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

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

Reynaldo O. Joson, MD, MS SurgCollator / Researcher / Rapporteur

Division of Surgical Oncology

UPM Centennial Professorial Chair (2008)


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.


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).


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)


Reynaldo O. Joson, MD, MS Surg

Collator / Researcher / Rapporteur

For Division of Surgical Oncology


Concept

Operational Definition of Mastectomy Morbidities

Mastectomy Morbidities: Concept and Operational Definition

Morbidities occurring as a result of modified radical mastectomy [MRM] (total mastectomy and axillary dissection).

Undesirable effects short of death or mortality.

Complications, side-effects, and adverse events may be used interchangeably with “morbidities” as

long as no mortality has occurred.


(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


(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






Hypertrophic scar - keloids

3 7

Dog ears 4 6

Lymphedema 6 4

Local recurrence 2 8







3 7

Dog ears 4 6

Lymphedema 6 4


√ √ √







3 7

Dog ears 4 6

Lymphedema 6 4


√ √ √

ALWAYS control / prevent AS MUCH AS POSSIBLE.

ALWAYS inform patients of risk PREOPERATIVELY!

Mastectomy Morbidities: Scope of Lecture

Limited to operative morbidities, those directly related to the operation of a modified radical mastectomy. SEROMA, INFECTION, HEMATOMA, FLAP NECROSIS, LATERAL DOG-EAR DEFORMITY

Anesthetic and other types of morbidities such as those associated with patient and pharmacologic factors excluded.


Common morbidities following MRM(statistics on frequency)

Experience from PGHDivision’s consultants

Literature

Common Morbidities Following MRM (PGH GS1 data – 04-07)

MORBIDITY 2004 (320) 2005 (351) 2006 (391) 2007 (535)

Seroma - - 5 (1.3%) 5 (0.9%)

Graft loss - - - 2 (0.3%)

SSSI - - 6 (1.5%) 6 (1.1%)

Axillary vein injury - - - 2 (0.3%)

Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%)

Flap Necrosis - 1 (0.2%) - 2 (0.3%)

Pneumothorax 2 (0.3%) - - -

HAP - 2 (0.5%) - -

AMI - - - 1(0.1%)


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%)


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.


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%)


Hematoma 3 (0.9%) 2 (0.5%) 6 (1.5%) 11 (2.07%)

Flap Necrosis - 1 (0.2%) - 2 (0.3%)

Note 2: NO reports of sensory loss, chronic pain, dehiscence and lymphedema (as seen in consultants’ experience as reflected in the survey of Division’s consultants).

Common Morbidities Following MRM Surveyed Data from GSI Consultants on Top 3-5 Mastectomy

Morbidities – July 10, 2008 (1 – being most common)

Consultant 1 2 3 4 5

1 seroma hematoma wound infection

flap necrosis

chronic incisional pain

2 seroma hematoma flap necrosis

wound infection

lymphedema of the arm

3 seroma wound infection

wound dehiscence

flap necrosis

hematoma

4 sensory loss, median aspect of arm

seroma hematoma

5 seroma hematoma infection




6 seroma flap necrosis (edge)

hematoma wound infection

wound dehiscence

7 seroma infection hematoma flap necrosis

8 seroma chronic incisional pain


flap necrosis


10 numbness, arm

seroma hematoma wound infection

flap necrosis






wound dehiscence




flap necrosis


10 numbness, arm


flap necrosis

Note:

With reports of sensory loss, chronic pain, dehiscence and lymphedema as morbidities (NOT seen in PGH GSI data).






wound dehiscence



hematoma Wound infection

flap necrosis


10 numbness, arm


flap necrosis

Note:

Seroma, hematoma, and infection are within the top 5 most common mastectomy morbidities.

Common Morbidities Following MRM (Review of Literature)

Because it is a peripheral soft tissue organ,

many wound complications related to breast procedures are relatively minor and

frequently are managed on an outpatient basis.

