Drainage after Modified Radical Mastectomy - A Methodological Mini-Review

Optimal Use of Drain Tubes for DIEP Flap Breast Reconstruction: Comprehensive Review

Background: Deep inferior epigastric perforator (DIEP) flap breast reconstruction is an increasingly popular technique, but controversy exists regarding the optimal use of closed suction drains (CSD) at the abdominal donor site. This narrative review synthesizes current evidence on CSD application, criteria for placement/removal, and complications in DIEP flap procedures. Alternative techniques and implications for postoperative care are also discussed. Methods: A systematic search was conducted in August 2024 across several databases to identify English language studies related to CSD use in DIEP flap breast reconstruction. Inclusion criteria consisted of original research on aspects such as CSD volume criteria, timing, complications, alternatives like progressive tension sutures, and impact on showering and patient outcomes. References from relevant papers were hand-searched. Results: The review found a lack of consensus on CSD protocols, with drainage volume triggering removal varying widely from 5 mL to 80 mL daily. While CSD may reduce seroma/hematoma formation, earlier removal (≤3 days) did not increase complications and shortened hospital stay. Progressive tension sutures show promise as an alternative, with evidence of comparable or reduced complications and improved recovery versus CSD. The safety of early showering with drains remains unclear. Conclusions: Although CSD aims to minimize postoperative complications, more rigorous randomized trials are needed to establish evidence-based practices for the timing of removal and demonstrate the efficacy of emerging drain-free techniques on patient-centered outcomes. Standardized criteria could reduce practice variability. Further research should also explore the long-term impact of drainage strategies on aesthetic and functional results.

Prospective Study to Evaluate Efficacy of Single Versus Double Drains in Breast Cancer Patients Undergoing Surgery

Seroma formation is a common sequel following modified radical mastectomy (MRM), which hinders healing, may prolong hospital stay, and cause a delay in adjuvant treatment. Closed suction drains have been used to prevent formation of seroma; however, the use of a single drain in the axilla along with draining the mastectomy flaps and axilla separately remains a topic of debate. This prospective randomized dual-arm study was conducted in the Department of Endocrine Surgery. All female patients with carcinoma breast diagnosed on core tissue biopsy, undergoing modified radical mastectomy, upfront or post neoadjuvant systemic therapy were included. Patients were randomized into two groups. In the first group, a single drain was placed in the axilla whereas in the second group, a drain each was placed below the mastectomy flaps and the axilla. Patients' particulars and the weight of the mass excised along with the operative details were documented. The volume of the drain was recorded daily. The flap drain was removed on postoperative day 5 and the axillary drain was removed when the drain volume was less than 30 mL/24 h for 2 consecutive days. The period of drain placement, volume of drainage, volume of seroma (if formed), and other complications (if any) were recorded. Patients in the single drain group had a significantly earlier drain removal time as compared to those with double drains (p = 0.01). The number of patients in whom seroma formation had occurred was more in the double drain group, but the difference was not significant. The average volume of aspirated seroma fluid was insignificantly more in the single drain group. The only other complication noticed was flap necrosis-in 5% patients of the double drain group. Total volume of drainage (p < 0.0001) and type of drain (p = 0.0208) were associated with higher rates of seroma formation, whereas BMI (p = 0.0516), weight of excised breast mass (p = 0.407), and age (p = 0.6379) were not associated with the rate of seroma formation. Outcomes in terms of drain volume or seroma formation were statistically indifferent between the two groups. Still, use of only a single axillary drain should be promoted, keeping in mind the earlier drain removal period, better patient compliance, and reduced hospital stay.

Opportunities and Challenges for Augmented Reality in Family Caregiving: Qualitative Video Elicitation Study

BACKGROUND

Although family caregivers play a critical role in care delivery, research has shown that they face significant physical, emotional, and informational challenges. One promising avenue to address some of caregivers' unmet needs is via the design of digital technologies that support caregivers' complex portfolio of responsibilities. Augmented reality (AR) applications, specifically, offer new affordances to aid caregivers as they perform care tasks in the home.

OBJECTIVE

This study explored how AR might assist family caregivers with the delivery of home-based cancer care. The specific objectives were to shed light on challenges caregivers face where AR might help, investigate opportunities for AR to support caregivers, and understand the risks of AR exacerbating caregiver burdens.

METHODS

We conducted a qualitative video elicitation study with clinicians and caregivers. We created 3 video elicitations that offer ways in which AR might support caregivers as they perform often high-stakes, unfamiliar, and anxiety-inducing tasks in postsurgical cancer care: wound care, drain care, and rehabilitative exercise. The elicitations show functional AR applications built using Unity Technologies software and Microsoft Hololens2. Using elicitations enabled us to avoid rediscovering known usability issues with current AR technologies, allowing us to focus on high-level, substantive feedback on potential future roles for AR in caregiving. Moreover, it enabled nonintrusive exploration of the inherently sensitive in-home cancer care context.

