Postoperative suction drainage of the axilla: for how long? Prospective randomised trial

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>.

Management of Postoperative Seroma: Recommendations Based on a 12-Year Retrospective Study

Introduction: Seroma formation is a serious postoperative complication. Since the management algorithms available in the literature are scarce, we aimed to analyze our experience with postoperative seroma in order to identify indicators for revisional surgery and propose recommendations for management. Methods: This retrospective study included all patients with postoperative seroma treated in a tertiary university hospital from 2008 to 2020. Patients’ demographics, medical history, and seroma treatment details were recorded and analyzed. Results: Overall, 156 patients were included: 41% were initially treated through needle aspiration, with 61% eventually undergoing surgical treatment for postoperative seroma. Comorbidities, such as heart failure and coronary heart disease, were significantly associated with an increased need for revisional surgery (p < 0.05). Both a duration of >40 days of repeated needle aspirations and drain re-insertions were significantly correlated with an increased risk for revisional surgery (p < 0.05). Conclusion: Patients requiring seroma aspiration should be counseled on surgical treatment sooner rather than later, as prolonged aspiration time (over 40 days) greatly increases the risk of surgical revision. Moreover, the reinsertion of a drain should only be used as a temporizing measure, at most, and patients requiring a drain to control the size of the seroma should promptly be scheduled for a surgical revision.

Fibrin Sealants Do Not Reduce the Rate of Seroma Formation in Postmastectomy Breast Reconstruction: A Systematic Review and Meta-analysis

Background Breast reconstruction using deep inferior epigastric perforator (DIEP) and latissimus dorsi (LD) flaps following mastectomy are associated with seroma formation, most commonly at the donor site. We sought to perform an updated systematic review and meta-analysis on the effects of fibrin sealant on donor-site complications following DIEP and LD flap breast reconstruction.

Methods A comprehensive literature search was conducted (March 2021) in PubMed, OVID, and Cochrane databases. Articles analyzing the efficacy of fibrin glue in reducing donor-site morbidity in DIEP and LD breast reconstruction were included. The outcomes assessed were seroma formation and duration of drainage.

Results A total of 17,265 articles were screened, and 9 articles were selected for analysis, which comprised 632 surgical sites in 611 patients. Comparing fibrin glue and quilting to quilting alone showed no significant difference in seroma formation (pooled risk ratio [RR]: 0.51; 95% confidence interval [CI]: 0.12, 2.25). Similarly, comparing fibrin glue alone to no fibrin glue showed no significant difference in seroma formation (pooled RR: 1.03; 95% CI: 0.66, 1.61) or duration of drain (pooled RR: −0.85; 95% CI: −4.09, 2.40); there was however a difference in duration of drain in those who received fibrin glue and quilting versus quilting alone (pooled RR: −2.13; 95% CI: −3.27, −0.99).

Conclusion The existing literature supports that the use of fibrin glue is not associated with a decrease in seroma formation in DIEP and LD flaps and is weakly associated with a reduction in the drainage duration only if used in conjunction with quilting.

The use of closed incision negative pressure therapy for incision and surrounding soft tissue management: Expert panel consensus recommendations

As the use of closed incision negative pressure therapy (ciNPT) becomes more widespread, dressing designs have evolved to address implementation challenges and meet surgeon demand. While traditional application of ciNPT was limited to the immediate suture line, a novel dressing that covers the incision and additional surrounding tissues has become available. To expand upon previous ciNPT recommendations and provide guidance on this new dressing, an expert panel of plastic surgeons convened to review the current literature, identify challenges to the implementation and sustainability of ciNPT, and use a modified Delphi technique to form a consensus on the appropriate use of ciNPT with full‐coverage dressings. After three rounds of collecting expert opinion via the Delphi method, consensus was reached if 80% of the panel agreed upon a statement. This manuscript establishes 10 consensus statements regarding when ciNPT with full‐coverage foam dressings should be considered or recommended in the presence of patient or incision risk factors, effective therapeutic settings and duration, precautions for use, and tools and techniques to support application. The panel also discussed areas of interest for future study of ciNPT with full‐coverage dressings. High‐quality, controlled studies are needed to expand the understanding of the benefits of ciNPT over the incision and surrounding tissues.

