Este ensaio clínico randomizado publicado em 2010, fala sobre a formação do seroma pós cirurgias de mama e coloca o linfotaping como uma opção de tratamento com bons resultados.
Abdominal Wall Endometrioma: A Diagnostic Enigma—A Case Report and Review of ...KETAN VAGHOLKAR
Background. Abdominal wall endometriomas are quite uncommon. They are usually misdiagnosed by both the surgeon and the
gynaecologist. Awareness of the details of this rare condition is therefore essential for prompt diagnosis and adequate treatment.
Introduction. Endometriosis though a condition commonly seen in the pelvic region can also occur at extrapelvic sites giving
rise to a diagnostic dilemma. Abdominal wall endometrioma is one such complex variant of extrapelvic endometriosis with an
incidence of less than 2% following gynaecologic operations. Case Report. A case of abdominal wall endometrioma diagnosed
clinically and treated by wide surgical resection is presented to highlight the importance of clinical evaluation in the diagnosis of
this condition. Discussion. The etiopathogenesis, presentation, investigations, and management are discussed briefly. Conclusion.
Clinical evaluation confirmed by supportive imaging is diagnostic.Wide local excision is the mainstay of treatment.
บรรยายในการประชุมวิชาการ Korat Hand and Reconstructive Surgery Day ครั้งที่ 3 "Update for Musculoskeletal Problems in Upper Extremities"
วันศุกร์ที่ 16 ธันวาคม 2559 ณ ห้องประชุมหลวงพ่อพุธ ฐานิโย อาคารเฉลิมพระเกีบรติ โรงพยาบาลมหาราชนครราชสีมา
Abdominal Wall Endometrioma: A Diagnostic Enigma—A Case Report and Review of ...KETAN VAGHOLKAR
Background. Abdominal wall endometriomas are quite uncommon. They are usually misdiagnosed by both the surgeon and the
gynaecologist. Awareness of the details of this rare condition is therefore essential for prompt diagnosis and adequate treatment.
Introduction. Endometriosis though a condition commonly seen in the pelvic region can also occur at extrapelvic sites giving
rise to a diagnostic dilemma. Abdominal wall endometrioma is one such complex variant of extrapelvic endometriosis with an
incidence of less than 2% following gynaecologic operations. Case Report. A case of abdominal wall endometrioma diagnosed
clinically and treated by wide surgical resection is presented to highlight the importance of clinical evaluation in the diagnosis of
this condition. Discussion. The etiopathogenesis, presentation, investigations, and management are discussed briefly. Conclusion.
Clinical evaluation confirmed by supportive imaging is diagnostic.Wide local excision is the mainstay of treatment.
บรรยายในการประชุมวิชาการ Korat Hand and Reconstructive Surgery Day ครั้งที่ 3 "Update for Musculoskeletal Problems in Upper Extremities"
วันศุกร์ที่ 16 ธันวาคม 2559 ณ ห้องประชุมหลวงพ่อพุธ ฐานิโย อาคารเฉลิมพระเกีบรติ โรงพยาบาลมหาราชนครราชสีมา
GCT of bone presentation by prof.Ahmad shaheen,M.D. prof.of orthopedic surger...ahmad shaheen
GCT is one of the most common benign bone tumors,characterized by high incidence of local recurrence.
the pathogenesis,pathology,clinical presentation and treatment options will be discussed.
Ewing's sarcoma is the 3rd most common primary malignant bone tumor in the world. It affects people at first 2 decades. In this presentation, every important aspect of this bone tumor has been described extensively but in brief.
A radiological insight into various musculoskeletal complications in patients suffering from AIDS and how it'll affect the management of the patient. A must know for all Radiologists.
Cystic hygroma or cystic lymphangioma is a congenital malformation of the lymphatic system that manifests itself as a soft, benign, and painless mass. It is widely accepted that they arise from the remnants of embryonic lymphatic tissue which retains the potential for proliferation. They grow in the fashion of sprouting and are capable of transgressing anatomical boundary. They can occur almost at any anatomical site.
Impact of dead space closure and lymph vessel ligation during MRM on Post-ope...Dr./ Ihab Samy
Hany F. Habashy MD.a , Ihab S. Fayek MD b , Mohamed I.Abd el aziz MD a
a:Department of Surgery-Fayoum University Hospital-El Fayoum , Egypt.
b:Department of Surgical Oncology –National Cancer Institute – Cairo University ,Egypt.
