RJ
Uploaded byReynaldo Joson
PPT, PDF13,693 views

Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bl

The document discusses mastectomy morbidities, focusing on seroma, infection, and bleeding. It provides data from a Philippine hospital showing that hematoma, infection, and seroma are the most common morbidities seen. It also summarizes surveys of surgeons which found seroma, hematoma, and infection or wound issues within the top 5 morbidities. The document discusses preventing and treating seroma by avoiding fluid accumulation under surgical flaps and continuing drainage until fluid stops accumulating. It recommends closed tube drainage and needle aspiration based on evidence and consensus among surgeons.

Embed presentation

Downloaded 101 times
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Reynaldo O. Joson, MD, MS Surg Collator / Researcher / Rapporteur Division of Surgical Oncology UPM Centennial Professorial Chair (2008)
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Objectives: 1) To share UPM-PGH Department of Surgery’s experience with morbidities following modified radical mastectomy (MRM) for patients with breast cancer; 2) To provide updates on clinical management (prevention, detection, and treatment) of common morbidities following MRM.
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Contents: 1) Concept of morbidities following MRM; 2) Common morbidities following MRM (experience from PGH; Division’s consultants; literature); 3) How to prevent, detect, and treat common morbidities following MRM (Division consultants’ evidence-process based recommendations).
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Methodologies: 1) Statistics and data gathering (local and foreign); 2) Review of literature on the concept and how to prevent, detect, and treat; 3) Consensus-gathering among Division’s consultants (Drs. Dofitas, de la Peňa, Cabaluna, Kho, Bisquera, Espiritu, Lim, Uy, de la Paz, and Joson)
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Reynaldo O. Joson, MD, MS Surg Collator / Researcher / Rapporteur For Division of Surgical Oncology
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Concept Operational Definition of Mastectomy Morbidities
Mastectomy Morbidities: Concept and Operational Definition Morbidities occurring as a result of modified radical mastectomy [MRM] (total mastectomy and axillary dissection). Undesirable effects short of death or mortality. Complications, side-effects, and adverse events may be used interchangeably with “morbidities” as long as no mortality has occurred.
Mastectomy Morbidities: Concept and Operational Definition (derived from survey of Division’s consultants) Some mastectomy morbidities are INEVITABLE, such as the incisional scar and incisional pain CONTROLLABLE / PREVENTABLE TO A CERTAIN DEGREE, such as seroma, numbness of medial aspect of arm, and lymphedema HIGHLY CONTROLLABLE / PREVENTABLE, such as flap necrosis, wound dehiscence, infection, and bleeding / hematoma
Mastectomy Morbidities: Concept and Operational Definition (derived from survey of 10 Division’s consultants) Mastectomy morbidities Inevitable Controllable to a certain degree Highly controllable / preventable Seroma 7 3 Bleeding / hematoma 10 Infection 10 Flap necrosis 10 Dehiscence 10 Numbness 4 6 Chronic incisional pain 5 5
Mastectomy Morbidities: Concept and Operational Definition (derived from survey of 10 Division’s consultants) Mastectomy morbidities Inevitable Controllable to a certain degree Highly controllable / preventable Hypertrophic scar - keloids 3 7 Dog ears 4 6 Lymphedema 6 4 Local recurrence 2 8
Mastectomy Morbidities: Concept and Operational Definition (derived from survey of 10 Division’s consultants) Mastectomy morbidities Inevitable Controllable to a certain degree Highly controllable / preventable Hypertrophic scar - keloids 3 7 Dog ears 4 6 Lymphedema 6 4 Local recurrence 2 8 √ √ √
Mastectomy Morbidities: Concept and Operational Definition (derived from survey of 10 Division’s consultants) Mastectomy morbidities Inevitable Controllable to a certain degree Highly controllable / preventable Hypertrophic scar - keloids 3 7 Dog ears 4 6 Lymphedema 6 4 Local recurrence 2 8 √ √ √ ALWAYS control / prevent AS MUCH AS POSSIBLE. ALWAYS inform patients of risk PREOPERATIVELY!
Mastectomy Morbidities: Scope of Lecture Limited to operative morbidities, those directly related to the operation of a modified radical mastectomy. SEROMA, INFECTION, HEMATOMA, FLAP NECROSIS, LATERAL DOG-EAR DEFORMITY Anesthetic and other types of morbidities such as those associated with patient and pharmacologic factors excluded.
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Common morbidities following MRM (statistics on frequency) Experience from PGH Division’s consultants Literature
Common Morbidities Following MRM (PGH GS1 data – 04-07) MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535) Seroma - - 5 (1.3%) 5 (0.9%) Graft loss - - - 2 (0.3%) SSSI - - 6 (1.5%) 6 (1.1%) Axillary vein injury - - - 2 (0.3%) Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%) Flap Necrosis - 1 (0.2%) - 2 (0.3%) Pneumothorax 2 (0.3%) - - - HAP - 2 (0.5%) - - AMI - - - 1(0.1%)
Common Morbidities Following MRM (PGH GS1 data – 04-07) MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535) Seroma - - 5 (1.3%) 5 (0.9%) Graft loss - - - 2 (0.3%) SSSI - - 6 (1.5%) 6 (1.1%) Axillary vein injury - - - 2 (0.3%) Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%) Flap Necrosis - 1 (0.2%) - 2 (0.3%) Note 1: Hematoma, infection, and seroma are the relatively more common mastectomy morbidities as seen in the PGH GSI data.
Common Morbidities Following MRM (PGH GS1 data – 04-07) MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535) Seroma - - 5 (1.3%) 5 (0.9%) Graft loss - - - 2 (0.3%) SSSI - - 6 (1.5%) 6 (1.1%) Axillary vein injury - - - 2 (0.3%) Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%) Flap Necrosis - 1 (0.2%) - 2 (0.3%) Note 2: NO reports of sensory loss, chronic pain, dehiscence and lymphedema (as seen in consultants’ experience as reflected in the survey of Division’s consultants).
Common Morbidities Following MRM Surveyed Data from GSI Consultants on Top 3-5 Mastectomy Morbidities – July 10, 2008 (1 – being most common) Consultant 1 2 3 4 5 1 seroma hematoma wound infection flap necrosis chronic incisional pain 2 seroma hematoma flap necrosis wound infection lymphedema of the arm 3 seroma wound infection wound dehiscence flap necrosis hematoma 4 sensory loss, median aspect of arm seroma hematoma 5 seroma hematoma infection
Common Morbidities Following MRM Surveyed Data from GSI Consultants on Top 3-5 Mastectomy Morbidities – July 10, 2008 (1 – being most common) Consultant 1 2 3 4 5 6 seroma flap necrosis (edge) hematoma wound infection wound dehiscence 7 seroma infection hematoma flap necrosis 8 seroma chronic incisional pain hematoma wound infection flap necrosis 9 seroma infection hematoma flap necrosis 10 numbness, arm seroma hematoma wound infection flap necrosis
Common Morbidities Following MRM Surveyed Data from GSI Consultants on Top 3-5 Mastectomy Morbidities – July 10, 2008 (1 – being most common) Consultant 1 2 3 4 5 6 seroma flap necrosis (edge) hematoma wound infection wound dehiscence 7 seroma infection hematoma flap necrosis 8 seroma chronic incisional pain hematoma wound infection flap necrosis 9 seroma infection hematoma flap necrosis 10 numbness, arm seroma hematoma wound infection flap necrosis Note: With reports of sensory loss, chronic pain, dehiscence and lymphedema as morbidities (NOT seen in PGH GSI data).
Common Morbidities Following MRM Surveyed Data from GSI Consultants on Top 3-5 Mastectomy Morbidities – July 10, 2008 (1 – being most common) Consultant 1 2 3 4 5 6 seroma flap necrosis (edge) hematoma wound infection wound dehiscence 7 seroma infection hematoma flap necrosis 8 seroma chronic incisional pain hematoma Wound infection flap necrosis 9 seroma infection hematoma flap necrosis 10 numbness, arm seroma hematoma wound infection flap necrosis Note: Seroma, hematoma, and infection are within the top 5 most common mastectomy morbidities.
Common Morbidities Following MRM (Review of Literature) Because it is a peripheral soft tissue organ, many wound complications related to breast procedures are relatively minor and frequently are managed on an outpatient basis. It therefore is difficult to establish accurate incidence rates for these events. Ref: Complications in Breast Surgery. Angelique F. Vitug, Lisa A. Newman. Surg Clin N Am (2007) 87:431–451.
