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

Quilting Suture Technique After Mastectomy: A Meta-Analysis

BACKGROUND

There is no level 1a evidence testing quilting suture (QS) technique after mastectomy on wound outcomes. The aim of this systematic review and meta-analysis evaluates QS and association with surgical site occurrences as compared to conventional closure (CC) for mastectomy.

METHODS

MEDLINE, PubMed, and Cochrane Library were systematically searched to include adult women with breast cancer undergoing mastectomy. The primary endpoint was postoperative seroma rate. Secondary endpoints included rates of hematoma, surgical site infection (SSI), and flap necrosis. The Mantel-Haenszel method with random-effects model was used for meta-analysis. Number needed to treat was calculated to assess clinical relevance of statistical findings.

RESULTS

Thirteen studies totaling 1748 patients (870 QS and 878 CC) were included. Seroma rates were statistically significantly lower in patients with QS (OR [95%CI] = .32 [.18, .57]; P < .0001) than CC. Hematoma rates (OR [95%CI] = 1.07 [.52, 2.20]; P = .85), SSI rates (OR [95%CI] = .93 [.61, 1.41]; P = .73), and flap necrosis rates (OR [95%CI] = .61 [.30, 1.23]; P = .17) did not significantly vary between QS and CC.

CONCLUSION

This meta-analysis found that QS was associated with significantly decreased seroma rates when compared to CC in patients undergoing mastectomy for cancer. However, improvement in seroma rates did not translate into a difference in hematoma, SSI, or flap necrosis rates.

Does rapid discharge after breast cancer surgery have an impact on wound healing and complications? COVID-19 pandemic experience

The COVID-19 pandemic has challenged the health systems worldwide. Because of high volume of COVID-19 patients, all hospitals in our region were re-configured as COVID-19 centres and elective surgery procedures were cancelled. Our clinic was the only active centre in the region and grave increase in our patient volume urged our clinic to modify our discharge protocol. This retrospective study included all breast cancer patients underwent mastectomy and/or axillary dissection, in the Breast Surgery Clinic of Kocaeli State Hospital, a regional pandemic hospital, between December 2020 and January 2021. Patients were mostly discharged the day of surgery with drains because of congestion, while some of the patients had traditional stay, when beds were available. The patients were evaluated postoperatively (the first 30 days) in terms of wound complications, Clavien-Dindo classification grade, satisfaction, presence of pain and nausea, and treatment costs during the follow-up period of the study. Outcomes were compared between early discharged patients and patients who had traditional long stay. Compared with long-stay patients, in the early discharged group, postoperative wound complications was significantly lower (P < .01) with significant cost savings. There were no significant changes in variables such as surgery type, ASA class, satisfaction, need for additional medication and Clavien-Dindo between the groups. Adaptation to an early discharge protocol for breast cancer surgeries may be an efficient way of practicing surgery in a pandemic. Early discharge with drains may be beneficial for patients.

Accelerated Perioperative Rehabilitation for Breast Cancer Patients Undergoing Radical Mastectomy: A Systematic Review

PURPOSE

To summarize and analyze available evidence on perioperative accelerated rehabilitation programs for patients diagnosed with breast cancer that have had a radical mastectomy.

DESIGN

This article is a systematic review of literature based on evidence-based methodology.

METHODS

The '6S' evidence resource pyramid model was used to systematically search a range of databases.

FINDINGS

A total of 19 articles were extracted from the literature and used in this study, including 9 clinical decisions, 4 systematic evaluations, 4 expert consensuses, and 2 guidelines. We summarized a total of 47 lines of evidence with regard to various aspects, including preoperative, intraoperative, and postoperative nursing measures.

CONCLUSIONS

In this systematic review, an evidence-based methodology was used to summarize and analyze the best suggestions for perioperative accelerated rehabilitation nursing programs for breast cancer inpatients undergoing radical mastectomy. We aimed to provide a good reference value and evidence-based guidelines for the continuous improvement and development of nursing practice for the breast cancer patient population.

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.

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.