Kasr el-aini journal of surgery Volume 14, No.2, May 2013
GCT of bone presentation by prof.Ahmad shaheen,M.D. prof.of orthopedic surger...ahmad shaheen
GCT is one of the most common benign bone tumors,characterized by high incidence of local recurrence.
the pathogenesis,pathology,clinical presentation and treatment options will be discussed.
Ewing's sarcoma is the 3rd most common primary malignant bone tumor in the world. It affects people at first 2 decades. In this presentation, every important aspect of this bone tumor has been described extensively but in brief.
A radiological insight into various musculoskeletal complications in patients suffering from AIDS and how it'll affect the management of the patient. A must know for all Radiologists.
Cystic hygroma or cystic lymphangioma is a congenital malformation of the lymphatic system that manifests itself as a soft, benign, and painless mass. It is widely accepted that they arise from the remnants of embryonic lymphatic tissue which retains the potential for proliferation. They grow in the fashion of sprouting and are capable of transgressing anatomical boundary. They can occur almost at any anatomical site.
Impact of dead space closure and lymph vessel ligation during MRM on Post-ope...Dr./ Ihab Samy
Hany F. Habashy MD.a , Ihab S. Fayek MD b , Mohamed I.Abd el aziz MD a
a:Department of Surgery-Fayoum University Hospital-El Fayoum , Egypt.
b:Department of Surgical Oncology –National Cancer Institute – Cairo University ,Egypt.
Kasr el-aini journal of surgery Volume 14, No.2, May 2013
Pilonidal sinus disease is a soft tissue infection. It presents either acutely with abscess or the chronic form of sinus formation. The disease affects multiple body regions but the commonest is the sacrococcygeal region. There are different treatment strategies ranging from simple incision and
drainage of an abscess to complex constructive procedures.
Lipoma is one of the most common soft tissue tumor arising from the mesenchyme. It is slow growing, encapsulated, and usually benign in nature. Tumors over the back, shoulder, and neck region have a high propensity to assume large size thereby getting redefined as a giant lipoma when they exceed 10 cm in width or weigh more than 1000 grams. MRI is the investigation of choice for evaluating giant lipomas. Fine needle aspiration cytology (FNAC) or frozen section may be pertinent in suspected cases of liposarcoma. Complete surgical incision is the treatment of choice. A case of a giant lipoma on the back of a 64-year-old lady is presented with a view to revisit conceptual understanding of the clinical evaluation, investigation, and management of giant lipomas.
Cesarean scar endometriosis: Clinical presentation and imaging features with a focus on MRI.
Endometriose der Bauchwand nach Kaiserschnitt [Presentation in English].
Highly malignant tumor of mesenchymal origin.Spindle shaped cells that produce osteoid.2nd most common primary malignant bone tumor after MM.Incidence – 1 to 3 per million per year
Treated by chemo,amputation or rotationplasty
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...semualkaira
Desmoid tumors or aggressive fibromatosis of the breast, are a rare entity, representing less than
0.2% of all primary breast tumors. The clinical presentation and evolution can mimic a malignant
carcinoma, with the notable difference that a desmoid tumor cannot generate distant metastases. The
aim of the treatment is to achieve local control of this tumor, which can be highly aggressive by
deeply infiltrating surrounding structures, and frequently reoccurs after resection. Both the tumor and
its treatment may cause significant morbidity, causing a real therapeutic challenge.
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...semualkaira
Desmoid tumors or aggressive fibromatosis of the breast, are a rare entity, representing less than 0.2% of all primary breast tumors. The clinical presentation and evolution can mimic a malignant carcinoma, with the notable difference that a desmoid tumor cannot generate distant metastases.
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...semualkaira
Desmoid tumors or aggressive fibromatosis of the breast, are a rare entity, representing less than 0.2% of all primary breast tumors. The clinical presentation and evolution can mimic a malignant carcinoma, with the notable difference that a desmoid tumor cannot generate distant metastases
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lymph taping and seroma formation post breast cancer
1. Clinical RESEARCH/AUDIT
Lymph taping and seroma
formation post breast cancer
Joyce Bosman, Neil Piller
Abstract
Background: The most common complication of breast cancer treatment is seroma formation. Lymph taping has the
potential to prevent or reduce seroma formation, but currently its potential benefits have not been fully investigated.