Common morbidities following MRM (Review of Literature) Incidence rates Overall morbidity 30% Seroma 10 to 80%* Infection 1% to 20% [3.8% - meta-ana > 2500 pts]** Hematoma 2-10% Ref: Vitug AF, Newman LA. Complications in Breast Surgery. Surg Clin N Am 2007; 87:431–451. *Pogson CJ, Adwani A, Ebbs SR. Seroma following breast cancer surgery. Eur J Surg Oncol 2003; 29(9):711–7. **Platt R, Zucker JR, Zaleznik DF, et al. Perioperative antibiotic prophylaxis and wound infection following breast surgery. J Antimicrob Chemother 1993;31(Suppl B):43–8.
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) How to prevent, detect, and treat common morbidities following MRM Survey of Consultants’ Practices and Recommendations Review of Literature Consensus-gathering Evidence-process-based Recommendations
Postmastectomy Seroma Physical Examination Signs for Pattern Recognition Bulge under the flaps with signs suggestive of presence of fluid such as fluctuancy and fluid wave
Postmastectomy Seroma Diagnostic Procedures (if needed) and Positive Findings Needle aspiration – yellowish, nonsanguinous fluid
Postmastectomy Seroma Prevention Treatment Seroma Avoid fluid accumulation under the flaps Continual drainage until fluid accumulation stops
Mastectomy Morbidities: Prevention and Treatment Management Principles Prevention Treatment Seroma Avoid fluid accumulation under the flaps Continual drainage until fluid accumulation stops GS1 Division’s Recommended Practice: Closed tube suction drain at axillary space Medial drain indicated if there is a significant cavity after laying down of flaps prior to wound repair Drain removed if output is less than 50 cc past 24 hours (assumption: tube functional) Drain may stay as long as needed if NO indication to remove it such as dysfunctionality and infection.
Postmastectomy Seroma Prevention Treatment Seroma Avoid fluid accumulation under the flaps Continual drainage until fluid accumulation stops
Mastectomy Morbidities: Prevention and Treatment Management Principles Prevention Treatment Seroma Avoid fluid accumulation under the flaps Continual drainage until fluid accumulation stops GSI Division’s Recommended Practice: Needle aspiration of seroma until fluid accumulation stops. Usually weekly or as required by patient’s symptoms. NOT DAILY.
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) Recommendation: Repeated Aspirations How frequent? Daily or based on patient symptoms? Conclusion: DAILY aspiration of symptomatic seroma did NOT result in swifter resolution! Anand R, Skinner R, Dennison G, Pain J. A prospective randomised trial of two treatments for wound seroma after breast surgery. Euro J Surg Oncol, 2003; 28(6):620 - 622 RCT [36 patients]
Postmastectomy Seroma Process - Pathophysiology (collection of serum in a cavity) Reabsorption / re- establishment of lymphatic channels Cavity for fluid accumulation Transected lymphatic vessels cause serum fluid entry into cavity
Postmastectomy Seroma Prevention and Treatment Management Principles Reabsorption / re- establishment of lymphatic channels Cavity for fluid accumulation Transected lymphatic vessels cause serum fluid entry into cavity Minimize transection! Just have to wait! Minimize and avoid if possible! Minimize and avoid!
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) N=90 patients Incidence of seroma Duration of seroma (until resolution) NO drainage 97% 16% (2-3 weeks) 84% (4 weeks)2-day drainage 86% Prolonged closed- suction drainage (10 days) 73% Talbot ML, Magarey CJ. Reduced use of drains following axillary lymphadenectomy for breast cancer. ANZ J Surg 2002;72(7):488–90. Drainage is advised to avoid seroma! (unless there is NO cavity!)
Postmastectomy Seroma Prevention and Treatment Management Principles Reabsorption / re- establishment of lymphatic channels Cavity for fluid accumulation Transected lymphatic vessels cause serum fluid entry into cavity Minimize transection! Just have to wait! Minimize and avoid if possible! OBLITERATION Chemical / Mechanical Means!
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) OBLITERATION OF CAVITY by Chemical Manuevers Sclerosing agents (tetracycline) Bovin thrombin Fibrin glue, sealants, patches Steroids LIMITED SUCCESS / INCONSISTENT RESULTS COST AVAILABILITY
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) OBLITERATION OF CAVITY by Mechanical Means Axillary padding External compression External garment do NOT significantly reduce incidence of seroma!
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) Obliteration of Cavity by Mechanical Means Axillary padding does NOT significantly reduce incidence of seroma. RCT [135 patients] Incidence of seroma aspiration Axillary padding (4 days) 2.9 Catheter drainage with no padding 1.8 Classe J, Dupre P, Francois T, et al. Axillary padding as an alternative to closed suction drain for ambulatory axillary lymphadenectomy. Arch Surg 2002;137:169–73.
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) External compression does NOT significantly reduce incidence of seroma. RCT N Amount of drainage (P = 0.48) Number of days with drain (P = 0.69) No. of seroma aspiration (P <0.01) Catheter drainage with compression dressing (4 days) 66 490 cc 6.4 2.9 Catheter drainage with no compression dressing 69 517 cc 6.1 1.8 O' Hea BJ, Ho MN, Petrek JA: External compression dressing versus standard dressing after axillary lymphadenectomy. Am J Surg 1999, 177:450-453.
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) External garment does NOT significantly reduce incidence of seroma. Chen CY, Hoe AL, Wong CY. The effect of a pressure garment on post-surgical drainage and seroma formation in breast cancer patients. Singapore Med J. 1998 Sep;39(9):412-5. RCT- Use of a pressure garment NO improvement in post-operative drainage “One of the patients in the pressure garment group was unable to tolerate the warmth and discontinued wearing the garment in the third post-operative day.”
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) Axillary padding, external garment, and external compression do NOT significantly reduce incidence of seroma. Chen CY, Hoe AL, Wong CY. The effect of a pressure garment on post-surgical drainage and seroma formation in breast cancer patients. Singapore Med J. 1998 Sep;39(9):412-5. RCT- Use of a pressure garment NO improvement in post-operative drainage “One of the patients in the pressure garment group was unable to tolerate the warmth and discontinued wearing the garment in the third post-operative day.” RECOMMENDATION - DON’T USE. NOT RELIABLE! FOR PATIENT’S COMFORT!
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) Obliteration of dead space by mechanical means Suture flap fixation surgical technique for securing flaps to underlying tissues to close the dead space with sutures
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) Obliteration of dead space by mechanical means Suture flap fixation RCT [39 patients] Incidence of seroma Suture flap fixation (with drain) 5 (25%) Catheter drainage only 17 (85%) Coveney EC, O’Dwyer PJ, Geraghty JG, O’Higgins NJ. Effect of closing dead space on seroma formation after mastectomy–a prospective randomized clinical trial. Eur J Surg Oncol 1993;19:143–6.
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles (Review of Literature) Obliteration of dead space by mechanical means Suture flap fixation RCT [190 patients] Incidence of seroma Suture flap fixation (no drain) 61 Catheter drainage 55 Purushotham AD, McLatchie E, Young D, George WD, Stallard S, Doughty J, et al. Randomized clinical trial of no wound drains and early discharge in the treatment of women with breast cancer. Br J Surg 2002;89:286–92.
Mastectomy Morbidities: SEROMA Prevention and Treatment Management Principles Division’s Recommended Practice: Drain removed if output is less than 50 cc past 24 hours (assumption: tube functional) Drain may stay as long as needed if NO indication to remove it such as dysfunctionality and infection.
Postmastectomy Infection Physical Examination Signs for Pattern Recognition Erythema on the skin; pus Diagnostic Procedures (if needed) and Positive Findings Needle aspiration – pus