Management of complex surgical wounds of the back: identifying an evidence-based approach

Background

Postoperative dehiscence and surgical site infection after spinal surgery can carry serious morbidity. Multidisciplinary involvement of plastic surgery is essential to minimizing morbidity and achieving definitive closure. However, a standardized approach is lacking. The aim of this study was to identify effective reconstructive interventions for the basis of an evidence-based management protocol.

Methods

A retrospective review was performed at a single tertiary institution for 45 patients who required 53 reconstruction procedures with plastic surgery for wounds secondary to spinal surgery from 2010 to 2019. Statistical analysis was performed for demographics, comorbidities, and treatment methods. Primary outcomes were postoperative complications, including dehiscence, seroma, and infection. The secondary outcome was time to healing.

Results

The overall complication rate was 32%, with dehiscence occurring in 17%, seroma in 15% and infection in 11% of cases. Median follow-up was 10 months (interquartile range, 4–23). Use of antibiotic beads did not affect rate of infection occurrence after wound closure (P=0.146). Use of incisional negative pressure wound therapy (iNPWT) was significant for reduced time to healing (P=0.001). Patients treated without iNPWT healed at median of 67.5 days while the patients who received iNPWT healed in 33 days. Demographics and comorbidities between these two groups were similar.

Conclusions

This data provides groundwork for an evidence-based approach to soft tissue reconstruction and management of dehiscence after spinal surgery. Timely involvement of plastic surgery in high-risk patients and utilization of evidence-based interventions such as iNPWT are essential for improving outcomes in this population.

Experience with modified radical mastectomy in a low-income country: a multi-center prospective observational study

BACKGROUND

Modified radical mastectomy is the procedure of choice in centers with little to no radiotherapy services. Studying the in-hospital outcome and complications associated with the procedure is important in low-income countries.

METHODS

This is a multi-center prospective observational study involving all patients operated with modified radical mastectomy with curative intent.

RESULTS

A total of 87 patients were studied with 10.3% of which were male and 54% were between the age of 30-49 years. Clinical stage IIB and IIIA were reported in 33 (37.9%) and 25 (28.7%) respectively and 62.1% had clinically positive lymph nodes at presentation. All of the studied patients underwent curative surgery, with an average lymph node dissection of 10.2 ± 0.83. Seroma rate was 17.2% and was significantly associated with diabetes (AOR: 6.2 (CI 1.5-8.7)) and neoadjuvant chemotherapy (AOR: 8.9 (CI 1.2-14.2)). Surgical site infection occurred in 14.9% and was significantly associated with Retroviral infections (AOR: 4.2 (CI 2.1-5.8)) and neoadjuvant chemotherapy (AOR: 1.8 (CI 1.3-3.9)). No in-hospital mortality occurred during the course of the study.

CONCLUSION

Seroma rate was lower than published studies while surgical site infections rate was higher. Neoadjuvant chemotherapy was associated with increase in seroma and surgical site infection rates. Additionally, diabetes increased the rate of seroma. Surgical site infections were higher in patients with retroviral infections.

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.

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.

Comparison between Early and Late Drain Released after Modified Radical Mastectomy Surgery through Observation over Proportion of Percutaneous Aspiration Technique of Seroma Production in Surgical Polyclinic of Dr. Soetomo Hospital, Surabaya

Surgery is the most frequent indication and major therapy in the management of malignancy of breasts. Drain is one method to drainage the seroma formed after the modified radical mastectomy surgery. The drain-release protocol varies in each hospitals. This study aimed to compare the proportion of percutaneous aspiration in patients with early drain release with late drain release in postoperative MRM patients. The present study is a prospective cohort study comparing the proportion of percutaneous aspiration in 30 patients with early drain released with 30 patients with late drain release in Dr. Soetomo hospital The recording of the proportion of aspiration actions was conducted serially on days 3, 7, 10, and 14 after drain release. Recording of age, nutritional status (BMI), tumor histopathology type, stage, shoulder mobilization time, obliterant usage, wound infections surgery, flap necrosis and hematom were analyzed to find out if there was any effect on seroma event In our study we did not find the difference in serum aspiration proportions both in the early and late drain observation group. Age factor, nutritional status (BMI), histopathology type, stage, shoulder mobilization time, obliterant use, presence of surgical wound infection, flap necrosis and hematom did not differ significantly statistically to seroma events. Statistically, there was no difference in the proportion of percutaneous aspiration in a group of observed patients with early and late drain release. Late drain release can be avoided to potentially harm the patient in decreasing the lives’ quality of the patients.