RESULTS

We recruited 22 participants for our study: 15 clinicians (eg, oncologists and nurses) and 7 family caregivers. Our findings shed light on clinicians' and caregivers' perceptions of current information and communication challenges caregivers face as they perform important physical care tasks as part of cancer treatment plans. Most significant was the need to provide better and ongoing support for execution of caregiving tasks in situ, when and where the tasks need to be performed. Such support needs to be tailored to the specific needs of the patient, to the stress-impaired capacities of the caregiver, and to the time-constrained communication availability of clinicians. We uncover opportunities for AR technologies to potentially increase caregiver confidence and reduce anxiety by supporting the capture and review of images and videos and by improving communication with clinicians. However, our findings also suggest ways in which, if not deployed carefully, AR technologies might exacerbate caregivers' already significant burdens.

CONCLUSIONS

These findings can inform both the design of future AR devices, software, and applications and the design of caregiver support interventions based on already available technology and processes. Our study suggests that AR technologies and the affordances they provide (eg, tailored support, enhanced monitoring and task accuracy, and improved communications) should be considered as a part of an integrated care journey involving multiple stakeholders, changing information needs, and different communication channels that blend in-person and internet-based synchronous and asynchronous care, illness, and recovery.

Single-port insufflation endoscopic nipple-sparing mastectomy in early breast cancer: a retrospective cohort study

Background

Breast cancer is the most common malignancy in female patients. In recent years, more and more studies have focused on how to improve the appearance and the quality of life for patients. This study aimed to compare the oncologic safety, aesthetic results, and upper extremity function between single-port insufflation endoscopic nipple-sparing mastectomy (SIE-NSM) and conventional open mastectomy (C-OM) in early-stage breast cancer treatment.

Methods

In our retrospective cohort, 285 patients with stage I and II breast cancer were categorized into the SIE-NSM group (n=71) and the C-OM group (n=214). We assessed local recurrence, distant metastasis, and upper extremity function across the two groups. The BREAST-Q scale was employed to analyze differences in aesthetic results, psychosocial well-being, and sexual health. The risk of local recurrence was evaluated using multivariable binary logistic regression, while a multivariable linear regression model gauged upper extremity function and aesthetic outcomes.

Results

Local recurrence rates between the two groups were statistically similar (1/71, 1.4% for SIE-NSM vs. 2/214, 0.9% for C-OM, P=0.735), as confirmed by the multivariable binary logistic regression analysis. Neither group exhibited distant metastases. The SIE-NSM group demonstrated higher scores in satisfaction with breasts, chest wellness, psychosocial health, and sexual well-being (P<0.001). The SIE-NSM group also exhibited superior outcomes regarding chest wall/breast pain, shoulder mobility, and daily arm usage (P<0.001). No subcutaneous effusion was reported in the SIE-NSM group, whereas the C-OM group had a 10.7% incidence rate (P=0.004).

Conclusions

SIE-NSM offers comparable oncologic safety to C-OM but provides enhanced satisfaction regarding breast appearance, physical comfort, psychosocial health, sexual health, and improved upper extremity functionality. Consequently, this innovative approach is a suitable surgical alternative for treating early-stage breast cancer.

Single vs. double drain in modified radical mastectomy: A randomized controlled trial

Objectives

It was aimed to test the hypothesis that the use of a double drain results in less seroma formation, duration of the hospital stay, surgical site infection (SSI), postoperative pain, hematoma, flap necrosis compared to a single drain in patients undergoing modified radical mastectomy.

Material and Methods

This parallel-group, single-institution randomized controlled trial was conducted at the department of surgery of our institute between April 2015 and July 2018. Women undergoing modified radical mastectomy were randomly allocated to either a single drain (n= 98) or double drain (n= 98).

Results

Both groups were comparable for baseline variables such as age, co-morbidity, BMI, and tumor characteristics. The variables of single drain yielded no better outcomes compared to double drain with estimated blood loss (101.67 ± 25.14 vs.101.67 ± 24.40, p> 0.001), drain volume (898.81 ± 116.42 vs 803.97 ± 103.22 mL, p> 0.001), duration of surgery in minutes (103.19 ± 15.96, 103.19 ± 15.93) and seroma formation (13.4% vs 6.1%, p= 0.082). However, single drain yielded less postoperative pain (mean 2.5 ± 0.70 vs 5.22 ± 5.10, p <0.000). On multivariable Cox regression analysis, single drain was associated with a lower risk of significant postoperative pain [adjusted relative risk 0.14 (95% confidence interval (CI) 0.070-0.25)] and overall complications [adjusted relative risk 0.47, (95% CI 0.26-0.86)]. On multiple linear regression, the duration of drains in the single drain group was 0.01 days less than double drain (r2= 0.00, b= 0.388, p> 0.001).

