Seroma following breast cancer surgery

EJSO 2003; 29: 711–717 doi:10.1016/S0748-7983(03)00096-9

Seroma following breast cancer surgery C. J. Pogson*, A. Adwani and S. R. Ebbs Breast Unit, Mayday University Hospital, London Road, Croydon CR7 7YE, UK

Background: Seroma is a common problem following breast cancer surgery causing patient discomfort and prolongation of hospital stay. Methods: This manuscript reviews the relevant literature obtained by an extensive search of the medline database. In addition papers were also derived from the reference lists of retrieved articles. Results and conclusion: The advantages and disadvantages of the various methods to deal with seroma are discussed. Based on this an individual patient based policy can be formulated. q 2003 Elsevier Ltd. All rights reserved. Key words: seroma; breast cancer surgery; drains; early discharge.

INTRODUCTION There are widely varying recommendations to prevent the development of a seroma, one of the most common complications of breast cancer surgery. In this article, we present a review of the literature in an attempt to clarify the evidence. The relevant literature was obtained by an extensive search of the Medline database. In addition, papers were also derived from the reference lists of retrieved articles. Randomised control trials, retrospective studies as well as smaller descriptive studies were included in order to provide a comprehensive review of the literature and to increase the evidence base in each of the reviewed categories.

ORIGIN OF SEROMA Aetiological factors A seroma is a serous fluid collection, which develops following the formation of skin flaps during mastectomy or in the axillary dead space after axillary dissection. The incidence of seroma has been shown to correlate with patient’s age,1 breast size, hypertension,2 presence of malignant nodes in the axilla,3 number of malignant nodes,4 previous surgical biopsy4 and use of heparin.1 Tamoxifen may contribute to seroma formation by Correspondence to: A. Adwani FRCS, Breast Unit, Mayday University Hospital, London Road, Croydon CR7 7YE, UK. Tel.: þ 44-20-84013405; Fax: þ44-20-8401-3406; E-mail: [email protected] * Specialist Registrar General Surgery, St George’s Healthcare NHS Trust, Blackshaw Road, Tooting London SW17 0QT, UK. 0748–7983/03/$30.00

delaying adherence of skin flaps to the chest wall, perhaps by inhibiting the early stages of collagen synthesis.3 The origin of seroma is unclear. Watt-Boolsen5 suggested that it is an exudate from an acute inflammatory reaction. Oertli et al.6 suggested that the fibrinolytic activity in serum and lymph might contribute. Tranexamic acid is an antifibrinolyic agent, which reduces drainage when used peri and post operatively.6 Bonnema et al. showed that the fibrinogen level in seroma was very low compared with plasma on day 1 but on days 5 and 10 post operatively it was virtually undetectable,7 and that peripheral lymph does not clot and contains only a trace amount of fibrinogen. Consequently they hypothesized that seroma is most likely to originate from lymph.8 Seroma may be influenced by surgical techniques.9 The use of electrocautery10,11 in mastectomy may reduce blood loss but increases the rate of seroma formation. Argon diathermy and laser scalpel, produce similar volumes of seroma to knife dissection.12,13

REDUCTION OF SEROMA Obliteration of dead space by mechanical means The techniques that have been described to obliterate the dead space in order to reduce seroma formation are listed in Table 1. However, suturing flaps may add to the operating time.18 Mechanical pressure has also been applied to obliterate the dead space. The use of a pressure garment q 2003 Elsevier Ltd. All rights reserved.

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Table 1

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Obliteration of dead space by mechanical means

Author

Technique

Halsted14 1913

Short superior flap sutured with interrupted silk to the fascia below the first rib. Rest of defect skin grafted. Tension sutures tied over rubber tubing bolsters to tack flaps down. Through and through sutures between the skin and the chest wall. Multiple cotton subcutaneous sutures to tack the flaps down. Avoided using drains if possible Dexon tacking sutures to skin flaps. Axillary dead space obliterated with approximation of muscle. Closed suction drains together with flap attachment resulted in fewer seromas and a lower infection rate. Large study ðn ¼ 204Þ Avoided the use of drains by surgical wadding of the axilla with proximate muscle. Significant reduction in seroma formation, aspiration volume and number of aspirations. Small study ðn ¼ 53Þ Skin flaps tacked down with vicryl. Drains removed at 48 hours. Low incidence of seroma (8%) Small study ðn ¼ 33Þ Randomised comparison of suturing skin flaps to underlying muscle with conventional skin closure. Closed suction drainage and seroma less in flap suture group. Small study ðn ¼ 39Þ