It therefore is difficult to establish accurate incidence rates for these events.

Ref: Complications in Breast Surgery. Angelique F. Vitug, Lisa A. Newman. Surg Clin N Am (2007) 87:431–451.

Common morbidities following MRM (Review of Literature)

Incidence rates

Overall morbidity 30%

Seroma 10 to 80%*

Infection 1% to 20% [3.8% - meta-ana > 2500 pts]**

Hematoma 2-10%

Ref: Vitug AF, Newman LA. Complications in Breast Surgery. Surg Clin N Am 2007; 87:431–451.*Pogson CJ, Adwani A, Ebbs SR. Seroma following breast cancer surgery. Eur J Surg Oncol 2003; 29(9):711–7.**Platt R, Zucker JR, Zaleznik DF, et al. Perioperative antibiotic prophylaxis and wound infection following breast surgery. J Antimicrob Chemother 1993;31(Suppl B):43–8.


How to prevent, detect, and treat common morbidities following MRM

Survey of Consultants’ Practices and Recommendations

Review of LiteratureConsensus-gathering

Evidence-process-based Recommendations

PostmastectomySeroma

Physical ExaminationSigns for Pattern Recognition

Bulge under the flaps with signs suggestive of presence of fluid such as

fluctuancy and fluid wave


Diagnostic Procedures (if needed) and Positive

Findings

Needle aspiration – yellowish, nonsanguinous

fluid


Prevention Treatment

Seroma Avoid fluid accumulation under the flaps

Continual drainage until fluid accumulation stops

Mastectomy Morbidities: Prevention and Treatment Management Principles




GS1 Division’s Recommended Practice:

Closed tube suction drain at axillary spaceMedial 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.





GSI Division’s Recommended Practice:

Needle aspiration of seroma until fluid accumulation stops.

Usually weekly or as required by patient’s symptoms.

NOT DAILY.

Mastectomy Morbidities: SEROMAPrevention 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]


Process - Pathophysiology(collection of serum in a cavity)

Reabsorption / re-establishment of lymphatic channels

Cavity for fluid accumulation

Transected lymphatic vessels cause serum fluid entry into cavity

Postmastectomy Seroma Prevention and Treatment Management Principles




Minimize transection!

Just have to wait!

Minimize and avoid if

possible!Minimize

and avoid!



N=90 patients Incidence of seroma

Duration of seroma (until resolution)

NO drainage 97% 16% (2-3 weeks)84% (4 weeks)2-day drainage 86%

Prolonged closed-suction drainage (10 days)

73%

Talbot ML, Magarey CJ. Reduced use of drains following axillary lymphadenectomy for breast cancer. ANZ J Surg 2002;72(7):488–90.

Drainage is advised to avoid

seroma!(unless there is

NO cavity!)

Postmastectomy Seroma Prevention and Treatment Management Principles




Minimize transection!

Just have to wait!

Minimize and avoid if possible!OBLITERATION

Chemical / Mechanical Means!



OBLITERATION OF CAVITY by Chemical Manuevers

Sclerosing agents (tetracycline)

Bovin thrombin

Fibrin glue, sealants, patches

Steroids

LIMITED SUCCESS / INCONSISTENT RESULTS

COST

AVAILABILITY



OBLITERATION OF CAVITY by Mechanical Means

Axillary padding

External compression

External garment

do NOT significantly reduce incidence of seroma!



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.



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.



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.”



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!



Obliteration of dead space by mechanical means

Suture flap fixation

surgical technique for securing flapsto underlying tissues to close the dead space with sutures





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.





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.


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.

PostmastectomyInfection


Erythema on the skin; pus

Diagnostic Procedures (if needed) and Positive Findings

Needle aspiration – pus


(Focus: Seroma, Infection, Bleeding)


Infection Aseptic techniqueAntibiotics, if warranted

Antibiotics during cellulitis stage

Drainage with or without antibiotics for abscess

Mastectomy Morbidities: INFECTIONPrevention and Treatment Management Principles


Prophylactic antibiotics in MRM

DISPARATE RESULTS !!!

