Seroma prevention following axillary dissection in patients with breast cancer by using ultrasound scissors: a prospective clinical study

doi:10.1016/j.ejso.2004.03.003

European Journal of Surgical Oncology (EJSO)

Volume 30, Issue 5, June 2004, Pages 526-530

https://doi.org/10.1016/j.ejso.2004.03.003 Get rights and content

Abstract

Aims. Seroma formation following axillary dissection is a common complication of breast surgery. The aims of this study were (1) to analyse the risk factors of seroma formation, and (2) to evaluate the role of ultrasound scissors in performing axillary dissection in patients with primary breast cancer undergoing mastectomy and breast-conserving surgery.

Methods. Ninety-two women (median age 55 years, range 33–73 years) requiring surgery for known unilateral primary breast cancer (pT1a=1, pT1b=20, pT1c=43, pT2=25, pT3=3) were prospectively randomised to undergo axillary dissection by either using (Group A, 45 patients) or not using (Group B, 47 patients) ultrasound scissors (US). Thirty-eight (41.3%) patients underwent modified radical mastectomy, while 54 (58.7%) underwent breast-conserving surgery.

Results. Twenty-eight (30.4%) patients (Group A=9 out of 45, 20%; Group B=19 out of 47, 42%; P=NS) developed a wound seroma. Multivariate analysis using a logistic regression model showed that surgical procedure (RR=8.9; 95% CI: 3.2–25.3), total amount of drainage (RR=7.8; 95% CI: 2.8–22.0), and size of the tumour (RR=6.0; 95% CI: 2.2–16.5) independently correlated with seroma formation. The logistic regression function (RR=19.4; 95% CI: 6–62) correctly allocated 75 out of 92 (81.5%) patients.

Conclusions. Size of the tumour, and total amount of drainage represent the principal factors of seroma formation following axillary dissection in patients undergoing surgery for breast cancer. Although the use of ultrasound cutting devices may reduce the risk of seroma formation, further studies are need to verify the real impact on long-term morbidity of such technique.

Introduction

Seroma formation following axillary dissection is a common wound complication of both modified radical mastectomy and breast-conserving surgery. The incidence of such occurrence varies widely, according to the type of surgical treatment and the operative techniques used, ranging from less than 10% to more than 50%.1., 2., 3., 4., 5., 6. The optimal way to reduce seroma formation and its pathophysiology are still unknown. Several aetiological factors have been suggested, including patient's age, breast size, number of involved nodes, or use of electocautery, and there are widely varying recommendations to prevent the development of a seroma.⁷

We report the results of a preliminary prospective trial with the aim to analyse the risk factors of seroma formation and the role of ultrasound scissors (US) in performing axillary dissection in patients undergoing curative surgery for breast cancer (BC).

Section snippets

Methods

Ninety-two women (median age 55 years, range 33–73 years) requiring surgery for known unilateral primary BC were prospectively randomised to undergo axillary dissection by either using (Group A, 45 patients) or not using (Group B, 47 patients) US. Randomisation was obtained by the use of random-number table. There were 27 pre-menopausal women, and 65 post-menopausal women. Written informed consent was obtained from each patient, who agree to participate in a study that had full ethical approval

Results

All patients who were enrolled in the study completed the trial. The main characteristics of the tumours in the overall population at final pathology are reported in Table 1. The mean body mass index (BMI) of the overall population was 24.1±2.8 (range 19.2–31.2) kg/m². Sixty-three (68.5%) patients had negative nodes (N0), whilst 29 had histologically confirmed lymph node involvement (N1). The mean number of removed nodes was 17.5±4.1 (range 11–27), whilst the number of positive nodes was

Discussion

Unfortunately, in patients with BC undergoing surgery, neither preoperative imaging studies11., 12., 13. nor sentinel node biopsy technique14., 15., 16., 17. may at present reach 100% sensitivity in detecting (or excluding) axillary node metastases. Results are promising, but accuracy of diagnostic tests might be highly dependent on the number of histologically involved lymph nodes, especially when lymph-node micro-metastases could be missed.¹⁵ Thus, axillary dissection still represents the

Acknowledgements

A special thank you to Dr Silvia Dall'Acqua for help in writing the manuscript and for reviewing the English.

References (42)

A.L Vinton et al.
Wound complications after modified radical mastectomy compared with tylectomy with axillary lymph node dissection
Am J Surg
(1991)
C.J Pogson et al.
Seroma following breast cancer surgery
Eur J Surg Oncol
(2003)
D.A Sisto et al.
Use of Ultracision harmonic scalpel for isolation of intramyocardial coronary vessels during coronary revascularization of the beating hearth
J Thorac Cardiovasc Surg
(1998)
U Eichfeld et al.
Evaluation of Ultracision in lung metastatic surgery
Ann Thorac Surg
(2000)
J.S Vaidya et al.
Role of ultrasonography to detect axillary node involvement in operable breast cancer
Eur J Surg Oncol
(1996)
F Lumachi et al.
Usefulness of 99mTc-sestamibi scintimammography in suspected breast cancer and in axillary lymph node metastases detection
Eur J Surg Oncol
(2001)
Y Rajesh et al.
Preoperative axillary ultrasound scan: its accuracy in assessing the axillary nodal status in carcinoma breast
Breast
(2002)
B.J O'Hea et al.
External compression dressing versus standard dressing after axillary lymphadenectomy
Am J Surg
(1999)
D.J Browse et al.
Axillary node clearance: who wants to immobilize the shoulder?
Eur J Surg Oncol
(1996)
J Bonnema et al.
A prospective randomized trial of high versus low vacuum drainage after axillary dissection for breast cancer
Am J Surg
(1997)

A Wedderburn et al.