Mastectomy Morbidities: Prevention and Treatment Management Principles (Focus: Seroma, Infection, Bleeding) Prevention Treatment Infection Aseptic technique Antibiotics, if warranted Antibiotics during cellulitis stage Drainage with or without antibiotics for abscess
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) Prophylactic antibiotics in MRM DISPARATE RESULTS !!! But MOST show positive effect!!!!!
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) Positive effect -single dose of preoperative antibiotic (usually a cephalosporin, administered approximately 30min before surgery) will effectively reduce infection rate by 40% or more - Platt et al. meta-analysis (with antibiotics used in high risk cases) reduced the infection rate by 38%! Platt R, Zaleznik DF, Hopkins CC, et al. Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med 1990;322(3):153–60. Platt R, Zucker JR, Zaleznik DF, et al. Prophylaxis against wound infection following herniorrhaphy or breast surgery. J Infect Dis 1992;166(3):556–60. Platt R, Zucker JR, Zaleznik DF, et al. Perioperative antibiotic prophylaxis and wound infection following breast surgery. J Antimicrob Chemother 1993;31(Suppl B):43–8. Tran CL, Langer S, Broderick-Villa G, et al. Does reoperation predispose to postoperative wound infection in women undergoing operation for breast cancer? Am Surg 2003;69(10): 852–6.
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) NEGATIVE EFFECT Wagman et al. – cephalosporin – placebo 118 breast cancer patients (5% vs 8%). Gupta et al. – amoxicillin/clavulinic acid – placebo (17.7% vs 18.8%) Wagman LD, Tegtmeier B, Beatty JD, et al. A prospective, randomized double-blind study of the use of antibiotics at the time of mastectomy. Surg Gynecol Obstet 1990; 170(1):12–6. Gupta R, Sinnett D, Carpenter R, et al. Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery. Eur J Surg Oncol 2000;26(4):363–6.
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) http://www.pcs.org.ph/?s=documents EVIDENCE – BASED CLINICAL PRACTICE GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS IN ELECTIVE SURGICAL PROCEDURES 2000 BREAST SURGERY Antibiotic prophylaxis is recommended for the following elective breast surgical procedures: (Grade A Recommendation) Mastectomy Axillary lymph node dissection Reduction mammoplasty Excisional biopsy and lumpectomy
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) http://www.pcs.org.ph/?s=documents EVIDENCE – BASED CLINICAL PRACTICE GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS IN ELECTIVE SURGICAL PROCEDURES 2000 BREAST SURGERY Cefazolin 2 grams IV (Grade A Recommendation) single dose (Grade C Recommendation) Cefuroxime 1.5 grams IV single dose is recommended as an alternative (Grade C Recommendation)
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) M Cunningham, F. B., K Handscomb (2006). "Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery." Cochrane Database of Systematic Reviews . Art. No.: CD005360. DOI: 10.1002/14651858.CD005360.pub2. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005360. DOI: 10.1002/14651858.CD005360.pub2. (Issue 2).
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) M Cunningham, F. B., K Handscomb (2006). "Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery." Cochrane Database of Systematic Reviews. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. There is no current consensus on prophylactic antibiotic use in breast cancer surgery.
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) M Cunningham, F. B., K Handscomb (2006). "Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery." Cochrane Database of Systematic Reviews. Main results Six studies - pre-operative antibiotic compared with no antibiotic or placebo. Pooling of the results demonstrated that prophylactic antibiotics significantly reduce the incidence of surgical site infection for patients undergoing breast cancer surgery without reconstruction (pooled RR 0.66, 95% CI, 0.48 to 0.89).
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) M Cunningham, F. B., K Handscomb (2006). "Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery." Cochrane Database of Systematic Reviews. The review is NOT able to establish which antibiotic is most appropriate.
Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) Use of prophylactic antibiotics in MRM Because of disparate results, and in an attempt to minimize cost, many clinicians have adopted the practice of limiting antibiotic prophylaxis to high-risk patients! GSI Division conducting RCT study at the moment!
Mastectomy Morbidities: Infection GSI Division consultants’ recommendations on Prevention Aseptic technique Prophylactic antibiotics only in high-risk patients Diabetes mellitus (>200mg/dL) Obesity (BMI >40) With other co-morbidity
Postmastectomy Hematoma Physical Examination Signs for Pattern Recognition Bulge under the flaps with discoloration on the skin (red, blue, violaceous) suggestive of blood accumulation Diagnostic Procedures (if needed) and Positive Findings Needle aspiration – blood
Mastectomy Morbidities: Prevention and Treatment Management Principles (Focus: Seroma, Infection, Bleeding) Prevention Treatment Bleeding / hematoma Meticulous hemostasis during dissection and prior to wound closure Control of bleeding Evacuation of hematoma
Mastectomy Morbidities: HEMATOMA / BLEEDING Prevention and Treatment Management Principles (Review of Literature) NOT ABLE to find literature on METICULOUS HEMOSTASIS during mastectomy!
Mastectomy Morbidities: HEMATOMA / BLEEDING Prevention and Treatment Management Principles Division consultants’ recommendations on Prevention Meticulous hemostasis during dissection Ligate transected blood vessels ≥ 2mm in diameter Cauterize fully transected vessels which will not be ligated Ligate and cauterize transected blood vessels right away Strict and on the spot hemostasis during axillary dissection Checking of hemostasis prior to wound closure
Postmastectomy Flap Necrosis Physical Examination Signs for Pattern Recognition Blackish to black discoloration on the flap
Mastectomy Morbidities: Prevention and Treatment Management Principles FLAP NECROSIS Prevention Treatment Flap necrosis NOT too thin a flap About 0.5 to 1 cm thick subcutaneous layer on the flap (for vascular supply) Debridement
Postmastectomy Lateral Dog-Ear Deformity (Redundant axillary fat pad) Frequent, particularly in patients with large body habitus and large breast Unsightly and source of long-term discomfort Need to prevent as much as possible.
Mastectomy Morbidities: Lateral Dog-ear Deformity Tear-drop shaped incision Mirza M, S. K., Fortes-Mayer K. and W. M. H. (2003). "Tear-drop incision for mastectomy to avoid dog-ear deformity." Ann R Coll Surg Engl. 85(2):131.
Mastectomy Morbidities: Lateral Dog-ear Deformity Sliding-suturing (Devalia Technique) Devalia H, Chaudhry A, Rainsbury RM, Minakaran N, Banerjee D. An oncoplastic technique to reduce the formation of lateral 'dog-ears' after mastectomy. Int Semin Surg Oncol. 2007 Dec 17; 4:29.
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Objectives: 1) To share UPM-PGH Department of Surgery’s experience with morbidities following modified radical mastectomy (MRM) for patients with breast cancer; 2) To provide updates on clinical management (prevention, detection, and treatment) of common morbidities following MRM.
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Contents: 1) Concept of morbidities following MRM; 2) Common morbidities following MRM (experience from PGH; Division’s consultants; literature); 3) How to prevent, detect, and treat common morbidities following MRM (Division consultants’ evidence-process based recommendations).
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Methodologies: 1) Statistics and data gathering (local and foreign); 2) Review of literature on the concept and how to prevent, detect, and treat; 3) Consensus-gathering among Division’s consultants (Drs. Dofitas, de la Peňa, Cabaluna, Kho, Bisquera, Espiritu, Lim, Uy, de la Paz, and Joson)
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Reynaldo O. Joson, MD, MS Surg Email: rjoson@maniladoctors.com.ph Cell no. 0918-8040304 THANK YOU FOR YOUR KIND ATTENTION!
Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Reynaldo O. Joson, MD, MS Surg Collator / Researcher / Rapporteur Division of Surgical Oncology UPM Centennial Professorial Chair (2008) THANK YOU FOR YOUR KIND ATTENTION!