Aims: To investigate the potential of lymph taping to combat seroma formation. Methods: Nine women treated for breast
cancer were recruited to this randomised clinical trial; four developed seromas requiring aspiration. Bio-impedance
spectroscopy of the breast was used to assess intra and extracellular fluid levels in each of the four quadrants of the
breast. From day one postoperatively, lymph taping was applied over the watershed between skin territories on the
posterior thorax between the spine and axilla on those allocated to the treatment group. Measurements were repeated
at five, nine and 16 days. Results: The extracellular fluid value at t16 was 0.1037 ± 0.0324 (15.3 % decrease) over t1 in the
lymph taping group and 0.1066 ± 0.0227 (4.6 % decrease) in the current best practice group (n=4 in each group). After
16 days of treatment, substantial changes were found in burning sensations, tightness and heaviness in favour of the lymph
taping group. In particular, pain perception in the lymph taping group improved. Conclusions: This study has demonstrated
that lymph taping has the ability to reduce extracellular fluid accumulation and improve a range of quality of life measures.
seroma formation after breast surgery of the investigated criteria suggested
Key words varies between 2.5% and 51% (Brayant that:
and Baum, 1987; Barwell et al, 1997; 8 Seroma is not an accumulation of
Breast cancer Woodworth et al, 2000). Vitug and serum, but an exudate
Lymphoedema Newman (2007) report that 10% to 8 Exudate is an element in an acute
Seroma formation 80% of ALND and mastectomy cases inflammatory reaction, i.e. the first
Lymph taping require seroma aspiration. phase of wound repair
8 Seroma formation reflects
Various methods have been an increased intensity and a
used to prevent seroma formation. prolongation of this repair phase.
However, the use of lymph taping
B
reast cancer surgery is treated in this context has not been fully Watt-Boolsen et al (1989) also
with either modified radical evaluated in the current literature. posited that the predominant white
mastectomy (MRM), wide local cells present in a seroma were
excision (WLE) and axillary lymph Seroma granulocytes rather than lymphocytes,
node dissection (ALND), or sentinel Seroma is defined as a serous fluid indicating that the fluid is likely to be
lymph node biopsy (SLNB). Common collection that develops under the exudate. The protein concentration
complications of breast surgery skin flaps during mastectomy or in in seromas was found to be more
include bleeding, infection, lymph the axillary dead space after axillary consistent with that of an exudate
oedema and nerve damage (Leica and dissection (Pogson et al, 2003). produced as a result of acute
Apantaku, 2002). The most common Seroma formation generally begins on inflammation during wound healing
complication following breast surgery the seventh day post surgery, reaches (Watt-Boolsen et al, 1989).
is seroma formation. Incidence of a peak rate of growth on the eighth
day and slows continuously until Gardner et al (2005) suggests
the sixteenth day when it generally that there are seven causative factors
Joyce Bosman is an oedematherapist at Medisch Centrum resolves (Menton and Roemer, 1990). contributing to seroma formation:
Zuid, Groningen, the Netherlands; Neil Piller is a Professor 8 Poor adherence of flaps to
and Director of the Lymphoedema Assessment Clinic, Watt-Boolsen et al (1989) found chest wall
Department of Surgery, Flinders University and Medical that the composition of the fluid and 8 Division of several larger lymph
Centre, South Australia aspirates and the time-related changes trunks
?? Journal of Lymphoedema, 2010, Vol 5, No 2
2. Clinical RESEARCH/AUDIT
8 Large dead space/large raw area in when symptomatic (Anand et al, immobilisation of the shoulder until
the axilla 2002). In some cases, the fluid day seven postoperatively significantly
8 Pump action of upper limb collection may recur so this may need reduced the incidence of seroma.
increasing lymph flow to be done more than once (Cancer However, other authors describe
8 Local inflammatory mediators, Society of New Zealand, 2003). how immobilisation of the upper
8 Irregular shape of chest wall Seromas can generally be managed by limb generated unacceptable rates of
and axilla one to six aspirations (Gonzalez et al, frozen shoulder and, therefore, advise
8 Shear forces during respiration. 2003). However, the use of fine needle early shoulder exercises. Evidence for a
aspiration to assess changes in an clear role of immobilisation in seroma
Although seromas are not life- oedematous breast can be problematic prevention is still lacking (Gardner et
threatening, they can lead to significant and may, in itself, produce additional al, 2005).
morbidity (e.g. flap necrosis, wound inflammation and oedema (Williams,
dehiscence, predisposition to sepsis, 2006). Postoperative breast seroma,
impaired shoulder function [muscle therefore, is an important cause of
strength weakness], prolonged morbidity that continues to cause
recovery period and multiple physician Although seromas are difficulties for surgeons and for which
visits) and may delay adjuvant therapy not life-threatening, they the best treatment has long been
(Budd et al, 1978; Aitkin and Minton, can lead to significant debated (Gardner et al, 2005).