Orr15 1951 Keys et al.16 1953 Larsen et al.17 1955 Aitken et al.18 1984

Hamy et al.19 1990

O’Dwyer et al.20 1991 Coveney et al.21 1993

has not been shown to reduce post-operative drainage, has a low tolerance and a higher complication rate.22,23

Obliteration of dead space by chemical means In an animal model fibrin glue,24,25 light activated fibrin sealant26 and transdermal photopolymerised adhesive,27 reduced seroma formation after mastectomy in the rat. Sanders et al.28 reported that the highest concentrations of fibrinogen and thrombin in the fibrin sealant, were the most effective. In human studies, no significant advantage to the use of fibrin glue was seen.29 – 31 In three other studies, fibrin glue significantly reduced the total seroma drainage,32 allowed earlier drain removal33 and reduced hospital stay.34 However, most studies had a relatively small sample size (21 – 68 patients). A prospective randomised study by Gilly et al. with 108 patients showed that the use of fibrin glue reduced daily postoperative drainage and hospital stay but did not affect delayed seroma formation.34 Bovine thrombin application to the axilla has no effect on subsequent seroma development.35 Sclerotherapy using tetracycline, has led to severe pain on introduction of the drug into the drains36,37 with no demonstrable benefit.37

Shoulder movement restriction Wound seromas and shoulder dysfunction are common complications of a mastectomy.38 Temporary immobilis-

ation of the shoulder may help. Jansen et al.39 and Browse et al.40 immobilised the shoulder using a collar and cuff. Dawson et al.41 immobilised the shoulder with a sling and Petrek et al.9 wrapped a loose fitting bandage around the upper arm and secured this to a surgical bra. Immobilisation of the shoulder has shown no significant advantage, in terms of seroma formation or shoulder function, in these studies. Conversely, a study of 64 patients, in 1979 showed a benefit from using a triangular bandage for 7 days.42 The mean volume of wound drainage was reduced by 40% and mean drainage time reduced by 29% with no difference in shoulder function but was associated with an increased incidence of mild lymphoedema of the arm. In general, the evidence suggests that shoulder immobilisation confers little benefit. Is there a benefit in delaying active shoulder mobilisation by physiotherapy on seroma formation? Lotze43 reported that patients randomised to receive early physiotherapy had more total wound drainage, longer drainage, and a longer hospital stay, but no differences in the functional range of movement in the longer term. Schultz et al.44 reported the incidence of seromas after modified radical mastectomy was reduced by delaying physiotherapy, without impairing shoulder function. Chen et al.45 delayed physiotherapy until after drain removal (113 patients). The axillary drainage was less than in groups commencing physiotherapy on day 3 or day 6 (231 patients). No functional difference was noted at 6 months. Rodier et al.46 and Van Der Horst et al.47 found no significant difference in seroma production with early or delayed

SEROMA FOLLOWING BREAST CANCER SURGERY physiotherapy. Delayed physiotherapy may thus reduce seroma formation at the expense of mild short-term shoulder dysfunction but without long term restriction of movement.

CLOSED WOUND DRAINAGE Suction and passive drainage Closed suction wound drainage revolutionized mastectomy when introduced by Murphey in 1947 48 by obliterating the dead space.49 Morris et al.50,51 showed that the use of closed suction drainage in radical mastectomy patients accelerated wound healing and was also associated with a lower incidence of wound infection, necrosis and breakdown. The incidence of seroma formation was higher in the suction drain group. Bourke et al.52 found no differences in the use of closed suction wound drainage and corrugated wound drainage in 51 simple mastectomy patients. Suction drains are comfortable and reduce more frequent dressing changes.53 Whitfield et al.54 found no significant differences between suction and closed siphon (20Fr Robinson; Wallace) drainage.

Single and multiple drains The use of multiple drains in the axilla might reduce postoperative drainage. Petrek et al. in 1992,55 randomised 65 women with stage I or II carcinoma undergoing axillary dissection or modified radical mastectomy, to one or four redivac axillary drains. Both groups had one further drain inserted under the inferior mastectomy flap. The use of multiple drains did not confer any significant advantage on the amount or duration of drainage. Terrell et al.56 compared the use of one (axillary), versus two (axillary and pectoral) closed suction drains in 84 women undergoing modified radical mastectomy. There was no advantage conferred by the pectoral drain.

