Argon-enhanced cutting and coagulation confers advantages over conventional electrocautery for mastectomy

A Comparative Study Between Mastectomy Flap Quilting Sutures with Axillary Drain Versus Conventional Sutures with Axillary and Pectoral Drain in Reducing Post-Modified Radical Mastectomy Seroma Formation

The aim of this study was to compare quilting suture with axillary drain versus conventional sutures with axillary and pectoral drain on the formation of seroma after modified radical mastectomy with axillary lymph node dissection. The study was undertaken among 90 female patients with breast cancer who were candidates for modified radical mastectomy with axillary clearance. The intervention group (N = 43) with quilting and axillary drain placement and the control group (N = 33) without quilting with axillary and pectoral drain placement. All the patients were followed up for complications pertaining to this procedure. There were no significant differences between the two groups with regard to demographic characteristics, comorbidities, pre-operative chemotherapy, post-operative pathological findings, lymph node involvement or clinical staging. The incidence of seroma formation on follow-up was significantly lower in the intervention group than that in the control group (23% versus 58%; p < 0.05) whereas there was no significant difference with respect to flap necrosis, superficial skin necrosis and wound gaping between the two groups. Furthermore, it took a shorter duration for seroma to resolve in the intervention group (4 days versus 9 days; p < 0.001) with a smaller duration of hospital stay (4 days versus 9 days; p < 0.001). The use of quilting sutures for flap fixation in order to obliterate dead space post-modified radical mastectomy with placement of axillary drain significantly reduced seroma formation along with shorter duration of wound drainage and a smaller hospital stay with only slightly increased operative time. Therefore, we recommend quilting of flap as a routine step after mastectomy.

The effect of fibrin glue on the postoperative lymphatic leakage after D2-lymphadenectomy and gastrectomy in patients with gastric cancer

Introduction

Disturbance in the lymphatic drainage during D2 dissection is associated with significant morbidity. We aimed to assess the effect of fibrin glue on the reduction of postoperative lymphatic leakage.

Methods

Prospective double-blinded randomized clinical trial with forty patients in each study arm was conducted. All patients diagnosed, staged, and became a candidate for D2 dissection based on NCCN 2019 guideline for gastric cancer. The intervention group received 1 cc of IFABOND® applied to the surgical bed.

Results

The difference between study groups regarding age, gender, tumor stage was insignificant. (All p-values > 0.05). The median daily drainage volume was 120 ml with the first and the third interquartile being 75 and 210 ml, respectively for the intervention group. The control group had median, the first, and the third interquartile of 350, 290, and 420 ml. The difference between daily drainage volumes was statistically significant (p-value < 0.001). The length of hospital stay was significantly different between the two groups. Notably, the intervention group was discharged sooner (median of 7 Vs 9 days, p-value: 0.001).

Conclusion

This study showed the possible role of fibrin glue in reducing postoperative lymphatic leakage after gastrectomy and D2 dissection.

Registration trial number: IRCT20200710048071N1, 2020.08.16

The Efficacy of Fibrin Sealant Patches in Reducing the Incidence of Lymphatic Morbidity After Radical Lymphadenectomy: A Meta-Analysis

BACKGROUND

Although pivotal in the oncological management of most tumors, radical lymphadenectomy is associated with a significant number of lymphatic complications. The aim of this meta-analysis is to evaluate the efficacy of fibrinogen sealant patches in reducing lymphadenectomy-related postoperative complications.

METHODS/MATERIALS

The electronic databases PubMed, Medline, and Scopus were searched using the terms "lymphadenectomy" or "lymph node dissection" and "TachoSil," "TachoComb," or "fibrin sealant patch." Series evaluating the efficacy of fibrin-thrombin collagen sealant patches were included in the meta-analysis.

RESULTS

Overall, 26 studies were retrieved through the literature search. Ten studies including 720 patients met selection criteria. The use of fibrin-thrombin sealant patches to the sole scope of reducing lymphadenectomy-related complications significantly reduced the incidence of lymphocele, symptomatic lymphocele, the need of percutaneous drainage procedures, the volume of lymph drained, and the duration of the drainage. No effect on wound and/or lymphocele infection was noted.

CONCLUSIONS

This meta-analysis demonstrates that the use of fibrin-thrombin sealant patches significantly reduces the total volume of lymph drained, the duration of the drainage, the incidence of lymphocele and symptomatic lymphocele, and the need for postoperative percutaneous drainage procedures. Its use does not affect the incidence of wound or lymphocele infections.