1983; Gardner et al, 2005).
morbidity (e.g. flap
The use of taping for the
Extensive dissection generates a necrosis, wound dehiscence, management of seroma is gaining
considerable potential space as breast predisposition to sepsis, popularity and while there is significant
tissue is removed and lymphatic impaired shoulder clinical experience of this approach,
vessels are severed allowing lymph function [muscle strength there is little published research.
to pass into the dead space. The weakness], prolonged Lymph taping is a part of the Medical
distensibility of the skin flaps raised Taping Concept, which is believed
recovery period and
during the surgery further establishes to contribute to the stimulation and
a potential space in which fluid can multiple physician visits) improvement of lymphatic drainage
collect. In addition, axillary lymph node and may delay adjuvant (www.medicaltaping.com).
dissection results in the division of therapy.
several larger lymph trunks, and when Lymph taping
the arm is mobilised post-operatively, In its most common application,
the upper-limb musculature acts as a Several interventions have been lymph taping is applied to the poorly
pump, increasing lymph flow (Gardner reported with the aim of reducing draining area (lymphatic territory) of
et al, 2005). seroma formation including the use the lymphoedematous limb or area.
of pressure garment and prolonged The special tape used has an elasticity
It is common for people who have limitation of arm activity. However, it similar to that of the skin and is similar
had their lymph nodes removed to has been suggested that the use of in weight to the epidermis. By applying
experience fullness under the arm these interventions not only reduces the tape in a proximal to distal
after the drain(s) has been removed. seroma formation, but may also direction and positioning the body in
Evidence on the effect of drains on increase the incidence of seroma a way that the tape is stretched during
seroma formation is inconclusive formation after removal of the drain application, the lymphatic drainage
(Gardner et al, 2005). People often (O’Hea et al, 1999), and even might system is stimulated 24 hours a day.
describe seroma as like ‘having a ball cause shoulder dysfunction (Dawson
fixed into their armpit’. et al, 1989). The tape must be applied in
accordance with the anatomy of
Following a modified radical Seroma formation after breast the lymph flow. The tape lifts the
mastectomy it is also possible to cancer surgery occurs independently skin slightly, opening the lumen of
develop seroma on the chest wall. of drainage duration, compression the lymph angioma and reducing
As with a haematoma, this fluid is dressing and other known prognostic the pressure on the blood vessels.
reabsorbed by the body over time. factors in breast cancer patients Moreover, the tape acts as a conductor
except the type of surgery, i.e. there of interstitial fluid, moving fluids from
Persistent seromas have is a 2.5 times higher risk of seroma areas of higher pressure towards
traditionally been treated with formation in patients who undergo areas of lower pressure (Kase et al,
repeated aspirations, local pressure a modified radical mastectomy 2003). The tape may also influence
dressings, and occasionally surgical compared to breast-conserving the deeper lymphatic system and
ablation (Gardner et al, 2005). surgery (Hashemi et al, 2004). Schultz encourage myofascial release,
Seromas should only be aspirated et al (1997) were able to show that enhancing drainage in the subfascial
Journal of Lymphoedema, 2010, Vol 5, No 2 ??
3. Clinical RESEARCH/AUDIT
lymphatics (although this remains to Flinders University and Medical Centre performed, tumour size, number
be proven). Clinical Research Ethics Committee of lymph nodes removed, number
prior to commencing the study. of lymph nodes infiltrated and the
Shim et al (2003) posit that frequency and number of aspirations.
endothelium may act as a micro-valve Nine women who had undergone Bio-impedance and QoL was
along the walls of the initial lymphatics. surgical treatment for their measured on day one postoperatively
These valves open during any breast cancer (± radiotherapy ± (t1), day five postoperatively (t5), day
stretching of the lymphatics and during chemotherapy) were recruited for nine postoperatively (t9) and day 16
the influx of interstitial fluid into the this clinical trial. Before surgery (t0), postoperatively (t16).
