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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 69-73

Dead space obliteration for reducing seroma formation after mastectomy and axillary dissection


Department of General Surgery, Faculty of Medicine, Menofia University, Menofia, Egypt

Date of Submission16-Oct-2014
Date of Acceptance11-Dec-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Naglaa F Amer
Shamma, Ashmoun, Menofia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155946

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  Abstract 

Objective
The aim of the study was to detect the efficiency of dead space obliteration to reduce postmastectomy seroma formation, leading to early drain removal.
Background
Breast cancer is the most common female cancer worldwide. It accounts for 33% of female cancers at the National Cancer Institute (NCI). Primary operable breast cancer can be treated by either modified radical mastectomy or conservative breast surgery. Seroma represents the most important complication after modified radical mastectomy.
Patients and methods
Forty patients with primary operable breast cancer were included in this study from February 2013 to March 2014. They underwent modified radical mastectomy and were then divided into two groups: group A and group B. In group A patients, the wound was closed by means of the flap-fixation technique by continuous suturing of the upper flap to the pectoralis major muscle and lateral chest wall and suturing the pectoralis major muscle to the pectoralis minor muscle by four to six interrupted sutures using vicryl 2/0. In group B patients, the wound was closed by means of simple closure and application of a crepe bandage.
Results
There were significant differences between the two groups as regards the total amount of drained serous fluid (P < 0.001) and the duration for drain removal (P < 0.001). The flap-fixation technique shows significant decrease in the number of patients who developed seroma after drain removal (P < 0.001).
Conclusion
The flap-fixation technique is a valuable technique for reducing seroma formation after mastectomy and axillary dissection.

Keywords: Axillary dissection, dead space obliteration, mastectomy, seroma


How to cite this article:
El-Sisi AA, Mohamed AMF, Amer NF. Dead space obliteration for reducing seroma formation after mastectomy and axillary dissection. Menoufia Med J 2015;28:69-73

How to cite this URL:
El-Sisi AA, Mohamed AMF, Amer NF. Dead space obliteration for reducing seroma formation after mastectomy and axillary dissection. Menoufia Med J [serial online] 2015 [cited 2019 Jun 17];28:69-73. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/69/155946


  Introduction Top


Breast cancer is the most common malignancy in women, and the most common cause of cancer-related death among them. Despite advances in adjuvant therapy for breast cancer, surgery is still the mainstay of treatment [1].

Primary operable breast cancer can be treated by modified radical mastectomy or conservative breast therapy.

Seroma represents the most common complication of breast cancer surgery. Although its consequences most often involve nothing more than discomfort and anxiety, more serious complications include flap necrosis and wound breakdown. Infection developing within the seroma increases morbidity and often results in the need for readmission, reimaging, drainage, and antibiotic usage [2].

The significance of postoperative seroma in breast surgery lies in its frequency. The incidence is thought to be somewhere between 25 and 60% for mastectomy and axillary clearance, but has been reported to be as high as 85% [3].

Seroma is an accumulation of serous fluid that develops following the formation of skin flaps during mastectomy or in the axillary dead space in the postoperative period. The most likely cause for the formation of seroma is the disruption of lymphatic channels in the axilla. However, laboratory studies have shown conflicting evidence, some determining the fluid to be lymph-like in quality and others showing an inflammatory exudate [4].

Various techniques have been studied in an attempt to minimize postmastectomy drainage volumes and the incidence of seroma. None, however, have been found to be consistently successful and consequently none are used in common practice. It is believed that obliteration of axillary fossa space will minimize fluid collection [5].

Various studies have attempted to reduce seroma formation to improve outcome and reduce morbidity. Techniques that have been advocated over the years include shoulder immobilization, prolonged suction drainage, perioperative tranexamic acid, choice of surgical instrument, and obliteration of dead space [5].

Electrocautery has been described as possibly increasing the frequency of seroma. Time of initiation of arm movement has also been studied on the basis that chest wall motion and shoulder use create shearing forces that delay flap adherence, and that postoperative arm use acts as a pump forcing lymph into the empty axillary fossa. However, studies have shown no significant differences when delaying rehabilitation, but in fact the causes of immobilization of the shoulder and shoulder stiffness can be far greater than that of simple seroma. Several studies have looked into suturing skin flaps to underlying muscle in an attempt to minimize dead space. Some authors have used external sutures passing through the flap from the underlying muscle, but of course these may predispose to wound infection or local skin necrosis [6].

