Earり′remOValqfdrainsandtheincidence

qfseroma‘昨erbreastsurgejy

NaoyaOkada，YoshiakiNarita，Minoru

Takada，HiroakiKato，Yo担iyasuAmbo，

FumitakaNakamura，AkihiroKishida＆

Nob証Chi‾‾Kashimura

BreastCanter

lSSN1340－6868

VoIume22

Numberl

BreaStCancer（2015）22：79－83

DOl10．1007／S12282－013－0457－3

reaSt

amer 1億両伸一leSeere鵡tCanCer気高叫

㊧springcr

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監醒艶

BreastCancer（2015）22：79－83

DOllO．1007ls12282－013－0457－3

ORIGINAL ARTICLE

Earlyremovalordrainsandtheincidenceorscromaanerbreast

Surgery

NaoyaOkada・Yos軸akiNarita・MinoruTakada・

HiroakiKato・YosIliyasuAmbo・FumtakaNakamura・

AkihiroKis油da・NotIuichiKashimura

Received：11September2012IAccepted：18Febmary20131Publishedonline：14March2013

⑤TheJapaneseBreastCancerSociety2013

Abstract

Background Women undergolng Surgery for pnmary

breastcancerroutinelyhavesuctiondrainsinserteddeepto

me wounds．Alack ofdata existsin relatlng howlong

SuCtiondrainsshouldstaylnSituaftermajorbI’eaStSurgery．

Purpose This smdyevaluates theappropnatetimlngOf

drainremovalbycompanngthe5－day－longpostoperative

drainageordminremovalwhenlessthan50mLI24hto

conventionaldrain removal．

Methods This con億011ed clinical thal was undertakcn

betweenFebruary1997andMay2012withatotalof214

COnSeCutivepatientswhounderwentelectivetotalorpartial

mastectomywithlevelITaxillarylymphnodedissection．

ThemainoutcomemeasureSincludedthelengmofhospitaJ

Stay，andsurgicalmorbidity，eSpeCiallyseromafbmation．

ResuLtsIn the study group，theageand operation time

WereSign誼cantlylnCreaSedcomparedtotheconventional

groupwhereasthemedianhospitalstaywas signmcantlyShorterinthesmdygroupthaI＝thecontrolgroup（7days