Retrospective Evaluation of the Effectiveness of a Synthetic Glue and a Fibrin-Based Sealant for the Prevention of Seroma Following Axillary Dissection in Breast Cancer Patients

Introduction: Seroma formation represents one of the most frequent postoperative complications of axillary dissection in breast cancer (BC) patients. We aimed to retrospectively explore the effectiveness of the intraoperative use of a synthetic cyanoacrylate glue (specifically Glubran®2) vs. the intraoperative use of a fibrin sealant (specifically Tisseel) in reducing seroma formation compared to the use of nonsealant in BC patients who underwent breast surgery and axillary dissection. Materials and Methods: We conducted a retrospective, monocentric observational study on BC patients who underwent axillary dissection associated with breast surgery. The axillary dissection was completed with the application of a closed suction drain and was preceded by the application of either Glubran®2 glue or Tisseel sealant or nonsealant. We analyzed the quantity of serum drained in the first 3 postoperative days, length of hospitalization, days of permanence of axillary drain, seroma development, and presence of postoperative infection signs. Results: Forty-one BC patients were considered. Based on the device used during the surgical treatment, the patients were divided into three groups: group A (17 patients), to whom suction axillary drain was applied; group B (7 patients), to whom Tisseel and axillary suction drain were applied; and group C (17 patients), to whom Glubran®2 and axillary suction drain were applied. Among the three groups, we did not find significant differences in terms of amount of serum drained in the first 3 postoperative days, length of hospitalization, and incidence of seroma. Group C maintained the axillary drain in a significantly lower number of days compared to the other two groups (p = 0.02); it also had a lower incidence of postoperative infections (6%) compared to group A (23%) and group B (57%) (p = 0.02). Conclusions: We did not find any evidence that the use of surgical glues may reduce the formation of seroma following axillary dissection in BC patients. Nevertheless, the use of cyanoacrylate glue in association with closed suction axillary drain seems to contribute to the reduction in days of axillary drain permanence and of postoperative infections, which are known factors delaying the schedule of any adjuvant oncological therapies.

Quilting suture is better than conventional suture with drain in preventing seroma formation at pectoral area after mastectomy

BACKGROUND

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

METHODS

Two hundred thirty-five consecutive breast cancer patients were retrospectively analyzed. The primary outcome was the incidence of Grade 2 or Grade 3 seroma at anterior pectoral area within 1 month postoperatively. We categorized seroma into early or late seroma according to the drainage removal time. Cox regression was used for analysis.

RESULTS

The incidence of Grade 2 and 3 seroma was significantly higher in the conventional suture group compared with that in the quilting suture group (19.3% vs. 9.5%, p = 0.032), which was attributed to the late seroma in Grade 2 and 3. Quilting suture was associated with longer time for fixing flaps compared with that of conventional suture (504.7 s vs. 109.1 s, p < 0.001), but with less volume of drainage. Old age, high body mass index and conventional suture were independently risk factors for Grade 2 and 3 seroma.

CONCLUSIONS

Quilting suture decreased the incidence of Grade 2 and 3 seroma at pectoral area within 1 month after mastectomy, especially the late seroma in Grade 2 and 3.

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.

Impact of the surgical modality for axillary lymph node dissection on postoperative drainage and seroma formation after total mastectomy

Background

The most common complications after total mastectomy with axillary lymph node treatment are prolonged drainage and seroma formation. The aim of this study was to find factors correlated with prolonged fluid discharge (prolonged drainage or seroma formation after 20th operative day or later), including surgical techniques or devices and clinical factors.

