Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Reynaldo O. Joson, MD, M...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Objectives:
1) To share ...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Contents:
1) Concept of ...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Methodologies:
1) Statis...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Reynaldo O. Joson, MD, M...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Concept
Operational Defi...
Mastectomy Morbidities:
Concept and Operational Definition
Morbidities occurring as a result of modified radical
mastectom...
Mastectomy Morbidities:
Concept and Operational Definition
(derived from survey of Division’s consultants)
Some mastectomy...
Mastectomy Morbidities:
Concept and Operational Definition
(derived from survey of 10 Division’s consultants)
Mastectomy
m...
Mastectomy Morbidities:
Concept and Operational Definition
(derived from survey of 10 Division’s consultants)
Mastectomy
m...
Mastectomy Morbidities:
Concept and Operational Definition
(derived from survey of 10 Division’s consultants)
Mastectomy
m...
Mastectomy Morbidities:
Concept and Operational Definition
(derived from survey of 10 Division’s consultants)
Mastectomy
m...
Mastectomy Morbidities:
Scope of Lecture
Limited to operative morbidities, those
directly related to the operation of a
mo...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Common morbidities follo...
Common Morbidities Following MRM
(PGH GS1 data – 04-07)
MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535)
Seroma - - 5...
Common Morbidities Following MRM
(PGH GS1 data – 04-07)
MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535)
Seroma - - 5...
Common Morbidities Following MRM
(PGH GS1 data – 04-07)
MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535)
Seroma - - 5...
Common Morbidities Following MRM
Surveyed Data from GSI Consultants on Top 3-5 Mastectomy
Morbidities – July 10, 2008 (1 –...
Common Morbidities Following MRM
Surveyed Data from GSI Consultants on Top 3-5 Mastectomy
Morbidities – July 10, 2008 (1 –...
Common Morbidities Following MRM
Surveyed Data from GSI Consultants on Top 3-5 Mastectomy
Morbidities – July 10, 2008 (1 –...
Common Morbidities Following MRM
Surveyed Data from GSI Consultants on Top 3-5 Mastectomy
Morbidities – July 10, 2008 (1 –...
Common Morbidities Following MRM
(Review of Literature)
Because it is a peripheral soft tissue organ,
many wound complicat...
Common morbidities following MRM
(Review of Literature)
Incidence rates
Overall morbidity 30%
Seroma 10 to 80%*
Infection ...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
How to prevent, detect, ...
Postmastectomy
Seroma
Physical Examination
Signs for Pattern Recognition
Bulge under the flaps with signs
suggestive of pr...
Postmastectomy
Seroma
Diagnostic Procedures (if
needed) and Positive
Findings
Needle aspiration –
yellowish, nonsanguinous...
Postmastectomy
Seroma
Prevention Treatment
Seroma Avoid fluid accumulation under
the flaps
Continual drainage until
fluid ...
Mastectomy Morbidities: Prevention and Treatment
Management Principles
Prevention Treatment
Seroma Avoid fluid accumulatio...
Postmastectomy
Seroma
Prevention Treatment
Seroma Avoid fluid accumulation under
the flaps
Continual drainage until
fluid ...
Mastectomy Morbidities: Prevention and Treatment
Management Principles
Prevention Treatment
Seroma Avoid fluid accumulatio...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
Recommendation: Repea...
Postmastectomy
Seroma
Process - Pathophysiology
(collection of serum in a cavity)
Reabsorption / re-
establishment of
lymp...
Postmastectomy Seroma
Prevention and Treatment Management Principles
Reabsorption / re-
establishment of
lymphatic channel...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
N=90 patients Inciden...
Postmastectomy Seroma
Prevention and Treatment Management Principles
Reabsorption / re-
establishment of
lymphatic channel...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
OBLITERATION OF CAVIT...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
OBLITERATION OF CAVIT...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
Obliteration of Cavit...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
External compression ...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
External garment does...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
Axillary padding, ext...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
Obliteration of dead ...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
Obliteration of dead ...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
(Review of Literature)
Obliteration of dead ...
Mastectomy Morbidities: SEROMA
Prevention and Treatment Management Principles
Division’s Recommended Practice:
Drain remov...
Postmastectomy
Infection
Physical Examination
Signs for Pattern Recognition
Erythema on the skin; pus
Diagnostic Procedure...
Mastectomy Morbidities: Prevention and Treatment
Management Principles
(Focus: Seroma, Infection, Bleeding)
Prevention Tre...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
Prophylactic antib...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
Positive effect
-s...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
NEGATIVE EFFECT
Wa...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
http://www.pcs.org...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
http://www.pcs.org...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
M Cunningham, F. B...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
M Cunningham, F. B...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
M Cunningham, F. B...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
M Cunningham, F. B...
