Egyptian Journal of Surgery Vol 28, No 3, July, 2009 ORIGINAL ARTICLE TETRACYCLINE SCLEROTHERAPY IN TREATING POSTMASTECTOMY SEROMA: A SIMPLE SOLUTION FOR A FREQUENTLY OCCURRING PROBLEM Emad Hokkam, Sherif Farrag, Soliman El Kammash Department of General Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt Correspondence to: Emad Hokkam, Email: firstname.lastname@example.org Aim: Seroma is the most common complication occurring after breast surgery. Its management usually involves repeated aspiration and drain insertion. Tetracycline sclerotherapy appeared successful for treating many chronic fluid collections e.g. pleural effusions, hydrocele, liver cysts, renal cysts….etc. The present study aimed to evaluate the efficacy of topical tetracycline (TCN) sclerotherapy in treating postmastectomy seroma. Methods: Forty nine female patients with resistant post mastectomy seroma were enrolled in the study. All patients were subjected to aspiration of the seroma and instillation of 2g tetracycline dissolved in 100 ml sodium chloride 0.9% + 10 ml Lidocaine. After 24 hours, the solution is re-aspirated and a crepe bandage is applied to the chest wall. Each patient is asked to record her pain using the Visual Analogue Scale (VAS). The procedure is repeated in patients who had experienced seroma recollection. Results: Thirty six patients (73.4%) were successfully treated with one sclerotherapy session while nine patients (18.4%) needed two sessions and four patients (8.2%) needed three sessions. The majority of the patients (85.7%) had no complications after the technique. Conclusion: the topical application of tetracycline is effective and feasible method in the management of refractory post mastectomy seroma. Keywords: Breast, lymphocele, seromadesis.
a tendency towards less extensive and rather more conservative interventions.(1)
Breast cancer is the most common cause of cancer deaths among women worldwide. Incidence rates are high in
Seroma formation is the most frequent postoperative
more developed countries, whereas, rates in developing
complication after breast cancer surgery. Its incidence
countries and Japan are low but are lately increasing.(1) In
after breast surgery is (15-81%).(3) It occurs in most
Egypt, breast cancer is the most common cancer in
patients after mastectomy and is increasingly being
females constituting 33% of all female cancers.(2)
considered as a side effect of surgery rather than a complication, however not all patients are clinically
For a long period, surgery was the main line of treatment
of breast cancer. Application of new techniques in the treatment of cancer such as radiotherapy, hormonal
Seroma is defined as a serous fluid collection that
therapy, and chemotherapy allowed better management
develops under skin flaps after mastectomy or in the
of the advanced cases. Although other therapeutic
axillary dead space after axillary dissection (as a
modalities competed with surgery in the treatment of the
consequence of both, lymphatic disruption and oozing of
loco-regional primary tumor, nevertheless, surgery is
still the major diagnostic and therapeutic mean, but with
Although seroma is not life threatening, it can lead to
3. Patients prepared for reconstructive surgery.
significant morbidity e.g. infection, flap necrosis, wound
4. Chronic medical illness (diabetes mellitus, end stage
dehiscence, predisposes to sepsis, prolonged recovery
renal disease and chronic liver disease).
period, multiple physician visits and may delay adjuvant therapy. Fluid collection is ideally managed by repeated
Forty nine patients were eligible for the study. All
needle aspiration to seal the skin flaps against chest
patients were reviewed to evaluate the method, timing,
and outcome of TCN sclerotherapy. Indication for sclerotherapy was based on recurrent seroma despite of
Several interventions have been reported with the aim of
three consecutive sessions of aspiration and crepe
reducing seroma formation including the use of
bandaging. All sclerotherapy sessions were conducted in
ultrasound scissors in performing lymphadenectomy,(7)
the one-day operative room using local anaesthesia. The
using fibrin glue,(8,9) bovine thrombin application,(10) and
technique involves inserting wide bore canula (14 or 16
altering surgical technique to close the dead space.(11)
gauge) to aspirate seroma fluid which is calculated and recorded for every patient (Fig. 1). Then, instillation of 2g
Despite numerous trials of new techniques which have
of TCN in 100 ml of 0.9% of NaCl + 10 ml Lidocaine was
attempted to reduce the incidence of seroma formation,
done. The instillated amount remains in the cavity for 24
no single method appears to be uniformly effective.
hours after which it is aspirated and a crepe bandage is
Topical sclerotherapy with Tetracycline (TCN) has long
applied to the chest wall. Pain is recorded according the
been used successfully in the treatment of malignant
Visual Analogue Scale (VAS) which was classified as
pleural effusions to cause obliteration of the pleural
mild (1-4), moderate (5-6) and severe (7-10).