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.

Reduction of seroma and improvement of quality of life after early drain removal in immediate breast reconstruction with tissue expander. Preliminary report from a randomized controlled study

Seroma is the most common complication of breast reconstruction with tissue expander (incidence 0.2-20%) with increased risk of infection and implant loss by 4-6 fold. About 90% of plastic surgeons routinely placed drains for its prevention. We theorized that early drain removal is a safe procedure that improves postoperative quality of life (QoL), reducing pain, length of hospital stay, and limitations on daily activities. We divided 49 patients operated on between September 2016 and March 2018 (follow-up: 9-26 months) into two groups: Group1 (output-based; drains removed when <30 ml/day); and Group2 (early-removal; at 3-4 days postop.). A study-specific questionnaire about the patient's QoL was conducted 3 weeks after surgery. We performed an intention-to-treat analysis. A comparison was performed using a Fisher test and a Mann-Whitney U test with p = 0.05. We observed lower production of wound fluid (641±49 ml vs 231±20 ml; p = 0.004), and a shorter time until wound healing (31.3±4.2 days vs 22±3.9 days; p = 0.031) for Group 2. The difference for infection (p = 0.36), impaired wound healing (p = 0.22), and the seroma formation period (p = 0.11) was not significant. Group 2 experienced less breast pain (8% vs 87.5%; p = 0.001), fewer limitations in daily activities (16% vs 50%; p = 0.002), in mobility (20% vs 83.3%; p = 0.001), and in social life (8% vs 91.7%; p < 0.001), and a better quality of sleep than Group 1 (36% vs 75%; p = 0.002). Group 2 did not require home care after hospital discharge (p < 0.001). The limitations of study are: its small sample size, the wound healing assessment, and the use of a non-validated questionnaire.

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.

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.

When should axillary drains be removed? A meta-analysis of time-limited versus volume controlled strategies for timing of drain removal following axillary lymphadenectomy

BACKGROUND

Despite numerous studies over the past few decades, the optimum strategy for deciding when to remove drains following axillary lymphadenectomy remains unknown. This meta-analysis aims to compare time-limited and volume-controlled strategies for drain removal.

METHODS

A total of 584 titles were identified following a systematic literature search of EMBASE, MEDLINE, Cinahl and the Cochrane library; 6 titles met our eligibility criteria. Data were extracted and independently verified by two authors. Time-limited drain removal was defined as drain removal at <5 days; volume-controlled strategies ranged from <20 ml/24 h to <50 ml/24 h.

RESULTS

In all the studies, the time-limited approach resulted in earlier drain removal. Development of a seroma is 2.54 times more likely with early drain removal (Mantel-Haenszel Fixed Odds Ratio (OR) 2.54, p < 0.00001). However, there is no difference in infection rates between early and late drain removal (OR = 1.07, p = 0.76).

CONCLUSIONS

This meta-analysis demonstrates that a strategy of early drain removal following axillary lymphadenectomy is safe, with no difference in infection rates; however, the incidence of seroma is significantly higher, which may necessitate more demanding outpatient care. There is a need for further well-designed clinical trials to address the clinical equipoise in this common area of surgical practice.

Coordination of Care for Breast Reconstruction Patients: A Provider Survey

OBJECTIVES

Communication between medical oncologists (MOs) and plastic surgeons (PSs) is important to optimize outcomes for patients with breast cancer seeking breast reconstruction. We sought to evaluate the knowledge MOs and PSs have of each others' fields, roles expected of each other, and frequency of communication.

METHODS

A cross-sectional survey was conducted in a convenience sample of MOs and PSs. The survey included knowledge questions about reconstruction and chemotherapy, questions about provider and patient responsibilities for timely chemotherapy initiation, and questions about communication with other specialties.

RESULTS

MOs and PSs had similar knowledge scores (MOs, 59%; PSs, 56%; P = .5), but both lacked knowledge about aspects of the other specialty's field related to breast reconstruction. The MOs and PSs agreed on the MOs' degree of responsibility for timely chemotherapy initiation (MOs mean, 4.6; PSs mean, 4.4 (out of 5); P = .2). However, they disagreed about the PS's responsibility for timely chemotherapy initiation (MOs mean, 3.8; PSs mean, 3.0; P = .01). Communication occurred about 2.5 times more often for patients with complications than patients without complications (P < .0001).

