del sitio operatorio asociadas a cirugías mamarias varía desde el 6 hasta el 38 %. Se presentan la incidencia local y el perfil microbiológico de las infecciones en una clínica oncológica.  Métodos. Se trata de un estudio de cohorte, prospectivo, descriptivo, durante un periodo de un año en el Instituto Médico de Alta Tecnología, IMAT Oncomédica, de mujeres con diagnóstico de cáncer de mama, que presentaron infecciones del sitio operatorio después de la mastectomía. Resultados. Se encontraron 335 cirugías registradas y la incidencia de infecciones del sitio operatorio fue del 3,38 %, todas en mastectomías radicales con reconstrucción. Se obtuvo crecimiento bacteriano en el 77 % de los cultivos, principalmente de cocos Gram positivos, con predominio de Staphylococcus aureus sensible a la meticilina (SAMS). Los bacilos Gram negativos representaron el 40 %. Se administraron cefalosporinas de primera generación como profilaxis antibiótica prequirúrgica, la cual fue correcta en el 31 % de los casos. En el 50 % de las pacientes infectadas se practicó el baño prequirúrgico y se cumplió el protocolo institucional. Conclusiones. La incidencia encontrada de infecciones del sitio operatorio es menor que la reportada en otras series. Staphylococcus aureus sensible a la meticilina fue el microorganismo responsable más frecuente. El cumplimiento de la profilaxis con cefalosporina y baño prequirúrgico es fundamental para disminuir la incidencia de infecciones del sitio operatorio.

Surgeon's preference of subcutaneous tissue resection: most important factor for short-term complications in subcutaneous implant placement after mastectomy-results of a cohort study

Purpose

Little is known about the reason of high short-term complication rates after the subcutaneous placement of breast implants or expanders after mastectomy without biological matrices or synthetic meshes. This study aims to evaluate complications and their risk factors to develop guidelines for decreasing complication rates.

Methods

We included all cases of mastectomy followed by subcutaneous implant or expander placement between 06/2017 and 05/2018 (n = 92). Mean follow-up time was 12 months.

Results

Explantation occurred in 15 cases (16.3%). The surgeon’s preference for moderate vs. radical subcutaneous tissue resection had a significant influence on explantation rates (p = 0.026), impaired wound healing or infection (requiring surgery) (p = 0.029, p = 0.003 respectively) and major complications (p = 0.018).

Multivariate analysis revealed significant influence on complication rates for radical subcutaneous tissue resection (p up to 0.003), higher implant volume (p up to 0.023), higher drain volume during the last 24 h (p = 0.049), higher resection weight (p = 0.035) and incision type (p = 0.011).

Conclusion

Based on the significant risk factors we suggest the following guidelines to decrease complication rates: favoring thicker skin envelopes after surgical preparation, using smaller implants, removing drains based on a low output volume during the last 24 h and no use of periareolar incision with extension medial or lateral. We should consider ADMs for subcutaneous one-stage reconstructions.

The individual surgeon’s preference of subcutaneous tissue resection is of highest relevance for short-term complications—this has to be part of internal team discussions and should be considered in future trials for comparable results.

Effect of topical microporous polysaccharide hemospheres on the duration and amount of fluid drainage following mastectomy: a prospective randomized clinical trial

Background

Seroma formation is the most common complication after mastectomy and places patients at risk of associated morbidities. Microporous polysaccharide hemospheres (MPH) consists of hydrophilic, plant based, polysaccharide particles and is currently used as an absorbable hemostatic agent. An animal model evaluating MPH and seroma formation after mastectomy with axillary lymph node dissection showed a significant decrease in seroma volume. Study aim was to evaluate topical MPH on the risk of post-mastectomy seroma formation as measured by total drain output and total drain days.

Methods

Prospective randomized single-blinded clinical trial of patients undergoing mastectomy for the treatment of breast cancer. MPH was applied to the surgical site in the study group and no application in the control group.

Results

Fifty patients were enrolled; eight were excluded due to missing data. Forty-two patients were evaluated, control (n = 21) vs. MPH (n = 21). No difference was identified between the two groups regarding demographics, tumor stage, total drain days, total drain output, number of clinic visits, or complication rates. On a subset analysis, body mass index (BMI) greater than 30 was identified as an independent risk factor for high drain output. Post hoc analyses of MPH controlling for BMI also revealed no statistical difference.

Conclusions

Unlike the data presented in an animal model, no difference was demonstrated in the duration and quantity of serosanguinous drainage related to the use of MPH in patients undergoing mastectomy for the treatment of breast cancer. BMI greater than 30 was identified as an independent risk factor for high drain output and this risk was not affected by MPH use. NCT03647930, retrospectively registered 08/2018.