Comparison between low and high pressure drainage following axillary clearance

Eur J Surg Oncol

(2000)

R Gupta et al.

A comparison of 5-day and 8-day drainage following mastectomy and axillary clearance

Eur J Surg Oncol

(2001)

K.A Porter et al.

Electrocautery as a factor in seroma formation following mastectomy

Am J Surg

(1998)

R Anand et al.

A prospective randomised trial of two treatments for wound seroma after breast surgery

Eur J Surg Oncol

(2002)

H Galatius et al.

Mastectomy using ultrasonic dissection: effect on seroma formation

Breast

(2003)

G Tejler et al.

Comparisons and hospital stay after surgery for breast cancer: a prospective study of 385 patients

Br J Surg

(1985)

R.A Hofler et al.

Wound complications following radical mastectomy: an analysis of perioperative factors

J Am Osteopath Assoc

(1990)

P.J O'Dwyer et al.

Effect of closing dead space on incidence of seroma after mastectomy

Surg Gynecol Obstet

(1991)

E.C Coveney et al.

Effect of closing dead space on seroma formation after mastectomy. A prospective randomised clinical study

Eur J Surg Oncol

(1993)

W Burak et al.

Seroma formation following axillary dissection for breast cancer: risk factors and lack of influence of bovine thrombin

J Surg Oncol

(1997)

S Schmidbauer et al.

Experience with ultrasound scissors and blades (UltraCision) in open and laparoscopic liver resection

Ann Surg

(2002)

Cited by (102)

