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The use of closed suction drainage in patients who underwent mastectomy accelerates wound healing and is also associated with a lower incidence of wound infection, necrosis, and breakdown [ 75 , 76 ]. A study by Bourke et al. In a study by Whitfield and Rainsbury [ 79 ], no significant difference was observed between suction and closed siphon drainage on the formation of seroma.
The choice of the number of drain tubes used has been studied. Two randomized trials reported that use of multiple drains does not confer any significant advantage on either the amount or duration of seroma drainage [ 80 , 81 ]. Studies comparing the intensity of negative drain suction have shown mixed results.
In a study of 46 patients who underwent mastectomy, randomized between high vacuum drain and low vacuum drain, seroma drainage and postoperative hospital stay was longer in the low vacuum system group than that in the high vacuum system possibly because the high vacuum drain led to more efficient flap approximation to the chest wall [ 82 ].
In contrast, van Heurn and Brink [ 83 ] found that the mean volume evacuated was significantly lower from a low vacuum system, which lead to early drain removal in 76 patients who underwent axillary dissection with breast-conserving surgery.
Bonnema et al. No significant difference was observed in the volume of axillary fluid produced, drainage duration or wound complication rates between the two groups.
High vacuum drains had a higher incidence of vacuum loss but a lower incidence of leakage around the drain. Thus, no strong evidence is available to recommend high or low pressure suction to reduce seroma formation. Discharge with drain in situ Patients can be safely discharged with drains in situ with adequate patient education and coordination of inpatient and outpatient facilities, including telephone contacts [ 85 , 86 ].
Interestingly, patients who choose early discharge tend to be significantly younger, are living with another adult, and are more likely to have had breast-conserving surgery [ 88 ]. A number of studies have evaluated the effect of different days of postoperative discharges [ 86 , 88 - 92 ]. Early discharge from the hospital with the drain in situ does not appear to be associated with any untoward events [ 87 , 90 , 93 ].
Holcombe et al. However no significant decrease in seroma rates was observed with early discharge at a mean of 4.
Orr et al. Concerns expressed in the early discharge group of patients include personal care, bed posture, dressing themselves, fatigue, loneliness, pain, and worries about the wound and the arm [ 87 ].
Despite these factors, studies have shown that patient acceptance of early discharge with drains in situ remains good [ 87 , 91 ]. However, some reports have expressed mixed results and no compelling evidence points to a uniform reduction in seroma rate following early discharge with a drain in situ, although discharge within a day of surgery has been fraught with a higher rate of seroma formation.
Early drain removal It is common practice to remove drains when drainage decreases to a minimal volume mL in the preceding 24 hours to minimize seroma formation [ 96 ]. It has also been observed that drains may be safely removed after axillary dissection, if the total drainage during the first 3 days is less than mL [ 98 ].
Somers et al. No significant difference was observed with respect to drainage volume at the time of drain removal, subsequent mean number of aspirations, and time to resolution of seromas.
Parikh et al. More seroma fluid was collected in the group whose drain was left in situ longer, but no difference in the volume, number, or duration of percutaneous aspirations was observed once the drain was removed. Inwang et al. Yii et al. No significant difference in drainage at 48 hours and no significant difference in seroma frequency were observed.
Liu and McFadden [ ] removed drains at 23 hours postoperatively in 50 patients who underwent axillary lymphadenectomy. Thus, there appears to be good evidence in favor of early drain removal. No wound drainage When drainage and no drainage were compared in patients who underwent lumpectomy and axillary dissection [ 19 ], short duration closed suction drainage appeared advantageous for decreasing the incidence and degree of seroma formation and did not seem to delay early hospital discharge.
Cameron et al. Jeffrey et al. All seromas resolved clinically within 1 month or within 4 months on ultrasonographic examination. Siegel et al. Zavotsky et al. PATIENT FACTORS Although a number of surgical technique-related factors have been described to play a role in seroma formation, most patient and tumor-related factors have been shown consistently to have no significant association with seroma formation.
A number of studies have attempted to associate patient and tumour characteristics to postoperative seroma formation. Body weight [ 2 , ] and body mass index [ ] are associated with increased seroma formation, whereas no consistent association has been found between seroma formation and hormone receptor status [ 26 , ], axillary nodal status, lymph node positivity [ 18 , 20 , ] or disease stage and grade [ 18 , 26 ].