But MOST show positive effect!!!!!



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.



NEGATIVE EFFECT

Wagman et al. – cephalosporin – placebo 118 breast cancerpatients (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-blindstudy 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.


(Review of Literature)http://www.pcs.org.ph/?s=documents

EVIDENCE – BASED CLINICAL PRACTICE GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS IN ELECTIVE SURGICAL PROCEDURES

2000BREAST SURGERY

Antibiotic prophylaxis is recommended for the following elective breast surgical procedures: (Grade A Recommendation)

Mastectomy Axillary lymph node dissectionReduction mammoplastyExcisional biopsy and lumpectomy



http://www.pcs.org.ph/?s=documents

EVIDENCE – BASED CLINICAL PRACTICE GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS IN ELECTIVE SURGICAL PROCEDURES

2000BREAST 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)



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).



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.





Main resultsSix 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).





The review is NOT able to establish which antibiotic is most appropriate.



Use of prophylactic antibiotics in MRM

Because of disparate results, and in an attempt tominimize cost, many clinicians have adopted the practice of

limiting antibioticprophylaxis to high-risk patients!

GSI Division conducting RCT

study at the moment!

Mastectomy Morbidities: Infection

GSI Division consultants’ recommendations on Prevention

Aseptic technique

Prophylactic antibiotics only in high-risk patientsDiabetes mellitus (>200mg/dL)

Obesity (BMI >40)With other co-morbidity

PostmastectomyHematoma


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


(Focus: Seroma, Infection, Bleeding)


Bleeding / hematoma

Meticulous hemostasis during dissection and prior to wound closure

Control of bleeding Evacuation of hematoma

Mastectomy Morbidities: HEMATOMA / BLEEDINGPrevention and Treatment Management Principles


NOT ABLE

to find literature on

METICULOUS HEMOSTASIS

during mastectomy!

Mastectomy Morbidities: HEMATOMA / BLEEDINGPrevention and Treatment Management Principles

Division consultants’ recommendations on Prevention

Meticulous hemostasis during dissection

Ligate transected blood vessels ≥ 2mm in diameterCauterize fully transected vessels which will not be ligatedLigate and cauterize transected blood vessels right away

Strict and on the spot hemostasis during axillary dissection

Checking of hemostasis prior to wound closure

PostmastectomyFlap Necrosis


Blackish to black discoloration on the flap


FLAP NECROSIS


Flap necrosis

NOT too thin a flapAbout 0.5 to 1 cm thick subcutaneous layer on the flap(for vascular supply)

Debridement

PostmastectomyLateral Dog-Ear Deformity

(Redundant axillary fat pad)

Frequent, particularly in patients with large body habitus and large breast

Unsightly and source of long-term discomfort

Need to prevent as much as possible.

Mastectomy Morbidities: Lateral Dog-ear Deformity

Tear-drop shaped incision

Mirza M, S. K., Fortes-Mayer K. and W. M. H. (2003). "Tear-drop incision for mastectomy to avoid dog-ear deformity." Ann R Coll Surg Engl. 85(2):131.

Mastectomy Morbidities: Lateral Dog-ear Deformity

Sliding-suturing

(Devalia Technique)

Devalia H, Chaudhry A, Rainsbury RM, Minakaran N, Banerjee D. An oncoplastic technique to reduce the formation of lateral 'dog-ears' after mastectomy. Int Semin

Surg Oncol. 2007 Dec 17; 4:29.


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.


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).


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)


Reynaldo O. Joson, MD, MS Surg

Email: [email protected]

Cell no. 0918-8040304

THANK YOU FOR YOUR KIND

ATTENTION!


Reynaldo O. Joson, MD, MS SurgCollator / Researcher / Rapporteur

Division of Surgical Oncology

UPM Centennial Professorial Chair (2008)

THANK YOU FOR YOUR KIND

ATTENTION!

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

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