It was demonstrated that drainage volumes and seroma formation were significantly reduced when dead space was obliterated by suturing flaps to the muscle along the skin closure suture line [2].

Thus, the aim of the study was to detect the efficiency of dead space obliteration technique to reduce postmastectomy seroma formation, leading to early drain removal.


  Patient and methods Top


Forty patients with primary operable breast cancer were included in this study from February 2013 to March 2014. Informed consent was obtained from all patients and the study was approved by the local ethics committee. All patients were subjected to history taking, clinical examination including general examination to exclude distant metastasis, and local examination of breast and axilla for tumor staging. All candidates for breast-conserving therapy, as well as diabetic patients and elderly people, were excluded. All patients in our study underwent modified radical mastectomy and were then divided into two groups: group A and group B. In group A patients, the wound was closed by means of the flap-fixation technique by continuous suturing of the upper flap to the pectoralis major muscle and the lateral chest wall and suturing the pectoralis major muscle to the pectoralis minor muscle by four to six interrupted sutures using vicryl 2/0. In group B patients, the wound was closed by simple closure and application of crepe bandage. Ten F Handy Vac suction drains were placed at the time of surgery in all patients with the tip placed within the mastectomy cavity, and total drain outputs were recorded for all patients before drain removal.

The patients were discharged from the hospital after 1-2 days and followed up at the outpatient clinic for about 2-3 weeks until the stitches were removed.

The drains were removed when the amount of fluid in the drain was less than 50 ml per 24 h. All cases were followed up to detect seroma formation.

Methods for detection of seroma formation

Clinical

Clinical diagnosis was made when the patients complained of fullness in the axilla and pain or heaviness in the arm with clinically apparent fluid collection in the axilla or under the skin flaps.

Radiological

Suspicious cases on clinical examination were radiologically investigated by means of ultrasonography for confirmation of diagnosis.

Treatment

Seroma cases were treated by means of multiple aspirations (twice weekly) until it disappeared clinically and were confirmed by ultrasound. Some cases needed ultrasound-guided aspiration.


  Results Top


The mean age of patients in group A was 50.95 ± 8.18 years, whereas that in group B was 54.25 ± 10.96 years. There was no significant difference between the two groups with regard to age at diagnosis (P = 0.273). There were no significant differences between the two groups with regard to histological type, stage, and tumor size. The histopathology of group A was as follows: 18 patients had intraductal carcinoma; one patient had intralobular carcinoma; and one patient had mixed tumor.

The histopathology of group B was the same, with no significant difference between the two groups (P = 1.000). Sixteen patients in group A were categorized as having stage 1 breast cancer (80.0) and four patients were in stage 2 (20.0), whereas 15 patients in group B were in stage 1 (75.0) and five were in stage 2 (25.0), with no significant difference between the two groups (P = 1.000). There was no statistically significant difference between the two groups as regards tumor size (P = 0.242). When comparing the two groups as regards the operative characteristics, the mean number of lymph nodes removed in group A was 18.9 ± 3.8, whereas in group B the mean number of lymph nodes removed was 20.8 ± 10.1, with no significant difference between the two groups (P = 0.273). The mean number of positive lymph nodes removed in group A was 2.8 ± 4.8, whereas in group B the mean number of positive lymph nodes removed was 5.9 ± 12.7, with a P value of 0.775, which was not statistically significant. The mean operative time in minutes in group A was 94.9 ± 5.6 but in group B the mean time was 91.9 ± 3.7, with a P value of 0.05, which was not statistically significant.

In the flap-fixation group, the drain was removed in significantly shorter time compared with the no-flap-fixation group (P < 0.001; highly significant). The mean number of days for drain removal in group A was 10.5 ± 1.7, compared with 16.9 ± 1.2 in group B.

The total amount of fluid drained was significantly less in the flap-fixation group compared with the no-flap-fixation group (P < 0.001; highly significant). The mean amount of serous fluid drained was 1691.5 ± 265.2 in the flap-fixation group, compared with 2833.3 ± 253.0 in the no-flap-fixation group.

