To Study the Outcome of Dead Space Closure Utilizing Quilting Suture Versus Conventional Closure with Drainage for The Prevention of Seroma After Mastectomy for Breast Cancer

Abstract

Background: Postoperative seroma is a common complication after mastectomy with a highly variable cited incidence of 3% to more than 90%. Complications of seroma vary from delayed wound healing, repeated seroma aspirations with the risk of infection, prolonged hospital stay, skin flap necrosis, patient discomfort, repeated visits to the out-patient clinic, delay in commencing adjuvant therapies and higher surgical expenditures. Closing the dead space after mastectomy can be achieved by closed suction drainage, quilting of the skin flaps or application of adhesive tissue glues to the skin flaps before wound closure. There is however no consensus on which technique is most superior and their sequelae. Quilting suture consists in suturing the skin flaps to the underlying musculature to reduce ‘dead space’. The primary objective of this RCT is to assess the effect of flap fixation using sutures on the number of seroma aspirations after mastectomy for breast cancer in the first year following surgery. Secondary objectives include assessment of the number of out-patient clinic visits, infection rate, cosmesis and shoulder movement. Methods: This study was conducted in the department of General surgery, IGIMS, Patna, from   to, on patients diagnosed with carcinoma breast undergoing mastectomy. They were randomised into ‘Quilting’ and ‘Conventional’ group by systematic random method. Subsequently the patients underwent mastectomy (simple/ modified radical) with or without axillary dissection. Quilting of the subcutaneous tissue to the pectoralis muscle was done with the help of several parallel rows of continuous running sutures with 2-0 vicryl sutures in the ‘Quilting’ cohort. A close suction drain was placed in the cavity. If axillary dissection was done, a separate drain was placed. In the ‘Conventional’ group, the patients underwent mastectomy (simple/ modified radical) with or without axillary dissection with drain placement in axilla and beneath the flaps separately but without quilting. The wound was closed in 2 layers with vicryl 2-0 and skin staplers. 24- hour drain volume was recorded daily and drains was removed once drain volume was less than 40 mL over 24 h for 3 consecutive days, regardless of time elapsed after surgery or at 5 days following surgery. Result: The study enrolled a total of 229 patients after excluding 35 patients that did not meet the exclusion criteria and 15 patients were lost to follow up. 111 patients belonged to ‘Quilting’ cohort and 118 to the ‘Conventional’ group. The mean operative duration observed in the ‘Quilting’ was significantly higher than the Conventional group (p value-0.0274). The mean total drain content noted during the post-operative hospital stay in the ‘Quilting’ group was significantly lower (p value= 0.019). A significant higher mean frequency of aspirations was performed in the ‘Conventional’ group (p<0.001). The total number of visits were higher in the ‘Conventional’ group (p value=0.037). The infection rates consistent with the wound erythema and the need for surgical drainage evaluated in the two cohorts were not significant (p value: 0.190). The rates of wound dehiscence were significantly lower in the ‘Quilting’ cohort (p= 0.035). The range of arm abduction was non-significant with a p value of 0.106. The ‘Quilting’ cohort had a significantly better wound cosmesis than the ‘Conventional’ cohort (p value- 0.029). Conclusion: We conclude that ‘Quilting’ integrated in the wound closure helps in seroma reduction in the patients undergoing mastectomy in breast cancer patients. The incidence of seroma was significantly lower in the ‘Quilting’ group thus reducing the patients’ discomfort and the cost of the treatment. The mean total drain output, the frequency of hospital visits and aspirations were also lower. ‘Quilting’ was also associated with lower rates of wound dehiscence thus giving better cosmesis than the ‘Conventional’ patients. However, the mean total postoperative stay and infection rates were similar in both the groups