Patients and methods

A total of 202 conclusive primary breast cancer patients underwent total mastectomy with axillary lymph node treatment between January 7, 2014 and June 20, 2018 at our hospital. The factors that correlated with the total fluid discharge volume and prolonged fluid discharge were examined statistically. The surgical modalities for total mastectomy with axillary treatment were classified into the following three groups:, Group A; skin flap formation by EC and axillary lymph node dissection by EC with ligation of the arteries and veins, Group B; skin flap formation by EC and axillary lymph node dissection by ultrasonic dissector (UD) without ligation of the vessels. Group D; skin flap formation by electrocautery (EC) and axillary lymph node dissection by picking up using forceps and ligation (PL).

Results

The total fluid discharge volume and prolonged fluid discharge after total mastectomy with sentinel node retrieval (33 patients) were significantly lower than those after total mastectomy with axillary lymph node dissection (169 patients). In patients treated without drainage, a high rate of seroma formation and prolonged fluid discharge were observed, and 1 patient developed seroma infection.In the total mastectomy with axillary lymph node dissection group, logistic regression analysis revealed that body mass index, 1-week drainage volume, and surgical modality were independently correlated with prolonged fluid discharge.

Conclusions

The surgical procedure for axillary lymph node dissection should be considered to avoid prolonged fluid discharge, and the lymph vessels should be ligated in axillary lymph node dissection. An ultrasonic dissector was not effective in reducing the total fluid discharge volume. An optimal axillary lymph node dissection technique should be developed. For the patients without drainage, careful postoperative treatment should be given to avoid infectious seroma formation, even for patients who underwent total mastectomy with sentinel lymph node retrieval.

Complex Open Abdominal Wall Reconstruction: Management of the Skin and Subcutaneous Tissue

Optimal skin and soft tissue management in complex open abdominal wall reconstruction is an integral element of the operation to achieve optimal outcomes. Failure to provide stable, well-vascularized soft tissue coverage over the hernia repair can jeopardize the reconstruction through association with nonhealing wounds, mesh exposure, and even possible hernia recurrence. The literature has shown that careful attention to the skin and soft tissue, especially when part of a multidisciplinary approach to complex abdominal wall reconstruction, improves patient outcomes significantly.

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.

Safety and feasibility of early postmastectomy discharge and home drain care in a low resource setting

BACKGROUND

Early postmastectomy discharge with a drain in place is standard practice in most developed countries. Its feasibility has not been evaluated in low resource settings like Nigeria.

METHODS

Consenting patients undergoing mastectomy were discharged on the third postoperative day and assessed as outpatients for wound complications as well as their experience at home. Wound outcomes were compared with patients who had traditional long stay.

RESULTS

Forty-five of the 58 patients who had a mastectomy during the study period participated in the early discharge program (77.6%). Of these, four patients (8.9%) had drain malfunction, seroma occurred in eight patients (17.8%), eight patients (17.8%) had wound infection, and six patients (13.3%) had flap necrosis. There was no readmission. Compared with long stay patients, postoperative stay was significantly shorter (3 vs 11 days; P < 0.01) with significant cost savings, while complication rates were not statistically different. All the patients in the early discharge group were confident operating their drains and preferred early discharge. Being around relatives, reduced cost, and fear of the hospital environment were common reasons cited for their preference.

CONCLUSION

Our results support the implementation of an early postmastectomy discharge program in a low resource setting.

Management of skin and subcutaneous tissue in complex open abdominal wall reconstruction

PURPOSE

Open abdominal wall reconstruction is often a complex endeavor, usually performed on patients with multiple risk factors and co-morbidities.

METHODS

In this article, we review soft tissue management techniques that can optimize the skin and subcutaneous tissue, with the goal of reducing surgical-site occurrences.

RESULTS

Regardless of the hernia repair technique used, outcomes can be highly dependent on the appropriate management of the skin and subcutaneous tissue. Indeed, dehiscence and surgical-site infection can jeopardize the entire reconstruction, especially in cases where synthetic mesh might become exposed and/or infected, setting up a "vicious cycle" (Holihan et al. in J Am Coll Surg 221:478-485, 2015).

CONCLUSION

Multidisciplinary cooperation between the general and plastic surgeon is useful in cases of tenuous blood supply to the abdominal skin, in cases of redundant, marginal or excessive skin, and in cases of deficient skin.

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.