lumen, while anchoring filaments keep participants were measured using bio-
the endothelial cells tightly attached impedance spectroscopy and filled out
to the adjacent collagen network. a quality of life (QoL) questionnaire. Table 1
Expansion of the initial lymphatics A patch test was also performed
causes the interstitial fluid to fill the to ensure the participants were Between subject reproducibility:
open endothelial micro-valves through not allergic to the tape material or bio-impedance measurements
percolation, while compression causes adhesive. (Moseley and Piller, 2008)
closure of the endothelial micro-
valves and outflow along the lumen After surgery, participants were Position Covariance
of the micro-lymphatics, with eventual divided in two groups, a lymph taping (%)
transport to collecting lymphatics. group and a current best practice Affected Breast
Reflux towards the initial lymphatics is group 8 Upper outer quadrant (R0a) 0.34%
prevented by bicuspid valves. 8 Upper inner quadrant (R0) 0.24%
Starting on day one postoperatively, 8 Lower outer quadrant (R0) 0.24%
Bio-impedance lymph taping was applied every five 8 Lower inner quadrant (R0) 0.53%
A promising technique in measuring days to the lymph taping group. The 8 Upper outer quadrant (Rfb) 0.40%
breast changes is bio-impedance. tape was cut into three strips and 8 Upper inner quadrant (Rf) 0.48%
Local bio-impedance uses electrical applied over the watershed between 8 Lower outer quadrant (Rf) 0.86%
currents to measure the impedance the posterior thoracic skin territories 8 Lower inner quadrant (Rf) 0.54%
of the tissue and, therefore, the fluid and from spine to axilla (Figure 1).
volume. This type of technique has The patient was positioned so that Normal Breast
been previously used to measure the skin was slightly stretched before 8 Upper outer quadrant (R0) 0.20%
arm lymphoedema (Cornish et al, the application of the tape. Once the 8 Upper inner quadrant (R0) 0.36%
2001; Box et al, 2002), breast fluid skin returned to its normal position, it 8 Lower outer quadrant (R0) 0.48%
volume (Mosely and Piller, 2008), was drawn up to create an underlying 8 Lower inner quadrant (R0) 0.33%
and breast tumours (Ohmine et al, negative pressure (Williams, 2006). 8 Upper outer quadrant (Rf) 0.38%
2000). As demonstrated in Table 1, 8 Upper inner quadrant (Rf) 0.45%
the covariance for bio-impedance The participants were encouraged 8 Lower outer quadrant (Rf) 0.39%
measurements is quite low, ranging to perform early arm motion, including 8 Lower inner quadrant (Rf) 0.32%
from 0.20–0.86%, demonstrating that abduction of the arm at 90° and a R0 represents the extracellular fluid
the between subject reproducibility arm raising. Participants were also measurement
is consistent and therefore reliable encouraged to resume their normal b Rf represents both the intra and
(Mosely and Piller, 2008). daily activities (Gonzalez et al, 2003). extracellular measurement
General advice was provided to
Rationale participants regarding skincare, e.g.
This study was undertaken to how to wash and dry the skin, to avoid
determine the effect of lymph taping using warm air to dry the tape and to
on post-operative seroma following seek advice if problems occurred.
breast cancer surgery. Most of the
literature is based on the effect of In both the current best practice
lymph taping in oedema of the arm. group and the lymph taping group,
However, the use of lymph taping for seroma aspirations were taken using
seroma management does not appear techniques currently approved by the
to be considered, even though there Department of Surgery, at Flinders
are similarities in the nature of the University and Medical Centre.
fluid accumulation.
Parameters collected from the Figure 1. Lymph taping over the watershed between
Method sample groups included age, body the posterior thoracic skin territories from the
Ethical approval was obtained from mass index (BMI), type of surgery spine to axilla.
?? Journal of Lymphoedema, 2010, Vol 5, No 2
4. Clinical RESEARCH/AUDIT
Outer edge
of breast Table 2
Half way point
Characteristics of the participants
Subject Age (years) Weight Height (cms) BMI *
(kgs)
Nipple Mean 57.5 66.8 162 25.5
Standard Deviation 13.0 11.5 5.8 4.1
Figure 2. Breast quadrants and halfway point. * Body Mass Index calculated as weight (kgs) / height (m2)
Allocation to either the treatment
group or the current best practice their volume index and work out participants with a tumour diameter
group was performed by the toss of a the actual volume (ECF volume = less than 25mm and in three of the
coin for the first patient — subsequent pECF*L^2/R0). A P value of <0.05 five with a tumour diameter greater
participants were then allocated to was considered significant. than 25mm.
each group alternately.
Results There were two grade I tumours
Local bio-impedance Nine women who had treatment (25%), three grade II (37.5%), and two
The fluid impedance of each breast for their breast cancer entered the grade III (25%). In one patient there
quadrant was measured using the study but one was excluded due to a were no tumour grade details listed.