Conclusion

The use of a single drain significantly reduces postoperative discomfort and pain while demonstrating similar morbidity to the patient with two drains. We thus recommend preferential use of a single drain in modified radical mastectomy (NCT02411617).

The effects of the quality nursing mode intervention on the psychological moods, postoperative complications, and nursing satisfaction of breast cancer surgery patients

OBJECTIVE

To evaluate the influence of high-quality care on the psychological well-being, the postoperative complications, and patient satisfaction following a radical mastectomy.

METHODS

One hundred and eighteen breast cancer patients who underwent radical mastectomies from February, 2017 to May, 2019 in the Cancer Hospital of China Medical University were enrolled. Among them, 56 patients treated with regular care were included in the regular group, while the other 62 patients who underwent high-quality care were included in the high-quality group. The postoperative recoveries and complications were compared between the two groups. The visual analogue scale (VAS), the disabilities of the arm, shoulder and hand (DASH) questionnaire, the self-rating anxiety scale (SAS), the self-rating depression scale (SDS), the quality of life (QOL) assessment scale, and a patient satisfaction questionnaire were used to evaluate the degrees of pain, the upper limb recovery, the negative emotions, the QOL, the patient satisfaction and the two-year survival rate, respectively.

RESULTS

The ambulation times, the regression times of upper limb swelling, and the hospital stays in the high-quality group were remarkably shorter than they were in the regular group (P<0.05). The postoperative complications were less frequent in the high-quality group (P<0.05). The VAS scores in the high-quality group were lower than they were in the regular group at 1, 3, and 5 days after surgery, and the DASH scores in the high-quality group were lower at 1 month after discharge (P<0.05). The high-quality group showed lower SAS and SDS scores and higher QOL and patient satisfaction than the regular group (all P<0.05). There was no difference in the two-year survival rates between the two groups after the intervention (P>0.05).

CONCLUSION

High-quality care following a radical mastectomy contributes to postoperative recovery, the relief of negative emotions, the reduction of complications, as well as the enhancement of QOL and patient satisfaction, so it is worthy of clinical promotion.

[Personal preference, experience, intuition and school of surgery dominate the use of wound drainage in dermatosurgery]

Hintergrund

Die Verwendung von Drainagesystemen in der Dermatochirurgie erfolgt bislang ohne evidenzbasierte Daten. Indikationen, Komplikationen und Kontraindikationen werden traditionell von Operateur zu Operateur weitergegeben, sind jedoch bisher nicht definiert.

Methodik

Es wurde eine internetbasierte Umfrage erstellt und unter den Mitgliedern der DGDC e. V. (Deutsche Gesellschaft für Dermatochirurgie e. V.) ausgesandt. Abgefragt wurden das allgemeine Behandlungsverhalten im deutschsprachigen Raum in Bezug auf die Anwendung der Wunddrainage nach dermatologischen Operationen sowie die Nutzungsgewohnheiten und Erfahrungen der Kollegen mit Drainage-assoziierten Komplikationen.

Ergebnisse

Es haben 12,73 % der angeschriebenen DGDC-Mitglieder den Fragebogen beantwortet. Drainagen werden überwiegend im klinischen Umfeld eingesetzt, es werden alle abgefragten Drainagesysteme verwendet. Ausmaß und Komplexität des Eingriffs sind die wesentlichen Kriterien bei der Indikationsstellung. Der Einsatz von Drainagen ist abhängig vom Alter des Teilnehmers und erfolgt mehrheitlich bei Patienten, bei denen Komplikationen im postoperativen Verlauf erwartet werden (Adipositas, Nikotinabusus, Diabetiker).

Diskussion

Zusammenfassend verwendet die Mehrzahl der Teilnehmer Wunddrainagen und dies mehrheitlich intuitiv. Einheitliche fixe evidenzbasierte Parameter rund um die Verwendung von Wunddrainagen fehlen. Bei der Beurteilung der Notwendigkeit einer Wunddrainage scheint ein individuell unterschiedlich ausgeprägtes Sicherheitsbedürfnis bei den einen und „eminenzbasiertes“ Handeln bei den anderen Dermatochirurgen eine große Rolle zu spielen.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

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.

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.