CONCLUSION

MOs and PSs have deficits in knowledge about each other fields and differ in their opinion regarding the burden of responsibility in ensuring timely chemotherapy initiation, suggesting room for improvement in communication and understanding.

Prospective randomized controlled study to assess the value of a hemostatic and sealing agent for preventing seroma after axillary lymphadenectomy

BACKGROUND AND OBJECTIVES

Postoperative seroma after axillary lymphadenectomy leads to an increased use of resources and an impaired quality of life of patients. This randomized clinical trial was designed to assess the value of a hemostatic and sealing agent for decreasing seroma occurrence after axillary lymphadenectomy.

METHODS

A prospective, randomized, blind study was conducted on 91 axillary lymphadenectomies distributed into a control group (n = 47) and a test group in which a collagen sponge coated with human coagulation factors was used (n = 44). Primary end-points were number of days before removal of axillary drainage, axillary drainage output, and occurrence of seroma, wound infection, haematoma, or wound dehiscence, within 8 weeks of surgery. Bivariate and multivariate analyses on seroma occurrence were performed.

RESULTS

Seroma occurred in 29 patients (31.86%). A significant direct relationship (P = 0.002) was only noted between use of the hemostatic and sealing agent and nonoccurrence of seroma. In the multivariate study, the only variable found to be significantly related to seroma occurrence was use of the above agent (P = 0.046; odds ratio: 3.365 [95%CI: 1.024-11.060]).

CONCLUSIONS

Use of a collagen sponge coated with human coagulation factors following axillary lymphadenectomy was associated to a lower incidence of postoperative seroma. J. Surg. Oncol. 2016;114:423-427. © 2016 Wiley Periodicals, Inc.

Factors that Affect Drain Indwelling Time after Breast Cancer Surgery

OBJECTIVE

The most common procedure to prevent seroma formation, a common complication after breast and axillary surgery, is to use prophylactic surgical drains. Ongoing discussions continue regarding the ideal time for removing drains after surgical procedures. In this study, we aimed to investigate factors that affect drain indwelling time (DIT).

MATERIALS AND METHODS

From 2014 to 2015, a total of 91 consecutive patients with breast cancer were included in the study. The demographic characteristics of the patients, treatment methods, histopathologic features of the tumor, size of removed breast tissue (BS), tumor size (TS), number of totally removed lymph nodes (TLN), and metastatic lymph nodes (MLN), whether they had neoadjuvant chemotherapy, and the DIT were retrospectively recorded from the hospital database.

RESULTS

The mean age of the patients was 48.9 years, and the mean DIT was 4.8 days. The mean size of breast removed was 17.3 cm and tumor size was 4.7 cm, and the mean number of metastatic lymph nodes was 3.3, and mean total number of lymph nodes was 14.1. Patients who had neoadjuvant chemotherahpy had longer DIT. There was a positive correlation between the BS, TS, TLN, MLN, length of hospital stay, and DIT. Linear regresion analysis revealed that the BS, TLN, and history of neoadjuvant chemotherahpy were independent risk factors for DIT.

CONCLUSION

DIT primarily depends on BS, TLN, and history of neoadjuvant chemotherahpy. A policy for the management of removing drains to prevent seroma formation should thus be individualized.