More Related Content

PPTX
Peripheral artery disease
byDr Dinesh Pandey
 
PPTX
Presentation1.pptx, radiological imaging of benign bone tumour.
byAbdellah Nazeer
 
PPTX
Chest Auscultation
bymedlearn
 
PPTX
Sympathectomy for pheripheral arterial disease present role
byAravind Endamu
 
PPTX
Superior mesenteric artery syndrome
byAbhilash Cheriyan
 
PPTX
Open Pyelolithotomy
byEko indra
 
PDF
Surgical short case stoma
byAR Muhamad Na'im
 
PPTX
Post operative complications
byMinhajuddin khurram
 
Peripheral artery disease
byDr Dinesh Pandey
 
Presentation1.pptx, radiological imaging of benign bone tumour.
byAbdellah Nazeer
 
Chest Auscultation
bymedlearn
 
Sympathectomy for pheripheral arterial disease present role
byAravind Endamu
 
Superior mesenteric artery syndrome
byAbhilash Cheriyan
 
Open Pyelolithotomy
byEko indra
 
Surgical short case stoma
byAR Muhamad Na'im
 
Post operative complications
byMinhajuddin khurram
 

What's hot

PPTX
Neurovascular Assessment
byGianne Gregorio
 
PPTX
Neoadjuvant chemotherapy ver 2.0
byVivek Verma
 
PPTX
Seminar on stamm, janeway & PE gastrostomy
byBiswajit Deka
 
PPTX
Dnb clearing is not a rocket science
byHimabindu Adusumillii
 
PPTX
radiographic analysis of bone tumors
byNilesh Kucha
 
PPTX
Presentation1.pptx, interpretation of x ray on bone tumour.
byAbdellah Nazeer
 
PPTX
Consent in surgical patient
byrashree-singh
 
PPTX
Imaging in scurvy
byVikram Patil
 
PPTX
Open right hemicolectomy/ step by step/ operative surgery
bySelvaraj Balasubramani
 
PPT
Fat embolism syndrome
byAftab Hussain
 
PPTX
LAP LEFT HEMICOLECTOMY-STEP BY STEP Operative Surgery.pptx
bySelvaraj Balasubramani
 
PPTX
Enterocutaneous fistula
byFidelSimba
 
PPTX
Chondrosarcoma
byDr Thouseef Abdul Majeed
 
PPTX
Chronic venous insufficiency
bySeng Hui Chua
 
PDF
Acute Limb Ischemia
bySun Yai-Cheng
 
PPTX
Spinal shock
bysnich
 
PPTX
"Osteosarcoma"- Case Presentation
byShaheed Suhrawardy Medical College
 
PPTX
Splenectomy
bymithun benjamin
 
PPTX
pre and post operative management of paediatric Splenectomy patients
byVernon Pashi
 
PPTX
Right hemicolectomy
byWarujpong Boonkum
 
Neurovascular Assessment
byGianne Gregorio
 
Neoadjuvant chemotherapy ver 2.0
byVivek Verma
 
Seminar on stamm, janeway & PE gastrostomy
byBiswajit Deka
 
Dnb clearing is not a rocket science
byHimabindu Adusumillii
 
radiographic analysis of bone tumors
byNilesh Kucha
 
Presentation1.pptx, interpretation of x ray on bone tumour.
byAbdellah Nazeer
 
Consent in surgical patient
byrashree-singh
 
Imaging in scurvy
byVikram Patil
 
Open right hemicolectomy/ step by step/ operative surgery
bySelvaraj Balasubramani
 
Fat embolism syndrome
byAftab Hussain
 
LAP LEFT HEMICOLECTOMY-STEP BY STEP Operative Surgery.pptx
bySelvaraj Balasubramani
 
Enterocutaneous fistula
byFidelSimba
 
Chondrosarcoma
byDr Thouseef Abdul Majeed
 
Chronic venous insufficiency
bySeng Hui Chua
 
Acute Limb Ischemia
bySun Yai-Cheng
 
Spinal shock
bysnich
 
"Osteosarcoma"- Case Presentation
byShaheed Suhrawardy Medical College
 
Splenectomy
bymithun benjamin
 
pre and post operative management of paediatric Splenectomy patients
byVernon Pashi
 
Right hemicolectomy
byWarujpong Boonkum
 

Similar to Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bl

PPTX
Surgical management of carcinoma breast and breast reconstruction procedures
byJonathan Abish David
 
PDF
Mastectomy and its physiotherapy managment
byShubham Singh
 
PPT
Br Ca- MRM the lect.ppt
byHamedRashad1
 
PPTX
Mastectomy
bychaurasia028
 
PPT
Preventing Surgical Complications of Modified Radical Mastectomy
byReynaldo Joson
 
PDF
Mastectomy
byUrvishWaghela
 
PPTX
Mastectomía
byMiguel Orellana Falcones
 
PPTX
Mastectomy and Breast Cancer
byULVAN OZAD
 
PPTX
Seroma presentation
byabhishak bhattacharjee
 
PPTX
Pre and post of care for mastectomy
byGianne Gregorio
 
PPT
Preventing Surgical Complications of Modified Radical Mastectomy - ROJoson - ...
byReynaldo Joson
 
PDF
MASTECTOMY AND ITS NURSING MANAGEMENT.pdf
byDolisha Warbi
 
PPTX
Mastectomy physiotherapy management notes.pptx
byzmh89v7mgc
 
PDF
Lymph taping and seroma formation post breast cancer
bydiasmirella
 
PDF
Wound drainage-information-booklet-pue1201
bymita1304
 
PDF
Impact of dead space closure and lymph vessel ligation during MRM on Post-ope...
byDr./ Ihab Samy
 
PPTX
Surgical thesis protocol formation ppt.pptx
byspd7327
 
PPTX
mastectomy techniqucccccccccccccffe.pptx
bymekuriatadesse
 
DOCX
Mastectomy.docx
byMahir Mohamet
 
PDF
Novel technique of mastectomy for breast cancer presenting as an abscess
byKETAN VAGHOLKAR
 
Surgical management of carcinoma breast and breast reconstruction procedures
byJonathan Abish David
 
Mastectomy and its physiotherapy managment
byShubham Singh
 
Br Ca- MRM the lect.ppt
byHamedRashad1
 
Mastectomy
bychaurasia028
 
Preventing Surgical Complications of Modified Radical Mastectomy
byReynaldo Joson
 
Mastectomy
byUrvishWaghela
 
Mastectomía
byMiguel Orellana Falcones
 
Mastectomy and Breast Cancer
byULVAN OZAD
 
Seroma presentation
byabhishak bhattacharjee
 
Pre and post of care for mastectomy
byGianne Gregorio
 
Preventing Surgical Complications of Modified Radical Mastectomy - ROJoson - ...
byReynaldo Joson
 
MASTECTOMY AND ITS NURSING MANAGEMENT.pdf
byDolisha Warbi
 
Mastectomy physiotherapy management notes.pptx
byzmh89v7mgc
 
Lymph taping and seroma formation post breast cancer
bydiasmirella
 
Wound drainage-information-booklet-pue1201
bymita1304
 
Impact of dead space closure and lymph vessel ligation during MRM on Post-ope...
byDr./ Ihab Samy
 
Surgical thesis protocol formation ppt.pptx
byspd7327
 
mastectomy techniqucccccccccccccffe.pptx
bymekuriatadesse
 
Mastectomy.docx
byMahir Mohamet
 
Novel technique of mastectomy for breast cancer presenting as an abscess
byKETAN VAGHOLKAR
 

More from Reynaldo Joson

PPTX
ROJoson PEP Talk: How to Live a Life with Threat for Cancer Development, Recu...
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: Symptom-Sign-Based Breast Cancer Surveillance - How I Usual...
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: Breast Cancer Surveillance after Definitive Treatment
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: October Breast Cancer Awareness Month - What to be Aware of...
byReynaldo Joson
 
PPTX
Management Algorithm for Women with Breast Complaints for Basic Physicians an...
byReynaldo Joson
 
PPTX
October Breast Cancer Awareness - What to be Aware of - Part 2 - Diagnostic T...
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: October Breast Cancer Awareness Month - What to be Aware of...
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: Do ALL Operations Need Antibiotics?
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: Patient Story: Short Suffering in an Advanced Pancreatic Ca...
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: Cancer Journey Sharing Among ROJoson Cancer Crusaders
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: Beware of New Year Eve's Health Dangers - 2025
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: Why Laypeople Hesitant to Use Tap Water in Wound Cleaning
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: October Breast Cancer Awareness Month - What Is It? 2025
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: What / Who is a General Surgeon in the Philippines?
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: ROJoson Cancer Crusaders and Club - Who, What and How
byReynaldo Joson
 