Impedimed® Imp SFB7 bio-impedance prolonged surgical intervention. The There were two seromas requiring
unit (Impedimed). The electrodes mean age of the women was 57.5 aspiration in the grade II tumour group
were placed in a straight line along the years with a range of 41–79 years. and one in the grade III tumour group.
halfway point of the breast (Figure 2) Four participants had undergone MRM,
and a multi-frequency current (5-500Hz) while the other four had undergone The model number of lymph nodes
was applied through the electrodes WLE. Six were also treated with removed was 10 ± 6 (range 1–15).
to measure the fluid impedance. ALND, while a further two underwent Four participants (50%) had positive
The measurement data was then a SLNB. Table 2 displays the group lymph nodes, while three of the four
downloaded and stored in a laptop. demographic and anthropometric developed seromas that needed
characteristics. aspiration.
Analysis
All data was analysed using SPSS®. Closed suction drainage was used The bio-impedance figure (see
All results are expressed as means ± in all participants and the carcinoma Analysis section above for explanation)
standard deviation in tables. Paired was invasive in all of the participants. representing the mean volume of
t-tests were used to compare the Four participants developed seromas extracellular fluid (ECF) at t0 was
extracellular fluid (ECF) volume and that required aspiration — three of 0.0868 ± 0.0106 and 0.0858 ± 0.0182
QoL with and without lymph taping. these had undergone MRM and one for lymph taping and current best
The ECF volume was determined had undergone WLE. All were treated practice groups respectively. At one
using the formula: with ALND. day postoperatively the mean volume
of ECF was 0.1224 ± 0.0279 (a 41%
ECF volume index = L^2/R0 Two of the four participants who increase) and 0.1118 ± 0.0083 (a
(where ‘L’ is the length and R0 is the developed seromas were treated 30% increase) respectively for the
value measured by the bio-impedance with lymph taping, while the other lymph taping and current best practice
device) two received current best practice, groups. Taping was commenced after
including general skin and limb this first postoperative measure.
Because the resistivities for care advice and a gentle exercise
extracellular fluid (ECF), intracellular programme. The mean amount of The mean volume of ECF on
fluid (ICF) and total body fluid (TBF) aspirate was 175.82 ± 109.29ml day five was 0.1189 ± 0.0308 (2.9%
are not known, the authors could not (range 20–335ml). The number of decrease) and 0.1165 ± 0.0181 (4.3%
draw interferences about the relative aspirations ranged from 2–5. increase) respectively for the lymph
amounts. Nevertheless, it was possible taping and current best practice
to draw conclusions from the trend The mean tumour diameter of groups.
in each. If the resistivity of ECF in the all participants was 33.63±14.59mm
breast quadrants is ever measured in (range 13–50mm). Seromas required On day 9 this volume was 0.1302
the future, the authors could multiply aspiration in one of the three ± 0.2922 (6.4% increase) and 0.1190
Journal of Lymphoedema, 2010, Vol 5, No 2 ??
5. Clinical RESEARCH/AUDIT
current best practice results in an
Table 3 increase in volume of ECF.
Extracellular fluid Quality of life was scored on seven
variables (Table 4). Between t1 and
t5 there was a substantial difference
Randomisation ECF t0 ECF t1 ECF t5 ECF t9 ECF t16 between the lymph taping group
by treatment and current best practice group, but
Current best Mean 0.0858 0.1118 0.1165 0.1190 0.1066 after t5 the variables showed large
practice total SD 0.0182 0.0083 0.0181 0.2059 0.0227 improvements as shown in Figures 3–5.
group n=4 Percentage 30% +4.27% +6.48% –4.59%
Lymph taping Mean 0.0868 0.1224 0.1189 0.1302 0.1037 The subjects’ range of motion
total group n=4 SD 0.0106 0.0279 0.0308 0.2922 0.0324 (ROM) improved during t1 and t16 in
Percentage +41% –2.86% +6.36% –15.32% the lymph taping group. After 16 days
of treatment, substantial improvements
Current best Mean 0.0855 0.1138 0.1260 0.1259 0.1210
were found in burning sensations
practice with SD 0.0235 0.0138 0.0106 0.0274 0.0228
(66.7%), tightness (50%) and heaviness
aspirations n=2 Percentage +33.1% +10.7% +10.6% +6.3%
(100%) in the lymph taping group.
Lymph taping Mean 0.0859 0.1329 0.1409 0.1503 0.1301 However, the ‘ball-like’ feeling increased
with aspirations SD 0.0157 0.0344 0.0278 0.0227 0.0145 by 150% in the current best practice
n=2 Percentage +54.7% +6% +13.1% –2.1% group compared to 250% in the
ECF volume index = L^2/R0 lymph taping group. There was a small
increase in pain (11.1%) in the current
best practice group.