High and low pressure suction drains Forty six patients undergoing simple mastectomy were randomised to either use of a high vacuum (Redivac) drain or a low vacuum (Portovac) drain.57 The low vacuum system drained significantly more fluid post operatively and hospital stay was longer. The high vacuum drain led to more efficient flap approximation to the chest wall. Van Heurn et al.58 assessed the effect of low versus high vacuum drainage in 76 patients undergoing axillary dissection with breast conserving surgery. The mean volume evacuated was significantly lower from the low vacuum system and the drains could be removed earlier. Bonnema et al.59 compared high versus low vacuum drainage, in 141

713 patients undergoing modified radical mastectomy, lumpectomy with axillary dissection or axillary dissection alone. There was no significant difference in the volume of axillary fluid production, duration of drainage or wound complication rates between the two groups. High vacuum drains had a higher incidence of vacuum loss but a lower incidence of leakage around the drain. There is thus no strong evidence to recommend high or low pressure of suction.

PATIENT DISCHARGE WITH DRAIN IN SITU The average hospital stay in the United Kingdom is 7 days for breast surgery.60 The most expeditious way of reducing surgical costs is through shortening hospital stay.61 With adequate patient education and co-ordination of inpatient and outpatient facilities, including telephone contacts patients can be safely discharged with drains in situ.62,63 Wagman et al. reported that preoperative training had no impact on length of inpatient stay.64 Acceptance rates for early discharge with drains in situ vary between 24 and 41%.63,65 Patients who chose early discharge tended to be significantly younger, were living with another adult and were more likely to have had breast conserving surgery.65 Patients studied have been discharged with drain in situ the same day;66 – 68 the day following surgery;62,67,69 – 71 day 2 – 3 post op;65,72 – 73 day 3 –4 post op;63,64,74 or day 4– 5 post op.75,76

Consequences of early discharge with drain in situ Early discharge from hospital with the drain in situ does not appear to be associated with any untoward events.64, 65,68,74 Holcombe et al.63 reported in a series of patients undergoing axillary dissection, a lower seroma rate in the early discharge with drain in situ group (18%), compared to a standard treatment group (34%) and a reduction in median hospital stay of 5 days. Edwards et al. reported no significant difference in seroma rates between post mastectomy patients discharged early at a mean of 4.3 days.76 Orr et al.72 reported discharging 72 patients who had undergone either total mastectomy/axillary dissection, segmental mastectomy/axillary dissection, or total mastectomy alone at a mean of 2.9 days. The seroma rate was 11%. The seroma rate for mastectomy patients discharged on the day following surgery has been reported to be between 4569 and 67%.70 Tan has reported that breast cancer surgery including axillary dissection, simple mastectomy or modified radical mastectomy can be safely performed on a short stay basis. Ninety four percent of the patients were discharged within 23 hours of surgery and 50% the same day.68 Hoehn et al.70 discharged 150 patients after breast

714 conserving surgery on the day of surgery with a seroma rate of 20%, requiring a mean of 4.4 aspirations.

Psychological acceptance of early discharge Concerns expressed in the early discharge group of patients included personal care, posture in bed, dressing themselves, fatigue, loneliness, pain, worries about the wound and the arm.65 Despite this, patient acceptance of early discharge with drains in situ remains good.63,64,72 Burke et al. conducted telephone interviews of 23-hour short stay patients. Of these patients, 84% had no difficulty with drain or wound care, 95% reported satisfactory analgesia and patient education and care was highly rated.62 Bonnema, compared discharge on day 4 with drain in situ to discharge on day 9 post drain removal. The two groups did not differ in scores for psychosocial problems, physical or psychological complaints or in the coping strategies used.74 In a similar trial,60 patients were offered either early discharge on day 2 with drains in situ or standard discharge (i.e. once drains removed). Psychological problems were not increased by early discharge.

Cost implications of early discharge with drain in situ Short surgical stay programs increase operating efficiency and reduce medical care costs without compromising quality of care.63,69,75,77,78 24 hour surgery stays can reduce the average hospital cost by 36%.69 Patient care in the community must also be taken into account. Early discharge with drains in situ for suitable patients, is a cost effective and safe strategy.