VS．9days；p＜0．05）．Theincidenceofseromawas42．8％

in the study group and　31．6％in the control group

O＝0．14）．Themeannumberofoutpatientvisitsfbrser－

OmaWaS3．6inthestudygroupandl．5inthecontrolgroup

O＜0．05）．Drainagevolumeofmorethan150mLl24hall

resultedin seromafomation．

ConclusionslmenewcriteriafbrearlydIainremovaJare

Safeandacceptabledespltetheslightlyincreasedchanceof

seI・0malbmation．

N．Okada（函）・Y．Nahta・M．Takada H．Kato・Y Ambo

F NakamuraiA．Kishida・N．Kashimura

DepaJlmentOfSurgery，TeineKeijinkaiHospltal，1－12Maeda，

Teine－ku，Sapporo006－8555，Japan

e－mail：0＿naOya＿0＠mecom

Kcywords Axillarylymphnodedissection・Seroma・

Breastcancer

Inlroduction

Inthemajorityofwomenwithbreastcancer，eXCisionof

theprimarytumor（bymastectomyorwideexcision）wim

axi11arylymphadenectomyhasbeenconsideredthesurgl－

Caltreamentofchoice；unfomnately，ltCanalsoresultin

Signincant morbidity言ncluding seroma fomation・Post－

OPerativedrainagehasbeenusedroutinelyintheexpec－

tationthatitreducesseromafomation；however，itaddsto

the patient，s discomfort and mayincrease the hsk of

inrection．Holongeddminage usually resultsin alonger

hospitalstaypostoperatively．InordertOreducetheper－

Ceivedproblemsresultingindrainageuse，SOmeSuJgeOnS

arecunentlyremovlngdrainsmuchearlier，OrnOtplaclng

them at all．

Inbreastcancersurgery，thedrainageperioddictates

thclength of postoperative hospital stay・In previous

studies，thetimlngOfdrainremovalhasbeenequlVOCal・

Somereportthatnodrainormerelyshort－temdrainage

after axillarylymph node dissectionin breast cancer

Surgeryissafel1－41；however，Othersreportthattheyare

not safebecause oftheincreased occurrence ofseromas

requlnng frequent asplrations，thereby extending the

lengthofhospitalstayL5－7）・Othershavealsoreported

thata5－day－longpostoperativedrainageissafecompared

to8days［Sl．Regarding the drainage volume，SOme

reportthat50mLIdayissafeandreasonablel3，41・We

herein hypothesize that the mostreasonablelimlngfor

drain removalis on postoperative day50rless than

50mL／day，andassessitsclinicalemcacyretrospectively

inacontrolledstudy・

㊧sphngcr

80　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　BreastCancer（2015）2279－83

