Key words
breast cancer - breast - breast malignancy - complication - drainage - seroma
Schlüsselwörter
Mammakarzinom - Mamma - Mammamalignom - Komplikation - Drainage - Serom
Introduction
The surgical therapy of breast cancer has fundamentally changed in the last 20 years.
While oncological outcomes have remained the same or even improved, the Halsted
radical mastectomy procedure has largely been replaced by breast-conserving surgery
combined with radiotherapy. The more general use of neoadjuvant chemotherapy has
further reduced the extent of surgery required in patients who respond well to
chemotherapy.
The rate of complications following surgery, including nerve damage, infections and
skin necrosis [1], [2], has also
decreased. However, seromas and haematomas still commonly occur postoperatively.
This can lead to delayed treatment after surgery, impaired wound healing and longer
hospital stays.
Drainage placement was first described by Murphy in 1947 and aimed to reduce these
problems [3]. However, evidence for the medical benefit of
drain placement after breast surgery is controversial. Some studies have reported
wound infections [4], [5], [6], increased pain [7], [8] and longer hospital stays [8], [9], [10], [11] as a consequence of drainage placement during breast
surgery.
In the past, various attempts were proposed to reduce the formation of seromas. The
methods used ranged from simple compression bandages [12], the use of special surgical instruments [13],
the injection of sclerosing agents [14] to wound closure
with fibrin glue [15] and physiotherapy [16]. The published data on the benefits of these
respective methods are, however, contradictory. Several review articles came to the
conclusion that a clinical benefit in the form of reduced seroma formation rates
after breast surgery could not be demonstrated for any of these methods with
sufficient statistical confidence [5], [17], [18].
The removal of drains is usually possible without any problems in the first few days
postoperatively if the amount of drained fluid is low [11]. The question therefore arises whether, given the latest surgical
techniques, using a Redon drain in breast surgery still effects the rates of
revision and of conservatively treated complications (secondary bleeding or seroma)
or whether it would be possible to dispense with drain placement if there are no
additional risk factors.
Materials and Method
A retrospective analysis of patients operated on in the Hohenlohe Breast Centre in
the period from January 2009 to April 2012 included datasets of 678 patients with a
diagnosis of breast cancer or ductal carcinoma in situ (DCIS). Data were collected
from the tumour database of the certified breast centre, surgery reports, medical
charts and discharge letters. A total of 105 out of 678 patients were excluded from
further analysis for any one of the following reasons ([Fig. 1]): all patients classified as “secondary carcinoma”, with
bilateral breast cancer, with recurrence, with metastases or with an unknown primary
tumour were excluded from statistical analysis as well as patients who had started
neoadjuvant chemotherapy or hormone therapy or who had had surgery outside the
survey period. Some patients rejected surgical treatment or preferred to undergo
further treatment in another hospital. Two patients died during the time of
treatment planning from causes unrelated to cancer.
Fig. 1 Selection criteria for the database with case numbers.
The remaining 573 patients were operated on by any one of 7 experienced breast
surgeons (number of operations n1/2/3/4/5/6/7 = 25/26/44/45/123/152/158).
Approval for the study was applied for and received from the appropriate Ethics
Committee (Approval number S-509/2011). Patients were informed preoperatively about
the procedure.
If breast-conserving tumorectomy was not possible because of tumour size, the patient
was offered neoadjuvant chemotherapy or two-stage reconstruction after breast
ablation. The standard surgery protocol allowed the use of scalpels, scissors and
bipolar forceps as standard instruments for haemostasis. Monopolar instruments or
argon-ion lasers were used in individual cases. The surgeon decided on the type of
incision based on considerations of oncological safety and cosmesis.
Patients were given one intraoperative dose of antibiotics (cefazolin 2 g i. v.);
haemostatic agents (e.g. Arista®, Floseal®, Tabotamp®) were not used.