Drainage after Modified Radical Mastectomy - A Methodological Mini-Review

Breast cancer is a socially relevant group of malignant conditions of the mammary gland, affecting both males and females. Most commonly the surgical approach of choice is a modified radical mastectomy (MRM), due to it allowing for both the removal of the main tumor mass and adjacent glandular tissue, which are suspected of infiltration and multifocality of the process, and a sentinel axillary lymph node removal. Most common post-surgical complications following MRM are the formation of a hematoma, the infection of the surgical wound and the formation of a seroma. These post-surgical complications can, at least in part, be attributed to the drainage of the surgical wound. However, the lack of modern and official guidelines provides an ample scope for innovation, but also leads to a need for a randomized comparison of the results. We compared different approaches to wound drainage after MRM, reviewed based on the armamentarium, number of drains, location, type of drainage system, timing of drain removal and no drainage alternatives. Currently, based on the general results, scientific and comparative discussions, seemingly the most affordable methodology with the best patient outcome, with regards to hospital stay and post-operative complications, is the placement of one medial to lateral (pectoro-axillary) drain with low negative pressure. Ideally, the drain should be removed on the second or third postoperative day or when the amount of drained fluid in the last 24 hours reaches below 50 milliliters.

New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective

Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.

Wound drainage after plastic and reconstructive surgery of the breast

BACKGROUND

Wound drains are often used after plastic and reconstructive surgery of the breast, in order to reduce potential complications. It is unclear whether there is any evidence to support this practice and we therefore undertook a systematic review of the best evidence available.

OBJECTIVES

To compare the safety and efficacy of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast.

SEARCH METHODS

For the first update of this review we searched the Cochrane Wounds Group Specialised Register (searched 4 March 2015); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid MEDLINE (2012 to March 3 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations March 3 2015); Ovid EMBASE (2012 to March 3 2015); and EBSCO CINAHL (2012 to March 4 2015). There were no restrictions on the basis of date or language of publication.

SELECTION CRITERIA

Three review authors undertook independent screening of the search results. All randomised trials (RCTs) that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g. infection, other wound complications, pain, and length of hospital stay). Risk of bias was assessed independently by two review authors. We calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals. Analysis was on an intention-to-treat basis.

MAIN RESULTS

Three randomised trials were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. No new trials were identified for this first update. In total there were 306 women in the three trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Apart from a significantly shorter duration of hospital stay for those participants who did not have drains (MD 0.77; 95% CI 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes.

AUTHORS' CONCLUSIONS

The limited evidence available shows no significant benefit of using post-operative wound drains in reduction mammoplasty, though hospital stay may be shorter when drains are not used. No data are available for breast augmentation or breast reconstruction, and this requires investigation.

Breast cancer surgery without drains: no influence on seroma formation

It is not clear whether drains are necessary after breast cancer surgery. The purpose of this study was to compare seroma formation in patients that had postoperative drainage for 24 h with patients that had no drain after breast cancer surgery. In this retrospective cohort study 96 patients with a primary breast cancer were included. Between January 2009 and April 2011 44 patients had breast cancer surgery followed by postoperative drainage. Between May 2011 and February 2013 52 patients underwent breast cancer surgery without drainage. The operative procedures that were included were: axillary lymph node dissection, modified radical mastectomy or simple mastectomy±sentinel lymph node biopsy. There was no difference between both groups regarding frequency of seroma (84.6% versus 90.9%; p=0.290) and amount of seroma (540 ml versus 590 ml; p=0.446). Postoperative hospital stay was shorter in patients without drainage (2 versus 2.5 days; p=0.003). There was no difference between both groups in other secondary outcome measures. Modified radical mastectomy was an independent predictor of the amount of postoperative seroma (HR 0.039 [0.007-0.235]; p<0.001). These results suggest that there is no difference in seroma after breast cancer surgery between patients that had postoperative drainage and patients that had no postoperative drainage.

The volume and duration of wound drainage are independent prognostic factors for breast cancer

Drain insertion is routinely done after breast cancer surgery. However, the prognostic value of suction drains in breast cancer is still unknown. This study aimed to reveal the prognostic value of drain insertion in breast cancer. A total of 296 female breast cancer patients undergoing surgery were retrospectively recruited. The correlation of drainage volume as well as drain duration with clinicopathological parameters and prognosis was assessed statistically. We found that breast cancer patients with a drainage volume of >240 ml had a better overall survival time. Breast cancer patients with more than 5 days postoperative drain duration would have better survival time. In addition, both the volume and duration of wound drainage are independent prognostic factors in multivariate analysis. Therefore, the volume of drainage as well as drain duration is a potential novel prognostic marker for breast cancer.

Randomized controlled trial to reduce bacterial colonization of surgical drains after breast and axillary operations

OBJECTIVE

To determine whether bacterial colonization of drains can be reduced by local antiseptic interventions.

BACKGROUND

Drains are a potential source of bacterial entry into surgical wounds and may contribute to surgical site infection after breast surgery.