PatientS and melhods

Atotalof214Consecutivepatientswhounderwentelective

totalor partialmastectomy withlevelIIaxillarylymph

nodedissectionatTeineKeijinkaiHospital（550－bedph－

Vatehospital）inJapan between Febmary1997andMay

2012hadtheircasesreviewed．Thecriteriafortheremoval

0日heaxillarydrainincludedeitherdrainagevolumeless

than50mL／dayoronpostoperativeday5regardlessofthe

amountofdischarge．Thepatientsinwhomthedrainwas

removedonpostoperativeday5withmorethan50mL／day

drainage were discharged with compression bandages to

the axilla．A seroma was defined as an accumulation of

SerOuSduideitherundertheskinnapsofthechestwallor

the axillary deadspace，Which required atleastoneper－

CutaneOuSneedleasplration・

Thecontrolgroupconsistedof．76Consecutivewomen

WhohadatotalorpartialmastectomywithlevelsIandⅡ

1ymphnodedissectionsfbrbreastcancer，betweenFebru－

ary1997andApri12001．Theyhadtlledrainsremovedat

me discretion of their physicians．The criteria for dmin

removalwere completely changed after May2001．me

Study groupconsistedof138patientS Whohadthe same

Operation and drain removalaccording to the afbremen－

tionedc証eriabetweenMay200landMay2012．Twenty－

SeVenpatientsをomthesameintervalwereexcluded龍om

thissmdybecausedminremovaJwasdeliberatelydelayed

due to consideration ofthoseliving far血om the clinic，

Whichwouldmaketheirfollow－upVisitburdensomeinthe

cases wim seromalbmation．

Allpatients were fbllowedfbratleast2monthspost－

OPeratively，andthefollowlnginfomation wasrecorded：

age，bodymassindex（BMI），tOtalorpartialmastectomy，

Operation time，bloodloss，duration ofsuction drainage，

lengthofpostoperativehospitalstay，1nCidenceofseroma，

and woundinfection rate．The number and duralion of

asplrationsrequiredfbrseromaswerealsoevaluated．The

dischargecritetiaweredeteminedbytheipsilateralam’s

mobility wmoutdrainage during theiractivities ofdaily

life．In the control group，many Patients∴Stayedin the

hospltalaftersurgeryforadjuvantchemotherapya皿Ough

dlepOStOperativehospltalstayattributedtochemotherapy

WaSOmittedftomthissmdy．

Duhng mastectomies，patients were positioned wim

their almS abducted and nexed at90°．ThelevelI and H

lymphnodesinferiortodleaXillaryveinandbetweenthe

anterior border of thelatissimus dorsi and the medial

border ofthe pectoralis minor muscles were excised en

bloc．A19－Frenchfour－Channelvacuumdrainwasplaced

in the axilla．In total mastectomies，a17－French k）ur－

Channelvacuumdrainwasadditionallyplacedbenea曲目he

Skin nap whileinbreastconservlng Surgeries，15－French

drainswereusedinbothareas．Insomecases，adrainunder

包sphnger

theskinnapwasomitted；mesedIainswereconnectedtoa

COntinuoussucliondrainagedevice．

Statisticalanalysis

Comparisons between the groups had been pertomed

uslng meChi－SquareteSt，theMann－Whitney U－teS and

theFisher’sexacttestwithSPSS（Version14，Chicago，IL，

USA）software．The signiGcancelevel had been set at

p＜0．05．Standard deviations（SD）were∴Shown for the

mem values．

Resul露

Comparisonofthepatientdemographics

andthepenoperativestams

Thepatientdemographicsrorbothgroupswereshownin

Tablel．mepatientswereslgn誼cantlyolderinthestudy

groupthaninthecontrolgroup（p＜0・05），andmemedian

Operationtimewassigni斤cantlylongerindleStudygroup

thanthecontrolgroup（p＜0．05）．AIso，thetotaldrainage

VOlumewassigni飴a細Ldymoreinthecontrolgroup血劃nme

Studygroup（p＜0．05）．Theotherpreoperativedalawere

notslgnincandydi挽rentbetweenmetwogroups・

Durationofdrainage，hospitalstay，SerOmafomation，

and woundinfection

Table2showedthatmemedianduationofdrainageinthe

Studygroupwasoneday shoIlerthanthecontrolgroup・

Accordingly，melengmofthepostoperativehospitalstay

WaSSlgn誼cantlyshorterby2days・Althoughtherateof

SerOmafomationinthestudygroupwashigherthanthe

COntrOlgroup，nOSignincantdi飾訂enCeeXisted（p＝0・14）；

theincidenceofseromainthecontrolgroupwas240f76

patients（31．6％）whiletheoneinthestudygroupwas59

0日38patients（42．8％）・Inthecontrolgroup，Onepatient

hadapostoperativehospitalstayof57days，becauseshe

hadawoundinfectionwithskinHapnecrosis．Nostatisti－

Cally slgnincant difference between the two groups was

observedfbrwoundinfectionrates（Table2）．

Meannumberofseromaasplrationandoutpatientvisit

Inthecontrolgroup，24seromapatientsneededanaverage

Of5asplrationsandl．50utpatientvisits・Inthesmdygroup，

59seromapatientsneededanaverageof4・lasplrationsand

3．60utpatients visit．Between the twogroups，themean

numberofoutpatientvisitswassignincantlymoreinthe

Studygroupthanthecontrolgroup・NosignincantdifEer－

enceexistedinmemeannumberofaspirations（Tablei）・

BreastCancer（2015）2279－83　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　81

Tablel Baselinedemographicsofpatients

Parameter ControI Study pValue

（n＝76）　　（n＝138）

Age（years）

DM0位gIm2）

Totaupam心

血astectomya

0匹rationtime（min）

Bloodloss（mL）

Tot日直ainagevolume

（mL）

52（28－83）

23．1

（17．2－35．0）

26150

103（60－188）

40（（1340）

416（86－1322）

59（31－87）　　＜0．05

22．9　　　　　　　N．S．

（16．3－39．2）

58／80　　　　　　N．S．

115（55－255）　＜0．05

50（0－353）　　N．S．

351　　　　　　　＜0．05

（12－1550）

Datawasshownasmedian（interquarlilerange）ornumberofpatientS

BMtbodymassindex，NS．notslgni6cant

a Numberofpatients

Table2Duralionofdrainage，hospitalstay，SerOmak）malion，and

WOundinfection

Parameters ControI Study pVaIue

（n＝76）　（n＝138）

Dul’ationofdrainage　　　　6（3－15）　　5（1－5）　　＜005

（心ys）a

Postoperalivehospitalslay　9（4－57）　　7（3－19）　＜0．05

（days）a

SeromafomatlOn　　　　　24（31．6％）　59（42．8％）　N．S．

Woundinfection　　　　　　3（3．9％）　　6（4．3％）　N．S．

a Median（IQR）

Table3Mean（SD）numberofaspiralionsandouIpatientsvisits

Parameters∴∴∴SeromaincontTOI Seromainsmdy pValue

group（n＝24）　　group（n＝59）

Numberof　　　5．0（4．8）

継p－ra‘ionsa

Numberof l．5（4．1）

OutpaIienl

visita

4－1（5，3）　　　　　N．S．

3．6（5．4）　　　　　＜0．05

a Mean（SD），SDstandaTddeviation

Table4RelationshipofdTainagevolumesonremovaldaytoseroma

fomaoon

mnagevolumeon Numberof Numberof Seromaremovalday（mL／24h）　patientS∴∴SerOma fomation