Postoperatively, all patients were treated with a circular compression bandage which
was removed on the 1st postoperative day.
In breast-conserving therapy (BCT) the preferred approach was tumorectomy with
resection of the skin and fascia. Coverage of the defect was done by subcutaneous
mobilisation of breast glands in adjacent quadrants. Rotationplasty or
reconstruction (free or pedicled flaps, B-plasty) were not done. If drains were
used, a suction drain was placed in each separate wound (tumour bed and axilla).
The surgical technique used in mastectomy procedures included resection of the
mammary gland with removal of the nipple and the pectoral fascia. Lymph node
dissection was done from the lateral resection border. Drainage of fluids was done
through the chest wall.
Removal of sentinel lymph nodes was done through an incision with a length of around
3 cm directly over the area with the highest count subsequent to marking with
technetium-99 and methylene blue. For axillary dissection the incision was extended
accordingly.
In the period to April 2012, no drains were placed in 143 patients who had surgery
with limited blood loss. Only the primary intervention was included in the analysis;
subsequent interventions were not taken into account.
A total of 443 patients (77.3 %) underwent additional treatment after surgical
therapy in our breast centre. Of the remaining 130 patients, 103 patients (18.0 %)
had a documented follow-up examination by their general practitioner or
gynaecologist. In such cases, the breast centre annually contacts all registered
doctors caring for former patients of the breast centre, asking the physicians about
the patientʼs performance status (ECOG status), the findings at examination and any
complications.
No information was available for 27 patients. Of these patients, 2 patients (0.3 %)
did not wish any data to be passed on to the centre, while no further information
about performance status or follow-up care was available for the remaining 25
patients (4.4 %).
Overall, this corresponds to a follow-up rate of 95.3 % in the 1st half year after
diagnosis. Postoperative complications such as haematomas, wound infections, seroma
formation or seroma puncture were recorded immediately postoperatively or the
information obtained from the gynaecologist or physician responsible for follow-up
care or recorded at follow-up examinations. In addition, the wound was examined
prior to initiating drug treatment or radiotherapy. For patients with clinically
relevant complaints or functional impairments due to seroma formation, we followed
the recommendations of previous studies [9], [19] and carried out ultrasound-guided seroma aspiration.
Clinically occult seromas or haematomas were followed up and punctured if they
became symptomatic.
All statistical analysis was done using SPSS (Version 19; IBM Corporation, New York,
USA). Data are represented using descriptive baseline comparisons of all
investigated variables with empirical measures of central tendency and measures of
dispersion. Depending on the scale of measurement, data are shown using mean values
and standard deviation, median values and range or frequency. Statistical
comparisons between patient groups with and without drains were done with Fisherʼs
test or χ2-test (for frequency data), t-tests (for normally distributed
metric data) or Mann-Whitney U-test (for non-normally distributed metrical data).
Adjustment of significance level for multiple tests (Bonferroni correction) was done
for statistical comparisons between patient groups.
Results
Of the 573 patients, 425 (74.2 %) cases underwent breast-conserving therapy (BCT) at
initial surgery. A total of 148 (25.8 %) patients had primary mastectomy. After all
surgical interventions were completed, the rate of breast-conserving surgeries was
407/573 or 71.0 %.
Patients with primary mastectomy were significantly older (BCT: 60.3 ± 11.5 years;
mastectomy 67.8 ± 14.2 years; t-test: t = 5.82; p < 0.001), and tumours in
patients with primary mastectomy were significantly larger (pT3, pT4) compared to
patients with primary breast-conserving surgery (χ2-test:
χ2 = 137.3; p < 0.001). Patients with primary mastectomy also had
tumours with less differentiated cells (grade 3) significantly more often compared
to patients with BCT (χ2-test: χ2 = 18.9; p < 0.001). There
was no significant difference between patients with BCT and patients with mastectomy
with regard to rates of hormone receptor-positive tumours (χ2-test;
χ2 = 0.2; p = 0.65) and HER2/neu-positive tumours
(χ2-test; χ2 = 3.3; p = 0.07). A second resection had to be
carried out in 123 patients (23.0 %) due to pathological findings (R1 or too small
safety margins). The proportion of patients requiring a second resection did not
differ significantly between patients with BCT and patients with mastectomy (BCT:
24.7 %; mastectomy: 18.2 %; χ2-test: χ2 = 2.59; p = 0.11).