The first report of TCN sclerotherapy for treating seromas after mastectomy was in 1983 by Sitzmann and his colleagues,(13) who instilled 2 g of TCN in 150 ml of 0.9% NaCl following aspiration of seromas in 5 patients. All patients had a marked decrease in the size of seromas within 48 hrs. In the same year Nichter and his team,(14) demonstrated efficacy of TCN in 4 patients with persistent postoperative seromas. Numerous reports described the use of TCN sclerotherapy in a diverse range of conditions. TCN was used in the past for the treatment of malignant pleural effusions,(12) hydroceles of the testes,(15) endometrial cysts,(16) hepatic cysts,(17) pericardial effusions,(18) and even the gallbladder lumen.(19)
PATIENTS AND METHODS
Following research committee approval and informed
Fig 1. Aspiration of seroma
patient consent, our study was designed as prospective
research that was carried on female patients presented with postmastectomy seroma at surgery outpatient
VAS is a measurement instrument that tries to measure a
clinic, Suez Canal University Hospital in the period
characteristic or attitude that is believed to range across a
between December 2007 and July 2008. All patients
continuum of values and cannot easily be directly
fulfilling the following inclusion criteria were enrolled in
measured. VAS is usually a horizontal line, 100 mm in
length, anchored by word descriptors at each end. The patients mark on the line the point that they feel
1. All females with resistant postmastectomy seroma.
represents their perception of their current state. The
VAS score is determined by measuring the millimeters
Any type of mastectomy operations (modified radical mastectomy, radical mastectomy, simple
from the left hand end of the line to the point that the
mastectomy and breast conservative technique).
All Patients were followed up every 2 weeks for the
4. Any time of presentation (post operatively).
development of complications like fever, infection and flap necrosis. Patients, who experienced seroma
Patients with the following criteria were excluded from
recollection, were subjected to reaspiration of the
collected seroma, recording its amount and TCN sclerotherapy. The subsequent sclerotherapy sessions
were performed using the same volume and
concentration of previously used formula. The sessions
were repeated till the seroma disappeared.
postoperative chemotherapy; half of them had seroma before starting chemotherapy sessions and the other half
Data were collected through history of the surgical
operations, clinical examination of the wound and seroma cavity, investigations like ultrasound to measure
In the first session; the amount of aspirated fluid was
the precise size of the seroma and all details about
<100cc in 10 patients (20.4%), 100-150cc in 22 patients
sclerotherapy sessions for every patient. Data were
(44.9%), and >150cc in 17 patients (34.7%). In the second
analyzed by Statistical Package for Social Science (SPSS)
session; the amount of aspirated fluid was <100cc in 10
version 13.0. Quantitative data were expressed as mean
patients (76.9%), 100-150cc in 3 patients (23.1%), and no
and stander deviation (SD), and qualitative data were
patients had >150cc. In the third session; the amount of
expressed as number & percentage of the total. Student t
aspirated fluid was <100cc in 3 patients (75%), 100-150cc
test was used to test the significance of the difference
in one patient (25%), and no patients had >150cc Table 3.
between quantitative variable while chi square test was
The mean aspiration volume across all patients in the
first session was 120.9±3.6 ml while it was 100.0±25.2 ml and 75.0±35.4 ml in the second and third sessions
respectively. The amount of aspirated seroma was significantly decrease in the second and third session
The study was conducted on 49 female patients with
compared with the first one (t-test, P = 0.006, P = 0.003
mean age 48.5±7.7 years. Modified radical mastectomy
was the most frequent operation done to the patients (71.4%), while the frequencies of simple mastectomy and
The majority of the patients had no pain during or/and
breast conservative technique operations were 18.4% and
after instillation (91.8% & 89.8% of the patients
10.2% respectively. The amount of aspirated seroma was
respectively), the rest of the patients experienced mild to
significantly high in the modified radical mastectomy
moderate pain and no patients had severe pain during
operations rather than other types of operations (chi
or/and after instillation (as assessed by the Visual
square test, P<0.05). The relation between the type of the
Analogue Scale) Table 4. The majority of the patients had
operation and the aspirated fluid in the first session is
no complications after instillation (85.7%), 3 patients
(6.1%) suffered from low grade fever and 4 patients (8.2%) had infections in the wound site. Five out of the
Thirty seven patients (75.5%) presented as early as ≤ 4
seven patients (71.4%) who experienced complications
weeks postoperatively, while 12 patients (24.5%)
were treated in the outpatient clinic by broad spectrum
presented late (> 4 weeks), with the mean time of
antibiotics and antipyretics while two patients needed
presentation 3.3±0.9 weeks. Thirty six patients (73.4%)
hospitalization for treatment with intravenous
had only one instillation, 9 patients (18.4%) had 2
antibiotics. All the seven patients who experienced
instillations, and 4 patients had 3 instillations (8.2%),
complications were subjected to multiple
with the mean of 1.3±0.6 instillations. Table 2 correlates
aspiration/injection sessions (4 patients had two sessions
between amount of aspirated fluid in the first session
while 3 patients had three sessions). Complications
developed in (53.8%) of patients who underwent multiple aspiration/injection sessions while no patient
As regards chemo and radiotherapy, none of the patients
(0%) developed complications in the single
had history of previous radiation to the affected side
aspiration/injection group; it was significantly high in
while 5 patients (10%) had received neoadjuvant
patients who underwent multiple aspiration/injection
chemotherapy. Twelve patients had received
Table 1. The relation between the type of the operation and the aspirated fluid in the first session. Type of operation Amount/ cc Modified radical mastectomy Simple mastectomy Breast conserving therapy Table 2. Correlation between amount of aspirated fluid in the first session and number of aspiration/injections. Number of instillations Amount/ cc Table 3. Amount of aspirated fluid in different sessions of injections. Aspirate fluid 1st session of injection (n=49) 2nd session of injection (n=13) 3rd session of injection (n=4)
* Statistically significant difference versus 1st session value (t-test, p-value < 0.05).