METHODS

After institutional review board approval, patients undergoing total mastectomy and/or axillary lymph node dissection were randomized to standard drain care (control) or drain antisepsis (treated). Standard drain care comprised twice daily cleansing with alcohol swabs. Antisepsis drain care included (1) a chlorhexidine disc at the drain exit site and (2) irrigation of the drain bulb twice daily with dilute sodium hypochlorite (Dakin's) solution. Culture results of drain fluid and tubing were compared between control and antisepsis groups.

RESULTS

Overall, 100 patients with 125 drains completed the study with 48 patients (58 drains) in the control group and 52 patients (67 drains) in the antisepsis group. Cultures of drain bulb fluid at 1 week were positive (1+ or greater growth) in 66% (38/58) of control drains compared with 21% (14/67) of antisepsis drains (P = 0.0001). Drain tubing cultures demonstrated more than 50 colony-forming units in 19% (8/43) of control drains versus 0% (0/53) of treated drains (P = 0.004). Surgical site infection was diagnosed in 6 patients (6%)--5 patients in the control group and 1 patient in the antisepsis group (P = 0.06).

CONCLUSIONS

Simple and inexpensive local antiseptic interventions with a chlorhexidine disc and hypochlorite solution reduce bacterial colonization of drains. Based on these data, further study of drain antisepsis and its potential impact on surgical site infection rate is warranted (ClinicalTrials.gov Identifier: NCT01286168).

Prevention of seroma formation after axillary dissection--a comparative randomized clinical trial of three methods

Seroma is a frequent complication after breast cancer surgery. Closed suction drainage for several days is the standard procedure to reduce seroma formation. The aim of this study was to compare the efficacy of external compression dressing, suture flap fixation, and the conventional method of closed suction drains in the prevention of seroma formation. A total of 161 patients were prospectively randomized in a three groups × two subgroups design into control (n = 48), compression dressing (n = 53) and suturing groups (n = 49), and two subgroups, conventional drain removal (n = 75) and early drain removal (n = 75). All patients underwent ALND as part of MRM or BCT. The primary end point was the incidence of seroma. Suture flap fixation significantly reduced the incidence of seroma (p = 0.003), total drain output (p = 0.005), and duration of drainage (p = 0.001) without increase in wound complications. Compression dressing reduced duration of drainage significantly (p = 0.03), but not the total drain output (p = 0.15) or seromas (p = 0.58). Early drain removal on postoperative day 7 irrespective of drain output does not significantly increase seroma formation (p = 0.34) or wound complications. On multivariate analysis, BMI ≥ 30 (p = 0.02) and longer duration of drainage (p = 0.04) were identified as independent predictors for seroma formation. Obliteration of the dead space after breast cancer surgery by suture flap fixation is a safe and easy procedure, which significantly reduces postoperative seroma formation and duration of drainage. Compression dressing offers no advantage over normal dressing. Drains can be removed safely on postoperative day 7 irrespective of output without significant increase in complications.

Fibrin glue instillation under skin flaps to prevent seroma-related morbidity following breast and axillary surgery

BACKGROUND

Fibrin glue (FG) combines fibrinogen and thrombin, under the presence of factor XIII and calcium chloride, and produces a 'fibrin clot' as would occur through the natural clotting cascade. FG is thought to close over any small vessels including lymphatics that are too small for conventional surgical closure, thereby reducing seroma formation, seroma incidence and related comorbidities.

OBJECTIVES

To assess the evidence on the effectiveness of FG in people undergoing breast and axillary surgery and to establish whether FG is an efficient modality to prevent postoperative seroma and seroma-related outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register (9 December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2012), MEDLINE (9 December 2011), EMBASE (9 December 2011), LILACS (22 October 2012), SCI-E (22 October 2012), the World Health Organization's International Clinical Trial Registry (9 December 2011) and ClinicalTrials.gov (22 October 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of FG in terms of reducing the postoperative seroma incidence and related comorbidities in people undergoing breast and axillary surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. The pooled analysis of the extracted data was achieved by the statistical analysis on Review Manager software. The quality of studies was assessed using The Cochrane Collaboration's 'Risk of bias' tool.

MAIN RESULTS

The search of four standard electronic databases yielded 119 potentially relevant studies but only 18 RCTs involving 1252 people were found suitable for statistical analysis. There was significant heterogeneity among trials and the majority of trials were of poor quality. The use of FG under skin flaps following breast and axillary surgery failed to reduce the incidence of postoperative seroma (risk ratio (RR) 1.02; 95% Confidence Interval (CI) 0.90 to 1.16, P value = 0.73), mean volume of seroma (standardised mean difference (SMD) -0.25; 95% CI -0.92 to 0.42, P value = 0.46), wound infection (RR 1.05; 95% CI 0.63 to 1.77, P value = 0.84), postoperative complications (RR 1.13; 95% CI 0.63 to 2.04, P value = 0.68) and length of hospital stay (SMD -0.2; 95% CI -0.78 to 0.39, P value = 0.51). FG reduced the total volume of drained seroma (SMD -0.75, 95% CI -1.24 to -0.26, P value = 0.003) and duration of persistent seromas requiring frequent aspirations (SMD -0.59; CI 95% -0.95 to -0.23, P value = 0.001).