Risk of infection is associated more with drain duration than daily drainage volume in prosthesis-based breast reconstruction: A cohort study

In prosthesis-based breast reconstruction, drains are used to prevent seroma formation and to reduce the risk of infection. However, prolonged drainage increases the risk of ascending infection. Although the volume often accepted for drain removal is ≤30 mL per day, the optimal timing to remove the drain for best clinical outcome remains controversial.We did a retrospective cohort study of 569 patients of prosthesis-based breast reconstruction with infection rate as the outcome variable; drain duration and last daily drainage volume as the main independent variables. Data on age, smoking history, diabetes mellitus history, body mass index, breast weight, tissue expander size, drain size, number of retrieved lymph nodes, tumor size, number of metastatic lymph nodes, tumor stage, mastectomy type, reconstruction type, submuscular implantation, skin defect, operative time, duration of antibiotics use, chemotherapy, and radiotherapy were collected as covariates. Multivariable logistic regression analysis was used to control for confounding.The total infection rate was 5.1% (29/569). The daily drainage volume ≥30 mL/d at the time of drain removal was not found associated with increased infection rate (P = 0.32). Of the various cutoff values of last daily drainage volume, none was found to be a determinant for drain removal where the risk of infection was concerned. By contrast, drain duration over 21 days significantly increased infection rate (P = 0.001). The multivariable logistic regression analysis showed an increase of 76.2% in the infection rate with each additional week of drain retention (P = 0.001). Breast weight also had a significant influence on risk of infection. Chemotherapy and drain size showed borderline effect on risk of infection whereas the last daily drainage volume was not associated with risk of infectionIn summary, our study revealed that drain duration, rather than the last daily drainage volume, significantly affects the infection rate in prosthesis-based breast reconstruction. We recommend that the drain is better removed no longer than 3 weeks postoperatively and can be removed as early as postoperative day 7, even when the drainage is over 30 mL in a 24-hour period.

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.

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.

Dead space closure with quilting suture versus conventional closure with drainage for the prevention of seroma after mastectomy for breast cancer (QUISERMAS): protocol for a multicentre randomised controlled trial

INTRODUCTION

Postoperative wound seroma is common after mastectomy. This complication is associated with significant impact on patient outcomes and healthcare costs. The optimal closure approach for seroma prevention remains unknown but some evidence suggests that quilting suture of the dead space could lower the incidence of seroma. The aim of this trial is to compare seroma formation using quilting suture versus conventional closure with drainage in patients undergoing mastectomy.

METHODS AND ANALYSIS

This is a multicentre, superiority, randomised controlled trial in women undergoing mastectomy with or without axillary involvement. Exclusion criteria include indication of bilateral mastectomy or immediate reconstruction and any physical or psychiatric condition that could impair patient's ability to cooperate with postoperative data collection or that do not allow an informed consent. 320 participants will be randomised in a 1:1 ratio to receive either quilting suture or conventional wound closure with drain. The primary outcome is seroma requiring either aspiration or surgical intervention within 21 days following mastectomy. Secondary outcomes include seroma regardless of whether or not it requires an intervention, surgical site infection, pain score, cosmetic result, patient's quality of life, costs and cost-effectiveness. The primary analysis will be an intention-to treat analysis performed with a χ(2) test (or Fisher's exact test).

ETHICS AND DISSEMINATION

Written informed consent will be obtained from all participants. This study was approved by Tours Research ethics committee (CPP TOURS-Region Centre-Ouest 1, 2014-R20, 16 December 2014). Study findings will be published in peer-reviewed journals and presented at relevant national and international breast cancer conferences.

TRIAL REGISTRATION NUMBER

NCT02263651.

Improving the recording of surgical drain output

Monitoring the output from surgical drains is an important part of post-operative care and is often undertaken poorly. Failure to have accurate documentation of daily outputs may delay the removal of drains and increase the risk of complications. Following discussions with medical and nursing staff we listed eight key criteria that should be routinely monitored for surgical drains. A baseline measurement demonstrated only 20% compliance with these criteria. As such we decided to design a chart, after discussing with the multidisciplinary team, with adequate space to document drain output clearly. Post-intervention data collection showed a reasonable uptake of the chart (70%) with overall criteria compliance increasing to 55%.