Evaluation of the Quilting Technique for Reduction of Postmastectomy Seroma: A Randomized Controlled Study

Background. Postmastectomy seroma causes patients' discomfort, delays starting the adjuvant therapy, and may increase the possibility of surgical site infection. Objective. To evaluate quilting of the mastectomy flaps with obliteration of the axillary space in reducing postmastectomy seroma. Methods. A randomized controlled study was carried out among 120 females who were candidates for mastectomy and axillary clearance. The intervention group (N = 60) with quilting and the control group without quilting. All patients were followed up routinely for immediate and late complications. Results. There were no significant differences between the two groups as regards the demographic characteristics, postoperative pathological finding, and the immediate postoperative complications. The incidence of seroma was significantly lower in the intervention group compared with the control group (20% versus 78.3%, P < 0.001). Additionally, the intervention group had a shorter duration till seroma resolution (9 days versus 11 days, P < 0.001) and a smaller volume of drainage (710 mL versus 1160 mL, P < 0.001) compared with the control group. Conclusion. The use of mastectomy with quilting of flaps and obliteration of the axillary space is an efficient method to significantly reduce the postoperative seroma in addition to significantly reducing the duration and volume of wound drainage. Therefore we recommend quilting of flaps as a routine step at the end of any mastectomy.

Techniques in the prevention and management of seromas after breast surgery

Seromas are the most frequent complications following breast surgery, resulting in significant discomfort and morbidity with possible delays in commencing adjuvant therapies. Varied clinical practices exist in the techniques employed to prevent and manage seromata. This article assesses published literature on the techniques employed in prevention of seroma formation following breast surgery, evaluating the different methodologies used. Although prevention is the best strategy, seromata remain problematic and we consider their management. The principle findings were that prevention is key to the management of seromata. Methods employed to prevent seromata include suction drainage, shoulder immobilization, quilting sutures, fibrin sealants and innovative measures of managing the axilla, among others. The evidence demonstrated that a combination of quilting and drains significantly reduces the incidence and volumes of seromata. These effects are sustained by minimizing use of electrocautery, alongside increasing frequencies of axillary sentinel lymph node biopsies and node sampling. The efficacy data on fibrin sealants is inconclusive and consequently should not be routinely used alone or accompanied by quilting sutures. Clinically significant seromas deemed 'symptomatic' by patients and complicating infected seromas should be aspirated. There are limited data on the recommended treatment of established seromas with a paucity of high-quality studies and further research involving randomized trials are indicated.

Potential risk factors for the development of seroma following mastectomy with axillary dissection

Seroma is a common complication following breast cancer surgery and the controllable predictive factors remain unknown. Patients who underwent mastectomy with axillary dissection between 2008 and 2011 in our hospital were retrospectively investigated. The demographics, clinical characteristics and therapeutic factors of each patient were recorded. The association of seroma incidence with each variable was evaluated by univariate logistic regression analysis. All the variables were considered independent predictors of seroma incidence. The probability of developing seroma following surgery was evaluated by multivariate logistic regression analysis. A total of 102 patients, with a mean age of 54.86±13.02 years (range, 30-89 years), were included in this study and the incidence of seroma was found to be 22.55%. The operative time (P=0.0066, coefficient = 0.0261, OR=1.03) and the use of patient-controlled intravenous analgesia (PCA) (P=0.0002, coefficient = -1.8089, OR=0.03, ref = no) was significantly associated with the incidence of seroma postoperatively. In conclusion, the prediction of the development of seroma following mastectomy with axillary dissection is challenging. However, a longer operative time and the non-use of PCA may represent potential risk factors for this complication.

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.

Seroma formation after breast cancer surgery: what we have learned in the last two decades

Formation of a seroma most frequently occurs after mastectomy and axillary surgery. Prolonged drainage is troublesome as it increases the risk for infection and can significantly delay adjuvant therapy. Seroma has been defined as serous fluid collection under the skin flaps or in the axillary dead space following mastectomy and/or axillary dissection. Because the true etiology of a seroma is unknown, a multifactorial-causation hypothesis has been accepted. Surgical factors include technique, extent of dissection and the surgical devices used for dissection. Obliteration of dead space with various flap fixation techniques, use of sclerosants, fibrin glue and sealants, octreotide, and pressure garments have been attempted with conflicting results and none have been consistent. Early movement of the shoulder during the postoperative period may increase the formation of seroma, although delayed physiotherapy decreases the formation of seroma. A detailed analysis of the use of drains showed that use of single or multiple drains, early or late removal, and drains with or without suction are not significantly different for the incidence of seroma. Although there is evidence for reduced seroma formation after early drain removal, very early removal within 24 hours seems to increase formation of seroma. No patient or tumor factors seem to affect seroma formation except body mass index and body weight. Consensus is lacking among studies/trials with different groups producing conflicting evidence. Besides a few established factors such as body mass index, the use of electrocautery for dissection, early drain removal, low vacuum drains, obliteration of dead space, and delayed shoulder physiotherapy, most of the hypothesized causes have not been demonstrated consistently. Thus, seroma remains a threat to both the patient and surgeon. Recurrent transcutaneous aspiration remains the only successful management.