AUTHORS' CONCLUSIONS

FG did not influence the incidence of postoperative seroma, the mean volume of seroma, wound infections, complications and the length of hospital stays in people undergoing breast cancer surgery. Due to significant methodological and clinical diversity among the included studies this conclusion may be considered weak and biased. Therefore, a major multicentre and high-quality RCT is required to validate these findings.

Fibrin glue instillation under skin flaps to prevent seroma-related morbidity following breast and axillary surgery

BACKGROUND

Fibrin glue (FG) combines fibrinogen and thrombin, under the presence of factor XIII and calcium chloride, and produces a 'fibrin clot' as would occur through the natural clotting cascade. FG is thought to close over any small vessels including lymphatics that are too small for conventional surgical closure, thereby reducing seroma formation, seroma incidence and related comorbidities.

OBJECTIVES

To assess the evidence on the effectiveness of FG in people undergoing breast and axillary surgery and to establish whether FG is an efficient modality to prevent postoperative seroma and seroma-related outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register (9 December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2012), MEDLINE (9 December 2011), EMBASE (9 December 2011), LILACS (22 October 2012), SCI-E (22 October 2012), the World Health Organization's International Clinical Trial Registry (9 December 2011) and ClinicalTrials.gov (22 October 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of FG in terms of reducing the postoperative seroma incidence and related comorbidities in people undergoing breast and axillary surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. The pooled analysis of the extracted data was achieved by the statistical analysis on Review Manager software. The quality of studies was assessed using The Cochrane Collaboration's 'Risk of bias' tool.

MAIN RESULTS

The search of four standard electronic databases yielded 119 potentially relevant studies but only 18 RCTs involving 1252 people were found suitable for statistical analysis. There was significant heterogeneity among trials and the majority of trials were of poor quality. The use of FG under skin flaps following breast and axillary surgery failed to reduce the incidence of postoperative seroma (risk ratio (RR) 1.02; 95% Confidence Interval (CI) 0.90 to 1.16, P value = 0.73), mean volume of seroma (standardised mean difference (SMD) -0.25; 95% CI -0.92 to 0.42, P value = 0.46), wound infection (RR 1.05; 95% CI 0.63 to 1.77, P value = 0.84), postoperative complications (RR 1.13; 95% CI 0.63 to 2.04, P value = 0.68) and length of hospital stay (SMD -0.2; 95% CI -0.78 to 0.39, P value = 0.51). FG reduced the total volume of drained seroma (SMD -0.75, 95% CI -1.24 to -0.26, P value = 0.003) and duration of persistent seromas requiring frequent aspirations (SMD -0.59; CI 95% -0.95 to -0.23, P value = 0.001).

AUTHORS' CONCLUSIONS

FG did not influence the incidence of postoperative seroma, the mean volume of seroma, wound infections, complications and the length of hospital stays in people undergoing breast cancer surgery. Due to significant methodological and clinical diversity among the included studies this conclusion may be considered weak and biased. Therefore, a major multicentre and high-quality RCT is required to validate these findings.

Wound drainage after plastic and reconstructive surgery of the breast

BACKGROUND

Wound drains are often used after plastic and reconstructive surgery of the breast, in order to reduce potential complications. It is unclear whether there is any evidence to support this practice and we therefore undertook a systematic review of the best evidence available.

OBJECTIVES

To compare the safety and efficacy of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 3 August 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); Ovid MEDLINE (1950 to July Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 2, 2011); Ovid EMBASE (1980 to 2012 Week 30); and EBSCO CINAHL (1982 to 2 August 2012). There were no restrictions on the basis of date or language of publication.

SELECTION CRITERIA

Two review authors undertook independent screening of the search results. All randomised trials that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g. infection, other wound complications, pain, and length of hospital stay). Risk of bias was assessed independently by two review authors. We calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals. Analysis was on an intention-to-treat basis.

MAIN RESULTS

Three randomised trials were identified and included in the review out of 109 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. In total there were 306 women in the three trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Apart from a significantly shorter duration of hospital stay for those participants who did not have drains (MD 0.77; 95% CI 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes.

AUTHORS' CONCLUSIONS

The limited evidence available shows no significant benefit of using post-operative wound drains in reduction mammoplasty, though hospital stay may be shorter when drains are not used. No data are available for breast augmentation or breast reconstruction, and this requires investigation.

Analysis of selected factors influencing seroma formation in breast cancer patients undergoing mastectomy

INTRODUCTION

The aim of the work was to analyze the impact of selected factors on the incidence of seroma formation in breast cancer patients undergoing mastectomy.

MATERIAL AND METHODS

One hundred and fifty breast cancer patients were prospectively enrolled in the study. All patients had mastectomy performed using the same operative technique with electrocoagulation. The amount of seroma formed after surgery and its duration were correlated with selected demographic, clinical and pathological parameters.

