The national IR rate increased throughout the study period. Substantial regional variation remains, although considerable time has elapsed since a period of service reorganization, guideline revision and a national audit.
161Breast reconstruction and oncoplastic techniques have been widely adopted in the surgical management of patients with breast cancer. The National Mastectomy and Breast Reconstruction Audit (NMBRA) 1 is the largest prospective audit of breast reconstruction ever carried out. It was designed and implemented by the Clinical Effectiveness Unit at The Royal College of Surgeons of England with input from the Association of Breast Surgery (ABS), the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), and the Royal College of Nursing. The NMBRA examined a broad range of clinical and patient reported outcomes in more than 18,000 women. Factors examined included patient information and access to reconstructive services as well as the level of pain, complications, quality of life and wellbeing after surgery.The patient reported outcomes in the NMBRA highlight the positive effects of breast reconstruction on quality of life and the very high levels of satisfaction with the clinical care provided. The audit did, however, find complication rates, levels of postoperative pain and readmission rates that were much higher than expected. There were also variations in preoperative provision of information, access to services and some clinical outcomes.The original ABS guidelines 2 predated the NMBRA. One of the key recommendations of the audit was that new guid-ance should be written that describes 'best practice' and sets current standards of care. Following this, a multidisciplinary writing group of specialists with expertise in the management of patients undergoing oncoplastic procedures was set up by the ABS and BAPRAS to develop comprehensive new guidelines: Oncoplastic Breast Reconstruction: Guidelines for Best Practice. 3 A patient representative was involved throughout as a core member of the group. Feedback from a wide range of stakeholders has been incorporated into the document, which enjoys the support of Professor Sir Mike Richards, the National Cancer Director. The guidelines are available on the ABS and BAPRAS websites.The NMBRA identified more than 80 unique metrics, reflecting previously undisclosed standards of care. These provided a benchmark for the selection and development of 25 new quality criteria, which form the backbone of the new guidelines (Table 1). The quality criteria were selected to be outcome based, measurable and clinically relevant. They set standards that can be used for future audits, within individual units or nationally.Since oncoplastic breast surgery is a developing area of clinical practice with a limited evidence base, the guidance reflects a combination of peer opinion and the best available evidence informed by peer reviewed publications. External advice was commissioned on pain management from
ReferencesClosed suction drainage is beneficial in reducing the incidence of axillary seroma following breast surgery'-3. The incidence of postoperative seroma formation is less when the volume drained is under 30 ml per 24 h but to achieve this4 drains occasionally need to remain in situ for more than 10 days. Suction drainage may encourage continued lymphatic flow by virtue of a negative pressure effect. The present prospective study examined this hypothesis by comparing the duration and volume of drainage from a suction drain with that from a siphon drain. Patients and methodsAll women with breast cancer undergoing axillary dissection between September 1991 and April 1992 were included in the study. The axilla was approached through a mastectomy incision or a separate axillary incision and level 1 axillary dissection performed. After haemostasis had been achieved, each patient was randomized by sealed envelopes to receive a closed siphon drain (2CFr Robinson; H. G. Wallace, Colchester, UK) or -750 mmHg suction drain (10-Fr Medinorm S600;Medinorm, Abnieuwegein, The Netherlands). After placement of the drain the wound was closed and further diathermy prohibited. A record of drainage volume was kept and drains removed when this was less than 30 ml per 24 h. At 5 days after drain removal, or earlier if symptomatic, the wound was examined for signs of infection and seroma formation. Seroma was defined as any fluctuant fluid collection. All collections were aspirated, with reaspiration 72 h later if indicated. Data concerning the incidence of late complications were not collected. Statistical analysis was performed using Student's t test. ResultsFifty-one patients htially entered the study; one declined to consent to randomization and was excluded. The two groups Paper accepted 3 September 1993 were matched for age, weight, number of nodes excised, frequency of axillary pathology, perioperative tamoxifen administration and type of surgical procedure. The results are shown in Table 1. DiscussionThe need for axillary drainage after radical dissection is undisputed. This study shows that siphon and suction techniques are associated with a similar duration of drainage. Siphon drainage resulted in lower daily and total fluid losses but this was not at the expense of higher seroma or wound infection rates.The siphon drain is simple in design, easy to use and difficult to disrupt. Patients may leave hospital early with a drain in situ, recording daily volumes before returning for drain removal when appropriate. Unlike the siphon device, a suction drain may lose vacuum (occurring in one-third of the present patients; Table I), which may reduce efficiency.The performance of a siphon drain is comparable to that of a suction drain without the associated risk of vacuum loss. ReferencesCameron AEP, Ebbs SR, Wylie F, Baum M.
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