We made further interventions designed to raise awareness of the chart, which increased chart uptake to 79% and compliance to 63%, leading to the adoption of the chart by the department. Twelve months after introducing the chart we conducted a final data collection which demonstrated the chart was now being used in 100% of patients and that overall criteria compliance had increased to 78%. While some of the key criteria are still not documented for all patients, we have demonstrated that the introduction of a simple and well-designed drain chart can significantly improve the documentation of drain output, thereby improving patient safety and discharge efficiency.

Quilting Suture of Mastectomy Dead Space Compared with Conventional Closure with Drain

PURPOSE

This study was designed to compare conventional closure with a drain and quilting suture of mastectomy dead space for preventing wound seroma.

METHODS

Consecutive patients undergoing mastectomy for breast cancer were included in this retrospective observational study. Patients received conventional closure with drainage or quilting suture for wound closure. Propensity score (PS) matching was performed based on potential confounders to minimize selection bias. The primary outcome was the rate of type 2 or 3 wound seroma according to the common terminology criteria for adverse events (CTCAE) definition.

RESULTS

A total of 119 patients were included (quilting suture n = 59; conventional closure n = 60). Type 2 or 3 seroma was observed in 6.8 % of the quilting suture group and 21.7 % of the conventional closure group (crude odds ratio 0.26; 95 % confidence interval 0.08-0.86; p = 0.03). The overall seroma rate was 15.2 % in the quilting suture group and 51.7 % in the conventional closure group (p < 0.001). Persistent pain at days 15-21 was significantly less frequent in the quilting suture group than in the conventional suture group. PS matched analysis confirmed these findings, in particular the lower rate of type 2 or 3 seroma in the quilting suture group than in the conventional closure group (PS-matched odds ratio 0.16; 95 % confidence interval 0.04-0.72; p = 0.02).

CONCLUSIONS

Quilting suture of the mastectomy dead space is associated with significantly less frequent seroma than conventional closure with drain.

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.

Is routine drainage necessary after pancreaticoduodenectomy?

With the development of imaging technology and surgical techniques, pancreatic resections to treat pancreatic tumors, ampulla tumors, and other pancreatic diseases have increased. Pancreaticoduodenectomy, one type of pancreatic resection, is a complex surgery with the loss of pancreatic integrity and various anastomoses. Complications after pancreaticoduodenectomy such as pancreatic fistulas and anastomosis leakage are common and significantly associated with patient outcomes. Pancreatic fistula is one of the most important postoperative complications; this condition can cause intraperitoneal hemorrhage, septic shock, or even death. An effective way has not yet been found to avoid the occurrence of pancreatic fistula. In most medical centers, the frequency of pancreatic fistula has remained between 9% and 13%. The early detection and routine drainage of anastomotic fistulas, pancreatic fistulas, bleeding, or other intra-abdominal fluid collections after pancreatic resections are considered as important and effective ways to reduce postoperative complications and the mortality rate. However, many recent studies have argued that routine drainage after abdominal operations, including pancreaticoduodenectomies, does not affect the incidence of postoperative complications. Although inserting drains after pancreatic resections continues to be a routine procedure, its necessity remains controversial. This article reviews studies of the advantages and disadvantages of routine drainage after pancreaticoduodenectomy and discusses the necessity of this procedure.

Accuracy of surgical wound drainage measurements: an analysis and comparison

BACKGROUND

Surgical drain tube readings can influence the clinical management of the post-operative patient. The accuracy of these readings has not been documented in the current literature and this experimental study aims to address this paucity.

METHODS

Aliquots (10, 25, 40 and 90 mL) of black tea solution prepared to mimic haemoserous fluid were injected into UnoVac, RedoVac and Jackson-Pratt drain tubes. Nursing and medical staff from a tertiary hospital were asked to estimate drain volumes by direct observation; analysis of variance was performed on the results and significance level was set at 0.05.

RESULTS

Doctors and nurses are equally accurate in estimating drain tube volumes. Jackson-Pratt systems were found to be the most accurate for intermediate volumes of 25 and 40 mL. For extreme of volumes (both high and low), all drainage systems were inaccurate.