PPTX
ROJoson Orientation and Introduction - UPCM-PGH LU7 SGD - 2025
byReynaldo Joson
 
PPTX
Introduction - 38th Cancer Crusaders Club Annual Christmas Get-Together Virtu...
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: Can Wounds Be Wet and How to Clean Them
byReynaldo Joson
 
PPTX
ROJoson PEP Talk: Dangerous to Swallow Santol Seeds
byReynaldo Joson
 
PPTX
ROJoson-PEP-Talk-GOITER-Sa-Loob-o-Sa-Labas-A-Layfolk-Descriptor-A-Clarification
byReynaldo Joson
 
ROJoson PEP Talk: How to Live a Life with Threat for Cancer Development, Recu...
byReynaldo Joson
 
ROJoson PEP Talk: Symptom-Sign-Based Breast Cancer Surveillance - How I Usual...
byReynaldo Joson
 
ROJoson PEP Talk: Breast Cancer Surveillance after Definitive Treatment
byReynaldo Joson
 
ROJoson PEP Talk: October Breast Cancer Awareness Month - What to be Aware of...
byReynaldo Joson
 
Management Algorithm for Women with Breast Complaints for Basic Physicians an...
byReynaldo Joson
 
October Breast Cancer Awareness - What to be Aware of - Part 2 - Diagnostic T...
byReynaldo Joson
 
ROJoson PEP Talk: October Breast Cancer Awareness Month - What to be Aware of...
byReynaldo Joson
 
ROJoson PEP Talk: Do ALL Operations Need Antibiotics?
byReynaldo Joson
 
ROJoson PEP Talk: Patient Story: Short Suffering in an Advanced Pancreatic Ca...
byReynaldo Joson
 
ROJoson PEP Talk: Cancer Journey Sharing Among ROJoson Cancer Crusaders
byReynaldo Joson
 
ROJoson PEP Talk: Beware of New Year Eve's Health Dangers - 2025
byReynaldo Joson
 
ROJoson PEP Talk: Why Laypeople Hesitant to Use Tap Water in Wound Cleaning
byReynaldo Joson
 
ROJoson PEP Talk: October Breast Cancer Awareness Month - What Is It? 2025
byReynaldo Joson
 
ROJoson PEP Talk: What / Who is a General Surgeon in the Philippines?
byReynaldo Joson
 
ROJoson PEP Talk: ROJoson Cancer Crusaders and Club - Who, What and How
byReynaldo Joson
 
ROJoson Orientation and Introduction - UPCM-PGH LU7 SGD - 2025
byReynaldo Joson
 
Introduction - 38th Cancer Crusaders Club Annual Christmas Get-Together Virtu...
byReynaldo Joson
 
ROJoson PEP Talk: Can Wounds Be Wet and How to Clean Them
byReynaldo Joson
 
ROJoson PEP Talk: Dangerous to Swallow Santol Seeds
byReynaldo Joson
 
ROJoson-PEP-Talk-GOITER-Sa-Loob-o-Sa-Labas-A-Layfolk-Descriptor-A-Clarification
byReynaldo Joson
 

Recently uploaded

PPTX
SPS_PE_LAB 2_Liquid Operation-Centrifugation.pptx
bysupriyabhagwatsps
 
PPTX
Differential Diagnosis OF PERIAPICAL LESION.pptx
byvijit17
 
PPTX
Transport of Oxygen& CO2.pptx by dr ambareesha
byDr K Ambareesha Goud PhD
 
PPTX
Journal Abstract Presentation (Neurology & Cardiovascular system)
byManoj Khadka
 
PDF
Vernal Keratoconjunctivitis (VKC) & Trachoma- Clinical Features, Diagnosis, &...
bySamikshaRai22
 
PPTX
Hepatitis presentation for adult peoples.
bymotbayhonewunetu
 
PPTX
NEUROBIOLOGY OF AUTISM SPECTRUM DISORDER
byDr Hari Ram Sedai
 
PDF
RETINAL VEIN OCCLUSION; CRVO & BRVO types, pathophysiology, diagnosis & manag...
bySamikshaRai22
 
PPTX
EVALUATION OF CATARACT BY DR. SURBHI THAKUR .pptx
byadvicesurbhi
 
PPTX
B SCAN . TECHNIQUES , PROBE POSITIONS , INDICATIONS
byDr Aarushi Choudhary
 
PPTX
ELISA PPT in detail enzyme linked immunosorbent assay
byROHIT PATEL
 
PPTX
Chronic Viral Hepatitis HEP B HEP C HEP D
byNAWEEN KUMAR
 
PPTX
Structural elucidation of Menthol by uv vis ir nmr mass
byswathireddy6585
 
PDF
Femoral Triangle-Prof.Dr.N.Mugunthan KMMC Medical College, Muttom.pdf
byKanyakumari Medical Mission Research Center, Muttom
 
PDF
Dyes/ Stain Used In Ophthalmology - Clinical uses, Indication & Side effects....
bySamikshaRai22
 
PPTX
Pharmacology and Toxicology Multiple Choice Questions (MCQs) Part 3
byVanarajRabari
 
PDF
Malke Heiman - A Medical Assistant
byMalke Heiman
 
PPTX
COGNITION IN DEPRESSION
byDr Hari Ram Sedai
 
PPTX
A critical review on Parpati kalpana .pptx
byDr. Vaishnavi B R
 
PPTX
Concept of Shodhana in Rasashastra PPT.pptx
byDr. Vaishnavi B R
 
SPS_PE_LAB 2_Liquid Operation-Centrifugation.pptx
bysupriyabhagwatsps
 
Differential Diagnosis OF PERIAPICAL LESION.pptx
byvijit17
 
Transport of Oxygen& CO2.pptx by dr ambareesha
byDr K Ambareesha Goud PhD
 
Journal Abstract Presentation (Neurology & Cardiovascular system)
byManoj Khadka
 
Vernal Keratoconjunctivitis (VKC) & Trachoma- Clinical Features, Diagnosis, &...
bySamikshaRai22
 
Hepatitis presentation for adult peoples.
bymotbayhonewunetu
 
NEUROBIOLOGY OF AUTISM SPECTRUM DISORDER
byDr Hari Ram Sedai
 
RETINAL VEIN OCCLUSION; CRVO & BRVO types, pathophysiology, diagnosis & manag...
bySamikshaRai22
 
EVALUATION OF CATARACT BY DR. SURBHI THAKUR .pptx
byadvicesurbhi
 
B SCAN . TECHNIQUES , PROBE POSITIONS , INDICATIONS
byDr Aarushi Choudhary
 
ELISA PPT in detail enzyme linked immunosorbent assay
byROHIT PATEL
 
Chronic Viral Hepatitis HEP B HEP C HEP D
byNAWEEN KUMAR
 
Structural elucidation of Menthol by uv vis ir nmr mass
byswathireddy6585
 
Femoral Triangle-Prof.Dr.N.Mugunthan KMMC Medical College, Muttom.pdf
byKanyakumari Medical Mission Research Center, Muttom
 
Dyes/ Stain Used In Ophthalmology - Clinical uses, Indication & Side effects....
bySamikshaRai22
 
Pharmacology and Toxicology Multiple Choice Questions (MCQs) Part 3
byVanarajRabari
 