Outcome Evaluation after 2023 Nipple-Sparing Mastectomies: Our Experience

BACKGROUND

Although quadrantectomy and lumpectomy help diminish the psychological and physical devastation inflicted, mastectomy is still elected in 20 to 30 percent of breast cancers. Although initially inciting controversy over heightened risk of local recurrences, recent studies maintain that nipple-sparing mastectomy can be used in any patient qualifying for total mastectomy and also improves aesthetic and psychologic outcomes. The manner in which mastectomy influences reconstructive implant outcomes has been documented by several groups. This report details the authors' experience performing nipple-sparing mastectomy with immediate implant-based breast reconstruction, focusing attention on patient characteristics and aspects of surgical mastectomy that influence reconstruction outcomes. The aim of the study was to examine various issues, such as surgical access, mode of tissue dissection, and flap thickness, clearly linked to development of complications and poor results.

METHODS

A retrospective study was conducted, analyzing patients with breast cancer. An external three-surgeon panel served to generate average scores for predefined parameters. Based on total scores, outcomes were designated excellent, good, moderate, or poor.

RESULTS

The authors' cohort included 1647 patients. Overall, 2023 nipple-sparing mastectomies were performed, including bilateral procedures in 376 patients. After a minimum follow-up period of 12 months, the authors' cohort was stratified by scored outcomes. Significant impact of body mass index, skin incision, flap thickness, and grade of ptosis has been demonstrated.

CONCLUSIONS

The authors' data suggest that proper patient selection and well-executed operations are mandatory to limit complications. They also indicate that aesthetic outcome is clearly dependent on surgical proficiency and some patient characteristics.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

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.

Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction

Skin sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is not only oncologically safe but provides also significant benefits both cosmetically and functionally. The superiority of this technique can only be fully established, however, by developing a framework for minimising complications. The present study seeks to elucidate the key factors affecting outcome.

METHODS

Data for all skin sparing mastectomies with immediate autologous and implant based reconstructions, performed in a three year period (2006-2008) was retrospectively collated. Complications were classified into major and minor. Patients were excluded who had flap loss due to vascular complications.

RESULTS

The total number analysed was 151. 17.2% had major complications, 23% had minor and 61% had no complications. The Wise and the "tennis" incision had significantly higher rates of wound dehiscence when compared with the periareolar incision (p = 0.025, p = 0.098). There was no significant difference between diathermy or blade dissection techniques, or the use of subcutaneous adrenaline infiltration. Increasing BMI was associated with increased skin flap necrosis and wound dehiscence, and an excised breast mass of greater than 750 g and a sternal notch to nipple length of greater than 26 cm are associated as well with increased flap-related complications (p = 0.0002, p = 0.0049).

CONCLUSION

Factors such as Wise pattern and tennis racquet incision, BMI and breast mass and sternal notch to nipple length adversely affect skin sparing mastectomy flap morbidity. These factors should be factored in to patient selection and operative planning especially for obese and large breasted women undergoing skin sparing mastectomy with immediate breast reconstruction.

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.

Klippel Trenauney syndrome and reduction mammoplasty

Klippel Trenauney syndrome is a rare congenital abnormality that includes extremity hypertrophy. We report an unusual case of breast asymmetry due to unilateral chest and limb hypertrophy and describe successful unilateral breast reduction. We highlight the potential problems of surgery within this group and a management approach to minimise complications.

Ultracision reduces acute blood loss but not seroma formation after mastectomy and axillary dissection: a pilot study

Various surgical cutting coagulation devices are used during breast surgery. A pilot study was set up to determine if ultracision would reduce complications of intraoperative blood loss and seroma formation. Acute blood loss was significantly reduced in the harmonic scalpel group in comparison with the control group. However, there was little difference between the two groups in terms of hospital stay, volume or duration of postoperative drainage or subsequent aspiration of seroma.

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.

Seroma following breast cancer surgery

BACKGROUND

Seroma is a common problem following breast cancer surgery causing patient discomfort and prolongation of hospital stay.

METHODS

This manuscript reviews the relevant literature obtained by an extensive search of the medline database. In addition papers were also derived from the reference lists of retrieved articles.

RESULTS AND CONCLUSION

The advantages and disadvantages of the various methods to deal with seroma are discussed. Based on this an individual patient based policy can be formulated.

Might patients benefit from oral iron therapy following operative treatment of breast carcinoma?

AIMS

To assess the changes in blood haemoglobin concentration and serum iron indices as a consequence of breast operations for cancer in our unit.

METHODS

Haematological parameters were measured in 109 patients undergoing definitive operative treatment for breast carcinoma.

RESULTS

A mean fall in haemoglobin of 2.1 g (P=0.001) occurred in patients undergoing mastectomy and axillary clearance and of 1.3 g (P<0.001) in patients undergoing wide local excision and axillary clearance. The transferrin saturation (serum iron/total iron binding capacity) in both sets of patients after surgery fell on average to levels that would be expected to impair subsequent red cell production.

CONCLUSION

The changes in iron indices that occurred were unrelated to the degree of blood loss consistent with a possible inflammatory effect of the operation. Oral iron therapy is unlikely to be of benefit to operative breast patients if they have normal pre-operative iron stores.