A total of 77 (13.4 %) patients had neither sentinel lymph node biopsy (SNB) nor
axillary lymph node dissection (ALND). All of these were either patients with DCIS
or elderly patients (75+ years), for whom the comorbidity associated with axillary
surgery was weighed against the potential oncological benefit and considered too
high. The proportion of these patients in each group did not differ significantly
between the group with BCT and the group with mastectomy (χ2-test:
χ2 = 0.10; p = 0.76).
Patients with BCT had SNB without subsequent ALND significantly more often compared
to patients with mastectomy (BCT: 58.1 %; mastectomy: 34.5 %; χ2-test:
χ2 = 24.62; p < 0.001), while conversely, patients with mastectomy
underwent ALND significantly more often than patients with BCT (mastectomy: 51.4 %;
BCT: 28.7 %; χ2-test: χ2 = 24.89; p < 0.001). Clinically
asymptomatic seromas were treated conservatively. Symptomatic seromas and seromas
causing functional impairment were treated using puncture. One patient who had
breast-conserving surgery without drainage required treatment for seroma for a
period after discharge. A second operation was necessary in 23 cases due to
complications such as haematomas or infections. The proportion of patients who had
revision surgery was significantly higher in the group of patients with mastectomy
compared to the group of patients with BCT (Mastectomy: 6.8 %; BCT: 3.1 %;
χ2-test: χ2 = 3.9; p = 0.048). For this reason, patients
with BCT and patients with mastectomy will be examined and analysed separately
below.
Patients with breast-conserving surgery
No drains were placed in 110 patients (25.9 %) out of a total of 425 patients
undergoing breast-conserving primary intervention. A statistical comparison of
the tumour characteristics and surgical data for BCT patients with and without
placement of drains showed – with one exception – no significant differences
between groups after adjusting the level of significance for multiple tests (cf.
[Tables 1] and [2]).
The exception was those patients who were HER2/neu positive; the proportion of
HER2/neu-positive patients was significantly higher in the group with placement
of drains compared to the group without drains (χ2-test:
χ2 = 10.0; p = 0.002). If only BCT patients who had revision
surgery (n = 13) were evaluated, then there were no significant differences with
regard to tumour characteristics and surgical data between the group without
drains and the group with drains (all p > 0.05). However, the limited number
of cases means that these results should be interpreted with care (no
statistical tests could be performed for some of the variables due to the
limited case numbers). There was no significant difference with regard to the
incidence of revision surgery for complications between the group without drains
(3.6 %, 4 of 110 patients) and the group with drains (2.9 %, 9 of 315 patients;
χ2-test: χ2 = 0.17, p = 0.68; cf. also [Table 2]).
Table 1 Patient and tumour characteristics of patients
with breast-conserving surgery (n = 425).