RESULTS

The cumulative total seroma volume collected by the end of treatment was higher and the overall time of seroma treatment was longer in patients over the age of 60 years (p = 0.001 and p = 0.001 respectively). Duration of seroma was significantly longer in obese patients (p = 0.036). The cumulative total seroma volume collected by the end of treatment was higher and the overall time of seroma treatment was longer in patients who had over 130 ml of lymph drained during the first 24 postoperative hours (p < 0.001 and p = 0.001 respectively). Additionally, longer duration of seroma was observed in patients with pathological stage I and II according to TNM-UICC (p = 0.042) and in patients with ≥ 1200 g weight resected of mammary gland (p = 0.05).

CONCLUSIONS

Age and obesity are important prognostic factors influencing seroma formation in breast cancer patients undergoing mastectomy. The amount of lymph formed during first postoperative day may have predictive value in assessing cumulative total seroma volume collected during treatment and its overall duration.

Breast cancer surgery without suction drainage: the impact of adopting a 'no drains' policy on symptomatic seroma formation rates

AIM

To determine the effect of a 'no drains' policy on seroma formation and other complications in women undergoing breast cancer surgery.

MATERIALS AND METHODS

Before May 2010 drains were routinely used in our unit following mastectomy ± axillary surgery and axillary lymph node dissection (ALND) ± wide local excision (WLE). Since then, a 'no drains' policy has been adopted. Data was collected prospectively between 01/12/06 and 30/11/11 to compare symptomatic seroma, wound infection, re-admission and re-operation rates in women treated with a drain and those without.

RESULTS

596 women were included in the study. 247 women underwent modified radical mastectomy (MRM) and ALND (Group 1), 184 MRM ± sentinel lymph node biopsy (SLNB)/axillary node sampling (ANS) (Group 2) and 165 ALND ± WLE (Group 3). In group 1, 149 had a drain, in group 2, 62, and in group 3, 50. Within each group, the presence or absence of a drain did not significantly affect the rate of symptomatic seroma, number of aspirations performed, wound infection rates or the incidence of complications requiring re-admission. Having a drain was associated with lower volumes of seroma aspirated. In all three groups, the presence of a drain was associated with a longer hospital stay (p < 0.001).

CONCLUSION

This study suggests that MRM ± ALND/SLNB/ANS and ALND ± WLE can be performed without the use of suction drains without increasing seroma formation and other complication rates. Adopting a 'no-drains' policy may also contribute to earlier hospital discharge.

Use of ultrasonic shears in patients with breast cancer undergoing axillary dissection-a pilot study

Patients with breast cancer and positive sentinel node biopsy usually require axillary dissection. Different instruments are used for axillary dissection like regular scalpel,monopolar cautery, bipolar cautery etc. All these instruments are having its advantages and disadvantages. Our dept did a pilot study to know the efficacy of ultrasonic shears over cautery for axillary dissection. Parameters considered were cumulative drain amount, number of days with the drain and number of lymphnodes harvested. Ultrasonic shear machine delivers precisely directed mechanical energy with an ultrasonic vibrating blade.A single device dissects, cuts, grasps, spot coagulates. This machine was used for doing axillary dissection in one group and regular cautery in the other group. Study period was from April 2011 to June 2011 at Dept of Surgical Oncology, St Johns Hospital, Bangalore. Nine people in the ultrasonic shear group and 11 people in the cautery group were included in the pilot study. No significant difference were noticed in the cumulative drain amount, number of days with the drain, and number of lymphnodes harvested in both the groups. Axillary dissection using ultrasonic shears do not show any significant difference in the cumulative drain amount, number of days with the drain, and number of lymphnodes harvested. These are the findings of the pilot study, further prospective randomized studies are required for substantiating the findings.

When should axillary drains be removed post axillary dissection? A systematic review of randomised control trials

OBJECTIVE

To determine the evidence-based optimal strategy for management of drains following axillary dissection.

BACKGROUND

Despite randomised control trials addressing the issue over the past 20-30 years, there is no widely accepted consensus as to when drains should be removed post axillary dissection.

METHODS

We searched the electronic databases Medline, Embase, Cinahl, Cochrane Library of Systematic Reviews and Web of Science Citation Index. References within identified studies were also searched. Studies were independently identified and data extracted according to a pre-determined proforma based on the Cochrane Collaboration data extraction template by two independent researchers. Validity was determined according to a published standard. Discrepancies were corrected by consensus.

RESULTS

There was no difference in infection rates between early and late drain removal, hospital stay was reduced when drains were removed earlier, and higher total volume drainage prior to drain removal predicted subsequent seroma formation. The optimal timing of drain removal post axillary dissection could not be determined from the literature.

CONCLUSION

Optimal timing of drain removal following axillary dissection remains unknown after this systematic review due to heterogeneity between included studies leading to an inability to provide evidence-based consensus guidance.