CONCLUSION

This study suggests that for intermediate volumes (25 and 40 mL), Jackson-Pratt is the drainage system of choice. The accuracy of volume measurement is diminished at the extremes of drain volumes; emptying of drainage systems is recommended to avoid overfilling of drainage systems.

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.

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.

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.

Use of multiple drains after mastectomy is associated with more patient discomfort and longer postoperative stay

BACKGROUND

Seromas constitute a common complication following surgery for breast cancer, and closed drainage is used routinely to reduce its incidence. The aim of this study was to evaluate the influence of number of drains on patient discomfort, seroma formation, and hospital stay during the immediate postoperative period after mastectomy for breast cancer.

PATIENTS AND METHODS

Based on a retrospective review of our clinical database, 110 consecutive patients from January 2004 through January 2006 who had undergone a mastectomy and axillary clearance for breast cancer were sent a simple postal questionnaire for collection of data.

RESULTS

A total of 70 patients responded (all women; mean age, 69.4 +/- 11.4 years). Twenty-seven patients (38.57%) had 3 drains implanted unilaterally, 24 (34.28%) had 2, and 19 (27.14%) had 1 drain. They were divided into 2 groups: the first group with 1 drain (19 patients) and the other with 2 or 3 drains (51 patients). Median postoperative hospital stay was 2 days (range, 1-8 days); patients with 1 drain had a significantly shorter postoperative hospital stay (median, 2 days [range, 1-4 days] vs. 2 days [range, 1-8 days]; Mann-Whitney U test, P = .02). A total of 15 patients (21.43%) complained of a seroma. There was no difference in seroma rates between groups. Patients who had a single drain implanted had a significantly lower rate of discomfort (median, 2 [range, 1-5] vs. 3 [range, 1-7]; Mann-Whitney U test; P = .04).

CONCLUSION

The number of drains used after a mastectomy for breast cancer did not significantly affect the rate or amount of seromas in this study, but the use of a single drain after mastectomy was significantly associated with less discomfort and shorter postoperative hospital stay.

Use of drains in surgery: a review

Drains have been used in surgery for several years to remove body fluids thereby preventing the accumulation of serous fluid and improving wound healing. Drains may be classified as closed or open systems, and active or passive depending on their intended function. Closed vacuum drains apply negative suction in a sealed environment, producing apposition of tissues and thus promoting healing. Correct assessment of clinical indications might reduce unnecessary usage. This article will introduce the principles and practice of various types of drains and highlight the importance of understanding how surgical drains promote quality patient care.

Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies

BACKGROUND

The most common complications following body contouring surgery for massive weight loss include delayed wound healing and seroma. The authors investigated risk factors for seroma in this patient population and describe treatment strategies.

METHODS

A retrospective review of 222 patients who underwent body contouring surgery for massive weight loss from March of 1997 to December of 2005 was performed. Risk factors assessed included age, sex, medical conditions, tobacco use, body mass index, weight of skin excised, and surgery performed.

RESULTS

Within this group, there were 187 women and 35 men, with a mean age of 42 years. Weight loss was achieved by open (n = 167) or laparoscopic (n = 35) gastric bypass surgery, or diet (n = 20). Average body mass index at contouring was 33, ranging from 20 to 69. Surgical areas addressed alone or in combination included the abdomen (n = 205), thigh (n = 71), arm (n = 69), back (n = 59), and chest (n = 57). Average weight of skin excised at surgery was 9.6 lb, ranging up to 49 lb. Seroma occurred in 31 patients, placing the risk at 14 percent in this series. Seroma risk in abdominal panniculectomy was 12 percent; in circumferential belt lipectomy, the risk was 18 percent; and in thigh lift, the risk was 4 percent. On multivariate statistical analysis, the major risk factor for seroma formation was weight of skin excised, with seroma risk increasing 9 percent for each additional pound of skin excised.

CONCLUSIONS

The most important risk factor for seroma is weight of skin excised at the time of surgery. Treatment strategies include aspiration, drain placement, sclerosis, and surgery.