EARLY DRAIN REMOVAL It is common practice to remove drains when the drainage falls to a minimal volume (20 –50 ml), in the preceding 24 hours to minimize seroma formation.79 By 48 hours after surgery, 74% of the total volume drained has been collected.80 Drains may be safely removed after axillary dissection, if the drainage during the first 3 days is less than 250 ml.81 Somers et al.82 studied 108 patients with level one or two axillary node dissection, whose drains were removed and patients discharged on the first postoperative day regardless of volume of drainage. There was no significant difference with respect to volume at time of drain removal (, or . 30 ml), subsequent mean number of aspirations and time to resolution of seromas. Parikh et al.83 randomised 100 patients having undergone mastectomy with axillary clearance (mean number of lymph nodes ¼ 23), to either drain removal at 3 or at 6 days post-operatively. More seroma was collected in

C. J. POGSON ET AL. the group whose drain was left in situ longer, but once the drain was removed there was no difference in the volume, number and duration of percutaneous aspirations. Inwang et al. randomised 84 patients to drain removal when drainage was less than 20 ml over two consecutive days, or removal on day 5. There was no significant difference in the mean number of aspirations required, wound complications and no detriment of cosmesis.84 Yii et al. compared drains removed at 48 hours to a ‘standard’ removal group. There was no significant difference in drainage at 48 hours and no significant difference in seroma frequency.85 Liu et al. removed drains at 23 hours post operatively in 50 patients undergoing axillary lymphadenectomy. There was only a 2% seroma rate, 49 out of the 50 patients had no symptomatic seroma.86 Thus there appears to be good evidence in the favour of early drain removal.

NO WOUND DRAINAGE Somers et al. compared drainage and no drainage in 227 patients undergoing lumpectomy and axillary dissection.82 Short duration closed suction drainage appeared advantageous in decreasing the incidence and degree of seroma formation and need not delay early hospital discharge. Cameron et al. in 1988,87 studied 40 axillary drainage patients 20 of whom were allocated to no drain. There was a significantly higher rate of seroma in the undrained group (45% vs 10%). Jeffrey et al. reported safe axillary dissection without drainage with breast conserving cancer surgery.88 34 of the 81 women in the study, required seroma aspiration, all patients except one were discharged within 1 day of surgery. All the seromas resolved clinically within 1 month and within 4 months on ultrasound. Seigal et al.89 also reported that axillary dissections combined with breast conserving surgery can safely be performed without axillary drainage. Zavotsky et al.90 demonstrated that axillary node dissection can be managed with or without a drain. More aspirations in the no drain group were required (50%) compared to the drain group (8.3%), but there was no difference in the complication rate and the pain rating was significantly less in the no drain group.

CONCLUSIONS Seroma formation is more of a nuisance than a complication, but may delay patient recovery and cause unpleasant symptoms. Physical closure of the dead space appears to reduce seroma rate, but studies have failed to address the issues of cosmesis, movement and acceptability with this technique. The evidence for the use of fibrin glue remains

SEROMA FOLLOWING BREAST CANCER SURGERY controversial. Thrombin spray, sclerotherapy and mechanical pressure do not reduce the drainage of seroma. Shoulder immobilisation is of no advantage to the patient, but delaying shoulder physiotherapy appears to reduce drainage. Closed suction drainage systems appear to be superior to open drainage systems. There is no good evidence to support the use of multiple drains. High pressure vacuum drains may be better than low suction in mastectomy wounds by producing good flap apposition. In the axilla, low vacuum drains result in less seroma formation, earlier drain removal and earlier discharge. High pressure vacuum drains in the axilla may promote increased drainage due to flap irregularity and poor flap adherence. It appears safe and acceptable to discharge many patients early with drains in situ, with adequate patient counseling and nursing support. Seroma formation, can be safely dealt with on an outpatient basis by aspiration. The value of using no drains following axillary surgery is unproven. Seroma formation does not appear to be a significant problem after axillary node sampling. Its significance after sentinel node biopsy is unknown. A policy for the management of wound drains to prevent seroma formation should thus be individualized, taking into account age, social support, geographic location and general fitness of each patient. This policy must also consider aspects relating to preoperative counselling, nursing (both clinical nurse specialists in breast care and community nursing), accessibility of seroma aspiration clinics and patient education.

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Accepted for publication 7 April 2003