Malke Heiman - A Medical Assistant
byMalke Heiman
 
COGNITION IN DEPRESSION
byDr Hari Ram Sedai
 
A critical review on Parpati kalpana .pptx
byDr. Vaishnavi B R
 
Concept of Shodhana in Rasashastra PPT.pptx
byDr. Vaishnavi B R
 

Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bl

  • 1.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Reynaldo O. Joson, MD, MS Surg Collator / Researcher / Rapporteur Division of Surgical Oncology UPM Centennial Professorial Chair (2008)
  • 2.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Objectives: 1) To share UPM-PGH Department of Surgery’s experience with morbidities following modified radical mastectomy (MRM) for patients with breast cancer; 2) To provide updates on clinical management (prevention, detection, and treatment) of common morbidities following MRM.
  • 3.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Contents: 1) Concept of morbidities following MRM; 2) Common morbidities following MRM (experience from PGH; Division’s consultants; literature); 3) How to prevent, detect, and treat common morbidities following MRM (Division consultants’ evidence-process based recommendations).
  • 4.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Methodologies: 1) Statistics and data gathering (local and foreign); 2) Review of literature on the concept and how to prevent, detect, and treat; 3) Consensus-gathering among Division’s consultants (Drs. Dofitas, de la Peňa, Cabaluna, Kho, Bisquera, Espiritu, Lim, Uy, de la Paz, and Joson)
  • 5.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Reynaldo O. Joson, MD, MS Surg Collator / Researcher / Rapporteur For Division of Surgical Oncology
  • 6.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Concept Operational Definition of Mastectomy Morbidities
  • 7.
    Mastectomy Morbidities: Concept andOperational Definition Morbidities occurring as a result of modified radical mastectomy [MRM] (total mastectomy and axillary dissection). Undesirable effects short of death or mortality. Complications, side-effects, and adverse events may be used interchangeably with “morbidities” as long as no mortality has occurred.
  • 8.
    Mastectomy Morbidities: Concept andOperational Definition (derived from survey of Division’s consultants) Some mastectomy morbidities are INEVITABLE, such as the incisional scar and incisional pain CONTROLLABLE / PREVENTABLE TO A CERTAIN DEGREE, such as seroma, numbness of medial aspect of arm, and lymphedema HIGHLY CONTROLLABLE / PREVENTABLE, such as flap necrosis, wound dehiscence, infection, and bleeding / hematoma
  • 9.
    Mastectomy Morbidities: Concept andOperational Definition (derived from survey of 10 Division’s consultants) Mastectomy morbidities Inevitable Controllable to a certain degree Highly controllable / preventable Seroma 7 3 Bleeding / hematoma 10 Infection 10 Flap necrosis 10 Dehiscence 10 Numbness 4 6 Chronic incisional pain 5 5
  • 10.
    Mastectomy Morbidities: Concept andOperational Definition (derived from survey of 10 Division’s consultants) Mastectomy morbidities Inevitable Controllable to a certain degree Highly controllable / preventable Hypertrophic scar - keloids 3 7 Dog ears 4 6 Lymphedema 6 4 Local recurrence 2 8
  • 11.
    Mastectomy Morbidities: Concept andOperational Definition (derived from survey of 10 Division’s consultants) Mastectomy morbidities Inevitable Controllable to a certain degree Highly controllable / preventable Hypertrophic scar - keloids 3 7 Dog ears 4 6 Lymphedema 6 4 Local recurrence 2 8 √ √ √
  • 12.
    Mastectomy Morbidities: Concept andOperational Definition (derived from survey of 10 Division’s consultants) Mastectomy morbidities Inevitable Controllable to a certain degree Highly controllable / preventable Hypertrophic scar - keloids 3 7 Dog ears 4 6 Lymphedema 6 4 Local recurrence 2 8 √ √ √ ALWAYS control / prevent AS MUCH AS POSSIBLE. ALWAYS inform patients of risk PREOPERATIVELY!
  • 13.
    Mastectomy Morbidities: Scope ofLecture Limited to operative morbidities, those directly related to the operation of a modified radical mastectomy. SEROMA, INFECTION, HEMATOMA, FLAP NECROSIS, LATERAL DOG-EAR DEFORMITY Anesthetic and other types of morbidities such as those associated with patient and pharmacologic factors excluded.
  • 14.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Common morbidities following MRM (statistics on frequency) Experience from PGH Division’s consultants Literature
  • 15.
    Common Morbidities FollowingMRM (PGH GS1 data – 04-07) MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535) Seroma - - 5 (1.3%) 5 (0.9%) Graft loss - - - 2 (0.3%) SSSI - - 6 (1.5%) 6 (1.1%) Axillary vein injury - - - 2 (0.3%) Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%) Flap Necrosis - 1 (0.2%) - 2 (0.3%) Pneumothorax 2 (0.3%) - - - HAP - 2 (0.5%) - - AMI - - - 1(0.1%)
  • 16.
    Common Morbidities FollowingMRM (PGH GS1 data – 04-07) MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535) Seroma - - 5 (1.3%) 5 (0.9%) Graft loss - - - 2 (0.3%) SSSI - - 6 (1.5%) 6 (1.1%) Axillary vein injury - - - 2 (0.3%) Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%) Flap Necrosis - 1 (0.2%) - 2 (0.3%) Note 1: Hematoma, infection, and seroma are the relatively more common mastectomy morbidities as seen in the PGH GSI data.
  • 17.
    Common Morbidities FollowingMRM (PGH GS1 data – 04-07) MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535) Seroma - - 5 (1.3%) 5 (0.9%) Graft loss - - - 2 (0.3%) SSSI - - 6 (1.5%) 6 (1.1%) Axillary vein injury - - - 2 (0.3%) Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%) Flap Necrosis - 1 (0.2%) - 2 (0.3%) Note 2: NO reports of sensory loss, chronic pain, dehiscence and lymphedema (as seen in consultants’ experience as reflected in the survey of Division’s consultants).
  • 18.
    Common Morbidities FollowingMRM Surveyed Data from GSI Consultants on Top 3-5 Mastectomy Morbidities – July 10, 2008 (1 – being most common) Consultant 1 2 3 4 5 1 seroma hematoma wound infection flap necrosis chronic incisional pain 2 seroma hematoma flap necrosis wound infection lymphedema of the arm 3 seroma wound infection wound dehiscence flap necrosis hematoma 4 sensory loss, median aspect of arm seroma hematoma 5 seroma hematoma infection
  • 19.
    Common Morbidities FollowingMRM Surveyed Data from GSI Consultants on Top 3-5 Mastectomy Morbidities – July 10, 2008 (1 – being most common) Consultant 1 2 3 4 5 6 seroma flap necrosis (edge) hematoma wound infection wound dehiscence 7 seroma infection hematoma flap necrosis 8 seroma chronic incisional pain hematoma wound infection flap necrosis 9 seroma infection hematoma flap necrosis 10 numbness, arm seroma hematoma wound infection flap necrosis
  • 20.
    Common Morbidities FollowingMRM Surveyed Data from GSI Consultants on Top 3-5 Mastectomy Morbidities – July 10, 2008 (1 – being most common) Consultant 1 2 3 4 5 6 seroma flap necrosis (edge) hematoma wound infection wound dehiscence 7 seroma infection hematoma flap necrosis 8 seroma chronic incisional pain hematoma wound infection flap necrosis 9 seroma infection hematoma flap necrosis 10 numbness, arm seroma hematoma wound infection flap necrosis Note: With reports of sensory loss, chronic pain, dehiscence and lymphedema as morbidities (NOT seen in PGH GSI data).
  • 21.
    Common Morbidities FollowingMRM Surveyed Data from GSI Consultants on Top 3-5 Mastectomy Morbidities – July 10, 2008 (1 – being most common) Consultant 1 2 3 4 5 6 seroma flap necrosis (edge) hematoma wound infection wound dehiscence 7 seroma infection hematoma flap necrosis 8 seroma chronic incisional pain hematoma Wound infection flap necrosis 9 seroma infection hematoma flap necrosis 10 numbness, arm seroma hematoma wound infection flap necrosis Note: Seroma, hematoma, and infection are within the top 5 most common mastectomy morbidities.
  • 22.
    Common Morbidities FollowingMRM (Review of Literature) Because it is a peripheral soft tissue organ, many wound complications related to breast procedures are relatively minor and frequently are managed on an outpatient basis. It therefore is difficult to establish accurate incidence rates for these events. Ref: Complications in Breast Surgery. Angelique F. Vitug, Lisa A. Newman. Surg Clin N Am (2007) 87:431–451.
  • 23.