Effect of quilting on seroma formation in mastectomies: A meta-analysis
2021, Surgical Oncology
Citation Excerpt :
A review by Kuroi et al. found several associations with seroma formation, such as obesity, hypertension, longer operation time, lack of drainage, electrocautery use, and drainage volume in the first 3 post-operative days [14]. Some studies found that patients over the age of 60 were at higher risk for seromas [15–17] while others found no such difference [18,19]. Along with risk factors, studies have attempted to elucidate seroma prevention strategies, like the use of sharp or ultrasonic dissection [20–24], and introduction of talc into the wound cavity [25,26].
Seroma is the most common complication following mastectomy and can require several days of drainage and lead to delayed wound healing, longer hospital stays, and an increased financial and emotional burden. Seroma formation is not well understood and but there is good evidence that closing the dead space via quilting can help reduce seroma formation. This study assessed randomized controlled trials and reviewed current literature to elucidate if there is a strong association between quilting sutures and seroma formation.
A systematic search of 5 databases using search terms similar to “seroma”, “quilting”, “flap fixation”, “random”, and “mastectomy”. Data was extracted and Medcalc software used to perform a meta-analysis of the primary outcome: incidence of seroma formation, as well as secondary outcomes: volume and duration of drainage.
Eleven randomized controlled trials with 2009 patients were included. Quilting with sutures greatly reduced the incidence of seroma formation compared with conventional closure (p < 0.001, RR 0.367 [95% CI 0.25, 0.539]; I² = 63.56%) as well as duration of drainage (p = 0.015, SMD -1.657, SE 0.680 [95% CI -2.991, −0.324]; 8 studies, n = 1578; I² = 98.98%). Quilting did not significantly affect volume of drainage.
Quilting was found to be associated with lower seroma rates. Future studies should investigate the use of quilting in combination with other preventative techniques to search for a synergistic method that will further improve patient care.
Cyanoacrylate Adhesive Reduces Seroma Production After Modified Radical Mastectomy or Quadrantectomy With Lymph Node Dissection—A Prospective Randomized Clinical Trial
2017, Clinical Breast Cancer
Citation Excerpt :
Moreover, the number of lymph nodes removed and the number of infiltrated lymph nodes were found to be significantly greater in the cases than in the controls. A greater number of removed lymph nodes, including infiltrated ones, would be expected to be associated with increased seroma production.32 However, such a finding was not confirmed in our study, which, again, can be attributed to the use of cyanoacrylate adhesive in our case patients.
The accumulation of fluid, a seroma, is a frequent complication after modified radical mastectomy or quadrantectomy with lymph node dissection. The aim of the present study was to examine whether a new adhesive material made of cyanoacrylate can effectively provide a sealing coat to tissues and thus reduce the incidence of seroma significantly.
The present prospective, randomized case-control study included 128 women with a breast cancer diagnosis and scheduled for modified radical mastectomy or quadrantectomy with lymph node dissection in Thessaloniki, Greece. In 64 patients (cases), a cyanoacrylate adhesive was applied at the operative field after removal of the tumor and lymph nodes; the remaining 64 patients served as the controls.
Seroma production (P = .001), drainage duration (P = .001), and drainage amount (P = .001) were all significantly less for cases than for controls. The results from a stepwise multiple regression model incorporating the use of adhesive, body mass index, tumor size, and number of infiltrated lymph nodes were significant and able to explain 51.6% of the variability in seroma amount.
The results of our study have demonstrated that the cyanoacrylate adhesive can contribute to the reduction of seromas produced after mastectomy and subsequently decrease the duration of postoperative drainage and the frequency of seroma aspirations. However, because the pathogenesis of seroma formation is multifaceted and complex, further research of larger sample sizes is required to confirm the results of our study.
A mussel-inspired double-crosslinked tissue adhesive on rat mastectomy model: seroma prevention and in vivo biocompatibility
2017, Journal of Surgical Research
Seroma formation is a common postsurgical complication of breast cancer surgery. It delays wound healing and may lead to other more serious complications. Conventional methods of reducing seroma formation through suturing or placement of surgical drainage produce inconsistent clinical outcomes. Tissue adhesives are viable alternatives but most of them are unsuitable for internal use and for large-area applications because of weak tissue adhesion strength or biocompatibility issues. The aim of this study was to evaluate the efficacy and biocompatibility of a mussel-inspired double-crosslinked tissue adhesive (DCTA) in reducing seroma formation after mastectomy.
Thirty-six female Sprague–Dawley rats were randomly assigned to either the saline control group (n = 12), the TISSEEL sealant (Baxter) group (n = 12), or the DCTA group (n = 12). After performing a mastectomy and applying the corresponding treatment, the efficacy of DCTA was evaluated by measurement of seroma volume while its biocompatibility was assessed via micronuclei test and histopathologic examination.
During the 1-wk postsurgical period, the average total seroma volume of DCTA was significantly lower than the saline control group. Importantly, the mean seroma volume in DCTA showed a decreasing trend, whereas those in TISSEEL and saline control groups showed otherwise. The application of DCTA showed no genotoxic effect on the host and no severe inflammation.
This study demonstrates that the good tissue adhesion strength and stability of DCTA were successful in reducing seroma formation over a period of 1 wk. Furthermore, the results also showed that it is biocompatible, which makes it suitable for large-area, internal use.
Prospective comparison of Sapylin and Avitene for reducing hydrops after axillary lymphadenectomy in breast cancer patients
2017, Journal of Surgical Research
This study compared the efficacy of Sapylin and Avitene in reducing postoperative axillary seroma formation and effusion when applied topically after axillary lymphadenectomy.
A total of 224 patients were randomly divided into a Sapylin treatment group (STG), an Avitene treatment group, and a control group (CG). All patients underwent axillary lymphadenectomy and were treated during surgery with Sapylin, Avitene, or neither according to their group assignment. The duration and amount of postoperative drainage, as well as the occurrence of seromas were recorded. Outcomes were compared by one-way analysis of variance and chi-square tests.
Baseline patient data, including age, body mass index, history of neoadjuvant chemotherapy, type of surgery, number of resected lymph nodes, and number of positive metastases did not differ among the three groups. Patients in both the STG and the Avitene treatment group experienced significantly fewer days of drainage than those in the CG; there was no significant difference in drainage tube retention time between the two treated groups. The STG experienced significantly less drainage volume than the CG. Fewer patients in both treatment groups required seroma treatment or experienced complications compared with CG patients.
Both Sapylin and Avitene effectively reduced postoperative subcutaneous fluid accumulation after axillary lymphadenectomy. These treatments may be particularly useful for breast cancer patients at high risk of seroma formation, especially those with hypertension, diabetes mellitus, or a high body mass index who undergo axillary lymphadenectomy.
Seromas and Punctures after Axillary Lymph Node Dissection for Breast Cancer: The Impact and Interests of Per-Operative and Pre-Operative Icg Administration
2024, SSRN
The QUILT study: quilting sutures in patients undergoing breast cancer surgery: a stepped wedge cluster randomized trial study
2023, BMC Cancer

View all citing articles on Scopus

View full text

Seroma prevention following axillary dissection in patients with breast cancer by using ultrasound scissors: a prospective clinical study

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgements

Am J Surg

Eur J Surg Oncol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Eur J Surg Oncol

Eur J Surg Oncol

Breast

Am J Surg

Eur J Surg Oncol

Am J Surg

Eur J Surg Oncol

Eur J Surg Oncol

Am J Surg

Eur J Surg Oncol

Breast

Comparisons and hospital stay after surgery for breast cancer: a prospective study of 385 patients

Br J Surg

Wound complications following radical mastectomy: an analysis of perioperative factors

J Am Osteopath Assoc

Effect of closing dead space on incidence of seroma after mastectomy

Surg Gynecol Obstet

Effect of closing dead space on seroma formation after mastectomy. A prospective randomised clinical study

Eur J Surg Oncol

Seroma formation following axillary dissection for breast cancer: risk factors and lack of influence of bovine thrombin

J Surg Oncol

Experience with ultrasound scissors and blades (UltraCision) in open and laparoscopic liver resection

Ann Surg