|
|
|
Patients with breast-conserving surgery (n = 425)
|
|
|
|
No drains (n = 110)
|
Drain placement (n = 315)
|
p-value
|
|
SD: standard deviation
1
t-test
2 χ2-test
*
significant after Bonferroni correction to adjust the
significance level for multiple tests
|
|
Age
|
Mean
|
59.1
|
60.7
|
0.191
|
|
|
SD
|
11.2
|
11.6
|
|
|
Tumour size
|
pTis
|
11 (10.0 %)
|
36 (11.4 %)
|
0.122
|
|
|
pT1
|
57 (51.8 %)
|
186 (59.0 %)
|
|
|
|
pT2
|
37 (33.6 %)
|
84 (26.7 %)
|
|
|
|
pT3
|
0 (0.0 %)
|
2 (0.6 %)
|
|
|
|
pT4
|
2 (1.8 %)
|
0 (0.0 %)
|
|
|
|
pTX+ypT0
|
3 (2.7 %)
|
7 (2.2 %)
|
|
|
Hormone receptor status
|
positive
|
94 (85.5 %)
|
252 (80.0 %)
|
0.072
|
|
|
negative
|
12 (10.9 %)
|
59 (18.7 %)
|
|
|
|
unknown
|
4 (3.6 %)
|
4 (1.3 %)
|
|
|
HER2/neu status
|
positive
|
20 (18.2 %)
|
101 (32.1 %)
|
0.0022*
|
|
|
negative
|
85 (77.3 %)
|
181 (57.5 %)
|
|
|
|
unknown
|
5 (4.5 %)
|
33 (10.5 %)
|
|
|
Grade
|
G1
|
13 (11.8 %)
|
39 (12.4 %)
|
0.162
|
|
|
G2
|
69 (62.7 %)
|
165 (52.4 %)
|
|
|
|
G3
|
27 (24.5 %)
|
99 (31.4 %)
|
|
|
|
GX
|
1 (0.9 %)
|
12 (3.8 %)
|
|
|
Cancer location (side)
|
right
|
57
|
156
|
0.682
|
|
|
left
|
53
|
159
|
|
Table 2 Surgical data and complication rates for patients
with breast-conserving surgery (n = 425).
|
|
Patients with breast-conserving surgery (n = 425)
|
|
|
No drains (n = 110)
|
Drain placement (n = 315)
|
p-value
|
|
LN: lymph nodes; SNB: sentinel lymph node biopsy; ALND:
axillary lymph node dissection; SD: standard
deviation
1
χ2-test
2 Mann-Whitney
U-test
3 t-test
|
|
No LN removed
|
15 (13.6 %)
|
41 (13.0 %)
|
0.871
|
|
SNB (no ALND)
|
64 (58.2 %)
|
183 (58.1 %)
|
0.991
|
|
Number of LN removed (mean, range)
|
1, 0–7
|
2, 1–13
|
0.0132
|
|
ALND
|
31 (28.2 %)
|
91 (28.9 %)
|
0.891
|
|
Number of LN removed (mean, range)
|
12, 1–20
|
14, 1–37
|
0.072
|
|
Resection margin in mm (mean ± SD)
|
4.7 ± 3.0
|
5.3 ± 3.9
|
0.163
|
|
Second resection
|
29 (26.4 %)
|
76 (24.1 %)
|
0.641
|
|
Revision surgery (due to complications)
|
4 (3.6 %)
|
9 (2.9 %)
|
0.681
|
Patients with mastectomy
Out of a total of 148 patients with mastectomy, no drain placement was done in 33
patients (22.3 %). A statistical comparison of tumour characteristics and
surgical data showed no significant difference between mastectomy patients with
drains and mastectomy patients without drains after adjusting the significance
level for multiple tests (cf. [Tables 3] and [4]). In the group of mastectomy patients who required
revision surgery (n = 10), there were no significant differences with regard to
tumour characteristics and surgical data between the group with drains and the
group without drains (all p > 0.05). As was noted for the comparison of BCT
patients requiring revision surgery, the limited number of cases means that the
results must be interpreted with care (here too, no statistical tests could be
done for some of the variables due to the limited case numbers). As was reported
above for BCT patients, there was no significant difference in the incidence of
revision surgery for complications in the group of mastectomy patients between
the group without drains (9.1 %; 3 of 33 patients) and the group with drain
placement (6.1 %, 7 of 115 patients; χ2-test: χ2 = 0.37,
p = 0.54; cf. [Table 4]).