The difference in the amount of drained fluid over the last few days before drain removal was not statistically significant between the two groups (P = 0.175), but the difference in the amount of drained fluid on the last day was statistically significant (P = 0.002). The overall clinical incidence of seroma in the whole study was about 17.5% (7/40), all of which occurred in the no-flap-fixation group: five cases were of grade 2 and two were of grade 3; no cases develop clinical seroma in the flap-fixation group.

Two more cases were detected by ultrasonography, increasing radiological incidence to about 22.5% (9/40). Both were of grade 1 and were asymptomatic and could not be detected by the patient. One case was closed by simple wound closure, whereas in the other case flap fixation was used.

Morbidity in our study was calculated, as complications had developed in 10 patients (10/40, 25%). In the flap-fixation group two patients developed cellulitis, which was treated medically, and one patient developed partial flap necrosis, which was treated by debridement and daily dressing. In the control group four patients developed cellulitis and three developed partial flap necrosis.


  Discussion Top


Seroma is an accumulation of serous fluid that develops following the formation of skin flaps during mastectomy or in the axillary dead space in the immediate or early postoperative period [7].

Seroma represents the most common postoperative complication following mastectomy. It leads to patient discomfort and prolongation of hospital stay. Ideal wound closure should minimize lymph spillage and serum oozing, provide a means of holding skin flaps securely to the chest wall structures, obliterate dead space, and allow rapid removal of fluid as it forms. For this, several techniques of flap fixation or wound drainage, as well as limitation of postoperative shoulder movement and the use of adhesive glue, have been investigated to improve primary healing and minimize seroma formation [8].

Dead space obliteration by suturing the upper mastectomy flap to the pectoralis major muscle and lateral chest wall by continuous suture and suturing the pectoralis major to the pectoralis minor by interrupted sutures was carried out in our study to decrease postoperative seroma [9].

In our study the length of operation in the flap-fixation group was longer than that in the no-flap-fixation group by about 5 min, which seems to be the primary and only disadvantage of this technique, agreeing with the results of Alaa Eldin [10].

In our study we found that the flap-fixation technique significantly decreased the drainage period (P < 0.001; highly significant), which agrees with the results of Inwang et al. [11].

Our mean number of days for drain removal was 10.5 days in the flap-fixation group versus 16.9 days in the no-flap-fixation group; this disagrees with the results of Kopelman et al. [12], who said that most surgeons remove the drain when the drainage volume is less than 50 ml in the preceding 24 h, which usually takes about 10 days if the flap-fixation technique is not used [12].

In this study, we found that the flap-fixation technique significantly decreased the total amount of fluid drained (P < 0.001; highly significant), which agrees with the results of Alaa Eldin [10].

The mean amount of serous fluid drained was 1691.5 ml in the flap-fixation group versus 2833.3 ml in the no-flap-fixation group, whereas the mean amount of serous fluid drained was 262.2 ml in the flap-fixation group versus 763.5 ml in the no-flap-fixation group in the study conducted by Natalie et al. [9]. This may be due to the fewer number of patients in their study.

Our study showed that there was no statistically significant difference between the flap-fixation technique and the no-flap-fixation technique as regards the amount of serous fluid drained in the last 3 days, which agrees with the results of Alaa Eldin [10].

The overall clinical incidence of seroma in the whole study was about 17.5% (7/40): five were of grade 2 and two were of grade 3. Two more cases were detected by ultrasonography, both of which were grade 1 minor seromas that were clinically asymptomatic and not detected by the patient.

Woodworth et al. [13] reported that the incidence of seroma fell within the range of 15-81%, and this agrees with our result.

Our study showed that the flap-fixation technique was associated with no incidence of clinically symptomatic seroma (0%) after mastectomy, as compared with the control group (35%), with P value less than 0.001, which was highly significant.

Purushotham et al. [14] also found that flap fixation was useful in decreasing seroma formation after drain removal.

In our study the overall complication rate was 25% (10/40) of cases, with no mortality. This agrees with the reported studies, which stated that surgical morbidity from breast and/or axillary wounds occur in up to 30% of cases [15].

In our study, two patients developed cellulitis in the flap-fixation technique, whereas four patients developed cellulitis in the other technique, which was treated medically and improved later on.