Similarly, no consistent association has been found between seroma formation and the presence of anemia, smoking, diabetes mellitus, or breast size [ 14 ]. Tumor size and location, histological type, site of the disease and specimen weight are not associated with increased seroma formation [ 26 , ]. Patient and tumor-related factors have no significant bearing on seroma formation except possibly body weight and body mass index, which seem to be directly proportional to seroma formation.
Physical closure of the dead space appears to reduce seroma rate, but studies have failed to address the issues of cosmesis, and shoulder movement restrictions and these add to the operating time. Evidence for the use of fibrin glue remains controversial. Thrombin spray, sclerotherapy and mechanical pressure do not reduce seroma drainage.
Shoulder immobilization is of no advantage to the patient, but it appears that delaying shoulder physiotherapy reduces drainage. Drains should be used, but the number of drain tubes or a low pressure system does not decrease the formation of seroma. However, low vacuum drains in the axilla result in less seroma formation, earlier drain removal and earlier discharge.
High pressure vacuum drains in the axilla may promote increased drainage due to flap irregularity and poor flap adherence. High pressure vacuum drains appear safe and acceptable to discharge many patients early with drains in situ, if adequate patient counseling and nursing support are provided.
Seroma formation can be safely considered on an outpatient basis by multiple percutaneous aspirations. Footnotes The authors declare that they have no competing interests.
References 1. Cancer statistics, CA Cancer J Clin. Post-mastectomy seroma: a new look into the aetiology of an old problem. J R Coll Surg Edinb. Surgical resection for persistent seroma, following modified radical mastectomy. World J Surg Oncol. Bryant M, Baum M.
Postoperative seroma following mastectomy and axillary dissection. Br J Surg. Epidemiology and nongenetic causes of breast cancer. Diseases of the Breast. Postmastectomy seroma. A study of the nature and origin of seroma after mastectomy. Dan Med Bull. Perioperative and postoperative tranexamic acid reduces the local wound complication rate after surgery for breast cancer.
The composition of serous fluid after axillary dissection. Eur J Surg. Tejler G, Aspegren K. Complications and hospital stay after surgery for breast cancer: a prospective study of patients. Seroma formation related to electrocautery in breast surgery: a prospective randomized trial. Electrocautery as a factor in seroma formation following mastectomy. Am J Surg. Argon-enhanced cutting and coagulation confers advantages over conventional electrocautery for mastectomy.
Eur J Surg Oncol. Say CC, Donegan W.
A biostatistical evaluation of complications from mastectomy. Surg Gynecol Obstet. Prevention of seromas following mastectomy and axillary dissection. Seroma formation following breast cancer surgery.
Breast J. A randomised study of axillary drainage and pectoral fascia preservation after mastectomy for breast cancer. Seroma formation after breast cancer surgery: incidence and predicting factors.
The use of closed suction drainage after lumpectomy and axillary node dissection for breast cancer. A prospective randomized trial. Ann Surg. Axillary node clearance: who wants to immobilize the shoulder? Morbidity after sentinel lymph node biopsy in primary breast cancer: results from a randomized controlled trial.
J Clin Oncol. Seroma formation after surgery for breast cancer. Wyman A, Rogers K. Randomized trial of laser scalpel for modified radical mastectomy. Mastectomy using ultrasonic dissection: effect on seroma formation. Seroma prevention following axillary dissection in patients with breast cancer by using ultrasound scissors: a prospective clinical study. Does LigaSure TM reduce fluid drainage in axillary dissection? A randomised prospective clinical trial.
Modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system. Arch Surg. Cost effectiveness of Ligasure Precise versus surgical clips during axillary nodal dissection for breast cancer. Flap anchoring following primary breast cancer surgery facilitates early hospital discharge and reduces costs.
Breast Care Basel ;— Orr TG. Basting the axillary flap for wounds of radical mastectomy. Din 9 Pdf. Professor, Dr Vijai K. Shukla is director of International Food Science. Provide know how for operating parameters for optimization and improving. This natural antioxidant system is 50 to 60 times more powerful than existing available.
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