    Common morbidities followingMRM (Review of Literature) Incidence rates Overall morbidity 30% Seroma 10 to 80%* Infection 1% to 20% [3.8% - meta-ana > 2500 pts]** Hematoma 2-10% Ref: Vitug AF, Newman LA. Complications in Breast Surgery. Surg Clin N Am 2007; 87:431–451. *Pogson CJ, Adwani A, Ebbs SR. Seroma following breast cancer surgery. Eur J Surg Oncol 2003; 29(9):711–7. **Platt R, Zucker JR, Zaleznik DF, et al. Perioperative antibiotic prophylaxis and wound infection following breast surgery. J Antimicrob Chemother 1993;31(Suppl B):43–8.
  • 24.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) How to prevent, detect, and treat common morbidities following MRM Survey of Consultants’ Practices and Recommendations Review of Literature Consensus-gathering Evidence-process-based Recommendations
  • 25.
    Postmastectomy Seroma Physical Examination Signs forPattern Recognition Bulge under the flaps with signs suggestive of presence of fluid such as fluctuancy and fluid wave
  • 26.
    Postmastectomy Seroma Diagnostic Procedures (if needed)and Positive Findings Needle aspiration – yellowish, nonsanguinous fluid
  • 27.
    Postmastectomy Seroma Prevention Treatment Seroma Avoidfluid accumulation under the flaps Continual drainage until fluid accumulation stops
  • 28.
    Mastectomy Morbidities: Preventionand Treatment Management Principles Prevention Treatment Seroma Avoid fluid accumulation under the flaps Continual drainage until fluid accumulation stops GS1 Division’s Recommended Practice: Closed tube suction drain at axillary space Medial drain indicated if there is a significant cavity after laying down of flaps prior to wound repair Drain removed if output is less than 50 cc past 24 hours (assumption: tube functional) Drain may stay as long as needed if NO indication to remove it such as dysfunctionality and infection.
  • 29.
    Postmastectomy Seroma Prevention Treatment Seroma Avoidfluid accumulation under the flaps Continual drainage until fluid accumulation stops
  • 30.
    Mastectomy Morbidities: Preventionand Treatment Management Principles Prevention Treatment Seroma Avoid fluid accumulation under the flaps Continual drainage until fluid accumulation stops GSI Division’s Recommended Practice: Needle aspiration of seroma until fluid accumulation stops. Usually weekly or as required by patient’s symptoms. NOT DAILY.
  • 31.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) Recommendation: Repeated Aspirations How frequent? Daily or based on patient symptoms? Conclusion: DAILY aspiration of symptomatic seroma did NOT result in swifter resolution! Anand R, Skinner R, Dennison G, Pain J. A prospective randomised trial of two treatments for wound seroma after breast surgery. Euro J Surg Oncol, 2003; 28(6):620 - 622 RCT [36 patients]
  • 32.
    Postmastectomy Seroma Process - Pathophysiology (collectionof serum in a cavity) Reabsorption / re- establishment of lymphatic channels Cavity for fluid accumulation Transected lymphatic vessels cause serum fluid entry into cavity
  • 33.
    Postmastectomy Seroma Prevention andTreatment Management Principles Reabsorption / re- establishment of lymphatic channels Cavity for fluid accumulation Transected lymphatic vessels cause serum fluid entry into cavity Minimize transection! Just have to wait! Minimize and avoid if possible! Minimize and avoid!
  • 34.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) N=90 patients Incidence of seroma Duration of seroma (until resolution) NO drainage 97% 16% (2-3 weeks) 84% (4 weeks)2-day drainage 86% Prolonged closed- suction drainage (10 days) 73% Talbot ML, Magarey CJ. Reduced use of drains following axillary lymphadenectomy for breast cancer. ANZ J Surg 2002;72(7):488–90. Drainage is advised to avoid seroma! (unless there is NO cavity!)
  • 35.
    Postmastectomy Seroma Prevention andTreatment Management Principles Reabsorption / re- establishment of lymphatic channels Cavity for fluid accumulation Transected lymphatic vessels cause serum fluid entry into cavity Minimize transection! Just have to wait! Minimize and avoid if possible! OBLITERATION Chemical / Mechanical Means!
  • 36.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) OBLITERATION OF CAVITY by Chemical Manuevers Sclerosing agents (tetracycline) Bovin thrombin Fibrin glue, sealants, patches Steroids LIMITED SUCCESS / INCONSISTENT RESULTS COST AVAILABILITY
  • 37.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) OBLITERATION OF CAVITY by Mechanical Means Axillary padding External compression External garment do NOT significantly reduce incidence of seroma!
  • 38.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) Obliteration of Cavity by Mechanical Means Axillary padding does NOT significantly reduce incidence of seroma. RCT [135 patients] Incidence of seroma aspiration Axillary padding (4 days) 2.9 Catheter drainage with no padding 1.8 Classe J, Dupre P, Francois T, et al. Axillary padding as an alternative to closed suction drain for ambulatory axillary lymphadenectomy. Arch Surg 2002;137:169–73.
  • 39.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) External compression does NOT significantly reduce incidence of seroma. RCT N Amount of drainage (P = 0.48) Number of days with drain (P = 0.69) No. of seroma aspiration (P <0.01) Catheter drainage with compression dressing (4 days) 66 490 cc 6.4 2.9 Catheter drainage with no compression dressing 69 517 cc 6.1 1.8 O' Hea BJ, Ho MN, Petrek JA: External compression dressing versus standard dressing after axillary lymphadenectomy. Am J Surg 1999, 177:450-453.
  • 40.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) External garment does NOT significantly reduce incidence of seroma. Chen CY, Hoe AL, Wong CY. The effect of a pressure garment on post-surgical drainage and seroma formation in breast cancer patients. Singapore Med J. 1998 Sep;39(9):412-5. RCT- Use of a pressure garment NO improvement in post-operative drainage “One of the patients in the pressure garment group was unable to tolerate the warmth and discontinued wearing the garment in the third post-operative day.”
  • 41.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) Axillary padding, external garment, and external compression do NOT significantly reduce incidence of seroma. Chen CY, Hoe AL, Wong CY. The effect of a pressure garment on post-surgical drainage and seroma formation in breast cancer patients. Singapore Med J. 1998 Sep;39(9):412-5. RCT- Use of a pressure garment NO improvement in post-operative drainage “One of the patients in the pressure garment group was unable to tolerate the warmth and discontinued wearing the garment in the third post-operative day.” RECOMMENDATION - DON’T USE. NOT RELIABLE! FOR PATIENT’S COMFORT!
  • 42.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) Obliteration of dead space by mechanical means Suture flap fixation surgical technique for securing flaps to underlying tissues to close the dead space with sutures
  • 43.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) Obliteration of dead space by mechanical means Suture flap fixation RCT [39 patients] Incidence of seroma Suture flap fixation (with drain) 5 (25%) Catheter drainage only 17 (85%) Coveney EC, O’Dwyer PJ, Geraghty JG, O’Higgins NJ. Effect of closing dead space on seroma formation after mastectomy–a prospective randomized clinical trial. Eur J Surg Oncol 1993;19:143–6.
  • 44.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles (Review of Literature) Obliteration of dead space by mechanical means Suture flap fixation RCT [190 patients] Incidence of seroma Suture flap fixation (no drain) 61 Catheter drainage 55 Purushotham AD, McLatchie E, Young D, George WD, Stallard S, Doughty J, et al. Randomized clinical trial of no wound drains and early discharge in the treatment of women with breast cancer. Br J Surg 2002;89:286–92.
  • 45.
    Mastectomy Morbidities: SEROMA Preventionand Treatment Management Principles Division’s Recommended Practice: Drain removed if output is less than 50 cc past 24 hours (assumption: tube functional) Drain may stay as long as needed if NO indication to remove it such as dysfunctionality and infection.
  • 46.
    Postmastectomy Infection Physical Examination Signs forPattern Recognition Erythema on the skin; pus Diagnostic Procedures (if needed) and Positive Findings Needle aspiration – pus
  • 47.
    Mastectomy Morbidities: Preventionand Treatment Management Principles (Focus: Seroma, Infection, Bleeding) Prevention Treatment Infection Aseptic technique Antibiotics, if warranted Antibiotics during cellulitis stage Drainage with or without antibiotics for abscess