In our study 5% of patients who underwent the flap-fixation technique developed partial flap necrosis, which was treated by serial wound debridement and daily dressing and medical treatment, whereas 15% of patients in the no-flap-fixation technique developed partial flap necrosis that was treated similarly to the previous group [Figure 1],[Figure 2],[Figure 3] and [Figure 4].
Figure 1: Axillary fossa potential dead space after mastectomy and axillary clearance.

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Figure 2: Suturing of superior mastectomy fl ap to the pectoralis major.

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Figure 3: Superior mastectomy flap sutured to the free edge of the pectoralis major and lateral chest wall.

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Figure 4: Interrupted sutures to oppose the pectoralis major and minor.

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  Conclusion Top


The flap-fixation technique is a valuable technique for reducing seroma formation after mastectomy and axillary dissection, allowing early drain removal and increased patient satisfaction.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Harris JR, Lippman ME, Morrow M, et al. Breast cancer. Chapter 4. Diseases of the breast. Philadelphia: Lippincott Williams & Wilkins; 2000.  Back to cited text no. 1
    
2.
Coveney E, Archer TJ. Axillary flap fixation: technique that significantly reduces wound drainage and hospital stay following breast cancer surgery. London, England: 6th Nottingham International Breast Cancer Conference; 1999.  Back to cited text no. 2
    
3.
Carmen CS, Paul M, Steven DL, et al. In:??. Invasive breast cancer. Chapter 2. The MD Anderson surgical oncology. Philadelphia: Lippincott Williams & Wilkins; 2004. 14-39.  Back to cited text no. 3
    
4.
Agrawal A, Ayantunde AA, Cheung KL. Concepts of seroma formation and prevention in breast cancer surgery. ANZ J Surg 2006; 76 :1088-1095.  Back to cited text no. 4
    
5.
Unalp HR, Onal MA. Analysis of risk factors affecting the development of seromas following breast cancer surgeries: seromas following breast cancer surgeries. Breast J 2007; 13 :588-592.  Back to cited text no. 5
    
6.
Browse DJ, Goble D, Jones PA. Axillary node clearance: who wants to immobilize the shoulder? Eur J Surg Oncol 1996; 22 :569-570.  Back to cited text no. 6
    
7.
Pogson CJ, Adwani A, Ebbs SR. Seroma following breast cancer surgery. Eur J Surg Oncol 2003; 29 :711-717.  Back to cited text no. 7
    
8.
David S, Catherine M, Denise C. In: ??. Invasive breast cancer. Chapter 2. The MD Anderson surgical oncology handbook. Philadelphia: Lippincott Williams & Wilkins; 2012. 27-70.  Back to cited text no. 8
    
9.
Natalie C, Anna MG, Gavin TR. Axillary ′exclusion′ a successful technique for reducing seroma formation after mastectomy and axillary dissection. Available at: http://www.scrip.org/journal/abcr.  Back to cited text no. 9
    
10.
Alaa Eldin AM. The value of mechanical closure of the dead space after mastectomy in reducing post-operative drainage and seroma formation. Ain shams Med J 2013; 9 :511-527.  Back to cited text no. 10
    
11.
Inwang R, Hamed H, Chaudary MA, Fentiman IS. Controlled trial of short-term versus standard axillary drainage after axillary clearance and iridium implant treatment of early breast cancer. Eur J Surg 1991; 73 :326-328.  Back to cited text no. 11
    
12.
Kopelman D, Klemm O, Bahous H, Klein R, Krausz M, Hashmonai M. Postoperative suction drainage of the axilla: for how long? Prospective randomised trial. Eur J Surg 1999; 165 :117-120discussion 121-122.  Back to cited text no. 12
    
13.
Woodworth PA, McBoyle MF, Helmer SD, Beamer RL. Seroma formation after breast cancer surgery: incidence and predicting factors. Am Surg 2000; 66 :444-450discussion 450-451.  Back to cited text no. 13
    
14.
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 :286-292.  Back to cited text no. 14
    
15.
Hoefer RA Jr, DuBois JJ, Ostrow LB, Silver LF. Wound complications following modified radical mastectomy: an analysis of perioperative factors. J Am Osteopath Assoc 1990; 90 :47-53.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Patient and methods
Results
Discussion
Conclusion
Acknowledgements
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