Table 4 Substantial differences were
observed for the pain perception
Quality of life (scored on 10-point visual analog scale [means shown] between the two groups at t0 (P =
.08), t1 (P < .08) and t5 (P < .08).
t0 t1 t5 t9 T16 However at t9 (P < .22) and t16 (P
< .18) this difference was no longer
QoL LT CBP LT CBP LT CBP LT CBP LT CBP substantial, meaning that the pain
Pain 2.75 1.20 4.25 2.25 5.00 1.67 4.50 3.00 4.25 2.50 perception for the lymph taping group
Heaviness 1.50 1.00 1.50 1.00 3.25 1.00 1.75 2.25 2.00 2.00 improved (Table 5). None of these
values were statistically significantly
Tightness 1.00 1.00 2.50 1.50 5.25 1.67 2.75 3.50 2.50 2.25
different, however, a larger study may
Temperature 1.00 1.00 1.00 1.00 2.75 1.00 1.00 1.00 1.00 1.00 show them to be so.
Burning 1.00 1.40 1.00 1.50 1.00 1.00 1.00 2.25 1.00 2.50
sensations Discussion
Seroma is widely accepted as a
Ball-like feeling 2.00 1.00 1.00 1.00 4.25 1.00 2.50 2.25 3.50 1.50
normal complication following breast
ROM 2.75 1.00 5.00 3.50 4.00 2.83 2.50 2.88 1.88 1.75 cancer surgery. Gonzalez et al (2003)
called it a ‘necessary evil’ that occurs
unpredictably in a predictable number
± 0.2059 (6.5 % increase) for lymph 3). By looking at the par ticipants of patients. The authors believe that
taping and current best practice requiring aspirations (two in each of this view of seroma should change.
respectively. On day 16 the mean the current best practice and lymph Every aspiration may cause infection
volume measurement of ECF was taping groups), the mean volume of and, therefore, a higher risk of
0.1037 ± 0.0324 (15.3% decrease) ECF decreased more in the lymph lymphoedema. Seroma should not
and 0.1066 ± 0.0227 (4.6% decrease) taping group. be looked upon as being a normal
respectively for the lymph taping and complication.
current best practice groups. Table 3 shows a mean volume of
0.1301 ± 0.0145 (a 2.1% decrease) The incidence of lymphoedema
These results suggest that and 0.1210 ± 0.0228 (a 6.3% increase) has been evaluated in many
both the shor t term (five days respectively for the lymph taping studies. However, the incidence of
postoperatively) and longer term (16 and current best practice groups on lymphoedema after the presence of
days postoperatively) par ticipants day 16. Thus lymph taping results in a seroma has not yet been evaluated.
benefit from lymph taping (Table a decrease in volume of ECF, while The authors suggest that more
?? Journal of Lymphoedema, 2010, Vol 5, No 2
6. Clinical RESEARCH/AUDIT
research needs to be conducted into ROM
the incidence of lymphoedema after Ball-like
the presence of a seroma. feeling
Burning
sensation
QOL variables
In this study, one patient had Current best practice
Temperature
thyroid problems and developed Lymph taping
a seroma that needed aspiration. Tightness
Although the patient was taking Heaviness
medication, thyroid problems may
be a predisposing factor for seroma Pain
development. Because of the -50 0 50 100 150 200 250 300 350
presence of an oedematherapist Percentage
specialised in lymph taping at the
Figure 3. Quality of life: percentage changes on day one post-op’ versus day five post-op’
breast care unit, this patient was
referred for treatment. In most
ROM
settings this is not the case.
Ball-like feeling
A higher score of ‘ball-like feeling’ Burning
was reported in the lymph taping sensation
QOL variables
Current best practice
group. This might be explained through Temperature
Lymph taping
lymph taping pulling the fluids away Tightness
from one area and allowing them
to accumulate in another (resulting Heaviness
in the ‘ball-like feeling’). If this is the Pain
case it could be seen as a positive
-60 -30 0 30 60 90 120 150
development, i.e. the fluid moving away
Percentage
from the affected area, but perhaps
not far enough. Figure 4. Quality of life: percentage changes on day one post-op’ versus day nine post-op’
The authors continue to seek ROM
methods that will decrease this ‘ball- Ball-like feeling
like feeling’ and suggestions include
Burning
a breathing programme (i.e. to set sensation
QOL variables
Current best practice
up a proximal pressure gradient Temperature
Lymph taping
between this area and the drainage
Tightness
points) or the placement of further
lymph tape to stimulate drainage over Heaviness
the watershed to other lymphatic
Pain
territories.