Mastectomy Morbidities: INFECTION
Prevention and Treatment Management Principles
(Review of Literature)
Use of prophylacti...
Mastectomy Morbidities:
Infection
GSI Division consultants’ recommendations on
Prevention
Aseptic technique
Prophylactic a...
Postmastectomy
Hematoma
Physical Examination
Signs for Pattern Recognition
Bulge under the flaps with
discoloration on the...
Mastectomy Morbidities: Prevention and Treatment
Management Principles
(Focus: Seroma, Infection, Bleeding)
Prevention Tre...
Mastectomy Morbidities: HEMATOMA / BLEEDING
Prevention and Treatment Management Principles
(Review of Literature)
NOT ABLE...
Mastectomy Morbidities: HEMATOMA / BLEEDING
Prevention and Treatment Management Principles
Division consultants’ recommend...
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
NO...
Postmastectomy
Lateral Dog-Ear Deformity
(Redundant axillary fat pad)
Frequent, particularly in patients
with large body h...
Mastectomy Morbidities:
Lateral Dog-ear Deformity
Tear-drop shaped incision
Mirza M, S. K., Fortes-Mayer K. and W. M. H. (...
Mastectomy Morbidities:
Lateral Dog-ear Deformity
Sliding-suturing
(Devalia Technique)
Devalia H, Chaudhry A, Rainsbury RM...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Objectives:
1) To share ...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Contents:
1) Concept of ...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Methodologies:
1) Statis...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Reynaldo O. Joson, MD, M...
Mastectomy Morbidities:
Prevention, Detection, and Treatment
(Focus: Seroma, Infection, Bleeding)
Reynaldo O. Joson, MD, M...
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Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bl

  1. 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. 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. 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. 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. 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. 6. Mastectomy Morbidities: Prevention, Detection, and Treatment (Focus: Seroma, Infection, Bleeding) Concept Operational Definition of Mastectomy Morbidities
  7. 7. 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.
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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 √ √ √
  12. 12. 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!
  13. 13. 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.
  14. 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. 15. 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%)
  16. 16. 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.
  17. 17. 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).
  18. 18. 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
  19. 19. 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
  20. 20. 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).
  21. 21. 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.
  22. 22. 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.
  23. 23. 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.
  24. 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. 25. 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
  26. 26. Postmastectomy Seroma Diagnostic Procedures (if needed) and Positive Findings Needle aspiration – yellowish, nonsanguinous fluid
  27. 27. Postmastectomy Seroma Prevention Treatment Seroma Avoid fluid accumulation under the flaps Continual drainage until fluid accumulation stops
  28. 28. 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.
  29. 29. Postmastectomy Seroma Prevention Treatment Seroma Avoid fluid accumulation under the flaps Continual drainage until fluid accumulation stops
  30. 30. 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.
  31. 31. 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]
  32. 32. 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
  33. 33. 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!
  34. 34. 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!)
  35. 35. 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!
  36. 36. 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
  37. 37. 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!
  38. 38. 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.
  39. 39. 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.
  40. 40. 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.”
  41. 41. 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!
  42. 42. 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
  43. 43. 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.
  44. 44. 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.
  45. 45. 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.
  46. 46. Postmastectomy Infection Physical Examination Signs for Pattern Recognition Erythema on the skin; pus Diagnostic Procedures (if needed) and Positive Findings Needle aspiration – pus
  47. 47. 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
  48. 48. Mastectomy Morbidities: INFECTION Prevention and Treatment Management Principles (Review of Literature) Prophylactic antibiotics in MRM DISPARATE RESULTS !!! But MOST show positive effect!!!!!
  49. 49. 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.
  50. 50. 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.
  51. 51. 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
  52. 52. 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)
  53. 53. 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).
  54. 54. 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.
  55. 55. 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).
  56. 56. 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.
  57. 57. 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!
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. Mastectomy Morbidities: HEMATOMA / BLEEDING Prevention and Treatment Management Principles (Review of Literature) NOT ABLE to find literature on METICULOUS HEMOSTASIS during mastectomy!
  62. 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. 63. Postmastectomy Flap Necrosis Physical Examination Signs for Pattern Recognition Blackish to black discoloration on the flap
  64. 64. 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
  65. 65. 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.
  66. 66. 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.
  67. 67. 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.
  68. 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. 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. 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. 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. 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!

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