Table 3 Patient and tumour characteristics of patients
with mastectomy (n = 148).
|
|
|
Patients with mastectomy (n = 148)
|
|
|
|
No drains (n = 33)
|
Drain placement (n = 115)
|
p-value
|
|
SD: standard deviation
1
t-test
2 χ2-test
|
|
Age
|
Mean
|
65.3
|
68.5
|
0.251
|
|
|
SD
|
14.6
|
14.0
|
|
|
Tumour size
|
pTis
|
3 (9.1 %)
|
2 (1.7 %)
|
0.032
|
|
|
pT1
|
4 (12.1 %)
|
23 (20.0 %)
|
|
|
|
pT2
|
15 (45.5 %)
|
71 (61.7 %)
|
|
|
|
pT3
|
7 (21.2 %)
|
12 (10.4 %)
|
|
|
|
pT4
|
3 (9.1 %)
|
7 (6.1 %)
|
|
|
|
pTX+ypT0
|
1 (3.0 %)
|
0 (0.0 %)
|
|
|
Hormone receptor status
|
positive
|
27 (81.8 %)
|
91 (79.1 %)
|
0.562
|
|
|
negative
|
5 (15.2 %)
|
23 (20.0 %)
|
|
|
|
unknown
|
1 (3.0 %)
|
1 (0.9 %)
|
|
|
HER2/neu status
|
positive
|
8 (24.2 %)
|
46 (40.0 %)
|
0.242
|
|
|
negative
|
20 (60.6 %)
|
67 (58.3 %)
|
|
|
|
unknown
|
5 (15.2 %)
|
2 (1.7 %)
|
|
|
Grade
|
G1
|
0 (0.0 %)
|
3 (2.6 %)
|
0.152
|
|
|
G2
|
16 (48.5 %)
|
67 (58.3 %)
|
|
|
|
G3
|
16 (48.5 %)
|
45 (39.1 %)
|
|
|
|
GX
|
1 (3.0 %)
|
0 (0.0 %)
|
|
|
Tumour location (side)
|
right
|
15
|
60
|
0.502
|
|
|
left
|
18
|
55
|
|
Table 4 Surgical data and complication rates for patients
with mastectomy (n = 148).
|
|
Patients with mastectomy (n = 148)
|
|
|
No drains (n = 33)
|
Drain placement (n = 115)
|
p-value
|
|
LN: lymph nodes; SNB: sentinel lymph node biopsy; ALND:
axillary lymph node dissection; SD: standard
deviation
1
χ2-test
2 Mann-Whitney
U-test
3 t-test
|
|
No LN removed
|
8 (24.2 %)
|
13 (11.3 %)
|
0.061
|
|
SNB (no ALND)
|
11 (33.3 %)
|
40 (34.8 %)
|
0.881
|
|
Number of LN removed (mean, range)
|
2, 1–7
|
2, 1–5
|
0.872
|
|
ALND
|
14 (42.4 %)
|
62 (53.9 %)
|
0.241
|
|
Number of LN removed (mean, range)
|
13, 6–26
|
13.5, 1–27
|
0.502
|
|
Resection margin in mm (mean ± SD)
|
7.9 ± 8.5
|
7.0 ± 5.3
|
0.493
|
|
Second resection
|
6 (18.2 %)
|
21 (18.3 %)
|
0.991
|
|
Revision surgery (due to complications)
|
3 (9.1 %)
|
7 (6.1 %)
|
0.541
|
Discussion
This retrospective study investigated whether the placement of Redon drains is
necessary during primary surgery for breast cancer or its precursors. The results of
our study showed that in our cohort non-placement of a drain was not associated with
a higher rate of revision, neither in the group who had breast-conserving surgery
nor in the group with mastectomy; the overall rate of revision was very low at 4 %
(23 out of 573 cases) [20].