Table 4. Severity of pain as measured by visual analogue scale (VAS) among the studied patients during and after instillation of TCN. During instillation of TCN After instillation of TCN Severity of pain DISCUSSION
administered topically to the chest wall and skin flaps prior to skin closure. The control group received an
Postmastectomy seroma can pose a significant and time-
equal volume of normal saline. Patients were monitored
consuming problem to the surgeon and often resulting in
for the development of postoperative wound seroma
repeated out-patient attendance and aspiration.(21)
every 2 weeks. There were no significant differences
Treatment usually involves needle aspiration or drain
between groups regarding total volume of closed suction
replacement. The rare patient requires return to the
drainage. Seroma formation 2 weeks postoperatively was
operating room for excision of the seroma capsule, which
greater in the TCN group than the control group (53% vs.
22%, P = 0.01). There were no differences between groups regarding the degree of postoperative pain,
The use of sclerosant in the management of seroma is not
wound infection, or seroma formation 1 month
new. Various agents have been investigated, including
postoperatively. They concluded that topical TCN is not
marine mussel proteins and the Gram-positive anaerobe
effective at preventing post-mastectomy wound seromas.
Corynebacterium parvum in rat models.(23) In humans, seromadesis has been reported with erythromycin,(24)
The results of our study disagree with that of the
povidone iodine,(22) talc(25) and hypertonic saline.(26) The
previous study in which TCN was instillated
most commonly reported sclerosant in the literature is
intraoperatively and in a lower concentration (1g TCN in
tetracycline, and there are reports that found it
100cc 0.9% NaCl) which may be low to produce proper
useful(13,14,27) and those that did not.(28,29)
reaction that enhance tissue adhesion. Also the researchers performed the technique once with no trials
Tetracycline sclerotherapy can be administrated in two
ways. The first is to administrate it topically to the chest wall and skin flaps prior to skin closure.(28) while the
McCarthy et al,(29) designed a randomized controlled
second is to aspirate seroma postoperatively and instill
trial to study the effect of topical tetracycline on patients
tetracycline after its dilution in 0.9% NaCl.(13) The present
with post-mastectomy seroma. The trial was aborted as
study aimed to evaluate the efficacy of topical TCN
he found that tetracycline was painful and not effective.
sclerotherapy when used in the second way in treating
In the present study, we avoid the development of severe
pain by adding 10 cc Lidocaine to the used formula.
The results of the current work revealed that the topical
We suggest that post operative tetracycline sclerotherapy
use of TCN is highly efficient in treating post-operative
is a feasible treatment for refractory seroma after
seroma as most of the patients (73.4%) responded well to
mastectomy. It is effective and without serious
this technique from the first session. This result agrees
with that obtained by Sitzmann and his colleagues,(13) who treated five patients with seromas following
mastectomy and axillary clearance by aspiration and instillation of a sclerosant solution containing
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C U R R I C U L U M V I T A E INFORMAZIONI PERSONALI MOLINAS LUISA Italiana ESPERIENZA LAVORATIVA • Dal giugno 1997 ad oggi Consulente Neuropsichiatra Infantile • Nome e indirizzo del datore di Centro Riabilitativo “CTR - Comunicazione Territorio Relazioni” • Tipo di azienda o settore Coop. Soc. a.r.l. ONLUS, settore riabilitativo • Tipo di i
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