Risk factors for short- and long-term complications after groin surgery in vulvar cancer

Background:

The cornerstone of treatment in early-stage squamous cell carcinoma (SCC) of the vulva is surgery, predominantly consisting of wide local excision with elective uni- or bi-lateral inguinofemoral lymphadenectomy. This strategy is associated with a good prognosis, but also with impressive treatment-related morbidity. The aim of this study was to determine risk factors for the short-term (wound breakdown, infection and lymphocele) and long-term (lymphoedema and cellulitis/erysipelas) complications after groin surgery as part of the treatment of vulvar SCC.

Methods:

Between January 1988 and June 2009, 164 consecutive patients underwent an inguinofemoral lymphadenectomy as part of their surgical treatment for vulvar SCC at the Department of Gynaecologic Oncology at the Radboud University Nijmegen Medical Centre. The clinical and histopathological data were retrospectively analysed.

Results:

Multivariate analysis showed that older age, diabetes, ‘en bloc’ surgery and higher drain production on the last day of drain in situ gave a higher risk of developing short-term complications. Younger age and lymphocele gave higher risk of developing long-term complications. Higher number of lymph nodes dissected seems to protect against developing any long-term complications.

Conclusion:

Our analysis shows that patient characteristics, extension of surgery and postoperative management influence short- and/or long-term complications after inguinofemoral lymphadenectomy in vulvar SCC patients. Further research of postoperative management is necessary to analyse possibilities to decrease the complication rate of inguinofemoral lymphadenectomy; although the sentinel lymph node procedure appears to be a promising technique, in ∼50% of the patients an inguinofemoral lymphadenectomy is still indicated.

Seroma formation after mastectomy: pathogenesis and prevention

Post mastectomy seroma remains an unresolved quandary as the risk factors for its formation have still not been identified. Seromas of the axillary space following breast surgery can lead to significant morbidity and delay in the initiation of adjuvant therapy. Various techniques and their modifications have been practiced and published in English literature, but there seems to be no consensus. In this article, all aspects of seroma formation from pathogenesis to prevention including drug therapies have been discussed.

Concepts of seroma formation and prevention in breast cancer surgery

BACKGROUND

Seroma formation is the commonest early sequel to breast cancer surgery especially when axillary dissection is undertaken. It is associated with significant morbidity and financial burden. The main pathophysiology of seroma is still poorly understood and remains controversial. The optimal ways to reduce the incidence of seroma formation are unknown. The aim of this paper is to review the concepts of pathophysiology of seroma formation following mastectomy and breast-conserving surgery for cancer. The various techniques in practice to reduce its incidence and treatment are outlined.

METHOD

MEDLINE search of published work on the subject with respect to its pathophysiology, prevention and treatment was carried out. Manual retrieval of relevant articles in the reference lists of the original papers from the MEDLINE was then carried out.

RESULT

The pathophysiology and mechanism of seroma formation in breast cancer surgery remains controversial and not fully understood. Methods of prevention and treatment of seroma remain varied and inconclusive.

CONCLUSION

Evidence suggests an increase in the incidence of seroma because of thermal trauma from electrocautery dissection, but this is indispensable for surgical haemostasis. Obliteration of dead space by various flap apposition techniques has been shown to be advantageous in reducing incidence and volume of seroma. Low-pressure suction drainage reduces seroma volume and duration of drainage leading to earlier drain removal. Preventive measures have to be tailored according to individual patient and operative factors.

Early removal of postmastectomy drains is not beneficial: results from a halted randomized controlled trial

BACKGROUND

Closed-suction drainage to reduce seromas is standard after mastectomy. This study evaluates the safety of early drain removal.

METHODS

Women undergoing mastectomy were randomized to early removal on postoperative day 2 or standard removal (< 30 mL drainage in 24 hours or postoperative day 14). Primary endpoints were time to drain removal and physician visits. Secondary endpoints were number of seroma aspirations, drain reinsertions, and infections.

RESULTS

Twenty-seven patients were recruited before an interim analysis was performed to address safety concerns. Three patients withdrew before trial completion, leaving 14 patients in the standard group and 10 in the early group. Patients in the standard group had significantly fewer seroma aspirations, fewer drain reinsertions, and fewer physician visits. The trial was halted because of the higher rate of events in the early group.

CONCLUSION

Surgical drains cannot be safely removed on postoperative day 2 after mastectomy. Early removal significantly increases the occurrence of seromas requiring treatment.

Evidence-Based Risk Factors for Seroma Formation in Breast Surgery

BACKGROUND

Seroma is a common problem in breast surgery. The aim of this systematic review was to identify risk factors for seroma formation.

METHODS

Articles published in English were obtained from searches of Medline and additional references were found in the bibliographies of these articles. Risk factors were graded according to the quality and strength of evidence and to the direction of association.