  • 48.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) Prophylactic antibiotics in MRM DISPARATE RESULTS !!! But MOST show positive effect!!!!!
  • 49.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) Positive effect -single dose of preoperative antibiotic (usually a cephalosporin, administered approximately 30min before surgery) will effectively reduce infection rate by 40% or more - Platt et al. meta-analysis (with antibiotics used in high risk cases) reduced the infection rate by 38%! Platt R, Zaleznik DF, Hopkins CC, et al. Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med 1990;322(3):153–60. Platt R, Zucker JR, Zaleznik DF, et al. Prophylaxis against wound infection following herniorrhaphy or breast surgery. J Infect Dis 1992;166(3):556–60. Platt R, Zucker JR, Zaleznik DF, et al. Perioperative antibiotic prophylaxis and wound infection following breast surgery. J Antimicrob Chemother 1993;31(Suppl B):43–8. Tran CL, Langer S, Broderick-Villa G, et al. Does reoperation predispose to postoperative wound infection in women undergoing operation for breast cancer? Am Surg 2003;69(10): 852–6.
  • 50.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) NEGATIVE EFFECT Wagman et al. – cephalosporin – placebo 118 breast cancer patients (5% vs 8%). Gupta et al. – amoxicillin/clavulinic acid – placebo (17.7% vs 18.8%) Wagman LD, Tegtmeier B, Beatty JD, et al. A prospective, randomized double-blind study of the use of antibiotics at the time of mastectomy. Surg Gynecol Obstet 1990; 170(1):12–6. Gupta R, Sinnett D, Carpenter R, et al. Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery. Eur J Surg Oncol 2000;26(4):363–6.
  • 51.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) http://www.pcs.org.ph/?s=documents EVIDENCE – BASED CLINICAL PRACTICE GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS IN ELECTIVE SURGICAL PROCEDURES 2000 BREAST SURGERY Antibiotic prophylaxis is recommended for the following elective breast surgical procedures: (Grade A Recommendation) Mastectomy Axillary lymph node dissection Reduction mammoplasty Excisional biopsy and lumpectomy
  • 52.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) http://www.pcs.org.ph/?s=documents EVIDENCE – BASED CLINICAL PRACTICE GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS IN ELECTIVE SURGICAL PROCEDURES 2000 BREAST SURGERY Cefazolin 2 grams IV (Grade A Recommendation) single dose (Grade C Recommendation) Cefuroxime 1.5 grams IV single dose is recommended as an alternative (Grade C Recommendation)
  • 53.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) M Cunningham, F. B., K Handscomb (2006). "Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery." Cochrane Database of Systematic Reviews . Art. No.: CD005360. DOI: 10.1002/14651858.CD005360.pub2. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005360. DOI: 10.1002/14651858.CD005360.pub2. (Issue 2).
  • 54.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) M Cunningham, F. B., K Handscomb (2006). "Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery." Cochrane Database of Systematic Reviews. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. There is no current consensus on prophylactic antibiotic use in breast cancer surgery.
  • 55.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) M Cunningham, F. B., K Handscomb (2006). "Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery." Cochrane Database of Systematic Reviews. Main results Six studies - pre-operative antibiotic compared with no antibiotic or placebo. Pooling of the results demonstrated that prophylactic antibiotics significantly reduce the incidence of surgical site infection for patients undergoing breast cancer surgery without reconstruction (pooled RR 0.66, 95% CI, 0.48 to 0.89).
  • 56.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) M Cunningham, F. B., K Handscomb (2006). "Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery." Cochrane Database of Systematic Reviews. The review is NOT able to establish which antibiotic is most appropriate.
  • 57.
    Mastectomy Morbidities: INFECTION Preventionand Treatment Management Principles (Review of Literature) Use of prophylactic antibiotics in MRM Because of disparate results, and in an attempt to minimize cost, many clinicians have adopted the practice of limiting antibiotic prophylaxis to high-risk patients! GSI Division conducting RCT study at the moment!
  • 58.
    Mastectomy Morbidities: Infection GSI Divisionconsultants’ recommendations on Prevention Aseptic technique Prophylactic antibiotics only in high-risk patients Diabetes mellitus (>200mg/dL) Obesity (BMI >40) With other co-morbidity
  • 59.
    Postmastectomy Hematoma Physical Examination Signs forPattern Recognition Bulge under the flaps with discoloration on the skin (red, blue, violaceous) suggestive of blood accumulation Diagnostic Procedures (if needed) and Positive Findings Needle aspiration – blood
  • 60.
    Mastectomy Morbidities: Preventionand Treatment Management Principles (Focus: Seroma, Infection, Bleeding) Prevention Treatment Bleeding / hematoma Meticulous hemostasis during dissection and prior to wound closure Control of bleeding Evacuation of hematoma
  • 61.
    Mastectomy Morbidities: HEMATOMA/ BLEEDING Prevention and Treatment Management Principles (Review of Literature) NOT ABLE to find literature on METICULOUS HEMOSTASIS during mastectomy!
  • 62.
    Mastectomy Morbidities: HEMATOMA/ BLEEDING Prevention and Treatment Management Principles Division consultants’ recommendations on Prevention Meticulous hemostasis during dissection Ligate transected blood vessels ≥ 2mm in diameter Cauterize fully transected vessels which will not be ligated Ligate and cauterize transected blood vessels right away Strict and on the spot hemostasis during axillary dissection Checking of hemostasis prior to wound closure
  • 63.
    Postmastectomy Flap Necrosis Physical Examination Signsfor Pattern Recognition Blackish to black discoloration on the flap
  • 64.
    Mastectomy Morbidities: Preventionand Treatment Management Principles FLAP NECROSIS Prevention Treatment Flap necrosis NOT too thin a flap About 0.5 to 1 cm thick subcutaneous layer on the flap (for vascular supply) Debridement
  • 65.
    Postmastectomy Lateral Dog-Ear Deformity (Redundantaxillary fat pad) Frequent, particularly in patients with large body habitus and large breast Unsightly and source of long-term discomfort Need to prevent as much as possible.
  • 66.
    Mastectomy Morbidities: Lateral Dog-earDeformity Tear-drop shaped incision Mirza M, S. K., Fortes-Mayer K. and W. M. H. (2003). "Tear-drop incision for mastectomy to avoid dog-ear deformity." Ann R Coll Surg Engl. 85(2):131.
  • 67.
    Mastectomy Morbidities: Lateral Dog-earDeformity Sliding-suturing (Devalia Technique) Devalia H, Chaudhry A, Rainsbury RM, Minakaran N, Banerjee D. An oncoplastic technique to reduce the formation of lateral 'dog-ears' after mastectomy. Int Semin Surg Oncol. 2007 Dec 17; 4:29.
  • 68.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Objectives: 1) To share UPM-PGH Department of Surgery’s experience with morbidities following modified radical mastectomy (MRM) for patients with breast cancer; 2) To provide updates on clinical management (prevention, detection, and treatment) of common morbidities following MRM.
  • 69.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Contents: 1) Concept of morbidities following MRM; 2) Common morbidities following MRM (experience from PGH; Division’s consultants; literature); 3) How to prevent, detect, and treat common morbidities following MRM (Division consultants’ evidence-process based recommendations).
  • 70.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Methodologies: 1) Statistics and data gathering (local and foreign); 2) Review of literature on the concept and how to prevent, detect, and treat; 3) Consensus-gathering among Division’s consultants (Drs. Dofitas, de la Peňa, Cabaluna, Kho, Bisquera, Espiritu, Lim, Uy, de la Paz, and Joson)
  • 71.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Reynaldo O. Joson, MD, MS Surg Email: rjoson@maniladoctors.com.ph Cell no. 0918-8040304 THANK YOU FOR YOUR KIND ATTENTION!
  • 72.
    Mastectomy Morbidities: Prevention, Detection,and Treatment (Focus: Seroma, Infection, Bleeding) Reynaldo O. Joson, MD, MS Surg Collator / Researcher / Rapporteur Division of Surgical Oncology UPM Centennial Professorial Chair (2008) THANK YOU FOR YOUR KIND ATTENTION!