Our study differed from prospective studies on this topic [5], [11], [21], [22], as the basic population selected
for the cohort study consisted of patients treated in the breast centre with a
primary diagnosis of breast cancer. This means that our study covered a wide range
of different oncological treatment options, which also resulted in a higher number
of cases compared to other studies. The disadvantage of this retrospective
unicentral data mining is the lack of any preoperative randomisation. The final
investigations were done within the Department, but not all complications were
potentially known at the time of discharge. Prior to any radiotherapy or
chemotherapy, patients underwent a further physical examination with investigation
of their medical history. If the patients did not undergo any treatment after
surgery, it was up to the discretion of the physician providing follow-up care
whether to discuss any existing complaints with the patient. Despite comparable
tumour characteristics, it was not possible to exclude surgeonʼs bias.
Secondary bleeding
Haematomas are well known complications which can delay wound healing. Depending
on their size and the clinical findings, haematomas can be treated
conservatively. Nevertheless, haematomas occurring in the immediate
postoperative period due to acute secondary bleeding were the most common reason
for revision surgery in our study.
The number of cases with secondary bleeding can be reduced by a careful and
thorough coagulation of vessels. However, electrocoagulation has been reported
to be a risk factor for postoperative seroma formation [12]. Achieving maximum haemostasis with minimum coagulation therefore
depends on the surgeonʼs experience. Moreover, the placement of drains can
result in the formation of fewer postoperative haematomas requiring revision
surgery. A drain together with a compression dressing should ensure drainage of
haematomas or seromas in the wound site. Compression bandages should also stop
minimal secondary bleeding. Clinical experience, however, shows that this rarely
occurs as the formation of coagulum in the drainage tube during secondary
bleeding can plug the drainage early on. This can lead to haematoma formation in
the wound bed which presents as a firm, elastic, partly painful mass at the
operative site. In many cases, these acute haematomas have to be removed
surgically to provide relief or achieve haemostasis. There are still
insufficient studies in the literature on the impact of well-placed compression
dressings, the number of drains and different suction strengths on secondary
bleeding and haematomas [12], [23], [24].
Seroma formation
After acute haematoma, the postoperative formation of overlarge or infected
seromas is a complication which occasionally requires surgical intervention.
Seroma formation is caused by impaired or missing lymphatic vessels and
postoperative inflammatory reactions. Use of the sentinel lymph node technique
contributes to preserving lymphatic drainage in the majority of cases. Studies
have shown that use of SLNB reduced the incidence of lymphedema [2], [25], [26].
To reduce seroma formation, different surgical techniques and instruments have
been evaluated for their impact on postoperative seroma formation [10], [17], [27], [28]. In a recent
review, however, Srivastava and colleagues [5] showed
that the results of existing studies on this topic are contradictory. To date,
there is no convincing and unambiguous data available proving the efficacy of
the different surgical techniques and instruments for the reduction of seroma
formation.
The intraoperative use of fibrin glue to prevent the formation of seromas
postoperatively has also been studied. Particularly interesting in this context
was the prospective randomised study by Jain et al. [8], in which the efficacy of drain placement was compared with the
efficacy of fibrin sealant in 116 patients with BCT/mastectomy and level I &
II lymphadenectomy. The study came to the conclusion that the placement of
drains did not prevent the formation of seromas and resulted in a longer
postoperative hospital stay (2.9 vs. 1.9 days; p < 0.001) and increased pain
at 24 hours (pain score 4.5 vs. 3.2; p < 0.001) and 48 hours postoperatively
(pain score 2.2 vs. 1.4; p = 0.002). In patients with mastectomy, it was found
that fibrin glue significantly reduced the incidence and total volume of
seromas. The authors recommended dispensing with the drains and using fibrin
sealants, even in mastectomy procedures. The rate of revision reported by Jain
et al. was 0 %, although 3 patients received oral antibiotics and 1 patient was
treated for haematoma on an outpatient basis. Nevertheless, the efficacy of
fibrin sealant to reduce seroma formation remains controversial, and a recent
meta-analysis [18] showed no significant impact of
fibrin glue on the incidence of seroma formation, total seroma volume, wound
infection and length of hospital stay.