Effectiveness of OK-432 (Sapylin) to reduce seroma formation after axillary lymphadenectomy for breast cancer

BACKGROUND

The occurrence of seroma formation after axillary lymphadenectomy for breast cancer cannot be ignored. Various approaches have been used in an effort to reduce it, but these results are still controversial. We aimed to describe a new method of application of OK-432 (Sapylin, heat-treated Su strain of Streptococcus) to reduce seroma formation after axillary lymphadenectomy for breast cancer and to verify the safety and efficacy of it as a beneficial supplement for conventional surgery.

METHODS

A prospective, randomized analysis of consecutive quadrantectomy or mastectomy plus axillary lymphadenectomy using or not using OK-432 was designed. From July 2010 to November 2011, a total of 111 patients were enrolled in this prospective, randomized study and completed the follow-up. OK-432 applied to the axillary fossa plus placement of closed suction drainage was used in 54 patients (the experimental group); placement of closed suction drainage was used in 57 patients (the control group).

RESULTS

There were no statistical significance between the two groups in terms of age, body mass index, treatment received, tumor size, number of removed lymph nodes, and lymph node status. Postoperative drainage magnitude and duration were significantly reduced in the experimental group (P = 0.008 and 0.003, respectively). One week after hospital discharge, fewer patients developed a palpable seroma in the experimental group: 10 in the experimental group versus 28 in the control group (P = 0.001). Fewer seromas needed aspiration (mean 1 [range 0-3] in the experimental group vs. mean 4 [range 1-5] in the control group; P < 0.001). There were no significant differences in terms of the incidence of complications associated with axillary lymphadenectomy (P = 0.941).

CONCLUSIONS

OK-432 is a feasible and safe option for axillary lymphadenectomy for breast cancer. The use of it does not always prevent seroma formation, but it can reduce drainage magnitude and duration, as well as decrease the incidence of seroma after the removal of drainage. It may be increasingly conducted in day surgery clinics.

Efficacy of fibrin glue on seroma formation after breast surgery

Background and Objectives. This study was designed to determine the effectiveness of fibrin glue plus conventional drain placement versus conventional drain placement in the prevention of seromas after breast procedures. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies, with controversial results. Design and Setting. A prospective, randomized, controlled study of subjects who were randomized into control and experimental groups was conducted. Methods. Collected data included age, surgeon, medical and surgical history, comorbidities, procedure performed, number of axillary nodes, number of positive axillary nodes collected, final pathologic diagnosis, cancer stage, hospital stay, postoperative day of drain removal, complications, incidence of seroma formation, interval to seroma resolution, and number of postoperative visits. Results. Analysis of 60 patients showed similarly matched groups. Seroma formation rate was 24.1% in the control group and 16.1% in the fibrin glue group. The rate of wound complications was similar. Conclusions. Although use of fibrin sealant resulted in a nonsignificant decrease in seroma formation rate compared with that of drain placement, the higher cost and cumbersome technique tend to indicate that there is no advantage to using fibrin glue over drain placement with the technique described.

Axillary Padding without Drainage after Axillary Lymphadenectomy - a Prospective Study of 299 Patients with Early Breast Cancer

BACKGROUND: After lymphadenectomy for early breast cancer, seroma formation is a constant event requiring a suction drainage. This drainage is the strongest obstacle to reducing the hospital stay. Axillary padding without drainage appears to be a valuable option amid the various solutions for reducing the hospital stay. METHODS: We conducted a comparison between 114 patients with padding and 185 patients with drainage. Data were obtained from 2 successive prospective studies. RESULTS: The mean hospital stay was 2.4 days (range 1-4) in the padding group and 4.2 days (range 2-9) in the drainage group (p < 0.05). There were fewer needle aspirations for seroma in the padding group (8.8 vs. 23%, p < 0.05). At 6 weeks, only 28% (32/114) of the patients in the padding group reported pain versus 51% (94/185) in the drainage group. The mean pain intensity at 6 weeks was 3 and 4.3 respectively (p < 0.0001). CONCLUSION: Axillary padding without drainage was associated with a better post-operative course than suction drainage in this historical comparison, and the hospital stay was significantly shortened. There are only few series published on this new technique but they all indicate good feasibility and good tolerance. A large randomised multicentric evaluation is now warranted.