-100 -50 0 50 100 150 200 250
Before the study, it was Percentage
hypothesised that lymph taping can Figure 5. Quality of life: percentage changes on day one post-op’ versus day 16 post-op’
be a useful and harmless strategy for
the prevention or management of
Table 5
seroma after breast cancer surgery.
This hypothesis was supported as
Quality of life difference between groups (p values indicated)
those participants who received lymph
taping had substantially less seroma on
day 16 than those who received best QOL t0 QOL t1 QOL t5 QOL t9 QOL t16
current practice. However, the authors Pain .080 .076 .072 .215 .180
believe that studies with higher
Heaviness .264 .317 .079 .741 1.000
numbers of participants are required
to demonstrate statistically significant Tightness 1.000 .508 .138 .549 1.000
changes. Nevertheless, there is still Temperature 1.000 1.000 .186 1.000 1.000
a degree of practical significance to
Burning sensations .371 .127 1.000 .317 .317
support this hypothesis. In this study,
the authors demonstrated a decrease Ball-like feeling armpit .264 1.000 .186 .881 .225
in mean volume of extracellular fluid in
Journal of Lymphoedema, 2010, Vol 5, No 2 ??
7. Clinical RESEARCH/AUDIT
the breast. Concurrently, the subjects Cornish BH, Chapman M, Hirst C,
QoL improved on several variables, Mirolo B, Bunce IH, Ward LC, Thomas BJ
(2001) Early diagnosis of lymphedema
including ROM, burning sensations,
tightness and heaviness.
using multiple frequency bio-impedance. Key points
Lymphology 34(1): 2–11
These results suggest that the
Gardner A, Pass HA, Prance S (2005) 8 Frequent complications of
Techniques in the prevention and breast cancer treatment
outcome for participants can be management of breast seroma: An
improved using this relatively easy evaluation of current practice. Women’s
include bleeding, infection,
approach. Oncology Rev 5(3): 135–43 lymphoedema (arm and
breast) and nerve damage, but
Cancer Society of New Zealand (2003)
Conclusion Post-Operative Problems after Breast Cancer the most common is seroma
The optimal way to manage a seroma Surgery. Cancer Society – brief facts. formation.
is unknown. Most clinicians will aspirate Available at: http://66.70.201.199/csw-
latest/html/index.php?url=/csw-latest/html/ 8 Lymph taping has the potential
a symptomatic seroma and thereafter patient/cs_patient_01_facts.php (accessed
only re-aspirate if the seroma re- to reduce seroma formation
27 August, 2010)
appears. Usually this is indicated by but currently its potential
the patient or the breast nurse (on
Dawson I, Stam L, Heslinga JM, benefits in this context have
Kalsbeck HL (1989) Effect of shoulder not been fully investigated.
re-examination). In our opinion, the immobilization on wound seroma and
risk of additional inflammation and shoulder dysfunction following modified
8 This study used bio-impedance
associated increased oedema is not radical mastectomy: a randomized
prospective clinical trial. Br J Surg 76: spectroscopy of the breast,
acceptable with this invasive technique.
311–12 on the side of the surgery, to
This pilot study has demonstrated
Gonzalez EA, Saltzstein EC, Riedner CS, assess intra and extracellular
that Lymph Taping has the potential
Nelson BK (2003) Seroma formation fluid levels in each of the four
to become a non invasive method
following breast cancer surgery. Breast J quadrants of the breast. A
to manage seroma. However, further 9(5): 385–8 questionnaire measuring quality
controlled trials need to be conducted
Hashemi E, Kaviani A, Najafi M, Ebrahimi of life was administered.
to confirm this. JL
M, Hooshmand H, Montazeri A (2004)
Seroma formation after surgery for breast 8 The study also used a
Acknowledgement cancer. World J Surg Oncol 2: 44
questionnaire to measure
The CureTape® used in this study
Kase K, Wallis J, Kase T (2003) Clinical quality of life.
was funded by FysioTape B.V. the Therapeutic Applications of the Kinesio
Netherlands. Taping Method. Kinesio Taping Association,
8 The study showed that lymph
Tokyo
taping has the ability to reduce
Leica M, Apantaku MD (2002) Breast- extracellular fluid accumulation
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