Purushotham et al. [9] compared length of hospital stay
and psychological and physical morbidity for patients with primary breast cancer
treated either by conventional surgery with drain placement or surgically
without placement of drains (adaptation using remaining tissue/subcutaneous
tissue/pectoral fascia). In their study, non-placement of drains resulted in a
significant decrease in the length of hospital stay, while the level of patient
satisfaction and the incidence of seromas und wound infections did not differ
between groups.
In contrast, in a meta-analysis of 6 randomised studies published in 2009 by
Droeser and colleagues [11], they found that
volume-controlled placement of drains after breast surgery with axillary lymph
node dissection reduced the formation of clinically symptomatic seromas and the
number of seroma punctures compared to non-placement or only brief placement of
drains. There was no difference in the rate of infections. The investigated
studies only included patients who had axillary dissection and the majority
patients had undergone mastectomy. He et al. [22]
confirmed these results in a recent review article where the patient cohort was
surgically heterogeneous. But both authors recommended further prospective
studies to assess the necessity for drain placement in breast surgery with
axillary lymph node dissection.
The results of a large prospective study with 596 patients were recently
published by Taylor et al. [29]. No difference in the
incidence of seromas, the number of seroma punctures and wound infection rates
was found between patients with drains and patients without drain placement,
irrespective of the type of surgery. This data agrees with the results of our
retrospective study, which investigated a similar number of patients, although
it should be noted that in our study the proportion of patients who had
breast-conserving surgery was considerably higher compared to the study by
Taylor et al.
Wound infections
Postoperative infections are yet another type of complication; wound infections
are usually treated conservatively and only occasionally require revision
surgery.
Internationally, the reported rate of infection after breast surgery ranges
between 0.8 and 26 % [30], [31]. OnkoZert has proposed that the rate of infections in certified
breast centres should not exceed 5 % [32]. Our data
complies with this proposal, and no postoperative infections which led to a
delay in subsequent treatment or hospitalisation of the patient occurred during
the period under investigation.
In a systematic review by Xue et al. [4], postoperative
drains, longer drainage periods and the placement of a secondary drain were
identified as risk factors for postoperative wound infection. In contrast,
Droeser et al. [11] and He et al. [22] found no association between drain placement and
wound infection in their reviews.
Additional risk factors for complications after breast surgery
A body mass index (BMI) > 30 is a well-known risk factor for impaired wound
healing after abdominal surgery [33]. Similarly, a
12-fold higher risk of complications has been reported for elective breast
surgery in women with higher BMI [34], although the
majority of cases (80 %) in this study had reduction surgery. Helyer et al. also
described an association between obesity and lymphedema [35]. In addition to BMI, the study by Helyer and colleagues also
identified the number of resected lymph nodes as a risk factor for the
development of postoperative lymphedema. In our study, both the percentage of
patients undergoing ALND and the numbers of lymph nodes resected at ALND were
comparable for both groups (cf. [Tables 2] and [4]). Only in the group of mastectomy patients
requiring revision surgery for complications did patients with drains have ALND
more often than patients without drain placement. The average number of resected
lymph nodes was also slightly higher in the group with complications compared to
the remaining patients.
In addition to BMI [34], tumour size [13] and the relation between surgical specimen volume
and breast size could also have an impact. As no data on the size and weight of
the resected specimen or chest circumference/cup size was collected, these
variables were not included in our analysis.
Conclusion
Our data shows that in our cohort non-placement of drains had no effect on the rate
of surgical revisions due to complications, neither in the group with
breast-conserving surgery nor in the group with mastectomy. As a review of the
literature found no arguments either for or against the standard placement of
drains, we would recommend an individualised approach adapted to the individual
risk.