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.

The value of mastectomy flap fixation in reducing fluid drainage and seroma formation in breast cancer patients

Background

Prolonged and excessive drainage of serous fluid and seroma formation constitute the most common complications after mastectomy for breast carcinoma. Seroma formation delays wound healing, increases susceptibility to infection, skin flap necrosis, persistent pain and prolongs convalescence. For this, several techniques have been investigated to improve primary healing and minimize seroma formation.

Materials and methods

Between June 2009 and July 2010 forty patients with breast carcinoma, scheduled for modified radical mastectomy, were randomly divided into 2 groups, the study group (20) and the control group (20). In the study group; the mastectomy flaps were fixed to the underlying muscles in raws, at various parts of the flap and at the wound edge using fine absorbable sutures. In the control group; the wound was closed in the conventional method at the edges. Closed suction drains were used in both groups. Patients, tumor characteristics and operative related factors were recorded. The amount and color of drained fluid were recorded daily. The drains were removed when the amount become less than 50 cc. The total amount and duration of drained fluid and the formation of seroma were recorded and the results were compared between the two groups.

Results

In the flap fixation group, the drain was removed in significantly shorter time compared to the control group (p < 0.001). Also, the total amount of fluid drained was significantly lower in the flap fixation group (p < 0.001). The flap fixation group showed a significantly lower frequency of seroma formation compared to the control group, both clinically (p = 0.028) and ultrasonographically (p = 0.047).

Conclusions

The mastectomy flap fixation technique is a valuable procedure that significantly decreases the incidence of seroma formation, and reduces the duration and amount of drained fluid. However, it should be tried on a much wider scale to prove its validity.

A nomogram to predict the duration of drainage in patients with penile cancer treated with inguinal lymph node dissection

PURPOSE

We developed a nomogram to predict the duration of drainage in patients with penile cancer treated with inguinal lymph node dissection.

MATERIALS AND METHODS

A total of 111 groin basins in 56 patients who underwent radical inguinal lymph node dissection for penile cancer were retrospectively assessed. We retrieved the clinicopathological factors from the medical records including age, body mass index, albumin, smoking history, hypertension, diabetes, preoperative radiotherapy/chemotherapy, palpable lymph nodes, previous lymph node biopsy, total number of resected lymph nodes and ratio of positive lymph nodes. The criterion of drain removal was total drain output of 50 ml or less per day for 2 days starting from postoperative day 3. A multivariate Cox proportional hazards model was used to explore the risk factors of drainage duration and variable selection was performed according to Akaike's information criteria. A nomogram was built based on regression coefficients and internally validated with 200 bootstrap resamples.

RESULTS

Median postoperative drainage duration was 7 days. The prediction model using pretreatment factors showed a concordance index of 0.55. With the addition of lymph node related variables a second model was constructed which produced a better concordance index (0.65) and good calibration. On multivariate analysis young age, high body mass index, total number of resected lymph nodes and ratio of positive lymph nodes were independent predictors of prolonged lymphatic drainage.

CONCLUSIONS

On the basis of readily obtained clinicopathological variables we developed a nomogram to predict the duration of lymphatic drainage which, if externally validated, could be helpful for patient consultation, treatment decision making and clinical trial design.

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.

Axillary lymph node dissection for breast cancer utilizing Harmonic Focus®

Background

For patients with axillary lymph node metastases from breast cancer, performance of a complete axillary lymph node dissection (ALND) is the standard approach. Due to the rich lymphatic network in the axilla, it is necessary to carefully dissect and identify all lymphatic channels. Traditionally, these lymphatics are sealed with titanium clips or individually sutured. Recently, the Harmonic Focus^®, a hand-held ultrasonic dissector, allows lymphatics to be sealed without the utilization of clips or ties. We hypothesize that ALND performed with the Harmonic Focus^® will decrease operative time and reduce post-operative complications.

