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

A systematic review of randomised controlled trials in breast reconstruction

BACKGROUND

For preference sensitive treatments, such as breast reconstructions, there are barriers to conducting randomised controlled trials (RCTs). The primary aims of this systematic review were to investigate what type of research questions are explored by RCTs in breast reconstruction, where have they been performed and where have they been published, and to thematise the research questions and thus create an overview of the state of the research field.

METHODS

Randomised controlled trials investigating any aspect of breast reconstructions were included. The PubMed database was searched with a pre-defined search string. Inclusion and data abstraction was performed in a pre-defined standardised fashion. For the purpose of this study, we defined key issues as comparison of categories of breast reconstruction and comparison of immediate and delayed breast reconstruction, when the thematisation was done.

RESULTS

A total of 419 abstracts were retrieved from the search. Of the 419, 310 were excluded as they were not RCTs concerning some aspect of breast reconstruction, which left us with 110 abstracts to be included in the study. The research questions of the included studies could more or less be divided into seven different themes inclusive of 2 key issues: Other issues - comparison of different categories of breast reconstruction, comparison of immediate and delayed breast reconstruction, surgical details within a category of breast reconstruction, surgical details valid for several categories of breast reconstruction, donor site management, anaesthetics, and non-surgical details. Only five studies compared key issues, and they all illustrate the challenges with RCTs in breast reconstruction.

CONCLUSIONS

A total of 110 publications based on RCTs in breast reconstruction have been published. Seven themes of research questions could be identified. Only five studies have explored the key issues. Better scientific evidence is needed for the key issues in breast reconstruction, for example by implementing a new study design in the field.

Eliminating the routine use of postoperative drain placement in patients undergoing robotic-assisted radical cystectomy with intracorporeal urinary diversion

INTRODUCTION

Perioperative management of patients undergoing radical cystectomy and urinary diversion utilizing both open and minimally invasive techniques have routinely included the use of drains in the operative field. We herein demonstrate the safety of robotic-assisted radical cystectomy (RARC) without the routine use of postoperative drains.

METHODS

Patients who underwent drainless RARC with intracorporeal urinary diversion between 2017 and 2022 at our institution were reviewed. Baseline and clinical characteristics as well as perioperative and postoperative outcomes were analyzed. The primary study outcome was incidence of postoperative urinary leak or intra-abdominal infectious collections within 90 days of RARC. A univariate and multivariable logistic regression analysis was performed to determine associations between study variables and the primary outcome.

RESULTS

Of 381 patients, 298 (78.2%) were male and median age and BMI were 68 (63, 76) and 26.2 [23.0, 29.8], respectively. Overall 30 and 90-day complication rates were 39.6% and 50.4%, respectively. Twenty-one (5.5%) patients experienced a urine leak or intra-abdominal infectious collections. Sub-group analysis of patients who experienced the primary outcome demonstrated median postoperative day of presentation was day 19, and this group required 16 total additional procedures. On multivariable logistic regression analysis, only prior radiation therapy was associated with the development of the primary outcome of urinary leak or intra-abdominal infectious collection (odds ratio: 15.12, 95% confidence interval [1.52-156.8], p = 0.02).

CONCLUSION

Drainless RARC with totally intracorporeal urinary diversion achieved competitive perioperative and complications outcomes compared to prior open and robotic series. In the context of a larger enhanced recovery after surgery protocol in RARC patients, the routine use of drains may be safely omitted.

Does the Use of Negative Pressure Wound Therapy and Postoperative Drains Impact the Development of Surgical Site Infections?: A PARITY Trial Secondary Analysis

BACKGROUND

Surgical site infections (SSIs) represent a major complication following oncologic reconstructions. Our objectives were (1) to assess whether the use of postoperative drains and/or negative pressure wound therapy (NPWT) were associated with SSIs following lower-extremity oncologic reconstruction and (2) to identify factors associated with the duration of postoperative drains and with the duration of NPWT.

METHODS

This is a secondary analysis of the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial, a multi-institution randomized controlled trial of lower-extremity oncologic reconstructions. Data were recorded regarding the use of drains alone, NPWT alone, or both NPWT and drains, including the total duration of each postoperatively. We analyzed postoperative drain duration and associations with tourniquet use, intraoperative thromboprophylaxis or antifibrinolytic use, incision length, resection length, and total operative time, through use of a linear regression model. A Cox proportional hazards model was used to evaluate the independent predictors of SSI.