RESULTS

One meta-analysis, 51 randomized controlled trials, 7 prospective studies and 7 retrospective studies were identified. There was no risk factor supported by strong evidence, but there was moderate evidence to support a risk for seroma formation in individuals with heavier body weight, extended radical mastectomy as compared with simple mastectomy, and greater drainage volume in the initial 3 days. On the other hand, the following factors did not have a significant influence on seroma formation: duration of drainage; hormone receptor status; immobilization of the shoulder; intensity of negative suction pressure; lymph node status or lymph node positivity; number of drains; number of removed lymph nodes; previous biopsy; removal of drains on the fifth postoperative day versus when daily drainage volume fell to minimal; stage; type of drainage (closed suction versus static drainage); and use of fibrinolysis inhibitor. In contrast, sentinel lymph node biopsy reduced seroma formation. Evidence was weak, or unproven, for other factors that were commonly cited in the literature.

CONCLUSIONS

Although a number of factors have been correlated with seroma formation, strong evidence is still scarce. However, there is evidence showing that sentinel lymph node biopsy reduces seroma formation.

Short versus long-term postoperative drainage of the axilla after axillary lymph node dissection. A prospective randomized study

BACKGROUND

Axillary lymph node dissection (ALND) is a standard procedure in the treatment of breast cancer. Current practice following ALND involves several days of drainage of the axilla to reduce the formation of seroma. The aim of this study is to investigate the feasibility of 24 h drainage.

STUDY DESIGN

A prospective randomized trial was performed comparing 24 h drainage to long-term drainage. The primary outcome measure was duration of hospital stay. Formation of seroma and wound related complications were secondary outcome measures.

RESULTS

Fifty patients were randomised to the 24 h drainage group and 50 patients to the long-term drainage group. 24 h drainage was associated with a shorter hospital stay (2.5 versus 4.6 days, p < 0.001). Seroma aspiration was required in 76% of the patients after 24 h drainage and in 64% after long-term drainage (p = 0.19). The number of wound related complications was higher after long-term drainage (13 versus 9, p = 0.33). Infectious complications were seen in 11 patients after long-term drainage versus 6 after 24 h drainage (p = 0.18).

CONCLUSION

These results indicate that 24 h drainage following ALND is feasible and facilitates early hospital discharge. Furthermore, 24 h drainage is not associated with excess wound related complications compared to long-term drainage.

A randomised study of axillary drainage and pectoral fascia preservation after mastectomy for breast cancer

BACKGROUND

To reduce the risk of seroma after modified radical mastectomy in breast cancer patients, the use of suction axillary drainage is a standard procedure. The optimal time to remove the drain is not established. Whether the removal or preservation of the pectoral fascia influences the risk of seroma formation or loco-regional recurrence rate remains unclear.

METHOD

The trial included 247 patients with breast cancer who underwent modified radical mastectomy in five Swedish hospitals 1993-1997. The median follow-up time was 6 years. One hundred and twenty-two and 125 patients, respectively, were randomised between removal versus preservation of the pectoral fascia. Of these 247 patients a total of 198 patients were also randomised to have the drain removed 24 h postoperatively or to keep the drain in until discharge had decreased to less than 40 ml/24 h.

RESULTS

Early removal of the axillary drain was associated with significantly more seromas and a shorter average postoperative hospital stay. There were no differences between the two groups regarding the rate of wound infections and/or hematoma formation. Removal or preservation of the pectoral fascia did not influence the formation of seroma or the amount of peroperative bleeding. A trend towards an increased risk for chest wall recurrence was observed in patients with preserved pectoral fascia (16/125 compared with 8/122; hazard ratio=2.0, 95% confidence interval=0.9-4.7).

CONCLUSION

Early removal of axillary drain shortened the duration of hospital stay without any increase in wound complications. However, it yielded a significantly higher incidence of seroma. Seroma formation and the chest wall recurrence rate was not significantly influenced by the preservation of the pectoral fascia or not.

Seroma prevention following axillary dissection in patients with breast cancer by using ultrasound scissors: a prospective clinical study

AIMS

Seroma formation following axillary dissection is a common complication of breast surgery. The aims of this study were (1) to analyse the risk factors of seroma formation, and (2) to evaluate the role of ultrasound scissors in performing axillary dissection in patients with primary breast cancer undergoing mastectomy and breast-conserving surgery.

METHODS

Ninety-two women (median age 55 years, range 33-73 years) requiring surgery for known unilateral primary breast cancer (pT1a=1, pT1b=20, pT1c=43, pT2=25, pT3=3) were prospectively randomised to undergo axillary dissection by either using (Group A, 45 patients) or not using (Group B, 47 patients) ultrasound scissors (US). Thirty-eight (41.3%) patients underwent modified radical mastectomy, while 54 (58.7%) underwent breast-conserving surgery.