Methods

Retrospective review identified all patients who underwent ALND at a teaching hospital between January of 2005 and December of 2009. Patient demographics, presenting pathology, treatment course, operative time, days to drain removal, and surgical complications were recorded. Comparisons were made to a selected control group of patients who underwent similar surgical procedures along with an ALND performed utilizing hemostatic clips and electrocautery. A total of 41 patients were included in this study.

Results

Operative time was not improved with the use of ultrasonic dissection, however, there was a decrease in the total number of days that closed suction drainage was required, although this was not statistically significant. Complication rates were similar between the two groups.

Conclusion

In this case-matched retrospective review, there were fewer required days of closed suction drainage when ALND was performed with ultrasonic dissection versus clips and electrocautery.

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.

Prevalence, risk factors, and management of seroma formation after breast approach endoscopic thyroidectomy

BACKGROUND

Breast approach endoscopic thyroidectomy (BAET) allows surgeons to remove a thyroid tumor from a remote site while providing a scarless cosmetic appearance in the neck. However, seroma formation after subcutaneous dissection could lead to flap detachment, incision dehiscence, and wound infection. Chronic formation of seromas could substantially compromise the esthetic outcome of BAET. We evaluated the prevalence, risk factors, and treatments of seroma after BAET.

METHODS

A total of 344 patients who underwent BAET between 2001 and 2008 at our institution were recruited; data were collected prospectively. The characteristics and outcomes of patients who developed seromas were compared with those of patients who did not. Regression analysis was used to identify the independent risk factors for seroma formation. The frequency and volume of aspirations were noted until the seroma went into remission.

RESULTS

The overall postoperative prevalence of seroma formation was 2.9%. There was a significant difference in seroma formation based on age, hypertension, body mass index (BMI), and area of subcutaneous dissection space (ASDS). Percutaneous aspiration alone or combined with external compression was extremely effective. The frequency and total volume of aspirations were 1-7 and 6-120 ml, respectively. As a result of prolonged seroma formation, one patient developed an expanding pseudo-bursa that created a tumor-like effect in the anterior chest wall.

CONCLUSIONS

Seroma formation was an uncommon minor complication after BAET. Four independent etiologic factors could predispose patients to postoperative seroma formation. Percutaneous aspiration appeared to be very effective. Prolonged seroma formation followed by development of a pseudo-bursa could be very problematic and could substantially impair the esthetic effect of BAET.

Effectiveness of fibrin glue in conjunction with collagen patches to reduce seroma formation after axillary lymphadenectomy for breast cancer

BACKGROUND

Axillary lymphadenectomy remains an integral part of breast cancer treatment, yet seroma formation occurs in 15% to 85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies, with controversial results.

METHODS

Fifty patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray and a collagen patch were applied to the axillary fossa in 25 patients; the other 25 patients were treated conventionally.

RESULTS

Suction drainage was removed between postoperative days 3 and 4. Seroma magnitude and duration were significantly reduced (P = .004 and .02, respectively) and there were fewer evacuative punctures in patients receiving fibrin glue and collagen patches compared with the conventional treatment group.

CONCLUSIONS

Use of fibrin glue with collagen patches does not always prevent seroma formation, but it does reduce seroma magnitude and duration, as well as necessary evacuative punctures.

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.