RESULTS

Overall, 604 patients were included and the incidence of SSI was 15.9%. Postoperative drains alone were used in 409 patients (67.7%), NPWT alone was used in 15 patients (2.5%), and both postoperative drains and NPWT were used in 68 patients (11.3%). The median (and interquartile range [IQR]) duration of drains and of NPWT was 3 days (IQR, 2 to 5 days) and 6 days (IQR, 4 to 8 days), respectively. The use of postoperative drains alone, NPWT alone, or both drains and NPWT was not associated with SSI (p = 0.14). Increased postoperative drain duration was associated with longer operative times and no intraoperative tourniquet use, as shown on linear regression analysis (p < 0.001 and p = 0.03, respectively). A postoperative drain duration of ≥14 days (hazard ratio [HR], 3.6; 95% confidence interval [CI], 1.3 to 9.6; p = 0.01) and an operative time of ≥8 hours (HR, 4.5; 95% CI, 1.7 to 11.9; p = 0.002) were independent predictors of SSI following lower-extremity oncologic reconstruction.

CONCLUSIONS

A postoperative drain duration of ≥14 days and an operative time of ≥8 hours were independent predictors of SSI following lower-extremity oncologic reconstruction. Neither the use of postoperative drains nor the use of NPWT was a predictor of SSI. Future research is required to delineate the association of the combined use of postoperative drains and NPWT with SSI.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Modern tendencies in surgical treatment of cicatricial deformities of mammary gland

Modern tendencies in surgical treatment of cicatricial deformities of mammary gland

Using Drain-Free Flap Fixation Techniques Versus Traditional Wound Closure With Drain Placement to Prevent Seroma Formation and Its Complications in Breast Cancer Patients Undergoing Mastectomy: A Systematic Review and Meta-analysis

During the past decade, there has been some controversy related to using flap fixation techniques instead of conventional wound closure methods and drain placement during mastectomy procedures. The purpose of our study was to address this controversy using a systematic review and meta-analysis of current published literature. Nineteen studies met our inclusion criteria. Our sample population consisted of 2,956 participants divided into two groups. The study group (SG) consisted of 1,418 individuals and the control group (CG) consisted of 1,538 participants. We found there was a significant reduction in the incidence of seroma formation (odds ratio [OR] = 0.35; 95% confidence interval, CI [0.3, 0.42]; p < .000) and surgical site infection (OR = 0.65; 95% CI [0.48, 0.88]; p = .006) in the SG compared with the CG. The length of hospital stay was also significantly reduced in the SG (0.59 days; 95% CI [0.73, 0.46]; χ 2 [6, N = 502] = 52.88; p < .000) compared with the CG. The results of our study show that using a flap fixation technique after mastectomy can decrease the patient's risk for seroma formation and surgical site infection while reducing their length of hospital stay. Further studies with longer follow-up periods are warranted to evaluate long-term complications associated with using a flap fixation technique compared with using conventional wound closure techniques and drain placement.

Perioperative Risk Factors for Prolonged Blood Loss and Drainage Fluid Secretion after Breast Reconstruction

Background: Surgical breast reconstruction is an integral part of cancer treatment but must not compromise oncological safety. Patient-dependent risk factors (smoking, BMI, etc.) are said to influence perioperative outcomes and have often been investigated. Here, we analyzed independent perioperative risk factors for increased postoperative blood loss or drainage fluid volume loss and their possible impact. Methods: Patients undergoing breast reconstructions after breast cancer with either tissue expanders, definitive breast implants, or autologous breast reconstruction were analyzed. The collected data on patients’ characteristics, blood, and drainage fluid loss were correlated and statistically investigated. Results: Traditional patient-dependent risk factors did not influence blood loss or drainage volumes. On the contrary, patients with preoperative anemia had significantly higher drainage outputs compared to non-anemic patients (U = 2448.5; p = 0.0012). The administration of low molecular weight heparin showed a tendency of increased drainage output. Similar correlations could be seen in prolonged procedure time, all of which contributed to prolonged hospital stay (τb = 0.371; p < 0.00001). Conclusion: Preoperative anemia is one of the most critical factors influencing postoperative drainage fluid output. Previously assumed patient-dependent risk factors did not affect drainage output. Preoperative anemia must be monitored, and if possible, treated preoperatively to reduce postoperative morbidity.