RESULTS

Twenty-eight (30.4%) patients (Group A=9 out of 45, 20%; Group B=19 out of 47, 42%; P=NS) developed a wound seroma. Multivariate analysis using a logistic regression model showed that surgical procedure (RR=8.9; 95% CI: 3.2-25.3), total amount of drainage (RR=7.8; 95% CI: 2.8-22.0), and size of the tumour (RR=6.0; 95% CI: 2.2-16.5) independently correlated with seroma formation. The logistic regression function (RR=19.4; 95% CI: 6-62) correctly allocated 75 out of 92 (81.5%) patients.

CONCLUSIONS

Size of the tumour, and total amount of drainage represent the principal factors of seroma formation following axillary dissection in patients undergoing surgery for breast cancer. Although the use of ultrasound cutting devices may reduce the risk of seroma formation, further studies are need to verify the real impact on long-term morbidity of such technique.

Surgical site infections in breast surgery: case-control study

The purpose of this study was to estimate the frequency of surgical site infections (SSIs) and identify associated risk factors for each type of breast surgery at a cancer hospital. We used a nested case-control design. Between February 1, 2000 and July 31, 2000, all breast surgeries performed were recorded on a daily basis. After hospital discharge, we evaluated patients simultaneously with surgeons three times a week for 30 days or longer. The odds ratio (OR) was estimated using logistic regression analysis. The study followed 280 patients (298 wounds). Altogether, 77 SSIs were detected, for an overall SSI rate of 25.8% (77/298). For excisions, conservative surgery, and radical mastectomies the SSI rates were 1.4%, 18.0%, and 38.3%, respectively. Excisions were excluded ( n = 68) for risk factor analysis. After multivariate analysis, risk factors associated with SSIs were obesity [OR 2.5, 95% confidence interval (CI) 1.2-4.3], concomitant chemotherapy and radiation (OR 2.3, 95% CI 1.2-4.3), radical surgery (OR 3.1, 95% CI 1.1-8.6), insertion of a second drain during the late postoperative period (OR 3.7, 95% CI 1.8-7.8), and drainage duration > or = 19 days (OR 2.9, 95% CI 1.5-5.6). The bacteria most frequently isolated were Pseudomonas aeruginosa ( n = 18 ), Serratia sp. ( n = 18), Staphylococcus aureus ( n = 10), and Staphylococcus epidermidis ( n = 10). Poor compliance with infection control practices and wound management was detected throughout the study period. The overall frequency of SSIs for mastectomies was higher than the reported rates, which was principally related to the more radical surgery required for advanced-stage disease, preoperative irradiation, and inadequate wound and drain care.

Usefulness of Ultrasound Scissors in Reducing Serous Drainage after Axillary Dissection for Breast Cancer: A Prospective Randomized Clinical Study

Axillary dissection is usually associated with prolonged serous drainage that may result in several complications. We analyzed whether the use of ultrasound scissors may decrease the total amount of drainage from the axilla (AD) in patients requiring curative surgery for breast cancer. Seventy-six women (median age, 56 years; range, 32–73 years) with confirmed pT1–3, N0–1 breast cancer were prospectively randomly assigned to undergo mastectomy or breast-conserving surgery with axillary dissection by either using (group A) or not using (group B) ultrasound scissors. Overall, there was a linear relationship ( P < 0.05) between AD and both total number of the removed nodes and body mass index, whereas no correlation ( P = NS) was found with age and size of the tumor. Total AD was higher (492 ± 153 vs. 408 ± 136 mL, P = 0.013) in group B, whereas the postoperative hospital stay was shorter (2.4 ± 0.6 vs. 2.7 ± 0.7 days, P = NS) in group A. The three-way analysis of covariance using the number of total removed nodes as covariate showed that lymph node status, type of operation, and technique for axillary dissection significantly ( P < 0.05) correlated with AD. In conclusion, our initial study shows that the use of ultrasound scissors significantly reduced total AD in patients requiring axillary dissection and may shorten hospital stay.

Axillary lymphadenectomy for breast cancer - the influence of shoulder mobilisation on lymphatic drainage

AIM

The purpose of the present study was to study the influence of external axillary compression dressing with immobilisation of the ipsilateral shoulder after axillary lymph node dissection (ALND) on postoperative axillary drainage.

METHODS

One hundred consecutive women with breast cancer undergoing ALND were enrolled in this study. They were allowed free shoulder movement and were compared with a matched historical control group of 60 patients, in whom the ipsilateral arm was immobilised for four days. For all patients the amount of drainage was recorded each postoperative day until drain removal. Prognostic data on drainage amounts and duration were gathered from all patients. Complications were recorded.

RESULTS

Hospital stay was the only statistically significant difference between the two groups, it was prolonged for patients with immobilisation of the arm. The parameters found to influence the drain production with a statistically significant difference were body mass index and the removal of more than 10 lymph nodes. Postoperative complications were similar in both groups.

CONCLUSIONS

External compression dressing of the axillary cavity with immobilisation of the ipsilateral arm has no impact on the postoperative drainage volume and duration. It is associated with adverse effects, such as discomfort, prolonged hospital stay and shoulder stiffness.