INFLUENCE OF SURGICAL TECHNIQUE ON AXILLARY SEROMA FORMATION: A RANDOMIZED STUDY

The aim of this study was to evaluate the influence of surgical technique in the form of electrocautery and suction drains on seroma formation following surgery for breast cancer. A prospective randomized study was carried out. One hundred and sixty patients with breast cancer who underwent surgery were allocated to four arms using a 2 x 2 factorial design. This method enabled us to evaluate the independent effect of two different causative factors on the incidence of postoperative seroma formation using a single dataset with limited numbers. The main outcome measure was postoperative seroma formation defined as a postoperative axillary collection requiring more than one aspiration after removal of the drain. The incidence of seroma in our institution is 90%. Incidence of postoperative seroma was 88.3% if electrocautery was used, which reduced to 82.2% if surgery was carried out using scissors for dissection and ligatures for haemostasis (P = 0.358). There was no influence on the incidence of seroma formation whether suction drain (84.6%) or corrugated drains (86.1%) were used (P = 0.822). The use of electrocautery in axillary dissection does not adversely affect postoperative seroma formation after surgery for breast cancer. The use of different drainage techniques has no bearing on the postoperative seroma formation. The surgical technique has no influence on the rate of seroma formation after surgery for breast cancer.

Completely Autologous Platelet Gel in Breast Reduction Surgery: A Blinded, Randomized, Controlled Trial

BACKGROUND

The objective of this study was to assess the effectiveness of topical application of completely autologous platelet gel during breast surgery to reduce postoperative wound drainage. An increasing number of surgical centers are using tissue sealants to reduce postoperative drainage and improve surgical outcomes. However, there is a paucity of randomized, double-blind, controlled trials assessing the efficacy of these agents.

METHODS

The authors conducted a within-patient, randomized, patient- and assessor-blinded, controlled trial assessing the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammaplasty. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. The primary outcome was the difference in wound drainage over 24 hours. Secondary outcomes included subjective and objective assessments of pain and wound healing.

RESULTS

No statistically significant differences in the drainage, level of pain, size of open areas, clinical appearance, degree of scar pliability, or scar erythema were noted.

CONCLUSION

The authors' results do not support the use of completely autologous platelet gel to improve outcomes after reduction mammaplasty.

Randomized clinical trial of the effect of quilting latissimus dorsi flap donor site on seroma formation

Background

Latissimus dorsi (LD) flap breast reconstruction is associated with a high incidence of donor site seromas, despite the use of surgical drains. The aim of this study was to evaluate the use of donor site quilting sutures, as well as drains, on the incidence, volume and frequency of seroma aspiration.

Methods

The trial randomized 108 women undergoing LD breast reconstruction to quilting procedures (54) or control group (52) for intention-to-treat analysis; two were excluded. Outcome measures were the incidence and volume of postoperative seroma. Secondary outcome measures included postoperative back pain, analgesic consumption, shoulder movement and duration of hospital stay.

Results

Quilting significantly reduced the overall incidence of seroma from 46 of 48 (96 per cent) to 43 of 52 (83 per cent) (P = 0·036), including the 38 women who had extended LD flap (with or without implants). There were further significant reductions in seroma volume (P = 0·004), frequency of aspiration (P = 0·001) and overall seroma volumes, including surgical drainage and symptomatic seromas (P = 0·013). Subset analyses for LD–implant (60 women) and extended LD (with or without implant) showed similar significance. Quilting did not affect back pain or compromise shoulder mobility.

Conclusion

Quilting significantly reduced overall seroma volumes after LD breast reconstruction including extended LD, and is recommended in combination with surgical drains.

Randomized clinical trial comparing axillary padding with closed suction drainage for the axillary wound after lymphadenectomy for breast cancer

Background

After axillary lymphadenectomy for breast cancer, a suction drain is routinely inserted into the axilla to prevent seroma formation. This drain is an obstacle to reducing hospital stay after breast-conserving surgery. This was a prospective randomized clinical trial to assess the safety and results of axillary padding without the use of a drain.

Methods

Between May 2001 and August 2003, 100 women were randomly allocated axillary padding without a drain or with the use of an axillary suction drain. Prospective assessments were made of morbidity, pain, shoulder mobility, quality of life and medical costs including length of hospital stay.

Results

Using axillary padding significantly reduced the mean (s.d.) length of hospital stay (1·8(1) versus 4·5(2) days, P &lt; 0·001). Postoperative complications, pain, shoulder mobility and quality of life were similar in the two groups. There was no difference in the duration of the two procedures.

Conclusion

Axillary padding after axillary lymphadenectomy was feasible and safe, without a drain, and shortened hospital stay.

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.