Drainage after Modified Radical Mastectomy – A Methodological Mini-Review

Abstract

Breast cancer is a socially relevant group of malignant conditions of the mammary gland, affecting both males and females. Most commonly the surgical approach of choice is a modified radical mastectomy (MRM), due to it allowing for both the removal of the main tumor mass and adjacent glandular tissue, which are suspected of infiltration and multifocality of the process, and a sentinel axillary lymph node removal. Most common post-surgical complications following MRM are the formation of a hematoma, the infection of the surgical wound and the formation of a seroma. These post-surgical complications can, at least in part, be attributed to the drainage of the surgical wound. However, the lack of modern and official guidelines provides an ample scope for innovation, but also leads to a need for a randomized comparison of the results. We compared different approaches to wound drainage after MRM, reviewed based on the armamentarium, number of drains, location, type of drainage system, timing of drain removal and no drainage alternatives. Currently, based on the general results, scientific and comparative discussions, seemingly the most affordable methodology with the best patient outcome, with regards to hospital stay and post-operative complications, is the placement of one medial to lateral (pectoro-axillary) drain with low negative pressure. Ideally, the drain should be removed on the second or third postoperative day or when the amount of drained fluid in the last 24 hours reaches below 50 milliliters.

Effect of topical microporous polysaccharide hemospheres on the duration and amount of fluid drainage following mastectomy: a prospective randomized clinical trial

“…Therefore, all patients had a drain placed. However, several studies that have evaluated the risk of seroma formation following mastectomy without drain placement reporting increased postoperative seroma formation and higher seroma volumes [46, 50, 51]. Additional studies have evaluated the risk of sermoa formation following mastectomy without drain placement with the use of other surgical or chemical techniques for obliterations of dead space with some encouraging results [46, 52, 53].…”

“…However, several studies that have evaluated the risk of seroma formation following mastectomy without drain placement reporting increased postoperative seroma formation and higher seroma volumes [46, 50, 51]. Additional studies have evaluated the risk of sermoa formation following mastectomy without drain placement with the use of other surgical or chemical techniques for obliterations of dead space with some encouraging results [46, 52, 53]. Although encouraging, some major limiting factors of these studies include small sample sizes, retrospective studies, and reports suggesting that surgical techniques to close dead space have poor cosmetic results and potential increased morbidity [5, 54–57].…”

A single-center, randomized, non-inferiority study evaluating seroma formation after mastectomy combined with flap fixation with or without suction drainage: protocol for the Seroma reduction and drAin fRee mAstectomy (SARA) trial

“…Mastectomy with flap fixation is becoming standard practice and is currently combined with closed-suction drainage. The current standardized use of closed suction drainage is supported by trials showing a higher frequency of seroma and greater volumes of seroma in patients undergoing mastectomy without drains [19][20][21][22][23]. However, in these studies no flap fixation was performed.…”

“…For many years closed suction drainage was considered the most effective intervention for reducing seroma formation after breast cancer surgery. This practice was supported by trials showing that mastectomy without the use of drains was associated with a higher occurrence of seroma and greater volumes of seroma in the post-operative period [19][20][21][22][23]. Other studies in drain free mastectomy have shown that application of suction drainage does not prevent seroma formation and that there is no significant difference between the incidence of seroma formation [24][25][26].…”

“…These studies also concluded that closed suction drainage is associated with a longer postoperative hospital stay on average, and that a long duration of drainage was related to a higher incidence of seroma formation [27][28][29]. The question therefore is if there is still a place for closed-suction drainage after mastectomy with flap fixation, as this has shown to decrease seroma formation [21,22]. However, the evidence consists of only small case series and a large randomized controlled trial is needed to provide definitive proof.…”