（％）

1－50　　　　　　　　　　　　　117　　　　　30

51－100　　　　　　　　　　　　75　　　　　39

101－150　　　　　　　　　　　20　　　　　12

≧151　　　　　　　　　　　　　2　　　　　　2

Relationshipofthedrainagevolumesontheday

ofdrain removal to seroma fomation

Table4showedal00％incidenceofsubsequentseroma

fbmationinallpadentswhosethedrainagevolumeover

thepreceding24hwasgreaterthan150mL．

Discussion

PostoperativeseromaR）madoncommonlyoccuSめllow－

ingradicallymphadenectomyforbreastcancerl9，10］．A

seromaisanabnomalcollectionofserousnuidinthedead

SpaCebeneaththepost－maSteCtOmySkinnap，intheaxilla，

Or Within the breast parenchyma fbllowlng breast－COn－

SerVlng SurgeIy andis the most common early wound

Sequellae．Inthissmdy，SerOmaisdefinedasanaccumu－

lationofserousnuidbenead日田eskinnaporintheaxilla

afterbreastsurgery，Whichnecessitatespercutaneousneedle

asplration．ThepamogenesisofseromashasnotbeenmIly

elucidated［用，butseromascanleadtosignincantmor－

biditysuchaswoundhematoma，delayedwoundhealing，

WOundinfection，napneCrOSis，OrWOunddehiscencelead－

ingtodelayedinitiationofaquvantmerapyH2，13）．The

incidenceofseromasshouldbekeptasIowaspossiblefor

these reasons；however，long－tem drainage canlead to

PI’010nged hospitalstays and highmedicalcost15）．One

additionalhospltaldaycostsaboutlOO，00Oyenwhileonme

Otherhand，anOutpatientvisitwithonepuncmreforseroma

asplrationisaboutl，5（myen．meoptimaltimlngOfdl’ain

removal，therefore，CannOtbeoveremphasized．

SeveralreportShaveshownarelationshipbetweenthe

incidence of seroma fomation and theinterval of drain

placement［2一ら6，8，14，15］．Othershaveexamineddle

effects of early drain removal and the time of hospital

dischargein postoperalive patients of breast cancer

（Table5）．Itisdifficulttoextl．aPOlatethoseresultstothis

Studyintemsofmeincidenceofseroma，becausemetem

‘‘seroma’’is denned diHerently by each report．The

draimge durationin this∴Study can be reduced mrther；

however，early drain removalincreases dleincidence of

SerOma．Considerations shouldbemade，theref10re，inbal－

anclng the bene創ofeal’1y drain removaland dle disad－

VantageOfseromafomation．

Inmisstudy，dleincidenceofseromadoesnotincrease

mecomplicationsortotalnumberofasplrations・Table3

Showedthatthemeannumberofasplrationsis4．1inthe

Studygroup，Whichisalitdelowerthan5．0inmecontrol

group；however，thestudypatientsneedsignincandymore

ftequenlclinicvisitsfbraseromapuncmremanthecontrol

group．Outpatient visitS for aspmtions are slgnincandy

increasedbyameanof2．1daysbecausethetotalnumber

Of asplrations言ncluding seroma puncuure donein the

包sphnger

25．520000

82　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　BreastCancer（2015）2279－83

Table5Res血sofotherreportscompanngdmesfbrdI．ainremoval

Audor Publication ComparisongT’OuPS Numberof Seromatomation PostoEXiranVehosprtal

year patienls stay

AckyordetaL［ljI1997　　　　　POD5versus30mL／24h

Guptaetal．［即　　2001　　　　POD5versusPOD8

Pumshotham etal．　2002　　　　　　Nodrain verSuS

閏　　　　　　　　　　　　　poD5。r50mU24h

120　　　　　　　　29vs．25％　　　　　　No data

121　　　　　　　　48vs．28％　　　　　　POD5vs，POD8

375　　　　　　　　57vs．52％　　　　　　nOD均vs POD6

Talbotetal．［珂　　2002　　　　　NodrainversusPOD2versus∴∴∴∴90　　　　　　　97％vs．86％vs．　PODOvs．POD2vs．

50mLl24h　　　　　　　　　　　　　　　　　　　　　　　　　73％　　　　　　　　　　POD2

Thissmdy　　　　2012　　　　　POD5or5011LLI24hversusNo　　214　　　　　　43vs・32％　　　　　POD7vs・POD9

Cntena

Table6Comparisonbetweenanendingsandresidents

Parameters Attendings Residenls pValue

（n＝158）　　　　（n＝56）

Operationtime lO3（55－222）　　136・5（80－255）　＜0・05

（mn）

Seromafomation　58（36．7％）　　　　25（44．6％）　N．S．

NS．noIslgn誼C狐t

Data were shown as median（interquartile range）or number of

patienIs

hospltal，isincluded．Thecontrolgrouppatientsstayinthe

hospltallongerandhaveseromapunctueSinthehospital，

buttheydonotneedclinicvisitsforseromapuncmrein

COmparison to the study group patients．Although me

patientsneedmorefrequentclinicvisitsforasplration，me

Outpatientcostremainslowerthanthatofhospltalization；

hisinconveniencecanbetoleratedincaseswherepatients

haveeasy accesstotheclinic．Ifpatients havedi緬culty

followlnguplnClinic，dleSepadentswillappreciatepr0－

10nged dTainageinstead of early removal，Which will

requHegOlngbacktodleClinic．Table4showsal00％

incidence of seroma fbmation whose drainage over me

preceding24hisgreaterthan150mL，indicatlngdrains

should notbe removedin thoseinstances．

Incompanngthepatientdemographics andpenopera－

tive status，Tablel shows that patients are slgnincantly

Olderinthesddygroupthaninthecontrolgroup．Itmaybe

becauseyoungerpatientsundergobreastsuJgehesinme

Othernearbyclinics，Whichhaveopenedinthelatterhalfof

thestudyperiod．Themedianoperationtimeissigni飼candy

longerin the smdy group；the prolongation ofoperation

timeis attributed to dle Sentinellymph node biopsleS

introducedin thisinstimtionin2006．Another reason for

melongeroperationtimeistheinvolvementofthesurglCal

residents∴aS∴an OperatOrin association with me com－

mencement of the residency programin2003．In this

hospltal，2attendings∴andl resident perfom the breast

Surgeries．Table6Comparestheoperationtimeandseroma

romationbetweenattendingsandresidents；reSidentstake

esphngcr

aslgnincantlylongertime and have more，although not

Statisticallyslgnincant，SerOmafbmations．Totaldrainage

VOlumeis also slgn誼cantly greaterin the controlgroup

manthestudygroupbecausethelongdurationofdrainage

proportionallyincreasethetOtalvolume・

This study has∴SeVerallimitations．Firsdy，itis not a

randomized prospective study．Secondly，the early drain

removal does not necessarily shorten the postoperative

hospltalstay．ThepostoperativehospltalstaylSlonginthe

COntrOlgrouppaJ・dybecauseofthepostoperativeradiation

and／ora句uvantchemotherapy．Presendy，however，itisnot

POSSibleforpatientstostayinmehospitalft）rtheseadju－

Vant therapleS because ofthe revampedJapaneseheam

C紬e SyStem・

In conclusion，remOVlng aXillay dJrains on the5th

POStOperativedayorwhenthedminagevolumebecomeS

1essthan50mL／24hinpatientsundergolngbreastcancer

SurgerySlighdyincreasesseromafomation；however，the

totalnumberofasplrationis notslgnincantlylnCreaSed・

Thesenewlyproposedcriteriafordrainremoval，therefbre，

arepromislngalthoughfurtherevaluationinaprospective

Smdyisneeded・

AcImotpledgments TheauthorsthankDrs．HirokiSailo，Hyotaka

Imamura，Yoshihide Nanno，Mayu Shimaguchl，MinoriIshii，and

TomShimJZufbrtheirsupportinthissmdy・AIso，deywouldLlketo

thankdlehealthcareinfomation managers andmedicalclerkswho

havehelpedcollectpatientdataandDr・ChristineKwanbrherheIp

inpreparingtheEnglishmanuscnpt・

Con鮎ctofinter鐙I NaoyaOkadaandtheodlerCO－aulhorshaveno

connic10finterest．

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